Chapter 16: Suicide, Ethics, and Law

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Welcome to the Deep Dive, your shortcut to getting up to speed.

Today, we're really tackling a heavy but essential topic from psychopathology and mental distress.

Yeah, we're looking at the ethics and law.

It's a complex intersection, definitely.

Absolutely, and our mission here is to kind of unpack the core insights for you, especially if you're studying mental health.

We want to guide you through the key theories, the diagnostic debates, and importantly, the ethical and legal stuff that shapes practice.

Exactly.

We'll pull out some maybe surprising facts, try to clarify the jargon, and really link it all back to what happens in the clinic and people's actual experiences.

Okay, let's dive in.

First things first, we need to get our terms straight when we talk about suicide.

The sources define suicide proper pretty straightforwardly, right?

Intentionally ending one's life.

Right, but then it gets more nuanced pretty quickly with Edwin Schneidman's idea of subintentional death, sometimes called indirect suicide.

Subintentional death.

So what does that actually mean in practice?

It sounds less direct.

It is.

The compelling thing here is that it's not necessarily a conscious planned attempt to die.

It's more about an unconscious wish -finding expression through, well, recklessness or maybe negligence.

Careless behavior that increases risk.

Okay, so like taking unnecessary risks.

Exactly.

Schneidman described a few types, but a really striking one is the death -dearer.

This is someone who's actually ambivalent, you know, torn about dying.

So they might do something really dangerous.

Like playing Russian roulette or maybe overdosing, but then immediately calling for help.

It's a gamble with death driven by that internal conflict.

Wow, that really forces you to think differently about intent, doesn't it?

It's not just a simple yes or no to wanting to die.

Precisely.

It moves beyond just conscious desire and makes us consider those deeper perhaps unconscious factors in risk assessment.

And we should distinguish this from parasuicidal behavior too.

Right, parasuicide.

That's different again.

Yeah, that's more about self -harm used maybe to manage intense feelings, express distress, or sometimes influence others, but without that primary conscious goal of ending life.

Though the distinction can be blurry sometimes.

Okay, got it.

So with those definitions in mind, let's look at the scale of the problem.

The statistics mentioned are, well, they're pretty sobering.

They really are.

Globally, the World Health Organization flagged suicide as the fourth leading cause of death among 15 to 29 -year -olds back in 2019.

That's huge.

And bringing it to the US, the numbers are just stark.

In 2020, nearly 45 ,000 deaths by suicide.

Yes, but what's almost more staggering is the number behind that.

Over 3 million people made suicide plans that year and 1 .2 million actually attempted suicide.

It shows the sheer volume of distress out there.

And the methods mentioned firearms, suffocation, poisoning are the most common in the US?

Correct.

And then you layer on something like the COVID -19 pandemic.

Which made things worse.

Significantly, according to the data.

About 21 % of adults who made suicide plans in 2020 linked it partly to the pandemic's impact.

It amplified existing stressors for many.

And we have to remember, these numbers might even be low, right?

Because of underreporting or difficulty classifying intent sometimes?

Absolutely.

Attempts aren't always reported.

And distinguishing lethal intent from other forms of self -harm isn't always straightforward.

So the true scale could be even larger.

Okay, so given how widespread this is, it begs the question.

How do we even diagnose or conceptualize these behaviors?

I know this is a hot topic, a real area of debate.

What are the proposals our sources discuss?

It's a major debate.

The chapter introduces potential DSM diagnoses, suicidal behavior disorder, or SBD for someone who's attempted suicide within the last two years.

Okay.

And also non -suicidal self -injury disorder in SSI for deliberate self -injury, but without suicidal intent.

So creating specific labels for these behaviors, what's the argument for doing that?

Proponents say, look, SBD is a reliable and valid concept.

Making it a distinct diagnosis would encourage clinicians to assess for suicide risk more systematically in everyday practice.

It brings it front and center.

Makes sense.

But there are critics.

Oh, definitely.

Critics push back hard.

They argue that suicidal behavior isn't really a disorder in itself.

It's more often a symptom of other underlying conditions like depression, borderline personality disorder, substance use, severe anxiety, or maybe a reaction to overwhelming life events.

So it's part of a bigger picture, not the whole picture itself.

That's the argument.

They point to the high comorbidity, how often suicidal ideation, the thoughts and feelings about suicide, occurs alongside these other diagnoses.

Right.

And this leads to a deeper question.

Should we be medicalizing suicide like this?

Is it fundamentally a medical issue, or is it sometimes, as some argue, more of a moral or existential act?

There's concern about reducing complex human distress to just another diagnostic code.

That's a really profound point, the whole medicalization concern.

It is.

It raises questions about stigma, about how we view responsibility, and whether focusing on a discrete disorder might make us overlook the person's context for suffering.

Okay.

So clearly no single answer on diagnosis,

which probably explains why there are so many different theoretical lenses trying to understand why suicide happens.

Let's unpack those.

Maybe start with the psychodynamic view.

I know the classic idea was anger turned inward.

Right.

That was Freud's initial formulation aggression towards others redirected towards the self.

But modern psychodynamic thinking is much more relational.

How so?

It focuses more on early life experiences, particularly losses like a parent dying or a difficult divorce, and how those experiences shape attachment patterns and ways of relating to others later in life.

So troubled relationships or early trauma?

Exactly.

Problems in attachment, difficult interpersonal dynamics.

The source material has this point, quote,

behind every suicidal gesture, there is always a tragedy.

The therapy then focuses on understanding working through that underlying relational tragedy.

And these approaches can be effective.

Research suggests they can be, yes, in helping prevent future attempts by addressing those core relational issues.

Okay.

That's the individual focus.

What about broader societal factors?

Durkheim's sociological model comes up next.

Ah, yes.

Emil Durkheim.

His work is fascinating.

He focused on two key social forces,

social integration, how connected people feel to their

and social regulation,

the degree of external constraint on people.

And how do those relate to suicide?

Well, Durkheim identified different types of suicide based on these forces.

For example, egoistic suicide.

This happens when social integration is too low.

People feel isolated, alienated, like they don't belong.

Can you give an example of that?

The chapter points to the higher risk amongst a gay, lesbian and transgender individuals who often face significant social rejection, discrimination and stigma.

That lack of belonging, that isolation fits Durkheim's model of egoistic suicide risk.

It also links to non -suicidal self -injury in these groups.

That really brings it home how social forces impact individual vulnerability.

What about the other side of the coin?

Too much integration.

Exactly.

Durkheim called that altruistic suicide.

This occurs when social integration is extremely high.

Individuals are so deeply embedded in their group or society that they willingly sacrifice their lives for the collective good.

Like a soldier falling on a grenade.

Precisely.

Or a parent shielding a child, or even a political protestor dying for a cause.

In cultures that place a very high value on honor, duty and the group over the individual, you might see this more often.

It's a powerful reminder that our social context matters immensely.

It really does.

Okay, so we've covered psychodynamic and sociological views.

What other perspectives are mentioned?

Briefly, there's the biological perspective looking at genetics, stress hormones via the HPA axis, and neurotransmitters like serotonin.

This often informs the use of medications, antidepressants, move stabilizers, antipsychotics.

Then you have cognitive behavioral therapy for suicide prevention, or CBTSP.

This approach targets the specific thoughts and behaviors that contribute to suicidality, teaching coping skills and ways to challenge negative thought patterns.

And finally, the humanistic angle.

Yes, the humanistic perspective tends to view suicide less as a disorder, and more as a, quote, meaningful response, albeit a tragic one, to profound emotional pain.

Things like deep humiliation,

overwhelming anger, unbearable loss.

It emphasizes understanding the subjective experience of suffering.

Okay, that gives us a really broad range of ways to understand this.

Now, let's shift gears to prevention and the professional responsibilities involved.

What do suicide prevention programs typically look like?

They usually combine several elements.

Education is a big one, raising awareness about risks, warning signs, how to talk about suicide, emphasizing the value of life, and also the impact on those left behind.

Do those big media campaigns actually work?

The evidence suggests they can be helpful, yeah, but usually as part of a wider strategy, not just on their own, they need to be coupled with other resources.

Like hotlines.

Exactly.

Hotlines and crisis intervention services providing 24 -7 support via phone, text, chat.

They rely on skilled listening, empathy, and risk assessment.

And I know safety planning is mentioned as a key technique now.

How does that differ from those older no -suicide contracts?

That's a great point.

Safety planning is much more proactive and collaborative.

It's not just a promise not to do something.

Instead, the clinician helps the client develop a very concrete step -by -step plan for what they will do when suicidal thoughts arise.

So specific coping strategies, people to call, places to go.

Exactly.

Actions they can take to stay safe in that moment.

It empowers the client.

Other strategies include method restriction, basically, making lethal means harder to access, and of course, hospitalization for individuals at very high acute risk or those experiencing psychosis.

Okay, that covers prevention strategies.

Now let's get into the really tricky ethical and legal side.

All mental health professionals work under codes of ethics, right?

Absolutely.

Psychologists, psychiatrists, counselors, social workers, they all have ethics codes designed primarily to protect the welfare of the people they serve, the service users.

The American Psychological Association's code, for instance, lays out core principles.

And a fundamental ethical principle is informed consent.

Can you unpack that a bit?

Sure.

Informed consent is crucial.

It means providing potential clients or research participants with clear, understandable information about what they're agreeing to, the purpose, procedures, potential risks,

benefits,

alternatives, so they can make a truly voluntary and informed decision about participating.

Especially important when working with people who might be vulnerable.

Critically important.

Yeah.

And closely tied to this is confidentiality.

This is the ethical requirement that clinicians generally can't disclose information shared by a client without their explicit permission.

But there are exceptions, and that's where it gets complicated.

The chapter gives the example of Hugo.

Right.

Hugo is hesitant to tell his therapist about a past arrest or his sexual orientation because it's a small town.

The therapist explains confidentiality that what he shares stays private unless.

Unless he's a danger to himself or others.

Precisely.

That's the major exception.

Hugo feels relieved knowing the general rule, which allows him to open up.

But that exception, the danger to self or others part is huge.

It leads directly to the duty to protect, doesn't it?

It does.

While confidentiality is the ethical default, there's also a legal obligation in most places for therapists to breach confidentiality if a client poses a serious, imminent threat to themselves or another identifiable person.

This is the duty to protect.

That sounds like an incredibly difficult judgment call for a clinician.

Breaking that trust.

It's a profound ethical quandary.

You're balancing the duty to protect potential victims, including the client himself, against the duty to maintain confidentiality, which is the bedrock of the therapeutic relationship.

Breaking trust, even when legally required, can damage therapy.

Clinicians can also break confidentiality to defend themselves in a malpractice suit, for example.

It's complex.

Definitely a tightrope walk.

Okay, let's move fully into the legal arena now.

The insanity defense often grabs headlines.

What's the key thing to understand about it?

The absolute key thing is that insanity is a legal term, not a clinical diagnosis found in the DSM.

All right, so the courts define it, not doctors.

Exactly.

Legally, it generally refers to a state where, due to severe mental illness, a person couldn't distinguish reality from fantasy, couldn't control their behavior, or didn't understand the wrongfulness of their actions at the time of the crime.

And if the defense is successful?

Typically, the person isn't sent to prison, but is committed to a psychiatric hospital for treatment.

The idea is treatment, not punishment, because they weren't legally responsible.

There are different legal tests for insanity used in different places, right, like M.

Naughton?

Yes, there are several historical tests.

The M.

Naughton rule focuses on whether the defendant knew right from wrong.

The irresistible impulse test considers if they could control their actions.

The Durham test linked crime to a product mental disease.

And the Model Penal Code test, or ALI test, looks at lacking substantial capacity to appreciate wrongfulness or conform conduct to the law.

It sounds like a lot of variation.

There is.

And some states offer a verdict of guilty, but mentally ill, meaning the person is found guilty and sentenced.

But they're supposed to receive mental health treatment while incarcerated.

The Insanity Defense Reform Act also tightened federal standards after the

It's clearly very controversial.

Hugely controversial.

Arguments rage about responsibility, free will, the reliability of psychiatric assessment in court, and whether it lets people get away with crimes.

Related to court proceedings, there's also competence to stand trial.

What does that involve?

Competence is about the defendant's mental state at the time of the trial, not the crime.

It's a legal standard requiring that they can understand the charges against them, participate rationally in their own defense, and consult meaningfully with their lawyer.

So they need to be able to follow what's happening and help their case.

Basically, yes.

And the example given is important.

Someone charged with a minor offense may be facing just a fine if convicted.

If found incompetent, they could end up confined in a psychiatric facility for assessment and treatment for potentially longer than any sentence they might have received.

That raises serious liberty concerns, doesn't it?

It absolutely does.

Civil libertarians argue that finding someone incompetent and committing them involuntarily without a trial on the actual charges might violate fundamental rights like the UN resolution mentioned, saying disability shouldn't justify depriving liberty.

But what's the counterargument?

Why have the competency standard at all?

Vendors argue it's essential for due process.

You can't have a fair trial if the defendant doesn't understand what's going on or can't assist their counsel.

The goal is often to store competence so the trial can proceed fairly.

It's another tough balancing act.

Definitely.

Okay, one more major legal concept,

civil commitment or involuntary commitment.

Right.

This is when people are required to undergo mental health treatment against their will, either in a hospital or sometimes in the community, because they're deemed dangerous to themselves or others, or unable to care for their basic needs due to mental illness, sometimes called gravely disabled.

And the state has the power to do this.

Yes, based on two main legal principles, police power, which is the state's authority to protect public safety by confining dangerous individuals, and parent's patriae, Latin for parent of the country, which is the state's authority to act as guardian for those who can't care for themselves, like children or the severely mentally incompetent.

Is there a difference between long -term commitment and emergency situations?

Yes.

Temporary commitment or emergency commitment allows for short -term hospitalization, maybe just a few days, in a crisis.

This often happens quickly with less formal legal process, precisely because it's an emergency, but it's time limited.

Longer term commitment usually involves more rigorous legal review.

And like the insanity defense, civil commitment is highly controversial.

Extremely.

You have strong opinions on both sides.

Who argues for it?

Proponents often include patient advocacy groups like NAMI and psychiatrists like E.

Fuller Torrey.

They argue it's a necessary tool to protect vulnerable individuals who are dangerously ill or gravely disabled and lack insight into their need for treatment.

Torrey's quote is something like, I personally am inclined to give people who are not aware of their illness a shot at treatment.

It's seen as compassionate intervention for those unable to help themselves.

And the opposition.

Civil libertarians, famously figures like Thomas Sass, see it primarily as a deprivation of liberty.

They argue that mental illness shouldn't automatically negate a person's right to refuse treatment.

Sass worried about its potential for misuse, like political oppression, citing historical examples.

What are some other arguments against it?

Critics also question whether clinicians can reliably predict future dangerousness.

The evidence is mixed.

And there's the concern you raised earlier, the threat of being committed might actually scare people away from seeking voluntary help when they need it.

Sass put it bluntly, it is dishonest to pretend that caring coercively for the mentally ill invariably helps them.

It really lays bare the tension between individual autonomy and public safety or perceived best interests.

Absolutely.

A core conflict in mental health law and ethics.

Okay, shifting to the final section, let's touch on accessing care and some modern challenges.

Even if someone wants help, getting it can be tough.

Very tough.

Access barriers are a huge problem.

Our sources point to a significant shortage of mental health providers in the U .S.

and Canada, especially in rural areas.

One statistic suggests over 70 % of the need in the U .S.

isn't being met.

And wait times can be incredibly long elsewhere too.

Yeah, the example given is the UK's NHS, where in 2021, the average wait to see a psychiatrist could be around 18 weeks.

That's a long time to wait when you're in distress.

And these barriers aren't just about availability, are they?

There are racial and cultural factors too.

Definitely.

The chapter highlights how individuals from racial and ethnic minority groups, Black, Hispanic, Latino, Native Americans, often face greater hurdles.

This can be due to systemic discrimination,

cultural misunderstandings with providers, lack of culturally competent care, and negative past experiences leading to mistrust.

So improving access isn't just about more therapists.

It's equitable and culturally sensitive care.

Precisely.

Addressing those systemic issues is vital.

Now technology is offering some solutions, right?

E -mental health?

Yes.

E -mental health, delivering services remotely using technology, and specifically teletherapy via real -time video conferencing have become much more prominent, especially since the pandemic.

They can help bridge geographical gaps.

But technology also brings new challenges.

The chapter ends with a really contemporary, maybe controversial question about TikTok.

Ah, yes.

The TikTok self -diagnosis phenomenon.

Can social media tell you if you have a mental disorder?

It sounds wild, but apparently it's a real trend.

It seems to be.

The text mentions researchers documenting teens, in particular, watching videos on platforms like TikTok about symptoms of various disorders, and then concluding they have that disorder.

Like the example of Kiana.

Exactly.

Kiana, a 10th grader, watches lots of videos about depersonalization during the pandemic lockdown and becomes convinced she has depersonalization disorder.

Wow.

That's kind of scary.

What does that signify?

Well, it's a fascinating intersection of youth culture,

social media algorithms, the search for identity and answers, and maybe increased mental health awareness, coupled with difficulty accessing professional help.

It really highlights the need for critical media literacy, even for students like you entering the field.

Where are people getting their information?

Is it reliable?

That's a crucial point as we wrap up.

This whole deep dive shows just how interconnected everything is.

Individual distress, societal factors, professional ethics, the legal system.

It really does.

From defining suicide itself to debating diagnoses, understanding different theoretical views, navigating the ethics of confidentiality and duty to protect, grappling with laws around insanity and commitment.

It's incredibly complex.

And we've seen the importance of prevention, but also the stark realities of access barriers in these new digital challenges.

Yeah.

Understanding all these facets is essential for anyone working in or studying mental health.

It requires thinking critically and holding multiple perspectives.

Which leads perfectly into the final thought the chapter leaves us with from psychologist George Kelly.

Right.

Kelly said something like, the questions we ask are often more important than the answers we give them.

I love that.

In a field like this, which is so complex and constantly evolving, maybe the goal isn't always to find the definitive answer, but to keep asking better questions.

Exactly.

Embrace the ambiguity, the uncertainty.

Recognize how much we still don't know.

Keep that curiosity alive as you continue your studies.

Keep exploring, keep questioning, and always consider the real people behind the concepts.

Keep striving to understand that rich, complex tapestry of human experience.

Thank you for joining us on this deep dive.