Should psychiatrists de-stigmatize self immolation?

[wamcp]

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[birchswing]

It just seems like a reason to talk about his cause. It's a strawman to say there were psychiatrists coming out and calling this a mental health issue. I don't disagree with his cause, but I also don't recall any national voices decrying him.

If anything I find it more distressing how frequently euthanasia is being offered to people with disabilities who don't really want it but are told it's the only alternative left, or it's made out to be the more attractive offer by slow-walking other alternatives. It doesn't seem to be very stigmatized at all. I've seen uptick in talk about this in disability communities where people are being pushed into MAID, including for psychiatric illnesses like depression (not in the US, but in Europe for depression).

 

[aim-agm]

The self-immolation of Tibetan monks is the example I use when I want to illustrate suicidality is not synonymous with mental illness.

I don't know enough about the referenced incident to comment.

 

[comp1]

Suicidal ideation/action can be a symptom of a mental illness, but it most certainly doesn't have to be. In this particular case, I'd really rather psychiatry just not be involved. The suicidal individual clearly expressed why he was killing himself and his reasons did not relate in any way to a mental health condition. The fact that he might have had some sort of mental health condition is irrelevant. He was quite clear about his reasons and regardless if we agree or disagree with them, they did not involve frank delusional thought processes consistent with a primary psychotic condition. I believe we have no option but to accept his reasons as he stated them. Anything else is speculation.
The resident presentation is good to the extent that it argues suicide as a means of protest is not a mental health issue. However, at best, it sends mixed messages when you're literally giving a talk on something not a mental health issue at a mental health grand rounds. Definitely concur with above that we should be more focused on MAID since psychiatrists ARE actually being drawn into that chaos as opposed to this chaos.

 

[PsyDr]

I want to de-stigmatize setting one's genitals on fire about as much I want to de-stigmatize setting the rest on fire.

 

[Sushirolls]

 

[Crayola227]

It just seems like a reason to talk about his cause. It's a strawman to say there were psychiatrists coming out and calling this a mental health issue. I don't disagree with his cause, but I also don't recall any national voices decrying him.

If anything I find it more distressing how frequently euthanasia is being offered to people with disabilities who don't really want it but are told it's the only alternative left, or it's made out to be the more attractive offer by slow-walking other alternatives. It doesn't seem to be very stigmatized at all. I've seen uptick in talk about this in disability communities where people are being pushed into MAID, including for psychiatric illnesses like depression (not in the US, but in Europe for depression).

I looked into past threads about this on the psych forum, and we have a thread in the sociopolitical forum I had hoped to post and get traction here on.

Euthanasia for humans is in fact a slippery slope. Physicians should actually stay out of it as much as possible in my opinion. Military's job is arguably to kill people. Ours is life. Part of ours has to do with reducing suffering, but I think for born humans the positive actions (vs doing nothing) have to preserve life. People can ask us to not do things and then palliate and then they die. But our actions should not hasten death, unless death is inevitable in which case a focus on the suffering aspect can be emphasized. If there is one thing we should know about mental health 99% of the time is that death is not inevitable, the patient may make it happen but until they succeed we don't know.

Post in: 'Death with Dignity is Political?' https://forums.studentdoctor.net/threads/death-with-dignity-is-political.1242735/post-18630157

You can jump to the latest conversation we were having about it, which I wanted psych input because Europe was gonna euthanize (not just give a fatal prescription to, but administer by injection) someone with depression and high functioning autism and BPD.

Post in: 'Death with Dignity is Political?' https://forums.studentdoctor.net/threads/death-with-dignity-is-political.1242735/post-24279689

 

[Candidate2017]

Sure, we can start destigmatizing political self-immolation by classifying it as political speech rather than suicide. The zero suicide folks would be happy.

 

[Crayola227]

Culturally sanctioned suicide: Euthanasia, seppuku, and terrorist martyrdom

Suicide is one of the greatest concerns in psychiatric practice, with considerable efforts devoted to prevention. The psychiatric view of suicide tends to equate it with depression or other forms of mental illness. However, some forms of suicide occur ...

www.ncbi.nlm.nih.gov

Interesting read

 

[Ceke2002]

Thich Quang Duc's death was impactful enough to have become one of the most famous images of the Vietnam war era, and his death still achieved nothing in the end. Around 140 Tibetans have self immolated in protest of the occupation of Tibet as well, and their deaths haven't exactly changed the minds of China's government either. The thing with both those examples though is that the majority are practitioners of Mahayana Buddhism, which tolerates the practice of self immolation and doesn't always consider it to be suicide (in Thich Quang Duc's case specifically it was seen as a devotional act).

Having said all that I think there's a huge difference between a cultural tradition that may tolerate self immolation as a form of spiritual devotion or political protest, and someone just randomly deciding to light themselves up. With some immolation videos that have leaked online you can kind of tell the folks for whom it was an impulsive act that they really didn't think through, they're the ones who typically hit the ground within seconds and scream for help. It does seem as if these impulsive acts of self immolation are driven by something other than a desire for true protest and may be more of a sign of extremist indoctrination (which to me falls under the category of a mental, or at least, emotional health issue, whereby the indoctrination has lead the person to then not be able to think rationally).

In the case of Anthony Bushnell, he does appear to have held a strong belief that what he did was the right thing to do, and from the video at least it appears to also be something that he thought through and was determined to go through with (the video doesn't seem like its an act of impulsion). Without going into too much detail, he films himself walking to the area where the event occurs, he places his military cap on his head and then stands to attention and salutes just beforehand, and once he's lit himself up he shouts 'Free Palestine' three times, and for the rest of the time he simply remains standing and quietly burns until he loses consciousness. There's no sense of a 'Oh shoot, this was a stupid idea, somebody help me' kind of moment that you sometimes see with other self immolations; he seems committed and determined that what he was doing was the right thing. Of course that then leads to the question of extremism, and extremist indoctrination (something not exclusively reserved for the right wing only, extremism on any side is still extremism) and from what I understand at least there was evidence found in his social media, and online presence in general, to indicate his thought process was leaning well into extremist territory.

So I suppose the question then is how do you battle extremism, or extremist indoctrination, in a mental health setting, as opposed to viewing an act like self immolation strictly through the lens of suicidal ideation?

 

[Crayola227]

Thich Quang Duc's death was impactful enough to have become one of the most famous images of the Vietnam war era, and his death still achieved nothing in the end. Around 140 Tibetans have self immolated in protest of the occupation of Tibet as well, and their deaths haven't exactly changed the minds of China's government either. The thing with both those examples though is that the majority are practitioners of Mahayana Buddhism, which tolerates the practice of self immolation and doesn't always consider it to be suicide (in Thich Quang Duc's case specifically it was seen as a devotional act).

Having said all that I think there's a huge difference between a cultural tradition that may tolerate self immolation as a form of spiritual devotion or political protest, and someone just randomly deciding to light themselves up. With some immolation videos that have leaked online you can kind of tell the folks for whom it was an impulsive act that they really didn't think through, they're the ones who typically hit the ground within seconds and scream for help. It does seem as if these impulsive acts of self immolation are driven by something other than a desire for true protest and may be more of a sign of extremist indoctrination (which to me falls under the category of a mental, or at least, emotional health issue, whereby the indoctrination has lead the person to then not be able to think rationally).

In the case of Anthony Bushnell, he does appear to have held a strong belief that what he did was the right thing to do, and from the video at least it appears to also be something that he thought through and was determined to go through with (the video doesn't seem like its an act of impulsion). Without going into too much detail, he films himself walking to the area where the event occurs, he places his military cap on his head and then stands to attention and salutes just beforehand, and once he's lit himself up he shouts 'Free Palestine' three times, and for the rest of the time he simply remains standing and quietly burns until he loses consciousness. There's no sense of a 'Oh shoot, this was a stupid idea, somebody help me' kind of moment that you sometimes see with other self immolations; he seems committed and determined that what he was doing was the right thing. Of course that then leads to the question of extremism, and extremist indoctrination (something not exclusively reserved for the right wing only, extremism on any side is still extremism) and from what I understand at least there was evidence found in his social media, and online presence in general, to indicate his thought process was leaning well into extremist territory.

So I suppose the question then is how do you battle extremism, or extremist indoctrination, in a mental health setting, as opposed to viewing an act like self immolation strictly through the lens of suicidal ideation?

People forget with this guy he fell down the extremist rabbit hole of antisemitism and conspiracy theories.

I think it's very difficult to say exactly what is going on by appearances.

There is something to be said for the fact that yes, culturally sanctioned suicide exists. Not all suicide is pathology.

As far as psychiatry "destigmatizing" it as an "act of resistance," that is hogwash. Our duty to patients should be as apolitical as possible and principally we should be on the side of preserving and improving health. That is our function. Within our sphere, by and large, ours is not a world for welcoming killing oneself, it doesn't seem generally compatible with our mission. So I see little reason for physicians to "destigmatize" otherwise healthy folks killing themselves for politics. If people want to kill themselves for politics that is their perogative. But we don't need to be any part of it.

That is the Western and Hippocratic formulation of our role. If society wants to change and cultural sanction all this stuff and then it wants physicians to serve dual roles as shaman have in the past, with doing rituals or things known to cause harm with little chance of gain (like cutting for stone) then what it means to be a physician will need to be reformulated. The current formula is not consistent in my mind of taking action to legitimize people killing themselves for politics.

I can't help but wonder if a certain sort of mindframe about "martyr operations" is basically being proposed as a direction we as a Western society should go in. I reject the value of suicide for political change as a Westerner and a Western physician. Buddhists and others can do as they like.

If we weren't supposed to let politics (the government) compel us to kill people in Nazi Germany, why would be let the pressure of politics on people be a cause for us to help pave the way for death by politics? It seems totally bat****. This is why medicine should be divorced from killing and politics having undue influence on practice.

The best reply above was, this is not our wheelhouse so nothing for us to do here.

 

[PsyDr]

Maybe it’s not mental illness, maybe it’s political speech, maybe the term used is religious, maybe "you" go somewhere when you die so it doesn't matter, maybe unrelated parties find it to be impactful, maybe in social settings, self harm provokes others to change their behaviors.

But I am unaware of any military strategy where you hurt yourself, as opposed to your enemies. I am also unaware of any military strategy where you stop something because your enemy has engaged in self harm.

 

[ObsequiousAplomb]

Maybe it’s not mental illness, maybe it’s political speech, maybe the term used is religious, maybe "you" go somewhere when you die so it doesn't matter, maybe unrelated parties find it to be impactful, maybe in social settings, self harm provokes others to change their behaviors.

But I am unaware of any military strategy where you hurt yourself, as opposed to your enemies. I am also unaware of any military strategy where you stop something because your enemy has engaged in self harm.

Well, one might certainly stop interrupting their opponent when they're making a mistake.

 

[clausewitz2]

Maybe it’s not mental illness, maybe it’s political speech, maybe the term used is religious, maybe "you" go somewhere when you die so it doesn't matter, maybe unrelated parties find it to be impactful, maybe in social settings, self harm provokes others to change their behaviors.

But I am unaware of any military strategy where you hurt yourself, as opposed to your enemies. I am also unaware of any military strategy where you stop something because your enemy has engaged in self harm.

If we are talking semi-mythically there is King Goujian of Yue in the Spring and Autumn period who supposedly would start battles by having his front line of soldiers decapitate themselves to scare the bejeezus out of their enemy.

 

[Crayola227]

Presumably this guy didn't light himself on fire to directly impact the actions of Palestinians or Israelis, but in protest of the US govt's involvement in the conflict. He is a soldier so clearly his death in some situations is acceptable to his government, but it's not unreasonable for citizens to expect their deaths to potentially have some impact on their own country's actions. Or fellow citizens.

One person said, they wouldn't be surprised if this was regarded as destruction of govt property. Not sure a joke or not.

 

[SmallBird]

From a public health perspective validating the idea that things this far outside our locus of control are a basis for individual trauma is like reverse CBT. It’s like climate anxiety, which seems to be focused on making people develop believe they should be even more anxious than they thought.

 

[Stagg737]

From a public health perspective validating the idea that things this far outside our locus of control are a basis for individual trauma is like reverse CBT. It’s like climate anxiety, which seems to be focused on making people develop believe they should be even more anxious than they thought.

I agree with you, but from an ethical perspective on autonomy who are we to stop this if there is no treatable or even recognized mental illness contributing? I didn't listen to the presentations above, but I can see the benefit of de-stigmatizing self-harm when it's directly related to mental illness. I don't agree with de-stigmatizing self-harm from a protest/statement perspective, as this seems more aligned with a manipulative thought process ("look what you made me do") unlikely to achieve real change as stated above.

 

[calvnandhobbs68]

But I am unaware of any military strategy where you hurt yourself, as opposed to your enemies. I am also unaware of any military strategy where you stop something because your enemy has engaged in self harm.

This is a pretty limited way of looking at this. Do we say a soldier has a mental illness that led to "suicidal thinking" when they fall on a grenade in hopes of saving another or increase the chance that others will survive? This applies to almost any situation where you engage directly in actions where one almost certainly knows these actions will directly lead to their own death in the hopes of saving another or achieving some larger purpose.

From a philosophical perspective, if one truly believed that one's death may lead to increased pressure for earlier cessation of some conflict and may lead to even one additional life being saved by this, it would be essentially equivalent.

 

[Crayola227]

Man Sets Himself on Fire Near Courthouse Where Trump Is on Trial Man Sets Himself on Fire Near Courthouse Where Trump Is on Trial

Seems like folks are doing just fine destigmatizing without our encouragement.

 

[Stagg737]

Man Sets Himself on Fire Near Courthouse Where Trump Is on Trial Man Sets Himself on Fire Near Courthouse Where Trump Is on Trial

Seems like folks are doing just fine destigmatizing without our encouragement.

Sounds like this guy had some psychotic tendencies or a break. You can google his pamphlet (true history of the world: haunted carnival edition). His posts are all still on Reddit and you can still read the whole pamphlet on there, at least until it likely gets taken down.

Wonder how the residents who presented at UCLA would feel about this act and stigma...

 

[PsyDr]

Sounds like this guy had some psychotic tendencies or a break. You can google his pamphlet (true history of the world: haunted carnival edition). His posts are all still on Reddit and you can still read the whole pamphlet on there, at least until it likely gets taken down.

Wonder how the residents who presented at UCLA would feel about this act and stigma...

I wonder how their use of the term “martyr” intersects with professional terms

 

[Ceke2002]

For those who either can't access, or can't be bothered looking up Azzarello's manifesto, here it is quoted in full for people to read as a document of potential relative interest and/or discussion.

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(edited to remove: decided contents potentially not appropriate). If anyone would like to read the manifesto, and doesn't have access to news sites that have it published, message me and I will give you the text.

 

[comp1]

You can still do specific things for non-psychotic reasons (even things not widely supported) while having an underlying psychotic disorder. The rest of society can take this issue, mental health does not need it.

 

[Stagg737]

You can still do specific things for non-psychotic reasons (even things not widely supported) while having an underlying psychotic disorder. The rest of society can take this issue, mental health does not need it.

Sure, but our job (especially ER and inpatient) is often to determine if actions are related to a psychiatric condition or not. I'd argue that patients directly harming themselves due to psychosis/mania is one of the few times inpatient admission is truly necessary for appropriate care and not just a mitigation of liability. It's also why it's important for outpatient notes to be decent, so we can tell what a patient is actually like at baseline vs significantly ill.

 

[Tangerine123]

Like some posted, I also think suicide isn't necessarily linked to mental illness. This is a patient I saw in the ER a few months back:

30 year old male. Born in Russia, raised half of his life in Ukraine. He got a letter that he was being conscripted to fight on behalf of Russia. He seeked asylum in a EU country, it got rejected and he was going to be deported back to Russia. He came to the ER because of his anxiety and insomnia since he got the letter, and just wanted some meds to sleep for the night. After hearing the story I offered to admit him, to maybe overturn the deportation. He declined because he had to take care of his family members. He said, however, that of the deportation goes through, he would kill himself in Russia because he can't imagine himself killing his people in Ukraine.

If that were to happen, and that was his choice and will, I would not have tried to intervene at all

 

[clausewitz2]

Like some posted, I also think suicide isn't necessarily linked to mental illness. This is a patient I saw in the ER a few months back:

30 year old male. Born in Russia, raised half of his life in Ukraine. He got a letter that he was being conscripted to fight on behalf of Russia. He seeked asylum in a EU country, it got rejected and he was going to be deported back to Russia. He came to the ER because of his anxiety and insomnia since he got the letter, and just wanted some meds to sleep for the night. After hearing the story I offered to admit him, to maybe overturn the deportation. He declined because he had to take care of his family members. He said, however, that of the deportation goes through, he would kill himself in Russia because he can't imagine himself killing his people in Ukraine.

If that were to happen, and that was his choice and will, I would not have tried to intervene at all

The suicidologists will tell you that about half of people who complete suicide don't meet criteria for a diagnosable mental illness. Suicidality also clusters in families independent of other mental health diagnoses. It is absolutely its own thing and the fact our system takes it as prima facie evidence of, say, depression flies in the face of the research base.

 

[Stagg737]

The suicidologists will tell you that about half of people who complete suicide don't meet criteria for a diagnosable mental illness. Suicidality also clusters in families independent of other mental health diagnoses. It is absolutely its own thing and the fact our system takes it as prima facie evidence of, say, depression flies in the face of the research base.

I've heard the bolded before but I have a hard time believing that the number is as high as 50%. I would not be surprised if the number is much higher than most people would guess, but half seems unreasonable. I'd argue a more accurate description would be that completed suicides may not be driven by diagnoseable mental illness, even if people would technically meet criteria. The patients I see on consults who are "suicidal" due to gradual worsening of chronic pain which has led them to a life they no longer wish to live is one of the hardest groups for me personally; both in terms of what to actually do for them as well as legal vs ethical obligations. Most of these patients meet criteria for some form of diagnosis, but that's not the real etiology driving their SI.

Either way, agree that suicide is a more complex psychosocial problem in which MH is absolutely a massive contributing factor to, but not a sole causal factor of.

 

[clausewitz2]

I've heard the bolded before but I have a hard time believing that the number is as high as 50%. I would not be surprised if the number is much higher than most people would guess, but half seems unreasonable. I'd argue a more accurate description would be that completed suicides may not be driven by diagnoseable mental illness, even if people would technically meet criteria. The patients I see on consults who are "suicidal" due to gradual worsening of chronic pain which has led them to a life they no longer wish to live is one of the hardest groups for me personally; both in terms of what to actually do for them as well as legal vs ethical obligations. Most of these patients meet criteria for some form of diagnosis, but that's not the real etiology driving their SI.

Either way, agree that suicide is a more complex psychosocial problem in which MH is absolutely a massive contributing factor to, but not a sole causal factor of.

Looking at more recent metanalyses of psychological autopsy studies, the number that keeps coming up is closer to 30% not meeting criteria for a mental health disorder diagnosis. Bear in mind that psychological autopsies are always going to understate this to some extent because there is going to be just a tremendous recall bias. I am updating to "somewhere between 30 and 50% don't meet criteria for a mental health disorder."

EDIT: You are correct that having a mental health disorder does vastly increase the risk of completing suicide.