Is it really best to force someone into the hospital when they are suicidal? Do suicidal feelings plus “risk factors” really mean professionals can predict whether someone might try to kill themselves? And are suicidal feelings the symptom of a treatable illness that should include medication prescription?
I was locked up at San Francisco General Hospital’s psychiatric emergency ward because confinement was considered necessary to protect me from suicide. But when I was forcibly tied down, locked in an isolation cell, threatened with being strip-searched, kept behind barred hospital windows for months and subjected to degrading treatment, it was the hospital that I needed protection from – not my own feelings.
While people are not always mistreated at inpatient units like I was in the United States, the harm done to me in the name of care is a too-common tragedy. Even if some patients feel grateful for being brought into treatment against their will, and even if we recognize a diversity of experience in hospitals, the question remains: Is the possibility of harming people like I was harmed worth the risk? Would society tolerate any other medical intervention with such clear possibility of devastating harm, with such a high record of iatrogenic trauma? Shouldn’t we be looking for other approaches, with less potential for harm, rather than just accepting routine institutional violence?
Injuring some patients and violating their personal liberty, it is said, is the price we pay for preventing suicide. But is that calculation an accurate one? What does the research say about suicide prevention?
The United States Army, facing suicide rates higher than combat deaths, summarized existing research in a study by the Walter Reed Army Medical Center. It found that “…even when all the known risk factors are considered together, they may only account for a small proportion of the variance in suicidal behaviors. That is, the known risk factors do not provide clinicians with sufficient information to predict suicide.” As a result, hospitals are committing numerous “false positive” errors, and “well-intentioned interventions are surely targeting many for whom the intervention is not needed.” The study lists some of the adverse effects of intrusive interventions: violation of confidentiality, harm to the therapeutic relationship, increased stigma, treatment dropout, and avoidance of “forthright conversations about suicidal ideation in the future.”1
Forceful and intrusive interventions are not based on a sound calculation of risk prevention. Instead, they routinely damage people, and discourage many more, who fear involuntary treatment, from reaching out for help. (And people also sometimes learn to use the language of “safety” and “suicide” to elicit the response of hospitalization when no other treatment options are available – rather than speaking in terms of the pain, fear, sadness, or helplessness they feel.) To be honest, forced intervention cannot be shown to actually prevent suicide, and what it really treats is fear of responsibility and liability held by professionals. We need a new approach.
We need to speak openly about our suicidal feelings without fear of institutional reaction.
When we have these discussions, which I have had over the past 12 years as a support group organizer, trainer, and now as a therapist, we learn that suicidal feelings are much more common than we realize. Many people live with suicidal feelings, and being able to talk about the urge to die, like being able to talk about any extreme distress, is the key to recovery.
People become suicidal because of life circumstances and real experiences. While substances, drug side effects (sometimes from psychiatric medications themselves), chemical exposure, and other factors can contribute, suicidal feelings cannot be explained away as the symptom of faulty brain chemistry to be corrected by medications. Medications, when helpful, do not counter any known disease process, and often placebo and expectation are responsible for medication effects. As Joanna Moncrieff and David Cohen write in the British Medical Journal May 2009, “…psychiatric drugs are, first and foremost, psychoactive drugs. They induce complex, varied, often unpredictable physical and mental states that patients typically experience as global, rather than distinct therapeutic effects and side effects. Drugs may be useful because some altered states can suppress the manifestations of certain mental disorders.”2
When we begin to listen we also discover something very surprising. Suicidal feelings are not the same as giving up on life. Suicidal feelings often express a powerful and overwhelming need for a different life. Suicidal feelings can mean, in a desperate and unyielding way, a demand for something new. Listen to someone who is suicidal and you often hear a need for change so important, so indispensable, that they would rather die than go on living without the change. And when the person feels powerless to make that change happen, they become suicidal.
Help comes when the person identifies the change they want and starts to believe it can actually happen. Whether it is overcoming an impossible family situation, making a career or study change, standing up to an oppressor, gaining relief from chronic physical pain, igniting creative inspiration, feeling less alone, or beginning to value their self worth, at the root of suicidal feelings is often powerlessness to change your life – not giving up on life itself.
Suicide is and will always remain a mystery. We never know why, faced with that terrible urge to die, one person ends their life and another comes back from the brink. The science of suicidology has no conclusive answers for why I am alive today, how I survived suicidal feelings and endured states of despair so deep I could neither feed myself nor leave my apartment. I will never know why I am one of the people who, at the Golden Gate bridge in San Francisco, didn’t let myself fall into the water below but instead turned and walked back to shore. I am grateful to whatever it is in myself, or whatever it is in the world or the universe, that let me live.
While today I have found a commitment to living, I still at times struggle with suicidal feelings. I live with these moments, days, or even weeks of extreme pain because I have close friends courageous enough to listen and show that they care – rather than overreact with fear and turn me over to mental health professionals who rely on forced treatments. And I have learned to meet my suicidal feelings as messengers of change, an opportunity to search within myself for new directions in life.
I want to live in a world where we can talk openly about what happens to us, our feelings and our dreams, including the feelings we sometimes have of wanting to die. I might ask you to call me later, or stay at my house, I might ask you to give up the bottle of pills you have or I might even ask if you would feel safer in a hospital. But I won’t substitute listening to you for risk assessment, the false safety of forced confinement, or the reassuring belief in simple explanations and solutions. Suicidal feelings are among humanity’s worst forms of suffering: the response we give is a call to our greatest humanness.
First published in the Scottish Recovery Network
I am grateful to David Webb, Janice Sorensen, Ed Knight, Arnold Mindell, and the Western Massachusetts Recovery Learning Community for their innovative work on these issues.
 “Army Suicide Surveillance: A Prerequisite to Suicide Prevention” by Gregory Gahm and Mark Reger. In E. Ritchie (Ed.), Combat and Operational Behavioral Health (pp.393-402). Department of Defense, Office of the Surgeon General, US Army, Borden Institute. Found at https://ke.army.mil/bordeninstitute/published_volumes/combat_operational/CBM-ch24-final.pdf
 “How do psychiatric drugs work?” BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1963 (29 May 2009. BMJ 2009;338:b1963)
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Thank you, Will. I used to work at a suicide hotline in Portland, and found the exact things you state – that everyone who wanted to kill him/herself had a solid reason for doing so, and it almost always had to do with solving a problem they couldn’t find another way to solve. It was often the result of living in unrelenting pain for long periods of time and seeing no other way out. The key to helping them was to listen, acknowledge, and help them find some small thing they could do right now to regain some measure of control over the situation they found so objectionable. Anyone who would talk to me, I would almost always find a way to help them feel better in less than an hour of supportive conversation.
Suicidality is not a disease. It’s a state of mind that deserves gentle and supportive exploration. I can’t imagine how what happened to you in the hospital could have done anything but make it worse. When you do know what is really possible in helping someone in distress, watching what happens to people in need of that kind of support be abused is all that much more painful.
Thanks from a fellow Portlander for all the awesome work you’ve done, both personally and professionally, to humanize what is currently a very inhuman profession.
Lots of excellent points, Steve!
A few months ago it was the third year Angel Verrsary of my daughter death. Died by gunshot, suicide. I read everything I could to try and understand it. And was still so confused. In the 3 years since she has been gone the actions and at times just plain out evil I’ve endured from people was devastating. In one day everything and everyone I had ever believed was nothing like I had thought. I’ve been ridiculed and more than once I’ve had the did stink feeling that they were blaming her death on me. I’ve even been told I use her passing as a excuse for attention. The big shock is, this all came from family members. As of now other than my granddaughter from my daughter I have no family. The mental abuse and hatred I’ve endured finally pushed me to try to end my life. So happens a friend on Facebook set out to find me along with the police. Well within 5 minutes I was handcuffed and literally thrown in the SUV. Then was put in the state hospital even though I had two types of insurance. Once there I was strip searched then thrown in a filthy room with only a sheet. In two days I got one glass of water and nothing to eat. Nobody took vital signs nor gave me my routine medicine. I overdosed on a full bottle of Ativan. Which I later found out benzodiazepines are extremely dangerous to detox off. Finally they let me make a call and while out of my hole I threw one hell of a fit screaming I have insurance and I was suing someone. Within 15 minutes they had me to another place. But as far as treating me any better, that didn’t happen. I can guarantee a murder would have been treated better than me. And this is so sad and morally wrong in today’s society but I promise you I will never ever tell another soul if God forbid I sink to that desperate stage. No way in hell will I choose to go to a place like that. So I got my answer. My daughter must have known what goes on when you ask for help. Right now with kicking my mother out of my house and completely cutting ties with the family members who caused such torture I am emotionally feeling way better and can actually see a future. Oh and of course the family members all said I was wanting attention and playing games. Sir I assure you it was by no means remotely a game. Point is apparently I was reaching out for help but none of them have enough empathy and understanding to see that. But at the same time I didn’t deserve the horrible treatment either.
“”People become suicidal because of life circumstances and real experiences””
Yes, yes, yes, thank you so much for saying this Will. I was so upset when a mental health professional in a “Psychology Today” blog entry said that a teacher in LA who committed suicide after being despondent over his performance ratings posted on a website had to have been mentally ill to have done this. Her opinion was this event shouldn’t have caused him to commit suicide.
I totally agree with Steve that you have humanized a very inhuman profession
Boy this resonated with me in so many ways.
“But when I was forcibly tied down, locked in an isolation cell, threatened with being strip-searched, kept behind barred hospital windows for months and subjected to degrading treatment, it was the hospital that I needed protection from – not my own feelings.”
Only somebody who has been tied up and locked in an isolation cell can understand what that means. Even though I was tied up for around 1 day, it felt like an eternity. I was also kept incarcerated in a so called “hospital” for several weeks. As I have explained several times, in the European country where I was abused, “need for treatment” is enough to lock in somebody against his/her will. So it’s not that I was suicidal or anything, I just didn’t want to be “treated” (ie, forcibly drugged) for OCD. And yet, that’s what I had to “agree to” if I wanted to get out of there.
Then you correctly point out,
“Even if some patients feel grateful for being brought into treatment against their will, and even if we recognize a diversity of experience in hospitals, the question remains: Is the possibility of harming people like I was harmed worth the risk?”
Sorry, I don’t suffer from Stockholm syndrome. I never accepted that what happened was “for my own good”. Not even when I was “voluntarily” taking the drugs. I saw it then as I see it now: a blunt violation of my right to freedom in the name of a fraudulent endeavor.
As I have said many times, I deeply believe that the root cause of psychiatry’s evilness is its legally sanctioned status as a coercive force. There are other non nonsensical, pseudoscientific endeavors, in which people voluntarily engage, that do not cause so much misery. Think about the following. The evidence supporting astrology’s ability to predict people’s personalities is as strong (or weak) as antidepressants ability to improve people’s scores in the Hamilton Rating Scale for Depression or as strong (or weak) as psychiatry’s ability to predict who will become violent. No kidding, people have studied this stuff from a scientific point of view: http://www.nature.com/nature/journal/v318/n6045/abs/318419a0.html . Interested parties can access the full article from the Nature website or the library of their choice. The bottom line is this: using a carefully designed double-blind study, it was concluded that astrologers’ ability to match personalities to natal charts was no better than chance (Irving Kirsch anyone?).
Now, imagine for a second in what kind of regime we would live in if astrologers had managed to convince the powers that be that they (astrologers) have a reasonable ability to predict who and when will become violent based on natal charts and the positions of planets on a given day. Now, imagine that the powers that be are not very convinced of that but the astrologers counteract that even if they cannot possible predict 100% who and when will become violent, they can do it for a few cases and that that fact alone (because of common good bs) justifies them having extra powers to lock in preemptively people until the danger goes away (ie, planet positions change). Then the powers that be say, OK, will give you “civil law” ability to do that. People would be mad at astrology if it had managed to pull such scam off. But because it has not, astrology is a perfectly legal endeavor in which people can voluntarily engage if they are so inclined.
Well, that’s exactly the regime that psychiatry has created for itself. And that’s the prime reason psychiatry is such an evil endeavor.
When it comes to suicide prevention, many years ago I lost a good friend of mine to suicide. I can tell you that “suicide survivor syndrome” is real, ie, people who lose a good friend or a loved one to suicide have a very hard time for a long time after the suicide. That said, I don’t think I would have wanted to see my friend being submitted to the type of humiliation that I endured at the hands of psychiatry. My friend would have hated me for life afterwards, and rightly so.
I don’t have an answer as to the best way to get people who are suicidal to take a second look at living, but I can say with certitude that humiliating them in the way I was humiliated is not the answer. It can make matters much worse, not better.
Thank you for stating this so clearly and so well. I will always maintain that I was not “mentally ill” when I tried to kill myself. I just felt like my life was totally out of control and I had nowhere to go and no one to turn to; it felt like the only solution at the time.
In the medical hospital where I was held while waiting for a bed in a psychiatric facility the nurses took care of me very “professionally,” but they would not talk with or to me. Only one nurse and one nursing student sat down and listened to me. They helped me to set my feet on the path in my journey to find healing.
In the private psych hospital where I was held till I could be sent to the state hospital (because I had no insurance) I was pointblank told to not talk about my suicide attempt nor my feelings about it. I asked where I was supposed to go to be able to talk about what I felt. I received no reply. Finally, it was at the state hospital, where I was assigned to a young intern doctor, that someone finally sat down and listened to what I had to say. He came every afternoon for a month. He listened to me for one hour each time and let me say anything that I wanted to get out in the open. It was during those afternoons that I learned new ways to cope with my suicidal feelings so that I didn’t have to act on them. Do I still have such feelings every once in a while when I’m particularly stressed? You bet; but the difference now is that I can work through them.
My stay at the state hospital gave me the time I needed to establish balance once again in my life so that I wasn’t careening off into space, wobbling and weaving around. I have very mixed feelings about my stay but it did give me the precious time I needed to realize that I really did want to live.
The more we are willing to honestly listen, without being frightened or uncomfortable, to people who want to die, the more people we may help to begin their journey of healing. Thank you again.
Thank you. This message you’ve devoted a significant portion of your life towards effectively promoting – is essential in order to create communities of acceptance where all have an oppurtunity to thrive. I’ve heard you speak on this topic and am grateful that you continue to communicate that thoughts about wanting to die can be very constructive (as a manifestation of wanting something better and not accepting suffering). As you so powerfully wrote – we need to continue to do a better job of listening to each other and hearing that suicidality is not giving up but demanding a richer existence and refusal to accept a disatisfying existence. Sucidality is far more common than is suggested by some paradigms of thought. It is not the result of a pathology, disorder, disease, or chemical imbalance – and it is not abnormal. It is the result of legitimate responses to the context of one’s human existence – and it is very human. We need to encourage and try to facilitate individuals believing in the capability of their personal agency to fullfill their healthy need for change – which is suicidality. We have need to continue our process of not putting fear of responsibility and liability, before listening to each other and compassionately honoring what others are expressing.I think your last paragraph presents a humane approach that is feasible in every community – “I want to live in a world where we can talk openly about what happens to us, our feelings and our dreams, including the feelings we sometimes have of wanting to die. I might ask you to call me later, or stay at my house, I might ask you to give up the bottle of pills you have or I might even ask if you would feel safer in a hospital. But I won’t substitute listening to you for risk assessment, the false safety of forced confinement, or the reassuring belief in simple explanations and solutions. Suicidal feelings are among humanity’s worst forms of suffering: the response we give is a call to our greatest humanness.”
So many great points in the article and comments! So, the insight required to heal is a revelation of what change would help. This often requires the wisdom to perceive the dynamics of someone’s much larger social situation. What social structures could bring about greater harmony? Focusing as if the problem is in just one mind can draw attention away from this much larger focus required for healing.
Everyone’s situation is different. Yet, many people of conventional mindsets seem to have a preconception that suicidal feelings are driven by anger toward people who’ve hurt/neglected someone. This idea was popularized in the 1980’s by books like the bestseller, Smart Women, by Judy Blume. Preconceptions are pre-assessments, which are pre-judgments, which are thus prejudices. To assess is to judge; the dictionary proves it.
Such people don’t seem to consider that people who are intimately, sexually, emotionally and/or psychologically abused may pick up on emotional/mental signals from the abuser that his life would be easier if the victim killed herself. A victim gets conditioned through abuse to survive more harmoniously (healthfully) by doing the abuser’s will (so he relaxes rather than traumatizes). A victim whose mind has social connections to an abuser who wishes she’d kill herself may wonder why she’s considering it.
When she wonders about this out loud, people may not consider that she was selflessly trying to enable a highly traumatized abuser to experience greater harmony (health). Sure, she hadn’t obtained the hindsight that enables a larger perspective on how she’d been abused, how to extricate herself, and how to disentangle the whole situation for the benefit of all involved. Yet, brainwave technology can clarify which person in a relationship has the more tortured, unbalanced and disordered brainwave patterns. However, psychiatrists do not obtain this evidence before leading communities to think the person considering suicide may be selfishly, unhealthily angry.
Their focus that she harbors the biggest problem to fix in herself distracts her social network from realizing how big her heart is, and how clear her intuition is. Then, people don’t connect harmoniously (healthily) to the true state of her heart and mind. That harms her social health big-time. The worst consequence is that they don’t focus on the abuse as the biggest problem to fix. So, they don’t protect people from its spread.
Such prejudiced people don’t consider they may be angry with the person who considered suicide. Her contemplations make it clear they haven’t been wholly effective healers, nor have they fully protect her from harm. (Hey, who’s perfect anyway? We can all benefit from improving.) They don’t consider they may be projecting their selfish anger onto their image of her.
Abusers flatter their egos by underestimating their victim’s resilience and capacity for healthy social power. This is why severe abusers may wish victims would kill themselves. Then, other people who can’t wholly heal could also be biased to see the abuser as the victim of the bereavement, as they might see themselves. Abusers at least benefit when their victim’s perceptions are considered disordered or unclear. Then, victims who realize who abused them are considered less credible.
Of course, abusers can be women, and victims can be men. Until English adopts a gender-neutral pronoun, I must choose one at a time.
Thank you Will for raising this topic over and over again. There is still far too much silence and shame on this subject.
I have recently come to realize just how much double binds and unbearable dilemmas play into hopelessness and despair, and how rational death can seem as a way out of seemingly “no way out” situations that our culture seems to foster and multiply.
It really does matter that we have safe spaces to confide our innermost pain. To lay it out openly, look at the pieces and implications, and have the time and fearless support to make meaning of our darkest emotions.
I do find some irony in the role context plays.
Buddhist monks and acolytes are often instructed to spend a good deal of time contemplating their death. When possible, to meditate in charnel grounds. To be with the very intimate experience of dying in the flesh. It is believed that only by fully embracing one’s death can we hope to embrace life (and choose wisely how to live it).
Natural childbirth and indigenous rites of passage and vision quests often involve a metaphoric death of one life to enable rebirth in a new form.
And, perhaps most simply, in our culture where we are told to buck up and “suck it up,” we create a false “do or die” dilemma that can make a suicide attempt the first legitimate bid for help, love and support, a bid that becomes can become its own double bind and self fulfilling prophesy.
That you for creating an in between space for calling our greatest humanness forward.
Thanks for this. I run a suicide prevention charity which responds to suicidality using indigenous and sociological rather than medical approaches. The only thing I disagree with in your article is the statement that we can’t know why some with suicidal thoughts end their lives and why some don’t.
My child killed himself 15 days after being prescribed Prozac. Both my government and Mylan Pharmacueticals conducted causality assessments and found the drug to be the probable cause of his suicide. In some cases, the reason people end their lives is because of the pharmacological treatment they are given.
The Joiner model also explains some suicides as being a product of social isolation, a sense of being a burden and the ability to overcome the survival instinct through either the use of drugs or desensitisation to pain and suffering.
My charity’s work suggests that along with these factors, those who die are distinguished by their lack of self efficacy. They do not believe they have the power to change the circumstances causing their suffering. In our experience, no matter how bad the situation, if people believe they are capable of changing their circumstances through their own efforts, they will survive.