As therapists we’re taught that suicidality needs to be responded to with a list of crisis resources and a safety plan. But all too often, this happens WITHOUT a clear discussion about the risks and benefits of the proposed options—even though informed consent* is part of our Standards of Practice. 👉🏻
*terms at the bottom of the blog
"If people would rather die than experience psychiatric incarceration again, the psychiatric system isn't working." - Laurel Moore in a recent Instagram post.
Before we get into the nitty gritty, can I just say for the record that I have had HUNDREDS of people tell me about their harmful experiences in mental health crises? Lost trust with their therapist, forcibly restrained in hospital, arrested by police for suicidal behaviour? Let alone the hundreds if not thousands of individuals who have been killed at the hands of police during a mental health crisis? Our current "crisis response" IS causing harm, whether we like it or not.
Innocent people have been killed during wellness checks, as recently as September of this year.
The College of Registered Psychotherapists of Ontario (CRPO), a regulatory body that was created to regulate therapists and to protect the rights and needs of clients, has various standards of practice, including Standard 3.2 ("Consent"), more specifically 3.2.4 that states "Registrants ensure informed consent is obtained from the client or their authorized representative on an ongoing basis." This means that consistently, and especially when introducing new methods of treatment or care (e.g., including the use of outside crisis lines, police, or hospital services), the client needs to be informed about the risks and benefits before making a decision about whether or not they want to use it in their treatment.
Ironically, as I was writing this blog, I re-visited the "code of ethics" page that used to include "Justice: To strive to support justice and fairness in my professional and personal dealings and stand against oppression and discrimination" as recent as May of this year. When I looked at the page today, "Justice" had been removed.
As a practice, we at Baldwin Psychotherapy operate from an anti-carceral** position, and this doesn’t mean that you can't use “traditional” crisis supports or higher levels of care (e.g., crisis lines, police, hospital). Even if you DON’T consider yourself anti-carceral and you are perfectly fine suggesting services like 988, 911, or the hospital, you are setting your client up for harm if you only talk about how they could help and don’t talk about how they could HARM.
For those of us in Ontario, and in many regulated professionals across North America, our licensing requires us to engage in mandatory reporting in situations where we deem that there is "imminent risk of harm." This is problematic for many reasons that I won't go into here, but it means that many therapists, new and experienced, feel like existing crisis options are their ONLY option, and this also leads to over-reporting and clients being traumatized by the Mental Health Industrial Complex***. Ignoring the very real history and the current use of psychiatric abuse****, control, and restraint does not serve our clients. It is not ethical. It is not trauma informed. It is not consensual.
A client deserves to know what a wellness check may look like, what a crisis call may sound like, and what a hospital visit may entail—BEFORE they give consent to have it used in their care with a therapist.
If a client is adamantly saying they don’t want to use 911 or hospital services in crisis, that’s a whole other story (that you should prepare for and have harm reduction alternatives to suggest). But if they DO want to go to the hospital, because they believe they will be supported and calm and safe there—well that warrants a much bigger conversation.
You can tell a client about the positives of a psychiatric admittance. You can share that they may offer a short term stabilization period, they may have group classes and activities, the client may get a formal diagnosis and even medication if that’s what they hope for. You also have to tell them about the risks…
You need to tell them that they may be forcibly held in the unit for longer than they wish to be there. You need to tell them that if the client shows aggressive behaviour, they may be forcibly restrained. You need to tell them that if they don’t participate in group sessions, they may be kicked out. And in the capitalist-medical-system fashion, they may be denied admittance in the first place because they “aren’t a high enough risk.”
Providing crisis options (which have been built on colonial, ableist, and carceral systems) without providing adequate information about the pros and cons is not fulfilling your ethical duty as a therapist, especially when working with disabled, queer, and BIPOC clients. And I will continue to stand up for the rights of people to choose what THEY believe is best for them—
—EVEN WHEN THEY ARE ACTIVELY SUICIDAL.
Terms:
*informed consent: a person must have sufficient information and understanding before making decisions about accepting risk, such as their medical care
**anti-carceral: opposing punishment and policing as adequate responses to mental health care
***Mental Health Industrial Complex (MHIC): a sub-section of the Medical Industrial Complex that refers to a large network of private institutions and people in positions of authority that uphold classist, racist, ableist, and other oppressive structures to maximize their profits
****psychiatric abuse: the misuse of psychiatric diagnosis, detention, and treatment to suppress the rights of an individual or group
Relevant links:
Petition to change the CRPO's mandatory reporting of suicidality: https://www.change.org/p/reform-the-crpo-s-duty-to-report-to-a-duty-to-act-reasonably-for-suicidal-clients?recruiter=1342735585&recruited_by_id=0ea5ce20-39f6-11ef-a1f6-276e482538e5&utm_source=share_petition&utm_campaign=share_for_starters_page&utm_medium=
Alternatives to 911/988 for suicidality (compiled by comments from the community): https://docs.google.com/document/d/1_GF3iy7c9wJ_Bfdxt8OzdhqsQfJ7F8iAyr426RtlU8U/mobilebasic
Canadians killed by police during wellness checks: https://www.aptnnews.ca/national-news/indigenous-deaths-rcmp-windsor-winnipeg-shooting/
CRPO Professional Standard of Practice - Consent: https://crpo.ca/practice-standards/client-therapist-relationship/consent/
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