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.