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Predicting Danger to Themselves

The problems of self-mutilation, threat of suicide, suicide attempts, and suicide itself are extremely complex. Here I will limit myself to some comments about the grounds for justifying involuntary commitment regarding suicidal threats and suicidal behavior.

The first problem arising from suicidal threats is that it is generally accepted that these may be but are not necessarily related to a psychiatric disorder. There are people who, being quite capable of doing so and aware of their responsibilities, assess their own situation and arrive at the conclusion that their future prospects are unacceptable to them. This type of “rational” suicide does not qualify for involuntary commitment. In 1982 a court in the Netherlands refused to order commitment of a man who seriously neglected himself and lived in a way which was hazardous to his life, as “the patient not only realized very well what he wished, but also was sufficiently capable of freely determining his will in this regard.” The problem here is how can the professional judge whether people’s assessments of their future prospects are more or less correct? The extent of this problem is illustrated by a poll conducted by Giel and Bloemsma regarding an actual case of suicide threat. Of the 160 helping professionals polled (mostly psychiatrists and other physicians, but also nurses, psychologists, and social workers) 54% considered the patient in question “psychiatrically ill” and 35% would have wanted to have her involuntarily committed. Among the physicians (the only profession that can request involuntary commitment) 68% judged the patient to be “psychiatrically ill” and 65% wished to have her involuntarily committed. “These facts richly illustrate the confusion regarding the background of suicidal behavior, as well as the contradictory feelings helping professionals have about the how far one must go in intervening.” A similar investigation by Peszke et al revealed that psychiatrists were fairly unanimous about involuntary commitment of people who are both psychotic and suicidal. There was equal unanimity about not committing people who were neither. However regarding people who were psychotic but not suicidal, or suicidal but not psychotic, there were major differences of opinion. As such an invasive measure should be based on more than one subjective assessment anyway, as is the case with Peszke’s two subgroups, involuntary commitment could be considered when the intention to commit suicide is explained in totally absurd terms that most obviously contradict all reason as in a manifest psychosis. This would imply that a judge and anyone else who bothers to talk to such a person could reach the same conclusion.

Opinions differ about the ratio of “rational” suicides to “sick” suicides. People’s views on this are probably strongly influenced by their philosophical, ethical, and religious convictions. Diekstra found that the public’s view of suicide is quite negative (“objectionable, shameful, crazy”) and dominating psychiatric and psychological views are equally negative.
According to Diekstra there is no direct empirical relationship between (attempted) suicide on the one hand and the existence of psychiatric disorders on the other. He states that suicidal behavior is quite frequent among people who display no psychiatric symptomatology. He quotes Stengel and Cook, who estimate suicides by the psychiatrically disordered to be about one third of the total of suicides.

In a later publication Diekstra quotes comparable research by Robins in 1959 and by Barraclough in 1968. They investigated cases of suicide (the former 134, the latter 100) for signs of psychiatric disorder by interviewing the relatives. Barraclough compared his findings with 150 cases of people who died some other way and presented the findings to an independent panel of three psychiatrists. They concluded that in 94% of the cases (93% for Robins) psychiatric disorders were obviously present. Diekstra concludes that psychiatric disorders are much more common in people who commit suicide than in the general population. He cautions, however, that one cannot conclude from this that such disorders are responsible for the suicidal behavior, and presents several arguments for that. Furthermore, it seems to me that in the investigations by Robins and Barraclough the surviving relatives’ judgment of whether or not the person who committed suicide was psychiatrically disordered could have been influenced by the suicide itself.

In general a distinction should be made between those people who truly wish to end their lives and those who by attempting suicide are signaling despair and a wish to be helped. In the latter case the entreaty has a strongly dependent nature. It is an appeal to others to assume responsibility. An involuntary commitment would seem to confirm the patient’s negative opinion of himself as incompetent, dependent, and not responsible. As every treatment should be aimed at mitigating this irrational dependency, involuntary commitment is in most cases not only unnecessary but also undesirable.

Also in cases of suicidal behavior prediction of repetition can be highly unreliable due to the large number of false positives when predicting behavior that is statistically speaking unlikely. Rosen has demonstrated this mathematically already as long ago as 1954.

Schudel relates that in the years 1975 and 1976 only one out of every 40 people who attempted suicide in the municipality of The Hague were involuntarily committed. Of the remainder, 1154 cases in total, only 20 later committed suicide, ten of whom did so during psychiatric hospitalization. Furthermore, of the 99 people who actually committed suicide in The Hague in 1975 and 1976 only 20 had been known to have attempted it earlier. (Schudel does not reveal whether the other 79 were known to the social services because of other problems.) This means that most suicides transpire without advance signals that reach helping professionals. This also indicates the dubiousness of preventing suicide by involuntary commitment, both because it is apparently not discernible which people who have attempted suicide remain at risk and because the involuntary commitment apparently offers no protection against suicide. De Graaf provides statistics that show that the number of suicides in psychiatric hospitals between 1970 and 1977 rose much more rapidly than outside of them. The cases of suicide in the hospital were doubled whereas in the general population the rise was only 4%. In numbers, in 1970, 1092 people in the Netherlands committed suicide of which 66 did so while staying in a psychiatric hospital. In 1977, 1252 people committed suicide of which 132 did so while staying in psychiatric hospital. In 1977 the risk of suicide in a psychiatric hospital was 26 times the risk outside of it.

Diekstra posits that the custodial approach to the hospitalized suicidal patient has serious drawbacks. By constantly guarding patients to prevent their committing suicide they increasingly develop a suicidal identity which augments the risk. On the other hand following a more permissive policy, meaning less guarding, more freedom, and a larger supply of conversational contacts, can provide the opportunity for suicide to someone who really does need to be protected against himself.

It remains unclear whether the high frequency of suicide in psychiatric hospitals is caused only by a less custodial climate than formerly or whether the (involuntary) hospitalization itself or all sorts of events occurring during hospitalization are a factor. Van Ree suggests that there may be some relationship with (planned) changes of ward.

The possibility that some suicidal patients who commit suicide during involuntary commitment might not have done so if they were free cannot be ruled out. This is an alarming possibility when one realizes that the only justification for involuntary commitment is the elimination of this danger. De Graaf concludes that suicides in psychiatric hospitals occur most frequently during involuntary commitments which last longer than 3 but shorter than 12 months although this cannot be inferred from her data. The longer the stay, the lower the rate of suicide. Copas & Robin found the suicide risk to be highest during the first week of hospitalization.

Stone relates that California law sets a maximum of 31 days for involuntary commitment of suicidal patients. An investigation of 335 patients revealed that after six months not one had committed suicide. Caution must be exercised in interpreting such figures. As suicide is a rare event only very large numbers should be considered representative.

Pokorny’s comprehensive and thorough research confirms the inability to predict a future suicide. He assessed 4,800 hospitalized patients using a number of tests in order to determine whether in the long-term suicide would appear predictable. Five years later he followed up on what had happened to these people. Based on his research he posits, “The conclusion is inescapable that we do not possess any item of information or any combination of items that permit us to identify to a useful degree the particular persons who will commit suicide, in spite of the fact that we do have scores of items available, each of which is significantly related to suicide.”

Pokorny points out that his research relates to long-term predictions and that the situation is different regarding people in the midst of a suicidal crisis. He posits that in such a situation the suicide risk is essentially not researchable “as it would not be ethical to withhold taking appropriate emergency steps to ensure safety.” Here Pokorny is touching on an extremely complicated problem about which I will make some comments.

In the first place, there is a contrast between the ethical inadmissibility of refraining from involuntary hospitalization and the ethical relative inadmissibility of the involuntary hospitalization itself, which can be justified only as a last resort. In those cases, as here, where one is confronted with an ethical dilemma, it is important to deal with that dilemma, and seek either to augment our knowledge of such situations or offer alternatives. In my opinion Pokorny’s position is valid only when every other possibility of approaching the problem is barred.

Secondly, several treatment methods and strategies exist for such situations. In fact, as Schudel’s limited research revealed, the overwhelming majority of people are not involuntarily committed after attempting suicide. An involuntary hospitalization is evoked only when that seems to be the last resort. This shows that further research as to treatment methods can not only change the ethical dilemma but is very much necessary.

Thirdly, Diekstra repeatedly notes that crisis services for suicide prevention are often not an acceptable option to people who are about to commit suicide precisely because they are so focused on suicide prevention. It is quite conceivable that people who wish to talk about their plan to commit suicide do not want to do so with others who may be their adversaries, let alone who will foil their plans by forcing them into hospitalization. It is not impossible that helping professionals make themselves inaccessible to certain people in a suicidal crisis by expressly opposing suicide.

Fourthly, the severity of the emergency is not uncommonly partly determined by the therapists’ circumstances: how much time they have available, their personal stress in such situations, the degree to which they dare take risks, and the services that happen to be available in particular regions. These factors, too, are in principle mutable.

Fifthly, in such emergency situations, involuntary hospitalization provides therapists with a feeling of safety and security and of having successfully dealt with an urgent matter. Considering the many suicides in psychiatric hospitals one wonders whether this is not an illusion, comfortable for therapists but no real help to patients.

It is altogether uncertain whether suicide prevention by involuntary commitment produces the sought effect. Diekstra stated, “In conclusion, for now we can state that the preventive effect of forced commitment is unclear.” Most successful suicides appear to be committed before contact with mental health services has established suicidality. Only a very small amount of suicide attempts are followed by involuntary commitment. The subsequent suicides are not only unpredictable but it also seems there is no convincing evidence that the involuntary hospitalization provides any protection whatsoever. Finally, whoever wishes to make the fewest mistakes statistically should never involuntarily commit someone on the bases of suicidality or suicide attempt.
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