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Learning to talk openly with patients about their suicidal ruminations poses more of an emotional than intellectual challenge.
Earlier this week, Dr Steve Moffic wrote a powerful post about his experience as a psychiatrist dealing with suicide. He presents a moving discussion of how difficult it was to think and talk about the suicide of a patient he treated in residency. Here’s the concluding paragraph of Steve’s post:
Legal fears, confidentiality concerns, shame, and stigma are formidable obstacles. But talk we must, for talking-and listening-is a key to prevention and treatment. Any clinician knows that most who survive serious suicide attempts end up being glad they did, if they receive the help they need. They wanted to relieve the terrible psychological pain, not to die. Although the suicide will relieve the pain (as in the song from Mash, “Suicide is Painless”), it can cause intense pain in loved ones. Those left behind need the same forgiveness, relief of guilt, and community support that I received from my supervisors and fellow residents. Like a rock thrown into the river, the ripples of suicide can be mighty and wide.
In my experience, learning to talk with patients about their suicidal ruminations posed more of an emotional than intellectual challenge. When I first encountered seriously suicidal patients I was tempted to try to “talk them out of it.” There were three main ways I considered doing this: persuading them that their problems were solvable; emphasizing the reasons they had for wanting to be alive; and, imagining the impact of suicide on family and friends.
Luckily, wise supervisors pointed me in another direction. The task, they told me, was to find out what made suicide seem like such an appealing alternative. Over the years I learned to probe what I called the “logic” of suicide. What made suicide seem like the right thing to do? What was the source of its magnetism?
I found this approach easy to describe but hard to do. My own temperament is somewhat rigidly optimistic. Some aspects of my growing up were difficult, and in retrospect I believe I learned to see life’s glass as half full rather than half empty as a way of warding off depression. My father’s brother killed himself when I was 13. I didn’t know him well, but I believe that even as a youngster I sensed the pain he experienced. When my two sons were teenagers, they teased me about my determined attention to the bright side of life with the term “poptimism.”
When I first read The Myth of Sisyphus in high school, I was transfixed by Albert Camus’ opening sentence: “There is only one really serious philosophical question, and that is suicide.”1 I thought, “This man gets it,” and underlined page after page. But it took me years of clinical practice to truly “get it.” When is a patient’s wish to turn off the ventilator a “competent refusal of treatment” and when does it represent an “irrational” suicidal impulse that should be impeded? These are great questions for an ethics seminar, but when I was called upon to make real decisions in real time I learned at a vastly different level.
Thanks to Dr Moffic for so vigorously bringing the importance of talking about suicide into open discussion!
[Editor’s Note: Our thanks to Dr Sabin for granting permission to publish his blog, originally titled "Talking About Suicide," October 5, 2013, at http://healthcareorganizationalethics.blogspot.com/2013/10/talking-about-suicide.html].
Dr Sabin is Clinical Professor in the Departments of Population Medicine and Psychiatry at Harvard Medical School and Director of the Ethics Program at Harvard Pilgrim Health Care. His blog site: Health Care Organizational Ethics.
1. Camus A. The Myth of Sisyphus: And Other Essays. New York: Alfred A. Knopf, Inc: 1955.