I'm posting over my fellow co-bloggers today. So what else is new?
Please visit: Hot Grand Rounds-- The Summer Solstice medical blog posts with the pretty pictures, including a pink urinal with teeth. One could ask for anything more?
And Please Visit Clink's post over on our Shrink Rap News blog on ethical issues related to the psychological report on the suspected Anthrax killer.
When you're finished reading, please return Here to comment.
When you're finished reading, please return Here to comment.
For a while now, we've been having discussions in our comment sections about the issue of forced treatment: is it right or is it wrong? Some readers are very clear: no matter how sick, no matter how imminently dangerous, no one should be held in a hospital ever against their will. One reader tells us that suicide is a right of all persons as per their free will, and by the way, psychiatrists can't predict acts of violence and have no right pretending they can. They should stand up to the legal system and say so, and not go along with the charade.
Both ideas got me wondering: is suicidal behavior that results in the attention of mental health professionals really a product of free will? As psychiatrists, many of us believe that people have unconscious motivations--- they are guided by beliefs they are unaware they hold. People commit suicide all the time-- In 2008, 34,598 people in the United States committed suicide, making it the 11th ranked cause of death. Somehow they did it despite the proliferation of mental health professionals. Many completed suicide with firearms, and my guess is that these deaths often occur without the immediate involvement of psychiatrists. Those who wish to exert their free will to die often do so without alerting others or involving professional helpers. It leads me to wonder if those that present to Emergency Rooms or to their outpatient psychiatrists might do so because they have an unconscious (or not-so unconscious) desire to be stopped. Of course there are exceptions: those who are pulled off bridges, or discovered after a serious attempt that did not kill them. Do we not summon medical care for an unconscious overdose victim on the theory that they may have wanted to die and we're interfering with the advancement of their free will?
We put up a poll a few weeks ago where we asked if people would want to be treated by force if they had an episode of severe mental illness. Of our 280 respondents, a majority, 57%, said yes while 42% said no. Would the answers have been different if I'd asked a more provocative question: If you became psychotic and believed it necessary to kill your children, would you want to be treated? It's too provocative a question for a poll, but I thought I'd throw it out there. If you became demented, agitated, and combative towards those caring for you, would you want to be treated with a medication that increased your risk of death over the next year from 2% to 4%?
Don't worry, I won't be that provocative.
The issue of predicting violence is an interesting one, and our reader is right that we're not terribly good at it. Our most powerful magical tool is to ask the patient if they're planning to harm themselves or anyone else, and the truth is sometimes more legal than medical: we're told that if we don't ask and document, that if someone kills themselves, we'd lose a malpractice suit. It does get boring asking perfectly well appearing people if they're thinking about suicide and homicide on each visit, but it is a required check box at the clinic. If they say yes, we ask about a plan and intent, and it does seem it might be troublesome to the family if a hospital discharges a person who says they plan to leave to go shoot up a mall. Or someone who has been actively psychotic, disorganized, and behaving in a dangerous manner. There's medico-legal issues, but there is also common sense and kindness, and if you believe that someone who puts the barrier of the mental health field in the way of their violence may actually want help, even if they don't put it in those terms, then there is little to argue about. Oh, go ahead, argue anyway.
Free will? So many people who survive suicide attempts are glad they did. So many who attempt do so for impulsive reasons that pass, or because they were intoxicated. I'm not much for condoning a permanent solution to what are often temporary problems.
If you want to tell us that you were hospitalized for suicidal "ideation," this is another post for another day: I'm still thinking about that one.
Dr. Szasz's article deserves placement here too. He states the case more eloquently than I can (and age 91, to boot!)
Another money quote:
"Contemporary discourse about suicide seems to be about understanding the individual who says he intends to kill himself or to whom such intention is attributed by others. In fact the true subject of such discourse is the professional identity of the psychiatrist as bona fide physician, contingent on his presumed medical competence and legal duty to “save lives,” especially the lives of persons who do not want to live."
wv = finsta. A musical fusion of fine art and gansta
Free Will is a societal and philosophic construct, a religious one, and a legal one. It is not a scientific one. Anyone who has suffered from a major depression, who has faced major losses such as the death of a loved one, knows that one’s entire sense of what is rational can change in an instant, and later be looked at with dismay at what one considered doing, or tried to do.
The psychiatrists I know have treated enough patients who have attempted suicide, lived to talk about it, and later were shocked and horrified by how they could have actually believed that their suicide was the "right" thing to do, that I no longer consider this a subject for serious consideration. To argue otherwise is to do so out of "theory" without sufficient quantities of experience thrown in. Or any experience.
Many psychiatric patients are troubled, tortured really, by a very punitive conscience. It is this conscience that may urge their self-destruction for various sins, imagined or real. They deserve to die, their families would be better off, and so on. Those who actually have family members who have suicided know how devastating, for generations, such an act can be.
Our patients need to know that we will help them. They need to know where we stand. If we as professionals support suicide through "free will" we make it far harder for them to talk with us about it, because whatever reticence there is to speak of it because they fear we would dissuade them is minor compared to the effect of knowing that your psychiatrist actually approves of such an act.
At times the most sadistic wishes can appear as rational.
I have serious mental illness that didn't respond to years of treatment. Every morning, I wake up in depression Hell. Sometimes it gets better in the afternoon, sometimes not.
My situation is much different than a person who attempts or completes suicide due to a passing crisis.
If I do eventually suicide, which I consider likely to happen someday, I consider it to be a form of euthanasia, and not an impulsive act where I would be glad to be saved. A person can take only so much unrelieved suffering. I lost my religious faith over this.
All the suicide talk always assumes that everyone can be effectively treated for depression, and then they wouldn't want to die, which isn't true.
Anon, you are right. Your situation is, unfortunately, all too common. There are depressions that have not responded to any treatments. That is true, too, for various physical illnesses. At times new treatments are discovered, or a person's response changes. A good doctor will be there with you, trying to do the best he can for you. That can mean a lot.
Thinking more about Anon's comment above. I wish there were more we could do, and many times we come up against our own powerlessness. To some extent we physicians are driven by the fantasy that our work and skill can defeat suffering and death, and many times it is true. Sadly, at times it is not, and we are left with the caring we bring to our work. To be with those in pain, to do our best for them, is no little thing. Your comment meant a lot, Anon, and I hope your depression lifts in time.
The theme for this post isn't that people don't ever decide to commit suicide for reasons that aren't impulsive, but that those who "really want to die" (and I hate to say this) do so without the attention of the troops and that it may be safe to assume that someone who tells friends, posts it on Facebook, tells their doc, alerts family, may want help, even if they say they don't. It just doesn't seem reasonable to say "free will" okay, you've called me, if you want to die, go ahead."
Last anon: there are people who specialize in treatment resistant depression---if you haven't gotten several consultations and outside opinions, please do. It's worth trying Everything for when you're in horrible pain.
I just worry that you saying maybe those who DO seek help means they subconsciously or unconsciously want help, want to be stopped . . . . this may be peculiar to only me, but I have a BIG problem with thinking that if I was really serious, I wouldn't be talking about it, or telling anyone, or asking for help . . . that if I REALLY want to do it I should keep it a secret and not tell anyone.
Where this thinking leads me is obviously a dangerous place, of not telling and planning something. It's because when I did try, as they wheeled me out the door my older sister (sort of steward over us at the time and taking care of house while parents extended 2 years out of the country) told me with scorn, "If you'd really wanted to kill yourself, you wouldn't have called 911, you would have just done it."
Granted, that's true, but it was a vicious and cruel thing to say, especially then. Especially with that last part added. So ever since I've felt secretly that when I talk about it maybe the professionals think that I really don't want to or I'd not be talking about it . . .
So now that you say that, it is sort of messing me up.
No, my own distorted thinking is messing me up, YOU or what you SAY isn't messing me up.
I'm not trying to whine or complain about what you said, just I think maybe there might be others who wonder about this, or maybe it's just me. LOL doesn't really fit . . .
Shocked to say it, but I agree with Dinah. I've been dealing with severe treatment-resistant depression for twenty one years, three (serious) suicide attempts included. It's not that telling someone makes a suicide attempt not serious, but it does clearly show some ambiguity as far as the permanence of the choice. It's either that or some serious manipulation taking place. There's just no argument for letting other people know how suicidal you are, otherwise. When you're 100% set on killing yourself, you don't tell anyone when you try it. Sarebear, what your sister said was cruel. But, as you yourself said, it was also true.
What that means in terms of involuntary treatment? Really not all that sure.
I agree that individuals who call you and tell you they want to kill themselves are probably communicating a message that they want you to help them. Any human being would want to help them. I certainly would.
The anonymous commenter proves, as I believe Dinah suggests, suicide is often freely chosen. Morally repugnant, and freely chosen. The wrong choice, freely chosen.
Has anyone read the piece at the link? If you can't wait until October for the book (on suicide prevention), see "Fatal Freedom", also by Szasz.
Wv - anduc. Diminutive sister of patti duc
IMO, suicide is caused by a (temporary) sense of hopelessness.
So I would ask you, how does psychiatry bring hope to people by the "treatments" you provide?
How do you help someone feel more included?... Isolation in a psych ward?
How do you help someone feel more empowered?... Telling them they have a lifelong brain disorder?
How do you help someone find more peace in their life?... Locking them up with strangers?
How do you help someone reach a higher level of wellness and overall functioning?... Long-term psychoactive drugs with horrific "side effects" (actually, these are "effects", not "side effects"?
Back to suicide.
Psychoactive drugs have been used since the 1950's. Have they been successful in reducing the suicide rate? Check the statistics, and you'll find the answer to be, "No." In fact, they seem to increase suicide ideation, and actual suicide, especially the "antidepressant" and "mood-stabilizer" forms. (How did psychiatry pull-off the "mood stabilizer" term for anti-convulsant drugs?.... that's a post in itself... short-answer: no more money in lithium at the time).
Duane Sherry, M.S.
Sarebear: I'm sorry to have stressed you out.
My post was aimed purely at the idea that no one should ever, on any condition, be treated against their will and that their will should be assumed purely on stated intent.
From a psychiatric point of view, many people have suicidal thoughts as a symptom of depression. Many of these people state that the thoughts come when they are depressed and that they are a symptom they have no intention of acting on. It's one more way they know they have depression. We treat them as a symptom, one that will go away when the depression is better. So a suicide attempt is not necessarily "manipulative" because the victim didn't die, it may just be a strong symptom.
It is never a good idea to mock a suicide attempt-- it's horrible when someone dies "proving" they were serious when they didn't want to die, and it happens. Somewhere someone got the idea that if someone "just wants attention" the answer is to ignore them, because you don't want to 'reinforce' the behavior that seeks attention. My personal opinion is that if someone wants attention, pay attention to them so they don't have to up the ante and do awful things. I've never seen this documented, but it seems to work much of the time.
Duane, thank you for visiting. I know you've seen people who have really horrible responses to medications. Many of the patients I see find medications helpful. Is it possible that different people respond differently to medications?
Or to psychotherapy?
The push for "evidence-based medicine" which looks for responses in a group, would lead one to believe that there is a precise "answer" for a problem. I've grown to have a great deal of respect for the idea that different people experience things (illnesses, events, the spoken word, the joy of a blog, roller coasters, and even chocolate) differently.
Jesse writes, "If we as professionals support suicide through "free will" we make it far harder for them to talk with us about it, because whatever reticence there is to speak of it because they fear we would dissuade them is minor compared to the effect of knowing that your psychiatrist actually approves of such an act."
I would disagree. I think it's the exact opposite. Had I known that confiding the anguish I was in would result in teh kind of help they had in mind, I would have kept my mouth shut and after the hospitalization that's exactly what i did for a very long time. As a result, I became increasingly depressed and fearful of confiding in anyone lest I get more "help."
EVen though it may be well intentioned, help to me is not being forced to strip in front of someone, being put in a tiny room with a metal door and a mesh window, threatened to sign an informed consent document, wondering if I'm going to be sexually assaulted by the male patient who is inviting me to give him a bj, having to earn access to sunlight and fresh air, and so on. That was not life saving, and in fact was counterproductive.
I needed someone who would walk through the darkness with me without stripping me of my right to make my own decisions. Luckily, I did eventually find a therapist like that, and that's when things began to turn around.
Don't you think there is the possibility for a change of heart after making a suicide attempt? If the desire to suicide can be impulsive, don't you also agree that the impulse might pass in a few moments time? You sister really is cruel, and I am sorry that you had to endure that insult and presumably many more from her over the course of your life.
I think we, as a society, ought to treat people who threaten or attempt suicide with kindness, not cruelty.
Regarding the post's questions:
Yes, I would want involuntary treatment if I threatened to kill my children or anyone else as a result of psychosis. If I become "demented, agitated, and combative towards those caring for" me... I assume you mean as a result of Alzheimer's, I just would want to die. I am not saying that because I am depressed. I saw my grandmother and mother go through the deterioration of Alzheimer's and I hope if I am headed down that road I am capable of committing suicide before I am too far gone to do it. Living beyond one's brain is misery. By the time my mother wanted to kill herself because she knew how bad her brain was, she was too mentally disorganized and mentally incompetent to do it. Would I want antipsychotics at that point? No. They are awful. I suppose one could justify giving them for the sake of the caregivers.
I agree that the "help" you get when you are suicidal is better to avoid at all costs. I will never ever call 911 again for a psychiatric emergency. If I die, I guess that is too bad. The price of the "help" is too high.
If I were likely to harm others, it would be different, so far as involuntary treatment. I don't know what could be done though. Antipsychotics are torture pills for me. I wouldn't want people working in the mental hospital to be at risk from my behaviors, either.
I agree with Dinah about suicide being a symptom of depression. My moods are so completely detached from anything going on in my personal life.
The truth is, I have been horribly suicidal for days because the damned sun won't come out, and my house is too messy for me to use my light box because it has been the most overcast spring in memory so I am too depressed to do anything about my home, and it gets messier and messier. It rains every day. Now long term, I mentioned before that I am likely to suicide some day, because my depression seems to be untreatable, but it would be asinine for me to kill myself today. Hmmm, killed myself because I couldn't take day #5 of cloudy weather. I keep threatening to move to New Mexico, but I already lived down south and then the moods were just randomly cycling.
I just feel like the biggest idiot, sobbing and wanting to die, and there is no reason at all, except for that it has been raining for a few days. Come on, that kind of suicidal thinking is freely chosen?
Ok, so the involuntary treatment is worse than useless. At the same time, I would hate to suicide on impulse, just because it was a cloudy day. Now that I am avoiding hospitalization, I just keep my yap shut and don't tell anyone when I am doing extremely poorly. There seems to be no way to win.
Do I sound conflicted?
Thanks Dinah. And I hope I didn't distress you too much with what I said.
Sunny, thank you. I agree that killing oneself would be taking away the possibility of changing your mind . . . I appreciate your sincere concern.
There's been plenty of times I wanted to hide my ideation, or not talk about it with my therapist. But then part of me understands that the things I'm most reluctant to talk about are often the most important things for him to know . . . I try to apply that to ANY subject I don't want to talk about, to help me open up. It's a simplification, but it helps.
And last anon, my depression hasn't responded well to treatment either. I can't say mine is as bad as yours, but I feel for you and what you have to endure. Sorry for sounding sappy, but I wanted to express my concern and caring.
So if Duane is right about psychiatric treatment not preventing suicide, and I believe he is (Marsha Linehan says the same thing.), why are we held responsible when a patient kills herself or others? I believe this burden interferes with effective treatment and makes us want to avoid involvement with them just because of the liability. And I also believe even many "mentally ill" people who kill themselves do so for reasons unrelated to the mental illness.
If you or any of your colleagues want to tinker with your own brains, and experiment with SSRIs or SNRIs, and any of the other drugs... Fine. Have at it!
But the bar is raised once you become a licensed physician.
Now, you're tinkering with other people's brains. As you know, many of these folks are in very vulnerable spots... They are looking at you as a professional, and as a doctor your first oath is to "Do no Harm."
A psychotropic drug can do almost anything. They're entirely unpredictable... and psychiatrists have no way to measure neurotransmission in a living brain... in a breathing patient.
So, you're using guesswork.... at best.
You have patients that say they are "feeling better?".... And that's enough for you to keep giving them drugs.... Is that your argument?
Well, I say it's a very weak argument.
Are they given informed consent?
Informatioin on how to slowly taper off the drugs? Because to do so quickly can cause replapse, big-time....
Are other options exhausted before the drugs... Or, more importantly, do you know about other options? Are you well-versed enough in integrative medicine to pursue them?
The drugs numb.
They provide temporary relief.
And that's all they do.
The greatest injury happens in their long-term use... They are addictive, because they meet the medical definition of physiological addiction in two vital areas:
a) Increased tolerance
b) Measurable effects during withdrawal
Have your patients look at the "side effects" more closely... Really look at what the drugs do.
Then see how many want to be placed on them.
I hope these links might help -
@ Moviedoc, I don't believe there should be liability when a patient commits suicide. I'm all for both removing the authority of psychiatrists to hospitalize people against their will and along with that remove the liability for the outcome.
If hospitalized psych patients were free to leave like in outpatient care, more people might actually want to stay.
Normally, I would say that no, you shouldn't be held responsible if a patient commits suicide.
But here is a common scenario that sadly results in many offices of medical professionals. Person is put on a psych med that has no history of suicidal ideation. Maybe for mild depression or anxiety?
He/she develops severe akasthisea which normally is a sign this med is bad news. Psychiatrist or doctor interprets this as a sign of the person's illness worsening and doubles the dose.
The person continues to deteriorate and does nothing even though a family member has expressed concern.
The person on the med ends up tragically committing suicide.
In this case, I do think the physician bears some responsibility.
I was reading a bloody depressing book about suicide, it got so bad, I had to put it down.
1 gets oh so tired of listening to 10.000 MANIACS!
First, the important stuff:
Sarebear - Please take one large economy-sized hug, imported across the Pacific, from Australia. Yes, a complete stranger in the other side of the world cares about you. Isn't the world an amazing place? I can hardly wait to find out what happens next.
Something that helped me - because for 47 years, my life wasn't worth living. It got better, but that was a pure fluke, and this isn't about me anyway.....
On a clear night, look at the stars. Each one an immense ball of elemental fire, fusing atoms, just to send photons travelling, sometimes for millions of years through vast expanses of vacuum, just so you could be there, this night, to see them.
Every atom of phosphorus, and magnesium, all the higher elements in your body, they were baked to iron in one star that died to release it, then baked again in a supernova, an immense cataclysm that outshines galaxies.
Stars died to make you, just so you could be here, tonight, to see the Universe.
Those stars you see were here long before you were born. Each photon started its journey before humans existed, and the stars will exist long after you're gone.
In light of that... are your problems really that important? Isn't it just a wonderful thing to be, to exist, to observe the comedies and tragedies and weirdness and wonder all around us?
And to be given hugs, freely, from the other side of the world.
I've been where you are too, you see. It got better for me, I can't guarantee that it will for you of course. But it might. As long as you're still around to enjoy it.
Suicide is so permanent. You don't get a do-over. It might be that, if you exit the stage too early, you won't be around to save the mother of the child that prevents World War III. Or discovers the cure for cancer.
Your existence has worth, in its own right (though you may not see that, I certainly didn't) - but also to help others. To gain a Victory from cruel Fate, so you can spit in its eye and tell it that you've won by making a worthless existence worthwhile.
And who knows... your life may, like mine, miraculously become worth living for itself alone. Stranger things have happened. Trust me on that.
"Free Will is a societal and philosophic construct, a religious one, and a legal one. It is not a scientific one."
I agree completely. As free will is not a scientific construct, it is not a medical construct either. Yet physicians, psychiatrists in particular, have taken it upon themselves (or it was placed upon them, as some of my interlocutors insist) the 'responsibility' of determining who has free will and who does not.
This is huge epistemological error. I applaud my colleagues who refuse to pretend they can determine who has free will and who doesn't. Those psychiatrists who currently pretend that they have this ability should stop doing so.
Article on mental illness by Benedict Carey in today's New York Times.
It is on severely suicidal people. I tried to put a link above but it doesn't go through.
While I hope I would never want to kill my children due to psychosis, I have been involuntarily treated and hospitalized for a psychotic episode that "merely" rendered me running up and down the halls trying to stop a vast conspiracy and generally being a pain in the butt. I'm pretty sure that this episode would've subsided in a month or so anyway, so I don't think forced treatment with antipsychotics is all that and a bag of chips. The hospital was good for making a diagnosis--nothing more. Most mental health facilities are less than therapeutic and are a little like junior high school: The staff dotes on the popular ones and the ratio of psychiatrist (teacher) to patient (student) is 1 to 30. In my case anyway, nurses whisper to others, "I can't believe she did that!" when they are standing right outside your room.
I was one of the 42% who voted against involuntary treatment. I voted that way because I believe I could've been treated just as well, if not better, as an outpatient at my own pace. If the neighbors want to hide they children inside until I stablize from psychosis, that's their business, but forced treatment gets a NAY from me every time.
Is it so hard to believe that someone who has suffered for years, had treatment after treatment fail, who knows that it is not going to get any better (it never has), would really and truly want to die, in peace and with dignity, not with a bullet to the brain, not splattered on the pavement, not retching up their guts in a cold bathroom, not alone, but holding the hand of someone they love who will understand and support them and be there for them?
That is why I told someone. I will never make that mistake again.
Here's the link
Money quote from the longer piece:
"That basic idea — radical acceptance, she now calls it — became increasingly important as she began working with patients, first at a suicide clinic in Buffalo and later as a researcher. Yes, real change was possible. The emerging discipline of behaviorism taught that people could learn new behaviors — and that acting differently can in time alter underlying emotions from the top down."
Now how does she do this without drugs and ECT?
wv = devered. Delivered without the lies.
I don't believe in free will. There, I said it. Everyone who has posted gets to some degree ambivalent when the person with free will wants to harm the blogger's children. The medical system's treatment of 22 week neonates haunted me when I was pregnant. Talk about forced treatment! This may sound off topic, but there is a parallel. The parents who ARE of sound mind do not get to make any decisions to withhold care. To me the individual suffering of the baby with a likely lifetime on ventilator never speaking, sitting up, with unreadable IQ had a price tag that yielded an overall social good net loss. Yet the hospital neologist makes this decision of forced treatment. They are not vilified. No one talks about withholding their payment or calls them monsters. The baby here is the one unable to excersize free will because of social beliefs about the sanctity of life.
Welcome to being a pack animal! What we do to take care of each other we don't always all agree with, but the urge of the group to preserve its members trumps the individual. Sorry. We are mammals: notice the huddling in packs, the hierarchies. I happen to believe that socialism (not communism alà Stalin and Mao) is the best way to share resources, quell some waste, and help people with the cognitive dissonance the emptiness of "free will" as a concept creates in our culture. As Isaiah Berlin would ask "Free to be what?" Our culture's focus on the individual offers little meaningful help with that answer.
Okay, so to sum up:
Jesse said "If someone thinks their family would be better off if they killed themselves, they can't be thinking rationally." (I agree. Anybody for whom it might actually be true would never think about it in the first place.)
Anon said "If I kill myself, it will be because of long-term conditions that are no longer endurable, and would be a though-out decision."
Sarebear said "I don't want anybody to belittle my suffering."
Dinah said "Let's not belittle anybody's suffering."
Leslie said "It is not helpful to be treated like crap."
The next anon said "I disagree with Jesse's statement because the quality of involuntary 'care' is so incredibly low."
Sunny CA said "it could be perfectly rational not to want to prolong a degenerative, fatal disease that causes one to lose all independence and dignity."
The next anon said "I'm feeling suicidal and I know it's environmental, but I can't get help because I know that environment wouldn't be any better"
Duane said "Sometimes there are natural remedies that will work better and have fewer side effects than psychiatric medication."
AA said "If psychiatrists were held to no responsibility for patient suicide, it would invite negligence."
Zoe, reminiscent of Delenn, said "We are star stuff."
Have I got all of that about right?
Now my point: Many of these statements were posed as disagreements with others, but they don't seem to be mutually exclusive.
There's plenty of "It's not helpful to be treated like crap" from both sides, so I don't think that needs to be addressed here. Everybody here agrees that treating others like crap should be done away with.
Anon with the mess: Have you checked out flylady.net? Seriously. Just sign up for the e-mails and let them roll around your head. It's aimed at people who are sick of living in a mess but feel too overwhelmed to do anything about it. They use all these great mantras like "Housework done incorrectly still blesses your family" and "Don't try to catch up, just start where you are!" I don't keep up on it as much as I "should" but it's certainly better than if I didn't do any of it! And free. NAYY
(Argh, ran out of space!)
I agree that side effects of anti-psychotics can be devastating and that they should be more carefully considered. Never having been psychotic, I'll draw the closest comparison I can: the really bad upstairs neighbors I had at an apartment I lived at in college. The voices may not have been in my head, but they were there and hostile. When these people weren't pissed at me for things like bringing them their mail when it was put in my box by accident, the shouting and crashing coming from upstairs sounded like they must be up there killing each other. I couldn't usually hear exactly where they were saying, but the walls were echo-y and the hostility was obvious. Eventually exposure to that kind of constant hostility go to me. I started having horrible nightmares and generally losing it. If hearing voices is anything like that, but without any ability to escape, I can imagine why the side effects of antipsychotics might be worth it.
Drug companies did make some pretty outrageous claims and it seems as though the majority of doctors didn't question those claims. Should they have? It's easy to say "Yes, in the post-thalidomide world, everyone should know to question claims about new drugs." But psychiatry is a field that's still very speculative. Some things help some people, but when everything is based off of symptoms, no, it's not particularly scientific. The little that is known still leaves chicken-and-egg questions. Sure, some were just unscrupulous. Others saw hope for people for whom previous treatments hadn't worked.
As to the actual post: Dinah, I'm 96% sure that if you added a "Yes, but only if that 'involuntary' treatment adhered to criteria set forth in an advance directive" option, you would be significantly happier with your poll results. (I put involuntary in quotes there because if it adhered to an advance dirrective, I'm not sure it could be considered truely involuntary. It would be at the time, but would still have been chosen.) Most of the people who answered no or didn't answer at all did so because of very justified concerns about the quality of "help" they'd receive.
To anon way back there on akathisia, suicide and psychiatrist liability: In your example the psychiatrist was wrong. We do make mistakes. The doc should have considered with the patient the possibility of a side effect vs need for higher dose, but I submit the liability stops before the suicide. In other words, even tho the doc may have been responsible for the side effect the suicide is the patient's responsibility. Remember the patient could have stopped the drug; we don't know that the akathisia is what made the pt want to die; and suicide is probably a very rare outcome of akathisia anyway.
"the suicide is the patient's responsibility"
wv = extedi. RIP, EMK
Dr. Lindeman--I'm curious as to whether your position that "suicide is the patient's responsibility" and "the wrong choice, freely chosen" holds true for children and adolescents. If not, what would you deem the age of competence to choose to commit suicide?
Anon, your question for Dr. L is not just rhetorical. Both the age and competency tests are addressed in the WA, and probably OR death with dignity (assisted suicide) statutes. Determining Competence to Suicide...
What age? I don't know. It's a good question but it is not a medical or scientific question. That's my point.
I don't know if you have any religious training or knowledge of the story of the origins of the idea of "free will". But it goes like this: Adam and Eve were set up in perfect comfort with dominion over everything in the Garfen of Eden. Eve, of course, eats of the fruit of the Tree of Knowledge after being told not to by God. They were punished by being thrown out of the Garden of Eden and being given free will. It was part of a curse package given by an angry God. (So goes the ancient mythology.)
Maybe that's why there are so many restraints on this free will in our society? Because it not a good, safe, happy state of affairs for each individual to make any decision they want. The lone man acting on his own behalf may soothe
a certain type of male ego structure, but the rest us can make peace with the compromises required to live in the group setting. I call it maturity.
Clearly, Eve possessed free will when she ate the fruit. The snake doesn't force her, rather, he makes a rather convincing case that nothing bad will happen to her if she eats it!
"You will surely not die. For God knows that on the day that you eat thereof, your eyes will be opened, and you will be like angels, knowing good and evil." (Gen 3:4-5)
In other words, her act was not determined by forces beyond her control, it was freely chosen.
I don't remember the traditional interpretations of the meaning of the expulsion from the garden. But I remember being taught that the garden represented a sort of primeval nursery, from which man had to be expelled in order to achieve spiritual maturity.
Same text, polar opposite interpretations. That's the beauty of bible exegesis.
I believe we need to define our terms. When I say "free will" here, I'm referring to the opposite of "determinism", which says that man himself has no agency; all his actions are determined by forces beyond his control (Divine, genetic, unconscious impulse, etc)
Involuntary psychiatry rests in part on the presumption that mentally ill people lack free will, and mentally healthy people have it.
wv = clead. Past imperfect of clad
I disagree, Rob. I don't think involuntary treatment/commitment have any relation to notions about free will. If anything it's, "I don't like your free will, so I'm imposing mine." whether it relates to suicide/homicide or opposition to the communist party.
Lots of agreement here on the abysmal state of inpatient treatment. The loss of dignity associated with psychiatric hospitalization should be an embarrassment to our profession. I've always hated the token economy based concept of privilege levels and the like. As a psychiatrist, I've never been comfortable with the prison warden role inherent to being a ward psychiatrist. I don't know the answer. but I wish there was a more vigorous discussion seeking solutions. Where is the outrage from psychiatrists? We're supposed to be advocates for our patients' dignity and respect, yet we all seem complacent.
It's interesting to note, in light of your comment, that our word "heresy" derives from the Greek haeresis, meaning CHOICE. During the age of religion (and since), heresy came to mean an incorrect choice, that is, a choice contrary to teachings of the Church.
Teufelhunden, Devil Dogs are my favorite ready-to-eat snack treat! I like your comment, too.
wv = pinstr. Add the "ipes" and you have the New York Yankees
As a parent who speaks with many other parents, no one needs to be psychotic to consider killing their kids. It sounds awful, I would never do it, but what parent has not had the I could strangle them moments? It's a rhetorical question.
Other than that, I have been hospitalized while during a psychotic episode. I do believe, as another peson said above that I would have recieved better treatment in a different setting, but that is not the way the system is set up. My biggest problem lies in the fact that I have been kept against my will, medicated forcibly and locked up when I was not psychotic, not suicidal and not a danger to myself or society. I don't trust the system to figure out when I need "intervention" and when I need what it is I am asking for. It shouldn't be the case but once hospitalized, you are always seen as the crazy person and therefore eveything you say or do is suspect and could land you in a lonely, barren room awaiting "due process".
If you're not comfortable with the "warden role" in a psychiatric hospital, then why do you take on such a role... and stay in such a role?
Are you being forced to stay there?
If you're not comfortable with the lack of "outrage" from fellow psychiatrists, then why don't you do something positive with your rage?
Once again, are you forced to do nothing?
Surely, you've worked with patients who were unwilling to make changes in their life... Who kept trying the same failed methods, expecting different results.
Do you not encourage them to do something different... to try something new?
If not, why not?
Roll out the idea, put together a strategy, and make it happen.
In other words, be a good leader.
Or learn from people who have survived (and learned to thrive) after such horrific treatment.
In other words, be a good follower.
How about a 90 percent recovery rate, with newly diagnosed "schizophrenia?"....
The work of Abram Hoffer, M.D., Ph.D.... 5,000 patients over the course of 60 years -
Of if you think the nutritional approach is hogwash (like so many of your colleagues, who know nothing about nutrition... other than it "doesn't work"... ha!)....
How about the 'Open Dialogue Approach" from Lapland, Findland... with an 85 percent recovery rate from "psychosis?" -
Better yet, how about combining the best of both... Orthomolecular Medicine, and the Open Dialogue Approach?
That outta help some folks!
Duane Sherry, M.S.
Zoe Brain, your hug has been received and returned . . . THANK you doesn't begin to say it for the immense kindness and thoughtfulness of your comment.
As for the akasthesia (sp?) post, while I disagree that this sort of situation isn't something that would be happening as a broad, sweeping phenomenon with lots of psychiatrists (ie, I believe that many are good enough at their jobs to deal with this and take the person off the med), I do understand that it happens sometimes with some doctors.
Actually I'm not entirely sure what the word means, but from the sound of it, it sounds like the exact experience I had on Cymbalta. I ended up being on it for 7 months, and I turned into a zombie who was almost always in bed. I was a different person, almost a non-person. And I did have suicidal ideation caused by the medication which was reported to the doctor. Anyway, eventually after 7 months I "fired" that psychiatrist for incompetence and took myself off the med, slowly, guessing at how to titrate down off of it.
The thing is, someone says that the doctor's responsibility ends before the suicide because the patient can always come off the med themselves. While the patient CAN do this, as I did, do you KNOW how HARD it is drummed into you to not make changes to your meds without consulting your doc? The few times I've done this out of a pressing need before I've heard back from the doc, I've felt HORRIBLY guilty.
And lately, I've heard commercials for Cymbalta that say DO NOT STOP this medication without directions from your doctor. Which freaks me out a little . . . (and don't say they say it just because they want the money from people staying on it; they are warning about possible bad things happening in this section of the commercial if you take other certain meds or have certain conditions or do certain things like just stopping the med). These commercials have to be approved and I'm assuming there's medical reasoning behind everything in the warning section; what company would WANT all those horrific warnings to be associated with their drug . . .
Anyway, imagine being the patient with getting messages from all sides to not stop the medication, don't mess with it, without the doctor's approval.
Heck, every OTC medication I've seen has a variety of things they say, in x situation consult your doctor. The messages to always consult your doctor for so many things make it difficult or even impossible for some to consider stopping a medication . . . so don't just throw it out there that it's THE option for people, because especially for those with anxiety disorders, you fear the consequences of acting without doctor approval.
Still, after so many months of what was happening, I made it out of the mess. I suspect that some don't think they have that option because of this culture I talk about of you MUST consult your doctor.
wv= panties I'm not going to touch that . . .
This is the third recent post that dealt with the subject of "forced treatment".
I'd like to make a brief point, once-again, and hope not to be dragged into this, because it's very emotionally draining.
The point I'd like to make is this....
We keep calling it "treatment."
Incarceration is not treatment... It's mis-treatment.
We keep ignorning the 14th amendment:
“… nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.” – 14th Amendment, U.S. Constitution
Emphasis, on "ANY PERSON".
The Supreme Court has ruled that a person with a "mental illness" can be locked up against their will with "clear and convincing" evidence.
The court got this one wrong.
IMO, it got it wrong because it considers the current "treatment" to be beneficial to someone who does not have "insight" into their own mental/emotional state.
As was pointed out by ClinkShrink, the early laws regarding involuntary psychiatric "hospitalization" (incarceration) were based upon the isolation needed for disease control, such as the wards for tuberculosis.
But, "mental illness" is not such a "disease". And any doctor who is honest, will tell you as much.
The court likely made the assumption that the "treatments" given in psychiatric hospitals were "beneficial"...
But they are hardly beneficial.
The Supreme Court will likely hear another case... hopefully, in the not-so-distant future.
And I have faith that it will soon be required to prove "beynond a reasonable doubt" that a person is a threat to self or others... and the same person will have access to an attorney who can present options that promote healing and recovery, rather than the faile options we currently use.
One reason this subject is so tough for me, is that I come from a family with a long-line of military service... Veterans who took the oath "to defend and protect the Constitution of the United States"... and I see psychiatry spitting on the Constitution... and it really gets me angry as hell!
I've done something productive with the anger... put together a vision -
Duane Sherry, M.S.
I'm in 100% agreement with Sarebear
I got what I now think is akathisia for YEARS - it made me feel (not psychosis, I'm just being descriptive) like I was always scrabbling frantically in a pit of gravel, or there were buzzing insects in my head. I did literally want to claw my face off (too bad I have chewed my fingernails off) and struggled not to cut my chest open with my shiny Mundial sewing scissors or a sharp knife. I would sweat for hours each day not to cut myself open. I gave up on meds finally, and although I am still suicidal, it is much less intense, and I am no longer having to consciously control my behavior all the time.
Because I already had serious mental problems, I got the borderline label put on me in addition to the bipolar, and the fact that these agitation and behavioral problems were new to me, starting in in my mid 30's, was ignored. I hadn't known until recently that the borderline label was supposed to just warn other providers away from me, not be a correct diagnosis. So
I guess it didn't matter what caused the problem, the docs just wanted to get rid of me?
How was I supposed to figure out that this intense agitation was caused by the meds? I was completely messed up. I saw many psychiatrists thru the years and not one figured it out, that it was a side effect.
This idea that the patient should figure it out-it doesn't WORK. The meds mess you up!! They change who you are, and you don't realize things have changed so much for the worse. You can't think properly. And you're supposed to stay on your meds like a good psych patient, because someone with bipolar needs meds like a diabetic needs insulin.
Anyway, the whole way psychiatry is done, if the meds are driving you towards suicide, that's how it goes, I guess. The docs will not figure it out, and the patient cannot, due to being more messed up than before.
I really think this akathisia is behind a lot of the more violent suicides. I was literally sweating not to cut my chest open to let the (figurative) monster out of me.
Sarebear is right. We are taught not to go off our meds. And the docs tell you all your problems are symptoms of your illness, so keep taking the meds.
If only someone could afford a week or two in hospital to stop all the meds and start from scratch.
It's absolutely the case that numbers of patients do better without their meds. Trying different meds, or stopping them, is not like going into a clothing store and trying on a jacket, then trying another. So without being an apologist for psychiatry, it is hard often to know what to do, and it is helpful if a patient is clear about symptoms and knows the side effects of medications. A consultation can often be a good idea.
On free will: I have never heard psychiatrists talk about free will. What most every psychiatrist I know realizes is that what we think of as our "will" is variable and influenced by many factors. It is not a stable thing. Just think, for instance, of an obese person who decides to be on a diet. "I will eat no more desserts!" he exclaims. But a short time later he is passing the refrigerator and in the blink of an eye is eating from the container of ice cream. He does not fight what he now wants to do.
Chemical changes in the body can change our will; addictions produce some of the strongest changes, and serious mental illness completely changes the world seen by the patient. Speaking of will power in regard to Adam and Eve presumes they saw the Garden for what it was and understood what they were doing.
"What age? I don't know. It's a good question but it is not a medical or scientific question. That's my point."
Ahhh, Dr. Lindeman, I'm so disappointed in you. This seems to me such a cop-out for someone who puts so much stock free will.
I assume children and adolescents also possess free will. So at what point do their intellect and maturity temper their free will sufficiently to say that they are competent to choose suicide? Or should we just allow them to go ahead and make the wrong choice, freely chosen, and permanent?
You don't need to be obese to have that problem with the "no more desserts..." and the freezer and the ice cream.....
You were doing so well there for a while....sigh....
I've had the thought that even though this can be draining at times (look, Duane, something we agree on)...it's totally cool: Where else are you going to find such a conversation going between a bunch of psychiatrists (I think I counted 5-6 here), angry ex-patients and struggling current patients, a patient advocate, and a pediatrician thrown in for good measure, and who knows who else amongst the anons, plus whoever lurks silently reading.
I'm voting against free will. But Jesse, if you have any moose tracks in your freezer, please stop by later.
"We admitted we were powerless over Shrink Rap."
Seriously, another dimension of this involuntary treatment issue is the practice of hospitals and even docs like me demanding that patients sign agreements (the euphemism is forms). I would have difficulty understanding the ones I've seen when completely relaxed, free, and as free of mental illness as I ever hope to be. I can't imagine even a patient with a physical injury in an ED trying to decide whether to sign or not. For this we have judges and juries to thank.
Ah Dinah, yes, we all have that problem! That is my point. We can use our will power to do what we want, but how do we maintain what we want?
I'm hoping that the NY Times article on Marsha Linehan is available. You need to be a subscriber for some articles.
It's interesting that a person can elect to kill themselves by not agreeing to heart surgery or by refusing to take medication for serious medical conditions. I was involved with one case like this. It went to a tribunal, and in the end, the individual who refused surgery died soon after. Loved ones, parents, friends grieved. But here was one person who was not considered mentally ill. Just too frightened to undergo surgery and willing to die for that. If that is sane, then why is it so insane to take active measures to die?
Dinah, you're right, it's totally cool. It's a great conversation.
wv ailate: to cause to ail
In the spirit of Zoe Brain's comment, I hope you'll read the words to this poem...
It is sent to you with sincere hope that you will begin to understand your own worth -
I loved what you sent Sarebear!
I needed to be reminded that there are still some very caring people in this world!
That is a beautiful and meaningful poem, Duane. Thank you.
I too am delighted by what Zoe Brain said; especially that she would take the time to write something so profound and caring.
wv=layflu Um, what you do when you have the flu.
Anon, it is interesting how a cardiac patient would be allowed to make that decision. I made a similar observation while inpatient. I was hospitalized for being a danger to self. Yet, my nurse was a morbidly obese, type 2 diabetic, smoker. I think they should have been more concerned about that guy's lack of insight.
Generally, society is ok with people killing themselves. They just frown on people doing it quickly.
I've been searching for a while for a study linking "stated suicidal ideation" with completed suicide - and I can't find one. I can find many other risk factors that are linked to suicide - but I can't find a single study that links the act of saying your going to kill yourself - to actually doing it.
I just know I thought many times on my psych rotations in med school that we were treating the wrong people. The people who say they are suicidal do need help - they are asking for help - but I don't think we are stopping many people from committing suicide by locking them up for 72 hours. We are helping those who cried out,but we can't find those who are actually going to kill themselves - it's very sad.
I have only skimmed the comments but hope to come back later to thoroughly read them since I am actually currently using free will to not study for the human anatomy lab exam that I have in the am!
A bit off topic...I am interested in knowing why such a large proportion of people choose the Golden Gate Bridge for a picture on blog posts that address suicide.
Shrink2B: I remember a study linking DENIAL of intent to kill oneself to suicide risk.
Battle Weary: It's because the bridge is prettier than a picture of a detergent suicide. Looks do count no maater what people say.
Leslie: I am sure one nurse on the unit I stayed was into the meds. Tried to give me a fraction of my dose. presuamble was going to pocket the rest. Called her on it. Got my proper dose. Of course she gave me all the right doses of the APs I was prescribed. I would have shared those. Spit them out anyway.
When I first discovered Shrink Rap, I hard heartedly, selfishly thought I would mind the patients on Shrink Rap--that they would restrain the free dialogue among shrinks. But now I think what restrains actual free exchange of ideas and feeling it is the dogma of some of the compulsive, repeat bloggers. These non-shrinks, non-"patients" return to push anti-psychiatry agendas with very little feeling for what most of us who "blog" here to know to be the reality of human suffering. As a shrink, as a person, I know that we can all be patients, that all humans suffer at some time or another and can need someone to help us quite unexpectedly. This expertise can be in some area of health or human experience that we did not even know existed before that episode of illness or urgent pain. Why not form a blog of their own in which they espouse their own solutions or run for political office?
For example, I would like to get advice from other shrinks on when to report another shrink to the state board for bad practice without feeling that there is a gadfly mocking all of psychiatry in the room. But with avowed haters of psychiatry perched and waiting, how can any such mature dialogue take place? The practice of psychiatry is doubted, underpaid, and simply ignored most of the time. It would be a relief to have an open, honest forum.
(that was fun)
Golden Gate Bridge - Wikipedia, the free encyclopedia
Jump to Suicides: More people commit suicide at the Golden Gate Bridge than at any other site in the world. The deck is approximately 245 feet (75 m) ...
Suicide bridge - The Bridge (2006 film) - Verrazano-Narrows Bridge
In May, our professional society hosted "Whether, when, and how to report an impaired colleague" I didn't go. Maybe another shrink here did? If anyone (shrinkwise that is) would like to guest post on the topic, email us.
No one has comments on the post on Linehan? I think I messed up the original posting and it didn't go out to our RSS feeds right:
(I forgot to title it and it went out with the grand rounds title, oops)
Sideways, you could try sermo.com and webmd/medscape, which are restricted to docs, but alas you'll find a few psychiatry haters there too. Just have to take all the criticism with a grain of salt and see what you can learn from it.
I am from Seattle, but trained in New York. When I came back I became familiar with Linehan and DBT through referrals from therapists. My lack of comment comes from the general feeling/surmising that Dr. Linehan's history is as she describes it based on her behavior/her previous disclosures. Who better to develop Dialectical Behavioral Therapy? She is the first psychologist to realize and describe that most women with borderline personality disorder were sexually or physically molested in early childhood. Linehan was the first in the English speaking world to deconstruct Freud's "hysterics" as, in fact, having been molested in the pre-verbal stage and emerging with cracked ego structures as this having caused their symptoms (not fantasies of sex with molestation per Freud). While building on his work, she has contributed more than Kernberg to the diagnosis and treatment of Borderline Personality Disorder.
I respect that she is publicly disclosing her own past. Though I am analytically trained and too young for it, I am drawn to the work of Sheldon Kopp: therapist and patient are both pilgrims on the same road. The Rogerian approach is no longer respected in psychiatry as psychiatry is under siege. However, such self disclosure is at the center of psychiatric training process. (I think one of the weaknesses of many psychology programs is that they do not require psychotherapy of their degree candidates.)
Linehan has done more for the treatment of those with borderline personality disorder since the diagnosis was codified.
Sarebear, Duane - thank you.
I can't solve the world's problems (though that doesn't stop me from trying). I can, however, sometimes, make the world a little better, make things a little easier for individuals.
I can - so how could I not do that if it's within my power? You matter.
Hugs back atcha,
"When I first discovered Shrink Rap, I hard heartedly, selfishly thought I would mind the patients on Shrink Rap--that they would restrain the free dialogue among shrinks."
Ah, those damn pesky patients, always trying to sit at the grown-up table and butt into the grown-up conversations among the shrinks!
About the Linehan post. You linked to a New York Times article. It seemed more appropriate to comment there. I did, along with well over a hundred others. So, lots of comments on that post.
"When I first discovered Shrink Rap, I hard heartedly, selfishly thought I would mind the patients on Shrink Rap--that they would restrain the free dialogue among shrinks."
But the really funny part about that comment is that pretty well every shrink I have ever met has been in therapy or is in therapy. And some commenters here are both patients and practicing shrinks.
Not the Anon above
Oh, well, too bad you didn't read my entire post to see what actually bugs me. But now your failure to read my entire post in favor of leaping to assert that all patients have something important to say on a psychiatry blog by and for psychiatrists is bugging me because your innattention is providing an exemplar of the opposite of your assertion.
Do you believe that all doctors on a doctors only blog have only valuable insights, all of the time? If this blog is truly by and for psychiatrists ONLY then there should be a special secret link to sign in with your special secret number. Good thing the three shrinks let patients into the club because I am not sure their new book would sell very well to the doctors only community. It may not be tome-y enough for the inteeelechewal crowd that frequents bars for psychiatrists only.
There is no reason to be rude like that this. Nothing about it is productive and it is time to stop.
It's good I raised two children.
Sideways wrote: "For example, I would like to get advice from other shrinks on when to report another shrink to the state board for bad practice..."
Here's how I would look at it. A complaint to the state Board puts the license of the doctor in jeopardy. It should be reserved for a serious offense. It is a legal process.
A complaint to the state medical society might put you in touch with other Shrinks with expertise in the area at hand. The state branch of the American Psychiatric Association likewise.
Substance abuse: there are committees in all states I know of that deal with substance abuse and are connected to the state medical societie or the Boards.
The best course in any event is to discuss the situation with other Shrinks with experience in the area of concern. Information gleaned from patients has to dealt with properly. If a patient wants to make a complaint about someone, in general our role is to help him in a neutral manner. This is particularly true in the case of ethical issues, such as sexual acts. We don't become the agent for our patient without strong reasons which should be thoroughly explored.
I am sorry for my rude post. I wish be even more clear about my origin referrence to patients posting on Shrink Rap (not that I think my opinion is that important to anyone else). I have gained many insights from the patient's post on Shrink Rap and have learned something by observing the interactions between patients and between MDs and patients.
Thank you for your advice. I have spoken to the patient, her husband, and a family friend (all 3 of whom spoke to the shrink about the medication caused and looked up the prescribing record through patient's insurance company on my EMR. It is the worst case of psychiatric practice I have ever seen up close. I have been waiting for my upset/anger to calm down before going to the state board.
Has this patient asked you to report the other shrink? And also, did you have the patient's permission to look up her prior medication history through her insurance company on your EHR? What kind of power-of-attorney type of document does an insurance company need to release records like that to you?
I'm not a doctor, and I'm wondering from your post where this woman's privacy rights come in. Can you complain to the state board without violating her rights? I'm also wondering why the patient doesn't initiate the complaint against the other doctor.
Sideways Shrink--I'm not an M.D. but an attorney. Under our Code of Professional Responsibility we're ethically required to report unethical conduct of other attorneys of which we become aware. It's a hard decision, probably even harder for an M.D. I've done it on three occasions, all of which involved what I thought were pretty serious breaches of ethics. In all three cases, the attorneys involved got a slap on the wrist, though it's better than nothing. So these days I don't report these things any more. I suppose I would if there were actually criminal misconduct involved, or a client's interests were seriously damaged, but overall when I weigh the bad will accrued from reporting another attorney against the probability that the state bar association will actually take meaningful enforcement action, I've decided that it's just not worth it.
BTW--I was just joking with the "sit at the grown-up table" comment. Peace.
I believe it was either 1980 or 1981 the Supreme Court found that psychiatrist predicting the future violence/non-violence of patients for the benefit of criminal courts were wrong twice as often as they were right. In other words, the courts would be better on average if they didn't make predictions at all.
Late to this party, but here are a few thoughts:
Suicide is the farthest "downstream" result of intolerable distressors. So predicting "violence" as a proxy for a suicidal act as prevention isn't leading anywhere.
Going upstream to identify the distressors and to help identify who is separating from life might be more useful in developing resources to lower distress and to identify people who are alligning with thoughts of death.
The two researchers doing that work are Thomas Joiner - he idnetified perceived burdensomeness and thwarted belongingness as the two key distressors - and Matthew Nock who developed the implicit attention test(IAT) for suicidal ideation.
I'll provide links, but I'm afraid that Blogger is really a new generation of PacMan - it gobbles them.
Joiner is a psychology professor at Florida State University, and his books are easy reads. His academic pubs are also key to developing further understanding.
One thing that gets misunderstood is that people who commit suicide are trying to STOP pain/suffering. They are not trying further hurt themselves. Conflating these concepts has done a lot to keep research and treatment stuck in the middle ages.
I am a psychiatrist, and I agree with the sentiment that involuntary hospitalization is not the answer to suicidal behavior. Hospitalization, in most environments I've seen, is God awful: no place you would want to envision yourself or a loved one. I hate admitting someone voluntarily, especially if they're not psychotic. The reason we admit is because we HAVE TO. When you present to us in an ER in the wake of a botched attempt, or convey intent to die during an outpatient session, our hands are tied: we have to admit you, unless we want to subject ourselves to a career punctuated by law suits.
I'm a big believer in patient autonomy. I am an early career psychiatrists with a lot of doubts about what we can and can't do as a profession. I don't see much benefit in involuntarily admitting non-psychotic suicidal patients. It's often a revolving door that leads to dysfunctional relationship between that patient and the MH system as a whole. I think we should empower patients to be responsible for their own lives. I certainly think we should voluntarily admit patients who feel they require such for their own safety. I think we need more and improved outpatient safety plans (those would rely on a reliable social network, that's sadly not usually available).
Listen, I didn't go into psychiatry to be a part of some gestapo. I don't feel the urge to save every mental health patient who doesn't want treatment. I feel, that as a doctor, the duty to care for those who seek my care. Should society have laws to involuntarily treat people? Perhaps, but that IMHO should be carried out by non-clinicians. I don't like the idea of a doctor--a healer--who deprives someone of his or her liberty and forces "treatment" upon them that they reject.
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