Speaking of suicide: How institutions help people and save lives

As soon as I finished Ann Herrold’s OnlySky column on suicide and psychiatric care, I knew I needed to respond. (If you haven’t checked it out, please read it first). I knew my own column would call upon crucial aspects of my identity: psychiatrist, community educator on mental health, a person who’s battled depression and suicidal ideation, and devastated survivor of my son’s suicide.

My heart ached as I read of the harm Herrold suffered from individuals and institutions ostensibly in place to help. The baffling rush to an inpatient unit, the violations of privacy and confidentiality, the lack of timely and effective treatment. These are atrocious, unacceptable, and inexcusable.

I fear, however, that Herrold’s blanket condemnations and generalizations could do harm by preventing people from seeking life-saving care. In addition, the philosophical underpinnings of their column seemed lopsided, lacking in nuance.

Let’s start with Herrold’s second paragraph, where they write: “While there has been some progress regarding suicide legislation and treatment in the United States, it is by no means safe and caring. Police bully, brutalize, and shame people who have made the attempt. Suicide hotlines track your phone and send the police and ambulance, invading your privacy. Psych wards belittle and alienate you from your community.”

I certainly won’t defend the police, who in a functional society would not be employed as social workers or counselors. My dealings with them as a psychiatrist have been a mixed bag, from clueless to callous to useful. I vividly remember one patient early in my career who spent three days behind bars after a wellness check went horribly awry.

However, Herrold’s statement about suicide hotlines could be construed to mean that enlisting police or emergency services is a matter of course. Thankfully, the professionals on the other end of the phone are trained to help those in distress come up with a safety plan that does not involve ERs or hospitalization. Differing sources report that less than 3% or under 1% of such calls require outside intervention.

Herrold’s negative experience with their high school guidance counselor mirrors the harm inflicted by the counselor at my son’s school, who attributed his social anxiety to laziness. (When I phoned the principal multiple times to report this stigmatizing misconduct, I never received a return call.) I have to wonder if guidance counselor “training” is about as meaningful as a church pastor’s.

Any counselor worth a damn will do their utmost to channel their suicidal client’s autonomy into coping strategies that enhance a personal sense of agency. We strive to prevent ER visits and hospitalizations. As I wrote in this column, there are effective, evidence-based ways to assist suicidal individuals in developing personalized safety plans. I employ them routinely in my clinical practice, and they work. Since the start of the pandemic, I have needed to hospitalize exactly one suicidal outpatient, who knew she needed help and accepted my recommendation. Involuntary commitments are not the norm for recipients of mental health care.

I disagree strenuously with Herrold’s statement that suicide treatment is “by no means safe and caring.” Across 28 years, I’ve worked on three general adult inpatient units, two geriatric units, and one veterans’ unit. Sure, there is the occasional dud among clinical staff: the lazy doctor, the judgmental nurse. But the majority of doctors, nurse practitioners, therapists, social workers, and nurses are there for altruistic reasons. The high rates of burnout among these good people attest to their dedication.

The British Journal of Psychiatry article cited by Herrold regarding inpatient suicide risk is hardly a bombshell. Inpatients are typically there because they pose a danger to themselves or others. Hospitalization is inherently a high-risk period, as are the days immediately following discharge. This is precisely why patients are searched upon admission and why visits to the unit are supervised, two facets of the inpatient experience lamented by Herrold. Sharp objects are discovered in belongings, and visitors try to smuggle in drugs, frequently enough that these steps are essential for everyone’s safety.

Perusing the article’s disclosure section, two of its authors provide expert testimony in malpractice suits following inpatient suicide. This is just as much a conflict of interest as drug studies funded by pharmaceutical companies.

It is not my intent to dispute or minimize Herrold’s terrible experiences during their adolescent hospitalization. The lack of opportunity to attend to basic hygiene and the inconsistency of clinical services are indefensible. However, this has not been the norm anywhere I’ve worked, and organizations like the Joint Commission standardize the American hospital experience, for better and for worse.

Each of my hospitals required a daily visit with a prescriber (physician or nurse practitioner), weekends included. Monday through Friday, each patient also received daily individual psychotherapy and participated in 1-2 group sessions. At my last hospital, each arriving patient was provided with personal orientation, where they were given soap, toothbrush, and toothpaste, and informed that showers were available every evening.

Most of my career has been in outpatient care. Not uncommonly, I’m the first clinician a patient meets after hospitalization. I won’t lie: some people found it scary to share space with the homeless, the psychotic, the addicted. Some hated enclosure on a locked unit (another standard safety measure). And to be sure, US hospitals are depressing places, with institutionally bland food and décor. I’d love to see those six- and seven-figure CEO paychecks go instead towards making hospitals more, well, hospitable.

Only a handful of patients have gone so far as to call it traumatic. The majority appreciated a safe place, where they could be started on beneficial medication, where the intensity of their suicidal urges could diminish, where they could medically detox off alcohol, opiates, or benzodiazepines. My three friends who spent a few days in psych wards for suicide attempts or serious ideation similarly characterized their stays as helpful, but nothing they hoped to repeat.

As such, I feel it is unfair and inaccurate to claim that “the goal of these institutions is to incapacitate the individual, allowing time for shame to compel the person to conform to social norms.” Long gone are the One Flew Over the Cuckoo’s Nest days of commonplace physical or chemical restraints. Hospital inspectors analyze every instance of physical restraint under a microscope, for evidence of misuse. At my last hospital, we used soft cloth restraints on two patients in two years, because they were aggressively endangering staff and other patients. The use of medication to involuntarily calm a violent patient is scrutinized almost as closely.

I hear the influence of psychiatrist Thomas Szasz in Herrold’s assertions about control and coercion. After garnering attention in the 1960-70s, Szasz was discredited as inflammatory and reactionary, stripped of teaching responsibilities at the State University of New York. He didn’t help himself by allying with a Church of Scientology anti-psychiatry organization. He was also sued by the wife of a patient who killed himself, after Szasz practiced what he preached, and advised the husband to stop his Lithium.

In actuality, autonomy is one of the four bedrock principles of medical ethics, along with beneficence, non-maleficence, and justice. Incursions on patient autonomy aren’t taken lightly. In psychiatry, this happens primarily when a patient is an immediate danger to themselves or others. When it comes to imminent suicide risk, we hospitalize someone in the recognition that suicidal intent is typically an impulsive, ambivalent urge in response to a proximal stressor. A place of safety for a few days allows necessary space to talk through the stressor, to muster coping techniques, and to allow rationality to replace impulsivity.

The unambivalently suicidal, barring an incapacitating handicap, can be counted on to tell no-one of their suicidal intention and follow through with lethal means. My son Josh was one of those, last September. Thankfully, most suicidal individuals carry enough uncertainty that they tell someone about it, or request immediate assistance after their attempt. This is borne out by the US stats for 2020: 45,979 suicides and 1.2 million attempts.

I recognize that even a little talk of curbing autonomy feels toxic in the current American climate, with the Supreme Court eroding a woman’s right to choose, prison-for-profit, and the noxious war on drugs. However, as Jennifer Michael Hecht writes in Stay, her book-length philosophical argument against suicide, “[O]ne can advocate all sorts of liberties for humanity and still try to convince people to draw the line at self-murder.”

Among those left behind by suicide, I routinely hear the downside to our society’s heavy emphasis on autonomy. Family concerns for safety disregarded or unheard by medical staff. Emergency rooms sending loved ones home after a suicide attempt. Tragedy follows.

It is also possible to overemphasize autonomy at the expense of community. Gun control debates are a prime example. Never mind that a firearm in the home is used 22 times more often in suicide or domestic homicide than in legitimate self-defense. Autonomy still carries the day in the law of the land.

A completed suicide is a tragedy, compounded by the fact it often spawns more suicides among surviving family and peers. Since my son Josh took his life, I have to remind myself weekly of the reasons not to follow his path.

We can argue against suicide without invoking religion’s threats of damnation or its historical refusal of burial in hallowed ground for suicides. And by no means should we make moral judgments against those who attempt it. My son was mentally ill, as are the vast majority of those who take their lives. He was not weak. He was not selfish.

I agree absolutely with Herrold that suicide is not solely an individual issue. It is a societal problem, compounded by racism, homophobia, stigma, capitalistic inequality, and the monetization of healthcare. I’m grateful Herrold shared their story. I hope mine contributes to filling out the picture on psychiatric treatment and suicide prevention.