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William Reid July 17th, 2004 05:25 PM

Lots of lurkers, but few new posts so far. Maybe I can get the ball rolling with one of my interests: preventing suicide, and malpractice & risk management issues in the care of suicidal patients.

Wrongful death (usually a pseudonym for suicide) is the most common "cause of action" in lawsuits against mental health professionals. That is, it is the most common reason plaintiffs sue us. Sometimes the lawsuit is not deserved; tragedy does not necessarily mean malpractice. Unfortunately, there are too many times when the lawsuit IS deserved, because the suicide could have been prevented if the patient's assessment and/or treatment had been within the standard of care (generally defined in most states as that care reasonably expected of similar professionals in similar situations, but pointedly not inadequate care, even if everyone in your community does it).

Recognition of suicide risk, adequate initial and follow-up assessment of risk, appropriate treatment, and adequate follow-up are the keys to protecting the patient and lowering risk to both the patient and the clinician. They're not rocket science, but they do require professional competence and a disturbing number of otherwise very nice colleagues don't do it right.

Notice I haven't said anything about "prediction" of suicide. We all know it's not generally predictable, but that's not the point. Loudly proclaiming "Suicide isn't predictable!" won't help you if you are sued. The relevant concept is "risk." Patients have a right to expect competent mental health professionals to recognize reasonably known suicide risk and take whatever steps are feasible to manage it.

I am reminded of a new book that features a couple of plaintiffs' lawyers who specialize in suicide cases (The Suicide Lawyers, by Risenhoover). I think there's a website for it at something like It's designed for lay readers, but has stuff professionals should know as well (if you're interested in how good plaintiffs' lawyers think). It doesn't seem to be written for sensationalism (in spite of the title and cover), but to try to decrease suicides by increasing both lay and professional awareness.

Comments? Ideas? . . .

Bill Reid

Da Friendly Puter Tech July 18th, 2004 12:45 AM

Re: Suicide
Hey Dr. Reid,

On a related note I kept wondering during the court case against that Texan woman who drowned her children during a psychotic episode a couple of years back.

When it came out in the media that she had been really unstable before the episode and under a psychiatrists care I wondered what if any responsibilities the doctor had. How on earth could the doctor have missed how bad off this woman was?

Things I wondered about included:

Did the doctor(s) know the real shape of this woman? Had they asked her if she heard voices, and if yes what the voices said?

Had they asked her if she wanted to hurt herself or anyone else?

Had they discussed plans with her if she did become suicidal / homicidal?

If they had NOT discussed this with her why on earth not?

If they did discuss it with her what failed in their supervision and or preparation for taking care of this woman and her family?

What would be the level of responsibility for the doctors in this situation?

Warm regards
Da Friendly Puter Tech

Skip Simpson July 18th, 2004 12:50 PM

Re: Suicide
Da Friendly Puter Tech,
Great questions. I am somewhat familiar with the Yeates case. Having reviewed some of the charts it is clear that Mrs Yeates was likely headed to some disaster. One of the major failings of the healthcare providers was the failure to address the issue of filicide. When a mother with young children is thinking of suicide it is the standard of care to ask specific questions about her thinking regarding the children. For example a question with follow-ups might be "I have often had moms who were thinking of suicide who were also thinking of harming their children so they could be in a better place, have you had such thoughts?" This question allows the mom to now address this issue knowing other moms have had similar thoughts. The process is know as "normalization," and is often used in substance abuse cases to get the patient to talk about amounts of drugs used, etc.
Had the clinicians ask the questions they should have asked it is likely Ms Yeates would have provided clues to her homicidal thinking which could have been passed on to the husband. Preventive step would have been executed instead of children being executed. Most likely. When people are thinking of suicide they often enter into an internal dialogue on the pros and cons of suicide. They think of how they will do it, when, where, who will find them, etc. This planning stage is important for the clinician to eavesdrop on by good suicide assessment. Same for filicide.
Skip Simpson

Da Friendly Puter Tech July 18th, 2004 03:06 PM

Re: Suicide
Hey Skip Simpson,

Thanks for the answer, that one has bugged me for quite a while. Reading your answer pretty much tells me that the mental health professionals simply didnt ask. How incredibly alarming. I volunteered for 3 years at a suicide and crisis hotline, and many of those questions would have been asked by paraprofessionals already on the first call. How can professionals completely overlook it!?!

I was shocked that Mrs. Yeates got such a severe punishment simply because she was so obviously sick. I agree she still has some responsibility, just not all of it.

Maybe the responsibility should be shared by those mental health professionals who failed to ask the questions.

I am sure you cant comment on a specific case, but in general what kind of sanctions could mental health professionals - who fail to ask pertinent questions - and that has a deadly outcome be subject to?

Also, since I seem to have your attention :o). I noticed on your web site that you list false memories as an area of trial expertise. I would love it if you would comment on what kinds of false memories cases are actually prosecutable. I think this is an area within the mental health field that has so many shades of grey, I bet the cases easily become difficult when they are subject to stright standards of evidence.

Thanks and
Warm regards
Da Friendly Puter Tech

loftus75 July 18th, 2004 03:48 PM

Re: Suicide
I'm not sure what the various State laws are relating to patients rights, but in the UK we cannot retain patients against their will unless certain criteria is met. The 1986 Mental Health Act states that patients that might harm themselves or anyone else may be retained if two doctors, one (MD)and a psychiatrist have assessed the patient and agree that the patient is unable to be accountable for their actions, (excuse my paraphrasing). However families members can and do influence these decisions. So a family that has a suicidal member can have that family member released from care under certain conditions. Sometimes this flies in the face of the advice given to them, sometimes the families are right, sometimes they are wrong.

I would imagine there must be safe guards in the USA that protect patients rights along these lines as well. That being the case patients that are at risk, unless already under some form of health care supervision order, can and do commit suicide and a variety of other crimes. This notion of blame, that is a patient living in the community is not responsible for their actions and subsequently their mental health carer must be, seems bazaar.

If a person is receiving mental health care and it is deemed they are capable enough to remain in the community, perhaps because the law protects their rights and makes it difficult to retain a patient against their will, then should we blame the law for the crimes committed by this patient?

Here in the UK we can and do retain people suffering from suicidal tendencies, people can be brought into a hospital if they have attempted suicide...but they can only be held in a hospital for a certain period of time, days not years.

When we review sad events in hind sight it is easy to get things right. When reviewing our colleagues work we should remember that the situation most of us have to deal with is not a one sided event, patients have rights and sometimes these override the suspicions of the mental health worker, whether that be a psychologist, psychiatrist or MD. It's also remembering these patient rights are there for good reason, remember the eugenenic/behaviourist period of our own history.

ADMIN. NOTE: If you would like to respond to this post, please consider going to the same post in the "Criminal Responsibility . . ." thread and responding there unless your comments are related to the initial "suicide" topic. Thanks, Bill Reid

Da Friendly Puter Tech July 18th, 2004 06:10 PM

Re: Suicide
Hey There,

Its interesting to compare how different cultures handle the same situation.

I am not sure if the laws for this are the same across all states, but I can tell you what the laws are locally where I am at. (that would be in California).

A mental health professional or para professional have complete confidentiality unless they have reason to believe that the client is a danger to themselves or others. The question that was touched on above is if the clinician is obligated to ask certain questions to find out if the client is a danger to themselves or others. I absolutely think the clinician is obligated to ask, and to fully asses the answers. Even in situations where they "think" they might already know the answer.

In effect this means that any professional or para professional can contact the emergency response phone numbers and report a client as a danger to themselves or others. The police is then subsequently send out to the person and most often they follow the recommendations of the reporting professional and pick up the individual to be taken to the nearest emergency psychiatric unit for observation. A person that has been picked up will be put on a 72 hour observation during which time they are effectively restrained from leaving. They might be let go before the 72 hours are up if they have been fully evaluated and the risk to anyone's life seems to be contained. The 72 hour hold is to give the professionals enough time to completely evaluate the situation.

If a person is to be held against their will for more than 72 hours then the hospital need to gather evidence that this person is an ongoing risk to have in society and convince a judge that it is so. In practice this does not happen often because there is a considerable expense to society and this being such a capitalistic society no-one really wants to foot the bill for it. Most often the person is put on meds, given some time to settle down, and then released back into society with a prescription for meds. Some places the person might be offered further help after they are released. Other places no further help is offered.

The fact that it can be only the word of one professional or even a para professional that can land a person in a psychiatric unit can seem rather lax, but I personally like it. I will rather have one too many person fully evaluated, than one person to few. Of course clients around the country have to be careful of carelessly saying "damn it, I am just gonna kill myself or someone else" as a way to let off steam. If they do that around a mental health worker then they should expect some quite probing questions about when, where and how such an act would take place. THreats like that can land a person in some trouble, so its best not to say it carelessly. Again, I would rather that people who makes threats are offered help BEFORE they carry out the threats than after. If they never meant it to begin with maybe they need to look for a more constructive way to let off steam.

While we certainly cant make mental health workers responsible for every dangerous act a client might engage in, I do think we can expect mental health workers to be trained to ask some hard questions to fully evaluate a clients risk level, and to be ready and willing to respond to the answers given.

In the situation of Mrs. Yeates who was psychotic and under psychiatric care I absolutely think the doctors should be able to prove that they asked her if she wanted to kill anyone including herself. Or if the voices told her to hurt anyone. Answers to such questions could possibly have prevented the death of three innocent children. Even if she lied the professionals would have known that they at least did their best, and they would not be vulnerable to lawsuits. Neglecting to ask the questions is NOT "doing their best". Its down and out sloppy work. *If* the professionals really neglected to ask Mrs. Yeates the hard questions I think they should be sanctioned or at least given further training.

As a former mentor on the suicide and crisis hotline told me, asking the questions shows caring and concern. It provides a person the space to truly share what is going on inside them.

Da Friendly Puter Tech.

ADMIN. NOTE: If you would like to respond to this post, please consider going to the same post in the "Criminal Responsibility . . ." thread and responding there unless your comments are related to the initial "suicide" topic. Thanks, Bill Reid

William Reid July 18th, 2004 08:44 PM

Re: Suicide & Filicide
The Yates case reflects both a fairly simple legal question and a fairly complex standard-of-care issue. In her criminal case, the only question to be answered was (just about verbatim from the Texas insanity defense statute) "When she killed her children, was she suffering from a mental disease or defect that caused her either (1) not to know what she was doing or (2) not to know that it was wrong?" The criminal trial had little or nothing to do with her diagnosis per se (except that she had to have one) or her psychiatric care (except insofar as it helped determine the answer to the above question). In the end, the jury was not convinced that she met that narrow criterion. They then had to find her guilty of capital murder (there was no intermediate choice), for which there are only two possible sentences (an extremely long prison sentence or death; she received the former). The case is being appealed.

Texas's insanity defense statute is conservative (hard to meet), but not unusual among the states (it's very similar to that in a dozen other states). Texas juries are often conservative in awarding an insanity defense, particularly when children have been killed. The only recent exception I know of is the Laney case, in which a seriously mentally ill mother was acquitted by reason of insanity for killing two of her children and maiming the third. The Laney case involved several experts, two of whom had also testified in the Yates case (Dietz and Resnick); all of them -- for prosecution, defense, and an independent expert for the judge (me) -- agreed that Laney had been legally insane.

Back to your point: Did her doctors do anything wrong?. That's not an easy question (and may be in litigation). The standard of care requires all kinds of things for people with Ms. Yates's disorder and symptoms, depending on lots of variables. Those who had access to her medical records (which pretty much became public during her criminal trial) and to direct information about/from her family, church, and clinicians (some of which became public and some didn't) agree that her clinical treatment was not the only factor in the downhill course of her symptoms, and in the eventual deaths of her children. There were a number of family and social factors that interfered with her clinical care. Whether the clinicians' work was below the standard and, if so, was enough of a "cause" to merit a malpractice verdict against the clinicians, remains to be seen (if indeed a suit has been filed).

ADMIN. NOTE: If you would like to respond to this post, please consider going to the same post in the "Criminal Responsibility . . ." thread and responding there unless your comments are related to the initial "suicide" topic. Thanks, Bill Reid

loftus75 July 19th, 2004 07:07 AM

Re: Suicide
William Reid's posting draws out issues which underline legal/psychological differences between the USA and the UK. In the UK murder trials can not end in a death penalty, as I believe the law allows for this in the state of Texas. However the wider issue returns us to the mad/bad debate that continues here and in the USA.

It seems to me at the core of the legal argument, both in the USA and here in the UK, is one of choice. That is, if you are deemed legally insane you are not making a choice, whereas if you are deemed legally sane you are making a choice. However the definition of insanity remains dependant on geography and the belief's of those geographical areas. Therefore one might suggest that if you live in the Bible Belt for instance, where Christianity is the dominant belief, the legal system would be more likely to support the death sentence and be less likely to take a sympathetic view to mental health issues. This would also be true where any religious belief dominates, Saudi Arabia would be another example of this where crimes we would consider less heinous can also lead to the death penalty.

I have to confess that the complexity of the arguments on both sides can lead me to an indecisive state. Most models describing the human condition can argue for both. Example, if we have evolved by states of fitness, then humans are by definition killing machines in terms of one species over another. We can use examples of other species to illustrate this. If we use the medical model we can argue that any abnormal behaviour can be attributed to an abnormal development or physical condition. Example, alcoholism is likely the outcome of a genetic precondition. Of course here we would have to define what is abnormal. Too often what is considered abnormal behaviour is measured in the sociological rather than anthropological.

Beyond this there well always be tension between legalised murder and illegal murder. The state chooses to take the life of an individual, this is called legal execution. A man shots another and this can be called murder, manslaughter and sometimes self defence. The State, (I'm using the term State to include all governments), meets all the criteria we would normally use to describe a premeditation of murder, yet the State remains immune to the laws we apply to can be a curious state of duality.

I'm not suggesting that either stance is right or wrong, only that in the final analysis if we are to medicalise peoples behaviour we have to accept the notion that any socially destructive behaviour is mad. Also that agency and self determination is a political construct and has little to do with the individual, who in the medical model responds to their cognitive and sociobiochemical balances. On the other hand, if we take the legal stance, depending on the political masters concerned, e.g. democratic, socialist ect. we are answerable for our actions because we do have agency and the ability to self determine, therefore the perpetrator of a crime is simply bad.

At first glance this presentation may appear too simplistic. However the UK prisons hold very high levels of mentally ill and developmentally restricted inmates. I believe, (though I am unable to quote the statistics accurately the same applies to the USA). This suggests that either there are insufficient facilities to deal with the mentally ill or the state does not fully accept the mad side of the argument. Either way as it is the State that supports these facilities, it illustrates a reluctance to allow a fully inclusive approach to the law.

Saying, the question should have been asked is only saying, if we asked the questions then it's not our fault. This does nothing to advance our understanding, it just covers our backside. This view is as common on this side of the Atlantic as it is in the USA.

Returning to the thread and it's point relating to specific trials. If Mrs. X kills her children, can we really rely on any current model to tell us whether it was predictable or preventable?

Here in the UK we have recently had a mother accused of just this. She was tried, found guilty and sent to prison. While there were no witnesses to the crime the damning evidence came from an expert witness. The expert explained that the woman was likely suffering Munchoussen by Proxy, and she killed these children to get attention. Later in an appeal this same woman was released on new genetic evidence that infant mortality was a statistically significant visitor throughout her distant family. Since then, here in the UK at least, this theory Munchoussen by Proxy has been discredited. It seems that the woman concerned was one of those very unfortunate people that has lost her children through Sudden Infant Death Syndrome, something we still know very little about. In spite of all the evidence presented in her defence including that of her MD (referred to as GP here, General Practitioner), family, friends other expert witnesses one questionable theory condemned her to a prison cell for 3 years, and would have been no less that 15years had her appeal failed.

Sadly these types of events are all too frequent, so when we say that somebody, usually a main stream mental health worker, psychologist, psychiatrist, should have asked the right questions, it's worth remembering that the 'questions' sometimes themselves condemn the innocent. Questions can be loaded and framed in such a way that the person being questioned is left with a Catch 22.

ADMIN. NOTE: If you would like to respond to this post, please consider going to the same post in the "Criminal Responsibility . . ." thread and responding there unless your comments are related to the initial "suicide" topic. Thanks, Bill Reid

William Reid July 19th, 2004 09:18 AM

Re: Suicide & Filicide
Just a couple of comments. First, you rightly point out the crux of the insanity defense (ability to make a choice; that it, to intend to commit the alleged crime), in both Great Britain and the U.S. (some of our rules stem from your early cases, particularly M'Naughton -- spelled several ways in the literature, and by M/Naughton himself). The point is that "murder" is a crime, but "killing" is not necessarily a crime. In order to commit a crime such as murder (speaking generally; there are exceptions), the person must intend to commit that crime. Some mental "diseases or defects," in some situations, can make the person unable to intend the alleged crime.

Second, I disagree that the death penalty is so closely related to the U.S. Bible Belt, or to religion in general. The many states in the U.S. that allow the death penalty are not all in the so-called "Bible Belt," and there are lots of examples of death penalty countries in which religion does not prominently influence the national policy (China comes to mind).

ADMIN. NOTE: If you would like to respond to this post, please consider going to the same post in the "Criminal Responsibility . . ." thread and responding there unless your comments are related to the initial "suicide" topic. Thanks, Bill Reid

William Reid July 19th, 2004 11:25 AM

Re: See new thread, too
Since this thread seems to have diverged into two (suicide and filicide/Insanity), I'm going to try to start a new thread called "Criminal Responsibility/Filicide." I will try to copy several of the above posts to the new thread, and recommend that folks who want to comment on the new topic go to the new thread (and those who want to talk about suicide post on this one).

Note the use of the word "try" twice above. I'm no computer tech (not even a "Da friendly 'puter tech") but the new software and our administrator should make it a snap.

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