Sunday, June 02, 2013

The Emancipated Patient


On our last blog post pseudo-Kristen laid the groundwork for what I'm about to say. In a comment there she said:

"I want the same scenario as the cancer patient. I want to say, as someone who is presently competent to make decisions, that this form of intervention was not life saving for me, it was harmful to me personally and drove me further from care. I want to be able to opt out of all forced treatment in case of psychiatric emergency…"

Presently this isn't possible. Although psychiatric advance directives exist, the reaction I've gotten from both doctors and patients is that they are essentially useless. Doctors don't like them because they can lose the ability to give involuntary medications---leading to a patient taking up a hospital bed who can't be treated. Patients don't like them because in many states they can't be used to prevent civil commitment.

This got me thinking. What would happen if advance directives had teeth? What would be the outcome if certain patients, after a certain process, were essentially exempt from ever being subject to involuntary care?

There is an analogous process we can look to in juvenile law. (Forgive the comparison, I'm not implying that psychiatric patients should be or are lesser than adults although I'm sure sometimes it feels that way.)

In juvenile law, if someone can prove that he is living independently of his parents and is not financially dependent on them, or is married and raising a child, he may have himself declared emancipated by a judge. This essentially grants the chronological juvenile the same legal rights as an adult---he can sign contracts, consent or refuse medical treatments, and do other things not otherwise available to children.

Imagine a process by which a psychiatric patient could claim absolute treatment decision rights. He has perfect insight, has a reasonable understanding of what his illness is and what the symptoms are, the effects these symptoms have on his loved ones and employment, and all the possible ramifications of getting sick (yes, even the risk of suicide or criminal acts). Let's temporarily suspend all the obvious objections to this from family, psychiatry, and society in general and assume for the sake of discussion that such a process were magically adopted by the legislature.

Voila. You're free.

What happens next?

Ideally, nothing different. The patient gets better on his own or with the voluntary help of a mental health professional on either an outpatient basis or with a consenting inpatient admission.

Maybe he doesn't get better, but also doesn't want the "help." He struggles along on a daily basis, maybe functional or not-as-functional as he might be. Maybe he doesn't struggle along. He stops eating, stops bathing, stops drinking, loses weight and his family gets worried. He still doesn't want the "help."

Here's the point where everybody really starts getting nervous. The ugly question, the question not to be said out loud by any psychiatrist:

Should a psychiatric patient have the right to let himself die? (I feel a bit sick just writing that.)

At this point let me be clear that my own personal opinion is NO. This is only a theoretical discussion.

Now let's make things even more complicated. I'm going to draw on a real life, actual legal opinion for this hypothetical.

Before our hypothetical patient drew up his motion for emancipation he had to be assessed as competent to file for emancipation. Psychiatric advance directives have a similar requirement. But the Federal Court of Appeals for the state of Vermont has said that this is a violation of the Americans with Disabilities Act since medical patients don't have to prove competence before signing a medical advance directive. In Vermont, a theoretically incompetent person could sign an advance directive refusing all psychiatric care.

Personally I think a formal emancipation process would be better than taking that risk.

I could take this one step further and make the hypothetical even more extreme by pointing out that Vermont also just passed a law allowing physician assisted suicide (what if you want the right to die due to an terminal-if-untreated psychiatric condition?). I think I'll stop here for now. This slope is slippery enough.



Dinah said...

I think I finally got it when one of our readers said they have never been homicidal. The assumption is that if you've had an episode of mental illness, then future episodes will take the same form. This may or may not be true.

So if a seriously recurrently dangerous patient has an advance directive forbidding hospitalization or medication, should they be permitted to continue in treatment where they go to therapy each week and talk about plan to rape or harm people? What if they are a known sex offender? Do therapists have to sit there listening to something they feel terribly uncomfortable with, a complicit forced treater? Today's the day I jump, doc, take care and I'll see you in the next world.

Medical advance directives have caveats. If you have a very curable cancer, you may be able to say that if you progress to a terminal state, you don't want certain measures, but I don't think a doctor is going to be happy doing a minor procedure (say placing a port for chemo) on a patient who says Hey if I have an allergic reaction to the anesthesia, you have to let me die, no extreme measures, ever, under any circumstances.

jesse said...

One problem with these hypothetical scenarios is that they are so far from what actually happens in practice. Never, ever, has a patient sat week after week in my office talking about a plan he truyl intends to set into motion in order to die, but many times patients have brought up suicidal ideation, the wish to die, how worthless life is, and related thoughts, without my taking any action other than listening and responding as thoughtfully as I could.

It is also a fact that one does not need complex solutions in order to die. There are numerous ways in which it is easily done. If one went on a hunger strike in his apartment and had the fortitude to see it through it is possible to do it.

But if a patient is in my office and is talking about dying there is something that he wants back from me. Careful listening, thinking of how to help him, a consultation with another practitioner (for the doctor, the patient, or both!), a family intervention: SOMETHING. In the examples given by patients here on Shrink Rap one of the more common themes is that they wanted to talk but the doctor took action, and that particular action was not helpful. Too frequently there is a breakdown and the doctor acted inappropriately.

It is also true that frequently the patient brought to the ER has been acting in a way that has led to action from others, and the ER psychiatrist is only the last person on the chain of events. Yes, they can end up in jail rather than in a hospital. The alternative to forced hospitalization is not complete freedom. We live in a society and there are constraints on all of us. As Oliver wendell Holmes said, "Your right to swing your fist ends where my nose begins."

Anonymous said...

I apologize for the length – brevity has never been my strong suit.
This is actually something that I have been thinking about quite a bit lately and I have to say, I disagree with you. I absolutely believe that Psychiatric patients should have the right to die and the right to allow themselves to die.
I am not saying this lightly – I have seen ill family members refuse treatment, languish, and even succumb to suicide and I have seen the devastating effects that it can have on those left behind. My father continues to blame himself for the death of my grandfather 12 years ago, and it has certainly negatively affected many aspects of his life. I definitely understand the gravity of the act, and while I cannot speak for my grandfather, my other family members, or anyone else who has refused forced treatment or taken their own lives, I can speak as someone with a diagnosable psychiatric condition who would like that option afforded to me.
I know what happens when I stop treatment. I have spent enough time clawing my way out of this gigantic crater filled with tens of thousands of dollars of debt (on top of student loans), speeding tickets, burnt bridges, terrible decisions, and, most of all, extreme guilt, that I get it. Yes. It is bad. Okay. I am also 21 years old, which makes me a legal adult and fully culpable for my actions. I do not, under any circumstances, want to be admitted to a psychiatric hospital. If I become a danger to myself, live and let live. If I become a danger to others, charge me with criminal intent and throw me in jail. By forfeiting forced treatment, I believe that I waive my right to an insanity defense. If a therapist is uncomfortable with the topic of our discussion or anything else about myself or the session then he or she should be free to “fire me” regardless of whether I have an advanced directive or not. If I waive my right to forced treatment, then it is absolutely my choice and it absolutely should be respected, but that certainly does not give me carte blanche with regard to infringing upon the comfort and safety of others. In such circumstances, I should be held appropriately accountable as if I were not at all ill, because, as I am to be treated in accordance with the wishes of my competent self, I should also be treated with the responsibilities that would befall the competent self. When I signed the advanced directive, I did know the risks.
Having a mental illness is infuriating. I very much like to be in control of my life and I celebrated being an autonomous human being, which is something that I think most everyone enjoys, but being ill has forced me to rely on others – psychiatrists to prescribe medication, parents for insurance, and even the medication itself for stability. It feels as though everyone (except the creditors, of course!) view me as less capable as a result. It’s just not the way that I want to live my life. It makes me feel lesser and degrades my quality of living substantially. I feel that if I want to die with dignity, I should be allowed that right, as should anyone else in my position.

Anonymous said...

I love ethical and legal discussions. I'm going to have to think on all this before I respond to Clink's proposal.

I do want to say, though, that in arguing for an advance directive that allows a patient to opt out of forced treatment I am not arguing in favor of rational suicide. I am actually saying I would want a different approach in an emergency situation which I think is different. Of course, death could be the result if there is no forced intervention but it can also be the result if hospitalization goes badly, too. Anyway, you guys have given me a lot to think about. I'm going to try to assemble all the thoughts in my head into a coherent response.


roblindeman said...

"What would be the outcome if certain patients, after a certain process, were essentially exempt from ever being subject to involuntary care?"

Extend that to all people after no process. Now may we negotiate?

"There is an analogous process we can look to in juvenile law. (Forgive the comparison, I'm not implying that psychiatric patients should be or are lesser than adults although I'm sure sometimes it feels that way.)"

But this is precisely the way people with "mental illness" are treated and have been since the 18th century.

"Viola" was a nice touch. Much richer and more soulful than the violin, IMO.

And you state without explanation WHY it is that people should not be permitted to let themselves die, as if it were an axiom that individuals do not own their lives.

Without meaning to, Clink, I believe you stated, not in so many words, precisely what is wrong with psychiatry today: that you treat adults like children. Why else frame the discussion in terms of emancipation?

Dinah said...

36,000 people a year choose to commit suicide.

I think that is a travesty and the tragedy that is inflicted on the survivors is horrible. But I'm not standing in their way. Obviously, it can be done.

But if you are going to walk into an emergency room or a psychiatrist's office or tell a friend or relative first, one might expect some intervention.

roblindeman said...


If you're going to walk into an emergency room or tell a friend or relative, then one possibility is that you are "playing the suicide game". By this I mean your actions communicate to others something like the following: "I am in distress. Please help me".

It does NOT follow, however, that the kind of help you are asking for is to be involuntarily "hospitalized". Sadly, if that IS what you are asking for, you will have no trouble finding what you're looking for.

jcat said...

Ok, as someone who has failed at suicide once (albeit not for lack of effort) and been suicidal on and off for many years, I strongly believe in everyone's right to die at any time. It would be nice if it could be done with dignity, but assisted euthanasia for psychiatric illnesses will be a long time coming, if ever.

That said, if you are suicidal, and tell ANYONE, I believe you lose the right to refuse involuntary treatment. If you don't want help, then don't put that burden on anyone else - family, friends or therapists. If you want to talk, then call one of the right-to-die organisations, and chat to them. If you try it and stuff it up, then expect involuntary help, because that's the way the human race is - mostly, we don't like people to die without trying to help them.

If you are, or appear to be, a danger to others, then tough shit. You lose the right to refuse any and all forms of treatment right there. Do what you will to yourself, quietly, but you do not have the right to do to others. And hospitalisation and medication are unfortunately the most efficient options available - you can't send someone to prison for something they haven't done yet, and you can't leave them out there to do it. Even if they have never before acted on those possibilities.

As a non-American, I've been following the whole involuntary treatment debate here with some amazement. There's an awful lot written in comments about the patient's rights to refuse treatment with little consideration from them of other people's rights. Easy answer? If you don't want to be medicated, and don't want to be hospitalised, then don't act in ways that will lead to that in front of other people. Keep it to yourself, and you'll continue to have those choices.

Harsh, maybe, but true, and for those reasons, totally watertight advance directives for psychiatric illnesses will never really exist.

jesse said...

All day I've been thinking about my previous comments on this subject, waiting to get home to write a clarification, because I don't think I was clear enough. So to see the people (including Rob!) who are making essentially the same argument gives me hope. I was afraid it would go in the other direction.

This advance directive stuff is just plain wrong. It is against the most basic tenets of our profession, as well as our society. It is obvious that there are many ways to die, and each year many people figure them out. But when a patient comes into my office, however depressed he may be, however suicidal, however without hope, there is some voice in him that is asking for help. it is my obligation to listen to that voice, however weak and quiet, and help as best I can.

The effort to engage the State, to ask for help in carrying out our deaths, is asking others to share in a responsibility that should be ours alone, asking others to ignore that voice and to listen instead to our illness, our rage, our murderous impulses, rationalized to be clean and antiseptic.

A man once went to a priest and asked if he could help him get to Hell. "I am fascinated by the Devil," he said. The priest said that he would gladly help him find salvation, but that if he were intent on going to Hell he should have no trouble finding within himself the means to do so. He should not try to enlist others in that pursuit.

And nor should we.

Joel Hassman, MD said...

"A man once went to a priest and asked if he could help him get to Hell. "I am fascinated by the Devil," he said. The priest said that he would gladly help him find salvation, but that if he were intent on going to Hell he should have no trouble finding within himself the means to do so. He should not try to enlist others in that pursuit.

And nor should we."

That's good! Reminds me of a good joke, doubt it would be appreciated here, but here goes anyway:

"what did the masochist say to the sadist: Hurt me!"

"and the sadist replied: No!!!"

Freud would have had a field day with that one!

People are just trying to trap us into an outcome that makes us lose, and to me, doing too much is really less a negative outcome than doing too little. The adage "misery loves company" is a mind set fueling some of this behavior being falsely debated at the prior post.

I don't get this PC fueled understanding that does not promote care, just enabling, to me at least.

People with realistic insight and judgment have come back to tell me they appreciated I called them on trying to set up a failed outcome when they first presented with SI without an opportunity for a positive outcome.

To me, some of the murder-suicide thinking that is more common place these days, just not a frank murder by the patient, but a slow death for the provider as retroactive justice by the patient. Think about it as a hypothesis.

Anonymous said...

Should a psychiatric patient be allowed to let themselves die? I agree the answer should be no, but outside the US the answer is yes in certain places. I had a friend in Switzerland who had been anorexic since her early teen years who at age 20 decided she was ready to die and chose to stop eating entirely. Her family brought her to the hospital and the doctors said she legally had the right to end her own life, and was given palliative care for a week or two in the hospital until she died. This is not a heard-it-on-the-grapevine story, this really happened to my friend.

ClinkShrink said...

It's interesting how different the response to this post has been compared to all the others we've had on this blog regarding involuntary treatment.

Just out of curiosity, I went back and looked at all our posts that were tagged with "civil commitment." There were ten that had involuntary treatment as the main theme. On all of these posts the commenters were mostly patients, almost all talking about their negative experiences with civil commitment and how they'd never go to treatment again if they had to risk this.

Yet this post, discussing a theoretical way to be immune from involuntary treatment, has generated comment mainly from doctors and mainly to register objection.

I wonder if this is an indirect measure of the stigma that is attached to discussion of suicide, even among psychiatrists? The message that seems to be getting communicated is, "patients can already do this anytime they want, so why should we legitimize the process? They already can 'off' themselves as long as they don't involve me."

I'm thinking about this because we have a number of readers who are even afraid to set foot in a psychiatrist's office, much less talk about their suicidal thoughts. In my own clinic inmates often withhold their history of self-injurious behaviors at intake screening for fear of being put on suicide watch. I think figurative or literal immunity might bring more people into care who otherwise would run from it as fast as they could.

Conversely, the relative lack of patient comment also makes me wonder. Do our patient readers think it's an exercise in futility to even talk about emancipation? Or are they truly not quite so absolute about their objections?

I pretty much took it for granted that psychiatrists would be opposed to this idea but I'm curious about the silence from patients.

I know pseudo-Kristen is thinking and putting together her thoughts. What do the rest of you think?

Rob: Thank you for pointing out my typo. I'll fix it.

Anonymous said...

I do not support physician assisted suicide. I am not requesting a physician kill me. In fact, please don't kill me.

Just an hour ago I was reading this blog and a couple of Jehovah Witness believers stopped by my house. I converted. I decided I better run up to the hospital and get that on file, in case of an emergency. I definitely don't want blood as it violates my religious beliefs. So, as I walked back to my car I was playing candy crush on my iphone and inadvertently stepped out into the street without looking. Rob swerved to avoid hitting me, but it was too late. The doctors tell me if I do not get blood I could die. Nope, I say I don't want blood it's against my beliefs. They plead. I have not shared my psych history with them, I am oriented X 4, I sound reasonable except for the refusal of blood. But, how could you let them bring you to the hospital for help if you were only going to refuse the help they offered some wondered. I want help, just not blood. The blood loss is significant, and I am starting to fade. They plead with me to accept a transfusion, but I am resolute in my beliefs They respect my wishes. If I die, did the doctor kill me? Was this physician assisted suicide? I would argue no. It was a physician offering to provide treatment she believed was right, but also one who knew that I was a competent adult who had the right to decide what I did not want in an emergency. My wishes were on file. In withholding care, she did the right thing. She documented all of this in my medical record very, very well.

I am presumed to be a competent adult until proven otherwise. I can walk into a doctor's office today and sign a consent for medical treatment (or not). I can refuse blood, but I cannot refuse psychiatric care?

I see a clear difference in a competent patient requesting to discontinue or refuse treatment and a patient demanding the physician "do" something. In my state I don't have the legal right to demand my doctor "help" me die, and I'm glad that is the way it is. But, I come back to the fact that as a competent adult I have the legal right to refuse life saving treatment yet strangely I cannot refuse emergency psychiatric treatment. That's illogical. I have the legal right to make decisions regarding any of my medical treatment, even stupid life ending decisions, except when it comes to psychiatric care? Why?

Like jcat said, I could have kept my mouth closed and not sought help, thus avoiding forced intervention. I wanted help, just not force. I know it was all well meaning, I get that, but it was not in my best interests.

I am hugely relieved that not all physicians and therapists believe that the way to respond to someone who is suicidal is with force. I am glad the answer, at least with the care I have now, doesn't have to be keep your mouth closed or be treated with force. Were force the only response, I suppose I would have never received help. Thankfully, with effective, voluntary treatment, I no longer live with constant obsessive suicidal thoughts. The therapist and psychiatrist I have now are able to put aside whatever personal beliefs they may have on the subject and simply do what is right for me as an individual. I understand forced treatment may have helped John Doe, but I'm not him.

As a competent adult, I want to treated with the same respect as a cancer patient who decides she doesn't want chemotherapy or a Jehovah's Witness believer who doesn't want blood. I don't want to be emancipated. I wanted to be viewed as the competent adult woman that I am. I want to be able to say, the forced approach was not helpful to me, it scared me, it drove me away, please don't ever do that to me again.


jcat said...

Wow, Pseudo-Kristen, lots to think about there. I'm glad you have good voluntary care that makes you less likely to end up in a position where treatment might be forced on you - that's pretty much what I have too.

In the case of the hypothetical Jehovah's Witness refusing a life-saving transfusion, the outcome of refusing the blood is death. Fair enough, that should be the patient's choice (although to me it is still a bit unfair to involve the doctor whose entire ethos is to preserve life. However, if you are rational enough to persuade her not to give that care....)

But what if the result of refusing blood while accepting other treatment is not either recovery or death? The patient is in the hospital, taking up a bed, receiving medical care, and although there is a slim chance that he will heal enough on his own to return to his previous competence, it is more likely that he will languish there for a long time. Meanwhile, he's lost his job, the family is unable or unwilling to support him, and he is expecting that either the state or society should pay for his care. Why should they, when with a simple blood transfusion against his will he would have recovered enough to return to his life as a competent adult?

Oh, and don't forget that while the patient was effectively making a choice to utilise these resources for an extended period, a whole bunch of other people who really wanted to get better were unable to get the care that they needed.

If the consequences of refusing treatment are limited to oneself and the people who care about you enough to look after you (be they family/friends or people that you
pay to provide that care), then fair enough. In most cases though, they impact on society as a whole, and that has to be considered against any individual right to self-determination.

Unless of course, the patient has moved to the legendary cabin in the woods - in which case he has the right to be just as cuckoo as he chooses to be.

mctps said...

The problem I have with forced treatment is that, in my experience, it doesn't do anything about the symptoms. The worst symptoms go away for me in a couple of hours or couple of days or a week anyway, with or without drugs. The drugs are a pointless annoyance, and hospitalisations can be unnecessary as well as something that makes me bored out of my mind.

I guess I can only speak for myself.

Interesting that the idea of mere suicide of a hypothetical patient would make a psychiatrist feel somewhat ill. I've been catatonic with fear due to various rational and quasi-rationa delusions or speculations involving unbearable hells, virtual reality or otherwise. Just dying and some people feeling sad about it. Shrug. Why should one feel ill if a sad life is no longer sad, is no longer anything? Is it rational, truly empathetic to let decision-making be influenced by such emotion?

Sometimes death is better than life, so that death should be made easy for those who want out. This would quickly produce a society where suicide isn't thought of as such a huge deal, and loss of someone who didn't want to live would be considered a sort of happy thing "at least he's not suffering anymore."

But then that sort of system would end the soul crushing that modern civ is all about, so we can't have that, oh no.

styles said...

I haven't had access to a computer for a while, so I haven't posted. But here is my take.

People have brought up the Jehova's Witnesses and their right to refuse blood transfusions. Someone in my own family actually died for that reason. She was my great grandmother. She was also a Lutheran. But he her daughter converted to the Jehovas Witnesses faith. Great grandma had a fall and needed a blood transfusion. Her daughter was the nearest relative. The hospital got in contact with her so she could consent to a blood transfusion for her incapacitated mother. She refused. Remember that the MOTHER was not a Jehovas Witness. Only the daughter was. Great grandma died and my my grandfather literally did not talk to his sister for like twenty years after he found out that she killed their own mother by refusing to allow a blood transfusion. I don't know if the doctors were shedding any tears.

So should psych patients be allowed to call the shots just like the Witnesses do? I say if psych patients are willing to risk dying from their mental illnesses then so be it. However, I do not feel that a Jehova's Witness or a psych patient has any right to commit criminal acts or infringe on anyone's rights. I don't think someone should refuse a blood transfusion on behalf of a relative, even though the relative obviously would have wanted one, just because the person doesn't think the relative should have one after having recently converted to another faith.

I felt very bad reading about the commenter's friend who died from anorexia at the age of 20 :( I hope she did not make a rash decision and was not immediately put on palliative care. I would hope that there would have been a long screening process and discussion of other options first. That is so young to give up. But then again, what if she had become a vegetable? Isn't that was happened to Terri Schiavo? She was bulimic, had a heart attack as a result, and was in a persistent vegetative state until finally, after a lot of controversy, they pulled out the feeding tube and refused to give her anymore food or water. Would that have been better for the Swiss girl? To become another Terri Schiavo? Everyone else making decisions about her care, family members fighting, the possibility of being vegetative for 15 plus years.

That's the only reason I am for physician assisted suicide. It is not for the successful attempts. It's for the ones where something went terribly wrong and they are in a worse situation than if they had simply died. It's like that commercial that states sometimes people don't die from smoking. Sometimes the outcome is worse. I would hope that physician assisted suicied would reduce the risk of that happening.

Joel Hassman, MD said...

The topic here is not about people who are terminally ill from a somatic point of view, and again, a little candor here, when is suicidality from a psychiatric perspective completely unbiased, objective, and accounting for how it impacts on others close to the person contemplating it?

Suicide is basically a selfish and inconsiderate choice. those who will follow and claim otherwise, tell us all how those funerals for suicides were and how so comfortable to participate in.

People who want to die do not consider how it impacts on those who want to live, and just avoiding how those others have ideas and options to negate the biased and pessimistic viewpoint that drives the desire to die.

Impulsive narrow minded ideology does not take people very far, eh?

mctps said...

@Joel Hassman

I've heard that viewpoint so often I wonder if it's something in the air.

You say suicide is selfish. But how is wanting someone suicidal to keep suffering, so that you wouldn't have to, less selfish? Tell me. Where is the empathy and altruism in your viewpoint as regards the suffering of the person who wants escape?

If the impact on those who want to live were so bad, they'd kill themselves as well. Then everyone would be happy, Shakespeare style. (Of course, we'd need assisted suicide to minimise tragic failures of attempted suicide -- a huge problem in the form of people becoming paralytics instead of dying etc etc.)

I guess my comments are uncomfortable to read. But then I've experienced intolerable depression for a year, so I know how horrible it can be. Deep sorrow is heavenly bliss in comparison, so please just shut up about things you haven't got a clue about.

Je suis said...

@Joel Hassman, MD

"People who want to die do not consider how it impacts on those who want to live"

Why is it that this argument is always the default or fallback position for anyone arguing against suicide? If suicide is basically a a selfish and inconsiderate choice, then preventing the suicide of someone who is suffering - in whatever form - enough to attempt suicide is also selfish and inconsiderate, since all you are doing is prolonging an agony that has become unendurable. Is name-calling really the answer?
Then again, from a patient perspective, drugs and talk is really all you've got to offer, and frequently, it's far too little. Especially with the potential side-effects of the medications, and the exorbitant costs for a little "fireside chat", so to speak. So maybe the name-calling, and attempted guilt, are a final, desperate attempt to prevent a suicide? I can't see any other reason for it.

As for how it impacts others, well, most of our decisions impact others in some way; so what you really are referring to is the degree of impact. Even so, we all have to make our decisions for ourselves, regardless of how they affect someone else. You simply cannot live your life for someone else, making all your decisions based on how it will affect others. That ain't healthy, is it? So why is this suddenly the
go-to reason for not committing suicide?

And "narrow minded ideology"? Kind of like yours, where your answer is the only right one? The truth is, there is "more under heaven than dreamed of in your "philosophy", and you do not have a monopoly on the answers to the big questions. It's different for everyone.

Je suis said...

I disagree with at least some of your positions, to wit;

"That said, if you are suicidal, and tell ANYONE, I believe you lose the right to refuse involuntary treatment."

Why? Keep in mind that, ultimately, the patient is a consumer, and mental health care is a business, just like any other. Why, based on an utterance, should one be forced into a business transaction against their will?

"If you appear" (not are, which require concrete proof of course) "to be a danger to others"," you lose the right to refuse any and all forms of treatment". This is so ridiculous that I have a hard time believing anyone truly believes it. Let's see, the TSA searches travelers based on the presumption that any of them could be a terrorist, since terrorists appear much the same as the rest of us. Given that, we all appear to be terrorists. According to you, we all should be imprisoned then without rights as we appear to be a danger to others. A bit of a stretch, perhaps, but well within the context. Are you aware that there is a thing here called a restraining order, issued when one party feels threatened by another (among other reasons)? Yet that restrained party is not locked up and deprived of their rights, since they have not yet been proven to be a threat, just suspected. Why is that, do you think? Because that's a very slippery slope, and this country was founded on certain freedoms that are inalienable, ones that are not supposed to just disappear at a whim.

mctps said...

"the biased and pessimistic viewpoint that drives the desire to die"

This isn't my experience at all. What drove the desire to die for me was the intolerable emotional condition in which I found myself without apparent cause.

Then it suddenly disappeared last September, although nothing remotely significant in my life had changed.

Nobody kills himself because of philosophy. As Nietzsche realised, a philosophy, a perspective of pessimism, is merely a symptom of deeper problems. It's not the cause, it's the effect.

A normal person kills himself because life has become emotionally intolerable, often due to factors or influences that are hidden or realistically un-changeable. But before he kills himself, he rationalises his choice, and this is where ideas and other ideological symptoms may become apparent. They aren't the cause.

Then there are the inexplicable suicides that *seem* to be due to expectations that are too high, revenge, hatred, or loss of position, status, honor. Some of these aren't very relevant to the modern world and I don't really understand any of them personally.

EasternShoreMD said...

@ Joel Hassman
Suicide does have a lot of anger behind it, and it does cause those who are "left" behind a lot of grief and conflict. But what about the person's grief and conflict who takes the act. Does he or she really sit there and thing - hummm, maybe I'll be selfish today, I think I'll just check out.

Empathy???? There but by the grace of God??? It is difficult to read your comments and not feel that you accuse mentally ill persons of being mentally ill.

Brenda C Scribner, MD
Psychiatrist-in MD

styles said...

Joel, I will not pretend to read the minds of people who have wanted to die or to know their intentions. I will certainly not talk about what went on in the minds of those who actually succeeded. They aren't here anymore to ask and I will let them rest in peace.

Dinah said...

I'm glad you didn't kill yourself because I like what you have to add to Shrink Rap.

In the last few weeks, I have heard of 4 close-to-home suicides (meaning patients of friends, colleague of a relative, an acquaintance of mine).
They all left incredible trails of pain.

We know the numbers are rising, that suicides now out-number motor vehicle deaths.

It's all so tragic.

Joel Hassman, MD said...

If this issue appears to be so cut and dry to responding readers, just do this one "simple" thing before you either consider acting on suicidal impulses, or continue to advocate that suicide is an inherent right:

go to the funeral of a suicide.

Having been there as a friend, family member, and professional, it is probably the most painful experience you will have as a mourner. You listen to dozens of people just ask themselves "what could I have done to prevent this" and "why didn't he/she tell us of the pain".

For the one example that is perhaps somewhat an exception to this that could even remotely justify a suicidal act, the next 48-49 will not.

Yes, people have the right to choices, but, to argue with me that choice solely trumps the feelings of those who care about the suicidal patient, well, one reason why you try to be in treatment and engage these people.

Suicide is not a Tom Sawyer experience, and I have met people who give that illusion there are outs.

I leave you all with this vignette: As a resident, I had a woman in her late 20's with a history of suicidal gesturing, who one night, in a fit of anger with her current boyfriend who did not do what she wanted, OD'd on 20 extra strength Tylenol and then drank about a fifth of liquor to then pass out. When she awoke about 5 hours later, she went to the ER and asked for help, but, the tylenol was absorbed, and she blew out her liver. I spent the next 3 weeks trying to comfort her, along with her family, as she died of acute liver failure. She didn't want to die, she just made a very bad choice in trying to get attention.

Which is the textbook example of lethal gesturing. I hope some readers who have written here spend the moment to digest, pun intended, the point of the above tale. You can't fake it and then make it right.

I do not expect to figure out the right answer or formula to prevent those 30,000 deaths a year. But, if I can create some doubt and reconsideration in any reader and make it 29,999 , then, I have hopefully made a difference for the better.

And to my colleague above, you have an issue with what I write about, maybe talk to me in person, like we were together in the office today?

"It is difficult to read your comments and not feel that you accuse mentally ill persons of being mentally ill." Really, thanks for the vote of support from a colleague.

And what a wonderful venue to attack a colleague, I hope you are proud and vindicated.

Dinah said...


Please stop. Everyone is just feeling hurt and this has ceased to be productive.

jesse said...

@mctps: yes, right on. To your last comment an honest "Amen."

One fact that no one would dispute is that once a person has suicided no further change in his life is possible. It is the end. While hope was totally gone at the moment of suicide, those of us who work in this field know of many people who were suicidal, lost all hope, believed no recovery possible, yet did in fact recover and lived long and fulfilled lives.

It is also the case that many people who suicide do not do it, in fact, simply to end pain but rather to cause some effect on others. A wish, perhaps, that "after I am gone he will realize how much I loved him." It is quite rare that suicide does not have some motive such as this, which may or may not be conscious to the one who suicided. That this is true is born out by the notes that are frequently left behind. There are also quite sadistic impulses which are acted out with no apparent conscious understanding: How many of us have heard of family members who shot themselves with their parents guns, in their homes, leaving themselves to be found by the family, blood everywhere, but with a note stating how much better the family will be without them. I know of situations like this in which the terrible pain is now in the third generation of descendents...

So while I appreciate the honesty, and sensitivity, of many of the comments here, these comments were written by living people. Many are in therapy, with good therapists (it is hopeful that so many of the commenters here speak so well of their therapists) and are not, in fact, suicides. It seems that what they are so well arguing for is really the right to be able to suicide. That right to die, the belief in its possibility, may actually be a force that helps them go on, and hopefully they will be able to resolve their difficulties sufficiently that someday they will be glad they got through this terrible time.

jesse said...

Sorry Dinah, our comments crossed in the mail. I had not read Joel Hassman's last comment before I posted mine.

ClinkShrink said...

"That right to die, the belief in its possibility, may actually be a force that helps them go on"

Well said, Jesse. I think it's true that having a sense of control over one's destiny is someties the first step in taking control of one's life.

Anonymous said...

"Impulsive narrow minded ideology does not take people very far, eh?"

No, Dr. Hassman, it does not take a person very far at all. Irony, however, can make one's day.

Anonymous said...

Jcat says "if you ... appear to be, a danger to others, then tough shit. You lose the right to refuse any and all forms of treatment right there."

Psych patients and Gauntanamo prisoners are the only persons under U.S. law who get locked up based on an appearance of dangerousness, I guess.

Anonymous said...

I think some of you psychiatrists need psychiatrists! The psych patients behave better on this blog, lol!

Anonymous said...

I am not arguing for the right to suicide. I already have that right. I know how. I am actually arguing that forced intervention, while well intentioned, may actually push some patients closer to suicide. That's not good. It also may distance some from receiving the treatment that could help them. I think it's important for psychiatrists and therapists to listen to patients who have been in those situations as to what helped them and what didn't so they can best help that individual patient. I'm an introvert, and having a lot of people in my face wasn't helpful or life saving. It was scary and anxiety provoking. I recognize, though, that others feel hospitalization saved them. Maybe we could find a way to let those it harmed opt out, which would allow them to feel comfortable enough to get help without feeling so threatened. I don't believe that no hospitalization = death.

Perhaps the moral of the story is to choose your mental health professionals wisely. If forced intervention is a deal breaker, it's probably good to find out up front how often and under what conditions the therapist and/or psychiatrist responds this way. Some are certainly more calm and rational than others.


Anonymous said...

I do not believe that anyone should be forced to receive medical care that they do not want. Drawing lines is never as objective a process as we would like it to be. Once you begin, it’s a slippery slope. However, when it comes to suicide, there is no good answer.

Someone is always left suffering.
Dr. Hassman’s point about attending the funeral of someone who has committed suicide is a good one. It’s hard to really appreciate the gravity of the shocked silence that sort of hangs in the air until you’ve actually been there. It’s a truly harrowing experience. A closed-casket viewing in a Catholic church with the fate of the suicided soul being the stifling elephant in the room is an experience I will never forget. People were blaming themselves. They were blaming each other. They’re still at it today. They never really stop.

At the same time, I can’t help but wonder that if there were an option to discuss suicidal ideation without the fear of immediately forfeiting your rights, it might lead to a smaller number of people actually going through with the act. Jesse, I think, is spot on when she refers to the empowerment of choice. A suicidal person would have the ability to discuss options of which they may not be aware in a very real way – a way which they may not currently feel comfortable doing, knowing the potential consequences. I also think that the possibility exists than opening up suicide/right-to-die conversations with family members could allow for some closure on all sides. Suicide behind closed doors leaves a lot of painful questions that no note can ever adequately answer.

I suppose my main concern, personally, with forced hospitalization is not with regard to suicide. If I’m really going to do it, I’ll do it quietly and I won’t mess it up. It’s hospitalization at those times when the person has no interest in dying, has no interest in hospitalization, but instead has a vested interest in running barefoot down a four-lane highway in the rain at 3 in the morning in the name of science. They don’t want to die, but they might if they keep it up. They don’t want to be hospitalized, but if they don’t want to die, they should be. How does one act on their wishes when their wishes are conflicting? I suppose they would default to the advance directive, provided it exists, and release the person, but I do not envy the physician in that scenario. Again, I don’t support forced hospitalization, and I wouldn’t (and didn’t) choose hospitalization in a similar scenario for myself, but I’d be lying if I said that a nagging question doesn’t linger in the back of my mind as to whether or not that’s the right choice. Even taking medication every day doesn’t always prevent recurring episodes, but presenting (or probably more like being presented) in the ER in that manner puts an unfair responsibility on the hands of the ER doctors that should be on no one’s hands but those that signed the advanced directive. Again, no good answer.

Anonymous said...

I truly feel for all the terrible hospitalization stories that were unwarranted. But for each of those stories I can guarantee there is a story of a person who was out of their own control that needed to be hospitalized. My loved one was one of them and is glad that we stopped the bleeding so to speak. Whatever actions he was involved in he is glad we put a stop to as he had enough trouble dealing w that. While I commiserate w many of you, some people simply aren't in their right or usual mind. Should we let them commit crimes, suicide, etc, while I'll? I don't think so. I feel that some of you could still benefit from help but maybe from a counselor you can relate to. Wanting to kill yourself is not normal. I mean this w respect.

Sarebear said...

Joel, I dunno if they'll let this msg through but I think it is clear you don't understand what I was saying before.

"But, if I can create some doubt and reconsideration in any reader and make it 29,999 , then, I have hopefully made a difference for the better."

What you have DONE, with all your judging of suicidality and such, you and others, is enhance my black and white thinking (gee, maybe because yours is black and white?) that anything short of actually killing myself, isn't a serious desire to die, is "faking" it, that even talking about it means that I must not want to do it, and so I must not talk about it because anything short of actually dying is playing a suicide game and imposing on others.

You have basically really reinforced ideas in my head I struggle with, that make me really really fearful of talking about suicide, of asking for help, of trying to handle the matter when I have impulses perhaps contrary to my main desire to die, you have made me less likely to ask for help and more likely to die from what you call lethal gesturing, should I perhaps not be as serious as I keep insisting I get here; what the hell kind of tragedy would it be for someone to actually die, because they were too afraid of being judged as playing a game or whatever, when they wanted help, when they could have asked for it?

Me, I'm not going to let you or anyone have that much control over me, and I'll be working through these issues with my therapist; however, I feel it really necessary to make crystal clear, if I can, why yours and some others' approach to the suicidal really can make them more likely to die, not less. And you think you are HELPING? Just the opposite.

However, I am an adult and I know I can work through these things, and will do it. Still, I am really psychologically vulnerable to that sort of thing, or I'd not "impose" my experiences that lead what you've been saying here to have such a negative impact on me. I had to let you (and/or some few others) know that perhaps what you are trying to do actually makes things WORSE.


Jackie said...

Oh boy. There is an awful lot I could say here as a so called "suicide survivor"--my mom took her own life. And it is probably completely opposite of what most people would expect me to say. But I won't because reading some of these comments makes my blood boil and I don't want to get any further into that. I doubt it would be productive.

I guess my perspective is odd because in addition to being a suicide survivor, I have suffered from mental illness (depression in some form) my entire adult life--beginning way before my mom's suicide. I have failed a ton of drugs (every class of antidepressants, plus other things), got PTSD symptoms from seizure therapy, and talk therapy has been completely useless.

Over the long time I have futilely tried to seek help, I have expressed an awful lot of suicidal ideation to mental health professionals. Not once have I been on suicide watch. I am not "actively" suicidal--I am scared shitless of dying. Though I believe I will kill myself eventually because there's only so much of living this shithole of a life that one can take. My psychiatrist knows all of this.

My point is: I wonder if people worry that any talk of suicide will immediately land them in the hospital, when this is not the case. Or isn't the case in my personal experience; I am not a doctor. But I'm pretty sure you need to express more than a vague wish to kill yourself someday to be under suicide watch. And I also think that many people worry that merely the mention of suicide will have very serious consequences that are unlikely if you do not have an immediate wish to harm yourself. Or maybe I am a off-base. But I am so used to talking freely about suicide in the doctor's office and have yet to be hospitalized.

I also find the focus on suicide somewhat misplaced. People worry about you killing yourself, and the idea of it makes them sick...but the idea of you spending decades living a very painful life doesn't have nearly the same effect. Often it doesn't have much effect at all.

roblindeman said...

"People worry about you killing yourself, and the idea of it makes them sick...but the idea of you spending decades living a very painful life doesn't have nearly the same effect. Often it doesn't have much effect at all."

Bravo! Well-said. These remarks deserve examination.

When suicide was considered a serious violation of the law, the property of a suicide was confiscated by the State. Exceptions were made for those judged to have been of unsound mind. When courts in the UK realized the unfairness of depriving wives and potential heirs, they began to judge EVERY suicide as the result of an unsound mind.

From there it was a short step to transpose the act of suicide to "suicidal ideation" (how about "wanting to kill yourself"?) as the workings of an unsound mind. And not only unsound, but deserving of punishment in the form of incarceration.

I'm relieved that not everyone who tells a psychiatrist he wants to kill himself is then involuntarily committed. Perhaps there is more compassion in Shrink-dom than I had realized

Joel Hassman, MD said...

First, thank you to the above anonymous who at least noted I had some valid opinion about attending the funeral of a suicide before oneself considers completing the act.

Suicide is gray, just like fairly much every issue we deal with in this society. And I just want to again reiterate that I am tired and unaccepting of polarized, extreme positions especially said at mental health care blogs that attract all kinds of readers, providers, patients, and those involved peripherally or even those just reading for self interest or educational pursuits.

I do not recall having used words like "all", "every", "never", "completely", or any other polarized term, as there are not absolute applications involved in topics like this. People are putting those words in my writings, and I advise readers to read what I write, not take another's interpretation as the gospel.

I am sure there are suicides that have taken into consideration how it impacts on others, I know because my father once attempted, and wrote a very painful note (3 pages) addressing how it would affect others like me. Glad he had the chance to retract it, after being committed to Spring Grove for 3 days and I signed him out as I was not happy with his care there. He lived another 13 years and died on terms I hope he wanted, doubt it was a suicide, but, who will know.

So, I have been in the shoes of the affected family, and it is tough. But, more often than not a suicide intent has a level of inherent selfishness or at least minimal effort to consider the real impact on others. Call this whatever you want, but, it is a dynamic I have heard people who happily realized later a better outcome they were not appreciating all the choices they had access to, not just the skewed ones depression or hopelessness narrow the focus onto.

What bothers me is the lack of consideration some people have in their writings in making extreme applications of mind sets when the audience is varied. It has been that way for me since starting out at Furious Seasons, and really has not abated since.

For whatever it is worth, I have offered a post at to all the dissenters of psychiatry to have a fairly free reign to comment at my site to tell readers there why psychiatry is detrimental to society. I've told people my position why I practice psychiatry, so maybe the psychiatry detractors will show valid and reasonable dissent per issues here and other blogs about suicide, commitment, ECT, medication, psychotherapy, diagnosis assessments, whatever is one's bone to pick.

Not a sales pitch, I don't make a dime at my site, just interested to see what will be said if responsible yet unfettered opinion.

Death is a final choice; so many people let mood or thought disorders or just manipulated perspective by others minimize consideration of these other less invasive and non-terminal choices.

People to this day have thanked me for caring and showing interest in their lives, so, I must be doing something right for those who are interested in my opinion and expertise.

Thank you for the opportunity to comment at this thread one last time.

Joel H

Anonymous said...

A few years ago I read Final Exit, because I was trying to find some kind of method that would not scare me. (All methods scare me, and the description of methods in that book scared me much more). I am a proponent of euthanasia in general, do not necessarily see why euthanasia in this sense only applies to “medical” conditions, and I believe that a lot of the hand-wringing among health professionals over suicide, while I think is well-intentioned, does not make sense to me, But—I found the treatment of suicide in this book to feel extremely cold to me.
I have read once somewhere that suicide in extreme situations was a way of affirming life, or as a way of saying that I’ll go THIS far, but not further. I’m probably expressing this badly. I guess my point is that many discussions of suicide that I read seem to be focused very narrowly on body counts, or on rights, and it leaves me cold.
Dinah says: “But if you are going to walk into an emergency room or a psychiatrist's office or tell a friend or relative first, one might expect some intervention.” I think that this is exactly the problem. At this point I would not talk to a friend/ relative/ clinician about these thoughts, because I don’t understand what purpose this would serve, aside from upsetting people/ upsetting me/ etc. I am not interested in a diagnosis, or in treatment, or in protection, or even in therapy, and this is the (completely reasonable) response you would get if you discussed suicide with any of the above.
I wish that suicide was not viewed almost always as a “mental disorder”, that people who had these beliefs were not thought to be irrational/ sick/ etc. I wish that it was possible to discuss this with people—I don’t know who these people would be—not as a way of trying to access psychiatric care or therapy, etc., more as a way of trying to connect to someone, and trying to think through this feeling (detachment/ alienation/ feeling extremely apart from thigns and people). The problem as I see it is that the people who are generally considered to be the people you tell these thoughts to are psychiatrists/ therapists, and I do see that it makes sense that these are people who would actively prevent a suicide, because that is their philosophy and that is their job.
Jackie says:” I also find the focus on suicide somewhat misplaced. People worry about you killing yourself, and the idea of it makes them sick...but the idea of you spending decades living a very painful life doesn't have nearly the same effect. Often it doesn't have much effect at all.” I just wanted to say that this to me is exactly the point. I do believe that clinicians have good intentions, but I find this emphasis on a body count, on death as the only meaningful endpoint, to be a bit strange. I feel this way about medical treatments also. There are lots of things worse than death. I also imagine that people who continue to express Si for years, and do not do anything about these thoughts (because they are afraid to hurt their families, etc) just end up irritating clinicians. You know—either do something, or shut up about it already. I hope that I’m imagining this hostility, but sometimes I have felt it anyway.

Anonymous said...

I had to think this through for quite a while before commenting on this post. And the question I keep coming back to is--why do I need any kind of judicial or quasi-judicial process before I can execute a binding advance directive, specifying that I can not be hospitalized involuntarily?

To clarify, if I could sign such a legally binding document, I'd do it now, today. So why should I be able to execute a valid will just with the signature of two witnesses, yet have to go through an emancipation process to refuse involuntary incarceration in a hospital? Why should I be able to refuse heroic measures if I code on the operating table, again with a couple of witness signatures, and not be able to refuse involuntary hospitalization with the same two signatures?

If it's a question of current competence to make such a decision, I could walk out of my office right now and collect 30 or 40 signatures attesting that I'm competent. So if I make a decision now that I never want to be hospitalized involuntarily, that decision should be legally binding and respected by one and all.

I agree that if I do something that endangeres the lives of others, all bets are off. But short of that, my wishes should be respected.

mctps said...


Thanks. I'll try to add a fun little comment from time to time.

I completely forgot there were people still around who believed suicides go to hell. I guess if I were traditional Catholic I'd fake my own murder and leave something like a half-completed diary note behind: "Hmm, somebody is knocking on the door, I wonder who it might be..."

Anonymous said...

What I find really ironic are the arguments from so many of the anonymous commenters on this and other posts decrying the discrimination against psychiatric advance directives.

What you all are completely ignoring is the fact that by the time those directives might need to be in place, 99% of us are NO LONGER the people who signed them! Excluding those of us who are depressed, and remain depressed, and would just like to quietly leave the seems that there is a huge difference between the directive that the average medical patient would like in place (no heroic measures to resuscitate, no life above all kind of treatment) versus the attitude of "it's totally MY right to be batshit crazy and hurt anyone else who crosses my path. But OMG, don't upset MY tea party by confining me, or - god forbid - giving me any meds that just might return me to something approaching rational thought"

Hey, go ahead and screw things up for everybody. Make sure that any PAD isn't worth the paper that it's written on. Because by insisting that every psychotic no-meds no-hospital no-involuntary anything be regarded as gospel, all you are achieving is that no-ones hopes and wishes will be taken into account.

Great stuff dudes. You are NEVER going to get what you are demanding - the idea that your version of crazy trumps the whole of society's idea of normal, especially after the last couple of years worth of psychotic /schizophrenic /pschizo-affective /WTF /made in the USA versions of mass killings. But thanks to you, the chance of any kind of worthwhile PAD is totally disappearing down the drain.

And the rest of us, well hey.... that isn't nearly as important as YOUR right mot to have to take any psychiatric meds that might spoil your free ride!

Anonymous said...

2nd Anon on June 6,

That's the whole point of an advance directive - to say while competent you would want (and don't want) when you are not competent. That's the whole purpose. It follows that if you are competent enough to say you would want Latuda in an emergency but not Zyprexa, then you are competent enough to say you wouldn't want either one and/or wouldn't want hospitalization.

I agree with the first anon June 6. That's exactly how i feel. It makes me think of another issue that doesn't make sense, and someone else mentioned it on another thread. That's threatening a patient to sign consent, so they are classified as voluntary patients. But, of course they are not voluntary. No one could consider threatening a person to sign a legal document to have entered into a voluntary agreement of any sort. They do not document anywhere in the patient's medical record that I am aware of that they threatened a patient to when they threaten a patient to sign consent. Yet, it happens. Interesting that a patient is not competent enough to say no but they are competent to say yes they agree to risks of treatment. You can accept all the risks, but you cannot refuse the risks. Weird.

We don't do this, by the way, to patients with dementia. They are not threatened to sign a consent if they are not competent. We wouldn't think of saying, "Granny, if you don't sign this informed consent document, we're going to make you anyway and it will be harder for you to get out." Can you imagine?


Anonymous said...

I meant to say:

They do not document anywhere in the patient's medical record that I am aware of when they threaten a patient to sign consent. They should have to do that.


mctps said...

At one of the anons:

You're right that the whole of society's idea of crazy always trumps the individual's idea of what makes sense. This is hardly news, but you needn't express it in such confident language when you perhaps haven't quite investigated both sides of the issue.

Like 99% of humans, you seem to be satisfied when you can amplify the memes broadcast to your brain via televitz.

I have a TV at home so I don't really need you to repeat its messages to me, thanks. That's hardly a contribution any rational reader would miss unless they've lived in a mayonnaise jar with holes punched in the lid for air for the past thirty years.

Rationality begins from a dispassionate examination of competing viewpoints and admitting to yourself that sometimes there's no substitute for personal experience. You don't seem to have done or possess either, so I'd strive towards a style that retains at least an outward appearance of humility if that's the least you can do.

mem said...

"Is this then a real right? In my case, is repeatedly bashing my head against a concrete wall till both my head and the wall are bloody a right? Or cuts to my arms, slit with a razor blade -- a right? It is what I do without medication; it happens when I am ill with schizophrenia in order to release the millions of microscopic rats that I delusionally believe are eating my brain. When taking antipsychotics, the rats leave, the need to self-harm fades, and I am in my right mind."

ClinkShrink said...


I read the piece by Ms. Hawkes in the Huffington Post. When well, she knows what she would want if she were sick and she wants to make sure her decision is carried out. I don't think that's inconsistent with what's being talked about here. An emancipated patient would still have the right to choose to be treated when ill, if that decision is documented in advance.

The question here is whether or not that same person, when well, can or should have a binding decision to refuse admission and treatment.

jesse said...

Since the Emancipated thread began there have been many insightful opinions expressed. On June 6 the 2nd Anon wrote a particularly (to me) thoughtful comment in which she said “And the question I keep coming back to is -- why do I need any kind of judicial or quasi-judicial process before I can execute a binding advance directive, specifying that I can not be hospitalized involuntarily?” Clink posed that question in terms of Emancipation: why cannot a person be granted an emancipated status under which whatever their mental condition they should be able to choose whether to be hospitalized or medicated?

It seems to me that the people who argue in favor of this concept are imagining it in terms of their own histories: depressed, likely suicidal, but essentially functioning and not wanting intervention.

They are, I think, on one end of a spectrum. Imagine the other side of it, then try to craft a law that would govern how that patient should be treated.

Three of my patients from a long time ago come to mind: a man who lay down in the middle of the street, waiting to be run over; another who was pulling out of the apartment wall live electric outlets because the devil was speaking to him through them; a woman who was walking a train track, waiting for a train to hit her.

Any of the clinicians who follow SR can name numerous examples they have seen: patients who are disoriented, babbling incoherently, found standing on the edge of a rooftop, a bridge, wandering the streets on a frozen winter night.

Now imagine each of these is Emancipated. Had when totally competent signed a directive forbidding forced hospitalization or medication. So what should be done? You are a caring bystander, friend, policeman, who finds this person. What should be done? The person states “I signed and am Emancipated, go away.” Or maybe they can’t even coherently say this. You find a card stating it in their wallet. How would you even determine whether he was then capable of “choosing” treatment?

If no crime has yet been committed, do you just leave the person walking the train tracks; in the middle of the street; holding a knife while sitting next to her baby, laughing and muttering? You can reasonably project that something very bad will happen. Is the best alternative for the police to find a reason for arrest, and then the person is in the criminal system where other rules apply?

So in the spirit of Clink’s post it would be helpful to hear the responses of 2nd Anon June 6 and others. If you were writing the law, how could you craft it so it would apply to these (and much more severe!) examples but not to your own?

Joel Hassman, MD said...

Having read again today this and the preceding thread about involuntary commitment, I really see it as disingenuous for those who want the right to take their lives to forget what will the survivors do with your loss.

And I think allowing this alleged "living will" standard for psychiatric issues will not stand up in a court if/when a psychiatrist who accepted it then allowed a person to commit suicide.

I stand what I wrote earlier here, there is going to be a dynamic by some to want to see retroactive "punishment" for the psychiatrist not doing his/her job as fully allowed by law.

So, for those who do not like the LAW as it stands, then go after the rulers who can repeal these laws and allow this supposed freedom you are denied when exercising judgment and insight that most of society does not understand nor support.

This issue is simple, you want to die and yet reach out to others to access support, there will be few and far reasons that could justify a suicidal intent. Note I did not say NONE. But, some writers here still seem to allude their interpretations and expectations trump the dissenting views by everyone else.

And again what makes me nervous with this type of dialogue, more to me a monologue though, does it raise more risks for murder/suicide incidents when the outrage of not being supported to take one's own life creates a mindset of "if people can't accept my point of view, they have no reason to live either."

Outrageous to write, I acknowledge it, but, suicide is a final choice after exhausting all the others, and so far in my career, have yet to meet those who genuinely tried and were thwarted in fact did not exhaust all other options.

Even the one case I had some struggle with, of an older woman with terminal metastatic cancer did not want to kill herself, for fear it would affect her afterlife options, she wanted someone else to do it. She did not understand at first she was thus compromising others' limits in committing what would be murder to free her.

The issue was gray, and the patient came to see that. That color gray, still seems to disrupt people here at times.

Je suis said...

Dr. Hassman, MD (part 1)

Having read your comments, I find it disingenuous of you (and those who share your viewpoint) to attempt to guilt suicidal individuals with your
'think of the survivors' line of reasoning. Is that it? Guilt as a reason for continued survival? for continued suffering? If that's all you've got, then your argument is weak indeed.

I said it in a previous post, and I'll say it again: psychiatry has very little to offer some people. Mainly, drugs and therapy. Drugs come with some problematic side-effects, sometimes worse than the original problem; and therapy is absolutely uncertain at best; a complete waste of time and money at worst. Sure, if you can find the right therapist, one that you feel comfortable with, that practices the right form of therapy, and that you can afford, them maybe it might help, no guarantees. That's a lot of maybes, at quite the cost. And quite the risk. Risks of unwanted hospitalization, stigmatization, rights, and employment potential, just to name a few.

Je suis said...

Dr. Hassman, MD (part 2)

Let's talk a bit about selfishness: it seems the the suicidal individual is considered by some - and I believe you have mentioned this in a previous post -
to be acting selfishly. So, let me ask you this: do you charge for your services? What I mean is this:
the cost of seeing a psychiatrist or therapist is enormous, at least to those who earn a moderate income; which includes many people who struggle with mental health problems (especially those without insurance). You see, I saw several different psychiatrists and therapists during my encounters with "mental health care", each terminating when my insurance changed (via my employer) and I had to select a new provider (so much for finding someone you trust; there's no point in building a relationship when it's just going to end when you can no longer afford it). Each provider attempted to convince me to continue with them - they would work out a payment schedule, or some such thing. No. I'm not going into that kind of debt for something so uncertain; after all, there was no alleviation of any symptoms thus far, so why ransom my future to an uncertainty? My point here is, you claim that there is help, but the help is similar to gambling: no guarantee of a positive outcome and expensive enough to bankrupt you.
So, my question regarding selfishness is this: do you provide your services to everyone free of charge, or at least on a ability to pay basis (hell, maybe an outcome based fee: if I don't help, you don't pay kinda thing)? If not, then you are being selfish as well; your actions in witholding your services - services that you seem convinced will help - from those who cannot afford the ongoing exorbitant costs of your 'help' would be selfish indeed. If you do, do you do it 24 hours a day, 7 days a week? If not, are you selfishly witholding the enormous amount of good that your help would accomplish if you dedicated more time to it? Where, exactly, do you draw the line between your needs vs. others needs? Are you never allowed to put yourself ahead of others, to think of yourself first? Or do you always have to martyr yourself, endlessly suffering for others? Where is that division between you and them, and who decides it?

The issue is simple? Not really. It's difficult, and exhausting. If you reach the point that you decide that you want to (or have to, sometimes it's not want so much as must) die, you are not necessarily reaching out for support but, sometimes comfort. A last ditch connection maybe. Something. What you get instead is force, and imprisonment. Hell, sometimes you end up in the ER just because you did it wrong, and survived. Or survived despite your best attempt. That doesn't mean that you want help, or are asking for it.

Finally, "suicide is a final choice after exhausting all the others" and I "have yet to meet those who genuinely tried and were thwarted in fact did not exhaust all other options." Wrong. Suicide is not necessarily a choice after exhausting all others as you claim; it's is the choice after exhausting enough options that you are done. Who the hell is anyone to tell anyone else what options they have to attempt before they are allowed to commit suicide? Is there a checklist? Do you go over it saying "did you try this? And this? How about this?" Is that how it's supposed to work in your opinion? This is exactly why I would stay far away from psychiatric care; some of your options are just plain not acceptable. Like ECT. I would rather suicide than try that. But I have no doubt that's one of your unexplored potions. No thanks.

Anonymous said...

Wow. I think that Dr. Hassman’s posts must show up differently on my screen than they do on others’. The way I read them, he is not attempting to make any sort of “always” or “never” statement with regard to the act of suicide and those who take their own lives, but is instead providing a conflicting viewpoint to that which seems to prevail throughout this thread to prove the point that these situations are not so clear cut. He comes out and says as much when he refers to them as “grey.” On this point, I agree with him.

There is no right or wrong here and there is nothing selfless about this situation from any perspective. The person who commits suicide is acting selfishly by ending their own pain at the expense of others’. The family members are acting selfishly by willing the suicidal person to live miserably to spare them the pain of dealing with their death. Who here has the right to act selfishly? It’s not like a four-way stop. No one inherently has the right-of-way. If there were some sort of perfect procedure in dealing with these scenarios, none of us here would be arguing it. The necessary laws would be in place and everything would be moving smoothly in the world of mental health. Contrary to popular belief, the majority of people who make involuntary care decisions are not intentionally trying to make things difficult for the mentally ill.

Also, Dr. Hassman is a Psychiatrist. What do you want him to say? Please, go ahead and do whatever makes you feel you need to do? His job is to help his patients adjust to THIS life. It would be disingenuous for him to suggest otherwise. I do not read his comments as being personal attacks. I don’t know. Maybe I’m reading them incorrectly.

As for Clink Shrink’s proposal:

I don’t think that the people in the situations you’ve mentioned should be forced into care any more than those who are suicidal and functionally depressed. The mother with the baby should have her child removed as she is an unfit mother at this time, but the trouble with making the decision as to who does or does not require involuntary care is that some people are going to slip through screenings and some are going to be held unnecessarily. “Danger to self and/or others” is difficult enough to utilize successfully, as evidenced by the vignettes of others in this thread and also in the forced hospitalization thread, without adding additional qualifiers to further muddle things. I understand well that every episode of illness isn’t the same, but the competent self does have some idea of just how far into unreality he or she can descend while ill. The bottom of the pit can look different, but the distance from the surface is often the same or similar, in my experience. I admit that I am not unbiased in this as this kind of involuntary hospitalization is something that I fear, so my opinion should be regarded as one colored with emotion, but involuntary hospitalization removes the rights of vulnerable people and that is not something to be taken lightly.

Anonymous said...

Wow: Holy typos, Batman! The word others in sentence two, paragraph two should not have an apostrophe and the third sentence in paragraph three should say "Please, go ahead and do whatever you feel you need to do?"
Whoops. Sorry!

Anonymous said...

Also, that was Jesse's proposal *face palm* So many thoughts, so little organization. Sorry about that.

jesse said...

@Last Anon, yes, and thank you for your post. It seems too me that quite a few readers react to Dr. Hassman's "shoot from the hip" bluntness and miss the major point he is actually making, which to my thinking is often right on. I bet he is a very kind psychiatrist whose patients thank him when they leave his unit.

And yes, it is difficult to make those decisions: take the mother from the child, hold someone (where? How long? Under what standards?) until....what?. So I would be interested to see how some of the writers who seem to support the Emancipation concept and argue for the right of the depressed/suicidal patient to be left to his own devices would actually craft a law that could be applied more to their concepts than the "danger to self and others" standard appears to have been.

Je suis said...

@anon June 9, 2013

Contrary to how it appears, I do not consider Dr. Hassman's comments to be a personal attack; I do, however, have issues with some of them. I agree that suicide is a grey area, but then, the response is not. If you are unsuccessful, or confide your intent, you will be involuntarily hospitalized - nothing grey about that. Strictly black and white. Why, then, such a polarized response for a such a grey issue?

I also have issues with this statement " there will be few and far reasons that could justify a suicidal intent". There is no need to justify it; it's not a situation that requires "justification" or validation from anyone. What, a suicidal individual needs approval before carrying out the act? No, the question here is not one of approval, but non-interference. No one should be forced into helping someone who is suicidal, but on the other hand, no one who is serious about suicide, and who has made the decision to go through with it, should be prevented, either. If it's selfish to do it, it's also selfish to stop it. There's no winners here.

Speaking of selfish, the point I was trying to get across, perhaps unsuccessfully, is that we're all selfish. Dr. Hassman is a Dr., right? There are plenty of people who wanted to be a Dr., but did not get into medical school (I work with one). Was it selfish, then, for Dr. Hassman to fill a slot that someone else wanted? Note that this is not an attack on Dr. Hassman per se, but simply an example using his professional position to make a point. Unless all opportunities, commodities, and resources are infinitely open and available to everyone, always, there is always going to be someone who takes what someone else wants. It's a basic of supply and demand. it's also selfish, after all, your gain is someone's
loss. This is why I have a problem with the guilt via selfishness angle; we're all guilty. Now can the pot stop calling the kettle black?

Anonymous said...

"So in the spirit of Clink’s post it would be helpful to hear the responses of 2nd Anon June 6 and others. If you were writing the law, how could you craft it so it would apply to these (and much more severe!) examples but not to your own?"

Jesse--you nailed it on the head, at least as far as I'm concerned, that I'm thinking of this in terms of my own experience. My particular problem is severe, episodic depression. The episodes rarely last more than 4-5 days. And in my 40 or so years of dealing with this, I've learned that therapy is of limited use and psychiatric drugs don't help and frequently make things much, much worse. So my preferred way of dealing with this is just to try to remain unconscious as much as possible, usually with a combination with alcohol and ambien.

Dangerous? Yes. But better than being locked up. Alarming to family and friends? Absolutely, so I've learned to keep them unaware and uninvolved. I don't want to be hospitalized during these periods, and my wishes in that regard should be absolutely respected. I'm not hurting anybody but, perhaps, myself. On the other hand, perhaps I'm just doing what I need to do to avoid killing myself outright.

On the other end of the spectrum, you posit a person walking down a railroad track, in the middle of the street, or in similar situations. In these cases, a person poses a danger to others, and, as I said in my earlier comment, all bets are off once you pose a danger to others.

June 6 Anon

styles said...

Why cant' the help be more like this? I guess docs are better at taking care of their own than the patients....?

styles said...

I tell them, “Both men I dated in med school are dead. Brilliant physicians. Loved by their families and patients. Both died young—by ‘accidental overdose.’ Really? How many physicians accidentally overdose?”

The room is quiet.

It’s easier to say accident than suicide. Doctors can say gonorrhea and carcinoma. Why not suicide? Maybe we can’t face our own wounds.

Here, physicians, nurses, and medical students share their wounds and their wisdom—in community. We share new practice models, communication techniques, and strategies to care for ourselves—so we can care for our patients.

In four days, I witness more healing than in four years of med school. Once strangers, we’ve become family. Parting ways, the psychiatrist from Seattle thanks me again.

I didn’t know these doctors, but I know their despair. By speaking about my own pain, I validated their pain. By being vulnerable, I gave them the strength to be vulnerable too.

But mostly we healed each other by not being afraid to say the word suicide out loud."

Some of these doctors were acutely suicidal. And yet...they found meaningful help WITHOUT forced hospitalization

styles said...

I guess this is whey the help is getting better for docs...

A newlywed couple join in. “I’m a nurse. My husband is an internist. He’s suffering, but I don’t know how to help him. Doctors don’t seek psychiatric care because mental illness is reportable to the medical board. He fears he’ll lose his license.” Her husband adds, “I was suicidal three months ago. On the edge. My wife and I are hoping to find answers here.”

That is why. People being hospitalized and losing their rights, that is not so bad? People losing their medical license...too much?

Je suis said...

"People being hospitalized and losing their rights"

This is exactly my point - simply put, the cost of psychiatric care is too high. What good is it if the results are stigmatization, financial burden, or the loss of your profession? Especially when the end result of the "help" might be no help at all? If those losses are the fallout of the help received, can you still wonder why so many - especially men - don't seek help? If that's the trade-off, then once you've reached the point that you "need"
professional help, it's too late. Because the help comes with far too much burden. And if a medical board need to know this about a licensee, information which may put their license at risk, then it's obvious that these medical boards don't believe in the help that is being forced on the individual, anyway. So, where, exactly, does this help anyone? If these are the results of seeking help, then you are better off just going through with your plan and avoiding all of the unpleasant ramifications of this so-called help. Because this kind of help is passive-agressive; it might be labeled as help, but at it's core lies harm.

Joel Hassman, MD said...

I just want to know, these people who argue that inpatient psychiatric units are taking away liberties and that treatment should be about nothing less than negotiation and controlling the treatment process by the patient:

Do you get hospitalized for somatic issues and demand the same interaction and think there are no consequences if you just walked out of a somatic bed because "that is my right"?

Why is it people continue to frame psychiatry all one way, and then show full deference to somatic care? What responsible, attentive person who is in crisis, ends up in a hospital for trying to take one's life or someone else's, is not jailed, and then thinks that boundaries do not exist for such extreme behaviors?

I think the answer lies in the question, and colleagues can read between the lines how the question is asked to figure out what I am expecting.

Some of the discussion is just absurd to me. Again, if you want to die, why are you engaging others in your quest? Is it veiled absolution, an unconscious effort (or perhaps conscious) to see who cares and who doesn't, or is it just frank conflict and battle you want if you think this is your last moment?

Invested and caring physicians and providers don't want people to die, that is the oath we took, and expecting us to abandon it for the convenience or alleged exception some of you basically demand of us is, well, lame!

Yes, there are exceptions to rules, but, they are realized as exceptions because all the healthier alternatives are ruled out in responsible care interventions. You are not going to wear me down in this debate.

Many of the patients I have met who were involuntarily committed and then retained for longer stays ended up with that moment of clarity, and said almost word for word one of two things: "I should have never said anything to anyone", but more often "well, I guess it is good i did say something, because I was wrong, people do care."

Which sentence do you as dissenters in this debate really want to say? Think about it before you just reflexively spout usual rhetoric!

Anonymous said...


I can't speak for anyone else here, but I have also dealt with psychosis + suicidal thoughts. The examples you give seem to present a danger to others. I don't have the right to lie down in th e street because someone could have a wreck. In fact, I called 911 once because a guy was playing peek a boo while standing in the middle of an intersection. I don't think a anyone is arguing for the right to break laws or harm others.

I also would argue that forced hospitalization may actually be the final thing that pushes a suicidal person over the edge. I think we need to consider those folks, too. how many have committed suicide after discharge? Those were the patients who stopped reaching out. I think we owe it to them to question why that was the case.

Back to the issue of psychosis. In my case I remained oriented. I just thought people were listening through the vents and following me, etc. Believe it or not reaching out in a kind, gentle, non-threatening way worked a whole lot better for me. I just don't believe that forced hospitalization is the only way to reach someone who is psychotic and suicidal like I was. in fact, my current psychiatrist and therapist have been able to actually help me rather than m a me things worse. Again this should be about the individual not what happened with someone else's situation. I fully support forced treatment for those who would want it again. Just doesn't work for all of us.

Pseudo kristen

Anonymous said...

"Which sentence do you as dissenters in this debate really want to say? Think about it before you just reflexively spout usual rhetoric!"

Ahhh, Dr. Hassman, you don't know any of the "dissenters" on this blog beyond the limited amount that they choose to share. Your constant dark and cynical commentary says nothing about the inside of my mind, and everything about the inside of yours.

Anonymous said...

I would add that with medication I no longer struggle with suicidal thoughts and no longer have the paranoid fears I had in the past.

Pseudo kristen

Je suis said...

@ Joel Hassman, MD

As I stated before, I work in a local hospital. And yes, people do check out AMA, quite frequently. So, people hospitalized for somatic issues do just leave because "it's my right"; and they are allowed to. No one forces them to stay. Forces. That's the difference between psychiatry and somatic hospitalization - psychiatry uses, and seems comfortable in using, force in order to "help". Further, somatic medicine is much clearer about the outcomes; psychiatry is a vague promise at best. That's why psychiatry is 'framed" differently; because it is different. And clearly, many people subjected to it involuntarily feel harmed by it.

Why engage others? Sometimes it is incidental: the attempt was not successful for whatever reason, and you ended up there. Or someone else called, a family member, or friend, or therapist, whoever. it is not always a choice; again, force is involved. The police, for example.

As for your "sentence" - I've already said it multiple times: "I should have never said anything to anyone" - because it did no good at all, and caused more problems.
If I could do it all over again, I would never reach out for "help", just let what would be, be.

Psychiatry is not always helpful, frequently useless, and sometimes harmful. That's the truth that you don't want to face. You can't help everyone, but you can punish them.
That's what happens when your "help" doesn't work out, it feels like a punishment. As if the suffering wasn't enough already.

jesse said...

@Pseudo-Kristen and others: Dinah and Clink warned me that my examples encompassed situations in which others could be hurt (although I don't think getting hit by a train would hurt others) but I stubbornly would not listen and posted anyway. The situations, however, have the same problem: laws were not broken (at the time the intervention occurred, which was before the train or a car arrived) and harm was likely to ensue. By what standard should something be done, and by whom?

Assuming that the person involved did not want intervention, the very intervention itself would involve some form of force if the person refused, even if it were to take the person out of the road. But then what should be done? Jail? Detention of some kind? Where, for how long? So how specifically would you reword the existing standard that allows certification to inpatient treatment only if there is an imminent danger to self or others?

One problem is that as soon as one faces a hard, specific example one needs to think out consequences. Personally I have found that people in the mental health field tend to use the least force, the most kindness, the greatest empathy. That's why we ended up choosing psychiatry as opposed, for example, to orthopedic or neurologic surgery. We tend to talk rather than to act.

The second problem is that it appears the commenters are imagining a reasonably rational individual who would respond to verbal intervention. Imagine one who is totally non-responsive, psychotic, muttering about wanting to be killed by a train.... etc, but who refuses all kinds of intervention. What do you do? How should the law or intervention standard be modified?

Anonymous said...

Jesse, it surprises me that it's not illegal to stand on the tracks waiting for a train. I would have thought it would be. I can't park my car on it so I assumed I can't park my body on it.

If a person while competent decided they didn't want forced intervention then I think we respect that. The outcome in a few cases might be death just as the outcome for a person refusing treatment for a treatable cancer might be death. Then again, it may mean all of those living with suicidal thoughts posting here might actually feel safe enough to get help may actually save their lives by not threatening and not forcing.

This is not just about those who have felt saved by forced treatment, treat them. This is also about people like me me who refused all treatment for years because of threats and force. That's not going to be the way to get me to take antipsychotics that just made me increasingly likely to throw the bottles away, which is exactly what I did. Threats and force while well intentioned just didn't work. I do think some are a lot more skilled than others in gaining cooperation, even with psychotic patients. My first ones failed at it, the second ones were better communicators.

Pseudo kristen

mctps said...

"Again, if you want to die, why are you engaging others in your quest?"

Try it sometime without a gun or a very high place to jump from and let me know how it goes.

Remember also that 2% of those who jump from an adequate height manage to survive anyway. Ideally you'd shoot yourself in the head (70% chance of dying) while falling from a high place (98% of dying) and biting a cyanide capsule (painful but, you know).

Sometimes when you're depressed you don't have the will power to travel to the other side of the planet to live your dream. I think they're now even put a web below Golden Gate Bridge to make it even more difficult for people to find relatively safe places to jump from.

Here's the main thing. Killing yourself is very risky and/or very painful. There's also the instinct that makes it difficult to attempt as a pure act. That's why I'm for euthanasia. It's the only humane way to go, apart from dying in your sleep peacefully or being eaten by white shark while drunk (you need luck and patience for both of these).

When society makes ending one's life as difficult as it is, in most of the world, it is essentially condemning many people to hell.

Now I want you to repeat that hollow babble about altruism and caring about people again. I can see you're paraphrasing some 2000 year old idealist because there's no actual ring of experience to your words.

jcat said...

@Jesse, try asking the train driver who has hit someone on the lines, even though he couldn't avoid it, how much it hurts. Quite a large number end up with psych issues themselves, quitting jobs, have even heard of one killing himself. Although he was considerate enough not to make someone else do it for him.

jesse said...

@jcat: I'm completely with you, in your last and earlier comment on this thread. There was a man who jumped onto a subway track in NYC a short time ago and the train engineer had a very severe reaction. Almost always there are others who suffer in ways not foreseen nor seriously considered by the person who suicides.

I think those who are writing here for the right to be able to suicide, to be left alone, are arguing for a theoretical idea, for a right they wish to have, as they have not, in fact, suicided.

The wish to connect with others is almost always there. Those who have jumped from the Golden Gate Bridge almost always did so facing the city, not away from it.

Anonymous said...

Jesse, I don't know that people are asking for the right to suicide. The people by and large who would like to sign an advance directive stating no forced intervention are the ones who not only were not saved by forced intervention, they were harmed by it. I am not requesting the right to suicide. I already know how to do it effectively. I am asking for the right to reject a treatment that for me makes a bad situation worse. There's a difference.

Pseudo kristen

Sunny CA said...

Jesse: The side of the Golden Gate Bridge facing the city of San Francisco is the side you are automatically on if you are coming from San Francisco where most of the people are located. Purely on a basis of which community people live, there would be a lot more living in San Francisco that would access it from the "viewing San Francisco" side, so your reasoning does not ring true for me. On the Marin side nobody lives close enough to walk to the Golden Gate bridge. Look at it on Google maps, satellite version. I think yours is a psychological explanation, when a much simpler geographical explanation exists.

Sunny CA said...

I am a patient, and I previously have said on this blog, that I would rather die, than again be involuntarily hospitalized.

I am not certain that is true, because I have had many good years post hospitalization, but I would certainly attempt almost any solution short of death to prevent re-hospitalization.

In actual practice, many force-hospitalized patients would end up in jail if not force-hospitalized, and that can't be any fun either. Others would end up dead, and while I believe in personal mental health freedom, I would not want a loved one of mine to suicide.

Regarding physician assisted suicide for mentally ill, there is not one physician on the planet that would be willing to do that, unless they were warped in some way themselves.

If I were a psychiatrist presented with a suicidal patient I would try to assess how close to the brink the patient is, and what could be done, short of forced hospitalization, such as medication change or alerting family with permission of the patient.

As a patient who voluntarily appeared at the emergency room, but who was involuntarily committed, I think there should be a law against that. If a patient arrives voluntarily and asks for help, they should not be involuntarily committed, then, against their will, prevented from leaving, with all the loss of rights and future privileges that involves.

Also, all mental patients ought to be treated with the respect and kindness that is granted automatically to any adult or juvenile medical patient, but not to mental patients.

Anonymous said...

Sunny CA seems to make one of the most sensible arguments here. However, I have found this thread to be the most disturbing, sad, unfortunate blog I have ever read. I feel badly that many of you wish you were dead, wish you had the right to die etc. it seems that there must be some kind of help out there. Having been on the brink myself I am aware that there is bad care and good care. Forced hospitalization for reality based depressed people is unwarranted but you found yourself in brutal hands. I wish you all the best of luck and hope and hope you find something to make life worthwhile. Maybe a new blog idea would be what spurred depressed suicidal people out of their funks , besides medicine, and gave them hope to live?? I would read that book!!!

jesse said...

What I was saying using the bridge as a point (and I did not make that up, I read it. It was written by someone who was relating the facts of which side of the bridge is used more) is that even when people do try to commit, or do commit, suicide there is often evidence that they were trying to connect with others at that moment, not be distant from them.

@Pseudo Kristen, yes, I do hear you. There are a number of people on this blog who were hurt by forced treatment, and it should be clear that the doctors here are listeners, not forcers, who have worked for years with very depressed patients who spoke often of suicide, never did it, and were helped by treatment. So I believe that the force did harm.

Of course you should have the right to the kind of treatment that is best for you, but none of us can predict what all of the various practioners/social workers/family members/ first responders et al would do in every circumstance. So I asked for ideas on how a law could be written to better serve patients like you. No one responded. Is there a way to craft the lawso that it would better serve patients who would do better not to be forced, while allowing hospitalization (instead of jail) in other cases?

One practical suggestion would be to have on a zip drive (a little key-like thing you can always have available) relevant medical information including a description of the best way to treat you in a psychiatric emergency, what worked and did not, and answering all questions necessary so that your experience could be heeded.

Dinah said...

I, too, have found this whole line of commenting to be terribly disturbing. In the past few weeks, I know of 4 people who have completed suicides, 2 were patients of psychiatrist friends, 1 was a relative's colleague who was running a scam that came to an end, and the last was a friend's fiance who left a note blaming my friend. 40,000 people a year 'succeed' in committing suicide and it's horribly sad for those who remain, and tragic for those who die, whose pain may have remitted and let them move on to a full and good life. A permanent solution to a temporary problem. There is nothing that stopped those 40,000 people, the system 'allows' you to kill yourself.

People can get help with suicidal thoughts, they are part of depression and psychiatrists hear about them every day, we don't hospitalize people for 'thoughts.' It's when those thoughts become intent or when the patient is an unknown entity that there is the 'risk' of being hospitalized. The vast majority of people who got to an ER who are actively suicidal want to be voluntarily hospitalized, some of them get turned away because there are no available beds or their insurance companies won't cover it. Most of the hospitals I've worked in have had suicides on the unit, including one person who hung himself in the hallway of a psych unit.

I agree that lucid, reality-based depressed people should not be forcibly hospitalized and I agree that ALL patients should be treated kindly and respectfully.

In the time we've been discussing this, I lost my brother completely unexpectedly. He took very good care of himself, trying not to die of the heart disease that caused our father to die. Going through the pain of having my brother die while so many here have bickered about how they should be allowed to kill themselves, or even have doctors help them, has been very hard.

jesse said...

This has been a very hard week for Dinah, and this entire topic is most disturbing to most of us. All of us know people who have suicided, but while death from any cause can be wrenching suicide is particularly so.

I was wrong when I wrote that no one responded to my question: Sarebear did, and suggested that if a person appears voluntarily as a patient in an ER then forced hospitalization should not be allowed.

Anonymous said...

Dinah, I am sorry for the loss of your brother. I am the previous anon poster. As someone who was thinking very suicidaly after a bad trip on an ssri and various life misfortunes I want to speak out. I felt as many of the previous posters did until my five year old came into my room one day and said " real moms don't sleep all day". I dragged myself out of bed every day, got a very part time job (2 hours a day) and kept a mood chart. I hated every minute of it. But as time went by (. A year maybe) I started feeling normal again. I would never have thought this was possible. It took lots of hard work, meds, and not giving up. Thank god I have kids to not disappoint. My point is, there is hope. Sometimes you have to live the life you want until you want it.

Anonymous said...

Jesse, you said no one responded. I did respond. I support an enforceable advance directive. Those who were helped by forced treatment wouldn't have to fill out anything and what happens would depend upon the practitioner's decision of what is best. Those who were not helped could opt out, as could those who were never forcibly treated but wouldn't want it. This would require a change in law to ensure the advance directive could not be ignored by a psychiatrist in case of emergency which is is what can happen in my state currently. I don't see the need for a zip drive if I could have an enforceable psych advance directive to carry with me.

Pseudo kristen

Anonymous said...


I can't imagine the grief in losing a sibling. I'm sorry for your loss.

Pseudo kristen

Anonymous said...

Please be careful with all this advice. Many people have been saved by forced hospitalization. You guys who are blogging should be versed enough to know what not to say to get hospitalized. If not, maybe it's necessary.

jcat said...

Dinah, I'm really sorry for your loss.
Thinking of you and sending strength and healing.

mctps said...

I think there's been a misunderstanding or two here.

I'm not suicidal now, and I'm often glad to be alive. My argumentation is solely based on empathy, you know, genuine understanding of one type of suicidal person arising from personal experience of having been one.

No one I know believes in any sort of otherworldly hell, so Catholic funerals are kind of off-topic where I live. Europe more generally isn't much of a Christian place except nominally these days. I know it's different in the States, but even there Catholicism is a minority religion and in general I doubt Christians these days actually believe hell to be anything more than separation from God. C.S. Lewis said the doors of hell are locked from the inside: people who go, want to be there, and anyone who doesn't belong, won't go.

Sunny CA wrote: "Regarding physician assisted suicide for mentally ill, there is not one physician on the planet that would be willing to do that, unless they were warped in some way themselves."

There is also not one priest that would do it. That doesn't make the hypothetical act irrational, rather the opposite. This total refusal reveals a commonality, perhaps a common origin, a clue that this refusal to end pain has its origins in something irrational, that it can't be philosophically (rigorously) justified without referring to myth and mumbo jumbo, except in some cases where the suicidal intent isn't the result of longterm suffering. That's why I've suggested waiting periods for euthanasia.

And I'm not actually demanding physician assisted suicide. I don't care what the doctors do. They may do what they want and what they've been trained to do. There are other humans on this planet who reportedly are capable of pressing a button or overseeing an execution style euthanasia. It's not rocket science. Your inability to see these obvious and reasonable possibilities, such as using executioners for the job, points to irrational fixations on your part.

To the person who said he/she already knows an effective way to suicide: perhaps you do, perhaps you only think you do. Most suicide attempts fail. That's not because the attempt was "a gesture" or some silly nonsense like that. It's because humans are arrogant and stupid and don't even know what they don't know. There are virtually no effective and risk-free ways that aren't either very messy, cruel and/or painful. Inhumane in a word.

Empathy, is the point of view from which I write this. Not desire to die or to disturb. If empathy disturbs you, then it's perhaps you who has been warped, by "training" or other brainwashing or mind control.

styles said...

Sunny's comment about the golden gate bridge and geography is actually why I don't like discussing the intent of people who have passed on. It's easy to think that those people jumped facing the city for some romantic reason, maybe one last goodby to the city and people they loved. Or it could have just been the most convenient area to jump from if they are coming from San Francisco. Unless they actually stated that they were jumping on the San Francisco side so they could feel some connection to people before they died we really can't know.

But even suicide notes and past diary entries leave me feeling uncomfortable trying to speculate anything about the dead. Notes can be unclear or written hapahazardly. I have a diary and it if anyone were to read it after I die they would probably think I had a thought disorder. It's practically incoherent with the junk that comes out of my mind. There are people who write diaries with the idea that someone will someday read it (and even those are slanted because you are only reading how they wished to portray themselves to others). And then there are those who do not plan on people reading their diaries. They just want to get their thoughts out, no matter how bizarre, and they are nothing like their diary presentations of themselves in reality. This is actually making me want to leave a directive advising my family to burn all my diaries upon death.

I a much more curious about the people who survived and can talk with clarity why they did what they did. The dead should be left alone, because they aren't here anymore to explain themselves. Their diaries and notes are not them.

Also there is physician assisted suicide for the mentally ill. The commenter earlier brought this up when his 20 year old friend was put on palliative care for anorexia as she starved herself to death. It unnerves me that someone that young was encouraged to starve herself to death, and I do hope that many people, including psychiatrists, reached out to her and helped her explore options.

Anyhow, here is an article about physician assisted suicide in Switzerland for the mentall ill.

Je suis said...

A few misconceptions I would like to point out:

1) " we don't hospitalize people for 'thought'."

Perhaps 'you' don't, but others certainly do. It happened to me. For thoughts, not intent, while asking for help with those thoughts.

2) "People can get help with suicidal thoughts"

Sometimes that "help" is no help at all. It did me no good, I still have those thoughts, despite the best efforts of "help". Help that is no help, that comes at such a high cost - well, that forces one to consider their options rather carefully, doesn't it?

3) "A permanent solution to a temporary problem."

I hate this statement with a passion; because sometimes the problem is not temporary. In my case, I've been dealing with it for more years that I care to recount. Hell, I was told that I would be on medications for this
for the rest of my life. That's temporary?

4) "the system 'allows' you to kill yourself."

The "system" does not, it has laws designed to prevent it - such as involuntary hospitalization - although the laws in place are fairly ineffectual if one is really determined. Otherwise, you could announce your intention without any sort of intervention, but that's clearly not the case.
The real issue, however, is not "allows", but punishes. The "system" punishes an individual for either announcing intent or actually attempting, and failing at, suicide. The argument for the "right" to suicide is actually the argument against measures designed to interfere or punish. If you want help, you should by all means be free to ask for it, sans the fear of reprisals. If you do not, however, you should not suffer consequences devised by the well-meaning but myopic. Stigma, loss of freedom, loss of rights, financial burden; these are just some of the punishing consequences of the "help" you are likely to receive. As I said before, in the end, the cost of "help" is frequently to exorbitant a cost to pay.

Dinah said...

The issue of what happens to those who make a serious suicide attempt and live is an interesting one. Of those who survive jumping off the Golden Gate bridge --

"Of 515 people who had been prevented from jumping off the Golden Gate bridge, only 25 (5%) went on to kill themselves later. Of eight known survivors in 1975, one subsequently killed himself."

mctps said...

I think what people who are used to happiness tend to have a hard time realising is that life for a lot of people is typically nothing to write home about, even when they're not going through a suicidal period or aren't badly depressed.

This means that a couple of really bad years are difficult to redeem; the balance of whether your life as a whole has been worth living or not has forever shifted toward the negative.

There are a few things that could redeem hellish months or years: romantic love fulfilled, a series of great artistic creations completed, having and managing to raise happy and wonderful children who go on to live successful lives, discovering the philosopher's stone, conquering the world with your manly robot armies while sipping coke in the hidden control room, learning to teleport and becoming the world's most fearsome jewel thief.

Thing is, those deeds are generally speaking difficult to pull off (I've tried them all, CIA knows me) and they are beyond the means of most ordinary men. So, if we happen to off ourselves when we're having a bad year, it's not such a great tragedy, trust me. We'd die some day either way....isn't that the fate of all men? I'm personally not immortal, at any rate. If somebody told my parents that I would be, they lied.

It's not about when you die. It's about how you lived and can live.

Death is beautiful and merciful unless it involves your intestines painting postmodern art on the sidewalk or really anywhere. That's why I support euthanasia.

While I joke about this topic now, I expect there to be a day ... when I'm old, tired, in pain and alone ... when I'd appreciate a humane and quick end to my life.

Anonymous said...

Re: the idea that "suicide is a permanent solution to a temporary problem".

I have been thinking about this idea of help negation when it comes to suicide. I'm sure that there are many different reasons why people do not talk to people about this. Most of the time I feel extremely desperate to talk to someone about this because I am trying to think my way through this, but any available resource that I can think of right now seems like it would make this worse, for several reasons.

One of these reasons is this idea that suicide is a permanent solution to a temporary problem. Whenever I read descriptions (in the media, even in textbooks when I was in school) suicidal thoughts are depicted in a way that I just don't relate to. People are either depicted as having acute mental health problems that are obviously a change from the usual, and these suicidal thoughts are obviously a temporary symptom that resolves when the acute mental health problem gets better. Or else it seems that suicide is presented in a very irrational way, because of felling upset over a break-up, etc. It is presented as obviously irrational, a sign of bad coping, etc.

I feel that most depictions in the media of these thoughts do not do justice to these thoughts. I do not have the sense that clinicians understand this experience, or that they truly could provide help with this, because I think that they view these thoughts as irrational and as evidence of bad coping.

I wonder if part of the problem is that there is not enough recognition that often things simply can't be fixed, problems aren't temporary, there is no treatment or intervention that is really going to change very much.
Similarly, for all of the talk about miraculous cures for psychiatric disorders, I don't really see that this is necessarily true either. I think that it makes me feel worse to constantly hear about how fixable everything is, how treatable everything is, when in fact I think even many psychiatrists would acknowledge that the type of change that is possible is for many people not particularly overwhelming.

I do understand that it's possible to adopt the attitude that no matter what, you can't kill yourself because of the hurt it would cause other people. But this is a different argument from the one that says that things are fixable. I would be much more likely to feel heard by someone who acknowledged that in fact there is good reason for me to feel hopeless right now, that many people would probably feel just as hopeless as I do, that this problem is not clear-cut, etc.

jcat said...

@mctps, last anon - you really are completely lacking in empathy, aren't you.

Enough already.

Dinah said...

I still want to know -- if there are psychiatric advance directives that are binding no matter what-- what we do with the woman on the railroad tracks, or the person about to jump from a building into a crowded street. We can't just leave them, because others are at risk, so even if we say No Forced Treatment, it doesn't mean it's fine to derail a train, traumatize an engineer, splatter yourself on innocent bystanders who might swerve to avoid you or be killed by your falling body. So we remove the person, but what do we do then. No forced treatment. If we let go, they move back onto the tracks or to the edge of the building. So where do we remove them to? Jail? Charged with reckless endangerment? We don't think it's already a travesty that much of mental health care is now delivered in the criminal justice system, that the largest psychiatric institution in the country is a wing of the LA County Jail, the Twin Towers?
With an enforceable psychiatric advanced directive, it's a not a free pass to endanger others, or even to disturb the peace. I'm not sure I understand how this plays out.

"a permanent solution to a temporary problem" ....okay, granted, for some of the people some of the time, but you don't know if that's the case for you until the moment of death. I tend towards optimism and hopefulness, but life certainly has it's rough patches, and mental illness or not, no one got born with a guarantee that they wouldn't suffer. It does seem to be part of the journey.

mctps said...


I've alluded to the idea before a few times that if society made suicide easy, these dangerous and problematic scenarios would disappear. Until then, I think it's reasonable to intervene and forcibly treat for several months, but IMO not longer than that against will.

I also believe many mass murders would be prevented if suicide were made easy, especially if this were combined with a sane media treatment of such cases: no name or picture of the killer published, ever, no names or pictures or ages of the victims published, very brief and dry matter-of-fact reporting of the event in news.

Anonymous said...

I think that I'm the last anon that jcat referred to. I probably do have problems with empathy, but I also think that I must be expressing myself very badly right now. I didn't mean for anything that I wrote to sound cruel or unempathic to anyone who is suffering right now, and I'm sorry if anything I said sounded cruel or unempathic.

On the other hand, I was thinking right now that probably I am not doing a good job of pretending that I am in Dinah's living room right now. If I was in Dinah's living room right now I would not be saying these things.

It is sometimes easy to become so self-absorbed and wrapped up in your own problems that you fail to understand the effect that this has on other people. I am probably not doing a very good job right now of seeing things outside of me.

styles said...

I agree with mctps that if there was euthanasia available for people who are suicidal they would not be attempting to jump in front of trains or off of bridges. If they are too psychotic to understand why they shouldn't do that, then forced care would become necessary.

Also, thank you Dinah for responding with the statistics about the Gloden Gate bridge. That is interesting that many of them (survivors and attemtees) did not eventually die of suicide.

styles said...

Since Roe v Wade I would think many women would not even think to use coat hangers or other unsafe means to abort. No one actually likes abortion, but it does make things more safe when it's legal.