CLINICAL RISK ASSESSMENT AND EVALUATING THE THREAT OF TERROR

Wretchard has an interesting post that juxtaposes two different views of the amount of risk the US faces from terrorism in the next few years. One of those views comes from former-VP Dick Cheney; and the other from Glenn Carle ,in a Washington Post article. Wretchard makes several excellent points:

But what is the true value of that probability? Its magnitude is really at the core of any difference between Carle’s and Cheney’s point of view. I doubt it can be quantified, except in subjective terms. At any rate, it is probably hard to do without a continuous assessment of specific enemy operations in progress. In this case an assessment based on general capabilities is not that helpful. I don’t think the probabilities can be judged on general principles. We have to know the specifics to make a judgment.
[...]
But if the probabilties of a successful attack are uncertain, the consequences of a terrorist success would be less so. Even without the Cheney warning, a new September 11 sized attack would have been devastating to the Obama administration. What Cheney is doing is upping the political ante. From a political point of view, Cheney is ensuring that Obama had better make pretty damned sure another mass casualty attack doesn’t happen, or face an electoral apocalypse. That doesn’t answer any of the questions about what actually will happen in the future. The sad fact is that nobody can really predict that. We can only do our best based on imperfect information and see what happens.

Some of us in the mental health profession have been tasked by society to assess whether or not an individual is acutely suicidal or homicidal and therefore imminently a danger to themselves or others. The "sad fact" is that, as Wretchard notes, nobody can really predict that. The only thing we know is that a person who is absolutely intent on killing themselves or someone else will find a way to do it. But does that mean we should abandon the effort to save as many lives as possible?

I have written before on this, but it is worth repeating:

Sometimes all you have to go on is "soft" intelligence and imperfect information in making life or death decisions in my field.
According to the laws of most states, if a person is "suicidal or homicidal it is an indication that involuntary hospitalization is in order. So, how does a psychiatrist make that judgement and assess the risk...to the individual and to society?

It is especially difficult in that that many patients with mental illness are not particularly cooperative and deny that they have any problem to begin with. They see you and society as the problem.

Frankly, it is an extremely difficult task and a great responsibillity and burden. I happen to think that everyone is ultimately responsible for his or her own behavior; but I am also aware that I am in a position where I can intervene and possibly 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 and imperfect information.

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?

Again, the sad truth 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 quite 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 gone the other way. 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 one thing: 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.

I can only hope that my government is equally careful in calculating the potential risks and identifying red flags when they make decisions to protect me and my family from external threats. And I fervently hope that they can learn from their mistakes and constantly improve how they do this difficult task, because it is one of the most fundamental roles of US Government to make the same sort of "clinical assessment" of regimes and groups hostile or violent toward America.

Briefly, going through the same sort of clinical decision making described above when it comes to the potential suicidality/homicidality of terrorist groups and terrorist regimes and their fervent desire to hurt or destroy America, its allies (particularly Israel) and abolish the fundamental values of Western civilization:

-Nations like Iran, Syria (or North Korea); or terrorist groups like Hamas, Hezbollah and Al Qaeda all tell us explicitly and flat out what they intend. Not only that, but they tell us repeatedly. Their leaders do not mince words about it; and they very often follow up those words with specific behaviors that practically scream, "I will kill you if I get the chance."

-As far as assessing how honest they have been with the U.S. or the West in the past when it comes to situations in which we are willing to trust them: every agreement, treaty, and promise that has been made by these entities has been deliberately broken and it is apparent that they never meant to keep it even transiently except insofar as pretending to agree to create a smokescreen so that they continue their homicidal aspirations unabated, but without interference. In other words, the leaders of these countries are not to be trusted as "partners for peace." (See Victor Davis Hanson's excellent piece yesterday, "Been There, Done That in the Middle East").

-All of these terrorist entities have a long history of ACTING on their suicidal /homicidal feelings in the past? (Remember, one of the most significant predictors of future behavior is past behavior)

-When it comes to negotiating directly on indirectly with them; they consider it honorable to manipulate, lie, and distort in order to gain advantage over their enemies (which they consider the West) and they are smilingly willing to agree to all sorts of things they have no intention of following through on--because in doing so, it shames us and gains honor and status for them in their bizarro world.

-As for determining if they have the means to hurt us; let's just say that even without the possession of nuclear weapons (which some of them will have imminently and may have even as we speak) they manage to be very creative with boxcutters and airplanes; or whatever is at hand in order to achieve mass destruction. Allowing such entitities to actually develop WMD is a clear indication that we ourselves have become passively suicidal. For those who may have forgotten or never known, let me remind you that Iranian clerics have already issued a fatwa approving the use of nuclear weapons against the enemies of Islam.

Protecting we the people from the insanity of crazed regimes and lunatic groups who are determined to eliminate as many of us as possible would seem like a critical role for an elected government.

As Doug Feith has written:

"Preventing calamities is one of the most important and least appreciated functions of government. When an evil is averted - perhaps as a result of insight, intensive effort, and administrative skill - the result is that nothing happens. It is easy, after the fact, for critics to ignore or deprecate the accomplishment. Political opponents may scoff at the effort as unnecessary, citing the absence of disaster as proof that the problem could not have been very serious to begin with." --P. 523, War and Decision

The thing about preventing a really terrible thing from happening is that...it prevents a really terrible thing--or things-- from happening. So, nobody reads articles about how effectively the system works or how many lives were saved--because there is no way of calculating that metric.
Only when someone slips through the safety net; or when something horrific occurs, does it come to public awareness.

Since 9/11 our leaders have been--quite rightly-- taking the madmen of the world seriously. That is why we have had no further attacks [yet] on American soil. Those who want to pretend--for political and ideological reasons--that the fact we have had no further attacks in our country has nothing whatsoever to do with the actions of the evil Bushitler fascist administration, will go on belittlening, undermining and undoing everything that adminstration has done to keep us safe over the last eight years.

We know enough to assess that there are acutely homicidal countries and groups out there who want to wipe us off the map if they can. And, it makes you wonder sometimes if we are the ones who are acutely suicidal.