Problems in Preventing Suicide–or Murder

A caution against being too hopeful.

It is natural in the face of a calamity to set out to prevent it happening again. “Do something,” people will demand. But sometimes it is not clear exactly what can or should be done. If nothing useful can be done, there is pressure to do something so that we can feel a little more comfortable and secure.

Recently in the wake of the murderous rampages that have taken place around the country and which have involved random shootings, including the shooting of children, there has arisen a demand to do something to prevent further such outrages. The remedial measures that have been suggested are two: removing or controlling access to guns and improving the care of the mentally ill so that fewer people will be inclined to murder.

The argument about guns is currently being played out on the national scene. I am not optimistic about the possibility of passing meaningful laws to limit, even a little, access to guns. For some people, guns are literally a way of life. Being able to have a gun defines who they are. They threaten anyone who they think wants to take their guns away; and I think they mean it. And they have political power.

On the other hand, it is easy to agree that mentally ill persons should not have access to weapons. The problem here is that mentally ill is defined as someone who gives evidence of being inclined to kill. Simply being mentally ill, in terms of seeing a psychiatrist, can include anyone. Can there be screenings that will determine who among the universe of emotionally troubled people—which can be defined to include almost anyone—are actually, imminently dangerous?  I don’t think so. Those who are murderous—or suicidal, for that matter—only undertake these violent acts when there is a confluence of circumstances that very well might not be present during the rest of their lives. In other words, people become suicidal and homicidal only occasionally. The rest of the time they do not seem much different than the rest of us.

I mention here a few personal experiences that I think are relevant:

When I was serving as a psychiatrist in the military, a patient was helicoptered to the 20th Station Hospital in Nuremberg, Germany for emergency evaluation. When I spoke to him, it became apparent quickly that he was delusional and needed to be hospitalized and treated. Although the specifics of his delusion did not suggest any reason to think he was suicidal, I asked him, nevertheless, whether he was thinking of killing himself. He said, no; but since the facility at which I worked was not considered secure, I assigned a corpsman to stay with him until he could be sent by helicopter to a psychiatric hospital some miles away in Frankfurt.

This is what happened: The patient was lying quietly on a stretcher, apparently asleep. The corpsman was literally hovering over him and staring at him. Suddenly, silently, the patient got up off the stretcher, slipped out of his restraints, and jumped out of a window, killing himself.

Sometime later, I was called to see the chief of the hospital, a physician who happened to be an anesthesiologist.

“Headquarters wants you to write some guidelines for the transport of psychiatric patients that will prevent this sort of thing from happening again,” he told me.

“I can’t think of anything else we could have done,” I said. “He had a constant attendant. He was in restraints. People kill themselves sometimes. No matter what.” I went on to point out that twenty to thirty thousand people committed suicide every year in the United States despite heroic attempts to prevent such acts.

“That doesn’t matter,” he replied. “It has to look as if we’re responding. We have to do something. Set some sort of policy.”

“It won’t work.”

“It doesn’t have to work. They know it isn’t going to work. But we have to do something anyway.”

So, I wrote up seven or eight things to do—that I knew we would never do because they would not work.

As it happened, by coincidence, that same week two people—one a few days after the other—killed themselves in the secure facility in Frankfurt by aspirating toilet paper!

How should the people in charge respond? Remove all the toilet paper? Not out of the question, I thought. Once, when a psychiatric patient ripped off a toilet seat and assaulted another patient with it,  all the toilet seats were removed.

There are measures than can and should be taken to prevent suicide, but they cannot be expected to work unfailingly, however clever we are in designing such measures. I have known people to jump off the roofs of psychiatric buildings and to hang themselves from the end of a bed. People kill themselves in seclusion rooms. (See my book, “The Seclusion Room.”) In the end, I think doing something just so that it looks like we are doing something makes people cynical and inclined not to do anything at all.

And as for murder:

I saw this particular patient after he committed his crime. He was a middle-aged, quiet black man, who had given no indication of mental illness prior to his rather abruptly becoming paranoid. It was a time of inter-racial strife in this county, and he was caught up with the civil rights movement. He listened in a lecture to a particularly rabid man who was railing about the injustices perpetrated by white men on black men (not entirely exaggerated, of course.) The gentleman I am speaking about sat in the audience imagining violent behavior going on out of his sight. Suddenly, he got up and left the auditorium. He went home and wrestled a rifle away from his wife and then shot and killed the first white man he saw.

Because he was psychotic, it was felt that he was incapable of defending himself and so was not subject to trial. After a hospitalization of a year or two someone decided there was no point of his being tried for his crime. He was thought to be “cured.” Certainly, he was not obviously threatening to anyone.

I began at that point to see him as a patient. I agreed that he showed very little of the delusions or of the psychosis that had driven him to commit murder; but I was concerned that such a man with that sort of track record could commit another murder in the future. There was no way of being sure.

During the few years I saw him, he lived with his wife but otherwise lived a solitary existence. He spent much of his time sitting on park benches. I do not know what happened to him after I stopped seeing him.

Many murderers who have been released, or escaped, from psychiatric hospitals live the rest of their lives peaceably. It is hard to know in retrospect what led them at a particular moment to become violent. And there is no guarantee that they—or others—will not become violent in the future. Psychiatrists testify to such matters on the stand, often in contradiction to each other. All we can do is make an educated guess. Others who are just as ill never commit a violent act at all.

For this reason I think it is unlikely that mental health practitioners will with careful screening do much to head off the sort of mass murders that have recently occupied our attention. We can fool ourselves into doing something, but we are not likely to do anything that will work.  (c)  Fredric Neuman 2013