Discussion Would you trust psychiatry more if suicide risk assessments were replaced with capacity assessments?

[Le temps perdu]

If psychiatry were to remove suicide and self-harm risk assessments in the future, so that people would no longer lose their autonomy or be involuntarily hospitalized solely because they are suicidal, and instead focus on whether they have a basic ability to perceive reality and make informed decisions (while still assessing the risk of violence toward others), would you trust psychiatry more?

One of the main reasons I have been hesitant about seeing a psychiatrist is that I disagree with the current practice of involuntarily hospitalizing some people solely because they have suicidal thoughts with intent to act on them. If risk assessments were shifted toward evaluating a person's ability to perceive reality and make informed decisions, I might trust psychiatry more.

 

[Set Real Goul]

Partly, yes. But I still think it's a problem that psychiatric and psychological diagnoses are largely based on consensus. Kirsch's meta-analyses don't exactly inspire confidence either. And I also have some reservations about psychological approaches like CBT and DBT. So even though that would probably increase my trust to some extent, I don't think it would actually help me that much. Sometimes it feels like psychiatry is still at a stage comparable to the era when pneumonia, stroke, and epilepsy were treated with bloodletting.

 

[fadedghost]

If psychiatry were to remove suicide and self-harm risk assessments in the future, so that people would no longer lose their autonomy or be involuntarily hospitalized solely because they are suicidal, and instead focus on whether they have a basic ability to perceive reality and make informed decisions (while still assessing the risk of violence toward others), would you trust psychiatry more?

One of the main reasons I have been hesitant about seeing a psychiatrist is that I disagree with the current practice of involuntarily hospitalizing some people solely because they have suicidal thoughts with intent to act on them. If risk assessments were shifted toward evaluating a person's ability to perceive reality and make informed decisions, I might trust psychiatry more.

OP, I think this is a great question and needs to be asked more often.

my personal answer is no, because psychiatrists, forensic psychiatrists, and criminologists often link danger to self with danger to others under this common notion of safety. A criminologist would likely say a suicidal person is more likely to be dangerous to others. Because these are things considered to have covariance, they wouldn't really be able to measure one without implicitly looking at the other, so suicidality would still indirectly impact risk assessments under your concept and would be a possible back door to involuntary hospitalization.

but i've had horrific experiences with psychiatry and for ordinary people, it would possibly create more trust. it would be a less awful standard.

for many people who are involuntarily hospitalized, they bear the cost of the stay ($20K? 30K? 40K? 50K+) and the costs are huge, the hospitalization may be able to preclude the patient being fired due to the absence, but income does not automatically come in, nor do bills stop. it's not just the loss of autonomy. involuntary hospitalization is horrendously expensive and financially disastrous and often the amount of treatment relative to the high costs is a terrible value for patients and extremely lucrative for practitioners. really, this comes down to doctors not wanting to be blamed if something goes wrong, and so it's financially more lucrative and less risky for a doctor to recommend involuntary hospitalization, while rarely better for the patient, and it may be better or worse for society but it's hard to know.

We also don't really know with any certainty whether involuntary hospitalization causes suicides. It's so hard to isolate that variable but my guess is it does. (There's no way to perform the experiment because without liability since the study would be considered unethical: you'd have to take people who were all edge cases for involuntary hospitalization, right at the border, and hospitalize some and not hospitalize others using a coin toss or randomized method and then wait to see who dies; and to be a valid longitudinal study, there would have to be a lot of people in the sample. The mental health industry also makes tremendous amounts of money on the suffering of others and so would be incredibly disincentivized from finding out if involuntary hospitalization increases suicide rates; we will never know, no one will pay for the study and accept the potential liability of doing so, and a research organization or research professionals would be needed to perform such a large study properly so it's valid.)

 

[Le temps perdu]

Partly, yes. But I still think it's a problem that psychiatric and psychological diagnoses are largely based on consensus. Kirsch's meta-analyses don't exactly inspire confidence either. And I also have some reservations about psychological approaches like CBT and DBT. So even though that would probably increase my trust to some extent, I don't think it would actually help me that much. Sometimes it feels like psychiatry is still at a stage comparable to the era when pneumonia, stroke, and epilepsy were treated with bloodletting.

OP, I think this is a great question and needs to be asked more often.

my personal answer is no, because psychiatrists, forensic psychiatrists, and criminologists often link danger to self with danger to others under this common notion of safety. A criminologist would likely say a suicidal person is more likely to be dangerous to others. Because these are things considered to have covariance, they wouldn't really be able to measure one without implicitly looking at the other, so suicidality would still indirectly impact risk assessments under your concept and would be a possible back door to involuntary hospitalization.

but i've had horrific experiences with psychiatry and for ordinary people, it would possibly create more trust. it would be a less awful standard.

for many people who are involuntarily hospitalized, they bear the cost of the stay ($20K? 30K? 40K? 50K+) and the costs are huge, the hospitalization may be able to preclude the patient being fired due to the absence, but income does not automatically come in, nor do bills stop. it's not just the loss of autonomy. involuntary hospitalization is horrendously expensive and financially disastrous and often the amount of treatment relative to the high costs is a terrible value for patients and extremely lucrative for practitioners. really, this comes down to doctors not wanting to be blamed if something goes wrong, and so it's financially more lucrative and less risky for a doctor to recommend involuntary hospitalization, while rarely better for the patient, and it may be better or worse for society but it's hard to know.

We also don't really know with any certainty whether involuntary hospitalization causes suicides. It's so hard to isolate that variable but my guess is it does. (There's no way to perform the experiment because without liability since the study would be considered unethical: you'd have to take people who were all edge cases for involuntary hospitalization, right at the border, and hospitalize some and not hospitalize others using a coin toss or randomized method and then wait to see who dies; and to be a valid longitudinal study, there would have to be a lot of people in the sample. The mental health industry also makes tremendous amounts of money on the suffering of others and so would be incredibly disincentivized from finding out if involuntary hospitalization increases suicide rates; we will never know, no one will pay for the study and accept the potential liability of doing so, and a research organization or research professionals would be needed to perform such a large study properly so it's valid.)

Thank you all for the thoughtful responses, you raised points I hadn't considered.

 

[Forever Sleep]

It's an interesting idea. I think society as a whole would need to change too. There is such a culture of blame so- that would need to change.

Not only would psychiatrists need to acknowledge that suicidal people can have mental capacity- so would their loved ones when they are left behind after a suicide. I think it's become convenient/ emotionally easier for them to simply believe their loved one wasn't in their right mind and wasn't thinking rationally. Hence the need for pysche holds etc.

For things to change, they would need to accept that their loved one knew exactly what they were doing- including inflicting that pain of grief on them.

They'd also need to accept that their psychiatrist knew they were suicidal but didn't make any attempt to prevent an attempt. I doubt parents in particular would accept that. Given the choice- how many would prefer to see their child dead- rather than in a psyche ward?

It would also require psychiatrists and therapists to admit to their limitations. Even if they acknowledge someone has mental capacity, they can still be confident and insist they can cure their issues.

So- in that case- will they or their loved ones accept that they still want to suicide? It would need to be an acknowledgment that their problems are severe and unsolvable. Who wants to conceed that a person's life is utterly unsalvageable? Whatever the problems.

Again- that seems easier to determine in physical ailments. They do seem to have a better grasp there- on when nothing more can be done to help a patient.

I like the idea in principal. I just can't see it working though. I also agree with Set Real Goul. Even if they established a person could have ideation and still be mentally competent, that wouldn't magically make their diagnosis or treatment procedures better. Or- unfortunately- shake the public opinion that seems (to me) to have so much faith in mental healthcare.