The Suicide Lawyers
I had picked up The Suicide Lawyers some time ago but hadn’t read it. I have friends and clients who are attorneys. I like them. I couldn’t really understand why I hadn’t read the book. Then I realized that there was some sense of disconnect between the research about suicide prediction and holding accountable a mental health professional for not detecting suicide. An introduction to Skip Simpson from a trusted colleague moved the book to the top of the list.
Misunderstanding Suicide
“Suicide may be one of the most misunderstood acts, and subjects, on the planet.” It’s certainly very misunderstood. They claim that they want juries to deliver verdicts on fact, not myth. I agree. It’s a small part of the reason we developed https://SuicideMyths.org. We wanted a place where people could get the truth in a way that is sufficiently authoritative that people may stop believing the lies that are costing lives.
Ample Warning
A place that I’ll disagree with the author and Skip is that “nearly every person who commits suicide provides ample warning about his or her intention.” I think those are the kinds of cases that they get involved with – but I don’t think that’s true of every suicide death. Consider that roughly half of all deaths by suicide weren’t engaged with the mental health system. Given their role of suing mental health providers, it makes sense that there’s a whole other grouping of suicidal people they’ll never (or rarely) see.
Minor Tragedy
“There’s usually a lot more behind a suicide than some minor event. If a high school or college student commits suicide after getting a poor test grade, chances are that his or her decision was just the final straw of a rather hefty set of problems he or she was facing.” The tricky part here is that “usually” is probably right. However, this doesn’t eliminate the possibility that someone was thinking in a cognitively constricted way and made a hasty decision. (See The Suicidal Mind and Capture.)
The Copout
Responding to the author in an interview, Skip said, “That can be a copout. Most suicides can be prevented, and a caring, compassionate individual is going to do everything in his or her power to stop people from killing themselves.” The issue at stake is whether you can save someone else from suicide. The answer – as a technical matter – is no. No set of constraints that anyone can put on another will prevent them from dying by suicide. They can, if they’re determined, find a way.
That being said, Skip has a point. We should work towards preventing suicide in others where we can.
Foreseeability
Skip clarifies that the issue at stake in legal terms is foreseeability, not predictability. Foreseeability is about whether the consequences of an action or inaction could reasonably have been anticipated. In clinical settings, the key consideration is whether the clinician can predict the behavior of a patient which is a higher and more important standard.
Skip’s statement, “Professionals, who properly assess for suicide do, however, have enough knowledge to foresee a likelihood that someone will commit suicide in the near future,” can be troubling. It’s troubling, because when viewed from the prediction lens, this is incorrect. Research routinely characterizes our ability to predict short term risk as low. This applies both to screening tools and to clinician assessments.
The gap is that Skip is speaking of foreseeability. In tort law, if the harm was foreseeable and the person did not take reasonable steps to prevent it, they could be held liable for negligence. What are reasonable steps? The quip I’d expect from my attorney friends is, “Whatever the jury says.” In practical terms, it’s more complicated than that.
“Reasonable” is determined – in part – by the standard of care. That means that the standards brought forward by the National Action Alliance for Suicide Prevention’s recommended standard care matters. So, too, do the recommendations of The Joint Commission – an accreditation organization for health care organizations.
“Reasonable” can be as small as having considered the short-term risk and ruled it out based on a set of reasons that are written into the patient’s record. According to the colleague who introduced me to Skip, this is more than most do.
Proper Assessment, Diagnosis, and Treatment
Skip appropriately criticizes the mental health industry for failing to train clinicians on suicide risks. However, there are some overreaches in terms of the capacities of the assessment and diagnosis components. In addition to the assessment issue addressed above, diagnosis – using the standard DSM-V – is notoriously fickle between clinicians. There are criteria, but they’re broadly written and interpreted in ways that lead to poor reliability.
The good news is that Skip’s spot-on with regards to treatment. We have clinically validated treatment approaches (DBT, BCBT-SP, and CAMS) that are appropriate for those clinicians working with patients with suicidal ideation or attempts. I don’t agree with Skip’s statement, “Psychiatric treatments can be just as effective as those for other illnesses, if the clinician is competent.” We’ve got a long way to go to get to those levels of clinical efficacy.
Safer Cars
Skip says, “Why do we have safer cars today? I’ll answer that…one of the main reasons is because of trial lawyers. It was trial lawyers who forced automakers to design safer cars.” I’m relatively certain that Ralph Nader would disagree. In Unsafe at Any Speed and in his other advocacy work, he and others transformed public perception. As much as it pains me to say it, the claims made against carmakers were written into a cost of doing business rather than taken as an imperative to change their way of business. Do I think trial lawyers help to encourage accountability? Yes. Do I believe it stops there? No.
Firearms
When it comes to firearms in the United States, people can get sensitive. However, the facts aren’t equivocal. More than 50% of suicides in the US are completed with a firearm. However, like most things in suicide, it’s not that simple. It’s not as simple as saying that access to firearms causes suicide deaths. Skip explains, “Firearms account for more than 55 percent of suicides. However, guns are easily obtained in Texas, and it ranked 39th in per capita suicides.”
In the US, there’s probably not a more sensitive topic. Folks like John Lott write books like Gun Control Myths to combat what they feel like is excessive gun control. It’s a response to sometimes inflammatory writing, like Gun Country, which blames unrestricted capitalism for the explosion of guns and the resulting problems. More balanced approaches to the challenges of the topic, like Guns in America and America’s Gun Wars, are often drowned out in the competition for headspace.
Ultimately, I’m less concerned about ownership of guns (because that ship has sailed). I’m more concerned about making sure that guns are safely (or securely) stored. That means when not on one’s person, they should be locked. (See Guns and Suicide for a more nuanced conversation.) If we could just get everyone to store their guns safely, we might find that we don’t need as much from The Suicide Lawyers.