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Saturday, August 23, 2008


It is possible to reduce and manage our communication anxiety. Given below is a list of tips compiled from different sources.
1. Remember that communication apprehension or anxiety is a very natural and normal human emotion.
2. Accept that you have communication apprehension.
3. What are your fears? Make a list of your fears and see whether they are realistic.
4. Be determined to overcome your communication anxiety. Take steps immediately.
5. Practice breathing and relaxing. Deliberate slow breathing can reduce most fear.
6. Prepare ahead. Last minute preparation makes you feel uncomfortable in front of an audience.
7. Structure your presentation. It helps you reduce your fear to a great extent.
8. Use visual aids such as power point and videos; they can help you remember different parts of your speech. If your visual aids are effective, the focus of the audience will be on the visuals rather than on you.
9. Get support from your friends or teachers. Discuss your topic with them and get their guidance. It helps you gain confidence.
10. Have positive thoughts. Tell yourself that you are going to make a successful presentation.
11. Know your audience.
12. Don’t memorize your speech. This means, reduce your script to a key-word outline, constantly practicing reducing the notes to keywords. Eventually you might not even need notes.
13. Dress for focus. Wear comfortable and appropriate clothes.
14. Remember that you can learn from others. Watch your classmates and learn, but do not compare yourself to them and put yourself down.
15. Be aware of your time limit.
16. Remember you can become a successful communicator.

Wednesday, August 20, 2008

The Therapist as a Person

The Therapist as a Person

Index of Articles
Therapists as Patients: A National Survey of Psychologists' Experiences, Problems, and Beliefs [Professional Psychology]
This survey of psychologists found that of 84% who had been in therapy, 22% found it harmful, 61% reported clinical depression, 29% reported suicidal feelings, 4% reported attempting suicide, 26% reported being cradled by a therapist, 20% reported withholding important (mostly sexual) information, and 10% reported violations of confidentiality.

Therapists' Anger, Hate, Fear, and Sexual Feelings - National Survey of Therapist Responses, Client Characteristics, Critical Events, Formal Complaints, and Training [Professional Psychology]
Therapists reported frequencies of experiencing instances of feeling anger, hate, fear, and sexual attraction or arousal; encountering client events (e.g., client orgasm, client disrobing, client suicide, client assault on therapist or third party); and engaging in various behaviors (e.g., avoiding clients with human immunodeficiency virus, kissing clients, massaging clients, using weapons or summoning police for protection from clients), with findings differing according to therapist gender, client gender, and theoretical orientation.

National Survey of Psychologists' Sexual and Physical Abuse History and Their Evaluation of Training and Competence in These Areas [Professional Psychology]
This survey of clinical and counseling psychologists found that over two thirds of the women and one third of the men reported having experienced some form of physical or sexual abuse.

The Experience of 'Forgetting' Childhood Abuse: A National Survey of Psychologists [Journal of Consulting & Clinical Psychology]
Almost a quarter of this national sample of psychologists reported childhood abuse, and of those, about 40% reported a period of forgetting some or all of the abuse; major findings included (a) both sexual and nonsexual abuse were subject to periods of forgetting; (b) the most frequently reported factor related to recall was being in therapy; (c) about half of those who reported forgetting also reported corroboration of the abuse; and (d) reported forgetting was not related to gender or age of the respondent but was related to severity of the abuse.

Discussing Death With Children [U.S. Department of Health, Education, and Welfare, Office of Child Development, Children's Bureau]
Gerry Koocher, Ph.D., ABPP, discusses the developmental and other issues that arise in talking with children about death, whether the death of a parent, another relative, a friend, or even a school pet.

The Psychologist As Artist: Watercolors by Psychologist James N. Butcher
During a sabbatical, clinical and forensic psychologist Jim Butcher took up painting. This section includes 4 of his watercolors: Minnehaha Falls, Glacier Express, Bike Trail at Excelsior, and Vicksburg Courthouse.

Therapist's Guide To Making a Professional Will [American Psychological Association]
This chapter from the American Psychological Association's book, How To Survive and Thrive as a Therapist: Information, Ideas, & Resources for Psychologists, provides a step-by-step guide for preparing a professional will.

Clinical Practice Strategies Outside The Realm Of Managed Care [American Psychological Association annual meeting]
This paper by psychologist Steve Walfish presents ways to develop "a fee-for-service practice that does not take managed care clients at all so that clinical care and income will not be compromised."

What Therapists Don't Talk About and Why: Taboos That Hurt Us and Our Clients by Kenneth S. Pope, Ph.D., ABPP, Janet L. Sonne, Ph.D., and Beverly Greene, PhD., ABPP Publisher: American Psychological Association
"It is essentially a superb text about the practice of psychotherapy, with all its unexpected twists, turns, and difficulties for therapists and patients. From its excellent short courses on logical and ethical fallacies, to its astonishing variety of intensely provocative case examples with self-assessment questions, to its steamy discussions of therapists' sexual feelings, the book illuminates, in a non-threatening, conversational tone, the previously-avoided dimensions of the therapeutic endeavor. It belongs on the shelf of any therapist willing to learn or think critically about psychotherapy."Thomas G. Gutheil, M.D.Professor of PsychiatryHarvard University

How To Survive and Thrive as a Therapist: Information, Ideas, & Resources for Psychologists by Kenneth S. Pope, Ph.D., ABPP & Melba J. T. Vasquez, Ph.D., ABPP
Publisher: American Psychological Association
"This comprehensive practical guidebook is a must for all new and seasoned clinicians. From attorneys to ethics, from billing to possible errors in logic--it is all here. A remarkable compendium. Kudos to Pope and Vasquez!" --Donald Meichenbaum, PhD, University of Waterloo, Ontario, Canada

Sexual Issues in Psychology Training and Practice

Sexual Issues in Psychology Training and Practice

Links to Articles, Books, and Abstracts
Full-text Articles

Sexual Intimacy in Psychology Training: Results and Implications of a National Survey [American Psychologist]
This national study found that 17% of the women, compared with 3% of the men, reported sexual contact as psychology students with their psychology faculty; that 19% of the men, compared with 8% of the women, reported sexual contact as psychology educators with their psychology students; that 25% of recent female graduates reported engaging in sex as students with their psychology faculty; and that12% of the males, compared with 3% of the females, reported sexual contact as psychotherapists with their clients.

Sexual Attraction to Clients: The Human Therapist and the (Sometimes) Inhuman Training System [American Psychologist]
This national study found that 87% of the participants reported sexual attraction to at least one client; that 9.4% of men and 2.5% of women reported acting on such feelings (i.e., engaging in sex with a client); that a majority reported feeling guilty, anxious, or confused simply by feeling attracted; that about half reported receiving no guidance or training concerning this issue; and only 9% reported that their training or supervision was adequate.

Sex Between Therapists and Clients [Academic Press]
This 2001 chapter examines the history of this issue, reviews the research, discusses gender patterns, analyzes potential harm, and notes the profession's urgent, unfinished business in this area.

Prior Therapist-patient Sexual Involvement Among Patients Seen by Psychologists [Psychotherapy]
The findings from this national study suggested that harm occurred for about 90% of the patients who engaged in therapist-patient sex; harm occurred for about 80% when the sex began only after termination; 5% involved minor patients; 3% involved marriage to the therapist; 32% involved patients who had experienced child sex abuse; 10% involved patients with a history of rate; 11% required hospitalization of the patient; 14% involved patient suicide attempts; 1% involved completed suicides; and 12% involved formal complaints.

Therapist-Patient Sexual Intimacy Involving Children and Adolescents [American Psychologist]
In this study, the ages of the female patient ranged from 3 through 17, with an average of 14; the ages of the male patients ranged from 7 through 16, with an average of 13.

Therapist-patient Sex as Sex Abuse: Six Scientific, Professional, and Practical Dilemmas in Addressing Victimization and Rehabilitation [Professional Psychology]
This article uses historical quotes and data to examine 6 problems in adequately addressing issues of therapist-patient sex: (a) acknowledging the scope of the phenomenon, (b) affirming the notion and the mechanisms of accountability, (c) assessing the validity of allegations, (d) evaluating the nature and validity of research evidence, (e) overcoming perpetrator stereotypes and inclinations to collude with or to enable sex offenders, and (f) confronting the notion of victim responsibility.

Sexual Feelings In Psychotherapy:Explorations for Therapists and Therapists-in-Training by Kenneth S. Pope, Ph.D., ABPP, Janet Sonne, Ph.D. & Jean Holroyd, Ph.D. Publisher: American Psychological Association.
"Like a trusted confidant, this reassuring yet challenging book shows how research, theory, and the reader's own feelings can be used to guide clinical practice. It is that rarest of books with which the reader shares an intimate dialogue of personal discovery. Powerful, truthful, and adventurous, it will serve as an essential text to which seasoned therapists will return again and again and should be required reading in all training programs." -- Professor Jesse Geller, Yale University

Sexual Involvement With Therapists: Patient Assessment, Subsequent Therapy, Forensics by Kenneth S. Pope, Ph.D., ABPP. Publisher: American Psychological Association.
"A landmark contribution. The research, forms, and lists of cross-examination questions will be invaluable to subsequent therapists who appear in court. This unique resource is essential reading for expert witnesses and trial attorneys." -- Nancy Adel, Esq., Partner, Law Firm of Adel & Pollack

Sexual Intimacy Between Therapists and Patients by Kenneth S. Pope & Jacqueline Bouhoutsos
"A thoroughly unique, impressively comprehensive, and long-awaited contribution. A storehouse of information. Plaintiff and defense lawyers and expert witnesses would be well advised to be aware of its contents." --Jay Ziskin, Ph.D., LL.B. Past President, American Psychology-Law Society

National Survey of Social Workers' Sexual Attraction to their Clients: Results, Implications, and Comparison to Psychologists [Ethics & Behavior]
In this national study of social workers, most participants reported having experienced sexual attraction to a client, causing (for most) guilt, anxiety, or confusion; 3.6% of male participants and 0.5% of female participants reported sex with a client; training was related to likelihood of offending, though the effect was small and complex; an analysis of 8 national studies found significant effects for gender and year of study but not for profession.

Licensing Disciplinary Actions for Psychologists Who Have Been Sexually Involved with a Client [Professional Psychology]
This study of licensing disciplinary actions for psychologists who had been sexually involved with a client collected information about offender age, gender, and marital status; for each case, the number of clients involved and whether they were adults or minors are provided.

Therapists' Sexual Feelings and Behaviors: Research, Trends, and Quandaries. This chapter appears in Psychological Perspectives on Human Sexuality (pp. 603-658), edited by Lenore Szuchman and Frank Muscarella, published by John Wiley and Sons, 2000.
This chapter includes the following sections: introduction; Education About Sexual Feelings; A Topic Not Just for the Intellect (vignettes, exercises & discussion questions); What Percentage of Therapists Engage in Sex with Their Patients?; Common Scenarios of Therapist-Patient Sexual Involvement; History of the Prohibition; Initial Research; Gender Patterns; When The Majority Masks the Minority; How Therapist-Patient Sex Affects Patients; Special Treatment for Offenders; Research and Rehabilitation; What To Do When You Don't Know What To Do; References.

Sexual Behavior Between Clinical Supervisors and Trainees: Implications for Professional Standards [Professional Psychology]
This article notes that at least 4 areas need attention: the prevalence and nature of such sexual contact, its effects on clinical training, ethical implications, and the potential legal liability of supervisors who engage in sexual intimacies with trainees.

Therapist-patient Sexual Involvement: A Review of the Research [Clinical Psychology Review]
This article reviews research findings about the occurrence and effects of therapist-patient sexual intimacies, looking at such variables as gender, discipline, theoretical orientation, age, patient risk factors, and consequences for patients.

Responding to Suicidal Risk

Responding to Suicidal Risk
Ken Pope, Ph.D., ABPPMelba J.T. Vasquez, Ph.D., ABPP

View citation and copyright.
This chapter is divided into the following sections:
evaluating suicidal risk: 21 factors
10 steps to reduce risk
Avoidable pitfalls: advice from the experts (Norman Farberow, Marsha Linehan, Nadine Kaslow, Ricardo Munoz, Jessica Henderson Daniel, David Rudd, Daid Barlow, Erika Fromm, Larke Nahme Huang, Gary Schoener, Marla Craig, Jesse Geller, Don Hiroto, Helen Block Lewis, Hans Strupp, Michael Peck)
difficult scenarios & questions
related studies
Few responsibilities are so heavy and intimidating as responding to suicidal risk. The need for careful assessment is great. Suicide remains among the top dozen causes of death in the United States, as high as number two for some groups. Homicide rates seize popular attention, but far more people kill themselves than kill others. Authorities in the field are almost unanimous in their view that the reported figures vastly understate the actual incidence because of problems in reporting procedures.
Evaluating and responding to suicidal risk is a source of extraordinary stress for many therapists. This aspect of our work focuses virtually all of the troublesome issues that run through this book: questions of the therapist's influence, competence, efficacy, fallibility, over- or under-involvement, responsibility, and ability to make life-or-death decisions. Litman's (1965) study of over 200 clinicians soon after their clients had committed suicide found the experience to have had an almost nightmarish quality. They tended to have intense feelings of grief, loss, and sometimes depression as anyone—professional or nonprofessional—might at the death of someone they cared about. But they also had feelings associated with their professional role as psychotherapist: guilt, inadequacy, self-blame, and fears of being sued, investigated, or vilified in the media. In a similar study, both the short-term and permanent effects of a client's suicide upon the therapist were so intense that Goldstein and Buongiorno (1984) recommended providing support groups for surviving therapists.
Solo practitioners may be even more vulnerable than their colleagues who practice within the contexts of institutions with their natural support systems. Those in training may constitute one of the most vulnerable groups. Kleespies, Smith, and Becker (1990) found that "trainees with patient suicides reported stress levels equivalent to that found in patient samples with bereavement and higher than that found with professional clinicians who had patient suicides" (p. 257). They recommend that all training programs have a protocol for assisting trainees with client suicide: "There is a need for an immediate, supportive response to the student to prevent traumatization and minimize isolation . . . and . . . for a safe forum that will allow the student to express his or her feelings, will ensure positive learning from the experience, and will help the student to integrate it constructively into future work with high-risk patients" (pp. 262-263).
If the challenges of helping the suicidal client evoke extraordinary feelings of discomfort from many therapists, they also show the extraordinary efforts that some therapists take to help their clients stay alive. Davison and Neale (1982), for instance, described the ways in which "the clinician treating a suicidal person must be prepared to devote more energy and time than he or she usually does even to psychotic patients. Late-night phone calls and visits to the patient's home may be frequent."
Bruce Danto, a former director of the Detroit Suicide Prevention Center and former president of the American Association of Suicidology, stated: "With these problems, you can't simply sit back in your chair, stroke your beard and say, 'All the work is done right here in my office with my magical ears and tongue.' There has to be a time when you shift gears and become an activist. Support may involve helping a patient get a job, attending a graduation or play, visiting a hospital, even making house calls. I would never send somebody to a therapist who has an unlisted phone number. If therapists feel that being available for phone contact is an imposition, then they're in the wrong field or they're treating the wrong patient. They should treat only well people. Once you decide to help somebody, you have to take responsibility down the line" (Colt, 1983, p. 50).
Norman Farberow, one of the preeminent pioneers in the treatment of the suicidal client, described instances in which the therapist provided very frequent and very long sessions (some lasting all day) to a severely suicidal client as "examples of the extraordinary measures which are sometimes required to enable someone to live. Providing this degree of availability to the client gives the client evidence of caring when that caring is absolutely necessary to convince that client that life is both livable and worth living, and nothing less extreme would be effective in communicating the caring. In such circumstances, all other considerations -- dependence, transference, countertransference, and so on --become secondary. The overwhelming priority is to help the client stay alive. The secondary issues—put 'on hold' during the crisis—can be directly and effectively addressed once the client is in less danger" (Farberow, 1985, p. C9).
Stone (1982) describes a vivid example of the lengths to which a therapist can go to communicate caring in an effective and therapeutic manner to a client in crisis. Suffering from schizophrenia, a young woman who had been hospitalized during a psychotic episode continuously vilified her therapist for "not caring" about her. Without warning, she escaped from the hospital: "The therapist, upon hearing the news, got into her car and canvassed all the bars and social clubs in Greenwich Village which her patient was known to frequent. At about midnight, she found her patient and drove her back to the hospital. From that day forward, the patient grew calmer, less impulsive, and made great progress in treatment. Later, after making substantial recovery, she told her therapist that all the interpretations during the first few weeks in the hospital meant very little to her. But after the 'midnight rescue mission' it was clear, even to her, how concerned and sincere her therapist had been from the beginning" (p. 171)

Assessing Suicidal Risk

Awareness of the following twenty factors may be useful to clinicians evaluating suicidal risk. Four qualifications are particularly important. First, the comments concerning each factor are extremely general, and exceptions are frequent. In many instances, two or more factors may interact. For example, being married and being younger, taken as individual factors, tend to be associated with lower risk for suicide. However, married teenagers have historically shown an extremely high suicide rate (Peck & Seiden, 1975). Second, the figures are not static; new research is refining our understanding of the data as well as reflecting apparent changes. The suicide rate for women, for example, has been increasing, bringing it closer to that for men. Third, the list is not comprehensive. Fourth, these factors may be useful as general guidelines but cannot be applied in an unthinking, mechanical, conclusive manner. A given individual may rank in the lowest-risk category of each of these factors and nonetheless commit suicide. These factors can legitimately function as aids to, not as substitutes for, a comprehensive, humane, and personal evaluation of suicidal risk for a unique person. Again it is worth emphasizing a central theme of this book's approach to ethics: Perhaps the most frequent threat to ethical behavior is the therapist's inattention. Making certain that we consider such factors with each client can help us prevent the ethical lapses that come from neglect.

Direct verbal warning.

A direct statement of intention to commit suicide is one of the most useful single predictors. Take any such statement seriously. Resist the temptation to reflexively dismiss such warnings as "a hysterical bid for attention," "a borderline manipulation," "a clear expression of negative transference," "an attempt to provoke the therapist," or "yet another grab for power in the interpersonal struggle with the therapist." It may be any or all of those and yet still foreshadow suicide.


The presence of a plan increases the risk. The more specific, detailed, lethal, and feasible the plan, the greater the risk.

Past attempts.

Most, and perhaps 80 percent of, completed suicides were preceded by a prior attempt. Schneidman (1976) found that the client group with the greatest suicidal rate were those who had entered into treatment with a history of at least one attempt.

Indirect statements and behavioral signs.

People planning to end their lives may communicate their intent indirectly through their words and actions—for example, talking about "going away," speculating on what death would be like, giving away their most valued possessions, or acquiring lethal instruments.


The suicide rate for those with clinical depression is about twenty times greater than for the general population. Guze and Robins (1970; see also Vuorilehto, Melartin, & Isometsa, 2006), in a review of seventeen studies concerning death in primary affective disorder, found that fifteen percent of the individuals suffering from this disorder killed themselves. Effectively treating depression may lower the risk of suicide (Gibbons, Hur, Bhaumik, & Mann, 2005; Mann, 2005)
Hopelessness. The sense of hopelessness appears to be more closely associated with suicidal intent than any other aspect of depression (Beck, 1990; Beck, Kovaks & Weissman, 1975; Maris, 2002; Petrie & Chamberlain, 1983; Wetzel, 1976; however, see also Nimeus, Traskman-Bendz & Alsen, 1997).


Between one-fourth and one-third of all suicides are associated with alcohol as a contributing factor; a much higher percentage may be associated with the presence of alcohol (without clear indication of its contribution to the suicidal process and lethal outcome). Moscicki (2001; see also Kõlves, Värnik, Tooding, & Wasserman, 2006; Sher, 2006) notes that perhaps as many as half of those who kill themselves are intoxicated at the time. Hendin and his colleagues' study of " Problems in Psychotherapy With Suicidal Patients" emphasized that "Addressing and treating suicidal patients’ substance abuse, particularly alcohol abuse, is critical in effective treatment of other problems, including lack of response to antidepressant medication" (2006, p. 71).

Clinical syndromes.

As mentioned earlier, people suffering from depression or alcoholism are at much higher risk for suicide. Other clinical syndromes may also be associated with an increased risk. Perhaps as many as 90% of those who take their own lives have a DSM-IV diagnosis (Moscicki, 2001). Kramer, Pollack, Redick, and Locke (1972) found that the highest suicide rates exist among clients diagnosed as having primary mood disorders and psychoneuroses, with high rates also among those having organic brain syndrome and schizophrenia. Palmer, Pankratz, and Bostwick (2005) found that the lifetime risk for suicide among people with schizophrenia was around 5%. Drake, Gates, Cotton, and Whitaker (1984) discovered that those suffering from schizophrenia who had very high internalized standards were at particularly high risk. In a long-term study, Tsuang (1983) found that the suicide rate among the first-degree relatives of schizophrenic and manic-depressive clients was significantly higher than that for a control group of relatives of surgery patients; furthermore, relatives of clients who had committed suicide showed a higher rate than relatives of clients who did not take their lives. Using meta-analytic techniques, Harris and Barraclough (1997) obtained results suggesting that "virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders" (p. 205).


The suicide rate for men is about four times that for women (Joiner, 2005). For youths, the rate is closer to five to one (see, e.g., Safer, 1997). The rate of suicide attempts for women is about three times that for men.


The risk for suicide tends to increase over the adult life cycle, with the decade from the mid fifties to the mid sixties constituting the age span of highest risk. Attempts by older people are much more likely to be lethal. The ratio of attempts to completed suicides for those up to age sixty-five is about seven to one, but is two to one for those over sixty-five. Suicide risk assessment differs also according to whether the client is an adult or minor. The assessment of of suicidal risk among minors presents special challenges. Safer's review of the literature indicated that the "frequent practice of combining adult and adolescent suicide and suicide behavior findings can result in misleading conclusions" (1997, p. 61). Zametkin, Alter, and Yemini (2001) note that the "rate of suicide among adolescents has significantly increased in the past 30 years. In 1998, 4153 young people aged 15 to 24 years committed suicide in the United States, an average of 11.3 deaths per day. Suicide is the third leading cause of death in this age group and accounts for 13.5% of all deaths…. Children younger than 10 years are less likely to complete suicide, and the risk appears to increase gradually in children between 10 and 12 years of age. However, on average, 170 children 10 years or younger commit suicide each year" (p. 3122).


Generally in the United States, Caucasians tend to have one of the highest suicide rates. Gibbs (1997) discusses the apparent cultural paradox: "African-American suicide rates have traditionally been lower than White rates despite a legacy of racial discrimination, persistent poverty, social isolation, and lack of community resources" (p. 68). EchoHawk (1997) notes that the suicide rate for Native Americans is "greater than that of any other ethnic group in the U.S., especially in the age range of 15-24 years" (p. 60).


The suicide rates among Protestants tend to be higher than those among Jews and Catholics.

Living alone.

The risk of suicide tends to be reduced if someone is not living alone, reduced even more if he or she is living with a spouse, and reduced even further if there are children.


Brunch, Barraclough, Nelson, and Sainsbury (1971) found that 50 percent of those in their sample who had committed suicide had lost their mothers within the last three years (compared with a 20 percent rate among controls matched for age, sex, marital status, and geographic location). Furthermore, 22 percent of the suicides, compared with only 9 percent of the controls, had experienced the loss of their father within the past five years. Krupnick's (1984) review of studies revealed "a link between childhood bereavement and suicide attempts in adult life," perhaps doubling the risk for depressives who had lost a parent compared to depressives who had not experienced the death of a parent. Klerman and Clayton (1984; see also Beutler, 1985) found that suicide rates are higher among the widowed than the married (especially among elderly men) and that, among women, the suicide rate is not as high for widows as for the divorced or separated.


Unemployment tends to increase the risk for suicide.

Health status.

Illness and somatic complaints are associated with increased suicidal risk, as are disturbances in patterns of sleeping and eating. Clinicians who are helping people with AIDS, for example, need to be sensitive to this risk (Pope & Morin, 1990).


Those with poor impulse control are at increased risk for taking their own lives (Patsiokas, Clum & Luscumb, 1979).

Rigid thinking.

Suicidal individuals often display a rigid, all-or-none way of thinking (Maris, 2002; Neuringer, 1964). A typical statement might be: "If I don't find work within the next week then the only real alternative is suicide."

Stressful events.

Excessive numbers of undesirable events with negative outcomes have been associated with increased suicidal risk (Cohen-Sandler, Berman & King, 1982; Isherwood, Adam & Homblow, 1982). Bagley, Bolitho, and Bertrand (1997), in a study of 1,025 adolescent women in Grades 7-12, found that "15% of 38 women who experienced frequent, unwanted sexual touching had 'often' made suicidal gestures or attempts in the previous 6 months, compared with 2% of 824 women with no experience of sexual assault" (p. 341; see also McCauley, Kern, Kolodner, Dill, et al., 1997). Some types of recent events may place clients at extremely high risk. For example, Ellis, Atkeson, and Calhoun (1982) found that 52 percent of their sample of multiple-incident victims of sexual assault had attempted suicide.

Release from hospitalization.

Beck (1967, p. 57) has noted that "the available figures clearly indicate that the suicidal risk is greatest during weekend leaves from the hospital and shortly after discharge."

Lack of a sense of belonging.

Joiner's review of the research and his own studies led him to conclude that "an unmet need to belong is a contributor to suicidal desire: suicidal individuals may experience interactions that do not satisfy their need to belong (e.g., relationships that are unpleasant, unstable, infrequent, or without proximity) or may not feel connected to others and cared about" (2005, p. 97).

10 Steps To Reduce Risk

The risk of client suicide creates a special set of responsibilities. The themes stressed throughout this book gain exceptional importance: Failure of the therapist to take necessary steps can literally be fatal for the client. The following steps, which extend or supplement this book's themes, may be helpful in identifying and coping with the chance that a client may be at risk for suicide.
Screen all clients for suicidal risk during initial contact and remain alert to this issue throughout the therapy.Even clients who are seriously thinking of taking their own life may not present the classic picture of agitated depression or openly grim determination that is stereotypically (and sometimes falsely) portrayed as characteristic of the suicidal individual. Some suicidal clients seem, during initial sessions, calm, composed, and concerned with a seemingly minor presenting problem. Clients who are not suicidal during initial sessions and who sought therapy for a relatively minor problem may, during the course of therapy, become suicidal. The increase in suicidal risk may be due to external events, such as the loss of a job or a loved one, or to internal events, such as setting aside psychological defenses or the onset of Alzheimer's. What is crucial is an assessment of the client's suicidal potential at adequate intervals. In some cases, comprehensive psychological testing or the use of standardized scales developed to evaluate suicidal risk may be useful (see, for example, Beck, Resnick & Lettieri, 1974; Butcher, Graham, Williams & Ben-Porath, 1990; Lettieri, 1982; Neuringer, 1974; Nugent, 2006; Schulyer, 1974; Weisman & Worden, 1972). Range and Knott (1997) evaluated 20 suicide assessment instruments for validity and reliability. On the basis of their analysis, they recommended 3 most highly: Beck's Scale for Suicide Ideation series, Linehan's Reasons for living Inventory, and Cole's self-administered adaptation of Linehan's structured interview called the Suicidal Behaviors Questionnaire.
Work with the suicidal client to arrange an environment that will not offer easy access to the instruments the client might use to commit suicide. Suicidal clients who have purchased or focused upon a specific gun or other weapon may agree to place the weapon where they will not have access to it until the crisis or period of greatest risk is over. Suicidal clients who are currently taking psychotropic or other medication may be planning an overdose. The use of materials prescribed by and associated with mental health professionals may have great symbolic meaning for the client. Arrange that the client does not have access to sufficient quantities of the medication to carry out a suicidal plan.

Work with the client to create an actively supportive environment. To what extent can family, friends, and other resources such as community agencies and group or family therapy help a suicidal person through a crisis?
While not denying or minimizing the client's problems and desire to die, also recognize and work with the client's strengths and (though temporarily faint) desire to live.
Make every effort to communicate and justify realistic hope.Discuss practical approaches to the client's problems.
Explore any fantasies the client may have regarding suicide. Reevaluating unrealistic beliefs about what suicide will and will not accomplish can be an important step for clients attempting to remain alive.
Make sure communications are clear and evaluate the probable impact of any interventions. Ambiguous or confusing messages are unlikely to be helpful and may cause considerable harm. The literature documents the hazards of using such techniques as paradoxical intention with suicidal clients. Even well-meant and apparently clear messages may go awry in the stress of crisis. Beck (1967, p. 53) provides an example: "One woman, who was convinced by her psychotherapist that her children needed her even though she believed herself worthless, decided to kill them as well as herself to 'spare them the agony of growing up without a mother.' She subsequently followed through with her plan."
When considering hospitalization as an option, explore the drawbacks as fully as the benefits, the probable long-term and the immediate effects of this intervention. Norman Farberow (see Colt, 1983, p. 58), cofounder and former co-director and chief of research at the Los Angeles Suicide Prevention Center, warns: "We tend to think we've solved the problem by getting the person into the hospital, but psychiatric hospitals have a suicide rate more than 35 percent greater than in the community."
Be sensitive to negative reactions to the client's behavior. Alan Stone, professor of psychiatry and law at Harvard, has been a pioneer in the acknowledgment of the ways in which some overly fatigued therapists may react with boredom, malice, or even hatred to some suicidal clients. James Chu (quoted by Colt, 1983, p. 56), a psychiatrist in charge of Codman House at McClean Hospital, comments: "When you deal with suicidal people day after day after day, you just get plain tired. You get to the point of feeling, 'All right, get it over with.' The potential for fatigue, boredom, and negative transference is so great that we must remain constantly alert for signs that we are beginning to experience them." Colt notes that "Maltsberger and Buie discuss therapists' repression of such feelings. A therapist may glance often at his watch, feel drowsy, or daydream-or rationalize referral, premature termination, or hospitalization just to be rid of the patient. (Many studies have detailed the unintentional abandonment of suicidal patients; in a 1967 review of 32 suicides . . . Bloom found 'each . . . was preceded by rejecting behavior by the therapist.') Sometimes, in frustration, a therapist will issue an ultimatum. Maltsberger recalls one who, treating a chronic wrist-cutter, just couldn't stand it, and finally she said, 'If you don't stop that I'll stop treatment.' The patient did it again. She stopped treatment and the patient killed herself" (1983, p. 57).
Perhaps most important, communicate caring. Therapists differ in how they attempt to express this caring. A therapist (cited by Colt, 1983, p. 60) recounts an influential event early in her career: "I had a slasher my first year in the hospital. She kept cutting herself to ribbons—with glass, wire, anything she could get her hands on. Nobody could stop her. The nurses were getting very angry. . . . I didn't know what to do, but I was getting very upset. So I went to the director, and in my best Harvard Medical School manner began in a very intellectual way to describe the case. To my horror, I couldn't go on, and I began to weep. I couldn't stop. He said, 'I think if you showed the patient what you showed me, I think she'd know you cared.' So I did. I told her that I cared, and that it was distressing to me. She stopped. It was an important lesson." The home visits, the long and frequent sessions, the therapist's late-night search for a runaway client, and other special measures mentioned earlier are ways some therapists have found useful to communicate this caring, although such approaches obviously would not fit all therapists, all clients, or all theoretical orientations. One of the most fundamental aspects of this communication of caring is the therapist's willingness to listen, to take seriously what the client has to say. Farberow (1985, p. C9) puts it well: "If the person is really trying to communicate how unhappy he is, or his particular problems, then you can recognize that one of the most important things is to be able to hear his message. You'd want to say, 'Yes, I hear you. Yes, I recognize that this is a really tough situation. I'll be glad to listen. If I can't do anything, then we'll find someone who can.'"

Avoidable Pitfalls: Advice from Experts
A central theme of this book is that inattention or a lack of awareness is a—if not the—most frequent cause for a therapist's violation of his or her clinical responsibilities and of the client's trust. We asked a number of prominent therapists with expertise in identifying and responding to suicidal risk to discuss factors that contribute to therapists' inattention or lack of awareness when working with potentially suicidal clients. Careful attention to these factors can enable therapists to practice more responsively and responsibly.
Norman Farberow, Ph.D., cofounder and former co-director and chief of research at the Los Angeles Suicide Prevention Center, believes that there are four main problem areas. First, therapists tend to feel uncomfortable with the subject; they find it difficult to explore and investigate suicidal risk: "We don't want to hear about it. We discount it. But any indication of risk or intention must be addressed." Second, we must appreciate that each client is a unique person: "Each person becomes suicidal in his or her own framework. The person's point of view is crucial." Third, we tend to forget the preventive factors: "Clinicians run scared at the thought of suicide. They fail to recognize the true resources." Fourth, we fail to consult: "Outside opinion is invaluable."
Marsha Linehan, Ph. D., ABPP is a Professor of Psychology, Adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington and Director of the Behavioral Research and Therapy Clinic. Her primary research is development of effective treatments for suicidal behaviors, drug abuse, and borderline personality disorder. She believes that the single biggest problem in treating suicidal clients is that most therapists have inadequate training and experience in the assessment and treatment of suicidal behaviors. More distressing than that is that there does not appear to be a hue and cry from practicing therapists demanding such training. Deciding to limit one's practice to non-suicidal clients is not a solution because individuals can and do become suicidal after entering treatment. Secondary problem are as follows. 1) Therapists treating clients with disorders that make them high risk for suicide (e.g., depression, borderline personality disorder, bipolar disorder) do not ask about suicide ideation and planning in a routine, frequent way: depending on clients who have decided to kill themselves to first communicate risk directly or indirectly can be a fatal mistake. 2) Fears of legal liability often cloud therapists' abilities to focus on the welfare of the client: fear interferes with good clinical judgment. Many outpatient therapists simply "dump" their suicidal clients onto emergency and inpatient facilities believing that this will absolve them of risk. There is no empirical data that emergency department and/or inpatient treatmen reduces suicide risk in the slightest and the available literature could support a hypothesis that it may instead increase suicide risk. 3) Therapists often do not realize that when treating a highly suicidal client they must be available by phone and otherwise after hours: treating a highly suicidal client requires personally involved clinical care.
Nadine J. Kaslow, Ph.D., ABPP, Professor and Chief Psychologist at Emory School of Medicine, a well-funded researcher on the assessment and treatment of abused and suicidal African American women, and the recipient of the American Psychological Association’s 2004 award for Distinguished Contributions to Education and Training told us that assessment and intervention of suicidal persons needs to be culturally competent, gender sensitive, and developmentally informed. Our approach to suicidal individuals needs to consider both the relevant evidence base and sensitive attention to the person’s unique struggles, strengths, and sociocultural context. We need to interact with suicidal people with compassion and a desire to understand why their pain feels so intolerable that they believe that suicide will offer the only form of relief. It is always important to take suicidal concerns seriously, convey an appreciation for the person’s plight, and engage in a collaborative process. Since suicidal people often feel socially isolated and social support is a buffer against suicidal behavior, it is imperative that we assist suicidal men and women in mobilizing their social support networks. We must build upon people’s strengths, help them find meaning and hope, and empower them to overcome the trials and tribulations that lead them to feel and think that life is not worth living. As therapists, we will find our own countertransference reactions to be a very useful guide with regards to risk assessment, disposition planning, and the implementation of therapeutic strategies. Our own histories with suicide, whether that be our own suicidality, the loss of a loved one to suicide, or the death of a former patient to suicide, will greatly impact how we approach and respond to people who think actively about suicide, take steps to end their own life, or actually kill themselves. Our histories and reactions can also be instrumental in our efforts to help suicidal people heal from their pain so that they find life worth living. This in turn, enriches our own lives.
Ricardo F. Munoz, Ph.D., is professor of psychology at the University of California, San Francisco; is principal investigator on the N.I.M.H.-funded Depression Prevention Research Project involving English, Spanish, and Chinese-speaking populations; and is coauthor of Control Your Depression. Here are his thoughts:
First, clinicians often fail to identify what suicidal clients have that they care about, that they are responsible for, that they can live for. Include animals, campaigns, projects, religious values. Second, inexperienced liberal therapists in particular may fall into the trap of attempting to work out their philosophy regarding the right to die and the rationality or reasonableness of suicide while they are working with a client who is at critical risk. These issues demand careful consideration, but postponing them till the heat of crisis benefits no one. In the same way that we try to convince clients that the darkest hour of a severe depressive episode is not a good time to decide whether to live or die, clinicians must accept that while attempting to keep a seriously suicidal person alive is not a good time to decide complex philosophical questions. Third, don't overestimate your ability to speak someone else's language. Recently, a Spanish-speaking woman, suicidal, came to the emergency room talking of pills. The physician, who spoke limited Spanish, obtained what he thought was her promise not to attempt suicide and sent her back to her halfway house. It was later discovered that she'd been saying that she'd already taken a lethal dose of pills and was trying to get help.
Jessica Henderson Daniel, PhD, ABPP, Director of Training in Psychology in the Department of Psychiatry and Associate Director of the Leadership Education in Adolescent Health Training Program in the Division of Adolescent Medicine, at Boston's Children's Hospital states:
As some adolescents can be prone to be dramatic i.e. saying things that they do not mean, there can be a reluctance to take comments about suicide seriously. The adolescent may make several statements before actually engaging in suicidal behavior. The adolescent needs to know that such comments are in fact taken seriously and that action may be taken i.e. follow-up by their therapist, evaluation in the ER and/or inpatient hospitalization. Also, adolescents can become very upset about matters that may seem trivial to adults. Providers are reminded that the perspective of the patient trumps their views. When adolescents are in the midst of despair, minimizing the worry, hurt, and hopelessness can be problematic. Some providers may feel that life really cannot be that bad. Then, parents matter. With adolescents, state regulations can determine the legal role of parents. It is important to know this information. Should parents be legally responsible for their adolescent, providers may be reluctant to override the decision of parents who cannot bear to think that their child may be suicidal and who insist on taking them home. When the patient is a child or an adolescent, the parents are critical part of the management of the case and may need their own providers as well. Finally, consultation is critical in thinking through how to best provide under the particular circumstances.
M. David Rudd, Ph.D., is Professor and Chair of the Department of Psychology at Texas Tech University and Past-President, American Association of Suicidology and President-Elect of APA, Division 12, Section VII (Behavioral Emergencies). He told us:
One of the all too frequently neglected areas in suicide risk assessment is recognizing, discussing and implementing a distinction between acute and chronic risk. Assessment of acute risk alone is how the overwhelming majority of clinicians approach the task. Over the last decade, converging scientific evidence suggests it is important to address enduring or “chronic” suicidality in patients. More specifically, those that have made two or more suicide attempts likely have a “chronic” aspect to their presentation. Although acute risk may well resolve, it is important for the clinician to make a note about the individual’s enduring vulnerabilities and continuing suicide risk. It’s as straightforward as making a note such as: “Although acute risk has resolved, the patient has made three previous suicide attempts and there are aspects of the clinical scenario that suggest chronic risk for suicide. More specifically, the patient’s history of previous sexual abuse, episodic alcohol and cannabis abuse, along with two previous major depressive episodes, all indicate the need for longer-term and continuing care in order to more effectively treat these chronic markers of risk.”
David H. Barlow, Ph.D., is a Diplomate in clinical psychology and Director of the Center for Anxiety and Related Disorders at Boston University. He is former President of the Society of Clinical Psychology of APA, and maintains a private practice. He believes that there are 2 common problems often encountered in working with young or inexperienced therapists confronting a possible suicidal patient:
First, after forming an alliance with a new patient, some therapists begin to spin away from a professional, objective clinical stance and treat seemingly offhand comments about not wanting to live as casual conversation that might be occurring after work over a drink with a friend or in a college dormitory. Thus, they may respond sympathetically but not professionally, by downplaying the report. "Sometimes I feel that way too--I can understand how you'd get to that place..." Of course, one must always step back if this comes up and conduct the proper exam for intent, means etc., and take appropriate action. Second, some therapists undervalue the power of a contract, since patients sometimes say something like "Well…I'll say that if you want me to , but I don't know if my word is worth anything." The fact is--in the context of a good therapeutic relationship, the contract is very powerful, the occasional report to the contrary notwithstanding. The late Erika Fromm,Ph.D., a diplomate in both clinical psychology and clinical hypnosis, was professor emeritus of psychology at the University of Chicago, clinical editor of The Journal of Clinical and Experimental Hypnosis, and recipient of the American Psychological Association Division 39 (Psychoanalysis) 1985 Award for Distinguished Contributions to the Field. She stated:
Perhaps it's the countertransference or the highly stressful nature of this work, but some clinicians seem reluctant to provide suicidal patients anything more than minimal reassurance. We need to realize that the people who are about to take their own lives are crying out, are communicating their feelings that no one really cares about them. They are crying, in the only way they know how: "Show me that you really care!' It is so important for us to communicate that we care about them. When my patients are suicidal, I tell them that I care deeply about them and am fond of them. I do everything I can to let them know this."
Larke Nahme Huang, Ph.D., formerly on the faculty of the University of California, Berkeley, is currently an independent research and clinical consultant in the Washington, D.C., area. She stresses the problems involved in treating people with schizophrenia:
Especially as the treatment becomes a matter of years, there's a tendency to become less sensitive, to forget how painful their life can be. This can lead to problems as the clinician sets ever higher goals as the client continues to improve. A client can experience these goals as insufferable pressure. Frequently the client may make a very serious suicide attempt in an effort to escape the pressure. In working with people with severe disorders, clinicians may need to utilize hospitalization in times of crisis. Inpatient management issues, power struggles, rivalries between professional disciplines, and so on can aggravate the client's crisis. Don't wait until the last minute, when you're in the midst of a crisis, to learn about these realities and to take steps to prevent them from adding to your client's distress.
Gary Schoener, Clinical Psychologist and Executive Director of the Walk-In Counseling Center in Minneapolis for more than 33 years, consults, trains, and testifies around North America concerning professional boundaries and clinical supervision. He states:
Four most common deadly failures are (1) the failure to screen for the possession of firearms (it's not enough to ask about "weapons") with all distressed clients; (2) when acute suicidality becomes chronic, failure to appropriately refer to a DBT [Dialectic Behavior Therapy] program or qualified provider for cases of chronic suicidality; (3) reliance on the QPR [Question, Persuade, Refer] method with refugees and others, especially Muslems, for whom suicide is a serious sin and who should not be asked directly about suicidal thinking; and (4) over-reliance on "no-suicide agreements" despite the fact that they do not work. (No problem in using them clinically, but don't count on them.)
Marla C. Craig, Ph.D., psychologist and director of outreach services and special projects at the Counseling & Consultation Center, and an instructor and coordinator of a campus-wide suicide prevention program at St. Edward’s University. She reported that:
Most clinicians may not know that suicide is the second leading cause of death among college students. This information is important since there may be a tendency for clinicians not to take college students’ presenting concerns seriously enough. Presenting concerns such as academic and relationship difficulties may mask the underlying condition of depression. Also, stereotypes of college students’ being overly dramatic and emotional with fluctuating moods and situations can interfere with a clinician’s judgment to thoroughly assess for suicide. It also may be easy for clinicians to forget that traditional college students are still adolescents transitioning into young adulthood, and they may or may not be able to verbally identify what is going on internally/emotionally. Hence, it is important to assess for suicide even if the college student does not present as depressed. Finally, due to confidentiality and college students being 18 years of age and older, clinicians may be reluctant to get parents involved. If the parents are a source of support, do not hesitate to work with the college student to get them involved.
Jesse Geller, Ph.D., formerly director of the director of the Yale University Psychological Services Clinic and director of the Psychotherapy Division of the Connecticut Mental Health Center, currently maintains an independent practice. He told us:
One of the two main problems in treating suicidal patients is our own anger and defensiveness when confronted by someone who does not respond positively—and perhaps appreciatively—to our therapeutic efforts. It can stir up very primitive and childish feelings in us—we can start to feel vengeful, withholding, and spiteful. The key is to become aware of these potential reactions and not to act them out in our relationship with the patient. The other main problem seems to be more prevalent among beginning therapists. When we are inexperienced, we may be very cowardly regarding the mention of suicide in our initial interviews. We passively wait for the patient to raise the subject and we may unconsciously communicate that the subject is "taboo." If the subject does come up, we avoid using "hot" language such as "murder yourself" or "blow your brains out." Our avoidance of clear and direct communication, our clinging to euphemisms implies to the patient that we are unable to cope with his or her destructive impulses.
Don Hiroto, Ph.D., maintains a private practice, is chief of the Depression Research Laboratory at the Brentwood Veterans Administration Medical Center, and is a former president of the Los Angeles Society of Clinical Psychologists. He believes that a major area of difficulty involves alcohol use:
Alcoholics may constitute the highest risk group for violent death. The potential for suicide among alcoholics is extraordinarily high. At least 85 percent of completed suicides show the presence of at least some level of alcohol in their blood. There are two aspects to the problem for the clinician. First, there is the tendency for us to deny or minimize alcohol consumption as an issue when we assess all of our clients. Second, we are not sufficiently alert to the suicidal risk factors which are especially associated with alcoholics: episodic drinking, impulsivity, increased stress in relationships (especially separation), alienation, and the sense of helplessness.
The late Helen Block Lewis, Ph.D., was a diplomate in clinical psychology who maintained a private practice in New York and Connecticut; she also was professor emeritus at Yale University, president of the American Psychological Association Division of Psychoanalysis, and editor of Psychoanalytic Psychology. She believed that therapists tend to pay insufficient attention to the shame and guilt their clients experience. For example, clients may experience a sense of shame for needing psychotherapy and for being "needy" in regard to the therapist. The shame often leads to rage, which in turn leads to guilt because the client is not sure if the rage is justified. According to Lewis, the resultant "shame/rage" or "humiliated fury" can be a major factor in client suicides:
Clients may experience this progression of shame-rage-guilt in many aspects of their lives. It is important for the therapist to help the client understand the sequence not only as it might be related to a current incident 'out there' but also as it occurs in the session. Furthermore, it is helpful for clients who are in a frenzied suicidal state to understand that the experience of shame and guilt may represent their attempt to maintain attachments to important people in their lives. Understanding these sequences is important not only for the client but also for the therapist. It is essential that we maintain good feelings for our clients. Sometimes this is difficult when the client is furious, suicidal, and acting out. Our understanding that such feelings and behaviors by a client represent desperate attempts to maintain a connection can help us as therapists to function effectively and remain in touch with our genuine caring for the client.

Michael Peck, Ph.D., a diplomate in clinical psychology, maintains a private practice and was a consultant to the Los Angeles Suicide Prevention Center. He observes, "Many therapists fail to consult. Call an experienced clinician or an organization like the L.A. Suicide Prevention Center. Review the situation and get an outside opinion. Therapists may also let a client's improvement (for example, returning to school or work) lull them to sleep. Don't assume that if the mood is brighter, then the suicidal risk is gone." He stresses the importance of keeping adequate notes, including at least the symptoms, the clinician's response, and consultations and inquiries. "There are special issues in treating adolescents," Peck adds. "When they're under sixteen, keep the parents informed. If they are seventeen (when the client, rather than the parents, possesses the privilege) or older but still living with the parents, tell the client that you will breach confidentiality only to save his or her life. In almost every case, the family's cooperation in treatment is of great importance."
The late Hans Strupp, Ph.D., was a diplomate in clinical psychology, distinguished professor of psychology, and director of clinical training at Vanderbilt University. He believed that one of the greatest pitfalls is the failure to assess suicidal potential comprehensively during initial sessions. Another frequent error, he told us, is that there too often is a failure to have in place a network of services appropriate for suicidal clients in crisis: "Whether it is an individual private practitioner, a training program run by a university . . . , a small . . . clinic, or [therapists] associated in group practice—there needs to be close and effective collaboration with other mental health professions . . . and with facilities equipped to deal with suicidal emergencies. I'm not talking about pro forma arrangements but a genuine and effective working relationship. In all cases involving suicidal risk, there should be frequent consultation and ready access to appropriate hospitals."

Difficult Scenarios and Questions You've been working with a moderately depressed client for 4 months. You feel that you have a good rapport but the treatment plan doesn't seem to be doing much good. Between sessions you check your answering machine and find this message from the client: "I want to thank you for trying to help me, but now I realize that nothing will do me any good. I won't be seeing you or anyone else ever again. I've left home and won't be returning. I didn't leave any notes because there really isn't anything to say. Thank you again for trying to help. Goodbye." Your next client is scheduled to see you in 2 minutes and you have clients for the next 4 hours.
*** *** ****** *** ***
What feelings do you experience?
What do you want to do?
What are your options?
What do you think you would do?
If there are things that you want to do but don't do, why do you reject these options?
What do you believe that your ethical and legal obligations are?
Are there any contradictions between your legal responsibilities and constraints and what you believe is ethical?
To what extent do you believe that your education and training have prepared you to deal with this situation?
*****You have been working with a client within a managed care framework. You believe that the client is at considerable risk for suicide. The case reviewer disagrees and, noting that the approved number of sessions have been provided, declines, despite your persistent protests, to approve any additional sessions.
How do you feel?
What are your options?
What do you believe your legal obligations to client are?
What do you believe your ethical responsibilities to the client are?
What would you do?
*****You have been providing family therapy to a mother and father and their 3 adolescents for 4 sessions. After the fourth session, you find that one of the adolescents has left a note on your desk. Here is what the note says: "My father has molested me for the last 2 years. He has threatened to kill my mother and me if anyone else finds out. I could not take it if you told anyone else. If you do, I will find a way to kill myself." Your clinical judgment, based on what you've learned during the course of the 4 sessions, is that the adolescent is extremely likely to commit suicide under those circumstances.
How do you feel?
More specifically, what are your feelings about the client who left you the note? What are your feelings about the father? What are your feelings about the mother? What are your feelings about the other 2 adolescents?
What do you believe that your legal obligations are?
What do you believe that your ethical responsibilities are?
What, if any, conflicts do you experience? How do you go about considering and deciding what to do about these conflicts?
What do you believe that you would do?
*****A client you've been seeing in outpatient therapy for 2 years doesn't show up for an appointment. The client has been depressed and has recently experienced some personal and occupational disappointments but the risk of suicide as you've assessed it has remained at a very low level. You call the client at home to see if the person has forgotten the appointment or if there's been a mix-up in scheduling. You reach a family member who tells you that the client has committed suicide.
What do you feel?
Are there any feelings that are difficult to identify or put into words?
What options do you consider?
Do you tell the family member that you were the person's therapist? Why or why not?
What, if anything, do you volunteer to tell the family?
Do you attend the funeral? Why or why not? Do you send flowers? Why or why not?
If a family member says that the suicide must have been your fault, what do you feel? What would you do?
Do you tell any of your friends or colleagues? Why? What concerns, if any, do you have?
Do your case notes and documentation show your failure to assess accurately the client's suicidal risk? Why or why not? Do you have any concerns about your documentation?

***** You've been discussing a new HMO patient, whom you've seen for 3 outpatient sessions, with both your clinical supervisor and the chief of outpatient services. The chief of services strongly believes that the client is at substantial risk for suicide but the clinical supervisor believes just as strongly that there is no real risk. You are caught in the middle, trying to create a treatment plan that makes sense in light of the conflicting views of the 2 people to whom you report. One morning you arrive at work and are informed that your clinical supervisor has committed suicide.
What do you feel?
Are there any feelings that are particularly difficult to identify, acknowledge, or articulate?
How, if at all, do you believe that this might influence your work with any of your patients?
Assume that at the first session you obtained the client's written informed consent for the work to be discussed with this particular clinical supervisor who has been counter-signing the client's chart notes. What, if anything, do you tell the client about the supervisor's suicide or the fact that the clinical work will now be discussed with a new supervisor?
To what extent has your graduate training and internship addressed issues of clinician's own suicidal ideation, impulses, or behaviors?

Related Studies:
National studies containing at least one item about suicide that are presented in full-text form on this site:
Ethics of Practice: Beliefs & Behaviors of Psychologists as Therapists [American Psychologist]
Ethical Dilemmas Encountered by Members of the American Psychological Association: A National Survey [American Psychologist]
Therapists As Patients" A National Survey of Psychologists' Experiences, Problems, and Beliefs [Professional Psychology: Research & Practice]
Therapists' Anger, Hate, Fear, and Sexual Feelings: A National Survey of Therapist Responses, Client Characteristics, Critical Events, Formal Complaints, and Training [Professional Psychology: Research & Practice]
Prior Therapist-Patient Sexual Involvement Among Patients Seen by Psychologists [American Psychologist]

Suicide in Asian Americans

The University of California, Davis, issued the following announcement:

Suicide in Asian Americans

Asian Americans whose families experience a high degree of interpersonal conflict have a three-fold greater risk of attempting suicide when compared with Asian Americans overall, according to a new study by University of California, Davis, researchers. The risk is tripled even among those who have never had a diagnosis of depression.

"Because of the great emphasis on harmony and family integration in many Asian cultures, family conflict is an important factor to consider when studying suicidal behaviors among Asian Americans," said Stanley Sue, a professor of psychology and Asian American studies at UC Davis and one of the study's authors. "Our study suggests that we need to more precisely determine the kinds of family conflicts that are associated with suicide risk among Asian Americans, and find means of preventing these family problems."

Sue's study is a new analysis of data from the 2002-2003 National Latino and Asian American Study, the largest nationally representative survey ever conducted of Asian Americans. Funded by the National Institute of Mental Health, the landmark survey involved in-person interviews with more than 2,000 Asian Americans nationwide. Subjects were asked about income, marital status, age at time of immigration or number of generations their families have been in the United States, English language proficiency, family conflict, and suicidal thoughts and suicide attempts, among other questions, yielding a wealth of raw data for researchers to examine for insights into Asian American mental health.

In the national survey, 2.7 percent of the Asian Americans interviewed reported having attempted suicide at some point during their lives; 9.1 percent of the total group reported having had suicidal thoughts.

Further mining the survey data, Sue and lead investigator Janice Cheng, a psychology graduate student, sorted out the suicide-prone individuals' answers to additional survey questions that asked about past diagnosis of depression and family income. The researchers compared the answers with those of interviewees who had not reported suicidal thoughts or suicide attempts.

The researchers found that among Asian Americans in the national survey, family conflict was a significant risk factor for suicidal thoughts and suicide attempts -- independent of depression, low income or gender.

"This is the first nationally representative investigation of family conflict and suicidal behaviors among Asian Americans," Sue said. "Our findings suggest that high family conflict has an independent and additive effect in predicting lifetime suicidal thoughts and suicide attempts among Asian Americans."

Previous studies by other researchers have shown that certain subgroups of Asian Americans, including college students and Asian American women older than 65, have relatively high rates of suicide or suicide attempts compared with the rest of the nation. However, the UC Davis study was not designed to compare rates of suicide among different groups.

Informed Consent in Psychotherapy and Counseling: Forms, Standards and Guidelines, and References

Informed Consent in Psychotherapy & Counseling: Forms, Standards & Guidelines, & References
Ken Pope

Here are some resources that may be helpful in thinking through the process of informed consent. They include:
links to a variety of forms for informed consent from the American Psychological Association Insurance Trust; the University of Rochester Counseling Center; the West Virginia University Carruth Center for Counseling & Psychological Services; Laura Brown Ph.D., ABPP; and the Center for Ethical Practice; excerpts addressing informed consent from the standards and guidelines of professional associations (with links to the original documents) including American Association for Marriage & Family Therapy; American Association of Christian Counselors; American Association of Spinal Cord Injury Psychologists & Social Workers; American Group Psychotherapy Association; American Mental Health Counselors Association; American Psychoanalytic Association; American Psychological Association; Association for Specialists in Group Work; British Association for Counselling & Psychotherapy; British Columbia Association of Clinical Counsellors; California Board of Behavioral Sciences; Canadian Counselling Association; Canadian Psychiatric Association; Canadian Psychological Association; European Federation of Psychologists' Associations; Irish Association for Counseling & Therapy; National Association of Social Workers; National Board for Certified Counselors; and Psychological Society of Ireland; and quotes and information about informed consent from articles, books, and studies.

Sample Informed Consent Forms
Sample Psychotherapist-Patient Contract from the American Psychological Association Insurance TrustThis site also includes forms for:
Sample Forensic Informed Consent Contract
Sample Outpatient Services Agreement for Collaterals
Informed Consent for Assessment and Treatment from the University of Rochester Counseling Center
Informed Consent for Psychotherapy or Other Services, and Notice of Privacy Practices from the West Virginia University Carruth Center for Counseling and Psychological Services
Informed Consent for Psychotherapy from Laura S. Brown, Ph.D., ABPP

This site also includes forms for:
Note-taking form for psychotherapy
Agreement to work with attorney as a forensic expert
Informed consent for forensic assessment
Adolescent Informed Consent for Psychotherapy from the Center for Ethical Practice

This site also includes forms for:
Clinical Consultation Contract
"Notice of Privacy Practices" - Informed Consent Re: Limits of Confidentiality
Confidentiality Contract (Couples Therapy)
Formal Standards and Guidelines for Informed Consent
NOTE: Please follow this link for a more comprehensive array of professional standards and guidelines than those below.
American Association for Marriage and Family Therapy (AAMFT) Code of Ethics
Excerpt: "1.2 Marriage and family therapists obtain appropriate informed consent to therapy or related procedures as early as feasible in the therapeutic relationship, and use language that is reasonably understandable to clients. The content of informed consent may vary depending upon the client and treatment plan; however, informed consent generally necessitates that the client: (a) has the capacity to consent; (b) has been adequately informed of significant information concerning treatment processes and procedures; (c) has been adequately informed of potential risks and benefits of treatments for which generally recognized standards do not yet exist; (d) has freely and without undue influence expressed consent; and (e) has provided consent that is appropriately documented. When persons, due to age or mental status, are legally incapable of giving informed consent, marriage and family therapists obtain informed permission from a legally authorized person, if such substitute consent is legally permissible."
American Association of Christian Counselors: Code of Ethics
Excerpt: "Christian counselors secure client consent for all counseling and related services. This includes the video/audio-taping of client sessions, the use of supervisory and consultative help, the application of special procedures and evaluations, and the communication of client data with other professionals and institutions. Christian counselors take care that (1) the client has the capacity to give consent; (2) we have discussed counseling together and the client reasonably understands the nature and process of counseling; the costs, time, and work required; the limits of counseling; and any appropriate alternatives; and (3) the client freely gives consent to counseling, without coercion or undue influence.... Christian counselors respect the need for informed consent regarding the structure and process of counseling. Early in counseling, counselor and client should discuss and agree upon these issues: the nature of and course of therapy; client issues and goals; potential problems and reasonable alternatives to counseling; counselor status and credentials; confidentiality and its limits; fees and financial procedures; limitations about time and access to the counselor, including directions in emergency situations; and procedures for resolution of disputes and misunderstandings. If the counselor is supervised, that fact shall be disclosed and the supervisor's name and role indicated to the client."
American Association of Spinal Cord Injury Psychologists & Social Workers: Standards for Psychologists and Social Workers in SCI Rehabilitation
Excerpt: "It is assumed that all referenced treatment components and processes of acute inpatient and outpatient rehabilitation are so embraced by the voluntary agreement of the individual with SCI or their legally appointed guardian. If a minor child or incompetent individual refuses treatment, the psychosocial professional is guided by state regulations that govern such situations. If, however, the competent adult refuses rehabilitative treatment with the full benefit of informed consent, the health care system is bound to accept that decision."
American Group Psychotherapy Association: Guidelines for Ethics
Excerpt: "1.1 The group psychotherapist shall provide the potential group patient/client with information about the nature of group psychotherapy and apprise him or her of the risks, rights and obligations as a member of a therapy group."
American Mental Health Counselors Association: Code of Ethics
Excerpt: "Mental health counselors are responsible for making their services readily accessible to clients in a manner that facilitates the clients' abilities to make an informed choice when selecting a provider. This responsibility includes a clear description of what the client can expect in the way of tests, reports, billing, therapeutic regime and schedules, and the use of the mental health counselor's statement of professional disclosure. In the event that a client is a minor or possesses disabilities that would prohibit informed consent, the mental health counselor acts in the client's best interest."
American Psychoanalytic Association: Principles & Standards of Ethics for Psychoanalysts
Excerpt: "III. Mutuality and Informed Consent. The treatment relationship between the patient and the psychoanalyst is founded upon trust and informed mutual agreement or consent. At the outset of treatment, the patient should be made aware of the nature of psychoanalysis and relevant alternative therapies. The psychoanalyst should make agreements pertaining to scheduling, fees, and other rules and obligations of treatment tactfully and humanely, with adequate regard for the realistic and therapeutic aspects of the relationship. Promises made should be honored. When the patient is a minor these same general principles pertain but the patient's age and stage of development should guide how specific arrangements will be handled and with whom."
American Psychological Association: Ethical Principles of Psychologists and Code of Conduct
Excerpt: "3.10 Informed Consent (a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code. (See also Standards 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; and 10.01, Informed Consent to Therapy.) (b) For persons who are legally incapable of giving informed consent, psychologists nevertheless (1) provide an appropriate explanation, (2) seek the individual's assent, (3) consider such persons' preferences and best interests, and (4) obtain appropriate permission from a legally authorized person, if such substitute consent is permitted or required by law. When consent by a legally authorized person is not permitted or required by law, psychologists take reasonable steps to protect the individual's rights and welfare. (c) When psychological services are court ordered or otherwise mandated, psychologists inform the individual of the nature of the anticipated services, including whether the services are court ordered or mandated and any limits of confidentiality, before proceeding. (d) Psychologists appropriately document written or oral consent, permission, and assent. (See also Standards 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; and 10.01, Informed Consent to Therapy.)"
Association for Specialists in Group Work Best Practice Guidelines: Best Practice Guidelines
Excerpt: "A7# b. Group Workers facilitate informed consent. Group Workers provide in oral and written form to prospective members (when appropriate to group type): the professional disclosure statement; group purpose and goals; group participation expectations including voluntary and involuntary membership; role expectations of members and leader(s); policies related to entering and exiting the group; policies governing substance use; policies and procedures governing mandated groups (where relevant); documentation requirements; disclosure of information to others; implications of out-of-group contact or involvement among members; procedures for consultation between group leader(s) and group member(s); fees and time parameters; and potential impacts of group participation. # c. Group Workers obtain the appropriate consent forms for work with minors and other dependent group members. # d. Group Workers define confidentiality and its limits (for example, legal and ethical exceptions and expectations; waivers implicit with treatment plans, documentation and insurance usage). Group Workers have the responsibility to inform all group participants of the need for confidentiality, potential consequences of breaching confidentiality and that legal privilege does not apply to group discussions (unless provided by state statute)."
British Association for Counselling & Psychotherapy: Ethical Framework for Good Practice in Counselling & Psychotherapy
Excerpt: "Autonomy: respect for the client’s right to be self-governing. This principle emphasizes the importance of the client’s commitment to participating in counselling or psychotherapy, usually on a voluntary basis. Practitioners who respect their clients’ autonomy: ensure accuracy in any advertising or information given in advance of services offered; seek freely given and adequately informed consent; engage in explicit contracting in advance of any commitment by the client; protect privacy; protect confidentiality; normally make any disclosures of confidential information conditional on the consent of the person concerned; and inform the client in advance of foreseeable conflicts of interest or as soon as possible after such conflicts become apparent. The principle of autonomy opposes the manipulation of clients against their will, even for beneficial social ends."
British Columbia Association of Clinical Counsellors: Code of Ethical Conduct & Standards of Clinical Practice for Registered Clinical Counsellors
Excerpt: "In the B.C.AC.C.'s Code of Ethical Conduct, principle #2 (Informed Consent) states: 'Counsellors uphold clients' rights to informed consent, that is the clients' full and active participation in decisions which affect them, and freedom of choice based on the information shared.' Obtaining the informed consent of a client to the proposed clinical counselling is a critical, first-step in the counselling relationship. If a counsellor provides counselling services without consent, the counsellor could be liable for any resulting negative consequences. In most situations, a counsellor can presume that every adult client the counsellor sees is capable of giving, refusing or revoking consent to clinical counselling services. In the rare circumstance that the counsellor believes that an adult client is not capable of giving or is unable to communicate informed consent (e.g. because of mental defect or a physical, psychological or emotional incapacity, as examples), the counsellor should obtain consent from an authorized substitute decision maker.1 Under the Infants Act, a client under the age of 19 who understands the nature of the therapy that he or she will receive can also give their consent and the child can give consent without a parent or guardian's knowledge or approval..... Once the client gives consent, this does not end the process. The counsellor must ensure that informed consent continues throughout the counselling relationship. The counsellor may have to seek the client's consent again if circumstances change, such as when the nature of counselling services changes significantly from what was originally agreed to. The client can also withdraw consent at any time, thus effectively ending the counselling relationship. If a client decides to stop the counselling, but agrees to continue after a brief rest, the counsellor does not have to go through the process of obtaining a new consent, so long as the counsellor is satisfied that the client understood what was involved with the continuation of services. The counsellor should make a note in the clinical record of such an event.... Counsellors should document their client's consent. For example, a counsellor can make a note in the clinical record that the client was informed and gave an implied or an oral consent. A more prudent practice is to ask a client to sign a consent to treatment form. Such a form can be evidence that the client was fully informed and consented freely to the proposed services. A model for a consent form is proposed at the end of this standard. For there to be valid, fully informed and freely given consent to clinical counselling, the counsellor must provide the client with sufficient information to allow the client to understand the purposes, risks and benefits of the proposed counselling. The counsellor must also allow the client to ask questions and receive answers to address any concerns. Only then can it be said that the client gave informed consent without reservation. Generally, the sort of information a counsellor must provide to a client before consent is given is information that a reasonable person in the client's particular circumstances would require so as to understand the proposed services and make an informed decision. Usually, this will include information about the client's condition or situation for which the services are being proposed, the nature of the proposed clinical services, the risks and benefits of those services that a reasonable person would expect to be told about, as well as any clinical options, including not doing anything. A counsellor has a duty to communicate with a client in a way that is appropriate to that client's particular skills, ability and language."
California Board of Behavioral Sciences: Notice to California Consumers Regarding Psychotherapy on the Internet
Excerpt: "According to Business and Professions Code Section 2290.5, prior to the delivery of health care via telemedicine, the health care practitioner who has ultimate authority over the care or primary diagnosis of the patient shall obtain verbal and written informed consent from the patient or the patient's legal representative. The informed consent procedure shall ensure that at least all of the following information is given to the patient or the patient's legal representative verbally and in writing: (1) The patient or the patient's legal representative retains the option to withhold or withdraw consent at any time without affecting the right to future care or treatment nor risking the loss or withdrawal of any program benefits to which the patient or the patient's legal representative would otherwise be entitled. (2) A description of the potential risks, consequences, and benefits of telemedicine. (3) All existing confidentiality protections apply. (4) All existing laws regarding patient access to medical information and copies of medical records apply. (5) Dissemination of any patient identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without the consent of the patient."
Canadian Counselling Association: Code of Ethics
Excerpt: "When counselling is initiated, and throughout the counselling process as necessary, counsellors inform clients of the purposes, goals, techniques, procedures, limitations, potential risks and benefits of services to be performed, and other such pertinent information. Counsellors make sure that clients understand the implications of diagnosis, fees and fee collection arrangements, record-keeping, and limits of confidentiality."
Canadian Psychiatric Association: The CMA Code of Ethics Annotated for Psychiatrists
Excerpt: "Inform your patient when your personal morality would influence the recommendation or practice of any medical procedure that the patient needs or wants.... Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability."
Canadian Psychological Association: Code of Ethics
Excerpt: "1.19 Obtain informed consent from all independent and particularly dependent persons for any psychological services f=provided to them except in circumstances of urgent need (e.g., disaster or other crisis). In urgent circumstances, psychologists, would proceed with the assent of such persons, but fully informed consent would be obtained as soon as possible."
European Federation of Psychologists' Associations: Charter of Professional Ethics for Psychologists
Excerpt: "3.1.3 Informed Consent and Freedom of Consent * Clarification and continued discussion of the professional actions, procedures and probable consequences of the psychologist's actions to ensure that a client provides informed consent before and during psychological intervention. * Clarification for clients of procedures on record-keeping and reporting. * Recognition that there may be more than one client, and that these may be first and second order clients having differing professional relationships with the psychologist, who consequently has a range of responsibilities."
Irish Association for Counseling & Therapy: Code of Ethics & Practice
Excerpt: "Principle 1: Respect for the rights and dignity of the client. Practitioners are required to treat their clients as persons of intrinsic worth with a right to determine their own priorities, to respect clients' dignity and to give due regard to their moral and cultural values. Practitioners take care not to intrude inappropriately on clients' privacy. They treat as confidential all information obtained in the course of their work. As far as possible, they ensure that clients understand and consent to whatever professional action they propose."
National Association of Social Workers: Code of Ethics
Excerpt: 1.03 Informed Consent (a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients' right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions. (b) In instances when clients are not literate or have difficulty understanding the primary language used in the practice setting, social workers should take steps to ensure clients' comprehension. This may include providing clients with a detailed verbal explanation or arranging for a qualified interpreter or translator whenever possible. (c) In instances when clients lack the capacity to provide informed consent, social workers should protect clients' interests by seeking permission from an appropriate third party, informing clients consistent with the clients' level of understanding. In such instances social workers should seek to ensure that the third party acts in a manner consistent with clients' wishes and interests. Social workers should take reasonable steps to enhance such clients' ability to give informed consent. (d) In instances when clients are receiving services involuntarily, social workers should provide information about the nature and extent of services and about the extent of clients' right to refuse service. (e) Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services. (f) Social workers should obtain clients' informed consent before audiotaping or videotaping clients or permitting observation of services to clients by a third party."
National Board for Certified Counselors: Code of Ethics
Excerpt: "8. When counseling is initiated, and throughout the counseling process as necessary, counselors inform clients of the purposes, goals, techniques, procedures, limitations, potential risks and benefits of services to be performed, and clearly indicate limitations that may affect the relationship as well as any other pertinent information."
Psychological Society of Ireland: Code of Professional Ethics
Excerpt: "1.3.3. Obtain informed consent from all independent and partially dependent persons for any psychological services provided to them."

Quotes and Information about Informed Consent from Articles, Books, & Studies

Ethics in Psychotherapy & Counseling: A Practical Guide, Third Edition by Kenneth S. Pope & Melba J.T. Vasquez. San Francisco: Jossey-Bass/John Wiley, 2007.
Excerpt: "The right to informed consent reflects respect for individual freedom, autonomy, and dignity. It is fundamental to the ethics of theraqpy and counseling. The APA ethics code (see Appendix A) sets forth specific standards for informed consent.... Truscott and Crook (2004) bnote that 'informed consent is the most represented value in the Canadian Code of Ethics for Psychologists; (p. 55; see Appendix B).
This fundamental concept can trip us up if we are not careful. Nothing blocks a patient's access to help with such cruel efficiency as a bungled attempt at informed consent.... The doors to our offices and clinics are wide open. The resources are all in place. But not even the most persistent patients can make their way past intimidating forms (which clerks may shove at patients when they first arrive), our set speeches full of noninformative information, and our nervous attempts to meet externally imposed legalistic requirements such as the Health Insurance Portability and Accountability Act. A first step is to recognize that informed consent is not a static ritual but a useful process."Psychologists should also consider and understand the potential impact of diversity on this process, such as the role that language, age (and developmental level), cultural background, and other factors may play in affecting the informed-consent process. Clinical work with individuals, couples, families, and groups each presents unique challenges with regard to informed consent, as do third-party requests for services, clinical supervision, research, and teaching. Knowing how best to address these challenges is of great importance for protecting clients' rights, promoting their autonomy, and working to achieve the best possible outcomes in the professional relationships we form with them.

"Informed Consent Through Contracting for Supervision: Minimizing Risks, Enhancing Benefits" by Janet T. Thomas. Professional Psychology: Research and Practice, June 2007, vol. 38, #3, pages 221–231.
Excerpt: "Obtaining the informed consent of supervisees at the outset of supervision is critical to minimizing risks and maximizing the benefits. Whether they are seeking supervision to meet academic, licensure, or certification requirements or to assist in rehabilitation following an ethical violation, supervisees all benefit from having clear information about that to which they are agreeing. Many authors and specialty guidelines recommend, and ethical standards require, that informed consent be obtained in writing. The format in which the information is presented will vary with the type of supervision, the context, and the preferences and theoretical orientation of the supervisor."
Clinical Handbook of Psychiatry & the Law by Paul Appelbaum & Thomas Gutheil. Philadelphia: Lippincott Williams & Wilkins, 2007.
Excerpt: "Because the doctrine of informed consent evolved from a series of court decisions, it may differ from jurisdiction to jurisdiction. Despite this, the general outlines of the doctrine are fairly well agreed on. Three components exist: information, voluntariness, and competence.""A Study of the Opinions and Behaviors of Physicians with Regard to Informed Consent and Refusing Treatment" by Adnan Ataç, Tolga Guven, Muharrem Uçarm & Tayfun Kir. Military Medicine, July, 2005, vol 170, #7, pages 566-571.
Excerpt: "Although opinions favoring the duties implied by informed consent are in the majority, these do not always reflect the behaviors in daily clinical practice..."

Ethics for the Practice of Psychology in Canada by Derek Truscott and Kenneth H. Crook. Edmonton, Alberta: University of Alberta Press, 2004.
Excerpt: "All other things being equal, the right to make decisions about whether or not to receive psychological services, and the nature of those services, belongs to the client. This conclusion finds support not only in psychologists' ethical values, particularly the social contract between a profession and society..., but also in our professional standards... and law.... Informed consent is the most represented value in the Canadian Code of Ethics for Psychologists...."

"Confidentiality and informed consent: School counsellors' perceptions of ethical practices" by Ron Lehr, Andrea Lehr, Andria, & John Sumarah. Canadian Journal of Counselling, 2007, vol. 41, #1, pages 16-30.
Excerpt: This study of school counsellors' views "identified five categories of issues and concerns related to confidentiality and informed consent: informing students on issues of confidentiality, age of consent, issues of professional confidentiality, sharing client information with others, and confidentiality with teachers and principals."

Clinical Manual of Psychiatry & Law by Robert Simon & Daniel Shuman. Washington, DC: American Psychiatric Publishing, 2007.
Excerpt: "The legl doctrine of informed consent is consistent with the provision of good clinical care. Informed consent allows patients to become partners in treatment determinations that accord with their own needs and values. In the past, phyisicians operated under the medical principle of primum non nocere - 'first do no harm.' Today, psychiatrists are required to practice within the legal model of informed consent and its concerns with patient autonomy. Most psychiatrists find increased patient autonomy desirable in fostering development of the therapeutic alliance that is so essential to treatment."

"Evolving Standards for Informed Consent: Is It Time for an Individualized and Flexible Approach?" by Doug Johnson-Greene. Professional Psychology: Research and Practice, April 2007, vol. 38, #2, pages 183-184.
Excerpt: "The importance of informed consent is probably vastly underestimated by many psychologists, and I suspect that some may tend to view it more cynically as an initial onetime legal hurdle for psychotherapy and research activities. There also appears to be an overemphasis on content issues (i.e., what do I need to include to make this a valid consent?) and comparatively little attention paid to process issues (i.e., what does a specific patient need to know to have a full appreciation for the parameters of this professional relationship?)."
Clinical Supervision: A Competency-Based Approach by Carol Falender & Edward Shafranske. Washington, DC: American Psychological Association, 2004.
Excerpt: "Ethics codes emphasize informed-consent requirements. For example, the state of Colorado requires psychologists to present certain written information to their clients, including therapist credentials, client rights, and the State Grievance Board address (Handelsman, 1990). Supervisors must be familiar with state regulations."

"Child consent and the law: An insight and discussion into the law relating to consent and competence" by S.A. Parekh. Child: Care, Health and Development, 2007, vol 33, #1, pages 78-82.
Excerpt: "A child can consent to treatment but usually in practice is unable to refuse it. Even if both the child and parents refuse treatment, courts are reluctant to accept this, particularly if it is in the best interest of the child.... The law in relation to child consent is unclear and requires changes in order to clarify what is perceived as the child's best interest."

"Readability Level of Health Insurance Portability and Accountability Act Notices of Privacy Practices Used by Psychologists in Clinical Practice" b y Steven Walfish & Bryan B. Ducey. Professional Psychology: Research and Practice, 2007, vol. 38, #2, pages 203-207.
Excerpt: "With an understanding of what makes a form readable, psychologists may revise their NPPs to include more concise sentences and fewer polysyllablic words. In this way they avoid risking an ethical violation, reduce their liability, and improve their informed consent process, which Handelsman (2001) suggested, can lead to better treatment outcomes. There is a misunderstanding that the federal government requires certain boilerplate language that is mandated for inclusion in these forms. However, what is mandated is that certain concepts be included, but the language is not specifically stated, other than that the forms should be written 'in plain English.' In providing an NPP that is readable, psychologists can better help clients understand how information shared with them will be treated or protected."

"Neuropsychological Considerations in Forensic Child Assessment" by Karen Wills & Jerry Sweet. In Forensic Mental Health Assessment of Children & Adolescents, edited by Steven Sparta & Gerry Koocher. New York: Oxford University Press, 2006.
Excerpt: "Written consent of the parents and of the retaining attorney should be obtained before contacting teachers to gather information about the child's functioning. Teachers and other collateral informants deserve to know, before they fill outa questionnaire or cooperate with an interview about their student, that they information they procvide may be used by the court or attorneys. Even though this knowledge may affect what the teacher says, it is unethical to imply to the teacher that the information athered will remain confidential, when, in fact, it will not."

"Assessment of Patients' Competence to Consent to Treatment" by Paul S. Appelbaum. New England Journal of Medicine, November, 2007, vol. 357, #18, pages 1834-1840.
Excerpt: "Legal standards for decision-making capacity for consent to treatment vary somewhat across jurisdictions, but generally they embody the abilities to communicate a choice, to understand the relevant information, to appreciate the...consequences of the situation, and to reason about treatment choices.... The level of impairment that renders a patient incompetent to make treatment decisions should ideally reflect a societal judgment about the appropriate balance between respecting the patient's autonomy and protecting the patient from the consequences of a bad decision.34 When physicians perform competence assessments, they should attempt to strike the same balance that would result if a court in the jurisdiction decided the case. In that regard, the presumption intrinsic to a modern democracy is that the vast majority of persons are capable of making their own decisions. Hence, only patients with impairment that places them at the very bottom of the performance curve should be considered to be incompetent. In practice, the stringency of the test applied varies directly with the seriousness of the likely consequences of patients' decisions.2,35 Although some commentators object to this "sliding scale" approach,36 it makes sense from a policy perspective, it was endorsed by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research,2 and in the judgment of many experts, it reflects how courts actually deal with these cases."

"Seeking an Understanding of Informed Consent" by Jeffrey Barnett. Professional Psychology: Research and Practice, April 2007, vol. 38, #2, pages 179–182.
Excerpt: "Psychologists should also consider and understand the potential impact of diversity on this process, such as the role that language, age (and developmental level), cultural background, and other factors may play in affecting the informed-consent process. Clinical work with individuals, couples, families, and groups each presents unique challenges with regard to informed consent, as do third-party requests for services, clinical supervision, research, and teaching. Knowing how best to address these challenges is of great importance for protecting clients' rights, promoting their autonomy, and working to achieve the best possible outcomes in the professional relationships we form with them."

"Patients' perceptions of written consent: A questionnaire study" by Andrea Akkad, Clare Jackson, Sara Kenyon, Mary Dixon-Woods, Nick Taub, and Marwan Habiba. British Medical Journal, September 9, 2006, Vol 333, No 7567.
Excerpt: "Our findings add to evidence showing that even when the consent process satisfies administrative and legal requirements, patients' needs may not be met.... Though patients did identify several important advantages of the consent process, there was substantial uncertainty about the implications of signing or not signing the consent form.... Many patients did not see written consent as functioning primarily in their interests nor as a way of making their wishes known.... Although there is no straightforward relation between knowledge of rights and ability to exercise those rights, a lack of awareness of the limits and scope of consent is clearly undesirable, potentially causing patients to feel disempowered and lacking in control."

Negotiating consent in psychotherapy by Patrick O'Neill. New York: New York University Press, 1998.
Excerpt: "While most therapists recognize that negotiation can clear up clients' misconceptions, fewer recognize that negotiation is also a vehicle for clearing up the therapist's misconceptions. An open dialogue can make the therapist aware of features of the case that depart from both the therapist's model and his or her previous experience, and thus it serves as a corrective to the representativeness and availability biases."

"Consent, Disclosure, and Waiver for the Forensic Psychological Evaluation: Rethinking the Roles of Psychologist and Lawyer" by William Foote & Daniel Shuman. Professional Psychology: Research & Practice, 2006, vol. 37, #5, pages 437–445.
Excerpt: "Separately and collectively, professional, ethical, and legal standards require that psychologists obtain consent from litigants prior to the initiation of forensic psychological evaluations. Psychologists have assumed this responsibility but may not have examined their professional capacity to fulfill this obligation. Psychologists lack the necessary legal training to fully inform the litigant of many legal ramifications of the psychological evaluation process. Even psychologists who are well informed in legal matters are not in a position to provide legal advice to litigants. Lawyers have also had the responsibility of preparing their clients for forensic psychological evaluations, and they may be hampered in this duty by a lack of understanding of psychological testing and interview procedures, psychological ethics, and the details of forensic evaluations. In this article, we have explicated the rationale for a joint procedure for informing the litigant about the psychological evaluation."

"Increasingly informed consent: Discussing distinct aspects of psychotherapy at different points in time" by Andrew Pomerantz. Ethics & Behavior, 15(4), October 2005, 351-360.
Excerpt: "Results indicate that, although psychologists believe that they are capable of presenting some information, such as payment and confidentiality policies, at the outset, they believe that a discussion of more substantive issues, such as psychotherapy duration, goals, orientation, and activities, can take place only after some therapy has transpired."

"Informed Consent in Psychotherapy" by John O. Beahrs and Thomas G. Gutheil. American Journal of Psychiatry, January, 2001, pages 4-10.
Excerpt: "While written consent might best meet formal legal criteria, it is our opinion that written contracts with the patients run the risk of sacrificing clinical rapport so essential to positive therapeutic outcome and fail to address new questions that emerge. Where written forms are required, nonetheless, they should be constructed with therapeutic intent, be relatively simple and straightforward, be framed in ordinary language without jargon, cover the key contractual business parameters and differential responsibilities, note the relevant uncertainties, and summarize general principles and specific emergency resources for what to do whenever the therapist is unavailable (58). Optimally, they also should mention the necessary role of patients’ self-therapeutic activity, which in certain cases can be elaborated to include voluntary abstinence from specific problem-maintaining behaviors such as abuse of controlled substances. Personalizing written informed consent forms has been shown to foster rapport and more constructive patient expectations (59). Finally, written forms should not be considered a substitute for ongoing verbal consent."

Ethics in Psychology: Professional Standards and Cases, 2nd Edition by Gerald P. Koocher and Patricia Keith-Spiegel. New York: Oxford University Press, 1998.
Excerpt: "Obtaining consent to treatment from a minor presents another set of issues.... Although a small number of states (e.g., the Commonwealth of Virginia) permit minors to consent to psychotherapy independently of their parents, such authority is an exception to the norm. In some states, such services could conceivably be provided as adjuncts to a minor's right to seek, without parental consent, birth control, or treatment for sexually transmitted diseases or substance abuse. Usually, however, a parent's permission would be needed to undertake psychotherapy with a minor client. When a child wishes to refuse treatment authorized by a parent, there is, under many circumstances, no legal recourse for the child even if the proposed treatment involves inpatient confinement...."

How To Survive and Thrive As a Therapist: Information, Ideas, & Resources for Psychologists in Practice by Kenneth S. Pope and Melba J.T. Vasquez. Washington, DC: American Psychological Association, 2005.
Excerpt: "As we discussed in more detail in Ethics in Psychotherapy and Counseling, informed consent cannot be reduced to a written form or confined to a static moment. It is a process that involves the therapist's ability to communicate with a particular person and make an informed judgment that he or she is in a good position to decide whether to consent to or decline specific psychological services. The information provided and the way it is provided depend on what kind of service (e.g., assessment or therapy) is under consideration, but the consent process can be assessed in terms of how well it addresses such questions as:
Does the person understand who will be providing the service and the psychologist's qualifications (e.g., license status)? If the service will be provided under supervision, with consultation, or other arrangements involving more than the individual psychologist, does the person understand the arrangement and its implications (e.g., for privacy, confidentiality, privilege, and record-keeping)?
Does the person understand the reason for meeting with the psychologist? Most people consulting an independent practitioner will have scheduled their own appointment on their own initiative, but some may show up because they were told to by an internist, an attorney, or a court and have no clear idea why they are there.
Does the person understand what services the psychologist will be offering and what the effects of these services may be?
Does the person understand the factors that may limit or significantly affect the services (e.g., the managed care coverage only authorizing five sessions of therapy)?
Does the person understand the relevant fee policies, including those for unpaid bills and for missed or canceled appointments?
Does the person understand the limitations to privacy, confidentiality, or privilege (e.g., conditions under which the psychologist either must or may disclose information to a third party)?"

"Informed consent documents of marriage and family therapists in private practice: A qualitative analysis" by Darryl Haslam and Steven Harris. American Journal of Family Therapy, 32(4), July-September 2004, 359-374.
Excerpt: "Findings suggest that there were both substantial consistency in the major areas of the documents but variance in their more detailed aspects. The latter was viewed as indicative of the subjectivity involved in creating ICDs and suggests that developing a universal document could be nearly impossible."

"Informed consent to undergo treatment for substance abuse: A recommended approach" by Robert Walker, T.K. Logan, James Clark, & Carl Leukefeld. Journal of Substance Abuse Treatment, 29(4), December 2005, 241-251.
Excerpt: "Standard treatment consent issues include (1) the clinical characteristics of the problem, including diagnosis; (2) treatment recommendations; (3) the risks and benefits of treatment; (4) the financial costs of the intervention; (5) alternative services or interventions should a client refuse the recommended form of care; and (6) freedom to choose or refuse treatment."

"Informed Consent Revisited: An Updated Written Question Format" by Andrew M. Pomerantz and Mitchell M. Handelsman. Professional Psychology: Research and Practice, 35(2), April 2004, 201-205.
Excerpt: "This updated question form offers many strengths. It facilitates open and honest discussion about important issues in psychotherapy, including common contemporary issues like third-party payment, manualization, and psychopharmacology, which reasonable people seeking contemporary psychotherapy would find relevant (Braaten & Handelsman, 1997; Canterbury v. Spence, 1972). Discussions around this form may also improve the effectiveness of whatever written information therapists give their clients or ask them to read and sign. Such open discussion enables the growth of a strong therapeutic relationship between therapist and client (Appelbaum, Lidz, & Meisel, 1987; Handelsman, 2001), one based on autonomy and empowerment through information rather than withholding, distrust, or patronization. Moreover, such a practice not only matches the recommendations of the newly revised APA ethics code (APA, 2002a), but it is also self-protective in that it helps psychologists to avoid legal problems (Plante, 1999). As with the original form (Handelsman & Galvin, 1988), discussion of these questions alone does not constitute a completed informed consent process, but it is one important facet of a process that will enable clients to make genuinely informed decisions regarding contemporary psychotherapy."

"Internet-mediated psychological services and the American Psychological Association Ethics Code" by Celia B. Fisher and Adam L. Fried. Psychotherapy: Theory, Research, Practice, Training, 40(1-2), Spring-Summer 2003, 103-111.
Excerpt: "Informed consent is seen by many as the primary means of protecting the self-governing and privacy rights of those with whom psychologists work. In the previous APA (1992) Ethics Code, the obligation to obtain informed consent was limited to research and therapy. The broader informed consent requirements introduced into the current revision of the Ethics Code reflect the societal change from a paternalistic to an autonomy-based view of professional ethics. Required elements of informed consent specifically relevant to Internet practice are detailed in Standards 9.03, Informed Consent in Assessments, and in 10.01, Informed Consent to Therapy. The obligations described in Standard 3.10, Informed Consent, apply to these other consent standards. When psychologists provide assessment, therapy, counseling, or consulting services over the Internet, these psychologists must obtain the informed consent of the individual by providing an appropriate explanation of the nature and purpose of services provided, fees, involvement of third parties, and limits of confidentiality as well as sufficient opportunity for the client/patient to ask questions."

"Informed Consent" by Marilyn Berner, in The Mental Health Practitioner and the Law edited by Lawrence E. Lifson and Robert I. Simon. Cambridge, MA: Harvard University Press, 1998.
Excerpt: "Competence is another essential 'element' of informed consent, like voluntariness and disclosure of adequate information. It includes four basic and interrelated sub-elements, the first of which is that the person in question have a factual understanding of the situation, which includes relevant needs and alternatives.... The second sub-element requires an appreciation of the seriousness of the condition and the consequences of accepting or rejecting treatment.... The third sub-element is the requirement that the patient express a preference. This preference does not have to be consistent with the clinician's preference, or with what she thinks would be in the patient's best interests.... The fourth and final sub-element of competence demamnds that the patient be capableo f working with the information disclosed by the clinician in a rational fashion."

"Mental Illness and the Freedom to Refuse Treatment: Privilege or Right" by Ronald Bassman. Professional Psychology: Research and Practice, 36(5), Oct 2005, 488-497.
Excerpt: "Most people are allowed to make extremely foolish life decisions without facing government intervention. You can choose to smoke until you die. You can eat so much that you cannot get through the doorway to leave your home. Being a member of a recognized religion allows you to make a health decision based on a tenet of your religion even if it may put your life in danger. But if you are a mental patient, there is an automatic bias to believe that you are incapable of making good decisions. Therefore it is necessary for the court to determine what is in your best interest regardless of your beliefs. The freedom to make poor choices is a privilege that is denied to the person who is labeled mentally ill. Chronicity means always having to prove that you have the capacity to make appropriate independent choices. To comply with the requirements of your supported group-living arrangement, you may be forced to attend a day treatment program from morning until evening. Your money, and how you spend it, can be controlled by a court-appointed payee or guardian. When being a mental patient is the overriding explanation of who you are, you must endure others' suspicion and monitoring of your personal decisions. When judging whether a person with a serious mental illness diagnosis has the capacity to understand the cost-benefit ratio for making a decision, an underlying assumption of global incapacity often guides that determination. In health decisions, Gert (1997) advises that capacity evaluations for a particular decision should always be situation-specific. Other medical ethicists want capacity determinations to be based on assessments that reflect general reasoning ability rather than being situation-specific (Freedman, 1981). Also, there are ethicists who argue for the inclusion or exclusion of risk and consequences as primary factors to consider in capacity evaluations (Wicclair, 1991). Ethicists do agree that significant efforts need to be made to include a person's preferences and values in the decision-making process regardless of disability. Substituted judgment that is deemed to be in the best interest of the patient occurs too frequently for people with mental, physical, sensory, and cognitive disability (Mitchell & Snyder, 2000; Prilleltensky & Nelson, 1997). The complexity of these decisions demands more than the loose and arbitrary practices that a person faces today."

Decoding the ethics code: A practical guide for psychologists by Celia B. Fisher. Thousand Oaks, CA: Sage, 2003.
Excerpt: "Informed consent is seen by many as the primary means of protecting the self-governing and privacy rights of those with whom psychologists work. In the 1992 Ethics Code, the obligation to obtain informed consent was limited to research and therapy. In the 2002 Ethics Code, the broader informed consent requirement for most psychological activities reflects the societal sea change from a paternalistic to an autonomy-based view of professional and scientific ethics."

Ethics and Values in Psychotherapy by Alan C. Tjeltveit. London: Routledge, 1999.
Excerpt: "[F]eminist therapists (Feminist Therapy Institute, 1990), explicitly religious therapists (e.g., Jensen and Bergin, 1988), and others have argued that therapists should be explicit about their ethical convictions. As the Feminist Therapy Institute Code of Ethics states, "feminist therapists recognize that their values influence the therapeutic process and clarfiy with clients the nature and effect of those values" (FeministTherapy Institute, 1990: 38). Doing so makes truly infomed consent possible. And if clients know their therapist's values, therapists are less likely to have an untoward influence on client values."

Medical Choices, Medical Chances by Harold J. Bursztajn, Richard I. Feinbloom, Robert M. Hamm, and Archie Brodsky. San Jose, CA: iUniversity Press, 2000.
Excerpt: "The term informed consent is used to describe the requirement that a doctor inform the patient (within reason) of the available options and the risks of each. The weakness of this concept lies in the word consent, which implies a passive consumer accepting options that the doctor (like a car dealer) presents, rather than participating in creating the options. The words informed choice better describe the scienfific gambling that patients and doctors...must do together."

"Informed Consent: Do You Know It When You See It? Evaluating the adequacy of patient consent and the value of a lawsuit" by Michael Lamport Commons, Joseph Anthony Rodriguez, Kathryn Marie Adams, Eric Andrew Goodheart, Thomas Gordon Gutheil, and Ellen Davis Cyr. Psychiatric Annals, 36(6), June 2006, 430-435.
Excerpt: "This study consisted of brief vignettes of counselors obtaining informed consent. Each vignette represented an order of hierarchical complexity as explained in the introduction. Rasch analysis was used to determine--in an objective, empirical manner--the degree of perceived effectiveness of informed consent in each vignette."

"Manageing Uncertainty: The Therapeutic Alliance, Informed Consent, and Liability" by Thomas G. Gutheil, Harold J. Bursztajn, Archie Brodsky, and Victorial Alexandra, in Decision-Making in Psychiatry and the Law edited by Thomas G. Gutheil, Harold J. Bursztajn, Archie Brodsky, and Victorial Alexandra. Baltimore, MD: Williams & Wilkins, 1991.
Excerpt: "The most serious problem with the consent form, however, is not its language, the response it elicits from the patient, or the circumstances in which it is profeered and signed. The overriding danger of the form is that it tempts the clinician to treat the transaction as a discrete tas that is accomplished, and thus terminated, once the patient has signed the form. This unfortunate misuse of the form defeats the very purpose of informed consent, which is to foster and sustain an ongoing diablogue between patient and physician, as part of the process of joint decision making. Ideally, informed consent is never over. At any point along the way, the patient should feel free to ask questions about the impact of the treatment...."

"APS Position Statement on the Use of Placebos in Pain Management" by Mark Sullivan, Gregory Terman, Brian Peck, Darin Correll, Ben Rich, Cawford Clark, Kenneth Latta, Allen Lebovits, and Gerold Gebhart. Journal of Pain, 6(4), Apr 2005, 215-217.
Excerpt: "The American Pain Society (APS) opposes the inadequate treatment of pain using any therapeutic modality including the use of placebo.... Informed consent is essential in all therapeutic situations, including the use of placebo. The deceptive use of placebos and the misinterpretation of the placebo response to discredit the patient's pain report are unethical and should be avoided....Health care providers, when using placebos, have an ethical obligation to ensure that placebos are not used for the punishment, deception, or long-term undertreatment of patients with pain. The use of informed consent is essential in all therapeutic situations, including those involving placebos."

"Informed Consent to E-therapy" by Patricia R. Recupero and Samara E. Rainey. American Journal of Psychotherapy, 59(4), 2005, 319-331.
Excerpt: "Although e-therapy has numerous proponents, no clinical trials have assessed its long-term effectiveness. To limit liability and to protect patients, e-therapy providers should disclose material risks as well as possible benefits and engage patients in an active dialogue. A thorough informed consent procedure enables patients to make an educated decision about whether e-therapy is right for them. In the future, e-therapy and informed consent online may become more common; in the mean time, clinicians must be prepared for e-therapy's uncertain legal status and allow patients to decide for themselves whether or not to seek counseling on the Internet."

Related Material:
A Practical Approach to Boundaries in Psychotherapy: Making Decisions, Bypassing Blunders, and Mending Fences
Boundary Issues in Psychotherapy: Widely-used Guides, Research, & Resources
Ethics Codes & Practice Guidelines for Assessment, Therapy, Counseling, & Forensic Practice
Ethics for Psychologists: 7 Essential Steps
Psychological Assessment: Clinical and Forensic
Ethics & Malpractice
Psychology Laws & Licensing Boards In Canada & the United States