Tried to kill yourself? You're fired!

The mythical psychiatrist or psychotherapist accepts and understands everything. Or does she? Years ago a respected colleague told me of his policy. If a patient in his practice attempted suicide he would discharge them. The more I think about this the more I like it. Assume that either the patient's care has been transferred, likely to a hospital, and that the psychiatry has given the requisite thirty day notice in writing, not only to the patient but to the hospital. Ethics might obligate the original psychiatrist to continue providing care for the remainder of the thirty days, but the hospital should probably take the opportunity to refer the patient to a new provider for a fresh start.

One would likely invoke such a policy on a case by case basis with exceptions as indicated. Would ethics require the provider to notify all patients of the policy before starting treatment?

Many will balk at this idea, perhaps in part related to the professional's feelings of failure, anger, and perhaps fear of recurrence. But does a suicide attempt not represent the ultimate breach of treatment contract as well as a clear statement that the treatment has failed? Does rejection of the patient after the attempt not offer the possibility of more effective treatment?

From the psychiatrist's perspective such a policy also sets a limit, expressing the position that she will not accept society's misguided attempts to hold her responsible for the acts of another.

If all psychiatrists and psychotherapists refuse to work under such circumstances, who will take care of the patients. Perhaps society needs to answer that question.

Testing the Unconscious

Freud called dreams the "royal road to the unconscious," but the authors of the Implicit Association Test seem to claim an ability to measure "implicit cognition" (Is that a euphemism for unconscious?) by using a computer administered psychological instrument.

This approach was previously reported to uncover racial bias in the practice of medicine: http://www.ama-assn.org/amednews/2009/09/28/prsa0928.htm, but according to an article in a recent issue of Psychiatric News a variation of the test appeared to predict suicide risk more accurately than by traditional means such as psychiatric interview. I took one of the tests myself. The result was not what I would have expected. Did the test err, or do I simply not know or acknowledge my true attitudes? I suppose the authors might claim the result proves that my attitude is unconscious, but as far as I know no method of tapping the unconscious exists that might provide researchers with a way to validate the results of such a test, except perhaps by looking at my subsequent behavior.

The notion of a test of unconscious intent (Isn't that a contradiction in terms?) sends me on flights of fantasy. I imagine requiring psychiatric patients to undergo testing on a mobile device every 24 hours with results transmitted to a central clearinghouse. If the patient starts to lean toward suicide, the men in white coats home in on their GPS signal, pick them up, and hospitalize them until their attitudes right themselves, with or without treatment. Of course one would have to pass the test before purchasing a firearm, or razor blades, or matches. Or before being allowed to pilot an airplane or drive a car, or cross a street, or climb higher than the first floor of a building. Could we detect future suicide bombers?

Why limit the use of this technology to prediction of suicide, or to psychiatric patients? If such a test could detect intent to rob, rape or kill, to engage in insider trading, run a red light or shoplift, we could require everyone to take it and virtually eliminate crime. Maybe, rather than requiring formal testing, analysis of patterns of Internet use such as Web sites searched or visited could allow, for example, determination of how one might intend to vote in an election. Could such information be used to subtly influence attitude, intent or even religious belief by channeling selected stories through news sites and other media, or even what happens to you when you play World of Warcraft? And since it's all unconscious, how would you know? The possibilities for abuse approach infinity.

Somebody please make a movie!

You can take the tests yourself at: https://implicit.harvard.edu/implicit/, provided you can reign in your paranoia.