Tom, rational suicide does occur. It's much more common, however, to come across people in crisis, often in the context of mental ill-health. If you accept this as a premise - which you may not - then active support does seem a valid response. Coercion using relevant mental health legislation does occur, of course, but the great majority of people with suicidal ideas are either not in contact with services, or are not subject to coercive arrangements.

I don't recognise the distinction between talking and treatment, in the sense that most responses to suicidal ideas involve talking. The 'Connecting with People' programme is a good example of an intervention that is based on talking. It would often be combined with other approaches, of course, which might include drug treatments, or psychological interventions - which is back to more talking, of course.

Some colleagues and I did dome work on ministers of religion views of suicide. They were more likely to locate suicidal ideas as a spiritual crisis, but they still seemed to accept a role for treatment where relevant.

Dear Cameron,

Much appreciate your response. I don't know how it is in your neck of the woods but in the good ole' USA we routinely involuntarily hospitalize those who we deem to be at immediate risk for "self-harm" so that is what I am referring to as coerced. And these are many folks. I would respectfully disagree with your approach of not making a distinction between talking and "treatment." treatment is a medical term that I guess psychology and social work and some other helping professions have metaphorically transposed into a medical service. Talking is a persuasive activity using rhetoric to get the person to go along with suggestions from the helper. That to me is much more of an educational process than a treatment process. I think that mistaken way of viewing what we helping professionals are actually doing in part explains our abject failure to reduce the prevalence of any so called mental disorders. That is, regardless of the claims by academic mental health researchers that we have hundreds of EBPs none of these have moved prevalence down, in fact we have rapidly increased it. Perhaps education (regarding these problems) would help both the providers and the service recipients.

Best.

Tomi

My eccentric view is that suicide is a response. It may be a response to untreated/unresponsive painful mental illness, it may also be a response to painful socioeconomic stressors. You may be old and sick as is your life-long spouse and one is going to die soon - so you make the decision to exit together. These to call them all by the one label [suicide] introduces problems. The management of the formerly successful individual who is now significantly psychoticly depressed is of course quite different from that of the maladjusted personality disordered individual who uses suicidal behavior as a manipulative tool. What has psychiatry got to offer a public figure/celebrity who is imprisoned for pedophilia? An antidepressant? 'Suicide' covers a vast expanse of behavior - some, that which occurs in psychiatric patients is the business of psychiatry - the rest is for theologians, politicians, opinion makers, economists, police and family to manage

Dear Saxby:

Your point is well taken. Suicide is not a mysterious human happening but a comprehensible act to try to deal/respond to a serious difficulty confronted by the individual. It is an effort to cope sometimes an appropriate and sometimes not appropriate. The next question is who is authorized to decide what is and is not an appropriate act of suicide?

Dear Tomi,

It is a joy to hear from someone who doesn't say the usual stuff about suicide being all due to mental illness. But, why do we need anyone to decide what is and is not an appropriate act of suicide. If the individual completes [and are not severely mentally ill] then that suicide was appropriate, for that individual - it has nothing to do with anybody else. Maybe I'm coming across a bit too 1960s.

Saxby

Dear Saxby:

You are almost echoing what my late and dear friend Tom Szasz had to say about this issue (except the piece regarding the reality of metal illness and its cause for suicide). Of course he never denied that deeply disturbing behavior to one's self or to others did not occur in fact he felt this was the existential reality but the expanation for such disturbing behavior he argued was not a medical disease or amenable to medical treatment. I just had published a book, Mad Science, with two good friends and long time mental health academics that you might be interested in that attempts to point out the deep difficulties of current approaches to disturbing behavior and after the critique offers some tentative possible moves to improve the current state of affairs: http://www.amazon.com/Mad-Science-Psychiatric-Coercion-Diagnosis/dp/1412849764/ref=sr_1_1?s=books&ie=UTF8&qid=1376995316&sr=1-1&keywords=mad+science+psychiatric+coercion+diagnosis+and+drugs

By the way I love Tasmania. Back in 1989 I spent about 10 days circumnavigating it.

Best.

Tomi

Hello Tomi,

I think the approach to suicide intervention is highly context-dependent.

If the patient before me tells me needs to cut out his heart because he has suddenly realized he is Satan and by this act can deliver the world of evil, then yes, I will involuntarily admit, and treat (not sure what you intend by the quotation marks, but in the context you appear to mean medication or ECT - correct assumption?), and I will do so with a clear conscience.

If the individual before me is a 16 yr old girl who just survived a Tylenol overdose because she is absolute despondency over being dumped by her first love and can see nothing to live for, again, I will involuntarily admit. I will experience some guilt about this, because I know from the present perspective of the 16 year old, I am possibly no better than a jailer. However, I also keep in mind the future 26 year old bride, 36 year old mother and 56 year old grandmother. Medication, or even restraint, will be reserved for acute crisis and otherwise held at bay in the hope of de-escalating the broader crisis through understanding and therapy which, like Cameron (above), I do not distinguish from medication. See Eric Kandel's Psychotherapy and the Single Synapse for a much more eloquent elaboration than I can offer.

If the patient is a 31 year old with a history of violence, brought by police after being arrested for fighting, telling me if he has to go to jail he'll kill himself--but if he comes into hospital he promises he'll be as good as gold--I'll show him the door.

If the individual is a 76 year old man with ALS, diminishing respiratory function and no ability to control secretions, subject to pneumonia after pneumonia, seeking physician-assisted suicide, I will tell him, with tears in my eyes, that, as much as I would be honoured to assist in a dignified exit, the law as currently written would stupidly brand me a criminal, strip me of my license and thus my livelihood.

To put it more succinctly, I don't see any problem of suicide. What I see is the patient before me. The wish for death is simply the final common pathway at the end of a complex causal chain. It is the chain I must address. On the one hand, I am very glad I have the power of the state to compel treatment. On the other, I am dismayed that that same state power stays my hand where death is clearly rational. Who decides? Well, whether I like it or not, I decide. That's the mantle you get handed with the title "psychiatrist."

All the best!

Rob

Dear Rob:

i appreciate your perspective, but it seems to me that you're overlooking the simple empirical facts that coercive treatment of folks who want to kill themselves is not effective. We all would like to compassionately help but to assume that one can seems a bit arrogant. That is, to substitute our own judgement for the judgement of other adults about their lives lacking any credible research substantiating the use of involuntary treatment is not good or ethical practice.

All my best.

Tomi

Hi Tomi,

It seems that you raise an empirical and a philosophical issue.

First the empirical: if I keep that 16 year old girl, right now, who wants to go home and take another Tylenol dose, right now, then I have prevented that tragedy from occurring. My chief concern with empirical studies of suicide rates is that they look at a population level. I have no such luxury in the ER, where I am confronted with individuals, not populations. Furthermore, I suspect too much stock is set in epidemiological studies at a population level which cannot establish causation. If you want to demonstrate that involuntary admission is causally inefficacious, the study to do would be to randomize patients in suicidal crisis who want to leave to involuntary admission vs discharge. To my knowledge, no such study has been conducted, nor would any ethics review board permit it.

Second the philosophical: it seems you have a pretty big bullet to bite if you want to maintain the hard libertarian/Szaszian stance that a clearly psychotic individual who is at immanent self-risk is a competent adult. Is that the position you advocate? To me it seems pretty clear that there just can be such a thing as diminished capacity in an adult.

I wish Szasz was still alive. His writings were deeply influential on my formation during residency. While I ultimately came to disagree with many of his positions, I embarked on a much deeper journey of analysis and self-reflection, because it seems to me that libertarian arguments need to be taken seriously, not just dismissed out of hand.

Cheers!

Rob

Hi Tomi,

I just wanted to pause a moment longer on this issue of intervention as "highly context-dependent" that Robert Tarzwell raised.

In December 2011, I was a guest speaker at the Forum For Suicide Prevention Policy & Practice in Australia. In one of the debates Philip Nitschke - the founder of Exit International - presented scenarios; a rationale for assisted suicide (terminal illness cases predominantly). I found in the context of being a concerned citizen, rather than a clinician, I had a greater openness to there being exceptions to a rule of intervention to prevent death.

As a clinician though Robert's 4 case studies were all vary familiar kinds of scenarios to me in conducting assessments in ED. As a clinician my responses were very similar to Robert's and centred on being charged with the duty - ethical, professional and role-based - to prevent death in the short-term and reduce risk of further self-harm in the medium term.

At the time of acute suicidal crisis, the adults I have worked with - as individuals - did not present as having made informed choice re a 'right to die', but rather seem robbed of options, let alone rights, by their level of subjective distress.

I appreciate the gravity of the issues you are addressing and I simply suggest that all options short of coercion are appropriate help when someone is in distress. That of course is an ethical not "treatment" issue. The research is clear we cannot prevent or predict individual suicide at best we can offer to be present and accountable to aid but I suggest not against the objections of the person. I believe that the involuntary hospitalization protocols interfere rather than help the person in crisis.

Could you provide some links to research at an individual, clinical level demonstrating ineffectiveness of involuntary admission?