Via Alternet . . . can't say I disagree with this, but in our community there is no other option when suicidal ideation becomes suicidal intent. It would be nice to have a non-clinical chill house for some people, with lots of rooms, where people in crisis (but who not violent or in psychosis) can talk to a professional, talk with other people, and just generally take a time out from life.

Can't see that happening now, considering we can barely fund community mental health programs in Arizona as it is.

The main here is important. A big part of the problem is that we define psychological distress as a brain disease, in whatever form it takes. Nevermind that the evidence for this belief suffers from an ignorance of developmental psychology, interpersonal neurobiology, and epigenetics.

 

It's never as fun as it is shown to be in the movies.

 

Research Suggests That Psychiatric Interventions Like Admission to a Mental Facility Could Increase Suicide Risk

A major study identifying the highest risk factors for suicide we’ve ever found has been barely discussed.

AlterNet | October 23, 2014
By Rob Wipond

One of the most provocative studies of suicide ever done was published in the September edition of the journal Social Psychiatry and Psychiatric Epidemiology. It appeared shortly after Robin Williams’ suicide, and shortly before the World Health Organization’s World Suicide Prevention Day. Both of those events received widespread media attention, but this study was not reported by any media that I’ve seen, except relatively obscurely by me in my role as news editor for the online science and psychiatry community Mad In America.

The study looked at a broad population and identified some closely related, easily modifiable factors in people’s lives that were linked to being 6 times, 28 times, and even 44 times more likely to commit suicide.

It’s important to pause on those numbers. In the world of suicide prevention statistics, they are truly staggering. What other risk factor is associated with people being 44 times more likely to kill themselves? There aren’t any. Not even close. That’s why this year the US Preventive Services Task Force once again recommended against conducting suicide screening tests – they just aren’t reliable. That’s why the most sage advice that the American Foundation for Suicide Prevention’s web page about “Warning Signs” can provide us with is to check if our loved ones are “looking for a way to kill themselves” or “calling people to say goodbye.”

And that’s also why it’s all the more curious that this new study has gone largely unreported. Most discoveries of potential suicide risk factors -- no matter how seemingly tenuous -- ignite widespread discussion. For example, in June, NBC, Reuters, the Associated Press, NPR, USA Today, Bloomberg, the Washington Post and many other news media headlined a study that loosely linked US FDA warnings on antidepressants to a relative 30% increase or 0.0002% absolute increase in occurrences in drug poisonings, a tentative proxy for suicide attempts. Hundreds of outlets reported in September on a study that found increases in the rate of suicides to be associated with decreases in exposure to sunshine – differences in rates that were so low that no outlets I saw even bothered to quote the actual numbers. Another study covered recently in the American Psychiatric Association’s flagship Psychiatric News, and widely replayed in other media, sounded the alarm that not getting enough sleep was associated with a 1.2 times higher likelihood of suicide.

None of those studies proved that FDA warnings, clouds, or restless nights cause suicides, but the mere notion that they might was widely considered to be worthy of discussing. Yet in this more recent study, the researchers found increases in the rates of suicides climbing exponentially, by factors of 6, 28, 44…

So what were those dramatic increases linked to? University of Copenhagen researchers led a nationwide study in Denmark comparing individuals who died from suicide to matched controls between the years 1996 and 2009. They then graded the type of psychiatric treatment people had experienced within one year of their suicide on a scale which included no treatment, psychiatrically medicated, contact with an outpatient psychiatric clinic, entrance to a psychiatric emergency room, and admission, voluntarily or involuntarily, into a psychiatric hospital.

From 2,429 suicides and 50,323 controls, the researchers found that taking psychiatric medications during the previous year made a person 5.8 times more likely to have killed themselves. If a person had made contact with a psychiatric outpatient clinic, they were 8.2 times more likely to have killed themselves. Visiting a psychiatric emergency room was linked to a 27.9 times greater likelihood of committing suicide. And if someone had actually been admitted to a psychiatric hospital, they were 44.3 times more likely to have commited suicide within the year.

“Psychiatric admission in the preceding year was highly associated with risk of dying from suicide,” concluded the researchers. “Furthermore, even individuals who have been in contact with psychiatric treatment but who have not been admitted are at highly increased risk of suicide.” Essentially, the researchers found that increasing levels of psychiatric care are associated with “a severely increased risk of dying.” They concluded, “The public health significance of this finding may be considerable.”

What is the significance? The Danish researchers argued that we were seeing the results of something like a cancer treatment study. Sicker people were appropriately getting into more intensive treatments, but unfortunately the sicker they were the more likely it was that they would still die, despite even the best of medicines. They also suggested that we may have therefore discovered the most accurate predictor of suicide we’ve ever found: The more someone seeks or is forced into psychiatric care, the closer they probably are on the trajectory towards suicide.

The only problem with this line of reasoning is that there’s no evidence to support it. Suicide is not a progressive illness like cancer; that is, there’s no evidence that people with suicidal feelings travel on a trajectory of ever-intensifying, ever-more-constant suicidal feelings while getting into ever more intensive psychiatric care until they die at steadily increasing rates along the way. If suicidality was in fact progressive in that way, we’d be much better at identifying where people are along that path and intervening at the right time to prevent suicides. Instead, completed suicides tend to be impulsive, related to a myriad of cascading, confounding, unpredictable factors, not much more common overall in people diagnosed with mental disorders than in the general population, and most often surprising to even those closest to the victims.

So then what’s the real reason that this Danish study is showing a step-by-step trajectory of more people killing themselves as the intensity of their psychiatric care increases?

An accompanying editorial in the same journal by two Australian psychiatrists pointed down a different avenue of analysis.

The editorial authors noted that the study’s own findings showed that the odds of psychiatrists either identifying or successfully helping suicidal people seemed to steadily worsen as their time of exposure to those patients increased. That suggested a dose-effect relationship. It was like a graph showing suicides going up in relation to the amount of exposure to sunshine going down, except 26 or 44 times more vivid. “Associations that are strong, demonstrate a dose-effect relationship, and have a plausible mechanism are more likely to indicate a causal relationship than associations that lack these characteristics,” the editorial authors argued.

And what could that causal relationship be? “There is now little doubt that suicide is associated with both stigma and trauma in the general community,” the editorial stated. “It is therefore entirely plausible that the stigma and trauma inherent in (particularly involuntary) psychiatric treatment might, in already vulnerable individuals, contribute to some suicides… Perhaps some aspects of even outpatient psychiatric contact are suicidogenic. These strong stepwise associations urge that we pay closer attention to this troubling possibility.”

That “troubling possibility,” the editorial authors concluded pointedly, is that “psychiatric care might, at least in part, cause suicide.”

And that troubling possibility is likely at the root of the lack of media reporting and public discussion surrounding this study. The possibility it raises is extremely inflammatory. The study raises doubts about all of our well-intentioned campaigns to increase funding to the psychiatric care system and to bring psychiatry’s messages about mental illness and suicide more proactively into our schools and workplaces. It undermines many of the rationales behind the involuntary outpatient committal laws that are emerging around the country. And it casts a dark, sinister pall over the incessant refrain that people feeling suicidal should “seek help.”

Yet it’s important to recognize that this Danish study has not emerged in isolation. For example, several studies, including one of 100 countries in 2004 and of 191 countries in 2013, have shown links between increasing funding to modern, western-style psychiatric mental health systems and increasing – not decreasing – suicide rates. The authors of those studies did not uncover clear explanations for their findings. And this new Danish study, for its part, has simply more sharply identified the precise junctures in the psychiatric care system that are most strongly linked to those increasing suicide rates.

So we are left to speculate: What might be causing these striking numbers?

There’s no doubt that being treated with powerful psychiatric drugs against your will can be traumatizing for many people. Antidepressants are known to increase suicidal feelings in youth, and other psychiatric medications are strongly linked to increased suicidal feelings shortly after people begin to take them or change dosage levels. Many psychiatric medications also can cause disruptive or debilitating side effects that can have significant negative effects on overall quality of life.

However, I suspect that the real problem is more fundamental: It’s the very idea that “mental illness” is a “brain disease.” This is what most psychiatric professionals believe, and it’s the main message they give to patients seeking their help. This widely propagated idea is a mental-emotional toxic blight upon us all that’s ultimately killing far more people than it’s helping.

It is an unproven theory that psychological difficulties are symptoms of underlying, chronic diseases of the brain that require medications as treatment. No biological markers have yet been found for any syndromes described in the Diagnostic and Statistical Manual of Mental Disorders. Yet thanks to intensive promotion of biological psychiatric theories by pharmaceutical companies, psychiatric professionals and media, most people who’ve never researched the topic themselves quite reasonably assume that it was solidly established years ago that schizophrenia is caused by wayward genes, depression is biochemically induced, and psychiatric medications balance measurable imbalances in brain neurotransmitters.

Those theories help drug company profit margins, and can provide comforting reassurance that many of society’s social ills and life’s most profound pains can be solved with a pill – but they are just theories. Conversely, one need only imagine oneself in the position of patient to see how upsetting, even terrifying or emotionally crushing such an image of “mental illness” can often be.

Picture yourself going through intense, perhaps frightening psychological struggles, and feeling extremely vulnerable, and finally turning to professionals for help. And the first doctor you encounter looks into your eyes and tells you with an aura of authoritative medical certainty that you have an incurable brain disease that will require lifelong medicating with extremely toxic, potentially debilitating drugs just to – hopefully – keep it in check.

If you were feeling despair about your situation and suicidal before that conversation, how about after it?

In this light, a recent study by Emory University and University of Texas psychologists is not surprising, and provides a measure of hope. The researchers conducted a random-controlled trial where they gave a brief science lesson to one group of youth about neuroplasticity, neural pathway development, and other ways that brains can physically, neurologically change in response to lifestyle and thought-pattern changes. The youth who received that lesson experienced significant reductions in depression symptoms.


~ Rob Wipond is an investigative journalist and News Editor for the website Mad In America.

The Internet’s Own Boy: The Story of Aaron Swartz - New Documentary Is Free Online

This story is a tragedy, in my opinion. Aaron Swartz was being made an example of for having embarrassed the government on a couple of occasions. Even the case for which charges were finally brought did not cause any financial harm to his target (JSTOR), who urged the government to drop the charges. The Feds refused - Swartz's conviction would serve as a warning. Instead, the young man hanged himself in his NYC apartment.

Here is a key passage that explains why so many of us supported Swartz's "work":

Swartz’s manifesto didn’t just call for the widespread illegal downloading and sharing of copyrighted scientific and academic material, which was already a dangerous idea. It explained why. Much of the academic research held under lock and key by large institutional publishers like Reed Elsevier had been largely funded at public expense, but was now being treated as private property – and as Swartz understood, that was just one example of a massive ideological victory for corporate interests that had penetrated almost every aspect of society. The actual data theft for which Swartz was prosecuted, the download of a large volume of journal articles from the academic database called JSTOR, was largely symbolic and arguably almost pointless. (As a Harvard graduate student at the time, Swartz was entitled to read anything on JSTOR.)

Academic publishers like Reed Elsevier, JSTOR, Science Direct, Nature, Hindawi, Springer, and others control nearly all of the published research in nearly every field, much of which is funded by tax dollars either directly or indirectly.

These publishers then charge authors hundreds [sometimes thousands] of dollars to publish, and charge more if the author wants open access; they charge for images in articles; they charge libraries hundreds of dollars for subscriptions, even digital subscriptions; and they try to charge consumers (like me) between $30 and $70 for use of an article (often on 24 hours).

Anyway, first up here is a review of the film and the life of its subject, via Salon, followed by an open access version of the film from Open Culture.

“The Internet’s Own Boy”: How the government destroyed Aaron Swartz

A film tells the story of the coder-activist who fought corporate power and corruption -- and paid a cruel price

Andrew O'Hehir | Tuesday, Jun 24, 2014



Aaron Swartz (Credit: TakePart/Noah Berger)
Brian Knappenberger’s Kickstarter-funded documentary The Internet’s Own Boy: The Story of Aaron Swartz, which premiered at Sundance barely a year after the legendary hacker, programmer and information activist took his own life in January 2013, feels like the beginning of a conversation about Swartz and his legacy rather than the final word. This week it will be released in theaters, arriving in the middle of an evolving debate about what the Internet is, whose interests it serves and how best to manage it, now that the techno-utopian dreams that sounded so great in Wired magazine circa 1996 have begun to ring distinctly hollow.

What surprised me when I wrote about “The Internet’s Own Boy” from Sundance was the snarky, dismissive and downright hostile tone struck by at least a few commenters. There was a certain dark symmetry to it, I thought at the time: A tragic story about the downfall, destruction and death of an Internet idealist calls up all of the medium’s most distasteful qualities, including its unique ability to transform all discourse into binary and ill-considered nastiness, and its empowerment of the chorus of belittlers and begrudgers collectively known as trolls. In retrospect, I think the symbolism ran even deeper. Aaron Swartz’s life and career exemplified a central conflict within Internet culture, and one whose ramifications make many denizens of the Web highly uncomfortable.

For many of its pioneers, loyalists and self-professed deep thinkers, the Internet was conceived as a digital demi-paradise, a zone of total freedom and democracy. But when it comes to specifics things get a bit dicey. Paradise for whom, exactly, and what do we mean by democracy? In one enduringly popular version of this fantasy, the Internet is the ultimate libertarian free market, a zone of perfect entrepreneurial capitalism untrammeled by any government, any regulation or any taxation. As a teenage programming prodigy with an unusually deep understanding of the Internet’s underlying architecture, Swartz certainly participated in the private-sector, junior-millionaire version of the Internet. He founded his first software company following his freshman year at Stanford, and became a partner in the development of Reddit in 2006, which was sold to Condé Nast later that year.

That libertarian vision of the Internet – and of society too, for that matter – rests on an unacknowledged contradiction, in that some form of state power or authority is presumably required to enforce private property rights, including copyrights, patents and other forms of intellectual property. Indeed, this is one of the principal contradictions embedded within our current form of capitalism, as the Marxist scholar David Harvey notes: Those who claim to venerate private property above all else actually depend on an increasingly militarized and autocratic state. And from the beginning of Swartz’s career he also partook of the alternate vision of the Internet, the one with a more anarchistic or anarcho-socialist character. When he was 15 years old he participated in the launch of Creative Commons, the immensely important content-sharing nonprofit, and at age 17 he helped design Markdown, an open-source, newbie-friendly markup format that remains in widespread use.

One can certainly construct an argument that these ideas about the character of the Internet are not fundamentally incompatible, and may coexist peaceably enough. In the physical world we have public parks and privately owned supermarkets, and we all understand that different rules (backed of course by militarized state power) govern our conduct in each space. But there is still an ideological contest between the two, and the logic of the private sector has increasingly invaded the public sphere and undermined the ancient notion of the public commons. (Former New York Mayor Rudy Giuliani once proposed that city parks should charge admission fees.) As an adult Aaron Swartz took sides in this contest, moving away from the libertarian Silicon Valley model of the Internet and toward a more radical and social conception of the meaning of freedom and equality in the digital age. It seems possible and even likely that the Guerilla Open Access Manifesto Swartz wrote in 2008, at age 21, led directly to his exaggerated federal prosecution for what was by any standard a minor hacking offense.

Swartz’s manifesto didn’t just call for the widespread illegal downloading and sharing of copyrighted scientific and academic material, which was already a dangerous idea. It explained why. Much of the academic research held under lock and key by large institutional publishers like Reed Elsevier had been largely funded at public expense, but was now being treated as private property – and as Swartz understood, that was just one example of a massive ideological victory for corporate interests that had penetrated almost every aspect of society. The actual data theft for which Swartz was prosecuted, the download of a large volume of journal articles from the academic database called JSTOR, was largely symbolic and arguably almost pointless. (As a Harvard graduate student at the time, Swartz was entitled to read anything on JSTOR.)

But the symbolism was important: Swartz posed a direct challenge to the private-sector creep that has eaten away at any notion of the public commons or the public good, whether in the digital or physical worlds, and he also sought to expose the fact that in our age state power is primarily the proxy or servant of corporate power. He had already embarrassed the government twice previously. In 2006, he downloaded and released the entire bibliographic dataset of the Library of Congress, a public document for which the library had charged an access fee. In 2008, he downloaded and released about 2.7 million federal court documents stored in the government database called PACER, which charged 8 cents a page for public records that by definition had no copyright. In both cases, law enforcement ultimately concluded Swartz had committed no crime: Dispensing public information to the public turns out to be legal, even if the government would rather you didn’t. The JSTOR case was different, and the government saw its chance (one could argue) to punish him at last.

Knappenberger could only have made this film with the cooperation of Swartz’s family, which was dealing with a devastating recent loss. In that context, it’s more than understandable that he does not inquire into the circumstances of Swartz’s suicide in “Inside Edition”-level detail. It’s impossible to know anything about Swartz’s mental condition from the outside – for example, whether he suffered from undiagnosed depressive illness – but it seems clear that he grew increasingly disheartened over the government’s insistence that he serve prison time as part of any potential plea bargain. Such an outcome would have left him a convicted felon and, he believed, would have doomed his political aspirations; one can speculate that was the point. Carmen Ortiz, the U.S. attorney for Boston, along with her deputy Stephen Heymann, did more than throw the book at Swartz. They pretty much had to write it first, concocting an imaginative list of 13 felony indictments that carried a potential total of 50 years in federal prison.

As Knappenberger explained in a Q&A session at Sundance, that’s the correct context in which to understand Robert Swartz’s public remark that the government had killed his son. He didn’t mean that Aaron had actually been assassinated by the CIA, but rather that he was a fragile young man who had been targeted as an enemy of the state, held up as a public whipping boy, and hounded into severe psychological distress. Of course that cannot entirely explain what happened; Ortiz and Heymann, along with whoever above them in the Justice Department signed off on their display of prosecutorial energy, had no reason to expect that Swartz would kill himself. There’s more than enough pain and blame to go around, and purely on a human level it’s difficult to imagine what agony Swartz’s family and friends have put themselves through.

One of the most painful moments in “The Internet’s Own Boy” arrives when Quinn Norton, Swartz’s ex-girlfriend, struggles to explain how and why she wound up accepting immunity from prosecution in exchange for information about her former lover. Norton’s role in the sequence of events that led to Swartz hanging himself in his Brooklyn apartment 18 months ago has been much discussed by those who have followed this tragic story. I think the first thing to say is that Norton has been very forthright in talking about what happened, and clearly feels torn up about it.

Norton was a single mom living on a freelance writer’s income, who had been threatened with an indictment that could have cost her both her child and her livelihood. When prosecutors offered her an immunity deal, her lawyer insisted she should take it. For his part, Swartz’s attorney says he doesn’t think Norton told the feds anything that made Swartz’s legal predicament worse, but she herself does not agree. It was apparently Norton who told the government that Swartz had written the 2008 manifesto, which had spread far and wide in hacktivist circles. Not only did the manifesto explain why Swartz had wanted to download hundreds of thousands of copyrighted journal articles on JSTOR, it suggested what he wanted to do with them and framed it as an act of resistance to the private-property knowledge industry.

Amid her grief and guilt, Norton also expresses an even more appropriate emotion: the rage of wondering how in hell we got here. How did we wind up with a country where an activist is prosecuted like a major criminal for downloading articles from a database for noncommercial purposes, while no one goes to prison for the immense financial fraud of 2008 that bankrupted millions? As a person who has made a living as an Internet “content provider” for almost 20 years, I’m well aware that we can’t simply do away with the concept of copyright or intellectual property. I never download pirated movies, not because I care so much about the bottom line at Sony or Warner Bros., but because it just doesn’t feel right, and because you can never be sure who’s getting hurt. We’re not going to settle the debate about intellectual property rights in the digital age in a movie review, but we can say this: Aaron Swartz had chosen his targets carefully, and so did the government when it fixed its sights on him. (In fact, JSTOR suffered no financial loss, and urged the feds to drop the charges. They refused.)

A clean and straightforward work of advocacy cinema, blending archival footage and contemporary talking-head interviews, Knappenberger’s film makes clear that Swartz was always interested in the social and political consequences of technology. By the time he reached adulthood he began to see political power, in effect, as another system of control that could be hacked, subverted and turned to unintended purposes. In the late 2000s, Swartz moved rapidly through a variety of politically minded ventures, including a good-government site and several different progressive advocacy groups. He didn’t live long enough to learn about Edward Snowden or the NSA spy campaigns he exposed, but Swartz frequently spoke out against the hidden and dangerous nature of the security state, and played a key role in the 2011-12 campaign to defeat the Stop Online Piracy Act (SOPA), a far-reaching government-oversight bill that began with wide bipartisan support and appeared certain to sail through Congress. That campaign, and the Internet-wide protest of American Censorship Day in November 2011, looks in retrospect like the digital world’s political coming of age.

Earlier that year, Swartz had been arrested by MIT campus police, after they noticed that someone had plugged a laptop into a network switch in a server closet. He was clearly violating some campus rules and likely trespassing, but as the New York Times observed at the time, the arrest and subsequent indictment seemed to defy logic: Could downloading articles that he was legally entitled to read really be considered hacking? Wasn’t this the digital equivalent of ordering 250 pancakes at an all-you-can-eat breakfast? The whole incident seemed like a momentary blip in Swartz’s blossoming career – a terms-of-service violation that might result in academic censure, or at worst a misdemeanor conviction.

Instead, for reasons that have never been clear, Ortiz and Heymann insisted on a plea deal that would have sent Swartz to prison for six months, an unusually onerous sentence for an offense with no definable victim and no financial motive. Was he specifically singled out as a political scapegoat by Eric Holder or someone else in the Justice Department? Or was he simply bulldozed by a prosecutorial bureaucracy eager to justify its own existence? We will almost certainly never know for sure, but as numerous people in “The Internet’s Own Boy” observe, the former scenario cannot be dismissed easily. Young computer geniuses who embrace the logic of private property and corporate power, who launch start-ups and seek to join the 1 percent before they’re 25, are the heroes of our culture. Those who use technology to empower the public commons and to challenge the intertwined forces of corporate greed and state corruption, however, are the enemies of progress and must be crushed.


”The Internet’s Own Boy” opens this week in Atlanta, Boston, Chicago, Cleveland, Denver, Los Angeles, Miami, New York, Toronto, Washington and Columbus, Ohio. It opens June 30 in Vancouver, Canada; July 4 in Phoenix, San Francisco and San Jose, Calif.; and July 11 in Seattle, with other cities to follow. It’s also available on-demand from Amazon, Google Play, iTunes, Vimeo, Vudu and other providers.

* * * * *

Luckily for us (especially those of us in a town too small to get a showing of this film, or who can't afford to pay per view), there is an open access version of the film available online.

The Internet’s Own Boy: New Documentary About Aaron Swartz Now Free Online

Open Culture | June 29th, 2014

On BoingBoing today, Cory Doctorow writes: “The Creative Commons-licensed version of The Internet’s Own Boy, Brian Knappenberger’s documentary about Aaron Swartz, is now available on the Internet Archive, which is especially useful for people outside of the US, who aren’t able to pay to see it online…. The Internet Archive makes the movie available to download or stream, in MPEG 4 and Ogg. There’s also a torrentable version.”

According to the film summary, the new documentary “depicts the life of American computer programmer, writer, political organizer and Internet activist Aaron Swartz. It features interviews with his family and friends as well as the internet luminaries who worked with him. The film tells his story up to his eventual suicide after a legal battle, and explores the questions of access to information and civil liberties that drove his work.”

The Internet’s Own Boy will be added to our collection, 200 Free Documentaries Online, part of our larger collection, 675 Free Movies Online: Great Classics, Indies, Noir, Westerns, etc..

One of the most difficult things about being a therapist, especially working with a high acuity sexual trauma survivor population, is the likelihood and frequency of suicide attempts among a certain subset of this population.

I was still an intern, only a few months into my on-the-job training, when I first had to experience a client's choice to die. I had only seen him in person a couple of times, and spoken with him by phone a handful of times, but when I was notified it felt as though I had been punched in the stomach. I liked him, and I felt that I understood him, so despite his history and his situation, I was hopeful for a significant increase in his functioning and quality of life. Other circumstances intervened and I never had a chance to see what was possible for him.

Since then I have had many clients attempt suicide, and a couple nearly succeed, and I have learned to distinguish between wanting to die and not wanting to live. I have learned that my ability to prevent such a choice is limited at best. Still, each time it happens I feel sad that a person's life, a person whose fate I have come to care about, felt to desperate and hopeless that death seemed the best option. I feel sad because I have been in that place . . . and was able to talk myself out of it.

Because I know what that hopelessness feels like, I am accepting of the client, compassionate with the pain that led them to that choice. Even while the client often feels guilty or ashamed for making the attempt (or for failing), I try (gently) to move the client to a perspective from which s/he can feel compassion for the part of them that wanted to die, and if possible, to be curious about that part of themselves - to befriend it rather than fear it.

How therapists respond to a client's suicide attempt is the subject of the open access paper presented below. This is an important topic because how clinicians respond to clients has a lot to do with the effectiveness (or not) of the therapy.

Full Citation:
Yaseen, ZS, Briggs, J, Kopeykina, I, Orchard, KM, Silberlicht, J, Bhingradia, H, and Galynker, II. (2013, Sep 22). Distinctive emotional responses of clinicians to suicide-attempting patients - a comparative study. BMC Psychiatry, 13:230.
doi: 10.1186/1471-244X-13-230

Distinctive emotional responses of clinicians to suicide-attempting patients - a comparative study

Zimri S Yaseen, Jessica Briggs, Irina Kopeykina, Kali M Orchard, Jessica Silberlicht, Hetal Bhingradia, and Igor I Galynker - Author Affiliations

Abstract

Background

Clinician responses to patients have been recognized as an important factor in treatment outcome. Clinician responses to suicidal patients have received little attention in the literature however, and no quantitative studies have been published. Further, although patients with high versus low lethality suicidal behaviors have been speculated to represent two distinct populations, clinicians’ emotional responses to them have not been examined.

Methods

Clinicians’ responses to their patients when last seeing them prior to patients’ suicide attempt or death were assessed retrospectively with the Therapist Response/Countertransference Questionnaire, administered anonymously via an Internet survey service. Scores on individual items and subscale scores were compared between groups, and linear discriminant analysis was applied to determine the combination of items that best discriminated between groups.

Results

Clinicians reported on patients who completed suicide, made high-lethality attempts, low-lethality attempts, or died unexpected non-suicidal deaths in a total of 82 cases. We found that clinicians treating imminently suicidal patients had less positive feelings towards these patients than for non-suicidal patients, but had higher hopes for their treatment, while finding themselves notably more overwhelmed, distressed by, and to some degree avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/avoidance was a significant discriminator between suicidal patients and those who died unexpected non-suicidal deaths with 90% sensitivity and 56% specificity. In addition, we identified one questionnaire item that discriminated significantly between high- and low-lethality suicide patients.

Conclusions

Clinicians’ emotional responses to patients at risk versus not at risk for imminent suicide attempt may be distinct in ways consistent with responses theorized by Maltsberger and Buie in 1974. Prospective replication is needed to confirm these results, however. Our findings demonstrate the feasibility of using quantitative self-report methodologies for investigation of the relationship between clinicians’ emotional responses to suicidal patients and suicide risk. 

Background

When treating patients at risk for suicide, clinicians often struggle to identify signs, symptoms, or precipitating events that might afford opportunities for them to intervene. Clinically, we remain largely unable to accurately distinguish between patients who will attempt or die by suicide and patients who will not [1,2]. Clinicians’ emotional responses to patients (broadly speaking, their countertransference) have long and increasingly been recognized as an important factor in treatment outcome [3,4], however they have received relatively little attention in the literature on suicidal patients. Rather, current research on acute suicide prediction has focused largely on warning signs that are patient-dependent, such as precipitating events [5-9], behavior changes [10,11], or intense affective states [12-19]. Yet, even though they are easily identified retrospectively, such findings may be difficult to utilize clinically; these markers may be masked and/or minimized by the patient, or misattributed/misinterpreted by the therapist [20-22], and in some cases overzealous efforts at intervention, such as those that prematurely push an unready patient towards independence, even appear to precipitate patient suicide [5].

A potential factor contributing to these difficulties, beyond the general difficulty of predicting human behavior, and external constraints of the current mental health care system (e.g. [23]), may lie in clinicians’ own emotional responses to the suicidal patient. While clinical judgment is ultimately a conscious process, the suicidal patient elicits powerful responses that may not become directly conscious [4,24]. Indeed, neuroimaging studies suggest activation of brain regions primarily involved in unconscious processing during emotional as compared to cognitive empathy tasks [25]. Without (and even with [26]) tremendous experience, unaided conscious integration of unconscious emotional responses is likely to fail. A systematic assessment of these responses, however, has the potential to ameliorate the inherent distortions of the clinician’s judgment without discarding the data inherent in his or her interpersonal experience with the patient.

Clinician-focused research supports distinctive patterns of reaction to various patient types [27-29], and there is a relatively large body of literature examining clinicians’ reactions following patient suicide (e.g., [22,30-32]) and unexpected death [33] which observe prominent reactions of grief and mourning on the one hand [30], and guilt and anger on the other [32,34]. Similarly, clinicians confronted with patients’ desire for death in studies of physician assisted suicide (also only qualitative), elicited anxious, helpless, and overwhelmed responses most prominently [35]. Clinicians’ emotional responses to suicidal patients have not been the subject of many research studies. Since Maltsberger and Buie’s seminal 1974 paper [24], which elaborated an array of emotional experiences and behaviors rooted in different defense responses to negative countertransference towards the suicidal patient, only a few empirical studies have been conducted. These retrospective clinical studies have focused almost exclusively on countertransference hate and/or negative countertransference in general, finding feelings of anxiety and hostility as those most prominently elicited by suicidal patients [34,36]. The studies share a common conclusion that emotional responses must be recognized and acknowledged, and present evidence that the management of the clinicians’ emotional response is correlated with therapeutic outcome [3,22,37]. Quantifying clinicians’ emotional responses may thus potentially enhance suicide risk assessment.

The present preliminary study, though conducted retrospectively, assessed clinicians’ reported emotional responses toward their patients in the encounter preceding their suicide attempt, completed suicide, or unexpected (non-suicide) death, with a focus on quantifying differences in the patterns of clinician response to patients with differing levels or types of suicidality. The goal was to identify potential significant differences in clinicians’ emotional responses to the patients that were at imminent risk for suicidal behavior, compared with those who were not. Ultimately, a thorough understanding of characteristic emotional responses to imminently suicidal patients might allow clinicians to better recognize those responses to their patients that might interfere with taking appropriate measures to prevent imminent suicidal actions, or that in themselves may serve as warning signs of imminent suicidality.
 

Methods

An anonymous web-based survey (implemented through the surveymonkey.com website) was distributed to psychiatrists, psychologists, and social workers at the Beth Israel Medical Center in New York City via a department-wide email message requesting participation including the link to the anonymous survey. Participation occurred on a voluntary basis and participants had the ability to discontinue at any time. Participants were informed of the nature of the study in the email message inviting them to complete the survey. The study was approved by the Beth Israel Medical Center Institutional Review Board.

The survey consisted of the Therapist Response/Countertransference Questionnaire (CQ) – a 79-item self-report measure designed for clinicians which provides a validated instrument for assessing countertransference patterns in the psychotherapeutic setting [29], as well as questions regarding the demographic and clinical characteristics of the clinicians and the patients they reported on. The CQ has eight defined subscales (found to be independent of clinicians’ theoretical orientation): overwhelmed-disorganized (coefficient alpha = 0.90) “marked by items indicating a desire to avoid or flee the patient and strong negative feelings, including dread, repulsion, and resentment”, helpless-inadequate (coefficient alpha = 0.88), “describing feelings of inadequacy, incompetence, hopelessness, and anxiety”, positive (coefficient alpha = 0.86), “indicating the experience of a positive working alliance and close connection with the patient”, special-over-involved (coefficient alpha = 0.75), “describing a sense of the patient as special, relative to other patients, and … ‘soft signs’ of problems in maintaining boundaries”, sexualized (coefficient alpha = 0.77), “describing sexual feelings toward the patient or … sexual tension”, disengaged (coefficient alpha = 0.83), “describing feeling distracted, withdrawn, annoyed, or bored”, parental-protective (coefficient alpha = 0.80), “describing a wish to protect and nurture the patient in a parental way… beyond normal positive feelings”, and criticized-mistreated (coefficient alpha = 0.83), “describing feelings of being unappreciated, dismissed, or devalued” [29]. The CQ was used to assess countertransference in clinicians across four different patient categories: suicide completers, high-lethality suicide attempters (as indicated by clinical judgment and/or necessity for hospitalization), low-lethality suicide attempters (as indicated by clinical judgment), and patients who suffered sudden (unexpected) non-suicide death. The order of patient category presentation was randomized for each respondent. In each patient category the clinicians were prompted to fill out the questionnaire based on their experiences in regard to “the patient you remember best” in the last session preceding their suicide attempt or death. This prompt was chosen to elicit what, in the absence of prospective data, should be the most reliable. [38] If a clinician reported having treated a patient in more than one category, a separate CQ was filled out for each patient category individually. Clinicians were instructed to rate each item on the questionnaire as 1, 3, or 5, based on the extent to which it was true in their work with the patient in question; 1 = not true at all, 3 = somewhat true, and 5 = very true.
 
Statistical analysis

Two group comparisons were performed: 1) any suicidal behavior versus unexpected deaths (SA vs. UD), and 2) high lethality and completed suicide attempts versus low lethality attempts (HL vs. LL). The first comparison was chosen to address the primary aim of the study, identification and quantification of any distinctive clinician response to patients presenting with imminent suicidality. The second comparison addresses a secondary question – ‘are there clinician responses distinctive of high lethality attempters versus low-lethality ones?’ in light of extensive literature suggesting clinical and biological differences between these groups [39]. High lethality attempts and completed suicides were combined as completed suicides result, by definition, from highly lethal attempts.

Unpaired two-tailed t-tests were used to compare group means on each of the eight defined CQ subscales. To assess clinician effects, these group comparisons were repeated restricted to the subsets of clinicians who reported on patients in both groups in each comparison. In the repeated analysis means were compared pair-wise by clinician using paired two-tailed t-tests. We report both conservative estimates of significance, using Bonferroni correction of criterion alphas, and uncorrected estimates, as the Bonferroni correction has been considered inappropriately stringent for medical research, biasing results towards type II error, and thus potentially obscuring useful findings [40].

To identify an effective subscale of items that might best discriminate between suicide attempters and non-attempters, and high versus low lethality attempters, stepwise linear discriminant analyses were used with a threshold p = 0.05 for variable inclusion and p = 0.10 for exclusion in the linear discriminant analysis. In the analysis, cases with no missing values for any scale item were used. Leave-one-out cross-validation of the discriminant function provided a measure of the difference between groups in their responses on the CQ that is robust to over-fitting of the data (and thus false positive findings). All of the above analyses were carried out using the SPSS software package.

In secondary analysis, to account for possible chronic differences in level of suicidal capacity [41] between patients who attempt suicide and those who do not, findings from the above analyses were stratified by presence or absence of a past history of suicide attempt, as a control for the effect of past history of suicidality.

Post hoc power analyses indicate that for the achieved sample sizes the study had 80-95% power to detect moderate to large effects (Cohen’s d = 0.63-0.84) for the “High versus Low Lethality (HL vs. LL)” comparisons of means, and large effects (Cohen’s d = 0.70-0.92) for the “Any Suicidality versus Unexpected Death (SA vs. UD)” comparisons of means at the p < 0.05 probability level. Given the necessarily high level of interpersonal variability in clinicians’ emotional reactions to patients, large effects are those of greatest clinical interest.
 

Results

Sample characteristics

Two hundred clinicians received the invitation email with the survey link. 83 (42%) clinicians began the web-based survey, and 40 (20% of those approached, 48.2% of those responding) provided CQ reports on a total of 82 patients. The clinicians assessed in the study showed a near equal split between males and females, and held a variety of higher-level degrees; though the most common by far was an MD (50%). A small majority of the clinicians assessed had been in practice for less than five years or more than twenty; those who had been practicing for between five and twenty years were slightly less likely to complete the questionnaire (See Table 1).

Table 1. Clinician demographics

Of 82 reports assessed, 16 were regarding patients that died unexpectedly, 26 were on patients who made low lethality suicide attempts, 28 were on patients that made high lethality suicide attempts, and 12 were on suicide completers. Patients who made suicide attempts (of any lethality level) were generally younger than those who completed suicide or died unexpectedly (independent groups t-test 2-tailed p = 0.01). Those who made low lethality suicide attempts were predominantly female (76%), while those in the other three groups were closer to evenly split along gender lines (chi square p = 0.04). In all four groups, the patients assessed were predominantly white (no significant differences using chi square statistics). Finally, the groups of patients who attempted suicide had more members with a history of past suicide attempt than members without such a history. Conversely, more of the patients who died unexpectedly did not have a history of suicide attempt, and the patients who completed suicide were evenly split. These group differences were not statistically significant (using chi square statistics) however (See Table 2).

Table 2. Patient demographics

Group contrasts -- SA vs. UD

For the SA vs. UD group comparison of the mean scores on each of the eight defined subscales of the Therapist Response/Countertransference Questionnaire, one subscale differed significantly and one approached significance. Mean scores were 5.95 points (p = 0.005, criterion alpha corrected for 8 comparisons = 0.0063) higher on the “Overwhelmed/Disorganized” subscale, and 2.54 points (p = 0.054) higher on the “Hostile/Mistreated” subscales for the SA group. No differences approached significance on the other subscales. Thirteen clinicians reported on both SA and UD patients. T-test comparison of SA versus UD means for each subscale paired by clinician replicated the overall results with mean difference 7.00 points (p = 0.023) on the “Overwhelmed/Disorganized” subscale and 2.77 points (p = 0.056) on the “Hostile/Mistreated” subscale, and no differences approaching significance (p < 0.1) on the other subscales.

Eight individual questionnaire items differed significantly (using uncorrected criterion alpha = 0.05) between the SA and UD groups. The strongest effects were found for positive (in the sense of affiliative or approach-promoting) therapist response items, which, though generally rated highly, had significantly lower ratings for suicidal patients. Likewise, negative (in the sense of aggression or withdrawal-promoting) therapist response items were rated more highly for suicidal patients than for non-attempters, though in both cases the means fell between “somewhat” and “not at all”. For suicidal patients, mean score on the item “I liked him/her very much” was higher than that for any other item differing significantly from non-attempters. Self-report of sexualized therapist response was very low for all groups of patients; it was lower for patients that attempted or completed suicide than for non-attempters, however this difference may be driven by outliers in light of the small variances in the samples. No items differed with p-value less than criterion alpha corrected for 79 comparisons (alpha = 0.0006) (See Table 3).

Table 3. CQ items differing most strongly for SA vs. UD comparison

When analysis was stratified by history of past suicide attempts we found that of these eight items, among patients with no past history of suicide attempt, the differences remained statistically significant for all but two items: “24. I felt guilty about my feelings toward him/her” and item “5. I returned his/her phone calls less promptly than I did with my other patients”. Among patients with a past history of suicide attempt, no difference in means was statistically significant. This analysis was limited by the small number (4 patients) of patients in the UD group with a history of past suicide attempt(s).

Stepwise linear discriminant analysis for the SA vs. UD group comparison produced a discriminant function derived from scores on five items: “1. I am very hopeful about the gains s/he is making or will likely make in treatment”, canonical discriminant function coefficient 0.498, SA > UD, “23. S/he makes me feel good about myself”, coefficient −0.939, SA < UD, “52. I feel hopeless working with him/her”, coefficient −0.672, SA < UD, “70. I return his/her phone calls less promptly than I do with my other patients”, coefficient 0.629, SA > UD, and “79. I talk about him/her with my spouse or significant other more than my other patients”, coefficient 0.563, SA > UD. The discriminant function thus describes a combination of greater avowed hopefulness combined with more negative feelings about self, avoidance of the patient, and comfort seeking behavior by the clinician in treating suicidal patients. This discriminant function classified SA vs. UD patients with an 87.8% cross-validated correct classification rate (Chi-squared = 23.58, p < 0.0001), with 90% sensitivity and 56% specificity for suicidal patients (See Table 4).

Table 4. Discriminant analysis classification table: UD vs. SA

T-test comparison of SA versus UD means for discriminant function score, paired by clinician, replicated the overall results with a highly significant mean difference 1.77 points (p = 0.0003).

Further, when this analysis was stratified by history of SA, the discrimination was significant both when history of SA was present and when it was not. When history of SA was present, the cross-validated correct classification rate was 97.1% (Chi-squared = 21.71, p = 0.001), with sensitivity of 100% and specificity of 66.7% for suicidal patients. When history of SA was not present, the cross-validated correct classification rate was 78.8% (Chi-squared = 12.76, p = 0.026), with sensitivity of 84.0% and specificity of 62.5% for suicidal patients.
 
Group contrasts -- HL vs. LL

In the HL vs. LL group comparison of the mean scores on each of the eight defined subscales of the Therapist Response/Countertransference Questionnaire, no significant differences were found. The greatest difference in means was found for the “Positive/Satisfying” response scale, which was 2.6 points higher for the HL group (p = 0.18).

In clinician-wise paired t-tests on matched cases from 17 clinicians reporting on both HL and LL patients no significant differences were found. The greatest mean difference was found for the “Parental/Protective” subscale which averaged 3.1 points higher for the HL group (p = 0.07).

Comparison of the mean scores on each item of the Therapist Response/Countertransference Questionnaire found one item – “49. I felt sad in sessions with him/her” that differed with p < 0.05 between HL and LL groups (means 2.69 and 1.82, respectively; p = .024). In clinician-wise paired t-test means for this item were 2.82 and 1.94 respectively, p = 0.039. When analysis was stratified by history of past suicide attempts, we found that the mean score on item “49”differed significantly between HL and LL groups only for patients who had a past history of SA (means 3.00 and 1.43, respectively; p = .001). No items differed significantly after Bonferroni correction for 79 comparisons.

Four CQ items describing depression, guilt and helplessness had strong correlations (r > 0.5) with this item: “18. I feel depressed in sessions with him/her” (r = 0.665), “28. I feel guilty when s/he is distressed or deteriorates, as if I must be somehow responsible” (r = 0.575), “24. I feel guilty about my feelings toward him/her” (r = 0.528), and “26. I feel overwhelmed by his/her strong emotions” (r = 0.508). Group means for these items did not differ between groups at the 0.05 significance level, however, and they were thus excluded from the discriminant analysis.

Stepwise linear discriminant analysis for the HL vs. LL group comparison thus produced a discriminant function derived from scores on the single item – “49. I felt sad in sessions with him/her” – that classified high lethality suicidal behavior (high lethality attempts and completed suicides) versus low lethality suicide attempts with modest but statistically significant power. The cross-validated correct classification rate was 66.7% (Chi-squared = 5.19, p = 0.023), with sensitivity of 70% and specificity of 61.5% for high lethality and completed suicide. Application of the discriminant function to patients with unexpected non-suicide death resulted in random assignment of predicted group membership (50% predicted to each group) (See Table 5).

Table 5. Discriminant analysis classification table: HL vs. LL

When this analysis was stratified by history of SA, the discrimination was significant only when a past history of SA was present. Among patients with a past history of suicide attempts, the cross-validated correct classification rate was improved to 76.5% (Chi-squared = 10.86, p = 0.001), with sensitivity of 75% and specificity of 78.6% for high lethality and completed suicide.
 

Discussion

To the best of our knowledge, this is the first published study to provide a quantitative comparison of clinician responses to acutely suicidal patients versus non-attempters and to patients who made high lethality versus low-lethality suicide attempts.

Such investigation is important, as problems in the management of countertransference (or emotional reactions in general) to patients may hamper treatment efficacy and even contribute to patient suicide in a small but significant proportion of cases [5,36]. To date though, the literature has focused almost entirely on the development of qualitative treatments of the subject. A thorough literature search using the PsycINFO database resulted in our conclusion that there are no analogous studies in the literature. (Searches conducted using varied combinations of terms including “countertransference”, “suicide”, “therapist response”, “clinician response”, “predict”, “prevention”, “comparison”, and “quantitative” identified no peer-reviewed publications reporting on quantitative comparisons of clinician responses to suicidal versus non-suicidal patients or of patients with differing levels of suicidality). The only quantitative comparative work we have been able to find on the subject has been a small series of unpublished dissertations, which found no significant differences in negative therapist responses to suicidal versus “difficult” non-suicidal patients [42]. While rich qualitative data are an essential starting point, this preliminary study aimed to pilot a much-needed quantitative and comparative approach using a validated instrument and easily replicable quantitative methodology.

This study found that clinicians treating imminently suicidal patients recalled, on average, moderately positive feelings towards these patients (though less so than for non-attempters), with higher hopes for treatment, while finding themselves more overwhelmed, distressed by, and, at low levels, avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/avoidance was a significant discriminator between suicidal patients and those who had unexpected non-suicide deaths, and cross-validated classification by discriminant analysis remained statistically significant both when a past history of suicide attempt was present and when it was not. This finding of ‘paradoxical response’ is consistent with the higher scores observed on the “overwhelmed-disorganized” subscale of the CQ in clinician recollections of their encounters with suicide attempters.

In our second comparison, we found no clear evidence of differences between clinicians’ responses in encounters with patients preceding either completed suicides or highly lethal suicide attempts and their responses in encounters preceding low lethality suicide attempts. Despite a trend towards a slightly more positive emotional responses overall, clinicians also recalled experiencing more sadness in encounters with patients preceding either successful or highly lethal suicide attempts than in encounters preceding low lethality suicide attempts. This difference in recalled sadness was found to be a modest discriminator between patients that went on to exhibit high and low lethality suicidal behavior. It is worth noting, however, that this difference appears attributable specifically to recalled responses to patients with a history of previous attempts; among these patients sadness in session was a significant discriminator of attempt lethality while among first-time attempters clinicians’ experience of sadness in the session prior to suicide attempt did not differentiate between lethality levels. This finding has not been supported or opposed in the literature, as the difference in emotional response to high and low lethality suicide attempters has not previously been explored. Further, interpretation is limited by significant risk of type-1 error given the small n’s and multiple comparisons involved.

Thus our findings, while grossly consistent with the qualitative literature findings of negative responses to suicidal patients [34,36], differed in the important respect that the levels of recalled negative reactions to patients prior to their suicide attempts were, on average, fairly low, and even when significant, the magnitude of the differences in positive and negative responses elicited by suicidal versus non-suicidal patients was small. Maltsberger and Buie [24] were the first to describe in detail the negative countertransference (“countertransference hate”) that clinicians may experience in response to suicidal patients, and provided a theoretical framework which might account for our quantitative findings. First, as noted, we found that clinicians recalled fairly low levels of negative feelings towards their suicidal patients, though positive response was attenuated compared to non-attempters. This finding may be consistent with their predictions of repression of “countertransference hate”. On the other hand, our findings of distress and self-directed negative feelings combined with paradoxical hopefulness may be consistent with their predictions of turning of the countertransferential hate against the self and of reaction-formation against it, respectively. Indeed, our findings seem to suggest that the defense mechanisms described by Maltsberger and Buie may operate in concert.

Our findings point to the potential clinical utility of self-assessment of emotional response in the treatment of suicidal patients. This is a matter of some importance as both Modestin [36] and Marcinko et al., [22] have used observational evidence to support the theory that emotional responses to suicidal patients that are not properly managed can have harmful consequences. The latter group concluded that negative emotional response probably contributes to or correlates with negative patient outcomes [22], while Modestin, further indicates how the failure to control these reactions (hostility, hate, and aggressiveness in particular) may in some cases help push patients to suicide [36].

We should note, however, that while both emotional responses and judgments of suicide risk reside in the clinician, they are not the same. Indeed clinical judgment has been found to be a poor predictor of critical patient behavior such as suicide [1] and violence [43]. While clinical judgment is ultimately a conscious process, emotional responses may not become directly conscious [4,24]. Thus systematic assessment of these responses, even in using self-report measures may reveal patterns generated by the clinician’s unconscious processes such as the “paradoxical hopefulness” identified using discriminant analysis. Quantitative self-report assessment may thus reveal data inherent in the clinician’s interpersonal experience with the patient that could potentially augment suicide-risk assessment.

Limitations

The results of this preliminary study must be considered in light of several important limitations. Most prominently the study is subject to several kinds of recall bias.

First, many clinicians that have experienced a patient’s death by suicide report severe distress [32] and/or feelings of grief and self-doubt [31] stemming from treatment decisions that seem, in retrospect, to have been based on inaccurate assessments of the patient’s acute risk. Differences between such responses to patients’ suicide deaths, attempts of different severity, and unexpected non-suicide deaths have not been studied and are poorly understood [33]. It is possible that the differences in recalled reaction to patients in the encounters preceding such events are attributable to their recollection being colored differently by those very events. Furthermore, individual items in the CQ might be differently subject to such effects thereby increasing or decreasing their apparent discriminatory power in our results.

Second, clinicians’ recollection of their responses to their patients in the encounters immediately preceding such events are almost certainly significantly combined with the rest of their preceding experience with those patients. Thus our findings cannot be interpreted as necessarily indicative of a “pre-suicidal” countertransference or emotional response.

Third, we are unable to control for the possible effects of clinicians’ reporting on their best-remembered patient of each type. Additionally, we were not able to control for the effects on recall of time elapsed since the events.

Fourth, as we were unable to obtain responses on each category of patient from most clinicians, it is possible that clinicians responding on suicidal patients we more likely to treat suicidal patients and thus represented a distinct group from those responding regarding non-suicidal patients only. Thus it is conceivable that differences in response are attributable to clinician differences rather than patient ones. However, the consistency between aggregate group findings and the within-clinician findings, for those clinicians who reported on patients belonging to different comparison groups, makes such an interpretation less likely.

Further, because the survey was distributed only within one institution, and was completed voluntarily, we cannot say that it accurately represents all clinicians who have experienced a patients’ completed suicide, attempt, or unexpected death.

Finally, limitations of sample size did not allow for reliable analysis of potential mediators and moderators of differences in therapist responses to patients of different types. Nonetheless it should be noted that no statistically significant differences in the rates of any diagnostic or demographic characteristics were observed between groups.

In sum, our findings must be viewed as preliminary results that justify further research. In order to more definitively verify our conclusions, the study will need to be repeated with a wider, larger sample. Additionally, prospective replication is necessary to confirm the findings.
 

Conclusions

We find preliminary quantitative evidence consistent with Maltsberger and Buie’s theory of countertransference hate in the treatment of suicidal patients. Though our study does not speak to the ability of the differences in response to influence or predict a patient’s outcome, it is the first to quantify the differences in clinicians’ emotional responses to suicidal patients versus non-attempter patients. Our findings thus provide a starting point for further research that may change the way that clinicians assess their suicidal patients’ acute risk, and may justify further research on the use of the CQ or other conceptually similar scales as predictors of suicide risk.
 
Competing interests

The authors declare that they have no competing interests.
 
Authors’ contributions
IK, KMO, JS, HB & IIG participated in the design of the experiment. IK and IIG collected the data. ZSY designed and performed the data analysis. JB and IK prepared the data. ZSY, JB, and IIG participated in the writing of the manuscript. All authors read and approved the final manuscript.
 
Authors’ information
 
Jessica Briggs is co-first author.
 
Acknowledgements
The authors would like to thank the reviewers, Dr. Philip Batterham and Dr. Evan Kleiman for their very helpful editorial input.

References available at the BMC Psychiatry

Hacker, Open Commons Activist Aaron Swartz Commits Suicide

Sad that this has happened - he was only 26. Aaron Swartz was facing the possibility of dozens of years in prison for allegedly trying to share MIT academic journal articles on P2P file sharing sites. Over at ZDNet, Violet Blue provides the full story.

The charges were based on Swartz's sharing of four million academic articles from MIT, downloaded from the JSTOR site. Sadly, Swartz's suicide came two days after JSTOR announced it is releasing "more than 4.5 million articles" to the public.

Wired argued that many of the charges against Swartz were alleged Terms of Service violations. Their article strongly implies that the Department of Justice sought to make an example of Swartz:

The case tests the reach of the Computer Fraud and Abuse Act, which was passed in 1984 to enhance the government’s ability to prosecute hackers who accessed computers to steal information or to disrupt or destroy computer functionality. 

The government, however, has interpreted the anti-hacking provisions to include activities such as violating a website’s terms of service or a company’s computer usage policy, a position a federal appeals court in April said means “millions of unsuspecting individuals would find that they are engaging in criminal conduct.”

Asshats.

Hacker, Activist Aaron Swartz Commits Suicide

Summary: Aaron Swartz, hacker and information activist and Reddit cofounder, has committed suicide at age 26. UPDATED: Pirate Bay JSTOR torrent, public.resource.org memorial.



By Violet Blue for Zero Day | January 12, 2013

Reddit, Creative Commons and Demand Progress co-founder Aaron Swartz committed suicide in New York City on Friday, Jan. 11. He was 26 years old.

Lessig

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@lessig

public.resource.org has gone dark for @aaronsw. So shld the Net. public.resource.org/aaron/

12 Jan 13

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The tragedy was confirmed to MIT's The Tech by Swarz's uncle, and also his attorney.

This post has been updated to reflect public.resource.org going dark in mourning, and the extremely moving sharing of the JSTOR torrent on Pirate Bay to honor Swartz's memory.

Suhail Kazi@kazisuhail

The best tribute to #Aaron Swartz would be to keep this JSTOR torrent alive. Lasting legacy of a great prodigy -thepiratebay.se/torrent/655433…

12 Jan 13

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Dedicated to the free and open Internet

Swartz was dedicated to sharing data and information online. He worked tirelessly to develop and popularize standards for free and open information sharing.

He co-authored RSS 1.0, developed the site theinfo.org, released the Python framework he developed web.py as free software, he co-founded Creative Commons, and he was a member of the Harvard University Ethics Center Lab.

Swartz co-founded Demand Progress, which launched the primary campaign against Internet censorship bills (SOPA/PIPA). His work on Reddit enabled millions to share information and news socially (Swartz sold Infogami to Reddit).

Aaron Swartz was facing a potential sentence of dozens of years in prison for allegedly trying to make MIT academic journal articles public.

Charged with felony hacking

In September 2012, Aaron Swartz was charged with thirteen counts of felony hacking.

In July 2011 Swartz was arrested for allegedly scraping 4 million MIT papers from the JSTOR online journal archive.

He appeared in court in Sept. 2012 and pled not guilty.

Swartz's subsequent struggle for money to offset legal fees to fight the Department of Justice and stay afloat was no secret.

After the September charges came down, the wife of Creative Commons founder Larry Lessig - social justice lawyer Bettina Neuefeind - established and organized the site free.aaronsw.com to raise money for his defense.

Read the whole article.