Suicide, Self Injury and Hospitalization: Can your therapist have you hospitalized?

Allan N. Schwartz, LCSW, Ph.D.

Suicide, Self Injury and Hospitalization:
Can your therapist have you hospitalized?

Posting:

On March 7, 2009 someone posted this comment entitled:

"Distrust of Therapists"

http://www.mentalhelp.net/poc/view_doc.php?type=advice&id=3138&at=2&cn=91&ad_2=1&submit=I+Agree#ad8903

"I was hospitalized for self-injury and thoughts (not plans) of suicide and while the increased medication and enforced hospital stay did not help, I am now very afraid to report my true feelings to anyone and have actively avoided therapy, leaving me with no one to trust.

In the US, ethics usually doesn't have anything to do with it: as my callous former therapist explained to me, he was having me hospitalized because federal liability laws encouraged him to do so. These laws permit relatives of suicides to sue mental health care workers for neglect, and that's why you see rampant over hospitalization of patients in America."

______________________________________________________________

The anonymous writer of the posting cited above raises an interesting moral, ethical and practical dilemma for patients and their psychotherapist. The dilemma has to do with the question of when it is or is not proper to have a patient sent to the hospital emergency room?

Whether the therapist is a Licensed Clinical Psychologist, Licensed Clinical Social Worker, Psychiatrist or Licensed Marriage and Family Therapist, there is an obligation on their part to intervene under certain types of circumstances. By "intervene" is meant that they must report that someone is in imminent danger. This obligation overrides laws of confidentiality. The reason for this is that, under these circumstances, it is clear that a patient is in danger of committing suicide or homicide. If there is clear evidence that a child is being abused, the therapist must report this, as well. Outside of suicide, homicide and child abuse, the laws of confidentiality hold sway.

How does "reporting" really work?

In the case of a patient whom the therapist is convinced is in danger of suicide, a call can be made to 911 to report the suicide and have them go to the patient's home. In all of my years of practice there was one occasion where I asked 911 to come to my office and pick up the patient. I had to cancel my afternoon schedule to get this accomplished.

Other steps that can be taken are to call family, friends or neighbors and have them take the patient to the emergency room. One last possibility is to get the patient to go voluntarily go. The problem here is that, if someone is really suicidal and they are left to their own devices there is a good chance that they will attempt suicide.<>

Once sent to the emergency room of a hospital, there is absolutely no guarantee that a patient will be hospitalized. Instead, the hospital emergency room will do one of two things depending on where you live: 1. They will transfer the patient to a psychiatric hospital for evaluation or, 2. They have their own psychiatric emergency room and will do an evaluation right there.

In doing the evaluation, a group of psychiatrists, psychiatric nurses and clinical social workers, will decide whether or not the patient is truly suicidal and in need of hospitalization. Contrary to what the anonymous writer states above, it is not easy to be admitted to a psychiatric hospital. This is the reason why there is no such thing as "over hospitalization" in the United States. I have seen, on numerous occasions, where patients, brought to the hospital emergency room by 911 the emergency response team, were sent home.

In order to further elaborate on just how difficult it is to accomplish a psychiatric hospitalization, even if 911 is sent to the patient's home, the emergency response team does an immediate evaluation and can decide that a trip to the ER is not necessary.

In my opinion, the writer of the note above, was admitted to the hospital because she was deemed to be dangerously suicidal.

I cannot and will not defend the actions of every therapist because I do not know who they are or how well trained and experienced they may be. However, in the case of those therapists I have known, from New York to Colorado and California, the only time they will call 911 is when the fear for the safety of the patient.

What about self injury?

There are too many people, both male and female, who injure themselves. The most common type of self injury is probably self cutting, often with a razor. The cuts usually leave scars that bear witness to the self cutting. As a result and in order to hide the scars, people wear long sleeves even during the summer and long pants. Cutting occurs on the arms, legs and other parts of the body.

The goal of self mutilation is rarely connected to suicide. Instead, the strategy is to feel the sense of calmness that is followed by an episode of cutting. It is speculated that this calmness stems from endorphins that create a almost a euphoric state.

Therefore, it is unlikely that a therapist will feel impelled to report self cutting. Of course, there can be exceptions as for example, if it is believed that suicide is the intention. Just to repeat, suicide is very rarely the goal of self cutting. It should go without having to say it that there is always the risk of cutting in the wrong place, hitting an artery and causing a deadly bleed out. In my individual experience I have not come across or read about such an occurrence.

In by opinion, a psychiatric hospital will not admit a patient for self cutting unless the evaluating team lead by the psychiatrist, determine that the individual is suicidal. This even happens in cases of Anorexia Nervosa in which a patient will not be admitted unless the body weight places them in danger of death.

In an age where hospital and medical costs continue to surge and in which health insurance companies are reluctant to reimburse, it is unlikely that anyone will be admitted for frivolous reasons.

Trust:

It is true that trust is a key element to the successful completion of a psychotherapy. There are those times where a therapist may decide that a visit to the emergency room is important for a patient. In my experience, that happens with mutual cooperation between therapist and patient. Even in the case where I asked 911 to come to my office, the patient was cooperative, In fact, that individual was admitted and remained for quite a lengthy period (by today's standards, one week) and was not angry upon returning to treatment.

Trust is important because only with trust, can a person be willing to talk about all that they are thinking about and feeling.

Conclusion:

To answer the question within the title of this essay, a therapist can attempt to have you hospitalized if he has determined that you are in danger of attempting to kill yourself. However, in no way does that mean that, after being taken or going to the emergency room, will you be admitted. Only if you prove to the emergency room team and even the emergency response team, that you are suicidal, will you be admitted.

Your comments are encouraged.

Allan N. Schwartz, PhD

Source: MentalHelp.Net

Allan Schwartz, Ph.D.
Dr. Schwartz's Weblog

Bipolar Disorder Self Injury: Why You Must Be Concerned

In bipolar disorder, there is often concern about bipolar disorder self injury. It is usually serious, and comes in different forms.

A form of bipolar disorder self injury that’s coming most lately into the general public consciousness is self mutilation, or “cutting”. This practice is found in folk with other diagnoses, too. In reality, only a fraction of those who self injure are bipolar.

Cutting, burning or other self hurting behaviors are often seen in adolescent girls and others, even in men. A lot of this is a part of bipolar disorder self injury.

These acts aren’t suicide attempts, whether or not the people who do them are depressed or suicidal. They’re often desperate acts of anger, worthlessness, and loss of control. This is often a case of bipolar disorder self injury, and it’s not surprising when the symptoms are similar.

Suicide, naturally, is the most extreme form of bipolar disorder self injury. There will be plans and attempts before an individual commits suicide. In any case, all threats of bipolar disorder self injury should be regarded seriously.

Suicidal thoughts may cloud the thinking about a depressed person to the limit that he or she will be able to think about nothing else. It may appear the world would be better off without them, or that they can prove to others that they should have been treated better. At this time there is concern of bipolar disorder self injury, but the concepts are just at a low heat.

The danger becomes more imminent when the person starts to make plans. A person may make elaborate plans for some years. Another person may only think about a plausible way to go about it. The difficulty is that either of these folk may at any point basically commit suicide. It isn’t easy to predict the chance of bipolar disorder self injury.

Many times a person’s suicidal bents will not be spotted unless an attempt is made. A sensible person should treat all attempts seriously, though some may seem more serious than others. More significant attempts could be identified when the result was more certain compared to other attempts, or a note was found. Bipolar disorder self injury is always possible in these scenarios.

There’s always the possibility that a person is serious, in any case what type of attempt was employed. Statistics show that people who have never tried to commit suicide during the past are 40 times less sure to be successful than people who have.

Suicide may be on a person’s mind if he starts to set his affairs in order or make last agreements. It could be so simple as giving away possessions, or as complicated as making monetary arrangements. If this is suddenly seen in a bipolar individual, it should be determined whether that person is in danger of bipolar disorder self injury.

Many thoughts, plans, or attempts actually do end in suicide. 11 percent of deaths in the States are as a result of suicide. Roughly eighty percent of suicide deaths are by males, although more ladies attempt it. Every year, more and more teens are committing suicide. Bipolar disorder self injury, then, is a definite and increasing issue.

The disease’s physical, social, and affective consequences are tricky enough to handle. Self harm and suicide make attention to bipolar disorder self-mutilate most necessary.

Source: Unknown

Wordless Wednesday

Source

Tell them to remember hope. We have hope."

-renee yohee,
the story and inspiration of to write love on her arms,
my biggest hero.


we are only asked to love,
to offer hope to the many hopeless.
we don't get to choose all the endings,
but we are asked to play the rescuers.
we won't solve all mysteries,
and our hearts will certainly break in such a vulnerable life,
but it is the best way.
we were made to be lovers bold in broken places,
pouring ourselves out again and again,
until we're called home.


the vision is that community and hope and help would replace secrets and silence.

the vision is people putting down guns and blades and bottles.

the vision is that we can reduce the suicide rate in America and around the world.

the vision is that we would learn what it means to love our friends, and that we would love ourselves enough to get the help we need.

the vision is better endings.

the vision is the restoration of broken families and broken relationships.

the vision is people finding life, finding freedom, finding love.

the vision is graduation, a Super Bowl, a wedding, a child, a sunrise.

the vision is people becoming incredible parents, people breaking cycles, making change.

the vision is the possibility that your best days are ahead.

the vision is the possibility that we're more loved than we'll ever know.

the vision is hope, and hope is real.

you are not alone, and this is not the end of your story.

-jamie tworkowski,
founder of to write love on her arms.
Source: Ashley Rosex

I Think ...

Definitions of suicide and self-harm behavior in an Australian Aboriginal community

Farrelly T, Francis K (2009)
Definitions of suicide and self-harm behavior in an Australian Aboriginal community.
Suicide and Life-Threatening Behavior;39(2):182-189

Journal Article

Source: Australian Indigenous Health Bulletin

View abstract: PubMed
View website: PubMed

Three out of 10 students in study intentionally harm themselves

Three out of 10 students surveyed for a York University study acknowledged engaging in acts of deliberate self-harm, such as skin cutting, burning and using drugs or alcohol to excess.

The study evaluates the responses of 319 first-year university students who volunteered to answer a questionnaire that assessed their personality and personal history, and that asked whether they had ever intentionally engaged in 22 self-harm behaviours.

Of the 94 students who indicated they had, women were no more likely to self-harm than men, contrary to previous studies which suggest it is a predominantly female phenomenon.

There were, however, some clear differences in the type of self-harm acts engaged in by women and men.

Right: Cutting is one form of self-harm as seen in this photo of a person's arm

Among those who engaged in self-harm, the women surveyed (45 per cent) were more likely to report cutting the wrists, arms or other areas of the body, while men (23 per cent) were more likely to report engaging in gang activity or other forms of physical violence with the intention to harm themselves. The most frequent forms of self-harm were cutting, entering into risky situations, carving, scratching and the use of substances with the intent to self-harm.

The life circumstances of the participants are relevant to the study’s findings, says Gordon Flett, Canada Research Chair in Personality & Health at York, who co-authored the study with Abby Goldstein, (MA '00, PhD '05) now an assistant professor at the Ontario Institute for Studies in Education.

The average age of the participants was 19 years old and the majority (68 per cent) had just finished high school and were living with their parents (64 per cent). The sample was evenly split between Canadian-born students and those born outside of Canada.

“In many cases, these young people are throwing themselves into the student role as a way of overcompensating for some other emotional and relationship issue,” Flett says. “If they do well in university, that might get them over the hump, but if they don’t, they may be at risk for some more extreme behaviours.”

The latest clinical research suggests that self-harm may be a response to emotional pain that cannot be resolved in a more functional way. Goldstein hopes this information will begin to remove some of the secrecy often associated with self-harm.

“These findings suggest that a significant percentage of college students have engaged in an act of deliberate self-harm at some point in their lifetime,” Goldstein says. “Unfortunately, many people hide these acts or their intentions from others, which can often lead to isolation and greater suffering.”

By assessing the personality traits and personal history of the participants, the study was also able to identify factors which may help predict which students may be vulnerable to deliberately harming themselves.

“Some of these kids come from middle-class or affluent families but that’s no protection when the issue at hand is self-image,” Flett says.

"Personality, Child Maltreatment and Substance Use in Deliberate Self-Harm Among College Students" will be published in the Canadian Journal of Behavioural Science in October.

The study was supported by funding from the Canadian Institutes of Health Research.

Source: York files

Shelved report keeps suicide prevention reforms at bay

RUTH POLLARD INVESTIGATIONS EDITOR

August 22, 2009

A HERALD INVESTIGATION

AN EVALUATION of Australia's main suicide prevention program - which found there was little evidence the strategy had reduced rates of suicide and self harm - has been kept secret for three years, stalling much needed national reforms.

The 2006 evaluation reveals the Howard government was urged to review the National Suicide Prevention Strategy to ensure that funds were better targeted to those in greatest need. ''The current goals and objectives … are too broad to provide sufficient guidance,'' it concluded.

And while the national program floundered, suicide rates remained at historically high levels. The Herald revealed yesterday that the national suicide statistics had been undercounted, and the toll could be as high as 3000 a year, rather than the 1800 reported by the Australian Bureau of Statistics, without any corresponding increase in funding to prevent further deaths.

The Federal Health Minister, Nicola Roxon, said the Government was working with the Australian Suicide Prevention Advisory Council to develop ways to improve the data and respond to the needs of people at risk. ''I'm concerned by these reports,'' Ms Roxon said.

To make progress, access to quality mental health services must be improved and structures developed to co-ordinate a new national response, said John Mendoza, the chairman of the Federal Government's National Advisory Council on Mental Health.

''We have seen our governments … implement an assertive response to swine flu [and] now we have had 121 deaths since the outbreak and … 460 people are … in hospital from H1N1.

''In the same period we have had at least 10 times the number of suicides and … 20,000 hospital admissions for self-harm. This is the scale of the problem, and it's time we addressed it.''

Training GPs and other health care providers in recognising the warning signs for self harm and suicide, as well as reducing access to the means of suicide and investing in self-help services would go a long way to reducing risk, Professor Mendoza said.

The chairman of Suicide Prevention Australia, Michael Dudley, said: ''We have absolute evidence that putting barriers around jumping points makes a huge difference - people do not automatically go and try something else, and it is the same with reducing access to firearms, medications and other methods.

''Maintaining a social connection can make a difference - we should be following people … after they have had contact with health services, because we know they are very much at risk.''

Lifeline: 131 114

Source: The Sydney Morning Herald

Brisbane Times

Young people's distress is a wake-up call

The rise in self-harm points to something seriously askew in our priorities as a country

PARENTING INVOLVES an awful lot of stumbling along in the dark, hoping to God that you are doing something right. Every so often, parents are presented with situations that seem to confirm their worst fear: that they are actually doing everything wrong. As vividly illustrated by the two case studies written about by Sheila Wayman in the Healthplus supplement recently (August 11th, 2009), there is a particularly visceral feeling experienced by parents, like being punched hard in the stomach, when they discover that their child is harming him or herself.

Not unnaturally, most parents react with shame and panic, and become desperately worried about exacerbating the situation. The idea that a child would be so distressed that swallowing tablets or cutting oneself would constitute some kind of relief horrifies parents.

Levels of distress are clearly rising among young people, but that does not mean that parents are justified in shouldering all the blame. Young people resort to self-harm for complex reasons. For example, while it is more common in families where there are difficulties of one kind or another, it can also happen in so-called “good” families.

While no family is perfect, most families can learn to cope. Dr Keith Holmes, a consultant child psychiatrist in the Lucena Clinic, says that “the sign of a well-functioning family is not that bad stuff never happens, but that when it happens, it is dealt with well”.

Families who have kept the lines of communication open have an advantage when a crisis happens. Dr Holmes talks about how impressive it is that many families manage to get over the initial denial and sense of failure, and begin to do all that they can.

Even where things have gone awry, perhaps because of a messy and acrimonious breakdown, it is more than possible to help a child, if the parents can manage to retrieve enough of their relationship to make the welfare of the child a priority. Parents need to be parents more than ever, he says. They need to re-establish lines of communication, and healthy levels of discipline.

Many parents worry that something like cutting will lead to suicide attempts. Prof Carol Fitzpatrick of Children’s University Hospital, Temple Street, says it is important to realise that even though the risk of suicide is greater among people who self-harm, only a small minority will go on to die

by suicide. Some young people will have only a few incidents. Others will respond positively to parents’ willingness to listen and to help, and may not need further intervention.

However, if there are signs of deeper distress, or increasing isolation and depression, parents should seek help. Her advice to parents is to “trust your gut feeling”. Parents can go to their GP for a referral to child and adolescent mental health services for their child. It is a national scandal that so many of them will go on a waiting list for anything from six weeks to three years, depending on where they live.

A dedicated deliberate self-harm team was set up in Temple St some years ago, and while initially focused only on the young people, the need to provide support to parents soon became evident. The Space programme resulted. Initially only available on referral, a new course is available free to parents of children under 18, due to sponsorship by the ESB workers’ charity, Electric Aid.

The next course is being run in Wynn’s Hotel on Tuesdays, in October and November. It is important to register, as places are limited, by contacting Lorna Power, tel: 01-7166321 or e-mail Lorna.Power@cuh.ie.

The National Suicide Research Foundation suggests that the rise in unemployment may be a factor in the rise in self-harm among young men. Ironically, before the recession we blamed consumerism and conspicuous consumption instead.

Clearly, something deeper is going on. Why are people less able to deal with the challenges that life throws at them, or at least more likely to resort to self-harm as a deeply flawed way of trying to cope?

Ireland of the past was in many ways a dark and repressive place. However, we also have to face the fact that when we threw off the shackles of that time, we also inadvertently weakened societal constraints that helped to make self-harm and suicide much more rare.

While there is much greater openness in society, that same openness means that the idea of self-harm occurs to far more young people. It is one of the paradoxes of our age that we have never had so many means of communication, but more fundamental levels of communication, such as those between parents and children, have become much more difficult.

As Prof Kevin Malone of UCD has pointed out, many young people can live in a virtual cocoon, frantically interacting with peers, while parental influence is greatly diminished or even excluded. Behaviours such as cutting can even be become tacitly acceptable as a result.

Self-harm is not the only dysfunctional coping mechanism to which people resort. Our society has long had a problematic relationship with alcohol, while “workaholism” is often just a more acceptable way for adults to evade difficult emotions or situations.

Our young people’s distress is further evidence that something is seriously askew in our priorities as a country and a culture. It is an overt sign from our upcoming generation that all is not well, and perhaps we should pay more heed.

This article appears in the print edition of the Irish Times