So, liability comes up in a lot of conversations around treating suicidal people. 1/

It's on forms ("I understand that if I am having suicidal [thoughts]... that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required," from a template provided by @NASW). 2/

It's in every single suicide training. QPR! Question, Persuade, Refer. Refer, refer, refer. Warm hand off, like a suicidal hot potato (who said that to me recently? Apt! Hilarious!). 3/

@ashleyjaye told us earlier tonight, on @suicidenstuff, that her therapist fired her for being too suicidal—a story more common than any of us would like to believe. No one wants to work with the suicidal folk. 4/

I had a memory the other day that I'd talked with one of the couple of lawyers I know who specialize in mental health/suicide law, and that they'd told me that clinicians are rarely sued over client suicide deaths. So I emailed one of them to ask if I was remembering things. 5/

She said, "Correct-o-mundo. It is helpful, though, to focus on two different truths: very few clinicians are sued after a suicide, especially outpatient clinicians who did not prescribe medications. That is true; but even fewer clinicians are sued successfully. 6/

"The factors that militate against a successful lawsuit, primarily good documentation, are very different than the factors that militate against being sued at all... 7/

"...which have more to do with sensitivity and caring displayed to the grieving family (while preserving confidentiality, of course)." 8/

She offered the following case as an example: Erickson v. KERR, MDPS, INC ( https://law.justia.com/cases/washington/supreme-court/1994/61023-1-1.html): woman's suicide led to a lawsuit against her doctor claiming doctor had negligently failed to properly diagnose and treat the woman's clinical depression. 9/

[Lawsuit was filed after] “[i]n a conversation with the woman's husband after the suicide, the doctor asked about the woman's health, apparently forgetting that she had died.” 10/

Ope. Who the fuck does that? 11/

Then I asked about mandated reporting. She said, ""Mandated reporting" is generally not really applicable to suicidality. 12/

"It has to do with specified professionals observing child abuse, or the abuse of disabled people, or elders, depending on how the statute or regulations are written. 13/

"So-called "Tarasoff" reporting of likely threats of actual harm to identified others don't really come under the rubric of "mandated reporting" and neither do suicides. 14/

"Professionals have other ethical and legal mandates relating to suicidal people but the whole point of "mandated reporting" is that the reporter does not have the power or authority to deal with the situation him or herself... 15/

"which is not the case with professionals and suicidal people." 16/

Me again.

Our key words here are POWER and AUTHORITY. Training, though? Competence? Nah, [mostly] not really.

Most people who can work with suicidal folks—and well—came to that knowledge of their own accord. 17/

76% of graduate psychology program directors encountered barriers to including #suicide training in their curricula. Directors of graduate social work programs reported that their students get LESS THAN 4 HOURS of training, if any. https://twitter.com/deseraestage/status/1306957311269797891?s=20 18/

Suicide coursework is included in 6% of LMFT programs and 2% of counseling programs. Psychiatry is the exception. 94% of psychiatry residents get training in #suicide, but it's limited, passive, and vague. 19/

If the education is not there, the people delivering the support cannot do it effectively, and they will likely harm suicidal people (and already are). 20/

People who are seeking help using this avenue are often turned away or invalidated or forcibly hospitalized and restrained. 21/

Back to my lawyer friend: "Professionals never have to hospitalize a person involuntarily, in that there is no statute that requires them to do so."

22/

So then I said, "Alright, well, maybe we're conflating informed consent with mandatory reporting," and I referenced the @NASW template I quoted above. I said, "We're calling that mandated reporting in our roleplays." 23/

I'm not sure if that label came from us or from our prof, to be honest. 24/

She said, "I can see using mandated reporting as some sort of misleading euphemism for ‘professional obligation’ because it takes the responsibility for the decision out of the hands of the professional, or makes it sound that way. 25/

"But even mandated reporting requires a professional assessment that abuse or neglect is going on, and that involves discretion too. Calling it “mandated reporting” makes it sound like the professional had no choice, and that is not true." 26/

So what I'm trying to tease out is: is the problem liability? Is it ignorance? Carelessness? Thoughtlessness? Suicidal person hot potato?

IS IT FEAR? 27/

I rarely hear clinicians talk about fear. Liability, yes. Fear, no. Or, rather, not fear for their client, or their own emotional reactions—their potential grief. Fear OF liability. Fear OF being blamed. 28/

We don't touch that molten core: What will happen to me if I lose a client? How will I break? Will I be able to continue doing my work? Was it my fault? What could I have changed? What if it happens again? 29/

I'm thinking, again, of that horrible experience with my DSM prof last week. 30/

How his whole perspective is clouded by pain he clearly hasn't processed, and instead of talking about THAT, he yammered about best practices, keeping clients from doing "something like that," misinformation, and judgment.

Thread: https://twitter.com/deseraestage/status/1306753095284723713?s=20 31/

What a missed opportunity to do some real educating. It seems to me, from the listening I've done, that when a clinician loses a client to suicide, it's a unique, isolating, deeply painful experience. 32/

Again, in my earlier training thread, we see that 51% of psychiatrists have had MORE THAN ONE patient die by #suicide. Psychologists, social workers, and counselors experience loss of clients to suicide at rates between 20-30%.

https://twitter.com/deseraestage/status/1306957311269797891?s=20 33/

Can you imagine the death of someone you know well, whose thoughts you've had more access to than most? Maybe you've seen them through crises before. But then they're gone, and your relationship was structured a certain way. Boundaried and time-limited. 34/

All you know and all you knew is governed by HIPAA. You can't grieve in the same ways everyone else will. Your grief is bound up in confidentiality. You're floating in space, alone, with a world of hurt in your heart—your own, and what you held of theirs too, probably. 35/

What an awful thing. 36/

But just like with my professor, this isn't what we talk about. It's the liability, the need to adhere to "best practices" (reminder: if no one's trained, no one can possibly know what those are—and our research isn't great at bearing out what they are, anyway), 37/

the focus on KEEPING PEOPLE ALIVE, rather than asking WHAT THEY NEED. Maybe the truth about liability is (or was?) a secret, or maybe the real truth is that fear really is our main driver. 38/

I've long held that, in the suicide prevention/suicidology field(s) at large, we're tripping over our fear, and it's harming the people we want so desperately to help stay alive. How could things be different if it were easier to come down to earth and embrace that fear? 39/

To acknowledge it? To be transparent and open about it? To let go of the control and the power imbalances and really work alongside someone who's suicidal? To remember that the job of anyone walking with someone through a suicidal crisis is to SUPPORT, not SAVE. 40/

That fear is a weapon, not a salve. 41/

I don't think I have all the answers. I know I'm an artist and a storyteller and someone who can hold pain. I know my head is in the clouds and I have so much to learn. 42/

I know the system is fucked in innumerable ways, but I also know that individual people can make great change. Put down the power and the liability and the judgment and the adherence to systems that hurt people more than they help. 43/

Use the fear of loss as a tool to provide better support—support that matches actual need, rather than the same therapy and meds over and over forever—and help people build the worlds they think are worth living in. 44/