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Suicide Prevention -- Does it Work?

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A story is going viral on the internet of an Australian man who just died and who lived near a cliff. He observed people standing at the cliff for a long time and then disappearing. He decided to go to people who were standing overly long at the cliff and talk to them and invite them to his home for a meal. He is credited with preventing over 160 suicides. I suspect those results are better than our psychiatric service. Similarly, a dog is credited in Toronto with preventing a man from opening fire on innocent people in a park and then killing himself. The dog came to the man and wouldn't stop being affectionate to him. Apparently the dog knew what he needed. The man changed his plans, returned to his car, drove to the nearest police station, and presented himself and all his weapons. The dog's affection had inspired him to change his mind. I suspect that ordinary people and random acts of kindness are more effective than psychiatry. Paradoxically, if we professionals went to someone standing by a cliff and invited them home for a meal, we could be accused of unprofessional conduct. The most effective suicide prevention may be done by non-professional human beings, as I think the Recovery Movement would predict. Our psychiatric services may be far less effective.

In psychiatry we spend an enormous amount of time trying to prevent people from killing themselves. In the general hospital, one of our most common psychiatric consultations is to make an assessment as to whether or not someone is suicidal. The hospital spends greatly to provide sitters for people who might be suicidal -- in a 'one-on-one', a staff member is paid to sit and watch them, twenty-four hours per day. I think it's a miracle that we predict as well as we do, that more people don't leave the hospital and kill themselves. Often we are limited to just what the person tells us, and how they say it. Sometimes, we can reach family members and gain corroborating evidence to support or deny their story. People who do kill themselves learn to say what we want to hear. They learn to tell a convincing story that reassures us. When people have taken overdoses, for example, they learn to say how much they regret what they did, and that they don't want to die, and that it was a momentary impulsive act of bad judgment. We rely on the context of the attempt -- did the person immediately seek help or was it an accident that he or she was found? We rely on our assessment of the sincerity of the story. Does it sound true? Probably one of the most dangerous acts of a psychiatrist is to send a person home, just as I learned that the most dangerous act of an emergency medicine physician is to discharge the patient.

What I wonder is if this whole system of prevention actually works. Or do people make more attempts, knowing how hard we will go to prevent them from succeeding? Do we encourage impulsive, suicidal acts by our efforts to prevent them? I don't know, nor have I been able to find any studies to support a position, one way or the other.

I want to mention that I am not here talking about people who are psychotic. We could, as a society, say that people who are psychotic need protection from self-harm, while they are actively psychotic, while they are living in a dream-state. In dreams, we can walk off buildings and survive. We can fly. We are impervious to injury. People with lived experience have explained to me that being psychotic is like being in a dream. Dreams feel so real until we awaken. Some say they are real. Many indigenous people believe that we inhabit other realities while we dream and that we return to this one when we awaken. How would it feel to fail to wake up from a dream? We could say that we need to help each other in these circumstances, though there are a number of ways in which we could help and they needn't involve the hospital. {Paradoxically, we often give people the drugs they use to try to kill themselves. The very good question of whether or not these drugs actually work is beyond the scope of this essay.)

These questions have arisen for me from two separate sources. In my work in psychiatry in a general hospital, I am often called to assess whether or not people are still suicidal. I use the same benchmarks as everyone else -- the Columbia Suicide Risk Scale, my narrative ear to tell me if the story rings true, and any corroborating evidence I can find. I have been wrong at least once. The person returned within 12 hours having tried again. This attempt was more lethal. He was admitted to the intensive care unit. Luckily, he lived. I'm thrilled to know of only this one occasion, considering how many people I see, and the reality that I tend to believe what people tell me until it is proven wrong, as it sometimes is. However, some people return to the emergency department over and over, each time with a suicide attempt, albeit often half-hearted. Some people who struggle with life, have no housing or support, can offer suicidality as a strategy to gain shelter, or to find a 'safer' place away from their life's concerns, which is a sad commentary on our society. Barbara Mainguy, my wife and colleague, tells of one of her clients who regularly reported as suicidal to gain respite from a variety of bad social relationships and housing arrangements, and knew which hospitals had the best staff, best groups and activities. She was extremely indignant on one occasion when she reported to hospital after a fight with her son to find that she had inadvertently reported outside her favorite hospital's cachement area and was sent to a different hospital and was going to have to have 3 days of assessment to even get outside smoking privileges.

When I practiced in Tucson, a good option for drug deals when the deal went bad was to go to the emergency department and proclaim themselves suicidal. My colleagues could not tell that they actually weren't (I wasn't working in the emergency department there, though I doubt I could have told any better and, even if I could have, would I have taken the risk to deny someone admission who was proclaiming his or her lethality?). I wrote about this in a paper I published in the Permanente Journal, about a daily narrative therapy group on a locked inpatient unit. In that article, I noted that the patients were much better at detecting a drug dealer pretending to be suicidal than we professionals were. I remember one telling me, "Doc, he's not like the rest of us patients. He's really scary." This particular man was frightening. He admitted to killing people in the course of his dealings with even a hint of pride and a large dose of bravado. He took pleasure in scaring me and the other patients, it appeared.

To take the opposite side of the argument, what if we stopped trying to prevent suicide.

What would happen if we stopped assessing whether or not people were suicidal in the general hospital? What if we treated their overdose or the results of their attempt, admitted them if they wished, and discharged them otherwise. I think Thomas Szasz may have agreed with this. Though he has died, he is well-known for his book, The Myth of Mental Illness. Would people take life more seriously and attempt to end it less often if it wasn't such a coded event, and we weren't trying so hard to prevent them from doing so? Do more people die accidentally from their "attempt" than purposefully? I do see people returning repeatedly and being assessed and admitted repeatedly, leading me to wonder if we are actually helping.

The other impulse for my speculation is the upcoming visit of Ron Coleman and Karen Taylor to Maine. Ron and Karen loom large in the world of the recovery movement from mental illness. In this movement, people are encouraged to take self-responsibility and to free themselves from the mental illness system we have created. One cannot escape the mental health system if one is frequently threatening suicide. Within recovery, peer support is crucial. People reach out to their peers if they feel self-destructive. I have heard stories about peers spending days at a time with those who are in need of support to prevent their demise. Yet, this seems somehow different from our medicalized approach in which the suicidal thinking comes from a brain disease that we must treat. In that model, people think of suicide when life circumstances are so bad that no reasonable choices remain. And this brings us back to the social determinants of health, which apply equally to the mind as to diabetes. When people are homeless, isolated, poor, and malnourished, choices look very different, than when they are fed, sheltered, provided with community, and sufficient resources to feel that their life had dignity. Could we lower the suicide rate more by housing people than by admitting them to hospital? Could we lower it more by providing access to community, peer support and good food, than by all of our assessments? I suspect that Dr. Raphael, the leader of the social determinants of health movement at York University in Toronto, would say yes. I will have to ask him.

Does medicalizing and, in a sense, infantilizing people reduce the suicide rate, or increase it? That is my question to which I have no answer. Meanwhile, I continue with our current practice. I am licensed and must practice according to the standards and ethics set by my governing organizations and by our society, which dictates our current options. I could not change my approach even if I wanted to do so. Society would have to change first. We would have to change the way we think about personal responsibility and self-agency.

My wife, Barbara, and I attended Ron and Karen's Recovery Camp, in Mabie (near Dumfries), Scotland, this past June. Over 80 people who had been multiply diagnosed camped together in a forest and considered how to recover. Some were still on medications. Some were not. As this was a camp for mountain bikers, piles of firewood were scattered freely about the area -- an ample supply for each site. At the side of each pile, was a hatchet or an axe so that people could chop kindling for starting their fire. A former patient, now psychiatric nurse practitioner from Australia, made a point of photographing all these hatchets and wrote a blog about the unused axes among "the mental patients". We would never allow this in our professional settings. Yet, nothing happened, though there were a few emotional crises during the week. No effort was made to prevent people who had received psychiatric diagnoses from access to hatchets, and nothing happened! I think this would be the message of the Recovery Movement -- people do what you expect them to do. If you expect them to be responsible, they will be. If you expect them to be irresponsible and to take the first opportunity to chop themselves or others, then they will do that. People drop into the story we provide them, and perform it as expected. If we provide positive stories, we get positive results. If we provide negative stories, we get negative results.

I have also done dialectical behavior therapy groups for chronically suicidal people. This approach, pioneered by Marsha Linehan of the University of Washington, is recognized even in many mainstream circles as the best therapy for people who are chronically suicidal. DBT has a distinctly Buddhist flavor. The message is that life is unfair and unjust; embrace it and rise above it. Make the best of unfair and unjust situations through using coping skills and making the best choice available, even if it isn't the best choice. Within DBT, it is not uncommon for group members to respond to the "see you next week", statement with the answer, "I'll probably be dead before next week," to which we are trained to say, "I expect to see you here at group next week, whether you are dead or alive." Of course, DBT does not minimize the gravity of people's suffering. Rather, it teaches that to live is to suffer. We all suffer. What matters is how we manage that suffering. The unjust part is that many of us were made to suffer deeply as children through no choice of our own. Many of us were deeply traumatized before we even had language to describe what had happened. Nevertheless, we have to work together to shore up each other, and to assist each other in coping better, in surviving our pasts, and thereby heroically prevailing. This is the role of the hero's story in psychotherapy -- to teach the idea that we are all heroes of our lives just because we keep going. The more we incorporate the hero's story, the less likely we are to kill ourselves.

How many times have I sat with patients in medical settings who dared me to keep them from killing themselves? As anyone who works in emergency psychiatry can attest, more than I'd care to remember. What if I could say to them, "Well, that's one of your choices? You could do that? What else could you do? For that approach to succeed, I think they would need a decent place to live and a community; somewhere to go following their emergency department visit. The Clubhouse model is one viable option in which people live together and take care of each other. Ron and Karen's concept of Recovery Houses is another model. People in crisis can go to the Recovery House without being medicalized. They do not need a DSM-5 diagnosis. They do not have to take medication, though they may if that works for them. Trained peers are there to assist them. We hope to hear more about how this works in other countries this coming October 10th and 11th, in Onoro, Maine, when Ron and Karen visit us. The puzzle for the United States, which is so heavily directed by the medical model of mind, is to wonder who would pay for a Recovery House. Ron tells me he has a theory for how to make it work financially in the U.S. Won't that be interesting to hear?

Ron Coleman and Karen Taylor will join us (Coyote Institute) in Orono at the Community House, 19 Bennoch St., downtown Orono, 10am to 6pm each day, October 10th and 11th, 2015. For more information , visit http://www.coyoteinstitute.us/Recovery.html or check out Ron and Karen's website at http://www.workingtorecovery.co.uk. We plan to have an internet connection available for some or all of the day. Contact us at info|AT|coyoteinstitute.usEmail address for further details. Lewis Mehl-Madrona and Barbara Mainguy will also be in Yellow Springs, Ohio on October 3rd and 4th.

 

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
 

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