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Saturday, March 24, 2007

Chuck Mahoney and a preventable waste

This is why I blog. You have to know this stuff. People have to know. Especially kids who have friends who want to die. They need to know what to do.

What not to do is alluded to, if not spelled out in today's Wall Street Journal. The link may not be good for very long, WSJ may update it daily, so I'll tell the story over in the words of the journalist, Elizabeth Bernstein, whose eloquent story is on the front page of the only newspaper in town, no matter where you live.

Chuck Mahoney's parents sued Allegheny College in Meadville, PA, for his wrongful death in 2003. They alleged that the school had not taken enough action to prevent his suicide at the age of 20. Chuck's fraternity brothers and ex-girlfriend had alerted school officials that something was terribly wrong and they knew he needed help.

The school ultimately claimed there was no imminent cause to breach confidentiality and that the parents should have had better communication with their son who had been previously hospitalized as a suicide risk.

Chuck was a star athlete, tall and good-looking. He emotionally crashed immediately upon hitting campus: difficulty sleeping, anxiety, panic, fits of tears, the shakes. His parents helped arrange therapy and the therapist recommended a psychiatrist who prescribed medication.

Chuck was diagnosed with major depression, I'm assuming a 296.33, major affective depression, recurrent, severe, since court records revealed that he had a known history of depression (thus this was a recurrence) which included cutting and drinking alone.

He was treated and could study hard freshman year, maintain a relationship with a new girlfriend. He pledged Sigma Alpha Epsilon and got in but felt like a failure. He showed his therapist his writing. (he wrote well, by the way) :
It seems there is not a night, before I go to bed that I do not plead to God to please not let tomorrow come, but it comes and it comes.
The summer before sophomore year the therapist called his parents to tell them that their son wanted to take all of his medications and cut his wrists. (we call that a plan). Chuck had a five day stay in a hospital and felt better, like a weight had lifted. He did well that year academically.

But the following year he broke down, quit the football team in tears. He rescued a dog from a pound, took it home and carried the dog with him where-ever he went. But his mood was down. He broke up with the girlfriend and she told many others that he told her he wished he was dead. She told the therapist, too.

The therapist consulted with several people, other psychiatrists and administrators, about whom to tell and confidentiality issues were key, ultimately they became the substance of the case against the school.

In January, when he returned after winter break, Chuck spent much time alone in his room drinking heavily. He planned to give away his dog (a clue), in case
anything happens to me
He told his therapist that he had regular thoughts of suicide and a plan to kill himself with sleeping pills (another plan).

When he heard that a fraternity brother was dating his ex-girlfriend, Chuck threatened to kill him. School administrators were contacted. The dean and associate dean of students were contacted. The students didn't call Chuck's parents because they assumed the school would help him.

At 3:18 a.m. Feb. 11 Chuck wrote his therapist an email:
i hate living and i hate the prospect of going through another day.
At noon the next day she got another one:
I am sad and angry and alone, alone, alone, alone.
At what point do people who know these things think to say,

WOW, MAYBE WE SHOULD SOMEHOW FORCE A HOSPITALIZATION ON THIS KID!

Yes, the caps mean I'm shouting. SO MANY PEOPLE knew he was so very sick. No one knew what to do. I'm not blaming anyone, I'm really not. People just don't know. But they're much more powerful than they think.

You're much more powerful than you think.

Anyone can, you can:

Call the police, tell them that you suspect someone is going to kill himself. I have done this a few times, but a lay person can do it just as well.

As a friend/lay person, be there to substantiate your case when the police arrive. The police then will bring this person into an E.R. for an evaluation. The police would rather be safe than sorry. The docs in the E.R. will probably recognize suicidality and admit/treat the person at risk. Let them try their hand. They're good at this. It's their job. End of story.

But no, that's not how it ended. Around 6:45 that evening Chuck's friends found him asphyxiated by the dog's leash, hanging from the door in his room. The suicide note said,
To my parents, this is not your fault by no means, you were fantastic people and the world should worship you.
The jury voted 11-1 for the defense. They concurred with the school that since Chuck had not signed a waiver allowing the school to break his confidentiality, there was no way they could contact his parents. His parents who I suppose the school deemed responsible, were a 2 hour's drive away and didn't know how sick he was. The administration did know. But the administration somehow was not responsible because protecting the boy's confidentiality was more important than protecting his life.

Law is interesting like that. The case hinged on confidentiality, not responsibility. The school was not held responsible because responsibility wasn't the issue in the case.

So.

Once a week now, according to Elizabeth Bernstein's article, a father opens a closet and buries his head in his son's sweatshirt to remember him.

The therapist says she used a cognitive therapy.

I don't want to diss her, honestly, but when a person is this sick, cognitive therapy won't cut it. People can't "cognate" when they're this depressed. When a doc can sense that a patient can't think, a "thinking therapy" is inappropriate.

You meet him heart to heart. The goal is to ensure trust, trust not only in the therapy, but in the patient's own capacity to get well--with help, with support, and lots of it. The doc communicates that it may take a village to heal a child. The doc insists upon, doesn't suggest, hospitalization. Safety is the key word.

When a person is sick enough to dread tomorrow, as Chuck indicated in his journal? Plunk him in. TODAY. Keep him safe.

20/20 hindsight, doc?

No. Chuck had a psychotic depression, not an unusual presentation, either, and at the right age, 18-20 years old. Many therapydocs don't see it as such, not initially. They see the depression, but they miss the psychosis. They get stuck on the medical facts, the "times three" orientation rule. If a person is oriented times three (X-3), knows person, place and time, usually we can rule out psychosis.

But that criterion dismisses the most important criterion of all! Wanting to die can be enough to diagnose psychosis (rule out schizo-affective disorder, too, delusions/hallucinations).

Psychotic depression means that the hole is so deep (the one they can't crawl out of) the fog is so thick (the one they can't see through), the world is so horrible and painful (the one they live in) that life really is NOT worth living anymore.

The permanent solution to the temporary problem looks good. They think they are better off dead. They believe that, they say these things aloud. We've heard these words, MANY of us, not only therapydocs and health-care professionals.

Yet people still don't know what to do when someone says they want to die.

This is what you need to know. You don't give up on getting people help. If at first you don't succeed, you try, try again.

If, say, you did the police intervention and the E.R. sent a person like Chuck home, you have to be more creative next time. I'm not suggesting you do this, but in a case like Chuck's, I picture fraternity brothers planting an open bottle of spilled sleeping pills in the room, then calling police. They tell the police to come when they knew their friend will be in a stupor; they tell law enforcement that their friend wants to kill himself and they know he has the means to do it. They show the police the pills if the police don't see them.

The way those writer's think on Desperate Housewives, that conniving, out-thinking- the- status- quo- way of thinking is good, really. It is good to think creatively, but I'm not saying you should ever deceive law enforcement. I just can't resist the opportunity to make you think. It is a rare, extremely rare event, that would require such creativity.

One might think outside the box, but you should go with less drama. The truth socks enough punch, it really does. But it has to be told. Someone has to take a risk and stop the insanity.

The bottom line is that we're no longer powerless against mental illness. There is a an arsenal of medications at our disposal that grows larger every day, and if those don't work, electro-shock therapy really does work. We're not afraid of electro-shock therapy anymore. The professionals know how to manage it so that it doesn't make people into zombies forever after. We're not in the 1950's anymore.

If I were to look at the way this case was handled? I would honestly think that we were. A waste of life. Go to WSJ and see that video. Wall Street Journal

TherapyDoc

17 comments:

J said...

Chuck wasn't the only one not thinking clearly...

In regards to liability, do you have any thoughts on involuntary-leave for students who are severely depressed or who made suicidal gestures, a policy which is becoming increasingly common? I could be wrong, but it seems it would discourage some kids from seeking help and would make things seem worse for students affected by the policy--more to protect the school than to protect the student.

TherapyDoc said...

That is the problem, of course, with involuntary leave, kids won't get help thinking they might get kicked out. The schools are between a rock and a hard place.

That's why I'm pushing friends to take action, to do an intervention somehow, to get a sick friend to a higher level of care.

This case was just adjudicated, but it's 4 years old and many of the schools have made it a policy, as you've indicated, to force involuntary leave on kids with potentially life threatening mental illness and/or hospitalization.

I'm not a lawyer so questions of liability aren't for me to answer. But I'll tell you one thing. As a family therapist you have fewer problems with communication and more options for protecting a sick person, more minds to think up ways to help someone get help.

And you get people to sign releases of information right up front, renewing them monthly, and suicide contracts. But again, on these things, contracts, releases,I'm no lawyer. Get your own consultation.

The point of this entry for therapists is (a) this job ain't glamorous, the glamor dies as soon as you get your first kid like Chuck, the stress begins and suddenly you're not paid NEARLY enough and (b) don't be a hero, insist on a HIGHER LEVEL OF CARE when you even think you're over your head. That's the important lesson. It's never one person's job to keep a human being alive.

Familydoc said...

Great blog, and even better commentary!

My experience with depressed kids away from home at college is that some institutions of higher learning are good at providing entry-level care (student counseling centers, crisis lines) but cannot deftly bump up to the next level (psychiatric hospitalization, day program or assigned "sitters") with the efficiency of the general public healthcare system. So more severely ill kids (who often isolate themselves from or are avoided by fellow students) fall short of the help they need, as you describe. I

n this light, kicking them out of school may be beneficial, but I agree with you that a more elegant solution would be to increase public awareness of the risks of suicide (which is being done by organizations such as SAVE, AFSP, and DBS Alliance), and perhaps disseminating a kind of "mental-illness CPR" protocol that gets the victims into a safe milieu ASAP.

TherapyDoc said...

Thanks for those links especially, FamilyDoc

another point of view said...

This is a horrible tragedy -- horrible, horrible, horrible. But I don't agree with your take on who's "responsible." Where were the parents and other family members and friends? (and I'm not talking geography) Knowing that a child is vulnerable and ignoring that (i.e. not insisting on a waiver, not engaging in informal contact with profs, frat bros, girlfriend, etc) is called DENIAL.

Shifting the responsibility to higher education does not solve the problem. How many kids who suffer from severe mental illness make it through college (and graduate to a good job, etc) without professional intervention? I'm guessing that the number is not high. If you think that YOU don't get paid enough, ask a university prof, or a guidance counselor, or a dean if HE gets paid enough to be on suicide watch -- while performing his "day job" at full capacity.

Asking college kids to intervene in cases of severe mental illness is asking a bit too much(we are talking DSM -- not situational depression cuz they got a bad grade or got dumped by a girlfriend.) College kids are notorious for being sorta self-involved anyway -- so now we are going to ask them to be responsible for preventing a suicide? And then living with the consequences when they fail?

(I also want to mention that I was really disturbed by your suggestion that kids "plant" evidence -- this is a dangerous, slippery slope, esp among KIDS who may not be able to distinguish between a crisis and some other situation. The legal -- and ethical -- implications here are not pretty.)

Truth is, a kid who shows signs of severe mental illness does not belong at a "sleep away" university. Keep the kid close to home where parents and other community members (clergy, family doc, neighbors and family friends) who KNOW the kid and can clearly recognize signs of slipping BEFORE the kid becomes suicidal. Develop a LONG TERM plan for treatment and support. But don't send a kid far away and expect that he's just mysteriously gonna get better.

Sorry TD, you just touched a very raw nerve.

TherapyDoc said...

Thanks, APV, for your comments.

Let's take a closer look at them. Your stuff's in italics.

I don't agree with your take on who's "responsible."

I know it looked like I blamed the school, but I really wasn't trying to blame anyone. This was a situation where a dying child wasn't hospitalized. Everyone thought someone else was responsible. No one stepped up to the plate.

I'm hoping people will begin to look at their system and incorporate my It takes a village, when it comes to mental illness, thinking.

Where were the parents and other family members and friends?

Denial is the word. They did, however, get advice from providers who said, "He's okay." Surely they should have visited him OFTEN, questioned him hard. I would imagine that on the phone he said things like, "I've never felt better, Mom."

How many kids who suffer from severe mental illness make it through college (and graduate to a good job, etc) without professional intervention?

You're probably right about the odds. I agree that when you know a child is sick, you don't send the child away to college to "babysit."

If you think that YOU don't get paid enough, ask a university prof, or a guidance counselor, or a dean if HE gets paid enough to be on suicide watch -- while performing his "day job" at full capacity.

I'm happy when I'm paid at all, but when my patients improve, I know why I'm doing this.

I don't believe in asking university personnel to "watch" a suicidal young person. The very idea indicates that child needs a higher level of care.

A higher level of care means a hospitalization or a day program, not a "sitter."

Asking kids to be responsible for preventing a suicide? And then living with the consequences when they fail?

I'm not say be responsible, I'm say do something responsible. The consequences of having failed to act when a friend made overtly suicidal gestures (like giving away a beloved pet) are surely very haunting, indeed.

(I also want to mention that I was really disturbed by your suggestion that kids "plant" evidence -- this is a dangerous, slippery slope

I reiterated twice on the post that kids shouldn't do that, that the truth is enough and there isn't need for more drama. But it's worth reinforcing that deception is RARELY, IF EVER, warranted.

Truth is, a kid who shows signs of severe mental illness does not belong at a "sleep away" university. Keep the kid close to home where parents. . .

Right on, friend. Right on.

Thanks so much for keeping the discussion alive. It's a biggie, no?

jeanie said...

Good post, although I come from a slightly different culture where there is no $ figure and less emphasis on who is blameable... But I can see the point that someone should have been notified - the question then lurks what if he blamed his family for his problems - does the school have to tell them this? And what if he was right and had the sort of family that relatiated - it becomes a quagmire when you start pointing fingers.

The problem is over here that there seemingly is no help channels obvious.

My direct experience is not with a suicidal psychotic, but a schizophrenic who suicided - and the avenues, while looking clear, are not. Unless someone is actually in the act they cannot be sectioned...

Happy stuff, hey - you write well and I always enjoy seeing your points.

TherapyDoc said...

Jeannie, I'd love to know what culture we're talking about, here, profess ignorance.

Once confidentiality is out the window, it's out, so your point is excellent. Parents could do more harm. I never actually took this stand, that it was the parents who HAD TO KNOW.

I just thought the kid needed more help. Not enough information here to say, Yes, the Parents should have been contacted.

We have higher levels of care, and he's in school, so he's insured.

Thanks for your input. Tough about your schiz patient. Probably heard a voice.

I wish a lawyer would comment on this post. Anybody out there?

TherapyDoc said...

oops, meant to say, "patient with schizophrenia", much more true and p.c.

sorry

another point of view said...

TD, thanks for your reply. You are right, this tragedy would have been averted if someone -- anyone -- had called the police and/or taken this young man to the ER. Your post is an encouragement to anyone who might hesitate to act at a critical moment.

J said...

Thanks for your perspective. I guess what bothers me about the leave policies (besides the fact that it smacks of the discrimination you hear about towards employees who are then afraid to seek mental help) is that the school totally washes its hands of the student. If it allowed them to stay, it could stipulate terms that would ensure the student gets appropriate care. Plus, as you alluded to TD, they could lose insurance and the ability to afford help if they aren't in school; mine required me to be a full-time student for 2 semesters/year. Thus, seems like two common outcomes will be 1. students will be afraid to seek help or be honest with school counselors and 2. students who are honest will be dismissed and lose their primary channels to help (school and insurance).

And for the record, regarding "kids" with serious problems making it through college, I've had a handful of friends and aquaintences that were depressed/alcoholic/other/all-of-the-above, and only one of them failed out because of it. Still, that person immediately continued in a community college and succeeded. So I guess you could argue that they weren't all that sick—it's true they weren't as bad as Chuck, at least as far as I'm aware—but I think a large part of it had to do with a lack of other suitable options and/or a strong intrinsic and extrinsic pressure to get through school. I dunno, am I totally wrong about this; is it impossible to motivate someone with major depression if you have the right carrot?

TherapyDoc said...

J, that depends which modifyer on the major axis you're talking about. The number on the dx helps make that determination. Take a 296.23, affective disorder w/ depression, first presentation, severe. That last number, the 3, says it's severe. mild-1
moderate-2
severe-3.

There's no carrot for severe, probably not even one for moderate.

Thanks for your thoughts and excellent points.

Perhaps writing congresspeople will help. I know that more people hit on this post in one day than on any other since I've been blogging, so it's clearly a hot topic. Hopefully a serious one.

sandra said...

My god...how awful. I guess the lesson learned really is that when in doubt, say something -- anything!

TherapyDoc said...

yup. People, especially kids with sick BEST friends, think they have to fix it when they really don't. But they have to make sure someone is in a fixing role, and maybe even more, be sure that there's really some improvement.

Social workers, for example, even with patients who are not suicidal, are supposed to punt to another provider if after 6 months they see no improvement in the client.

lushgurl said...

I have battled with depression for as long as I can remember. One time I was very drunk and very suicidal, I had called a friend at a very late hour. Thankfully he called the police, who came and talked to me and removed the implement I had planned to cut my wrists with. I was not very happy with him at the time and vowed to never call someone again when I was feeling that badly. I AM still here today though.
I had a friend (in a family program) who also suffered from depression, he would call us (other group members), but it was really tough to be there for him. One by one he stopped calling us. Months later, we found out he had killed himself. We all felt such guilt, none of us had been brave enough to do something, anything.
I hope I would not make that same mistake again. I actually did call paramedics/police when another friend had a psychotic episode, she was observed in the hospital, in restraints, medicated, stabilized and released. She too lived. I dunno, I do think as a 'community' we need to get more involved. Depression is such a lonely and isolating disease. It makes it really tough to ask for help when 'we' need it the most!
I would just ask people to BE more aware...

TherapyDoc said...

Thanks, LG. Like you said, it's more about being aggressive in getting someone help than putting yourself in a position of helping, which will burn you out (heck, it burns out health care providers and we have some these tricks at our disposal.

I'm so glad you're still here.

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Thanks again!

DigitalRich