Good Practice: When a Patient Expresses Suicidal Ideation
April 1, 2016
Leanne Loranger, PT, Practice Advisor
From time-to-time I receive calls from clinicians who are caring for a patient who has disclosed that he/she is considering suicide. This is a delicate situation that can leave many physiotherapists wondering what to do. I can honestly say that I would not have been prepared to address this type of situation when I was in clinical practice.
In 2015, the suicide rate in Alberta increased by an alarming 30%.1 Considering that physiotherapists work with people facing significant illness or injury, ongoing pain or changes to their work or home lives as a consequence of their injury, it’s not surprising that mental health concerns such as anxiety, depression and suicidal ideation are issues that physiotherapists need to be aware of.
As health-care professionals, it makes sense that physiotherapists will want to help their patients, but how far should you go down that path? And how well-equipped are you to do so?
In Alberta, psychosocial intervention is a restricted activity under the Government Organization Act. Specifically, it is a restricted activity:
“to perform a psychosocial intervention with an expectation of treating a substantial disorder of thought, mood, perception, orientation or memory that grossly impairs
Capacity to recognize reality
Ability to meet the ordinary demands of life.”2
In addition, physiotherapist training does not provide sufficient education in the area of mental health for a physiotherapist to perform a psychosocial intervention, which is one of the reasons why this activity is not a restricted activity which physiotherapists can perform.
What that means is that a physiotherapist cannot treat or attempt to treat the depression, anxiety or other psychological disorder that may have led the patient to thoughts of suicide. This does not prevent you from expressing concern or attempting to help your patient to get the assistance they need from other professionals.
With that in mind, I contacted Jen Thomson and Lauren Groves from Momentum Walk-In Counselling in Edmonton for some helpful pointers on how to manage the situation, and most importantly, what NOT to say. As a walk-in counselling service, Jen, Lauren, and the volunteering health professionals at Momentum, work with clients with suicidal thoughts on a routine basis. Here are the key points from that discussion.
The absolute worst thing you can do is ignore the comment. Believe it or not, Jen tells me that some of her clients have reported that this is exactly the response that they’ve been faced with.
“It’s important to remember that someone who tells you they are suicidal is, in fact, looking for help,” says Jen.
Another unhelpful response is to minimize the person’s experience with comments like: “It will be ok.”“Things will get better as you get help.” “Suicide is a permanent solution to a temporary problem.” “You don’t really mean that, you have so much to live for.” But the worst action is to say nothing at all.
Sometimes clients will joke about suicide or drop hints such as “I might as well end it all” to see if it’s a safe place to open up. Asking the patient if he/she is considering suicide clearly and directly is not going to plant the idea, but will inform your client that you are a supportive person to talk to. You can use the PLISSIT framework to guide your approach (PLISSIT stands for Permission, Limited Information, Specific Suggestions, Intensive Therapy.)
Although it would be beyond the physiotherapist’s scope to provide intensive therapy, or even specific suggestions in most cases, it is not beyond your scope to give the patient permission to express their concerns and to convey the message “You can let me know. It’s OK to talk to me about this if it is troubling you.”
While it’s easy for a trained counsellor to advise you to speak up, I know I would have been silent out of fear of saying the wrong thing. Here is a mini-script and some tips.
Focus on the relationship
Your patient is talking to you because they feel they have a relationship with you. Leverage that relationship and your position as a health expert to help your patient by focusing on how the patient’s thoughts and feelings will impact their treatment, something you are well qualified to discuss. For example, you may say something like: “It’s important that you told me that you are feeling this way, as it will impact your physical recovery.”
The patient may be concerned that their condition will not improve, or be grieving for how things were before their injury. Providing accurate information about how recovery can often progress, and helping them to understand both frustration and worry are common reactions can help the patient to see the bigger picture.
Focus on hope
“Often, if the ‘expert’ expresses hope that the patient will improve, then the patient can hold on to that hope,” says Jen. “People typically have two reactions to being told that things will get better, either they grasp on to that hope, or they react with 'you say that to everyone.' If they give you the latter reaction they may be experiencing depression.”
Helping the patient to get help for that depression is the best thing that you can do for them.
Find out who else knows
“I’m glad you told me how you are feeling. Is there anyone else who knows what’s been going on with you?”
It could be that you are the first person that the patient has disclosed their feelings to. It could also be a longstanding problem, and the patient has spoken to his/her family doctor or a counsellor in the past. Finding out who else is involved in the care of the patient’s mental health becomes important when looking for resources to help the patient.
Think about contracts carefully
Although you may have heard about making a contract with a person who is expressing suicidal thoughts, contracts can be viewed by patients with some cynicism and be seen as a way for health providers to cover themselves, rather than really being about the patient’s interest. Again, it’s the strength of the relationship that matters. If you have a strong therapeutic relationship with the patient, you might ask him/her to call you the next day so you know he/she is OK, or could ask them to phone the distress line in his/her community when they get home and let you know if they found it helpful.
If you don’t have a strong relationship then asking for a contract with the patient may seem insincere and be counter-productive.
Help the patient to get help
As has already been pointed out, beyond expressing concern and offering support and hope, it is beyond the physiotherapist’s scope of practice to try to manage the underlying psychological condition that led to the patient’s disclosure. Again, try leveraging your relationship as a trusted and caring health professional, to encourage and assist the patient to get the help they need. This could mean facilitating a referral to a mental health practitioner, referring the patient to an emergency department, providing linkage to a distress line, or having them go back to their family doctor.
Also provides crisis counseling telephone support at 1-800-563-6106, and live chat and text message support at 587-315-5000.
The Calgary Distress Centre has a 24-hour crisis line at 403-266-4357 (HELP) and can also be reached at www.distresscentre.com
There is a rural distress line at 1-800-232-7288.
What if the patient doesn’t want me to tell anyone?
Although there is no positive duty to report, privacy law does provide the physiotherapist with the ability to breach patient confidentiality in certain circumstances. The test for determining if you can disclose private information without consent is as follows:
The physiotherapist perceives that there is a clear risk of harm to the patient or any other clearly identifiable individual,
The danger poses a risk of serious bodily harm or death, AND
The danger is imminent (“a sense of urgency must be created by the threat of danger”).3,4 (While the relevant legislation indicates that the danger must be ‘imminent’ this does not mean that the action must be occurring immediately. “The risk could be a future risk but must be serious enough that a reasonable person would believe that the harm would be carried out.”4)
When all three conditions are met, privacy legislation allows a breach of privacy without patient consent for the purpose of alerting the appropriate authorities which may include a family member or guardian, the patient’s family doctor, another healthcare provider involved in the patient’s care, or the local police authority.
Obviously taking this course of action may have repercussions on the therapeutic relationship the physiotherapist has with the patient; however, this must be balanced against the ethical and moral obligation you have to support the well-being of your patient and to act in their best interest.
The bottom line? Good practice when working with someone who is expressing suicidal thoughts is about caring, compassion and respect, and that is at the core of what we as physiotherapists do.
CBC News. (2015 December 8). Alberta’s suicide rate to be examined in mental health review. Available at: http://www.cbc.ca/news/canada/calgary/suicide-rate-alberta-increase-layoffs-mental-health-review-1.3355868. Accessed on January 15, 2016.
Province of Alberta. Government Organizations Act. Edmonton: Alberta Queen’s Printer; 2014. Available at: http://www.qp.alberta.ca/documents/Acts/g10.pdf. Accessed on January 15, 2016.
Government of Alberta. (2014). Personal Information Protection Act. Alberta Queen’s Printer. Available at: http://www.qp.alberta.ca/documents/Acts/P06P5.pdf. Accessed on January 15, 2016.
Government of Alberta. (2011). Health Information Act: Guidelines and practices manual. Alberta Queen’s Printer. Available at: http://www.health.alberta.ca/documents/HIA-Guidelines-Practices-Manual.pdf. Accessed on January 15, 2016.