A few months ago, a young man came to see me. He was depressed. He had far exceeded typical depression. His speech and manner were slow. His eye contact was minimal. He seemed so sad as if tears were too much effort to shed.
This patient seemed to have a reasonably decent quality of life: otherwise good health, favorable finances, a stable job, and a loving family. He had a recent breakup with his girlfriend, but this was not excessively traumatic. On the surface, he did not seem to have reason to live in such pain.
He told me that he wanted to die.
He evaded questions about any specific plans. I worked with him and his counsellor frequently, and he is now doing well, living in another city.
I recognized his words and how he appeared. His hopelessness and emptiness were all too familiar. Some years ago, I came within a few minutes of taking my own life.
Just as it seemed crazy that this guy would die at an early age; it now seems just as crazy that I had walked in the same shoes.
Theories of Suicide
Psychologist Thomas Joiner described the suicidal individual as one who is overcome with isolation and a sense of burden upon others. Emile Durkheim characterized suicidal people as emotionally dysregulated: either removed from society or so altruistic that they fear burdening others.
According to Durkheim, a suicidal person could be either too broken as to ignore a moral compass, or conversely tightly bound to crippling perfectionism.
Aaron Beck wrote how those who succumb to suicide are “sensitized” to the notion of killing themselves by suicidal experiences, thereby making the final act somehow more accessible.
There are perhaps a dozen more theories, all trying to explain what leads a person to end his or her own life.
Theories of suicide may provide comfort to the bereaved, guidance for therapists, and a framework for suicide prevention. But the theories perhaps try to explain the inexplicable.
One of my favorite colleagues, a clinical psychologist, took a more straightforward approach. “Think of it in terms of problem solving. A person is suffering, so he or she seeks a list of possible solutions. Somehow suicide ends up on the list, even though it makes no sense to an outsider.”
I am writing about suicide as a release from emotional pain and mental illness, not the planned suicides of those with terminal diseases. These are controlled, programmed journeys to the end of life. It is an understandable escape from pain and indignity.
I write instead of suicide that makes no sense. Suicide is not necessarily an act of logic. The hopelessness and emptiness that surround the will to die are muddled, indistinct infections of the mind.
Where Burnout and Depression Meet
I knew what depression was. I had experienced its grip, but a commitment to suicidality was different. Although everyone experiences it differently, depression felt like a frustration and conflict with life. Suicidality felt that life was immaterial.
There is increasing attention to burnout among healthcare providers. Not enough attention, but at least a bit. I found myself working inconceivably long hours—sometimes out of necessity; sometimes to escape from an otherwise empty existence.
In the assessment of suicidal risk, the unfortunate term “trigger” is the first item on the list. It could be a loss of a loved one or friend, an illness, a divorce. In my case, it was the all-too-common threat of a dysfunctional and menacing workplace.
The abyss deepened as a recognized the venom of work. Concealed beneath the veneer of a “we’re all family here” façade, I was mired in politics and backstabbing that driven by a culture pervasive with hatred, secrets, and seemingly constant dismissals. Characteristic of a sick workplace, employees would disappear overnight.
It is a story told quite frequently in America: there have been front-page articles about Amazon, Microsoft, and—of course—Enron. I lived in constant fear of being berated and dismissed despite my popularity with my own supervisors, colleagues, and my patients.
Depleted of all energy, crushed with loneliness, and a biting work environment left my life feeling not just depressed but entirely unworthy. Although worthlessness is a symptom of depression, this was not just “I’m no good,” it was a total and all-encompassing feeling that life had no value. No medicine, no workbook, no cognitive exercise could extricate me.
Legend Versus Practicality
There is a glossed, almost benign nature to legendary suicides. One’s mind turns to Sylvia Plath’s oven or Socrates’ sprigs of hemlock. These were undoubtedly violent—even disgusting deaths. But the gore is washed away. I thought of the The Aokigahara, Japan’s “Suicide Forest” or the Golden Gate Bridge. These seemed like misty outposts for a quiet exit rather than nightmarish sites of early death.
When my last stages of planning were underway, there was no poetry, no drama. Suicide was a remarkably practical endeavor. I ensured that my patients’ charts were suitable for someone else to take over, that my apartment was tidy, and I had made careful plans for my dog to be at a kennel. I even emptied my refrigerator as to ensure that the smell of spoiling milk would not disturb the neighbors.
The plan I had selected also made every effort to prevent me from being found. I did a couple of “dry runs” to make certain that I could get it right. I did not want anyone to stumble upon a decaying body, nor did I wish for any sort of funeral. I just wanted to disappear from this earth. Swiftly, quietly, in a cold, rainy night.
I also wanted to be certain that I did not end up in lace-less shoes playing musical chairs with meth addicts and schizophrenics on a locked psychiatric unit.
The questions I asked myself were not related to life or death. I wondered if I should leave my door unlocked, where to leave my car keys, and if I needed to take my wallet. In the loss of rational thinking that characterizes the most immediate of suicidal thoughts, “Should I do this?” was not on the checklist.
The Mask of Professional Identity
The deepest irony was that I spent much of my work dealing with suicidal patients. I taught classes on suicide assessment, I visited patients and families in crisis centers and psychiatric units.
Perhaps once a week, I found myself conferring with colleagues about the potential suicide risk of a patient. I even earned ironic praise for handling the suicide of a patient with grace and calm.
While talking with patients who expressed suicidal thoughts, I often found myself thinking, “Oh, you’re definitely not suicidal. I am suicidal.” Maybe it was my own escalating will to die that made it so easy for me to convince others that that they were not in such dire condition.
In a bit of macabre humor, I found myself taking suicide risk inventories. In my perfectionist, over-educated world, I wanted a grade. I never seemed to score that high. I was not physically ill, I did not fall in the right age ranges, I lacked a substance abuse problem, and my finances were not in jeopardy. I was failing the suicide tests.
Comedian Sam Grittner wrote about the strange task of writing a suicide note. He stumbled over font choices and he ran out of ink for his printer. I was fortunate enough to have a laser printer with adequate toner; and I was pretty set on using Palatino.
Although I wrote several drafts, they never seemed to say anything other than “I’m sorry.” I felt like including a few “fuck you’s.” It occurred to me that those I would mention were such sociopaths that they would be unlikely to be moved or even saddened by a suicide. I was not really interested in teaching anyone a lesson.
I never printed the note. I kept wondering where to put it, and if anyone would bother reading it. What purpose would it serve? I did not want anyone thinking, “Oh if only…” I did not want anyone thinking of me at all. I wanted my life erased.
One of the most frustrating lines is, “It was such a selfish act.” Suicide is a desperately-needed escape from a life too painful or meaningless to continue. Selfishness implies indulgence, diversion of resources to oneself. Suicide feels like the opposite of siphoning off the assets of others. It is one less mouth to feed, one less salary to pay. I even thought it would be a benefit to the healthcare system: one less patient availing himself of costly benefits.
An Unhealthy Dose of Guilt
It seems like human nature to seek comparisons. I was beyond the point of reflecting on my life, but I would sometimes get flashes of world news. “You could have ALS,” “You could be living amid genocide, war, appalling poverty… So many people have it worse than you do.”
This only adds to the damnation of suicide as “selfish”. The imminent will to end one’s life has nothing to do with Darfur or Donetsk. It is neither reassuring nor helpful to imagine squalor and pain elsewhere in the world.
“Count your blessings” has a pop psychology, Dr. Joyce Brothers superficiality. If one is truly committed to dying, “counting blessings” sounds like a childish diversion. Flip as it may sound, it would be the equivalent of saying, “I have an iPhone and I do not have cystic acne. Wow! This is fantastic! I should stay alive after all!”
It is also similar to saying, “It can’t be that bad.” In those last days and hours, there is no “bad” or “good”. It is only a matter of, finding an end. The pain is suppressed; one’s focus is just to make life disappear.
The Particular Burden of Professional Licensure
The most heartless and sinister aspect of being a healthcare provider struggling with suicide is that many state laws require investigation, oversight, and practice restrictions on doctors and nurses who “get caught” admitting to suicidal thoughts. In a misguided effort to “protect the public,” licensure boards crack down on those most in need of help, punishing anyone who reaches out at the last moment before leaving this world.
The boards tacitly endorse suicide: it is far easier to be dead than to have to suffer a public disclose one’s most painful, innermost thoughts repeatedly for the remainder of one’s career. Had I been hospitalized, the law would have required that the licensure board issue a press release, warning the public that I was mentally unwell. Any member of the public would be able to read the most intimate details. I would spend the rest of my career providing documents of my mental instability to insurance companies.
I paused. I do not know why. I doubt I will ever know why.
To paraphrase Sam Grittner: “Pro Tip: always call your therapist before pulling the trigger.”
“Pro Tip: always call your therapist before pulling the trigger.”
I had a psychologist. A wise, warm, and clever professional. He was deeply caring with an unmatched sense of humor. Trying avoid alarm, I did not call from a bridge, nor did I bother him in the middle of the night. I spent the remainder of that night agitated and foggy, and waited for his office open.
His response was what only the most confident and caring professionals would know to do: he gave me a huge hug, struggling to keep back his own tears.
There was no need for him to demand my shoelaces or submit me to the indignities of hospitalization. Without words, he was saying, “No. That’s not where this is going. You’re not doing this.”
He also knew to meet me in a place I knew well: the snarky gallows humor of medicine. We talked about how one particular attending psychiatrist was almost always on service at the nearby hospital. He was famous for being as arrogant as he was incompetent. If I somehow did not die from suicide, I could awake from a coma with that imbecile at my bedside.
I was deeply unwell, but made every effort to fake it. I got up went to work, and buried myself in routine.
I eventually moved on from the battles of my former job. Although it seems inconceivable, I just somehow did not feel like dying anymore.
Sufficient time has passed that I can think somewhat clearly about that dark 48 hours. The lesson I wish I could impart the most to others is that suicide makes no sense. One can read theory upon theory, but it is inherently irrational. I cannot explain why I did not kill myself.
Suicide assessments also try to impart some sort of method where there is no algorithm or equation. I did not score high enough on any of the “validated” suicide measures. There is thus a danger to suicide awareness campaigns and to clinicians who might turn to some sort of psychiatric inventory.
As I knew, the most lethally suicidal patients keep their mouths shut. Except at the very end; I said nothing. Although there is an art to working with more vocal patients, and their cries should not go unheard, it was a function of good luck that I happened to have a psychologist, and that he was both available and perceptive.
I think I am a better clinician because of my own experience. I obviously maintain boundaries and do not talk about myself. Like the patient in the introduction, I can at least feel a deep sense of empathy, and I try to take after the psychologist who looked after me.
Only the most monstrous of licensure boards would punish me for expressing my recollections here. I am no danger to myself–years have passed; and I was never a danger to others. I ended up avoiding the hospital, and thus would not meet the threshold for some sort of investigation.
If that person is you, and you are reading this, do me a favor: wait a day. Call the person most likely to help you. I wish you a hug, honesty, and hope.