Sunday, January 08, 2006


I guess you can think of the following reflections as a kind of professional parable. Sometimes all you have to go on is "soft" intelligence in making life or death decisions.

As a psychiatrist, I am often called on by society's laws to make a decision if a person is "suicidal or homicidal"-- either of which indicates that hospitalization is in order. How does one make that judgement? Especially when many patients with mental illness are not particularly cooperative and deny that they have any problem to begin with.

Well, it is an extremely difficult task and a great responsibillity. I happen to think that everyone is ultimately responsible for their own behavior; but I am also aware that I am in a position to intervene to save someone's life--at least in the short term. So I take the responsibility very seriously.

Sometimes people TELL me that they are having feelings of wanting to kill themselves; and they tell me the details of how they'd go about it. Occasionally, some patients will confide in me their desire to kill a specific person. This kind of honesty and self-awareness makes my job a bit easier. But most of the time I have to act on "soft intelligence".

What do I mean by that? Well, most of the time I have to take many little things into consideration:

-How honest do I think a person is being with me in regard to their feelings and intent?
-How honest have they been with me and/or others in the past?
-Do they have a history of ACTING on suicidal or homicidal feelings in the past? (one of the most significant predictors of future actions are past actions)
-Are they trying to manipulate me (either (1) they WANT to be hospitalized and have no real intent to harm themselves or others; or( 2) they DON'T WANT to be hospitalized because they have real intent to harm themselves or others. I look especially hard at those who I think might be "shining me on"
-Do they have the means to actually hurt themselves (e.g., if they have a plan to shoot themselves or someone else--do they actually have a gun at home? or access to a gun?
-How seriously do their family and friends take the possibility of their suicidality or homicidality?
-How impulsive are they now? How impulsive have they been in the past?

The above list does not include all the considerations and factors that come into play in my assessment, but they are some of the primary ones. A particular person might not meet ALL the criteria above; and each case is different, depending on the situation. I see many people who are what we call "chronically suicidal"--meaning that they express suicidal ideation all the time. When do you hospitalize them, and when do you not?

The truth of all these situations is actually quite painful, and it is that if a person really wants to kill themselves, they will succeed eventually. I have hospitalized suicidal individuals who when they were finally discharged because they were doing so well, went out and committed suicide successfully.

I have hospitalized people involuntarily who convinced a judge that they were not suicidal or homicidal. The judge released them, and they killed themselves or someone else.

But, I have also known many people for whom an intervention--even an involuntary hospitalization -- resulted in their abandoning for good their suicidal or homicidal plans.

Since people's lives are at stake, I try to err on the side of caution in most cases. The potential consequences are very high, and earlier in my career, I was a bit overwhelmed by the responsibility. I will admit that in the last 30 years, I have made mistakes. Sometimes I hospitalized someone against their will who really had no intention of hurting themselves or someone else. My judgement was incorrect about their homicidality or suicidality. The worse consequence of that situation was that the patient hated me and refused to ever see me again.

OK, I can live with that.

But it has also went the other way once. I remember when I didn't hospitalize a patient of mine, because she didn't have the past history of trying to kill herself; had never been suicidal before; and was seemingly cooperative in therapy. In addition, she didn't seem severely depressed any of the times I saw her; and she was always willing to contract with me for safety. I was an intern at the time and somewhat inexperienced. I was uncertain what to do, but finally decided to believe the person when she said she didn't really have any "plan" to kill herself--and I really couldn't see that she had any real intent.

But to my horror, that person not only killed herself the next day, but she killed her best friend --another patient of mine.

If I had acted two lives would have been saved. Perhaps I could have only delayed what happened if I had acted when I had the chance. I don't know. I will never know.

A person--even a psychiatrist--can only in the end be responsible for their own actions--not for others'. Since that time I have studied all that there is to know about predicting suicide. I have tried to hone that "instinct" that makes a person aware that someone is not telling the truth. I think I am pretty good at it, and I have come to trust my instinct in these situations. Now, if I have any doubt; if I find myself not quite convinced that a person will be safe, then I go with the doubt.

Because I am completely sure only of this: If I have the opportunity to do something to save a life, then I must do it.

I cannot know the future and I cannot know how someone will behave in the future. But I can use all available information I have at that one point in time; and my own professional skills and experience to the best of my ability to assess each situation individually. I can balance and weigh the hard and soft evidence--and sometimes it is only the soft evidence that I have to work with; balance and weigh the risks and benefits; and make the best decision possible at that moment.

And if I am to make a mistake in the future; I want it always to be on the side of saving lives.

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