Our response to regretted suicide attempts — Sloppy thinking in psychiatry 5

old chimpanzeeA person is drunk or angry or momentarily distraught.  Or all three.  He or she takes an overdose or cuts a wrist, then reconsiders — or never intended to die in the first place — and either calls 911 or tells someone else who calls 911.  The police come and transport the person to a psychiatric emergency service where a three-day legal hold is placed.  Despite expressing regret for the suicide attempt, the person is admitted for observation and safekeeping.

I sometimes question the clinical utility of short-term psychiatric hospitalization for regretted suicide attempts.  Not that it’s always wrong, of course, but sometimes it seems to result from sloppy thinking.  The usual rationale is that it’s better to be on the safe side.  I.e., if the person’s recent words or actions cast doubt on his or her wish to be alive, it’s better not to take chances.  This has merit in cases where there’s some honest doubt:  Since our statistical success in predicting dangerousness to others and to oneself is quite limited, “false positives” are the price we pay (well, they pay) to keep the “true positives” safe.

But another reason seems even more pervasive though less often stated:  Hospitalization is a predictable and presumably undesired consequence of expressing suicidal feelings.  At one level, legal holds and involuntary hospitalization “train” patients not to express suicidal feelings, lest they spend three or more days in an expensive inpatient unit with its attendant shame, stigma, and many inconvenient rules and expectations.  It may also serve a related function of taking the patient seriously.  Big consequences follow big actions, real or contemplated, and in this way discourage the patient from “upping the ante” with a more serious suicide attempt.

The other side of the coin is that legal holds and hospitalization make us feel better.  We’re taking action, not just sitting there.  Clinical management is clear-cut for a change.  We have an interesting little story with heroic overtones to tell our colleagues.  The treatment plan is easy to justify to third-party payors, unlike more subtle interpersonal interventions.  (A few days ago I was on the phone with a managed care reviewer who demanded a “5-axis diagnosis” and behavioral treatment plan for my dynamic psychotherapy patient.  A more pointless exercise I cannot imagine, except that my patient won’t receive insurance reimbursement without it.  This level of skeptical scrutiny rarely arises in hospitalizing the suicidal, even though the cost to the payor is far greater and the benefits sometimes less apparent.)  We’re hardly ever faulted for choosing to hospitalize.

Of course, this propensity to “hospitalize first and ask questions later” can backfire.  I recall several times in my residency when homeless veterans came to the VA emergency room with bags packed, seeking psychiatric admission.  Their claims of suicidal feelings — or even command hallucinations to commit suicide — were hard to argue with, even though it seemed obvious that the real goal was room and board, not psychiatric care.  Their complaints quickly disappeared once admission was assured.  At the time I noted that civil commitment laws exist to protect the unwilling and undeserving from being hospitalized; none address those who strive to be hospitalized without a valid reason.

A great many suicide attempts and gestures are communicative in nature.  Far from being unambivalent decisions to die, they are cries for help, expressions of rage, tests of whether anyone really cares.  Our responses as mental health professionals are communicative too.  Hospitalization can say, “I’m not playing your game of manipulative suicide threats — I’m calling your bluff.”  It can say, “I hear you, and I take your suicide threat very seriously.  It’s my job to keep you safe.”  It can say, “I blindly follow the rules.  You say suicide, I call 911.”  Conversely, choosing not to hospitalize can say, “I’m not playing into your drama of getting me to overreact,” or “I’m not taking you seriously, not hearing your pain,” or “I defy the conventions of my profession, you cannot count on me to hospitalize you.”

It’s important to pay attention to the message in one’s clinical actions, and also to realize that one’s message can be communicated in different ways.  Hospitalization is not the only way to convey serious concern, even if at times it may be the only way to assure physical safety.  If calling the police is an angry reaction to the patient’s misbehavior, it should be re-thought.  Nor should it be an unthinking, reflexive response.  The converse is true as well: If inaction is an expression of angry avoidance, denial of the severity of the patient’s risk, or a reflexive expression of the practitioner’s bold, iconoclastic nature, that too should be re-thought.

Failure to consider the risks and benefits (pros and cons) of hospitalization on a case-by-case basis would be evidence of sloppy thinking in psychiatric practice.  While it may be less common than other forms of sloppy thinking I’ve posted about, it still happens disappointingly often.  I also wanted to post about it to give readers a place to comment and ask questions about legal holds, as there is ongoing interest and concern on this topic.

Photo courtesy of Petr Kratochvil.


6 comments to Our response to regretted suicide attempts — Sloppy thinking in psychiatry 5

  • I have a diagnosis of depression. I was severely verbally abused by a landlord. I was so stressed, I admitted myself to a psychiatric hospital. I had wonderful care there. I returned home in about a week and thought things would be fine. It started in again, apparently the landlord’s wife thought I had a romantic interest in her husband. I attempted to readmit myself to this same hospital. However, in my first stay I had tried to change doctors. I was told I could but some how he blocked it. I had made a complaint about him. When things didn’t work out at home the first time, I returned to the hospital. I voluntarily admitted myself, but I had to accept this doctor again to be readmitted. I was previously in the “open” unit. But I was led to another department, and taken inside. Once I was inside I realized I was in a locked unit with dementia patients. I was accused of saying I was suicidal which was untrue. I had spoken to a social worker outside the hospital earlier in the day. I was upset and we both agreed that maybe I should go back into the “open” unit for a couple more days. We agreed to that and I was allowed to go home and get more clothes that I could wear in the “open” unit. I did this and came back ready to be placed in the “open” unit before I registered to admit myself voluntarily. I was led to another unit. When I went in, I realized immediately I was in a locked unit. When I realized this was retaliation by my doctor for having complained about him, I was informed that everyone had witnessed me saying I was suicidal. Would I not have been placed in custody if I said or even indicated I was suicidal at once? Would I have been allowed to go home and get extra clothes and come back if the things they said were true? It is my impression that you are immediately taken into custody if someone did say they were suicidal? I was in total shock that people would lie about me to please the doctor or save their jobs. I documented the whole time I was in the locked ward, 3-4 days. On my 3rd day, I believe, I was placed on a 72-hour hold. When that day came, I was discharged if I signed that I would not buy or have a gun for 5 years. Of course I signed it. I wanted out. My question is, if they believed I was really suicidal, why would they release me? They have made life very hard and hurtful because of this as it apparently known at whatever place I try to get health care, it is starting to become traumatic for me. This statement in no way indicates that I plan to hurt myself.

    • Your comment, which originally was a reply to another post but fits much better here, illustrates some of the problems with the 3-day legal hold for suicide risk. First, the law is written so that even suicidal patients can choose to be hospitalized voluntarily. At least in California, it is only when the patient refuses voluntary hospitalization, or is unable to make a lucid decision, can suicide risk be used as rationale to force an admission. The second point is that applying such a hold is always a judgment call which depends on subjective factors. It’s even possible that your hold was applied vindictively, as you suggest, although this is far from the only possibility. For example, if a suicidal patient enters voluntarily but then soon signs out “against medical advice” (AMA), an immediate readmission may trigger a legal hold on the theory that the person cannot be relied upon to stay safely in the hospital. Technically, this is a misuse of involuntary commitment, but I’ve never heard of it being legally challenged. There may have been other factors in your specific case that led to a legal hold the second time, e.g., you may have sounded more desperate or agitated. In any case, the 5-year firearm prohibition follows from the legal hold itself (in California), whether you sign anything or not. It is not a condition of discharge. I’m sorry you’ve had such a hard time lately. Thank you for writing.

  • Interesting article. I am bipolar and also a survivor of childhood trauma. Over the years (I’m 47 now) I have had to manage many occasions when I felt overwhelmingly suicidal, as well as 3 actual attempts. I have been both a voluntary patient as well as what they call in Ontario, “on a hold” (non-voluntary). I never experienced admission as punitive, although often I felt I was in a “holding pen” – simply kept safe with no access to methods, while they adjusted my meds and gave me space and time to wait out the thoughts.

    When I am at my most suicidal my thinking is completely muddled and confused – it’s like looking at the world through a dense fog. I have no idea what it is I’m supposed to be doing – kill myself? not kill myself? ask for help? stop taking my meds? take more? Being in the hospital these decisions are taken away from me. The hospital has never “fixed” me… but it has kept me alive to continue to do that work on the outside.

    Beds are in short supply here, so they don’t keep you in any longer than absolutely necessary. Doctors are overworked, too, and often I only saw my assigned psychiatrist for a few minutes each morning. No other treatment was offered. So I look on hospitalization as a safety measure for me, and then when I start to feel a bit better I return to therapy to do the hard work of getting well and tackling those underlying issues. Hospitalization, despite the rules, boredom, lack of privacy, and proximity to people who are very unwell, has saved my life several times over. It’s not something I’ve ever regretted.

  • anonymous

    I voluntarily sought out psychiatric care/psychological care in the mid 80’s.

    I unfortunately regret it, it impacted me negatively and my life has basically been stalled because of it.

    I wanted help to explore difficulties I had with depression and anxiety and not being able to meet life goals and expectations that I had for myself because of it.

    Seeking care resulted in basically a stigmatized label, bipolar 2, OCD, PTSD loss of every opportunity I had previously and I have been unable to work or have meaningful relationships since.

    I have often had suicidal thoughts, no plans, no intent, but as it is not safe to ever disclose those to a mental healthy professional, the assumption is you are manipulative or lying, and the result punitive, the pain you are trying to alleviate will only become worse.

    I have found that meditation and walking are beneficial and I wish I had just tried those early on and found a support system and learned about better coping skills for stress and setting better boundaries with others.

    I might have had a life.

    I guess I am trying to say that one should exercise great care in utilizing psychiatric services.

    You will become a second class citizen, stigmatized, marginalized and any dreams you had, put them to rest.

    And, if this causes depression, suffer in silence. Because a psychiatric hospital is equivalent to a prison. You have no rights. I was there once, voluntarily for depression. It was a nightmare. It was 30 days before I could leave and this coincided with my insurance running out. It was the 90’s.

    I know many bipolar sufferers who have adverse effects from medication and are unable to work. Or they are then labeled borderline, if the medication does not work.

    With electronic medical records and the access others have to very judgmental and demeaning wording in files that will follow you in so many areas, the benefits to this field are marginal.

    I have accepted reality at this point. I do the best I can daily to find meaning but when your educational, employment and family goals are thwarted, there is little to do.

    Holding people against their will when “dangerousness” cannot be predicted, short of an outright threat, is just a power trip for psychiatrists who are quickly becoming agents of social control and pawns in gun debates over recent tragedies.

    The tragedy is that most mentally ill are not dangerous and labeling them and stigmatizing them robs them of their lives. We have gone backwards. It is sad.

    • I have often had suicidal thoughts, no plans, no intent, but as it is not safe to ever disclose those to a mental healthy professional, the assumption is you are manipulative or lying, and the result punitive, the pain you are trying to alleviate will only become worse.

      I’m sorry that has been your experience. As I wrote in my post, in my opinion it is often more helpful to talk about suicidal feelings in a therapy office than to force the patient into a “safe” setting that is both emotionally cold and very temporary. Of course, there are also circumstances, as with commenter Catherine above, where hospitalization is helpful and valued by the patient.

      In my experience, applying psychiatric holds is not a “power trip” for psychiatrists. No one enjoys it. Sometimes, though, it’s overly cautious. Engaging with distraught, hopeless patients, seeing the world through their eyes, is often more helpful than declaring them an unmanageable risk.

      You are certainly right that most mentally ill are not dangerous. Thanks for writing.

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