Suicide Risk | Considering the Impact of Involuntary Actions
In my previous post, I discussed steps to take when your client presents with imminent risk of suicide and hospitalization becomes a consideration. While acute suicidality is stressful for clinicians, it’s equally important to recognize that hospitalization—whether voluntary or involuntary—can be a profoundly difficult experience for your client.
Involuntary hospitalization, in particular, is not a decision to be made lightly. The consequences can be significant, affecting not only your client’s immediate safety but also their long-term engagement in care. In this post, I want to build on the previous discussion by highlighting the potential impacts of involuntary hospitalization and examining why crisis lines, such as 988, are committed to this option when a person is at high risk of suicide.
Impact of Involuntary Actions
One of the policies of 988 Suicide & Crisis Lifeline for addressing imminent risk (IR) of suicide includes the requirement to send emergency services to a person they believe to be at IR - with or without consent - if they believe that not doing so will result in a person’s death. 988 crisis counselors are required to do everything they can to trace a call or obtain a person's location, and while they do this as an absolute last resort, it is a difficult choice to make and not without controversy.
When this 988 policy was put in place, and again when revised in 2022, many stakeholders had concerns with this requirement to take action without consent - these concerns related to the fact that
Contacting 911 to intervene during a behavioral health crisis will, in virtually all settings across the US, involve law enforcement
Police presence can lead to increased stigma and shame and can send the message that people with mental health concerns can be violent and unpredictable
For those in marginalized communities, the risk of adverse outcomes associated with police presence is only magnified due to bias, discrimination, and racism
As clinicians, it is important to recognize that, in the context of hospitalization (particularly involuntary), there can be impacts on an individual’s well-being that go far beyond the immediate crisis that include:
Physical Danger
There are inherent risks when armed law enforcement officers respond to a mental health crisis. Many officers receive limited training in assessing and managing suicide risk or the unpredictable behaviors of individuals in emotional distress, increasing the likelihood of unnecessary escalation. Additionally, systemic disparities affecting BIPOC and LGBTQ+ individuals are well-documented within both the medical and criminal justice systems, often resulting in disproportionate rates of involuntary hospitalization, incarceration, and civil commitment.
Emotional Impact
The emotional impact of an involuntary intervention can lead to both trauma and shame, potentially deterring those in need from seeking future crisis or mental health support. For some, the presence of police can provoke reactions from family members, neighbors, or others in their home, creating additional emotional and physical risks beyond their immediate crisis (e.g., LGBTQ+ youth who are not out to their parents or individuals in abusive relationships).
Financial Impact
Hospitalization can have a significant financial impact, as individuals may be charged for an ambulance, ER visit, or inpatient services. Individuals held in emergency rooms for observation may also face financial strain due to lost workdays. Since economic hardship is a significant risk factor for some who consider suicide, the financial burden of an unnecessary involuntary intervention could further exacerbate their distress.
Given These Risks, Why Involuntarily Hospitalize?
With these significant risks in mind, why would we ever choose to hospitalize someone against their will? And why does 988 Crisis Lifeline maintain its policy of intervening regardless of an individual’s consent?
The fact is that, as mental health clinicians, we have a professional duty to protect our clients from harm and, in some situations, undertaking an involuntary action may be the only option we have to keep a client safe. The following points inform my own belief that intervention must be pursued when all other options have been exhausted.
Ambivalence in Suicide
Research has shown that ambivalence about suicide is often present right up until the moment of an attempt. The very act of reaching out—whether by calling a crisis line or disclosing suicidal thoughts to a clinician—suggests an internal conflict between wanting to die and wanting help. This ambivalence provides an opportunity for intervention. (see previous post)
Impaired Decision Making
The distress associated with thoughts of suicide can impact an individual’s cognitive functioning and prevent them from considering alternative actions that could reduce their psychological pain (“cognitive constriction”) – we know that when individuals are experiencing heightened emotions that their ability to think clearly and access the decision making capacities is significantly impaired. Other factors, such as psychosis or substance use, can further compromise decision-making.
Crises Can Be Temporary
We also know that suicidal crises are frequently brief. Many of us have experienced moments of extreme distress, convinced that nothing will ever improve—only to wake up the next day with a different perspective. Delaying a person’s ability to act on thoughts of suicide and restricting access to lethal means, even briefly, can be life-saving.
Impact on Others
Beyond the individual, suicide has profound ripple effects on loved ones and the broader community. Survivors of suicide loss are at an increased risk of experiencing their own mental health crises, including suicidal thoughts. As clinicians, we have a responsibility not only to the individual in crisis but also to those who will be impacted by their loss.
Remember, determining that your client is at risk for suicide does not always mean hospitalization. There will be times when, despite experiencing active suicidal thoughts, your client has no immediate intent to act, can engage in safety planning, remove access to means, seek support, and/or increase session frequency.
When hospitalization is necessary and the client agrees, it can provide short-term safety, medication stabilization, and a brief respite for someone feeling overwhelmed. However, when involuntary hospitalization becomes the only option, it should always be a last resort—used only after all other avenues have been exhausted to ensure the client’s safety.
Involuntary Actions Are a Last Resort, Not a First Response
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