Friday, October 13, 2006

Let's Talk About Suicide


[posted by dinah]



The post I wrote on Suicidal Students got a number of comments, some of them rather distressed and distressing, and while stirring things up is kind of the point of our Shrink Rap blog, I realized I created some unintended fallout: there is the impression here that what one says to a psychiatrist becomes public information that can be used against you. While we are a blog by and for psychiatrists, I don't want our patient, or would-be patient, readers to be spooked out of seeking help.

First, let me say that I believe strongly that students should be able to seek help for their problems without fear of consequences. Mostly. If a student goes to a psychiatrist and threatens to kill others, confides that they have been sexually abusing children, intends to murder the president, or is concocting a terrorist plot, the psychiatrist is obligated to report or warn others. So no, this isn't confidential, though hopefully the psychiatrist is able to weed out plan and intent from simple thoughts or fantasies and the student/patient gets helped before someone is hurt and the student's life is ruined.

In terms of suicide, oh gosh. A psychiatrist is obligated to do something about suicidal intent, be it hospitalizing the imminently suicidal patient, or intervening in a way to prevent the occurrence of the act--for example asking a family member to sit watch over the patient. Why do I differentiate between intent and ideation? Simply put, Major Depression is a common illness, and thoughts along the spectrum of WantingItToEnd-- starting with feeling hopeless and progressing through a range of passive death wishes to suicidal planning-- are Symptoms of the illness. I'd say many people have these feelings, but actually I believe that most people with Major Depression have hopelessness &/or death wishes with varying intensity at some point during their illness. I was surprised to read the comment of the doctor who had never had a patient admit to suicidal feelings. The majority of patients I see have at some time thought about hurting themselves; few have acted on them. Viewing it as a symptom, and a common symptom at that, it takes more than the confession of a Thought to get me nervous-- I have to have the sense that something has changed, that this is acute, that there is some imminent risk, before I start thinking about violating someone's confidentiality. This is all much easier with an ongoing patient whom I know, and I think clinicians are much more likely to err on the side of being too careful when they don't know a patient well and aren't sure how safe it is to let someone go home--the stakes here can be very high for someone's "best guess."

Oh, and yes, I worked briefly (during my residency) at a major university student mental health center where I saw suicidal patients and it never occurred to me to report anyone's thoughts to the administration. Simply put, suicidal thoughts and behaviors are so common in psychiatry, both as symptoms of Major Depression and in many other psychiatric disorders, that universities and student mental health centers can't possibly be tossing out every student who reports such ideas.

Universities have been successfully sued when students have committed suicide. This has led them to act defensively; they don't want the responsibility for suicidal students and some don't feel they can provide a careful enough level of supervision, especially in the dorms. Plenty of schools, however, have a protocol for managing students following hospitalization and yes, psychiatrists sometimes clear students for return to the dorms and to classes, even if The Last Psychiatrist doesn't believe it.

The two stories I linked to (that of the Hunter student thrown out of the dorm for a suicide attempt, and of the GWU student barred from the campus for suicidal thoughts) are provocative stories, I blogged about them because they caught my attention and got me riled up. Hunter College has re-evaluated their policy. In the GWU case, it's still in litigation and the university has not made any statements; the Washington Post article presented only the student's side, so I do believe there may be more to this story. Some of our commenters have also posted distressing student mental health stories; my hope is that these are the exceptions, otherwise I imagine that such clinics would be boycotted by all.

Am I sure it's safe to tell a Student Mental Health Center therapist about suicidal ideation without fear of dismissal? It seems reasonable to me that any new patient might ask who has access to his records (no, therapy notes shouldn't go to the dermatologist) and how sensitive information is handled. Anyone contemplating suicide should get help-- even if your school has archaic policies, it's better to have a semester off to heal than it is to end up dead.

I wish we lived in a world where it was all about doing the right thing and not the fear of being sued.

11 comments:

NeoNurseChic said...
This comment has been removed by the author.
Sarebear said...

I think there is too much stigma about people who have suicidal thoughts, ideation, and/or intent.

I think if people would not judge so much, if people would LISTEN . . .

This sort of mess w/the universities just makes it worse, not only for other students at any university, but for fear of judgement by anyone who is experiencing thoughts along these lines. These clumsily-handled issues, especially when publicized, contribute to societal stigma against people having difficulties with these things, as well as the mentally ill in general.

UGH.

Not that I think discussion of it increases stigma, just the hoser universities taking the actions they did. Hell, the mental health professionals informing the institutions, although perhaps it was in their contract . . .

Don't professional organizations for ologists, iatrists, and other mental health professionals have ethics standards that would object to breaking confidentiality for reasons rather outside what you state in your post? I know, like the Pirate Code, they are guideliens and not law, but what do professional associations of mental health professionals have to say on this subject?

Sarebear said...

Further, to help counter stigma, and fearfulness of patients in general to open up to mental health professionals, it'd be nice to HEAR one of the professionals' associations speak out on the subject, and condemn the actions of the university, and restate what their recommended ethical guidelines are for patient/therapist confidentiality.

jw said...

If students get kicked out for suicidal thoughts then students do not report real suicidal thoughts and the risk of real damage to innocent bystanders goes up. It seems to me from that that this is a simple matter of balance of rights and thus the right to treatment supersedes the right of the school to know.

Yet, there are politics involved here. Zero tolerance to violence, for instance, means that suicidal students must be thrown out even if that means a HIGHER risk of violence: Daft, I know, but that's politics.

Also, protecting the suicidal student population would mean extending protection to a primarily male population and given current gender-politics that is not possible (without any regard to need).

Altogether, the whole thing is a bit of a mess.

This is a fine example of what I mean when I talk of the interactions between politics and psychiatry. What is best for the patient is very often not possible due to political / cultural considerations. One cannot therefore talk purely about what is best for the patient; one must add in what is possible given the politics of the day.

Sarebear said...

I KNOW i can't come from the same perspective you are, JW, but people are PEOPLE, and in some things, I don't think the gender thing makes as huge of an impact. I don't think the fact that college age men are alot more likely to have suicidal thinking or more, than women in their peer group, I don't think the fact that a suicide outreach program on-campus would be serving more men than women, would make a university that was considering such a program, NOT do it.

They're all people, and the point of preventing suicide is to save a LIFE. not to save a man, specifically, or a woman, specifically. To save the PERSON, specifically, and all the potential therein.

That's just MHO; that there'd be other factors much more likely to interfere w/implementation of a suicide outreach program, than the politics of gender.

Then again, I could be naive.

Roy said...

Sarebear: Yes, our organizations have ethical guidelines which prescribe maintaining confidentiality, except under conditions similar to those mentioned by Dinah.

I googled psych.org but could only find the "retired" position statements, meaning there are newer versions. Here are two of the older position statements which relate to this issue:

Confidentiality with reference to psychiatric patients [pdf]

Problems in confidentiality [pdf]

I haven't read through these, so feel free to summarize. Also, keep in mind there are more up-to-date documents, but I don't have time to keep looking right now.

NeoNurseChic said...

Regarding the gender issues, in reality it is important to target both men and women when talking suicide prevention. We could say this is even more important because some of these universities are expelling students for just suicidal thought alone, whereas others are waiting for an attempt. Men are 4 times more likely to complete suicide than women, but women are 3 times more likely to attempt. Based on those statistics, it's obvious that both need intervention - and not just one gender over the other. The last references I saw on those statistics were from 1999 - 2001:

HealthyPlace.com Suicide Statistics

NIMH: Suicide in America

NIMH: 2001 Suicide Facts and Statistics

jw said...

sarebear & neonursechic: Obviously one must target both and to their own needs. Yet, to leave out the very real and powerful anti-male politics of the universities & charities would be daft.

This goes to one of the most powerful and difficult to understand concepts in all of gender: That is, the common view that males are too powerful to deserve help.

This means that any effort towards a suicide prevention system must be regarded as anti-freedom and anti-woman. This hampers and distorts all efforts. I left suicide prevention due to the size, scope and power of the "males are too powerful to deserve protection" feeling within the system.

Britain is finally starting to stand up and demand an end to such twisted thinking. There, it will take another few decades to make real change. Here in North America it will take even longer as the first start to real change has not yet been made.

I'm neither joking nor jesting nor being nasty here ... The problem is quite real and a major player in what can be done in any social service area.

A good example of the political problem is the problem faced in getting welfare for fathers with custody of small children. I was called the most dangerous man in Canada for DARING to suggest that starving children for the minor reason that they are in their father's care is wrong. While the problem has been fixed in most of Canada it is still VERY real in the US. The heart of the problem is the size, scope and power of the "males are too powerful to deserve help" viewpoint. That view is real, common and a major player in what can be done in any social service area.

One cannot make a change in a mental health, social service or other societal area without realizing the size, scope and power of the politics which govern the situation!

In gaining good suicide prevention programs & policies for universities that politics includes a powerful piece of "males are too powerful to deserve help." Thus, the feeling is that being fair to suicidal students would be anti-woman which is NOT allowed. Sad, but there ya go ...

Anonymous said...

My issue is not with the policies of universities. My issue is with those universities that use crappy informed consents. It's always pretty obvious (at least from the ones that I have seen) that if a student threatens suicide that it can be reported.

However, if a university has the policy to alert the administration for suicidal thoughts then let the students know in advance before they open their mouths. Put it in print and have the student sign it. That would allow students to make the decision whether or not seeking mental health care at a student health center is worth it. As long as students are notified in advance, I have no problem with whatever policy the university wants to have. My thoughts are that they can do whatever they want just so long as they let me know in advance...so I can be sure and go somewhere else.

Gerbil said...

A very controversial subject indeed!

I had a psychotic break when I was an undergrad--in fact I was still a minor when it began--and even after two suicide attempts, my college really went out of its way to support my staying in school. I went to a small, high-powered school where students in distress are nothing new.

After my second attempt, I came up with a plan that involved a 6-week leave for day treatment, taking medical withdrawal on a lab course, and keeping up with my work in my other three classes. The freshman dean and my professors were all for it. The dean of students was also in support of the weekend I took at a respite house as a sophomore--as long as I checked in afterward to say I was still alive.

I know I was a huge risk to the school (not to mention to myself!), but in the end it was a good thing I wasn't forced to take leave or kicked out. Even though I was drugged to the gills for the rest of school, I was able to graduate with my friends... and I earned departmental honors, received magna cum laude, and just barely missed Phi Beta Kappa.

What my college didn't handle so well was (non-suicidal) self-harm. I had to meet with the dean weekly about this for a while, until I finally got it across to him that I wasn't a suicide or medical risk, and that he had my permission to talk to my psychiatrist any time. Turned out, he was just trying to assuage his own anxiety.

I had a rough time at one point in grad school also, and then I was afraid I'd be kicked out: I was going to school for clinical psychology, and who wants a crazy therapist? But my professors assured me I wouldn't be kicked out, that I should take care of myself.

While a graduate trainee in the counseling center, I heard all sorts of opinions about how to manage suicidal students. The one thing we all did agree on was that we would only release information to deans, departments, etc. about session attendance. (Of course, the deans, departments, etc. always wanted more!)

I ended up giving a talk to the staff about my own perspective on helping suicidal students. It was pretty powerful for all parties involved. I now give workshops on self-harm, and it amazes me how often people say, "whether they're suicidal or not, if you can't trust someone not to hurt themselves, they ought to be kicked out."

Don't get me started on no-harm contracts.

Jennifer said...

GW case update: Lawsuit settled
http://www.washingtonpost.com/wp-dyn/content/article/2006/10/31/AR2006103101193.html
and
http://www.cnn.com/2006/EDUCATION/11/01/college.depression.ap/index.html