The Suicidal Patient: Clinical and Legal Standards of Care, 2nd ed.

I was pleased to review this book for two reasons. First, for the past 5 years, I have had the honor of holding an academic chair dedicated to the study of suicide, the Arthur Sommer Rotenberg Chair in Suicide Studies at the University of Toronto. My main, and perhaps only, justification for accepting this honor is that I work daily with “the suicidal patient.” My second reason was my memory of reading Dr. Bongar’s first edition of this book. It was a valued resource as I readied myself for my new role as Chair. The first edition was published in 1991. Now, some 10 years later, Dr. Bongar has updated this important text.

Dr. Bongar, a psychologist who is Calvin Professor of Psychology at the Pacific Graduate School of Psychology, states that the primary purpose behind this volume is “to present suggestions for optimal psychological practice in the assessment, management, and treatment of the suicidal patient” with a particular focus on blending clinical and legal perspectives on the management of such patients. According to the author, the book is not intended to “impose standards of care” or to remove the need for consulting with colleagues or legal experts.

Before reviewing the merits of the book, I caution readers with a psychiatric background that this book is targeted at the practicing psychologist. Dr. Bongar not only directs his advice to the practicing psychologist but also often refers the reader to the American Psychological Association regarding standards of professional practice. For a reference book that focuses on suicide and psychiatric illnesses, I highly recommend The Harvard Medical School Guide to Suicide Assessment and Intervention(1).

Although The Suicidal Patient has been updated from 1991, I still found some sections to be lacking key references. For example, the psychological approach to repeat suicide attempters is discussed without reference to the work of Marsha Linehan. Risk factors for elderly suicide are mentioned without reference to the pivotal work of Yeates Conwell and colleagues. The discussion of gender and suicide does not include the classic paper by Canetto and Sakinofsky (2). In spite of these reservations, the book provides the practicing professional with much sound and practical advice that is not available elsewhere. For example, Dr. Bongar discusses the difficult issue of maintaining the confidentiality of a patient who is acutely suicidal. He unequivocally affirms “that if a breach of confidentiality is necessary to save the patient’s life,” the clinician is bound to take this step (p. 237). The book contains one of the few guides to “postvention,” that is, helping the survivors after a loved one has committed suicide, and the sound risk management strategies of these activities. The book concludes with a discussion of the possible legal aftermath of a suicide and desensitizes the reader to the role of the attorneys and some common legal defenses that are realities of malpractice actions.

The book begins with a chapter on the empirical evidence regarding the etiology of suicide. Overall, the chapter is a very balanced overview of this topic. The second chapter examines the care of the suicidal patient from the legal perspective and includes many important topics, including a discussion of physician-assisted suicide. Chapter 3 is devoted to the assessment of suicide risk and is targeted toward the practicing psychologist, containing a section on the Rorschach Inkblot Technique, the Minnesota Multiphasic Personality Inventory, and the Millon Clinical Multiaxial Inventory.

The appendixes to the book are extremely useful and contain some actual assessment tools such as the Lethality of Suicide Attempt Rating Scale and the Los Angeles Suicide Prevention Center Scale. The book is rich with quotations, such as Motto’s statement of the central clinical task of risk assessment: the clinician must “determine and monitor the patient’s threshold for pain (either physical or psychological)” (3). Truly, suicidology is the art of pain management.

Chapter 4, on the outpatient management of the suicidal patient, is full of practical advice. Dr. Bongar insists that during disruptions in the therapy of a patient at risk of suicide, the backup therapist should meet face-to-face with the patient in preparation for the transfer of care. He likens it to the care provided by an obstetrician anticipating the need for immediate care during a vacation period. Chapter 5 discusses the inpatient management of the suicidal patient. It is during inpatient stays when the clinician is held most responsible for the care and safety of a suicidal patient. The last chapter reviews risk management strategies when caring for high-risk patients and includes the section on “postvention.”

As I was reading this book for the Journal, I received a letter from a daughter of a former patient. She was writing to inform me of his suicide. I was immediately aware of this book’s value. Most of the time, Dr. Bongar’s practical, straightforward advice will seem self-evident. His advice was precisely what I needed after receiving this letter.