Head spin

That story in WSJ on Chuck Mahoney did that, triggered me, maybe it triggered some of you, too. For me it was less the outrage about nobody saving Chuck's life than it was the sadness I felt for his parents and his brother. Elizabeth Bernstein wrote:

About once a week, the elder Mr. Mahoney opens the closet and buries his head in a sweatshirt that belonged to his son, trying to detect the fading scent.

I read the story on Saturday, looked up from my newspaper, stared through an open window to the backyard and tranced back over thirty years ago, saw myself putting on my brother's clothes, picking out a jacket (way too big for me), burying my head in it. My mother found me and I turned to her, This is mine, okay?

I almost started my post (3-24-07) on Chuck Mahoney like this: If you're easily triggered, meaning if you get depressed and stay depressed for a long time and can't bring yourself out of it, YOU MIGHT NOT WANT TO READ THIS.

So Elizabeth Bernstein's article made me. . . pause. For quite awhile. A good four hours, and my brother didn't kill himself. Journalists can do that to you. This blog is journalistic in that way too, sometimes. Maybe now.

Emotionally manipulative-- intentionally. I'll let you in on a little secret. You already know it, probably. Feeling badly for most of us, soaking up a little sadness, relating to the pain of others or even feeling our very own pain isn't so bad. In fact, it's a good stretch. Almost sublime. Expands our sensory perception of reality.

In my world view if a day goes by and I haven't squirted out at least one tear then I've been out of touch with reality, the suffering around me. It's around you, too, of course.

There are triggers and there are triggers, and there are the triggered and there are the triggered. My warning on that post would have been to those individuals who wouldn't bounce back within the hour or the day. The warning would have been for people who could really lose their cognitive functioning and maybe wouldn't be able to work for a couple of days after that. It can happen.

Being unable to function when depressed means there's no capacity to think. That's why making decisions is so hard. When a person can't "think straight" then there can be an added feeling of panic. That's why you'll sometimes describe to me waking up with a horrific fear, crippling fear mixed with tears and sadness, all interwoven at the same time, severe, severe panic and pain. And you haven't even started your day! You haven't brushed your teeth yet!

Not a nice disorder, depression.

So therapydocs tell people who suffer from it to avoid triggers. Although in some types of depression (probably the severe one I just described above) triggers may have nothing whatsoever to do with the onset, meaning an episode can seemingly come from out of the air.

Bi-polar disorder can be this way, although bi-polars can be triggered too. They will usually cycle, however, and there are seasons and months that are more likely to be more severe in one direction or another. They jump around on the continuum below in every which way with no say so in the matter. Usually it's physiology is all.Sometimes that depression on the left can hit like a ton of bricks with no warning.

For most other types of depression, however, like adjustment disorders, the onset is a little slower, and things do get gradually more and more gray and horrible.

We tell patients recovering from depressions of all kinds to avoid stimuli that they know will make them sad, the thoughts that will stick with them, affect their thinking, send them back down again.

Here's my short list of how to avoid triggers that can either cause an episode or make it difficult to recover:

don't read the newspaper
don't watch t.v. (unless you're sure it's comedy)
don't follow the war
don't go to funerals or wakes unless you KNOW you'll be okay
don't talk to people who upset you
that might mean, don't answer the phone or the doorbell
do protect yourself from stress of all kinds
do try to live in a bubble (although you can't, really, but try)
do make your own emotionally safe, restful environment (don't accept visitors, don't do extra community work to make people happy until you're really better)

that's basically what being in the hospital is like, you know, protective

And of course, my advice is based upon empirical data vis a vis the things that trigger psychotic reactions Let's segue there because it's so interesting.

The psychotic fear, depression and paranoia of schizophrenia and schizo-affective disorder can be triggered by something called expressed emotion.

Expressed emotion is really anger/criticism expressed at anyone at all by anyone within the family or on the job. Families who have a member who suffers from schizophrenia are taught to keep the anger and the criticism, ANY anger/criticism to anyone to a minimum.

Best to lose it entirely from the family's range of emotions.

That's the best thing you can do for a mentally ill person in your family. Be really gentle and nice all of the time. That will reduce your vulnerable family member's screaming anxiety and depressive outbursts.

Now. I think we could take a leap, here. Maybe, just maybe, if anger and criticism are bad for people with severe mental disorders, then perhaps they're also bad for the rest of us?

Hmmm.


Copyright 2007, TherapyDoc

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