Psychiatry, Religion, and Suicide

October 2, 2013

It is hard for mental health professionals to discuss completed suicides. 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.

[[{"type":"media","view_mode":"media_crop","fid":"17683","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7163609565472","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1067","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px; float: right;","title":" ","typeof":"foaf:Image"}}]]When I was a psychiatrist, I was terrified that a patient might commit suicide.
-Jack Gorman, MD

To be or not to be, that is the question.
-William Shakespeare

Suicide is an event that is part of human nature. However much may have been said and done about it in the past, every person must confront it for himself anew, and every age must come to terms with it.
-Goethe

It was the middle of the recent Jewish High Holy Days. I had just finished reading Hemingway’s For Whom the Bell Tolls, when our phone rang out. It was the Rabbi of our synagogue. When a psychiatrist reads that book, you can’t help but think of Hemingway’s later suicide, the suicide of others in his family, and how suicide may be portrayed in his writings.

The suicide study session
In the first of a series of serendipities, what did my Rabbi want? To see if I would serve on a panel to discuss suicide during Yom Kippur, the day when most religious Jews pray that they have been put into next year’s “Book of Life.” Trying to model our forefather Abraham, I answered, “Heneinei” (here I am).

After I agreed, more serendipity seemed to occur. When I asked family, friends, and colleagues for their reactions to such a study session, my sister reminded me that Yom Kippur was also the last day, September 14, of our country’s National Suicide Prevention Week. My sister knew that from a suicide in a friend’s family, but why didn’t I as a psychiatrist? And, why had this week not been discussed in any professional Listservs or news reports that I received (with the exception of e-newsletters and other coverage from Psychiatric Times)?

After a mixed response from colleagues about the suicide study panel, I wondered what I should say. I heard that one of the panelists was planning to talk about the suicide of her father. Although there was a possible suicide attempt in my family, I (fortunately) never experienced a completed suicide in my family, nor have I ever had suicidal thoughts myself (probably thanks to my wife). What, then, could I say in 10 minutes that would be powerful and revealing enough for such a stigmatizing subject?

Then, a breakthrough, perhaps from my dissociated unconscious-I thought of the two suicides in my professional career. I decided that if these cases were so hard for me to recall, maybe processing them would help both me and the audience. This would be the first time I would do so publicly and in fact the first time in any sense since those two suicides.

When my turn came and I began to speak of these cases, I started to sob unexpectedly and I was not sure I could go on. I heard a soft and soothing comment from a man in the front row. He said, “Take your time, relax.” I did, and it worked. So, I went on.

The first case was in the second month of my residency, 40 years ago. The patient was an elderly man, depressed from loss of a job and a loveless marriage. I prescribed an older antidepressant and suggested some therapy sessions. At the second meeting, he seemed a bit better. But during the week following, his wife called and said he had walked into Lake Michigan and drowned.

Panic and sadness set in. How would I tell my supervisors? Was I not fit to be a psychiatrist? What could I have done differently? These were the same sorts of questions that loved ones of suicides seemed to have.

To my relief, I was supported. I was told that if I could have done anything differently, it might have been to recognize the increased risk right at the time when suicidal person is seemingly better and they have the energy and focus to plan and complete a suicide. This is counterintuitive, but psychologically sound, I emphasized to the audience. Of course, with more experience, I could have asked and discussed suicide with more sophistication. Maybe that case shouldn’t have been triaged to me in the first place.

My supervisors told me that what I learned would help me be a better psychiatrist. That seemed to turn out true. I never had another in a patient, despite working with the highest-risk patients. In a somewhat macabre statement, I was told, “You don’t become a real psychiatrist until you have your first suicide.”

To help make that statement irrelevant and out-of-date, I shared how some systems of care are now approaching zero suicides via better screening tools and comprehensive services, such as Magellan of Arizona. Modern approaches also recognize that the antidepressants often prescribed can not only be helpful, but one also has to watch closely and cautiously for akathesia, a side effect of restlessness that can paradoxically increase suicide risk.

The second case occurred about 15 years later. A staff member who was getting more erratic emotionally had not come to work for 3 days. Another staff member and I decided to go to his home. We found him dead, in bed, with a gunshot wound to his head. We were not completely surprised, because he might have had an AIDS diagnosis-but still, we were shocked. Some intrusive memories of this surfaced on and off over the years. I found out that the suicide rate among psychiatrists and other mental health clinicians was quite high, the highest among any professions at the time. We seemed to bond and care for one another even more after this tragedy.

The next presentations hit hard on other aspects of suicide. The Rabbi talked about how little suicide was mentioned in our sacred texts and that to this day it is a troubling subject for Judaism. The leader of the panel, a dean of a new school of public health, not only talked of her father, but also of the extensiveness of the problem and the need for more prevention. A young lady from our local university told of a new endeavor to do so, with the acronym RED:
•Resiliency building-Resource for the community
•Educating the community-Educating our youth
•Decreasing stigma-Determined to make a difference

As soon as the session ended, I walked up to the man who had reassured me. It turned out that he was the father of the young woman who recently committed suicide; it was so tragic to the community that the funeral had an overflow attendance. Just imagine! He, likely in suicide grief, comforted me, the professional.

When I returned home after the study session, I looked at the front page of The New York Times. Quickly, my eye caught the headline: “Girl’s Suicide Points to Rise in Apps Used by Cyberbullies.” This was exactly what we had talked about, including the misleading impression that the girl had been doing better in the week before she committed suicide.

A few days later, a colleague reminded me of yet another personal connection to suicide that had remained in my unconscious. My wife and I had been married in 1968 by a Rabbi who later committed suicide in 1976, my first year of being a full-fledged psychiatrist. As far as I know, he had been treated at the Menninger Clinic, at the time thought to be the state-of-the-art treatment facility when psychoanalysis was still dominant in psychiatry. In retrospect, I had to wonder whether the Freudian view of religion as neurotic and illusionary, was at all a complicating factor in the treatment of a well-known Rabbi whose devoted his career to the Jewish religion.

Initially, such memories and associations were painful, but ultimately therapeutic, I believe. I have faith that there is meaning in these serendipitous and meaningful events, both psychologically and spiritually.

Although the fact that my son became a Rabbi may have led me to see commonalities and overlaps of psychiatry and religion, psychiatry as a field seems to recognize how religion in moderation can enhance mental health for many. To incorporate the importance of religious beliefs, or the lack thereof, we have a bio-psycho-social-(and now) spiritual model to follow.

Preventing suicide
One of the current limitations of psychiatry as a preventive field is that we are not particularly good at predicting suicide. Shakespeare showed that unpredictability in Hamlet. Hamlet decides “to be,” but his girlfriend Ophelia decides “not to be,” by drowning herself like my patient did. Moreover, many who die by suicide do not come for help, nor do some even have a mental disorder. Whether so-called rational suicides should even be prevented is quite questionable.

As in my case, another obstacle is that it is hard for us to discuss completed suicides. 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.