Risk and fear

I sometimes wonder why we talk differently about risk in psychiatry than we do in other medical specialties. The risk of harm or death is high in many illnesses, yet in psychiatry we manage risk in a way that seems much more personally attributable. There are balances of risk in diagnosing and managing heart disease, cancer and many other conditions, and clinicians can get it wrong; but what disturbs me in psychiatry is the idea that bad outcomes are entirely preventable. In fact, in a way this trivialises mental illness, denying the fact that it can be serious, ongoing and sometimes fatal. Serious mental illness is not always preventable or curable, although it may be managed.

The tragedy of suicide is that it seems to embody choice. I don’t deny that sometimes motivation may be very confused, perhaps particularly where drugs and alcohol are involved; but when anyone dies this way, a great number of things have come together which, for them at that moment, have left them with no alternative. It would be foolish to think that mental health services can always prevent this, but I fully believe that they should try to do whatever they can to do so. Suicide is the ultimate tragic end to mental illness. But sometimes it will not be prevented, and we must acknowledge this.

Before saying any more about what psychiatry can or can’t do, one of the biggest problems we face is, of course, lack of resources. One of the saddest situations I have known as a clinician was down to this, no more, no less. More resource might not have changed the outcome, but it would have given the opportunity to try. There has been much talk of moral injury throughout the pandemic, but it’s not new, I fear.

As a patient with depression, I think clinicians avoid asking about suicidal thoughts. It’s much easier not to know the answer, particularly when it’s hard to know what one could or should – or, indeed, can do. Yet suicidal thoughts are a core symptom of depression – they are the cancer that should never be missed. This doesn’t mean that they are always lethal, but finding them seems to produce a fear in clinicians that almost equates to the fear of missing a tumour in other specialties. I think that if you have ever thought of suicide, even fleetingly, when depressed, that it will always be there as a possibility, mostly quiescent, sometimes even slightly comforting. But the problem is that if you do mention suicidal thoughts, most clinicians immediately grab for the lifebelt. They don’t want to talk about it; they want to prove – to you and themselves – that there is no chance of them being acted on. Then they can relax and talk to you again. But this doesn’t help, and only reduces risk on paper.

I am as guilty as any. I don’t generally avoid asking, but I quickly move to the ‘What stops you?’ type of question, and I do feel some shame about this. It is probably OK much of the time, and I hope I pick up when someone wants to talk; but I know it makes my life easier – not just in relation to resources and what I can do, but also because it is very, very difficult talking to people who are so distressed. I don’t see how clinicians can do it day in, day out, without a lot of support, and it’s hardly surprising that they, too, experience high rates of mental illness.

And this is one of the most difficult things for me – the different feelings as a patient and psychiatrist. As a patient, I expect my psychiatrist to ask me these things, to acknowledge my feelings and pain, but I know, as a psychiatrist myself, that it can sometimes be very hard. Sometimes it is just too tiring and too much, and I know that’s wrong.

This leads me to another question, which is what the patient does if the psychiatrist or clinician doesn’t actually ask. It’s extremely difficult, as a patient, to raise this oneself, and can feel almost staged or aggressive, when it really is just very difficult to find the words. And if the patient then feels unbelieved, where do they go from there? I think this can be the result of the very black and white thinking caused by risk management – either someone is acutely suicidal and going to end their life if not actively prevented, or they’re – not. But for many their minds are a confused muddle of thoughts, of pain and distress, of fears and hopes. Just letting them talk about all this, being there with them while they try to think about it, can be more important than anything. You may not get a guarantee of safety at the end, but what is a guarantee worth anyway? People want to talk, most hope things can improve – let’s face it, if people were always sure about suicide, we wouldn’t see them to have these conversations.

There will of course be other aspects to consider in any individual situation, and I’m not talking here about the often important medications, the sometimes necessary compulsory treatment; I’m talking about the patients and people that we see all the time in psychiatry. There’s always risk, and there seems to often be quite a lot of blame, which raises the stakes further. Think about that psychiatrist who has listened and comforted a patient, who has let them talk, and who believes them likely to be safe. They will, on their journey home, probably think of that patient. They may be quiet when they greet their family, they may lie awake, thinking.

Mental illness and suicidal thoughts are part of each other, and should be expected and held by clinicians, never avoided. But they themselves must also be supported to listen and not tick off their checklists. Doing the best you can isn’t always easy.