We all take risks every day. In some cases, they are risks we consider “necessary” in order to live full, meaningful lives—basics that might include driving a car, hiking in the woods, bearing children or eating a Snickers bar. Other risks are more personal: skydiving, traveling internationally, starting a new business or maybe even professing your love to your best friend. We take these risks, with both low and high probabilities for negative outcomes, based on our basic human need to not only survive, but to live. Taking them is deeply connected to personal autonomy and self-efficacy, which are in turn required for the confidence to take said risks. There is a kind of dignity in the ability to make these decisions. It is the dignity to live perfectly flawed human lives.
There are circumstances, however, in which people have this dignity to take risk mitigated or even removed. Parents, for example, put bumpers and gates around the house to protect their children from injury. We mitigate the risk of further crimes by incarcerating criminals. We even have laws that allow the police to lock someone in a hospital if a doctor agrees that their risk to themselves or others is too high—even if they haven’t committed a crime at all. Outside of these examples, there are myriad risks to examine, especially in the mental-health field. Examples include lowering or switching psychiatric medications when a client/patient is having side effects, using the harm-reduction model for problematic substance use and my focus in this blog: suicidality.
Providing someone with the “dignity of risk” is a collaborative way to approach dealing with thoughts that indicate potentially dangerous actions. Such an approach may sound like it makes a lot of sense, and yet a 2021 systematic review in BMC Psychiatry found that shared decision-making is not a concept commonly used by mental-health services to explore processes of risk assessment and risk management. Barriers to using shared decision-making include social and professional influences. In today’s society, for example, liability is a major factor that influences how mental-health providers react to potentially negative risk outcomes. Rather than having a collaborative discussion about how to stay safe, a practitioner may choose to instead hospitalize someone against their will—a decision made in part to save the life of the individual and in part to avoid any lawsuits. I do believe that there are circumstances in which this makes sense, for example in the event of an immediate psychiatric emergency, however, a trigger reaction to send someone to a higher level of care is not, in fact, the answer. As a 2017 meta-analysis published in JAMA found, suicide rates were found to be approximately 100 times the global suicide rate in the first three months after discharge from a psychiatric facility, regardless of the reason a patient was sent to a facility. In fact, for people who were admitted for suicidal thoughts or behaviors, that rate doubled to 200 times the global suicide rate.
As a psychiatric nurse practitioner, my interpretation of this data expands in two directions. The first is that a trigger reaction to hospitalize an individual should instead be a last-resort option that has been thoroughly examined. The second relates to my attempt to understand and explain the reasons behind this. I once worked in an inpatient hospital unit focused on psychosis at McLean Hospital, a leader in psychiatric care, research and education that was founded in 1811, and from that experience can attest to the fact that “stabilization” in that unnatural environment does not equate to stabilization in the face of real life. McLean provided each of its patients with 24-hour care delivered by extremely intelligent multidisciplinary teams in order to get them to that level of stability, often in a matter of days. However, unlike a medical/surgical unit, where objective data can determine whether someone is stabilizing, in a psychiatric unit, subjective data is almost always used to determine whether someone has reached stability or not. And since it may not be known at discharge if someone is actually objectively stable, the system almost always discharges patients back into the same situation they were in before they entered the hospital—which typically equates to almost no support at all. At best, patients may be given an appointment with a therapist, which they may not even make it to.
So, if support seems to be a key factor in improving mental-health conditions, I would argue that using a collaborative approach with clients/patients in order to find significant community-based support could eliminate the need for a large portion of inpatient psychiatric hospitalizations and make the hospitalizations that do occur more successful due to the high level of support upon discharge. Unfortunately, as many of us know, support is not an easy thing to find. It is also often expensive, and therefore inaccessible to those lacking significant financial means. State-run mental-health departments do what they can to provide increased levels of support for clients, but the process of receiving it is often lengthy and far from guaranteed. It is thus my sincere hope that this blog encourages flexibility in thinking about risk, and that, if there is an alternative to a higher level of care available, we seek it out on behalf of our clients. We must allow our clients/patients to live full, unencumbered lives while giving them the support they need to maintain the social structures that provide support: family, friends, school, work and bodily autonomy. The dignity of risk for our clients cannot be secondary to our professional anxieties.
