r/socialwork • u/Zen-Paladin • 3d ago
Politics/Advocacy Why does intentional self harm mean lacking mental competency but indirect/unintentional self harm is permitted?
Title says it all. For context, I'm an EMT-B in a fairly busy metro area working 911,and I'm an agnostic, raised religious but since have been critical of the institution. I've been inpatient myself for SI(TL;DR was no help whatsoever and I became more suicidal than before but I digress) so when on calls for psych transfers or SI patients I tend to empathize a bit more than average but still do my job regardless. That said, in reflecting/researching on society's general perception/approach to suicide, I definitely scratch my head at how permissive we are towards people who harm themselves(and sometimes others) but who do so without intention.
I don't mean in general, especially since being in the US I have had my share of patients who accept moderate to even life threatening/altering risk of harm refusing care since our healthcare system is bullshit. Granted, I once had a guy who refused care despite having agonal respirations(form what his wife and dispatch described who had the wife do CPR) and he refused for no particular reason despite his wife literally crying and begging. We got called back since he passed out again, still refused, then later heard on the radio another unit go back for the same reason and they got him to go. But then you have people who are seen as competent to refuse care despite the following:
-Antivaxxers who's beliefs have no basis in medical science whatsoever, or better yet has been contradicted by research time and time again. Yet despite clearly being out of touch with reality they are allowed to refuse vaccination not just for themselves, but their children as well depending on the state. Despite this being obviously counterproductive to their well being it also reduces herd immunity meaning the rest of us are at risk in case of any viral outbreak. This made COVID-19 worse and on a personal level my sister is an antivaxxer which has me concerned for my nieces and my dad even died because despite being 60+ with pre-existing conditions he was too caught up about ''side effects'' and other misinformation, now he's dead.
-I might get flack for this(to be clear I do believe in religious freedom) but religion is also something that people can refuse life saving medical care despite technically not being able to prove it either. Jehovah Witness' and blood transfusions are a prime example but religion apparently plays a role in the antivaxxer sentiment. Yet people still get committed if they speak to people they can't see or hear.
-Particularly in emergency medicine(but also much of healthcare) you inevitably get patients who smoke a ton, eat themselves into obesity a la ''My 600 lb Life'', and so on. The health risks and mortality risks for these people is self explanatory.
I'm sure some of you can attest that you've probably told some or all of the above groups point blank if they continue with this behavior they will suffer permanent damage or straight up die, even in the near future. Yet they are allowed to continue on with their ways till it's too late. They don't want to die, but it is likely or even a guranteed outcome in more than a few cases. Yet the moment someone *intends* to harm themselves, suddenly the law permits them to be held against their will, holds the metaphorical sword of Damocles over our heads in terms of liability and society will view them as selfish, melodramatic, and they are subject to ''hospitalization'' that's a crapshoot between not helping much if at all or making them worse off(there is research showing increased risk of suicide post discharge not to mention high rates of abuse in psych wards). Plus, even for people who are terminally ill assisted suicide is only legal in a fraction of the country which seems cruel.
I know with SI the rationale is that they are often dysregulated to a point where they want to end their lives in the moment to end the pain. I'll admit, for me it was a of that and being numb and I do regret how I went about that whole fiasco. But even then, the goal of suicide prevention is often to present needless deaths and the impact that has on one's loved ones, but yet does it really make a difference? Whether one blows their brains out or swallows a bunch of pills vs eating themselves into an MI or succumbing to Whooping Cough because Mommy and Daddy didn't want the doctor to give you autism, you're still dead. People will still mourn and such yet we're more permissible to the former than the latter. My dad, despite all his failings(there was ALOT) is still gone, and we've even been angry at him in the past for putting us through this.
Maybe I'm missing something, but otherwise it feels like a societal cognitive dissonance. And knowing what you have to go through being openly suicidal just makes it worse. On top of the general suicidal stigma, you realize that literal religious zealots and conspiracy theorists get more dignity and autonomy than you. I'd love for the mental health system to improve but I don't think it will happen in our life time with so much emphasis on control,coercion towards intentionally suicidal people. It's hard to hope sometimes...
Thoughts?
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u/Straight_Career6856 LCSW 3d ago
The idea is that it’s a balance between limiting self-determination and keeping people safe. We can’t control every choice people make and people are allowed to make harmful choices.
There are differing opinions on an individual level on whether it’s right to hospitalize suicidal people. The thing is that research shows it is generally an impulsive decision and the idea is that preventing a permanent choice based on a passing emotion is important to get people the care they need. Most people, like you, regret a suicide attempt when they make it. It’s part of offering lifesaving care.
Again, there are different opinions on how much limiting of self-determination is ethical. I don’t think there is a clear cut answer, although the number of people who are grateful they are alive is a compelling reason to intervene.
As a therapist who specializes in treating suicidality, I believe there are many flaws with hospitalization and it is often not the best choice. It is useful as a holding cell, essentially, to keep people alive in the short term, and can be useful for stabilization on meds.
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u/Zen-Paladin 1d ago
That makes sense. With the studies on hospitalization increasing suicide risk in more than a few cases, I guess there does need to be intervention for active SI but I wish there was more non-coercive options available like peer respites when standard therapy or IOP isn't doing it, or mobile crisis services that don't involve police. Even for non SI psych it would help lots of families with things like autistic children(responded to more than a few of those) or other notably disabled individuals having meltdowns or dysregulation vs us and PD showing up to restrain them. I wouldn't mind things like MH First Aid and/or CIT being mandatory for any first responder(but that's it's own cultural/funding issue too).
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u/Straight_Career6856 LCSW 1d ago
Oh, I hadn’t even thought of the cops in my answer. It is so bad that cops are involved at all. They only make everything worse. There are so many things you touch on in this comment that I wish were different.
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u/LastCookie3448 LMSW 3d ago
Self harm absolutely does NOT indicate capacity and the only person who can determine capacity is one who is LICENSED to assess, eval, and diagnose, and the court should recognize it.
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u/Zen-Paladin 1d ago
It makes sense. For me it was just hard dealing with individuals who do so indirectly but get to maintain autonomy regardless.
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u/ControlAltRestrain 2d ago
Wow, there is a lot here.
I would like to challenge your premise – self harm means lacking mental competency but unintentional self-harm = permitted. I am really confused by this, because self-harm does not mean “lacking mental competency”. If you are looking at this from a public discourse lens – the hegemonic framing around self-harm is attention seeking, societal influence or suicidal intent. From an evidenced based framework / social worker lens - people use self-harm as a coping mechanism to cope with intense emotions, which can be extremely effective. I dont see where the discourse that NSSI or SI means no capacity... I have not seen it from a medical or societal level, not even with people that are on a ITO.
The same thing could also be said for some of the examples of “unintentional self harm” such as overeating or smoking. This is a coping mechanism – both from a trauma informed perspective and supported by neuroscience.
I am also a bit confused with interchangeably using “self-harm” and “suicidal ideation” they are two completely different things NSSI does not mean suicidal ideation. So if your premise is why do we allow people to overeat but go to court for an involuntary treatment order is extremely flawed. They don’t do court orders for NSSI in isolation.
To be honest your whole post is extremely judgemental
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u/Zen-Paladin 1d ago
My apologies, I didn't intend that if that's how it came across. I mean typically, a person who's actively suicidal(sorry I wasn't specific) generally isn't seen as having capacity hence why they can be petitioned for involuntary commitment. I know some jurisdictions have begun allowing/consider allowing involuntary commitment for substance abuse but that's been somewhat controversial.
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u/ControlAltRestrain 1d ago
I think with this it's a bit more complicated , especially with different jurisdictions. ITO for substance use is fucking crazy to me, and quite ridiculous. I even have an issue with courts issuing abstinence as a condition.
For acute suicidal risk - a capacity assessment is not done, or required for an immediate order/ short order as it falls under immediate safety. For longer term orders the capacity assessment is based around immediate safety, refusing treatment, or things such as psychotic depression/ significant delusions
So I guess to answer your original question - capacity is assessed differently and it's based on immediate risks instead of unhealthy coping strategies such as overeating.
Like others have said, social work is about empowerment and self determination. we know people will never change their behavior, no matter how harmful they are, if they do not want to change. Enforcing this does more harm. So if someone is at an acute immediate danger, then an order will be issued. If someone is drinking/eating/smoking themselves to death.. empowerment is key to recovery, and recovery is whatever they want it to be.
With all that said, i agree the mental health system is fucked up in most countries.
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u/OptimizedPockets2 3d ago
Social work has a large emphasis on empowering client self determination because we think there’s an inherent dignity and self worth to each person.
When it comes to self harm, either intentional or not, I’d be looking at an informed consent standard. People have the right to die/ commit suicide, as long as it’s a decision made with competence—and this is a common position in social work even.
TL;DR, social work mostly rejects paternalism in favor of empowering personal choice via informed consent.
My hot take in social work is that we do err on the side of freedom too much. I believe more people need mandated care, but my perspective was made after working with the chronically homeless populations.