Ten Reasons Not to Kill Yourself

Suzie Gonzalez

I read the news today, oh, boy, 
About a lucky man who made the grade, \
And though the news was rather sad
Well I just had to laugh
I saw the photograph
He blew his mind out in a car, 
He didn't notice that the lights had changed
A crowd of people stood and stared
They'd seen his face before
Nobody was really sure if he was from the House of Lords

Beatles, A Day in the Life

For some reason, I always heard those lyrics as describing a suicide.
Not a pet cemetery

About the picture to your right. They try to make them look like parks, but these are really dreary places to visit. 

Matthew Warren, son of Pastor Rick Warren of the Saddleback Church in California, dead. Matthew's famous father spoke at President Obama's first inauguration. He wrote a letter to his congregants to tell them that Matthew had taken his own life, had lost his battle against depression. It was a self-inflicted gunshot that killed the 27-year old.  

Huff Post quotes the father  “No words can express the anguished grief we feel right now,” Warren wrote. “He had a brilliant intellect and a gift for sensing who was most in pain or most uncomfortable in a room. He’d then make a bee-line to that person to engage and encourage them."
“In spite of America’s best doctors, meds, counselors, and prayers for healing, the torture of mental illness never subsided."
We would say that Matthew had bad disease. What we lost, a picture of Matthew Warren.
I need to remind the reader at this point that the caveat at the top declaring much of what you read here as fiction is there for stories like these. 
A few years back I’m sitting across from an extraordinarily handsome young man in his early thirties. He has an excellent vocabulary and an eastern seaboard accent. He narrates about the mental illness in his family—schizophrenia, the schizo-affective disorders, bi-polar disease. He's been on his roller coaster of disorder and chronic drug and alcohol abuse, with multiple physical problems (as if these can be separate), too, all his life. 
He is talking and I am thinking, Oh My.
There is a feeling the therapist gets and I have it, a worried feeling that her patient will not make it, will kill himself, and it will be on her watch, and she will be held responsible for not getting him to the hospital in time, and even if she isn’t responsible, she will feel she could have intervened somehow.

He tells me that he knows he will kill himself one day, as sure as the sky is blue.

I tell him: Not on my watch.

He laughs and thanks me for that. He needs a great deal of direction in general.

Time passes, my friend leaves the city. We speak about continuing our work on the phone but I am reluctant. I want someone to lay eyes on him, as I like to put it, to feel him.  When we're with the patient we can get that feeling, some of us, that things aren't right, that the psychotic part of the depressive continuum is ascendant. The patient has checked out, wants no help, intends to finally carry through a plan that is always on his radar. He won’t tell any of us this. No, we won’t hear about it from his lips. In fact, when we try to get near to it we hear a resonant objection and a defense of his mental health. “I’m fine! Go back to your nap.” This I do hear, for he knows full well that a good nap does a body good.

He leaves, has a new team in another state, miles and miles away, people to keep him alive. Somehow. 
Six months later I get a call from his wife that he has finished the job. I am startled, surprised, upset, and very, very sad.  This was a pleasant man, a likable person. Surely he could have done something wonderful with his time on this planet, even if was some kind of volunteer work. But he is out of his pain, finally, is what everyone will say.

His wife, on the other hand, is furious at him. Selfish bastard! How dare he do this?  Why in the world would he do this to her? She would have stayed with him, headaches and all, no matter how difficult, no matter the drama! He was in total sobriety and on the right meds, in stable condition, as stable as he had ever been. He should have loved her more than to leave her like he did.

She hates him for this. She will never love anyone as much, or hate anyone so much, all in the same moment. We hold hands over the phone as she cries.

There are others he has left in his wake, parents, siblings, therapists, doctors, people kicking themselves, wishing they could have done more. Even I am thinking, Should I have called him once in awhile? No, he wasn’t my patient. But could I not have just checked in? Is that such a crazy thought?

Oh, it is water under the bridge. Sometimes there is nothing we can do. People leave clues, they tell us as much, that this is the plan, this is as it should be. We can call the police and the patient will charm her way out of an admission. Shlep a man squawking to the hospital, and if he is admitted, he is eventually released, and when he is, if he can get his hands on a gun, he’ll shoot himself. Or use a rope. A woman will ingest all of those meds she’s been hoarding for just the right moment. 

Sometimes we just have to face it. People are hell bent on suicide, either need a release from their pain or want to take others down with them as they go, make sure they are missed. We may not be able to stop it but we can try. 

We can say, "Not on my watch." 
And they can say, "Why not?"
And we have to find reasons why.

Maybe there is something we can do about it to slow it down, for this wave of youth killing themselves does seem to be an epidemic. We need to call it what it is, let’s talk, self-inflicted murder, no different from homicide except that the one pulling the trigger is the most obvious victim. 

To call attention to the problem we should support suicide awareness, visit AFSP's website. We can join in on their walk, donate. AFSP, the American Federation of Suicide Prevention, could use money to promote their anti-suicide campaign. We should make it our anti-suicide campaign. 

Taking a walk to draw attention to a cause is a nice idea. Good people do this. 

There's something else we must do. We have to counter the forces of death on the Internet. I feel it is a Star Wars mission we're talking about. We are the Jedi. 

If you aren't aware of this, you should know that there are websites that feed vulnerable, depressed kids step by step instructions on how to kill themselves. Here, where we are at this moment, people give advice on how to die. Go ahead. Open a new browser and Google: How can I kill myself? You'll fall off your chair there's so much advice out there. Sites share specs on lethal doses of poisons with anyone who asks for information. I imagine they teach rope knots, too.

This upsets me, that the Internet has become the Wild West, a dangerous place, because I like to shop here. There is nothing quite as amazing as Amazon, or useful as a university database, or Hulu. This is a wonderful place, cyberspace. A few rotten apples. Right? No. The tip of the iceberg.

They have to be shut down.

 Suzy Gonzalez was a child. 

Hear her story.

Suzanne's case has an unusual twist. She frequented an Internet newsgroup called called ASH, short for Alt.Suicide.Holiday.  Members of this news group trade advice on how to commit suicide, using code words like 'transitioning' and 'exiting' and 'catching the bus.' Suzanne found this group nine weeks before she died, posting nearly one hundred messages detailing her plans.

Her parents are grieving, her friends and teachers are, too. And it is clear that Suzy had much to offer. People who are very much still alive who say they've been there and respected her wishes to end her pain, persuaded her to hide away in a Florida hotel room and take cyanide.

They told her exactly how to do it so she would make no mistake. Hers was a copycat suicide. They coached her, told her over recipes to die.

Recipes for suicide.

So yes, THIS has to stop. These websites are taking free speech too far. Throw the perpetrators in jail. Pass stiffer laws. I plan to email my congressman. He writes me to say Mazal Tov! whenever something nice happens in my family. Time he did something more.

Is it possible that bloggers like me, bloggers like you, or just readers with Google circles or Facebook pages, Tweeters, any one of us, might participate or better, start a chain, post the reasons that suicide is a very bad option, all things considered?  I'm not technologically savvy enough to know how to do that, but some of you are.

 Feel free to cut and paste. 

         Why suicide is a bad idea. 
(1) There's an agent for everyone. We have new and better medications. Be patient. There's one coming out at a pharmacy near you soon.

(2) Brain research and the fields of psychology and neurobiology are exploding. There may be a cure for depression, a laser, a surgery, who knows? Think about it. One day, zap. You're better. Things are likely to get sunnier if you wait it out. Study up on these things. Learning anything makes you feel life is worth living, too.

(3) You are not bad, not evil, not the source of all that is wrong in your life, your world, the universe. The world will not be a better place without you, no matter what the relentless, unceasing voices in your head are telling you. This is as wrong as 2 plus 2 equals 1 to think that you MUST do this, totally irrational, the thinking of a sick mind, a mind on psychosis  It's not about you, frankly.

(4) People love you, so you can't do it. You don't have this right, no matter what anyone tells you. People love you and if you believe in God, that Higher Power does, too. She has declared all forms of murder out of bounds, even yours. We don't mess with God, but it's not just God. The people who love you will really, really hurt if you kill yourself. It is one thing to feel pain, quite another to give it to others. Wait because you  probably do have love inside, although it is surely fogged over by disease. But you loved and you will continue to love at least someone, or something, and others love you. Love is ephemeral, holy, and all that is good.. Why lose that?

(5) Tough it out because you are already in the process of change, you can't not change. Our cells change over every day. Our moods can, too. We have so many ways in therapy to accomplish this thing we call affective change. Pay attention. 

(6) Change your therapist if therapy isn't working. This should be obvious, but it isn't. A new set of eyes on you is refreshing. Therapists all get a little boring after awhile.

(7) You haven't even tried aging yet. It's not so bad. Age a little, give life a chance. See what is in your future. It will be better, you'll see. And how can you not want to know the future? Seriously.

(8) There are things that only you can do, no one else can do them, and these things have to be done.

(9) There are things that only you are. Nobody else will be the uncle that you will be, or the aunt, or the mother, the father, the daughter, the son. These are unique jobs, very, very important ones.

(10) We need you. We need a new poster child every year, at least one every year, someone who comes out to the world and tells young people: Wait! It really is a permanent solution to a temporary problem. They weren't kidding! I waited and look at me! My picture is on a bus!

We can't judge people like my friend who moved away and did what he said he would do, as sure as the sky is blue, although his wife always will, or the Matthews, the Suzy Gonzalez's. They really didn't know they had a future.They were convinced, in fact, to the contrary, that life would not get better. But  Suzy scooted around her neighborhood in a plaid skirt and green tennis shoes. And Matthew helped others as soon as he sensed their discomfort. A girl like that, a boy like that, knew how to make others happy. We can't afford to lose kids who suffer from depression. They get happiness on a level that no one else ever will. 

So why then? Why do they do it? Sure there's pain. But I propose that they lost that tiny sliver of affect that kept them alive, the one we think of as love, that very positive emotion. We need it to stay alive, need to love something, someone, and we're not talking romantic love, here, rather a sense of connectedness. Friendship will do. For some, a hobby.

On Suzy's website the people who loved her wrote:

Suzy Gonzales was a bright girl who needed to be reminded of the good things
in life, not encouraged to end it. At the time of her death, Suzy was the 14th confirmed
suicide associated with this particular site, they claim 24 "successes" today.

I'm so sorry for her family, and for Matthew's, and for all of you who have lost someone to suicide.



Oy. Timely.



My wife's cousin's son. 19. Ended his life 3 weeks ago.
Graciewilde said…
Thank you for this piece. I plan to Google the How to kill yourself question b/c I work at a middle school. I know know kids are investigating just that thing.
For my own sake, I appreciated your list of ten reasons not to kill yourself. Nice to see it in black and white like that.
Anonymous said…
A great piece. I haven't heard anyone say before that a therapist can get boring and that new eyes can be useful. Love your postings
Anonymous said…
Amazing words. Thank you for posting.
Brian S.
Anonymous said…
Thank you thank you thank you. I too have that scared feeling that one day it might be me. That list was very helpful and gives me something solid to hold on to.
Anonymous said…
I used to frequent alt.suicide.holiday, I have to admit, and acted on some of the knowledge I got there. I'm better now, though there is still a siren song. I have to be careful about keeping the wax in my ears.

I'm trying to reflect on your Top 10 list to see how those things would have sounded to me at my most suicidal. I know they seem obvious to you, but they would have made me angry to hear -- you would have been willfully MISSING THE POINT. The biggest mistake is to think you understand why people commit suicide -- there isn't any one reason; it's complicated, like. In my case, it goes something like this:

I have a terrible dark secret, something that I know that no one else does: I am the root of all evil in this world, yep, the Fount of Bad. And while I sort of know that this isn't literally true, it's still a powerful thought. It gives my life meaning, in a way, and a reason to end it. I don't care that I might feel "better" in the future, because how I feel now is how I SHOULD feel; I've got access to truth here and your points about how I'm a brother or uncle is to confuse the mundane details of my ordinary life with the Big Picture I am really dealing with here.

Now, of course, that's my particular suicidal mind. But the suicidal mind is a trickster, I think, and very good at portraying suicide as WHAT MUST HAPPEN. WHAT HAS ALREADY BEEN DETERMINED MUST HAPPEN. Like a car salesman closing the sale....

The other thing I'd like to say -- and this isn't just me, I think -- is that the suicidal thought/urge, once developed, is RELENTLESS. It's a thousand voices pounding your brain, day and night, flashing method upon method before your eyes, daring you, taunting you. It's a wonder it's survivable, really.

So I'm happy to see your list, happy to see you call a.s.h on its shenanigans. I hope it helps you fine-tune your list.
Smitty said…
This is beautiful. And real. And I thank you for facing the pain of it, that you experience as a therapist.

Thank you.

therapydoc said…
No, thanks to all of you. I did revise my list, read numbers 3 and 4. It is something I knew, that the reasons for suicide are multivariate, but I should have addressed that unrelenting feeling that it is NECESSARY and HAS TO HAPPEN. It isn't, of course, which is what my list is about, but boy-- if we don't tip our hats to the power of that suggestion, we're really missing the whole point.

So thank you, thank you, thank you, anonymous for pointing that out. Nobody's tougher than someone who can beat this disease. I'm in awe.
therapydoc said…
That came out wrong. First sentence should have read, Thanks to all of you. Mom always said haste makes waste.
Syd said…
One of the things that sticks in my memory is a group therapy session in which one of the members was telling the Doc that she was going to kill herself. He did not mess around and told her in no uncertain terms that he expected her to live and gave her the "not on my watch" talk in his own way. It was powerful and my first experience with someone who wanted to die.

Now many years later, I have had several people in my life who have killed themselves. It saddens me because I realize that they have lost all hope. Yet, every day is different and those who have attempted suicide and failed sometimes say that they were glad that they didn't succeed.

I saw my own mother's depression that was so deep, I know she would have died. Fortunately, ECT brought her back. Drastic situations call for drastic measures. But there is treatment for those who suffer from deep depression.

Anyway, great article. I hope that it helps some people who may be flirting with death.
mheobk said…
Thank you for this post.
I have bipolar, and the statistics say that 9% of people with depression and 20% of people with bipolar commit suicide. So, we bipolars struggle with suicidal ideation, too. I've dealt with it and kept it at bay through faith in my Higher Power and love for my family, particularly my children. I just can't stand to think of what my suicide would do to those I leave behind.

Referring to your list, I guess it's numbers 4 and 5 that help the most. I'm old enough to know that nothing lasts forever, good or bad. So, if I get ill, I call my doctor, talk to a couple of carefully selected friends, clue my husband in and wait it out. The waiting really is the hardest part....

I've seen the wreckage caused by other people's suicides. I can confirm that the ideas are sometimes relentless, and they are like a siren's song or a sore tooth. I have the most difficulty when I'm ill and driving a car alone. So...when I'm ill, I put my brain in a box and follow what my mind tells me--stay home and don't drive alone.

I'm blessed with not having a terrible case, with a desire to be medically compliant, and with a string urge to live.

I really appreciate the directness of this post, and I'm mulling over the best way to share this information.

Very grateful,
Such a great post/blog. I love getting lost in your words. Thank you!
Anonymous said…
Right now I don't want to live anymore. Walking up, school, homework, all of it just brings anxiety and depression. Everyday feels like I'm walking up a mountain. It's not easy. At times it physically feels as if I'm pushing a bolder uphill and the whole time I'm afraid that I'm going to slip or stumble and the bolder is going to roll over me. Am I going to commit suicide? No. But every day I dread getting up and going to sleep. I'm not sure what there is to look forward to. All I see are tests, bills, stress and frustration. To top it all off I hate myself for feeling like this when I watch classmates thriving and trying to get the most out of life. I'm on anitdepressants, I go to therapy but its sooooo hard. I hate feeling this way and I hate myself for being too lazy to work hard and compete. I don't think depression is a disease. It's me being lazy and not wanting to put in the work. I'm so tired but you can't talk to friends or family about these things. People sign it off as complaining and not working hard. I can understand the pain that those lost went through. I hope that others considering suicide can find strength and love within themselves and from others until they can feel it. Site encouraging how to commit suicide need to be taken down. The worst thing to do is combine someone that is depressed and socially isolated with the internet.
therapydoc said…
Thanks for all of your feedback and comments.
Syd, I'm glad you mentioned ECT. There are so many bad stories that doctors are afraid to recommend it. But I've also seen good results. Still, it is a gamble.
mheobk, I'm wish everyone had that desire to be medically compliant. It does keep people alive, for sure.
Get a Degree, what a fabulous compliment!
And finally, anonymous above, it's heart-breaking that kids like you are always looking down on you, and can't see that "lazy" is a symptom of the disease. Depression is exhausting, and by definition, sufferers are apathetic, not jumping in to volunteer for things, not always able to complete tasks. I don't do therapy on the blog, but I can tell you that from what you describe, you do have a life, and it is a difficult one at that, but it's yours right now. Stick with therapy, wait this developmental stage out-- it's a tough one. You'll be so glad, when you look back, that you did.

Anonymous said…
Your blog is wonderful! Im so thankful to have discovered this little treasure.
You had me at #3 and 4... and by "had me" I mean had me in tears. I'm two sessions away from "graduating" from my cognitive behavioral therapy... I've been jokingly telling people that in a couple weeks I will be "all better," "cured," or "perfectly sane"

...but the truth is, I feel like I'm still carrying this terrible secret: Even though I *know* the facts stated in #3, and have worked on checking my thoughts for accuracy throughout my CBT...even though I know some people love me, and God loves me, and things change, and here's the big one--even though I have HOPE, I still can't escape being knocked over by waves of despair which I can fully see potentially getting the best of me one day.

That's a secret I can't admit to... perhaps because I fear I will be declared an unfit mother or something like that (and no matter how unfit I may believe myself to be, I know nobody can love my kids like I do--and that has kept me going more than anything else in this world.)

It's a paradox. I feel incredibly frail--like the smallest breeze could snap the thread I am holding on by. And (maybe this is part of what made Matthew so empathetic toward those who were hurting...) I tend to view others who I see struggling, through the same lens of frailty that I see myself. Sometimes I'm not as strict as I should be with my kids because I don't want to upset them and thus cause them to do what I know I could so easily do... Or maybe not so easily. Sometimes I think I'm alive because I'm a wimp. I have often wished I had the willpower to starve myself. I sometimes see the inability to carry through on something like that as a weakness. But I can't admit that to anyone because I know that is irrational thought. There seems to be a difference between knowing and believing.

I tell my therapist that most of my depression is purely situational because I'm in the midst of the break-up of a crappy marriage that has taken up more than half of my life... but is that the whole truth? Probably not. I doubt we're going to be able to address that question in just two remaining sessions.

therapydoc said…
Thanks Soul, and Bridget, wow. So cool that you realize messing with your life will pretty much ruin those of others, mainly the ones you brought into the world. Wreck their whole day (if we think of life as one long day). Remember, I can't be anyone's therapist here, stay in therapy.

What I love about what you write (an extension of you, btw) is that whereas some would say you project, meaning you see others as fragile, too, which is why you're careful about confrontation, is true. So many of us are that it's worth assuming that they are, that they don't need the criticism, no thanks to those you feel otherwise. Abused kids, especially, can be especially careful about what they say to others because they know what it is like to feel less than. That said, you get more out of life when you ask for it, and that often feels like confrontation.

Thank you for contributing. Live to see them marry and have kids, call you Grandma. Great-grandma.
Lorri M said…
Thank you for this piece...such a necessary one...unfortunately.

I am sure it will bring inspiration and/or contemplation to many.
Anonymous said…
Thank you for this but I don't know if there is any help for me. My life has been one long uphill struggle. I did accomplish some things but things went bad in a confusing way. People who I thought were my friends have pushed me away,bar none.
I look back on my life and it is/was a life of enormous pain,anxiety.Even my family has pushed me away. I must be really horrible or something but I have always done my best to be kind and supportive of others.
I have a serious chronic disease with some sort of probable autoimmune disorder developing and I cannot work in my profession or even volunteer because my health is so dodgy. I feel so useless.
I'm closed down and am so wary of others because of past hurts.
I am not going to do this soon but it is inevitable because of so much pain,physical and emotional.
I appreciate your article and am not posting to argue with you but to give you insight to a person like me so that maybe something can be done.
Thank you.
therapydoc said…
Thanks for writing, anon. If you still have insurance, see if there's a DBT therapist/team in your woods. Barring that, there's a terrific book I just read, DBT Made Simple by Sheri Van Dijk. I'm going to be reviewing that. Just from what you write I see there's much to work with and reason to be hopeful. Acceptance of reality is a beginning, and you seem to be there, if not, then almost there.
Everything happen for a reason, it sounds cliche but that's how it is. And ending the reason why you are on earth does not make sense, so why not live it instead. We encounter issues in life to appreciate things, like this one.
Beno said…
This is a great post and when the time is right I will share it with all my friends. The comments are very insightful too. It's pretty messed up that there's a group on the internet trying to convince people to commit suicide. I noticed there's a SuicideWatch subreddit which offers some constructive support and advice.
Anonymous said…
I have often said " my mind is trying to kill me." I have fought depression the past few years and also thought about ending my life.

The thought of feeling so bad forever would never end made me think that way.

I think the mind is our enemy and when you get lost in those terribly lies your own mind tells you how can you fight that. A therapist should tell you that you can't believe everything you think.

I used The Work by Byron Katey to show myself that I was telling myself lies. I think the smarter you are the harder it is to break this pattern of lies. No one outside yourself knows what you are telling yourself 24 hours a day.

I am glad I didn't act on my feelings now. I have come out of the darkness finally. I can understand just wanting to end the pain.

You can't be in someone's mind that is why you can't save them from themselves.
therapydoc said…
Thanks Stop Panic, Beno, and Anonymous-- so glad you didn't act on it and can testify here that it is the mind doing its lying thing. The mind does lie, but that's counter-intuitive to the advice so many people give-- GO WITH YOUR GUT. Actually, DON'T GO WITH YOUR GUT! Not when the gut is listening to garbage.
I won't tell you what I "googled" to come upon your BLOG. I like it though. I am glad I found it and will definitely be back.
Anonymous said…
"And finally, anonymous above, it's heart-breaking that kids like you are always looking down on you, and can't see that "lazy" is a symptom of the disease. Depression is exhausting, and by definition, sufferers are apathetic, not jumping in to volunteer for things, not always able to complete tasks. I don't do therapy on the blog, but I can tell you that from what you describe, you do have a life, and it is a difficult one at that, but it's yours right now. Stick with therapy, wait this developmental stage out-- it's a tough one. You'll be so glad, when you look back, that you did."

Thanks for the response but I've been struggling for a while. It seems to me as if depression and anxiety never go away. They are just things that need to be 'managed'. I'm tired of 'managing' my life. It's hard when I see classmates excited about school and striving to do better. I honestly hate it. 'They' say that it gets better but it doesn't. To give an example: If you have been bullied all of your life guess who benefits? The bully. They are assertive,smart and resourceful and will get the great jobs and the great life. The bullied lack confidence, have anxiety that once it starts it's there for a lifetime, lack social skills and tend to avoid things in life rather than facing them. I honestly, don't see the sense in trying. Why? If you're going to be struggling for the rest of your life. If you are not smart, then you will also be left behind and struggle. You can't get good jobs and it's embarrassing to be around your peers and labeled as the slow on. I don't see my life getting better and I'm tired of trying.
therapydoc said…
It always looks this way, hopeless, and that's the problem with depression, or as one reader mentioned, believing your thoughts. I tell people to be very skeptical of themselves. And being smart, fyi, has a lot of different connotations. Frankly, I think life is all about luck. Or fate. Much more than what we think it's about, that's for sure.
Anonymous said…
I know that there are different types of intelligence. I'm told that all the time. I'm not trying to be antagonistic, I just want to further the conversation, unfortunately schools only recognize one type. It's that type of intelligence that ultimately determines how well you do in school.It's nice to be optimistic but the real world doesn't recognize that. I've experienced it first hand.
Medkid said…
Thank you for this post. I have unintentionally amassed in my tiny but growing practice as a resident a group of women who are mentally ill. My co-residents joke "the patient is mentally ill, an addict, and has a problem list 25 items long? It's a Dr. Medkid patient..." My gift and my curse. I consider it a huge success when some of my patients don't come to their appointment under the influence of something. But at least they come right?

It's no surprise I am good at this. My own struggles have lead to an understanding that others don't have the misfortune and blessing of having. I have the perspective of knowing what it's like when the tiny flame of hope disappears, when you feel nothing: no love, no hope, just darkness, and what it takes to choose the slow journey back to health and wholeness. Not to say other doctor's don't have a personal understanding of the same thing as our professional suicide rate will tell you (estimates are that 25% of a med school class will struggle with major depression in their time at med school though likely the number is higher).

I also have the knowledge of what a gigantic gift appropriate, skilled, mental health care (as well as the damage poor, unskilled mental health care causes, and pray I am not causing it). I too live with the fear after safety contracts and asking questions no one wants to ask about suicidality that my patient's will die on "my watch."

I didn't sign up to be a psychiatrist, but some studies estimate that over 50% of the mental health care in America is provided by the likes of me and my fellow primary care colleagues. I knew this, but I wasn't prepared for how poor the training would be in this part of the country regarding that fact. The northeast trains their primary care physicians aggressively and well in basic primary care treatment of mental illness fully aware that it is part of our scope of practice whether we like it or not (I am hoping to do a rotation in the Northeast knowing I will need that skill set).
Sometimes though you get a phone call like I did yesterday when a patient has made the choice to invest in healing, and she is overjoyed by the change that has happened in her life after years and years of struggling. As you mentioned in the list, the magical right medication and a good therapist can change someone's life entirely. Sure I tried a bunch of different meds with her and found one that worked (miraculously) though I remained frustrated and scared that no psychiatrist would see my uninsured patient. I knew this level of mental illness was beyond my scope of practice but having no choice (I am training in a state with an exceptionally poor mental health coverage and if you don't have medicaid or medicare you can get essentially no psychiatric care. Having a psychiatry residency in our state is useless. The depression center won't even see University residents let alone my uninsured patients. The price we pay for underfunding residency).
Desperate and feeling impotent because of my lack of knowledge at treating severe mental illness, I had no choice but to stand by my patient and try a variety of SSRIs and maybe an SNRI or two. If I'm lucky my attending will agree to an abilify adjunct, though many balk at the idea, forget a mood stabilizer. I do this and I pray as I flounder in over my head that their suicidality will abate. I see them frequently and I watch, hoping.
Sometimes they get better, sometimes they don't. I encourage them to do therapy, I drag them into my office week after week, and I pray in the face of seemingly impossible chances. My patients don't have resources and their list of trauma and familial history of serious mental illness is usually a long one thanks to downward drift. We do what we can knowing it will never be ideal.

Your list helps me for those times I will sit alone across from a suicidal patient not knowing what to say. Thank you again for this posting.
therapydoc said…
Anon, this is a great conversation, and MedKid, thanks as always, you always add so much to these posts.

Pretty soon, maybe tonight but maybe not until tomorrow or Monday, I'm going to post on DBT, Dialectical Behavioral Therapy skills training. I used to think that if you didn't work with a team (DBT always uses a team approach) that you set yourself up to fail, lean that way, still. Having the worldview helps tremendously, however, when working with the hopeless/helpless even without the benefit of a team, not that I would recommend going it alone. Our next discussion, however will hopefully lift up the curtain here, provide some structure, not that I don't intend to ramble on and on. Meanwhile, if you are suicidal, start looking for a DBT specialist near you. That's your next stop.
Anonymous said…
Many years ago I was in a dark, dark place. Fortunately I had an amazing therapist at the time who I trusted completely and adored (transference, natch). I told him I had a plan (and what it was) and he said, "promise me you will never do it. I would never get over it." I promised and I kept that promise. The transference was downright painful at times but it also kept me alive at a time when I was drowning under the weight of it all.
therapydoc said…
See, it really is all in the therapeutic relationship, and that has everything to do with not being clinical, but being human. So glad, anon, you had that.
Unknown said…
This was a really powerful article. It really is never known why people eventually decide to commit suicide. But whatever the reason, it is always tragic. It seems that once people get in their minds they want to end their life, it is hard to bring them back out of that mindset. Have you heard anything about counsellors in Calgary? I am wondering if they provide good services.
Anonymous said…
Thanks for writing, anon. This is a Great Post !! It's such an interesting post, I really like it. Thank you and keep sharing,

Anonymous said…
sometimes people can't get help because they can't afford it and don't want to burden the people around them. Maybe you could post some free sources for help.
therapydoc said…
The AFSP, American Federation for the Prevention of Suicide is excellent, as is NAMI, the National Alliance on Mental Illness.

But you can also use community mental health services. Depending upon how rural you are, you may have to commute to get help. But help is free or on a sliding scale, and people like me worked in those systems, some family agencies. One off my old friends still works in a public community mental health agency and she loves it, and I'll tell you-- she's a wonderful therapist. I believe there are many of us out there (social workers and psychologists) still working in public agencies. It isn't a stress-free job, that's for sure. You can look in the phone book (white pages) or google Community Mental Health.
therapydoc said…
Oh! And if you feel self-destructive, the emergency rooms of the world will see you (at some point during the day, earlier than later if you look the attendant right in the eye and say I'm leaving and I'm going to kill myself).

Then they will find help for you. It is an emergency, after all, human life.
Anonymous said…
Somewhat late after publishing, but I have only found your article recently.

I myself got lucky with my depression, went to multiple doctors, at their best they wasted my time and at their worst they actively worsened my state (although not intentionally, but still. The sheer lack of any common sense, basic people skills and empathy astonished me.) Then I stumbled upon my first antidepressants and luckily, they worked. I don't know if I'd try different ones if the first ones didn't help. In the state I was in, not likely.

I myself have come as far as weighing several options on suicide (didn't even need to look on the internet, knew all I needed to know from books). So I haven't ever really decided to actively pursue suicide.
But I saw my thoughts and I knew that I wasn't supposed to have them. I was also bombarded with things like "you can get over this on your own, you're strong" and "don't even say that!" followed by complete shutting me off and changing topics when I confided in my closest person (incidentally, a relative).

I mean, I was ready to talk about it. Consider options. But nobody seemed to want to listen to me. Because what I said made them nervous. I remember feeling so tired, death would just be a fitting end, like going to sleep after a long and eventful day. I also responded with boiling rage and taking control whenever someone told me I shouldn't/wouldn't commit suicide because blah blah.

My grandfather hung himself when he was 44. Massive depression, huge taboo about it as well. Thing is? My grandma moved on. Whatever you do, however you die, people move on. That's a normal and healthy process. That means two things: 1. There's really no good reason to kill yourself just to punish someone, and closely related, 2. If you tell me I shouldn't commit suicide, because it will hurt other people, that only makes me think you're completely clueless.
I don't care if people get hurt with my death. They'll move on. If they won't, then maybe they commit suicide. So what. Some of us make it, some of us don't. Anybody tries to assert control over my suicide plans, that only pushes me to withdraw. Not a good thing, if you need to keep a patient in therapy.

Now, this was all pretty recent (couple months back), which is why I remember so many details. I don't even have suicidal thoughts anymore, let alone intentions. But knowing what I know from my experience and reading what you wrote? I'd be more careful if I were you, because piling this on could very well be the last straw for someone to finally decide. And show everyone that nobody has control over his/her suicide, only him/her. I know it definitely would for me.
Anonymous said…
I'm one of those middle school kid's going on high school that is depressed and truthfully the list did help a bit but I still feel horrible like the world would be better with out me. Sometimes I wonder why it sometimes feels like the whole world would be better off. I mean as much as I would love to kill myself I know there will be people who miss. But sometimes it feels like they would be better off with out me. And even though I'm pretty young I know the world won't always be a dreary place. And yet even though I know that I still want to suicide.
therapydoc said…
Hi Anon, Absolutely the world won't always be a dreary place. Tell someone about your thoughts and ask if you can get therapy. We all need it at some point in our lives and in my opinion, the younger the better, and sometimes the more often the better, and the more therapists the better. Good luck!!

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