When a person is at risk of suicide, the response can be considered obvious. Get them safe. But what does safety really mean? If a person tries to kill themselves, and is taken into an acute inpatient unit, are they safe? If they continue to try and kill themselves when in hospital, they may be medicated, perhaps detained under mental health legislation, even restrained. Is this safe? It might prevent a person from dying, but undoubtedly these experiences can be horrific and may not feel safe at all, with a clear distinction between physical safety and psychological safety. We quickly see that there are ethical tensions involved in working with people who are recurrently suicidal, as the interventions which intend to help can also cause harm. These are some of the most ethically complex decisions across mental health care.
The action/consequences model is a thinking tool which encourages applied ethics in risk formulation. The actions are the degree to which decisions are made to contain risk (e.g. hospital admission, medication, legislation, physical restraint) versus decisions around how much to tolerate risk (e.g. how much freedom and autonomy does a person have within or outside the input of mental health services). The consequences are what happens following either of these decisions. The idea of exploring consequences comes from the ethical philosophy of consequentialism, which sees moral worth in the consequences of actions. Whilst other moral philosophies look at duties or the intentions of the decision makers, these can feel inadequate as measures of right and wrong. Despite any sense of duty or intention, the consequences are real, and they are felt.
The actions of tolerating and containing risk are framed as having potential consequences of benefit or harm. Containing risk can ensure safety, but also cause harm through coercion and restriction. Tolerating risk respects a person autonomy and freedom, but involves the anxiety around the risk of a person dying by suicide. The model details potential consequences which require careful thought as risk can never be eliminated, only changed. Consider holding a jelly. It wobbles and is unpredictable, and if you’re not careful it can be dropped. However, if you try to contain it by squashing it, you can’t control it indefinitely and it will seep through your fingers. The risk doesn’t disappear, it just changes.
The underpinning emphasis foundational to using this model is recognition that all decisions are made and communicated in the context of human relationships which are very complicated. Great care needs to be taken to consider the mental states and experiences of all involved, aiming for empathic and caring interactions which address a persons underpinning distress, and effectively communicate intentions. These decisions and interventions will always be complex and challenging, but with dedicated attention paid to relationships, and critical thinking around ethics, they can be as helpful as possible. The jelly needs to be held delicately.
A short blog struggles to do the complexity of these issues justice, but you can learn more about the action/consequences model at this recorded webinar, available here:
The action/consequences model is a thinking tool which encourages applied ethics in risk formulation. The actions are the degree to which decisions are made to contain risk (e.g. hospital admission, medication, legislation, physical restraint) versus decisions around how much to tolerate risk (e.g. how much freedom and autonomy does a person have within or outside the input of mental health services). The consequences are what happens following either of these decisions. The idea of exploring consequences comes from the ethical philosophy of consequentialism, which sees moral worth in the consequences of actions. Whilst other moral philosophies look at duties or the intentions of the decision makers, these can feel inadequate as measures of right and wrong. Despite any sense of duty or intention, the consequences are real, and they are felt.
The actions of tolerating and containing risk are framed as having potential consequences of benefit or harm. Containing risk can ensure safety, but also cause harm through coercion and restriction. Tolerating risk respects a person autonomy and freedom, but involves the anxiety around the risk of a person dying by suicide. The model details potential consequences which require careful thought as risk can never be eliminated, only changed. Consider holding a jelly. It wobbles and is unpredictable, and if you’re not careful it can be dropped. However, if you try to contain it by squashing it, you can’t control it indefinitely and it will seep through your fingers. The risk doesn’t disappear, it just changes.
The underpinning emphasis foundational to using this model is recognition that all decisions are made and communicated in the context of human relationships which are very complicated. Great care needs to be taken to consider the mental states and experiences of all involved, aiming for empathic and caring interactions which address a persons underpinning distress, and effectively communicate intentions. These decisions and interventions will always be complex and challenging, but with dedicated attention paid to relationships, and critical thinking around ethics, they can be as helpful as possible. The jelly needs to be held delicately.
A short blog struggles to do the complexity of these issues justice, but you can learn more about the action/consequences model at this recorded webinar, available here:
