Therapeutic Risk Management: Suicide Postvention

Abstract

When considering critical elements involved in suicide prevention, dialogs are often dominated by suicide assessment, management, and intervention themes. Proactive consideration on what to do if a patient dies by suicide is often overlooked, which can be especially detrimental to our practice and those we serve. In this article, we extend the philosophy of the therapeutic risk management model to consider ways in which we can take good care of the extended community of suicide loss survivors, including providers. We begin by briefly describing the widespread impact of suicide loss and the lack of suicide postvention education and awareness. Given the increased likelihood that providers will be touched by suicide loss, we then provide recommendations and resources to assist the provider in developing and/or enhancing suicide postvention practices.

Suicide and Life Insurance

“…30 Although a majority of courts have upheld the "sane or insane" clause, a minority of courts have held that, if it can be shown that the decedent's mental capacity at the time meant that he/she did/could not realize that the physical consequence of the act would be death, the death would not be legally determined to be a suicide. 12,31 As noted in Table 1, in some countries (eg, Estonia and Germany), this is codified as denying imposing the exclusionary clause if a serious mental disorder "that precludes free will" was present. 32 Further, in some countries, the suicide exclusion clause incorporates this issue of mental capacity (affecting, in this case, the ability to understand the permanence of death) by defining the insured's age as a mitigating circumstance.…”

“…A common exclusion clause written into insurance contracts regards death by suicide. Suicide presents a significant problem for the insurance industry in that it is assumed (a) to be under the control of the individual (see below) and (b) that having death benefits payable to beneficiaries could encourage the insured individual to bring about death prematurely 12. Particularly for individuals burdened by intense financial strain, the belief that “to my family my death has more value than does my life” may serve as a siren call to provide financial benefits through the taking of one’s life.…”

“…In the United States. the law knows no stronger presumption than that against suicide (ie, the decedent did not die by suicide), hence the insurer bears the burden of proof to defend its determination that the decedent did die by suicide, depending on the jurisdiction by either a “great preponderance of the evidence,” “clear and convincing evidence,” or “beyond a reasonable doubt.”12,29 The basis for this presumption against suicide originated in medieval England so as to avoid the harsh penalties inflicted by English coroners’ juries 29…”

“…This phrasing does not remove from the insurer the burden to prove the death was a suicide (ie, a self‐inflicted death) with evidence—either explicit or implicit—of intent to die 30. Although a majority of courts have upheld the “sane or insane” clause, a minority of courts have held that, if it can be shown that the decedent’s mental capacity at the time meant that he/she did/could not realize that the physical consequence of the act would be death, the death would not be legally determined to be a suicide 12,31. As noted in Table 1, in some countries (eg, Estonia and Germany), this is codified as denying imposing the exclusionary clause if a serious mental disorder “that precludes free will” was present 32.…”

“…Suicide postvention extends prevention efforts by providing immediate and ongoing support to those experiencing a suicide loss. Such support is essential to mitigating negative outcomes, such as depression and suicide risk, in a cohort of individuals now at increased risk due to their own exposure to suicide 12. Forensic experts consulting on cases involving questions about suicide death and exclusionary clauses are likely to encounter unique suicide postvention opportunities.…”