Wednesday, June 22, 2011

Suicide, Free Will, and the Shrink's Magical Ability to Predict Violence

I'm posting over my fellow co-bloggers today.  So what else is new?

Please visit: Hot Grand Rounds-- The Summer Solstice medical blog posts with the pretty pictures, including a pink urinal with teeth.  One could ask for anything more?

And Please Visit Clink's post over on our Shrink Rap News blog on ethical issues related to the psychological report on the suspected Anthrax killer.   
When you're finished reading, please return Here to comment. 

For a while now, we've been having discussions in our comment sections  about the issue of forced treatment: is it right or is it wrong?  Some readers are very clear: no matter how sick, no matter how imminently dangerous, no one should be held in a hospital ever against their will.  One reader tells us that suicide is a right of all persons as per their free will, and by the way, psychiatrists can't predict acts of violence and have no right pretending they can.  They should stand up to the legal system and say so, and not go along with the charade.
Both ideas got me wondering: is suicidal behavior that results in the attention of mental health professionals really a product of free will?  As psychiatrists, many of us believe that people have unconscious motivations--- they are guided by beliefs they are unaware they hold.  People commit suicide all the time-- In 2008, 34,598 people in the United States committed suicide, making it the 11th ranked cause of death.  Somehow they did it despite the proliferation of mental health professionals.  Many completed suicide with firearms, and my guess is that these deaths often occur without the immediate involvement of psychiatrists.  Those who wish to exert their free will to die often do so without alerting others or involving professional helpers.  It leads me to wonder if those that present to Emergency Rooms or to their outpatient psychiatrists might do so because they have an unconscious (or not-so unconscious) desire to be stopped.  Of course there are exceptions: those who are pulled off bridges, or discovered after a serious attempt that did not kill them.  Do we not summon medical care for an unconscious overdose victim on the theory that they may have wanted to die and we're interfering with the advancement of their free will?  
We put up a poll a few weeks ago where we asked if people would want to be treated by force if they had an episode of severe mental illness.  Of our 280 respondents, a majority, 57%, said yes while 42% said no.  Would the answers have been different if I'd asked a more provocative question: If you became psychotic and believed it necessary to kill your children, would you want to be treated?  It's too provocative a question for a poll, but I thought I'd throw it out there.  If you became demented, agitated, and combative towards those caring for you, would you want to be treated with a medication that increased your risk of death over the next year from 2% to 4%?
Don't worry, I won't be that provocative. 
The issue of predicting violence is an interesting one, and our reader is right that we're not terribly good at it.  Our most powerful magical tool is to ask the patient if they're planning to harm themselves or anyone else, and the truth is sometimes more legal than medical: we're told that if we don't ask and document, that if someone kills themselves, we'd lose a malpractice suit.  It does get boring asking perfectly well appearing people if they're thinking about suicide and homicide on each visit, but it is a required check box at the clinic.  If they say yes, we ask about a plan and intent, and it does seem it might be troublesome to the family if a hospital discharges a person who says they plan to leave to go shoot up a mall.  Or someone who has been actively psychotic, disorganized, and behaving in a dangerous manner.  There's medico-legal issues, but there is also common sense and kindness, and if you believe that someone who puts the barrier of the mental health field in the way of their violence may actually want help, even if they don't put it in those terms, then there is little to argue about.  Oh, go ahead, argue anyway.
Free will?  So many people who survive suicide attempts are glad they did.  So many who attempt do so for impulsive reasons that pass, or because they were intoxicated.  I'm not much for condoning a permanent solution to what are often temporary problems.
If you want to tell us that you were hospitalized for suicidal "ideation,"  this is another post for another day: I'm still thinking about that one.