Discussion If you were a pro-choice, mental health professional, how would you practice?

[TAW122]

So I just had an interesting thought but before I begin I will add a disclaimer just so there isn't any misunderstandings.

Disclaimer: I am not a counselor, therapist, nor mental health professional, nor a doctor. This is just a hypothetical thought that I've had and found interesting to explore for educational and philosophical purposes only. and in no way would I or have any inclination where I would see myself as one especially in the current world and its pro-life State, etc. This is just a thought I had that I found interesting.

With that said, in a hypothetical scenario, this thread is about how I would act if I was a psychotherapist or counselor in our current system while being a pro-choice champion and advocate. Again, this is for exploratory and informational purposes only. To start, here are a brief list of some of the things I would do if I were an mental health professional practicing if I had a client.

1. In the first session when a patient is meeting and introducing themselves, I would definitely set the boundary before proceeding with anything else, which will include the stating the terms and limits of confidentiality (as per dictated by legal and professional standards – a.k.a. the very minimal baseline). This allows a patient to understand the relationship and power dynamics upfront and the patient can decide whether he/she wants to proceed or not.

2. During the practice, while I may do something based on what the profession dictates, I would aim to not just parrot off things or do the things that all/most psychotherapists and mental health professionals do, and put myself in a position that I can actually be "constructively" helpful to the patient. This includes if the patient asks me for direct advice, I would give it while still maintaining the professional standards that the profession requires, which again, within boundaries.

3. If a patient crosses a line into danger to others or oneself (and as required by law in the current system (even if I personally am against it or disagree with it) and professional ethical requirements), I will do whatever I can to not have to break confidentiality or violate bodily autonomy, while still being compliant with the law (to avoid legal liabilities for myself) and professional ethics (to not lose the license or be barred from practice). By this, I would go through every hoop and steps to make sure that the patient isn't going to get me into trouble, nor be quick to rat/snitch/turn the patient in (breaking their trust or confidentiality), UNLESS it is 100% beyond a reasonable doubt. This means unless they explicitly said (and confirmed danger to self, imminent, no safety plan, and even insisted on it – leaving me with absolutely no other choice), then I would act. But merely discussing CTB or planning it (but not imminent) I would work with the patient to understand and empathize, but also gently remind the patient of the legal obligation and give every reasonable chance for the patient to either recant, come with a safety agreement (to protect from liability, legal issues), or ensure that the patient won't just go and CTB, and inform the patient of potential consequences of involuntary commitments and psych holds as well as the consequences. Of course, in a real world scenario there are many other factors and it isn't something really straightforward, granted my simple example is just that, an reductive one.

4. When interacting with the patient, I treat it more as a conversation, with constructive advice (if solicited) while also guiding the patient towards their choices (again while also reminding them of the boundaries) and not spew platitudes and what not. I will aim to be constructive and helpful, trying to be a friend rather than just do the same trite bullshit that most other mental health professionals do. Some may even claim that perhaps I'd be better being a life coach in the scenario versus a mental health professional, but I digress… I just don't want to throw labels or diagnosis, or dismiss, downplay, or even deflect and treat the patient as a me versus them dynamic.

In summary, if I was a psychotherapist or mental health professional (while being pro-choicer myself), I would do whatever I can within the limits of the system to honor the patient's bodily autonomy, dignity, and confidentiality (as well as trust). However, with all mental health professionals, if I was one, sadly, I would be still hard-bound by legal and ethical requirements to act (not because I want to but because I would be required to in very specific situations). Though I will do what I can to avoid being in a situation where I may have to act and go against my personal values. In an ideal system and one that I would always keep fighting and advocating for, of course, I would be 100% support of one that will NEVER breach confidentiality or violate bodily autonomy if the legal and ethical system changes to support that, which sadly isn't coming anytime soon. Anyways, I mainly wrote this thread and article because it was an interesting thought I had and I wanted to highlight and demonstrate what I would do if I was an MHP. What would you do if you were an MHP or someone in charge of patients, would you do the same as well or not?

 

[Namelesa]

I have to ask, what actually stops a mental health professional from not ratting out a patient that says they are going to kill themselves and not following the law? Like couldn't they just lie about the patient saying that they were going to ctb to them? I am probably being really ignorant and stupid here not knowing about some risk to this.

 

[TAW122]

Assuming I'm reading the question correctly, I suppose there are unscrupulous mental health professionals in the field too who would lie or twist words, and those are hard to prove. But generally I would think that most of them are more somewhat reasonable ones, where they would only act if it was more imminent and clear cut scenario where the patient explicitly states that they will CTB. My answer is based on the fact that I've been a patient before (ranging from social workers, psychologists and psychotherapists, as well as various other mental health professionals throughout my life), many years ago, but haven't in the past 7+ years.

I hope I answered the question that you asked, but feel free to clarify or restate if I haven't or if my answer was still too confusing...

 

[Michelstaedter]

Given my background, it's very difficult for me to try to help others just like that. In shitty countries like mine, you have to be aware of legal issues so you don't get into trouble, even if they try to do it indirectly and unfairly for something that has nothing to do with you.
I'll give a somewhat strange example that came to mind in recent months when I've definitely thought about leaving this world:
A doctor whose knowledge of my situation spans almost 20 years, who has known me and treated me for everything from a simple flu to the emotional problems I've had, has prescribed me anti-anxiety pills at more complex times in my life when I could say I really needed them. However, at least this year since my pets died, my desperation has reached the point where I would try any method to achieve my BBT. However, one of the difficulties I have is the anxiety I have about committing it, and that's where anti-anxiety pills come into play. If I were to commit such an act using anxiolytics and the (already elderly) doctor were blamed, I would feel bad for him, so I dismiss that detail and would prefer to get those anxiolytics elsewhere, even going to a psychiatric hospital so they have more to do with my CTB than the doctor whose affection and appreciation lead me to avoid even indirectly implicating him.

Being a therapist in Mexico is difficult, being a doctor is equally difficult. There are often problems in this regard, and people's ignorance and the laws make the situation even more complex.

P.S. I couldn't be both pro-choice and a mental health professional, in short. Being both pro-choice and a mental health professional is incompatible with me.

 

[Namelesa]

Assuming I'm reading the question correctly, I suppose there are unscrupulous mental health professionals in the field too who would lie or twist words, and those are hard to prove. But generally I would think that most of them are more somewhat reasonable ones, where they would only act if it was more imminent and clear cut scenario where the patient explicitly states that they will CTB. My answer is based on the fact that I've been a patient before (ranging from social workers, psychologists and psychotherapists, as well as various other mental health professionals throughout my life), many years ago, but haven't in the past 7+ years.

I hope I answered the question that you asked, but feel free to clarify or restate if I haven't or if my answer was still too confusing...

What i meant was could a thearpist be able to just not act or do anything about the patient and get away with not following the law even if the patient said they would ctb to them as they could just say to police if they asked questions to the thearpist that their patient didn't mention anything about suicide to them?

 

[TAW122]

What i meant was could a thearpist be able to just not act or do anything about the patient and get away with not following the law even if the patient said they would ctb to them as they could just say to police if they asked questions to the thearpist that their patient didn't mention anything about suicide to them?

Ah that makes more sense now, and I suppose they technically could (unless like the session is recorded somehow and there was actual evidence) feign plausible deniability even if the patient explicitly said they would CTB to the therapist. It would just be really hard to prove if there is no evidence (again, no recordings or any documentation such as notes or anything) and also due to the concept of confidentiality, they (the therapist) could just not tell the police or the courts (unless there was an court-order, but even then it's moot if again there is no evidence no realistic way of proving that the therapist had knowledge of it). Also, I'm not a lawyer or legal expert either so this isn't legal advice or anything just a layman's perspective based on a basic understanding of the law and also using some basic logic.

I hope that answers the question clearer.

 

[Forever Sleep]

It's an interesting idea. I don't think I could do it though. I'd be too scared of being blamed if they did end up CTB or, simply made a complaint. It's one thing to say you support being pro- choice. It's another to put yourself at risk of prosecution or, being struck off. (Assisting a suicide say.)

It's a huge amount of trust to be putting in another person- a patient. Possibly a very mentally ill patient. You're maybe assuming they will only see you during the course of their lives. What if they go on to see other 'professionals' and, they reveal the type of treatment they got from you? It could be the other therapist that makes the complaint. It could be their family and friends if they hear that their loved one's ideations aren't being challenged by the therapist.

I actually hate being disingenuous generally so- I'd struggle in any profession where I had to put on a positive face. I've considered teaching in my creative field in the past. But then, I hated the idea of lying to students- the very act of teaching would seem to suggest there are lots of jobs out there. Sometimes, I even question the morality of running some courses when the job market in that area is so sparse. Considering how much a course costs especially. But yeah, I wonder how these sorts of 'professionals' make people feel positive about their future, when they may not feel that way themselves. It's got to be difficult if they do simply have to lie.

I guess the more pro- choice ones do find a way to compromise. Some people here seem to have experienced therapists who weren't totally anti suicide. Pretty brave though, I think and, I'm not that brave.

 

[woofwag]

Well... I wouldn't be one. I don't see how I could be. To me, if someone is seeking out professional help, then there are certainly parts of them who want to recover. And I think it is worth it to honor those parts and let them live. Getting a bit into IFS therapy talk, but all of our parts are us (like when you say a part of me wants this, a part of me wants that, those are all parts that make up you). If there's even a chance some part of someone believes they can recover and is seeking it out, I would do everything in my power to push them to that. Death is permanent. Plenty of people have recovered and are glad they didn't act on their plans. There is also the issue of legality. No matter how careful you are, you very well could lose your license/be prosecuted for not doing something to stop a patient. It's why I won't tell any professionals my plans if I'm truly intent on trying to CBT.

I may be a bit hypocritical here considering I am in therapy, but in fairness, I do not have my heart totally set on dying just yet. It is when I am put into an unsalvageable situation (likely when I run out of money and will become homeless) that I will die once and for all. That, and this current bout of ideation is spurred on by horrible trauma recovery so, it's a bit hard to imagine a future where I'll be homeless, trans, disabled, and plagued with that. Anyway too much about me.

Now, being someone who could act as a social worker or a person who would have access to peaceful CBT methods, that is much more likely something I would be open to doing while acting as a sort of mediator to make sure it is what the person truly wants and that it is the best option for them. To me, there is no point in forcing someone to live if they have no other options and are 100% sure it is what they want. Then I wouldn't have to worry so much about the issue of legality (still have to be careful ofc, but less than a psych), and I wouldn't be someone who is seeing people who have genuine hope of wanting their life to improve and to stop the pain, not to actually die.

I worry a lot that there are many people on this site who are like that. I take comfort in it being here, and I will always be pro-choice. I actually had a friend who was in a genuinely unsalvageable situation who passed, and although I do miss her, I respect her decision and believe it was the best choice for her as she had exhausted every other possible option. I like knowing there is information on peaceful methods, as I know she was not in pain when she passed due to her research (idk if she knew about this site or not, but still). But yeah, if someone is in a position where they're seeking help, and they can be helped, I wouldn't in good conscious be able to support their desire to CBT. People deserve to have the chance to live and recover, just as they deserve to have the chance to die peacefully.

 

[TAW122]

@Forever Sleep Yeah that makes sense, and I don't think I'd be able to keep a constant facade myself while putting on two masks or so, it would just be too taxing for me. It was just an interesting thought or idea I had and wanted to explore and get some feedback on. Also I would likely need to go back to a lot of schooling and even licensing and certification, which I don't have all the time and money or energy to pursue... You also brought up a really valid point, a patient could go to other therapists or counselors and that alone could also present some issues too among other things..

@woofwag Interesting perspective and thank you for sharing your experience and story. Yes, it makes sense that one could end up being legally liable for not acting or not doing enough (if it is proven somehow). As for people who would recover and things, yes I personally would be in support of that (even as a pro-choicer myself), and would help them recover in a supportive way. I don't think you are hypocritical for being in therapy or so, since I was once a patient many years ago myself and have interacted with the mental health and psychiatric system extensively throughout my life (which of course didn't help my situation and many things, but I digress), so that's why I had the interesting thought for this thread. I do agree with you that if someone isn't 100% set on CTB'ing or changes their mind, then it would make sense to be hesitant to support their desire to CTB, though yes as someone who is pro-choice, if they are really set on CTB'ing after exhausting all their 'viable and feasible' options that only CTB would bring them relief, then in that scenario, I would be okay with them CTBing since they would have 100% determined that they would. Ultimately, what I'm saying is that if someone is open to recovery and wanted to try to improve things, yes I would be in favor of supporting them, but also if they already exhausted their choices and are going to CTB, then I respect that as well.

 

[marksofdespair]

I actually really like the idea of that. I wish there was somewhere to find a pro-choice therapist.

 

[TAW122]

I agree, and I hope one day there will be a shift in attitudes towards the right to die, going from mainstream rejection to mainstream tolerance (maybe not necessarily ever full acceptance as much as we like, but at least tolerance at the minimum). I also think that a serious reform on the mental health and psychiatric system would be a big step in the right direction.

 

[SomewhatLoved]

I work on an ambulance, so I often deal with people with acute/high-risk suicidality. Additionally, because of the nature of my job, I often work with a high level of independence. I am not a therapist or psychiatrist, so I do not really practice psychotherapy, but with the reality of my job I do often have "therapeutic" conversations with patients. Here's my two cents:

Obviously first mentioning that this will vary depending on where you live, medical legislature and liability works differently depending on legal jurisdiction. I am not going to disclose where I live and work for obvious reasons, but consider legislature as a factor.

I also want to say that while I do believe suicide is a matter of personal agency and should be a personal decision as we all have bodily autonomy, that doesn't mean I "like" suicide. I have seen enough successful suicide cases to know that it is always ugly, violent, and it leaves behind a mess (not physical, but emotional) for everyone around them. I do believe that recovery is better as suicide is not a nice ending for anybody, but I understand that sometimes individuals may feel that it is genuinely not worth it or potentially not possible, and I think there should be some input there from the side of the patient. After all, one of the four pillars of medical ethics is autonomy.

I agree with most of what you are saying, I am pro-choice and I try to practice it as well (within the limitations of the law). Often if I have a patient who is clearly in distress, I will reassure them that anything they say to me is confidential unless they are going to hurt themselves or someone else, and I make it clear at that if they are feeling that way, we cannot legally leave them on their own unless a solution is found. For example, I once responded to a patient who was acutely suicidal. They had a "protocol" in place from their GP/family doc because 911 was often called for them as they had been diagnosed with BPD and often had episodes of acute suicidality, even though they were generally a happy person. They had been prescribed a benzodiazepine to take in this instance, I believe it was lorazepam? However it may have been diazepam, this was almost a year ago. Anyways, after about an hour of talking and building rapport, I was able to convince them to take their prescribed medication which they are directed to use in these acute episodes, and they felt better. We were able to leave them at home with no further interventions, and no involuntary treatment. I was quite honest with this patient about the fact that I could not leave her there, and that some solution would have to be made. One thing to consider is that they were able to be left home because they had family present. If you have a patient who lives alone, often they have to go to hospital for the simple reason that if they are to make an attempt there is no one to call for help on their behalf. If they were alone, we could not have left them (even if they were feeling better), simply based on the fact that we had directed them to take a prescribed medication that decreases level of consciousness - and we could not leave a patient like that at home and alone.

Now for the limitations. Suicidality obviously comes with different levels of risk. While in school, we were shown the C-SSRS screening tool for risk (I will attach a picture below). If someone is low risk (yellow), generally it is possible for them to be left at home with no further intervention. With orange (medium risk) patients, I would be a more cautious, but not completely off of the table. With the red (high risk) categories, it is almost certainly off of the table to leave these patients at home. Anyone who is suicidal and has intent and access to means can never be left alone, from a liability standpoint. Even if you as an individual ideologically believe they should have the agency to make that choice for themselves, within the constraints of our system, if they go through with it and an investigation is conducted finding you were the last medical professional to have contact with them, the liability would likely fall on you and you may lose your licensure.

Also, this is probably obvious, but we can't give advice to patients on suicide. I've responded to attempts where people have taken lots of pills and they've asked me things like "if I took more would I be dead?" or "what type of pills would have killed me?", and obviously we can't answer these questions because it would be viewed as enabling these patients by giving them information that would assist them in further attempts. Even if I know exactly why their method failed, I can't tell them.

Generally, with calls relating to suicidality, if someone is unwell enough to call, they will usually have to go to hospital. People who are "low risk" don't generally call or have EMS called on their behalf. And I find it is very, very rare that someone is high risk and can't be convinced to go to hospital. Generally, I would say 9/10 people who are suicidal do actually want help. If you are a nice person, talk to them honestly, and try to be helpful and show them that there is potential for recovery, they will often go. Sometimes we do have to section people, though. That is never a pleasant experience, even for pro-life people. Sectioning is ALWAYS a last resport. It is awful for the patient, paramedics, police. Nobody likes it.

Worth mentioning this: I've heard in certain places, EMS can bypass the emergency department and take patients directly to psych wards for admission. Psych wards are obviously not perfect places and have their issues, but they are much better places for suicidal people to be than an ER. An ER is a very stressful, busy place and the practitioners there, like me, are not specialized in mental illness and are generally ill-equipped to deal with it and will end up calling a psychiatrist for a consult anyways. I would really like to see "direct admission" pathways be made available for EMS to psych.

What I will say to end this, is that I feel being pro-choice actually helps me have these conversations and help these patients. I think suicide is often treated as irrational or illegitimate, and as if life is 100% always good and the right choice. Being pro-choice and having chronic suicidality myself, I think this perspective helps me to see their problems legitimately and understand where they are coming from. I have a lot of colleagues who have never experienced depression or suicidality, and I think they struggle a bit more to relate to these patients.

 

[TAW122]

@SomewhatLoved Thanks for such an eloquent and well thoughtout post. I appreciate reading your perspectives and it makes sense. I think overall, in our current paradigm in present day reality, those who really want to CTB and are determined, would unfortunately just have to continue to remain quiet and never be truly honest for obvious reasons. I can definitely understand that from a professional's point of view, especially with liability, the way the system is set up, the attitudes of society and even the paternalistic policies of the State (in our present day of course) are the major factors driving the way patients present themselves.

While it is true there are indeed patients who do want help as you mentioned in your post, this system does help them in that regard. However, for those who truly want to die and are determined, sadly they would have to go about things in secrecy, take unwanted (but necessary) risks while acquiring, planning, and of course, attempting in hopes that they succeed (which can vary depending on method). It's a gamble for them for sure.

Ultimately, what I think will be the best of both worlds is for society to come to terms that suicidality is not solely and always a moral failing, an evil action, nor the product of an mentally defective mind, but rather that at times, can be a valid personal and dignified act to preserve one's dignity as well as curtail future potential (unwanted suffering). Then of course, the medical system and the State would need to redefine what suicide is. Of course, the likelihood of such a drastic change is not likely going to be within our lifetimes, or even in the foreseeable future (next few years or even decades), however, if there is a step towards the right direction where medical assistance in dying such as expanding eligibility for those who aren't necessarily terminally ill (six months or less to live), but also to those with chronic conditions (both mentally and physically) that do not abate and allows them an pathway to end suffering, then that would be a major step in the right direction.

Finally, as a critique to the C-SSRS screening tool, I see it as something that is rather paternalistic and too broad to lump those who have serious ideation and planning but not necessarily an imminent threat/risk of harm to others or oneself. This is especially true for questions 4, 5, and 6. Part of the criteria seems to be that if someone planned and took action, but has no immediate plan to act, but due to their ever changing criteria (within the last 3 months for question 6, but within the previous month for question 4 and 5), they are deemed great risk even if they got one. Of course, even though I am not a MHP nor worked as one, I would still be leery to taking such a position though again, it goes back to the previous paragraph about how the system would have to change in order to alleviate the liability for the professionals, but also honor and respect the autonomy of the patient as well. I could see someone who may not necessarily be suicidal but because they had a plan (no exact date or future), and then they had the means or acquired such means within a fairly recent period of time (with the previous 1-3 months), they are automatically deemed high risk and would be intervened against. I would just see the C-SSRS as another tool where the patient would only be incentivized to lie or downplay their severity to avoid the risk of intervention against their will.