Most states in the U.S. require a psychotherapist to break confidentiality when a client verbalizes suicidal intent (National Conference of State Legislatures, 2013). The purpose of this paper is to share a personal reflection on suicidal ideation within the therapeutic relationship, and to question whether a psychotherapist’s ethical responsibility and personal morality are consistently clear-cut.

Imagine you, as a psychotherapist, have a client who is terminally ill. She has come to you for help navigating the complex emotions and logistics around knowing she has limited time to live. During the course of therapy your client tells you that she does not want to suffer the burden of the imminent and inevitable physical and mental degeneration that results from having a terminal illness; because of this, she has been formulating a plan to commit suicide. In addition to her desire to avoid painful mental and physical suffering, her rationale for taking her life includes that she does not want her family, especially her children, to see her suffering; she has made peace with herself and her family; her family is emotionally secure with her decision, and she feels successfully accomplished through her work.

This scenario is not about a person who is expressing suicidal ideation as a cry for help. Rather, this hypothetical woman is contemplating suicide before becoming so ill that she would be forced to seek an assisted suicide, if such an option would even be possible. Would this example influence your feelings around this issue? If so, why would it take an extreme situation, such as terminal illness, to consider someone else’s personal choice?

Perhaps the client’s spiritual values are such that she believes in an afterlife or reincarnation. Why should the law govern an ethical issue by essentially placing judgment on what this client believes is right for her? Furthermore, why does the double standard exist where one can sacrifice one’s life in an act of heroism (i.e., to save someone else’s life; in war; in political protest, etc.), however, one cannot do so for one’s self?

I find myself reacting personally to this dilemma. It cuts at the heart of my belief system regarding the control of an individual’s own body, mind, and soul. It stirs up emotions around the violation of human rights, and I tend to feel stifled by the prohibitive nature of this hypothetical case example.

I also notice feeling guilty for my thinking on the subject. The guilt comes from my proclivity to be a helper, a caretaker, and a believer in persevering through life. I intuitively and instinctively know I would not break the law, but nevertheless this topic provides an ethical predicament for me. I believe in “do no harm,” but my moral conflict arises with the supposition that harm means different things to different people in different contexts.

It is without question that I know I would do my best to assist my client. I do not take lightly the concept of ending one’s life, and my first instinct would be to protect my client from hurting herself in any way. In general, I would work to create a safe space within therapy where my clients can come to terms with their past experiences, as well as uncover and modify stale patterns of thoughts and maladaptive behaviors to live healthful, successful, and purposeful lives.

But my client in this example is different. My client’s well-being would be of the utmost priority. I would ensure my client felt heard, validated, and understood, especially with regard to her suicidal deliberation. Gaining her trust would be imperative. Would she be less likely to confide in me if she risked being intruded upon by my reporting her and breaking our therapeutic alliance?

Philosophy, Religion, and the “Right to Die”

My values center on a conviction in the power of individuals to guide their own lives by the choices they make. While there is no law against the act of committing suicide in the United States, attempting or aiding in attempted suicide may be, and psychotherapists whose clients express an intent to end their lives may face sanctions if they do not act in accordance with their legal and ethical mandates (Mental Health Daily, 2014, p. 1).

What role does an individual’s religion play in the public discussion surrounding suicide? What are the potential institutionalized religious undertones and subtexts regarding the ethics of suicide? “Christianity’s respect for life mirrored that of the Hippocratic physicians—each human life was in the image and likeness of God. Christian physicians were Hippocratic both by profession and by doctrine” (Holt, 2013, p. 1).

Is it possible that, within the Christian religious context (and, by extension, codified into law in the U.S.), suicide is thus never acceptable? From a career standpoint, in addition to legal liability, I risk potential loss of respect, support, and acceptance from my colleagues as well as censure by or removal from professional organizations, if, in my hypothetical client’s case, I fail to follow these principles.

In his article, The Interpersonal-Psychological Theory of Suicidal Behavior: Current Empirical Status (2009), Dr. Thomas Joiner discusses his opinion on the two psychological states that most often lead to suicide. One is perceived burdensomeness to significant others, and the second is a sense of low belongingness or social alienation, in which one does not feel adequately involved with one’s own life.

Where does my hypothetical client fit into this model? An interesting, factual case that does not fit into this model is that of Brittany Maynard. Brittany, whose story was in the center of a recent controversial right-to-die movement (Egan, 2014), ended her own life on Saturday, November 1, 2014, at 29 years old:

Goodbye to all my dear friends and family that I love. Today is the day I have chosen to pass away with dignity in the face of my terminal illness, this terrible brain cancer that has taken so much from me … but would have taken so much more. My glioblastoma is going to kill me and that’s out of my control. I’ve discussed with many experts how I would die from it and it’s a terrible, terrible way to die. So being able to choose to go with dignity is less terrifying. For people to argue against this choice for sick people really seems evil to me. For me what matters most is the way I’m remembered by my family and my husband as a good woman who did my best to be a good wife and a good daughter. Beyond that, getting involved with this campaign, I hope to be making a difference here. If I’m leaving a legacy, it’s to change this health-care policy or be a part of this change of this health-care policy so it becomes available to all Americans. That would be an enormous contribution to make, even if I’m just a piece of it.

The philosopher Friedrich Nietzsche said, “When one has one’s wherefore of life, one gets along with almost every how” (2004, p. 4). I propose the reverse is also true with regard to having a wherefore for which to die. Existential therapy suggests that “we are not victims of circumstance, because to a large extent we are what we choose to be.

A major aim of therapy is to encourage clients to reflect on life, to recognize their range of alternatives, and to decide among them” (Corey, 2013, p. 131). The decision to end one’s life can be examined within this framework. “A characteristic existential theme is that people are free to choose among alternatives and therefore have a large role in shaping their destinies” (Corey, 2013, p. 138).

An existential idea is that death kills us but without it we would not know we are alive. Every individual is unique and all meaning matters. With respect for the concept of free will in existential theory, if a wish can be summarized by the desire to be in touch with what we want, then a will is how we organize ourselves and our lives in order to achieve that wish or goal.

My experiences travelling through Southeast Asia, before beginning my master’s program in International Disaster Psychology at the University of Denver, led me to believe that some cultures and societies view life and death in an infinite balanced continuum, where beginning and end are indistinguishable.

Relevant Ethical and Legal Standards

There is a provision of the American Counseling Association (ACA) ethical code that lends itself to respecting an individual’s right to self-determination or the right-to-die. B.2.b. Confidentiality Regarding End-of-Life Decisions states that “[c]ounselors who provide services to terminally ill individuals who are considering hastening their own deaths have the option to maintain confidentiality, depending on applicable laws” (ACA Code of Ethics, 2014, p. 7).

Some states, including Colorado, have a Mandatory Duty to Protect/Warn law whereas other states, such as Texas, have a Permissive Duty to Protect/Warn law, which may provide some legal and ethical flexibility. Maine, Nevada, North Carolina, and North Dakota all have No Duty to Protect/Warn, which translates to a client’s confidentiality being enforced in every instance (National Conference of State Legislatures, 2013). Perhaps No Duty states and some of the Permissive Duty states would be more apt in applying ACA code B.2.b.

Other ACA codes (ACA Code of Ethics, 2014) that support the opinion of allowing freedom of choice to clients are:

A.4 Avoiding Harm and Imposing Values, especially A.4.b. Personal Values: “Counselors respect the diversity of clients . . . and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature” (pp. 4-5).

B.1. Respecting Client Rights, especially B.1.a. Multicultural/Diversity Considerations: “Counselors respect differing views toward disclosure of information” (p. 6).

B.1.d. Explanation of Limitations provides some non-judgment and flexibility: By initiating discussion from the beginning of therapy regarding situations in which confidentiality must be breached, and then maintaining ongoing discussions on this topic with the client throughout therapy, it would appear that this framework could provide the safety and trust required for the client to work through the steps of any dilemma around suicide (p. 7).

These American Psychological Association (APA) codes (2010) could also be used to support and argue for client autonomy in deciding what is right for their bodies (Pope & Vasquez, 2011):

Principle D: Justice: “Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices” (p. 333).

1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority: “Under no circumstances may this standard be used to justify or defend violating human rights.” (p. 334).

In theory, clients should also be protected from intrusion into their lives in all three of the following (Pope & Vasquez, 2011): 3.04 Avoiding Harm (p. 337); 4.01 Maintaining Confidentiality (p. 340); 4.05 Disclosures [Duty to Protect] (pp. 341-342).

Best practices and ongoing dilemmas

In considering possible and probable courses of action for my hypothetical case example, I would be forced to remind my client of the disclosure law that we would have discussed before we began therapy. In addition, I would want to discuss all of the angles of the issue from her perspective, and I would assess her state of mind and reasoning throughout our sessions. Bearing in mind our therapeutic relationship, facts and truths about her terminal illness would have been discussed on an ongoing basis over the course of our therapy sessions.

In the context of my ultimate duty and my disclosure to her of this legal obligation, I would also want to explore with my client the idea of putting certain parameters and a time frame around our discussions concerning her suicide plan. I would trust that we could both come to an understanding of her decision as well as what the consequences of my reporting would be in the event that she was steadfast in her desire to commit suicide. The unfortunate reality is we cannot offer a client one of the most valuable aspects of therapy if we must disclose regardless of the client’s deeply-held convictions, or our own.

One lingering aspect of the issue that I would find difficult to negotiate ethically is: What if I follow my state’s statutory disclosure guidelines, leading to my client’s involuntary hospitalization; she feels betrayed and abandoned by me, but remains committed to her decision to end her life, and ultimately does so? I would have fulfilled my legal duty but failed my client. Dr. Atul Gawande, discusses how medical and psychological professionals can be a destructive force in their patient’s life by practicing heroic medicine (Bethune, 2014):

There are lots of humiliating, grim, bodily-fluidic aspects to living all the way to the end, and a beautiful death with dignity may not happen. When I was putting this together, I was a surgeon who took on problems I could not always fix . . . and a writer coming to realize I’m not the only one who seems to be struggling with these situations. But, yes, an ending always comes, and we need to honour people’s wishes during it as much as we can (p. 1).

I believe perhaps if I were to go through a real-life scenario with a client such as this one, I might work to amend legislation to honor the human rights of a client, but, equally as important, to honor those of the psychotherapist. It takes just one exception, in this case terminal illness, to call into question and taint a rule as a whole. Legislation could be proposed that would allow therapists some discretion in working with clients and their medical teams around death with dignity issues, with the goal of supporting clients’ mental health needs at the end of life. At some point down the line, this debate could lead to a dialog regarding the even more taboo subject of non-terminal illness right-to-die.

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Chantal Bushelle