Another question has to do with the efficacy of hospitalization in dealing with suicidality as a clinical problem in its own right. No outcome studies have shown that the inpatient location per se is a critical factor. Researchers who have looked at the treatment of suicidal patients in the inpatient setting tend to confound the setting with the type of treatment actually delivered. Often these treatments could have been delivered just as well in an outpatient environment. Results from inpatient clinical outcome reports are at best equivocal and at worst do not support this level of intervention. Germane to the potentially negative impact of hospitalization are a variety of research findings showing that suicidal patients tend to be received in a less than favorable way by hospital staff. The patient receives less-preferred forms and amounts of treatment and may have interactions hallmarked by confrontation, hostility, and mutual mistrust. Not surprisingly, the rates of elopement and discharges against medical advice in this population are among the highest of any of the patient populations treated in the psychiatric inpatient venue. A problem in reviewing articles on efficacy is the lack of clear clinical characteristics of suicidal persons who are hospitalized versus those who are not hospitalized. Crucial to the successful use of a hospital is a judicious and evidence-based process for selecting admissions.

When hospitalization occurs because no other options are available, a variety of bad reactions can set in. The patient can feel abandoned. The staff can feel angry because it appears that outpatient clinicians are not doing an adequate job. Both patient and staff can feel frustrated and disconnected from what went on before and what should go on after. These reactions can produce their own ill effects and muddle the meaning of outcome information.

Hospitalization is a very invasive treatment, and as a rule, the more invasive a treatment is, the more unintended side effects it is likely to have. There are several possible side effects of hospitalizing a suicidal patient.

First, labeling can determine behavior. People live up or down to the labels that are attached to them. The label psychiatric patient can lead to a negative view of self that is confirmed in subsequent behavior. The experience of being in an inpatient facility is something the patient may never forget, even when the stay is positive.

Second, admission highlights the issue of autonomy. When the essence of a suicidal crisis is a struggle with one’s sense of self-control over suicidal impulses, the decision to hospitalize can be a potent communication that the patient is out of control, thus confirming his or her worst fears. It is important to present hospitalization as a component of a rational, multimodal treatment plan, not as a last-ditch effort because all else has failed. Never give the message that if hospitalization does not produce change, there is nothing more to offer.

Third, hospitalization can act as reinforcement for suicidal behavior. The patient can experience a sense of immediate emotional relief by the act of entering the hospital, and this feeling paradoxically might be the most troubling side effect of all. Similarly, the intensity of response by clinicians at the time of hospitalization might reinforce the patient’s suicidal behavior. We believe that these factors are part of the explanation for the extremely high repetition rate among patients hospitalized for suicidal behavior. By providing short-term relief from long-term problems, hospitalization can reinforce the patient’s sense that suicidality works (e.g., “I made a suicide attempt, and things got better”). Hospitalization removes the individual from a stressful and seemingly unsolvable life situation, and the subsequent anxiety reduction can reinforce the recurrence of suicidal ideation or behavior. The patient moves from an environment marked by hostility, criticism, or confrontation into, we hope, an environment of caring and concern. In a hospital with a good therapeutic milieu, much of the conflict the patient has been experiencing is carefully governed in the hope that this strategy will protect the patient’s psychological stability. Troubled relationships seem to improve. For example, someone admitted for a suicide attempt is suddenly reconciled (at least temporarily) with a formerly hostile, alienated spouse who may feel guilty for “causing” the patient’s suicide attempt. After an adolescent’s suicide attempt, a dysfunctional family can be galvanized around the patient’s suicidal behavior in a way that seems as though the family is coming together. Because most negative consequences in these scenarios are longer term (e.g., over time family members increasingly avoid the patient, a spouse eventually gets even more angry) and therefore not immediately apparent, the patient may feel empowered to solve problems using suicidal behavior on a recurrent basis.

In addition to the complex and potentially negative psychological and interactional elements of the hospital setting, the architecture of the unit can be a major factor in determining inpatient efficacy. Some hospital wards, particularly older ones, are designed to maximize isolation rather than to promote ease of patient-staff mingling and positive interactions. Important concerns include whether nurses can be aware of activities from a central station and whether staff are cognizant about a patient’s location and behaviors so that therapeutic work can be done. Without a spacious, commodious, and eminently viewable unit, there is danger that ward staff will overuse suicidal precautions as a means of patient control. Wards full of nooks, crannies, and blind spots create a nearly guard-prisoner relationship between staff and patient. This atmosphere does not promote, and in fact demotes, the goals of successful treatment of suicidality: autonomy, self-efficacy, and self-control. If you have a choice of inpatient services, keep these components in mind as you visit the facilities. When you are involved in hospitalization, try to admit your patient to the unit that is the most efficiently unobtrusive. If you are fortunate enough to have a say in new unit construction or old unit remodeling, insist that clinical criteria be incorporated into design.

The case report literature has many examples of individuals who are hospitalized because of suicidality. This literature contains little or no long-term follow-up statements about the benefits of hospitalization. The following is a case report of an individual whose suicidal behavior escalated after hospitalization.

We do not know what would have happened to Ms. T if that first emergency department visit had gone differently. Would an alternative plan have provided adequate health maintenance until her primary physician returned? We do not know, and hindsight often is not fair. However, in this case, hospitalization of the suicidal person did not decrease the behavior and in fact may have had dramatic negative consequences. Did Ms. T have a devastating loss of self-control? Did social stigma and loss of civil rights have a profound effect on her identity? Were suicidal precautions and one-to-one close observations invasive and counterproductive? Was the sense of intense scrutiny that comes from ubiquitous staff presence experienced as oppressive, and did that scrutiny induce restlessness and frustration? For Ms. T, did any of these negative emotions and behaviors outweigh any benefit that suicide precaution might have had in providing a temporary aura of safety? Was Ms. T received less favorably by staff because of her repetitious suicidal behavior?

Staff-patient interactions can be confrontational and abrasive, marked by mutual hostility, anger, and mistrust. This intense environment can affect the judgment of both staff and patient. For many staff members, it is difficult to analyze a patient’s provocative behavior and at the same time try to rapidly respond to it. Also, one staff member can act in a way that other staff members might disagree with, and staff-staff conflict can ensue. Considering these factors, there are many times when the hospital atmosphere does not engender good therapeutics.

Many clinicians and clinical administrators believe that hospitalization is a way to prevent lawsuits. Our experience as expert witnesses over nearly three decades suggests the opposite—hospitalization does not prevent lawsuits. A good plaintiff’s attorney intent on prosecuting a negligence claim will find something that you did “wrong.” Do not carry around any illusions that because your patient is hospitalized, you are somehow off the hook of legal culpability. More important, you cannot predict which patient will die by suicide, and there are not enough beds to hospitalize everyone troubled by suicidal behavior. Think about that for a moment: If every individual who came to an emergency setting either with suicidal ideation or having made a suicide attempt were hospitalized, how many beds would need to be added to the system of care? We do not know the number but are pretty sure it is quite large.

Almost every mental health clinician has had some level of exposure to a suicide that occurs while a patient is undergoing treatment—either the clinician’s own patient or the patient of a colleague. The suicide of a patient can have a devastating effect. “What could I have done differently?” can become a painful and obsessive question for the clinician, just as for friends and family. The accusation that “You should have hospitalized your patient” can feed into troublesome second-guessing. The fear that a lawsuit will begin when a patient dies haunts many health care providers. Of course, a dispassionate reading of the literature can equally support an accusation of “Why did you hospitalize your patient?” followed by a powerful self-doubt that “I should not have hospitalized this patient.” Can you be sued for inappropriately hospitalizing a patient? It does not happen often—not yet—but fear of such lawsuits could become another worry.

Performing legally sanctioned interventions may not be the same as performing good treatment. There can be a discrepancy between what is stated in the law (a legislatively conceived attempt at health care) and what seems the best and most appropriate clinical way to approach the problem. Decisions made primarily to address liability issues are often not good treatment decisions. In the litigious climate of the United States, lawsuits can happen at any time and for any reason. The question should not be “Will I get sued?” The important question is “Have I used my training, experience, knowledge, and expertise to devise a treatment plan that can help my patient deal with the problem of suicidality?” Think clearly and document your thinking. If you do not write it down, it did not happen. Have a reasonable treatment plan and stick with it. Make sure that your clinic and your hospital document the risk management criteria that you believe represent sound practice, and then follow those criteria. Never be in the position of having to state that you did not know what those criteria were.