What’s the point?
What’s the point?
The radio at the desk carried the same story as always, in faintly static words, as if to echo the faintly static thoughts of everyone involved: ‘25-year-old female patient with suicide attempt.’ She had ingested a bottle of something that wasn’t quite dangerous enough; or maybe she superficially applied a razor to her wrist, in such a way that everything important beneath her pale skin remained intact, properly flexing and pulsatile. I don’t remember which it was, or if it was anything other than ‘I want to drive my car off a bridge’ or ‘I just want to go to sleep and die’.
What I do remember is that the excellent and caring nurse who took the report turned around and said what many physicians and nurses think at some point: ‘Why don’t we let her? Who cares? If she wants to die, we should let her!’
I thought about that later; thought about all of the time and money and effort. About the miles of stitches and staples placed in wounds that men and women inflict on themselves. I tried to imagine the uncounted tubes of charcoal we pour down thousands of feet of nasogastric tubes every weekend, every year. I remembered the many interactions I have had with psychiatric facilities in the night, all to rescue the people who said they wanted to die. Why do we do it?
Maybe physicians and nurses and paramedics do it because it is expected. After all, if we don’t do ‘the right thing’, there is the threat of malpractice suits and the stigma of not meeting the ‘standard of care’. Or maybe we just don’t want to feel guilty, as we know we will, for letting another human take their own life. Those are all parts of the puzzle. But I believe there may be more.
I hope that most nurses and doctors recognize that the minds of those patients are diseased, and that suicidal thoughts and actions, like hallucinations or delusions, are the symptoms of diseased brains. The psychic equivalent of jaundice or murmurs or deformed limbs. Even as these patients drive physicians to distraction, even as we struggle with the ethics of self-determination, on some level we know that a brain is an organ, and all organs are potentially diseased. We work pretty hard to save those with heart disease, emphysema, diabetes and terrible injuries, so maybe we know that diseased minds deserve the same effort.
But everyone can have a hard time with that. After years of controlling our lives, working hard, suppressing emotions and personal interest, it seems a little ridiculous that someone else couldn’t do the same. That someone couldn’t see tomorrow as a little brighter. It seems odd to physicians and nurses, secure as we generally are in position, influence, financial security and respect, that someone else could see the world as simply unmanageable and intolerable. How could they think life was less than wonderful, good and full of meaning? Maybe that’s why they can be so frustrating to our ‘type A’ personalities, what with their empty pill bottles and lolling eyes, their tearful families and crumpled, dirty suicide notes, with their bleeding arms and botched gunshot wounds. We think, ‘I would never do that!’ So too many doctors and nurses wonder why bother to try at all. The world of the suicidal is too far removed from most of our lives.
Beyond the fact that most of us just can’t relate, and beyond guilt, malpractice and ‘duty’, there lies another reason for we try to reach the suicidal. A reason born in the lives of the ones who try to cut and ingest their way to the morgue. After seeing enough people in my 13 years of practice to date, I have a few ideas about why we struggle year after year with so many patients’ attempts to end their lives. It’s because I believe that maybe we can sense, if we pay close attention, just how very much pain they are enduring.
The truth, that hopefully most of us see, is that our patients are suicidal because they were abused physically and sexually, as adults and children, and no one has ever told them it wasn’t their fault. The only way they see to end the guilt, and oblate the re-entrant path of painful images, is to die. Our patients are suicidal because their families gave them diseases of the mind that passed through the confluence of DNA, through the womb, and through the families where they grew up in constant chaos. Many of them can’t afford medication or psychiatric care. Death is an escape from diseases they inherited like the mark of Cain, and from the ties that bind them to others just as diseased. They are suicidal because they lost parents or children, spouses or lovers, friends or even pets who were the only things that gave them any hope or affection in a cold world. They want to die because tomorrow only seems more bleak than today, and because with no hope of vacation or shopping trip, no hope of education or achievement, death seems as good as life.
The suicidal come to us because they are slaves to drugs and alcohol, slaves to sex, slaves to food, society’s expectations, cruel families and misery. They know that death is a kind of liberation from the chains that bind them in every way. And the suicidal come to us because no one has ever said to them, ‘Whatever you do or don’t do, or did, you still have worth to me. I love you.’ The suicidal are suicidal because they either have no one to love them, or because they cannot believe that they are worthy of love.
Why do we do it? Now I know why we do it. In the end, even the most committed suicidal patients are seldom really suicidal; they’re only desperate for some anesthesia of the heart, and death is the only permanent sedative they know. We know that all of the thoughts that tell them to kill themselves are lies and deceptions of disordered minds and broken hearts.
As for me, I’ll keep pushing the charcoal and talking to the counselors and sewing the wounds. And God help me, I’ll try not to act angry or annoyed. Because if my child ever reaches that place, and I can’t be there to fight for them, I want someone to ask, not ‘Why do we do it?’, but rather, ‘Why would you do it, my dear? Let me pull you back from the edge and we’ll talk a while. There are other ways to take away the pain.’
I hate to say it, Dr. Leap, but you’re insane. How do you know suicidal depression is a “disease”? Can you identify with any precision its etiology? More important, can you identify any medical treatment that can be shown in a rigorous epidemiological way to work any better than say cognitive therapy–or just plain old time? If you answer NO and NO (and I believe you must), then “treating” depression is not really a medical concern.
Treating depression as a medical condition is disturbing. We all get depressed; learning to overcome our depression tends to make us stronger, better people. In this sense, depression has a strong moral component that its medicalization ignores. Further, it places in one profession–a profession that I would argue is singular unfit for the task–the job of saying what is “normal”?
Further, is depression so irrational or abnormal. When Marina Tsvetaeva said, “There’s just one answer to your / Senseless world–refusal.” and killed herself, was she wrong? Was Zweig or Tschaikovsky or, Socrates, as portrayed in the Crito, equally wrong when they killed themselves?
Nicely said. Depression is very difficult to explain to the non-depressed. People expect emotional states to conform to rules of logic, but depression doesn’t unless seen on a very long timeline. My own mother doesn’t believe it exists even though I think about killing myself every day.
Thanks for fighting the good fight, Doc.
Dear Dr Leap:
Your essay, particularly the last paragraph, has to be the most beautiful thing I’ve read on the issue of suicidality. Thank you for that and for feeling as you do and for doing what is needed.
With warm regards,
Rossweisse
Well said! One of my sisters is alive because someone — doubtless more than one — cared enough to pull her back from the edge.
Thank you. That was beautifully written, with compassion and empathy. I don’t know if the people who saved my life cared or just felt it was their duty since I wasn’t awake to know, but I am thankful that they did.
Unfortunately, I have since had to go to the ER a few times for incidents of self-injury, and I was never met with anything near compassion by the physicians. I was yelled at, given the complete silent treatment (no talking, no eye contact), and once, given stitches without any anesthesia. It is incomprehensible to me how a doctor could choose to inflict pain on a patient. But your explanation of how physicians are put together and view themselves gives me a better understanding of their behavior. I hope that those physicians reading your entry, while identifying with what you’ve written, won’t consider it an excuse for continuing to treat someone with a “brain disease” as someone not worth saving or having compassion for.
Thanks again.
“even the most committed suicidal patients are seldom really suicidal; they’re only desperate for some anesthesia of the heart, and death is the only permanent sedative they know.”
How true this is, and bravo to you for making public this important observation. As someone who has looked into that abyss first-person, I can attest this is precisely the case. “Intelligence” is no defense, so please don’t say “How could they be so stupid?” Selfish, maybe, but not stupid. “The intellect is a cleaver; it discerns and rifts into the secret of things,” said Thoreau. Such intellect, in the playground of a depressed mind, can cut and slice in damaging ways indeed.
It’s not about weakness/lamely taking the “easy way out,” or lack of care for the effect it would have on friends and family. One is blind to everything but the pain, seduced into a delusion that relief is only a razor slice/valium bottle/bullet away. I knew there was a glimmer of hope because I still felt, even though it seemed to be all pain and suffering. A patient crying and pleading, “I just want to die,” or “I can’t take it anymore,” is the surest sign that there is a possibility to positively intervene.
Beware the patient who no longer feels at all.
dr calagiri? tom cruise?
Dr Leap you have obviously been blessed with either knowing someone intimately who has been devastated by depression or God has given you a gift of understanding it from “the outside”.
Depression that comes from somewhere other than ones’ circumstances, (which we all have at one time or another) is not something you can pick yourself up by your boot-straps from. This depression comes from no where. It comes when everything in your world is good and normal and you “should” be content with it all. It comes with a vengeance and sometimes it stays for years and years without letting go.
I have been treated since 1992. Those first years, it responded splendidly to the medication. After that there have been periods of time where after requiring a change in meds, it took a while, but eventually it responded again. The past 4 years or so have indeed been horrible.
None of the meds are working for more than a few months now. The past 18-20 months have been the longest of my 46 years. I have never attempted suicide. I have thought about it. I have written letters to loved ones with the intentions of doing it. By God’s grace, I have never attempted to follow through, but when you are in that place in your sickness, where truth does not exist and your brain is telling you that you’re worthless and stupid and not even your God could love you and that there is no point, it is so hard not to listen.
No, we don’t want to die. We only want the pain to stop. We for whatever reason have been unable to make it stop either through counseling or medications or prayer. Those that pass through your doorways in the emergency rooms on their way to the morgues, they’re not there because they wanted pity. They were not there because they were “weak”. They were there because the pain got to be greater than the resources for coping with the pain.
What is Caligiri a doctor of? Obviously s/he has not familiarized him/herself on the latest literature on depression and it’s pharmacologic and behavioral treatments. A cursory PubMed search would bring multiple worthy reviews and meta-analyses to disprove Dr. Caligiri’s uninformed claims.
The brain is unlike any other bodily organ in so many ways. How is it so incomprehensible to some people that disease processes in that organ would differ from disease processes in other bodily organs?
Not to mention the fMRI and CT technology that allows us to quantify physiologic changes in the brain in certain disease states relative to normal brains. And to quantify and observe changes in brain physiology following various treatments.
Ugh.
I have just stumbled upon your blog. I’m in the midst of your archives. You wrote a very touching post. From someone who ended up in the ER more than once for self-hard, I truly appreciated the staff’s compassion in the ER and ICU. There were a few, “I could never do that to myself.” which I could have lived without. It took years, but I’m finally off meds and harmful thoughts free. Keep fighting for those who do not have the strength/sanity to fight for themselves.
All my respect goes to those suffering, be it you personally or a member of your family. My hope is for a major development in the near future to help all those in need.