On several occasions, when I was at the point of suicide, mental health professionals told me that it was "my choice" or "my decision" to end my life. It was their assessment that I had the mental capacity to do so.
I now run a Suicide Crisis Centre where we support clients who are at risk of suicide. Many of those we support are also under secondary mental health services, which means they have more enduring mental health diagnoses such as bipolar disorder, personality disorder or schizophrenia. A number of them have been told it is "their choice" or "their decision" to end their life, and this concerns me greatly.
When the phrase was said to me, it seemed to validate the "decision". It made it sound like a reasonable, lucid decision on my part. That is why it can be a dangerous comment to make.
I was subsequently diagnosed with bipolar disorder, and my suicidal intent only emerges during depressive episodes. When I am depressed, my thinking is entirely altered. I am unable to see any hope for the future. The things that usually matter to me seem unimportant. I feel entirely worthless. It is as if I have no value and that my life has no purpose. I am unable to see the impact of my death on those around me. I simply cannot see the people I love at all. They, and everything that usually matters to me, have disappeared out of my field of vision.
This is not how I think when I am well. Any decisions I make during these depressive episodes are influenced by this altered pattern of thinking. That is why I wish mental health and other professionals would stop telling patients "It's your decision" in a way that implies the patient is thinking rationally and clearly, and is fully well.
I recall telling a paramedic that I had received messages to end my life on a particular date. I explained these messages were not from any human source. He assessed me and said that I had the mental capacity to make this decision and that he was going to leave without taking any action. A police officer, who had been asked to make a welfare check on me and who had called the paramedic out to my home, took him outside and spoke to him. Moments later, the police officer returned and advised me that he was using his powers to detain me under mental health legislation. This incident shows how differently two professionals assessed my capacity, my mental health and my ability to make decisions on that occasion.
The Royal College of Psychiatrists' website gives information about the way in which mental illness may affect capacity. My concern is that not all professionals seem to be following this guidance. Many professionals focus on the ability of a patient to understand and retain information - the patient may understand what the professional says to them and may be able to answer questions and remember things. But when it comes to "weighing up information", a mental illness may impact significantly on this, as the RCP explains.
The RCP information sheet indicates that psychosis may mean that a person is hearing voices telling them to end their life. It also states: "If you are very depressed you may feel so hopeless that any treatment seems pointless, even if there is a good chance of recovery." Both of these conditions impact upon a person's ability to weigh information and make an informed decision:-
When I was "receiving messages" relating to the date of my death, this was impacting upon my weighing of information, but I was deemed by the first professional to have capacity. Similarly, in depressive episodes, I was told on more than one occasion by professionals that it was "my decision" to end my life.
In every case, when one of our clients has been at the point of making a suicide attempt, I have felt that their thinking has been affected by mental illness or profound emotional distress. This is one of the many reasons why we are tenacious in the way that we support clients, and do all we can to help them survive. If a client stated that they were going to walk out of our Suicide Crisis Centre, saying "thank you but I have now decided to end my life", I would never think this was "okay". I would never think: "Well, that's their decision".
A GP said to me recently that he felt that the very fact that a person was stating suicidal intent would make him think there is a question of mental capacity.
Perhaps the reason why mental health clinicians are using this phrase is that they wish to encourage patients to take responsibility for their actions and discourage dependence upon services. It seems to be used sometimes to discourage patients from thinking they should expect mental health professionals to "save" them.
One of our clients, who has a diagnosis of Emotionally Unstable Personality Disorder, was told by mental health clinicians that it was her decision to end her life. My question would be "To what extent is her illness impacting upon her decision-making?" She has felt suicidal every day for months. Surely this can be interpreted as part of being unwell. She took the comment as a sign they didn't care whether she lived or died. It may be interpreted in so many different ways. She now uses our services when in crisis, and not mental health services.
I hope that mental health professionals will be cautious about using this phrase in future. At our Suicide Crisis Centre, we never use it. In my opinion, aiming for zero suicide means doing all we can, for each individual, to help them to survive - not telling them it is their choice to die.
For information about the Suicide Crisis Centre: http://www.suicidecrisis.co.uk