A tale about the Jewish body and suicide

I just received this link.

It is a beauty, written by a dear friend about Jews and suicide.

13 Reasons Why

I know I've been away for awhile, and have so much to say, but all those snapshots about less essential things will have to wait. 

Because this is really important. 

There is a new show on Netflix, 13 Reasons Why, capturing the attention of teenagers and adults everywhere. When I saw it on the Netflix menu last week I passed without thinking. It seemed so much like work, you know?

But it is at the top of my list now. A therapist has to be informed.

This is a series of 13 shows focused on 13 people, people who in one way or another contributed to a teen's decision to end her life. Hannah Baker has already done the deed, leaves behind 13 audio cassettes implicating others. The screen adaptation is based on teen fiction writer Jay Ashers'  2007 novel of the same name.

Any therapist will tell you that we all, in one way or another, have at some point in our lives, affected the mental health of another person, for better or worse. Indeed, there is a therapy adage, well-understood:

For every suicide, there is someone else who wanted that person dead. 

Yes, that sounds macabre, but it is true. Well, sometimes it is true. Certain personalities are so grating, so annoying, so abusive (whether intentionally or not) so hard on us, so needy and intrusive, that loved ones (loved ones!) wish they were dead. And the one who is the problem picks up on that.

The suicides of patients diagnosed with BPD, Borderline Personality Disorder are often blamed (in notes) on family and friends who could not meet insatiable needs, or who outright rejected them, ended the relationship. The one who took his life likely put impossible demands upon others, expected them to drop everything to help. But it catches up on people, dropping everything else. It takes a toll. It becomes a matter of survival to limit the relationship.

We can't love everyone, and love can hurt. Mostly it is the lack of love that hurts the most, the withdrawal of love.

Borderline Personality Disorder is probably not what 13 Reasons Why is about (remember, I haven't seen it). In Alexa Curtis's article in Rolling Stone (a must read) we learn that Hannah has been raped by a popular boy, and witnessed sexual assault, suffered from bullying and the rejection of friends. She likely didn't have BPD, rather suffered loneliness, hopelessness, low self-worth, and depression.

Alexa Curtis, nineteen years old herself, a survivor of teenage bullying, upon hearing about 13 Reasons had to watch it. She is the founder of Media Impact and Navigation for Teens (M.I.N.T.), an online guide to media, self help. Alexa thought to herself, Had I watched this as a young teen I would have done it! I'd be dead today!  In her Rolling Stone opinion article she suggests that the show does more harm than good, the risk of glamorizing suicide is too great. Her opinion-- Hannah's story lives on forever in the audio tapes, and suicide should be an ending-- that's the point.

Which is not true, unfortunately. It is never an ending, because those who have loved and lost someone carry that person's legacy forever. They never forget the salient details of that person's life, now snuffed out, and will talk about it in therapy, given the opportunity, speak with tears and self-recrimination, of their own guilt, their failure to provide enough help, support, love. The survivors own it, right or wrong, their contribution, and attribute death to their failure.

There is that percentage, one in five of all borderline patients in a clinical population, for whom suicide will be the answer. The act is often to punish the "failures"of other people. The suicide literally says,

It Is Your Fault. 

For others suicide is the choice because they can no longer cope with their depression and need it to stop. Suicidal patients are at the greatest risk when they feel a little better, have the energy to do it. It takes a lot of energy to kill yourself. Depression, abated somewhat, is still close enough to touch. Why not now, is the thinking. It will come back.

And sometimes, with mental illness, even with much, much therapy, the memories of the many reasons not to do it, reasons discussed in therapy, are entirely erased. It is as if, in the throes of an episode, either manic or depressed, the only right thing to do is end it. It is the logical choice of an impaired, illogical mind, a painful choice, sometimes, and always illogical.

And there are other reasons, more than 13 of them, most likely. Complicated reasons.

So we have to have these discussions, talk about them. Make them long discussions.

Teenagers will be watching this new show that depicts fictional Hannah Baker's suicide in one of those episodes, and it looks frighteningly real. And our kids, our friends, the ones who watch, who are vulnerable and depressed, who have been bullied, perhaps, will consider the option. Peers, siblings, children. There will be copycats. Some are videotaping themselves right now.

It is a graphic show, we're warned, one that begs discussion, conversation.

And there is a media debate about it:

Is this the best way to raise suicide prevention, to get the conversation started?

Yes, because everybody's talking about it.
No, because there will be copycats. Kids will die as a result, will feel empowered. Hannah did it, so can I. 

We have a teenage suicide epidemic going on.

I thought about it and made a note in my calendar to make a few calls, catch up with the adolescents I've seen in the past year who haven't come back, who for one reason or another, dropped out of therapy or terminated therapy. That's one thing I can do.

What can you do?  Well, ask any teenager you know,

Have you seen 13 Reasons Why?

And get a conversation going. You might save a life.
Because for every reason why, you're likely to be able to counter with a good reason Why Not.

therapydoc

Other discussions on this blog about suicide:

Ten Reasons Not to Kill Yourself

How to Save a Life

How to Save a Life, Part 2

How to Save a Life, Part 3

How to Save a Life- Part Two

Terrorists from Pakistan attacked institutions, innocent people, in Mumbai last November; a group of about sixty armed Muslims (please read comments, no disrespect here to the entire family of Muslims), ready to die to make a statement, responsible for at least eighty deaths, more than 250 injured.

Not that I want to dwell on suicide and death, it is not the winter upper you're looking for. But we need to build a little on that last post, How to Save a Life.

I don't know if you noticed, but that one bled values. Not that that's bad, having values, in fact, the National Association of Social Workers has a code of ethics that uses the word repeatedly, values, and the American Psychological Association's code implies them, standards, beneficience, fidelity and responsibility. The American Psychiatric Association piggy backs on the American Medical Association, and you know doctors tend to be death-avoidant.

We're talking about saving lives, here, on this blog, in a society in which suicide is endemic, becoming more and more prevalent. And that salve, hope, although presidential rhetoric aspires to make it so, (thanks Star Trek, Next Generation), is sorely lacking. It's missing from among the poor, and the rich, as well.

Lost millions, to many something new, is lost identity. Lost jobs, lost identity. At least a piece of identity, self, is lost. Hard to stay hopeful, so confused, rudderless. For many hard-working people, the tagline might be, I am my money. If I'm doing well, I'm well. If I'm not, I'm not.

Tear money away, for the first time, from the identity of an income-earning adult, and you have an uncharted psyche. It's like being sixteen again. Who am I?

And that's fine, in fact we can all appreciate a make-over, it could do us all a world of good to redefine ourselves, reassess who we are and what we should be. Can be. But if other plates aren't twirling well, if the marriage has gone south, and the kids are using drugs, if your mother's been diagnosed with something you can't pronounce, and your dog just bit the neighbor, then not having money can be the stress that tips you over. Bring out the Puffs* about now, for sure.

I made a bad joke yesterday, forgive me, please, but I meant it, sort of, really wondered. Upon hearing that Japan is officially in a recession, I asked FD, "Does this mean that hari kari will go up in that country?"

Bad taste, he said with his eyes. And he's right. But I'm really worried about this trend, in general, the value on life disappearing in society. Life is less meaningful for so many when times are tough, and we are in an international recession. And our safety, our physical security is not even an assumption anymore, hasn't been, some say, since September 11, 2001, the day that terrorists declared war on the West, The Enemy, and smashed flying machines into buildings in New York City and Washington D.C.

The West is the enemy for terrorist suicidists (my new word of the year, people who encourage others or believe in the benefit of suicide, the right to take one's life, although maybe euthanasia applies). Those who see Western values as evil focus on our lack of modesty and promiscuity, as if these are only Western phenomena. We don't redistribute wealth as perhaps a communist society might. Or a king. A king? Or perhaps a benevolent dictator. (Someone stop this rant)

I don't know about you, but the other day a young man came to my door asking for money for Save the Children, an international cause. I get solicited quite regularly and give what I can. From the look of the pages of names on his clipboard, am apparently not alone.

Until recently, it is true, The West represented affluence, good health, the good life. And America, especially, is a country that defines itself with wonderful things, but these things include individual rights, freedoms, and a system of government that has functioned relatively well for over two centuries. The system shows signs of wear, but it is running better than ever.

The greatest country in the world, we used to say when I was a child, and if you listened to President Obama's speech on Wednesday night, still believe.

We will all cut back. We'll get by.
Someone said to me this week, "I can stay in denial for just so long, and then. . . reality sets in."

And I had to respond, "You can grieve what you've lost, that's fine. But it's what you have that matters."

If we define ourselves by our affluence, what are we? And if a nation defines itself this way, as some, apparently believe is true of America, and affluence disappears, then happiness does, as well.

But any mental health professional will tell you that mental health depends upon much more than money. We can't obsess on this. And America's future, in particular should be bright, has to be, because this country is not about affluence, it is about opportunity.

And we have enviable, unbelievably enviable rights.

These rights make us happy, too. Suicide isn't included as one of them, but freedoms of speech and religion, the right to life, liberty, and the pursuit of happiness, we take these for granted. They're in the "have" list.

The terrorist approach to Western ideals seems to be: Destroy people who express themselves (the entertainment industry, especially); destroy yourself if necessary to destroy others; nuke America, if at all possible, and by all means, while you're at it, destroy that Zionist state, too. I think the idea is that if some people have to be poor, others have to suffer. A good society suffers together.

Not so different from holding a friend's hand, as we discussed in the How to Save a Life post, or is it? Oh yes, it's much different.

Those of you who saw Slum Dog Millionaire saw hundreds of poor people in the streets of India, barefoot, hungry, wet from the rain, homeless. And yet India is not a hotbed of terrorism, indeed the country suffered a hit in Mumbai. Osama bin Laudin has not got a grip on India or its people, probably because there is meaning in life in that country. Meaning and a search for harmony that is not about having money or being angry if you don't have it. India is about survival and peace, although we surely see the underbelly in the movie. But there's not a readiness, a willingness, a value for blowing oneself up, murdering others to make a point.

Or have I missed something?

It is hard to understand how a culture could glorify suicide, how any child's life, anyone's life, could be distilled down to something that a society is willing to sacrifice to make a political statement. Last week the human sacrifices that delivered suicide bombs in Iraq were all women, not women who were depressed, who couldn't take it anymore so they killed themselves, but women who wanted to be remembered for their deeds, for the glorious deed of killing themselves. They wanted the glory of dying for their values, and valued dying.

All I can think is, desperate or brain-washed or both. Mentally ill? I haven't given the status exam. My guess is that the night before, before a person commits this atrocity, murdering innocent people, murdering oneself, there is a going away party.

A different suicide altogether. How did that song go?

Where did I go wrong, I lost a friend. Somewhere in the bitterness. If I had stayed up with you all night. . .Maybe I'd know. . How to save a life.

Something like that. Every life is invaluable; our worth, incalculable. Where there is life there is hope. Even now, when denial is hard to hold onto.

therapydoc

*Puffs is a Proctor and Gamble product. As soon as they pay me (this is America) I'll put a link to the P & G website right there!

How to Save a Life

Caveat: This may make you feel bad. If you know someone who killed himself, or herself, and you feel badly about your part in it somehow, get therapy. Or talk to someone about it. You matter, too, and despite what you might think after reading what I write below, you probably couldn't have helped that person, probably could not have saved a life. It's one of those things, best to take yourself off the hook.

One night last week FD said to me, "We should make a shiva call tonight."

Someone who sits shiva has lost a parent, sibling, or child, a member of the  family of origin. From burial to "getting up" from shiva, friends have a week to stop by and sit together with the mourners, console. Or they can call on the phone, if the mourners are out of town. My parents call it a condolence call.

I felt badly for not being on board, but it had been a long day. I just didn't want to sit anymore, not with anyone. I wanted to eat some dinner, make a few calls, work on taxes, try walking a little on the treadmill, see if I could ride a bit on the stationary bike. I told FD I had a break the next day and intended to visit our friend then, maybe do some shopping afterward. Did he want to come along then, skip tonight?

Call me before you leave, he said.

So I did, and he went along. We visited someone who had lost his father, a dear man in his eighties. Our friend talked about his mother, alone now and missing her spouse, what that must be like, missing him for what will be the rest of her life. To her, this man in his eighties died prematurely.

Sad but a relatively easy shiva call, as shiva calls go. No one lives forever, children should outlive their parents. There's a certain order that makes life just a little easier to take, sometimes.

After the visit we grocery-shopped and had some lunch. I dropped FD off at his office and started back towards mine.

Then I heard the song. I'd heard this song maybe three or four times before, and each time would think, Catchy, but what's he's saying? Is the refrain really, how to save a life? Is this song about suicide? It sounds like the lead singer is blaming himself, this mournful, plaintive voice in the band, the one full of regret.

But honestly, all due respect, words run together for me and I don't want to think this. I'm on my way to work thinking, how to save a God knows what, flashing on that first patient and  wondering where am I going with this woman. Is my treatment plan on target? One false move. . . No room for mistakes.

I’m an aquarist and have had a bad fish week, lost three, one to an attempted homicide. The bat fish didn't make it through the mauling. A trigger mistook him for a leaf, perhaps. The clowns died of broken hearts, in sympathy, no idea. They just couldn't smile anymore.

But these are people.

I get to the office early and log onto YouTube, because there's really nothing to worry about with that first patient and I know this, truly the job is in hand, the work's been done. We're in middle phase, putting together a few pieces, not resuscitating anything, anyone.

And there it is, the music video, obviously a hit, a clear winner, it pops right up. Many others boast videos "with lyrics." So apparently I am not the only one who didn't get them on the radio. Once you know the words, like everything else, meanings are clear as rain.

Where have I been? Why haven't my kids told me about this? Don't they know I need this stuff? It's like oxygen for me, a song like this. I print out the lyrics, then watch the video maybe five times, mesmerized.

Fray, the band, won't let me embed it on my blog, so readers must find it themselves or follow a link.  With their permission, here are the lyrics.

How To Save A Life:
Step one you say we need to talk
He walks you say sit down it's just a talk
He smiles politely back at you
You stare politely right on through
Some sort of window to your right
As he goes left and you stay right
Between the lines of fear and blame
You begin to wonder why you came

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life

Let him know that you know best
Cause after all you do know best
Try to slip past his defense
Without granting innocence
Lay down a list of what is wrong
The things you've told him all along
And pray to God he hears you
And pray to God he hears you

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life

As he begins to raise his voice
You lower yours and grant him one last choice
Drive until you lose the road
Or break with the ones you've followed
He will do one of two things
He will admit to everything
Or he'll say he's just not the same
And you'll begin to wonder why you came

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life
How to save a life
How to save a life

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to
Save a life

A critical thinker would watch the video and say, so emotionally manipulative. These are actors, hired to look sad, to draw attention to a problem affecting youth today, but there is no way that any of them would really want to die, would voluntarily take their lives.

But the truth could be otherwise. Although these are actors, they are representative. There is an ennui that affects young people, like old people, a psychic pain that affects the leaders of tomorrow, and I see them in my office and we talk and talk and talk, and there was a time, when I was young, that I would be on the phone all night with them. I knew so little back then.

More aggressive, I haven't done that in a long time. Not only are youth at risk, of course. Anyone who has lost everything, which is easy to do, is at risk—middle-aged men and women who have no savings, no jobs, fathers, mothers, grandfathers, grandmothers, the old and the young have angst, suicidal wishes. We know them.

Along comes one, distressed, withdrawn, glassy-eyed, a friend of any age, who has changed. And let's say you have this chance, somehow, to stay, to help this friend through one night in particular, one awful night. It is a horrible position, to have to do that, to make that choice. And with grown men, it's not as if anyone is asking you to stay and hold hands, not usually.

Maybe you know. He’s not going home to anyone. He’s isolated. In a book you are reading you learn that isolated people are at higher risk. It is sometimes easier if there are friends, family around. Living with someone is better than living alone; the support is built in, not that this always helps. People can be in the next room and not be there, not be very much help at all. They may even be a part of the problem.

Thus as a real friend, you have to stay to save a life, as Fray tells us. You may have to call someone else, explain why you'll be late, maybe why you'll be out all night. Mention that you might need some assistance, too.

But you have to stay, and you might have to stay up all night.

You never want to be in charge of someone's life, it's not a great position, it's not usually what we sign up for when we say, I'll be your friend. But sometimes, by staying, we make it a little easier for a friend in trouble to hold on. Stay just a little longer, until you have a chance to bring in bigger shoulders.

It can be hard hanging in there with someone who is seemingly smiling politely back at you. (Lyrics like these strike a familiar chord. We've seen this smile). You can't politely look right on through, go your own way. To be trite, you may not pass this way again.

Between the lines of fear and blame. You begin to wonder why you came.

Except you shouldn’t wonder, because your fear is nothing compared to his, and no one, really, is to blame. Depression happens and is obviously the domain of the therapists, the professionals—doctors. We have the tools. Sometimes all we need, however, is some unknown actor to play a quiet understudy role, to be a stand in for a few hours, keep our patient alive, watch him and don’t let him let that impulsive, senseless act happen. Get through the night and then find help, the bigger guns, to fight your friend's depression. Tell someone, a parent, a primary care doctor. A cop.

Anyone can sense a death wish, you know, feel that Spidey sense tingling. It is a scary feeling, sensing a death wish, because we have no control, none over the actions of others. Intimate information, insider knowledge direct from the mouths of our suicidal friends will haunt us if the act is consummated.

Like isolation, seeing self-destructive behavior is insider information. If a friend has been hurting himself, or has been hurting for a long time, drinking and drugging without any thoughts about tomorrow, then the direction of his mood won't spontaneously lift, the negativity won't fly away, not without medical intervention. That is when we have to seek help, can’t wait around for tomorrow. It is too dangerous a cocktail, negative thoughts mixed with accessibility, the accessibility of drugs, alcohol, bullets, ropes, blades. We can't walk away the truth of our violent world. We have what to fear, old Yiddish expression.

So scary, and we’re so powerless, You wonder why you came. So you go.

When we don’t, when we reach out, they punish us. This is how they make us feel, depressed people, like we're useless and powerless, like we can't help them. Why bother? This is how they feel, useless and powerless, failures, better off dead, not worth bothering about. It is called projection, and a sensitive friend feels what is in the heart of another, this feeling that there may be, truly, nothing that can be done.

Such a trap, and so wrong! Over-rated, powerlessness, hopelessness. Push help, find those friendly cost-effective social service people at the local mental health agency, the professionals. They’ll think of something. That is the rational way of seeing despair. The social scientists can't treat everything, not every time, but God knows, they can treat depression, and more often than not, win the battle.

Someone has to stay rational, unafraid, and above all, hopeful. You, the friend, perhaps the lover, sister, brother, parent, spouse, are elected. Maybe it won't work, maybe you will lose this person in the end, but you don't really know that, do you? So you can't run away, that's for sure, hoping that in the morning your friend will be okay.

You can't stay right if he turns left. This is the projected abandonment he is hoping for, you validating his worthlessness with your leave-taking. Don't fall for these words, I'm okay, go home. Be sure someone else is on call. Or stay.

This is not to say a person should be manipulated to stay by suicide threats designed to control the relationship. This is entirely different, a typically borderline personality modus operandi, and it is not an easy call to make. One in five with this disorder do kill themselves. But threats are threats, and as such need to be taken to a higher court. There is a fine line between dependency and despondency, but sensing you are walking that line, it is best to get out of the helper/rescue role.

It is too big for you. It is too big for most of us. That is why such people are so lonely.

Oh, so much to say. Why did I start?

Because so many people, after a suicide, say, I knew.

I tell people to talk openly about it, about this idea that most of us have had, at least once in our lives, that life is too tough, that we wouldn't mind finishing it. And they should discuss meaning, why choosing life is the better alternative, because there is meaning. It is our job to find it.

Having the discussion doesn’t make it your job to find meaning for your friend, the one who wants to die. It is the job of professionals. But you can play with it. It is a wonderful, rich, very intimate conversation we're talking about, and as such can be therapeutic. Therapists have no corner on these conversations. We do tell people that a suicide is permission to the generations to come that it is okay to throw their lives away. And if you do happen to help a friend find meaning, if together you find that elusive raison d’etre, within the throes of discussing depression, you are amazing, both of you are, and should consider this profession.

Oh, but we aren’t finished. In the process of this philosophical discussion, should your friend mention a suicide plan, then this is a heads up, don't take it lightly. There is real risk. Your friend is capable, armed, can exact a suicide. Now is the time to phone for help. More drama now, less later.

You can and should call parents, if there are any, and they are around. Real friends know how to find them, aren't afraid of these people, the ones who birthed a suicidal buddy, who brought a suicidal friend into the world. It is possible that these people hold the key to something very elemental to your friend's survival.

If there are no relatives nearby, then you may be the closest relative right now. You don’t want to lose him, but he can be such a burden, sometimes we give up. If it were our child with a fever, we wouldn’t give up. This is a child with a fever.

Where did I go wrong, I lost a friend. Somewhere along in the bitterness.

Whose bitterness? Suicide is an angry act, a vitriolic act. At some point there's energy, enough to make it so, that decision, the one that spells relief. It takes a lot of psychic energy. The decision to do it can be invigorating. So we watch people when they say they're feeling better, watch them more closely. We're thinking, the energy is available, the time is now. He's going to go left. There's so much energy in the bitterness and anger. Toxic stuff.

Let him know that you know best. Cause after all you do know best

All you know is there’s something really wrong here. Even we, the professionals, the ones who know, don't give advice. We listen. We teach from experience and we do it gently, if we do it at all. All we know is we find death repulsive. Our friend does not.

When your Spidey sense says, You're not getting through, this person is going to try it again, it is time to call for reinforcements. I've had kids never see me again because I forced a hospitalization.

Enough. It is a blogger’s prerogative to ramble on, but you get the idea. You know the symptoms to look out for, the loss of interest in the usual pleasurable activities, not caring about school or work, not caring about hygiene, expressing hopelessness and helplessness, giving away possessions, revealing a suicide plan.

You don't want to be an armchair therapist, here, not a self-appointed therapist, certainly don’t want to beat on someone's short-comings, not ever. Like Fray warns us in the song, we don't tell a person what he doesn't want to hear.

Our unconditional love and support? It might feel good, but it might not, won’t necessarily save anyone’s life and doesn't take the place of professional help. It is all we have to offer, however, when someone won’t get help. The real kicker is that people can fool the healthcare professionals. As soon as they’re released, they overdose or shoot a bullet through their heads.

When they have had help and given up, it is the worst. We have to reinforce that therapists are a dime a dozen. Try another.

Meanwhile, scheduling is impossible, and there are no appointments and your friend is taking his feelings into his own hands, dosing out his own medicine, not caring if it helps or not. And you're there and you can tell, he's too drugged up, or he's drinking too much, that this isn't good.

So you call 911.

And there, you've saved a life.

You don't have to wonder about any of it, you don't have to wonder why you came, why you stayed. The un-timeliness is what we're talking about, the premature death, the one we want to avoid, no different in its importance than the one we talked about earlier, the octogenarian who still died prematurely, at least according to his wife.

We want to save a life at any age. That's why we stay. We—you—are a part of it.

therapydoc

More School Killings

This is not the Red Sea. It's the Mediterranean. The Gaza Strip and Israel share the beach.

The killings are in Israel this time. My cell phone rang and rang as I saw patients yesterday. I knew. It was my mother wondering. Which Yeshiva, exactly, is it that Little One attends? (In her defense, the names of the schools do sound alike sometimes).

I heard about it from a patient. She came in for her appointment strolling her baby and told me, 8 students murdered in a Jerusalem seminary. I gasped and got on-line (what would YOU do?), cried for a moment, controlled myself, stifled what I wanted to say, Animals. Or maybe I said it.

I know the school. A friend of mine teaches there. I know the neighborhood. I have cousins there.

What gauls me, believe it or not, is the celebrating of death in the streets of the Palestinian territory, the Gaza Strip. What is this? How does an entire people celebrate the deaths of students, the deaths of the innocents?

They dance, they say, because these murders are retaliation for an Israeli military operation in Gaza in which Israelis targetting terrorists. The Israelis, once known for espionage, assasinate known terrorists. It is the only way they know to win this war. Otherwise it's back to destroying empty buildings again.

But CNN tells us:

. . .Dan Gillerman, Israel's ambassador to the United Nations, told CNN he saw no connection between Thursday's shooting and Israel's operations in Gaza.

"This is not a story of retaliation," he said. "These people have been terrorizing Israel for years, have been carrying out suicide bombings and indiscriminate attacks for years."

Gillerman said the Security Council should condemn the attack. "They they are so, so quick sometimes to criticize Israel for defending itself. I would like to see those members convene as we speak in order to condemn this in the strongest possible terms."

FD said to me when I picked him up last night, "A copycat of the Northern Illinois University massacre?"

Except that I think Kazmierczak was mentally ill. These Palestinians are homicidal. If the man who murdered children yesterday had been taken alive (and there is no one thinking that ever possible, this was a suicide mission) he would go to jail. Kazmierczak would get medication and a very long stay in a hospital.

Our story is like this. When the Jews fled Egyptian slavery, the Egyptians, sorry to have ever let them go, chased after them.

The Jews reached the Red Sea. The bravest jumped right in to swim across, but the Old Mighty, impressed with his bravery, parted the waters for the rest of the nation. The Jews crossed on dry land and the Egyptians followed, but The Old Mighty released the waters, let the Egyptians drown.

The Angels began to sing at the deaths of the Egyptians. The Old Mighty got angry and chastised them. "My creatures are dying and you sing?"

Sure, you can say, That's just a story.

But it's the way we think. The Jewish people don't sing when people are slaughtered, not ever. We cry when people die. I believe, when it comes down to it, most of us don't feel good about the assassinations of terrorists, either. We wish it would all stop.

May the mourners be comforted in the Gates of Zion.

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Staying Connected

I'm not going to get too wordy here because it's Monday and the implications are scary, so much to do. But the lesson here is worth a quick post.

The "he" in the story could be a female or a Martian, there are no true identifying features in this post.

Several years ago I had a professional acquaintance who called to give me a head's up that she had referred her father to me for therapy. Her father's sister committed suicide and she worried her father was at risk.

He called that day, and I couldn't get him in immediately, told him it would have to wait a couple of weeks (!). Could he wait? Sure. I've waited this long.

He presented with two Axis I disorders, severe anxiety and dysthymia (ever-present depression, the low-grade fever thing). You would think the two can't co-exist, but they can. You're never depressed ALL of the time. You're never anxious ALL of the time.

His sister had just committed suicide. I should have done that a long time ago, he whispered

Would you want this case?

Past retirement age, our guy still worked, very responsibly, even though each day he felt inadequate.

He had been in and out of therapy for over thirty years.

His crippling anxiety, which surely did come from severe childhood emotional abuse, made parenting (and partnering) very difficult. His wife left him while the children were small (she took them with her), and he never had any meaningful contact with the kids after that, even though they begged him to talk to them, to be a part of their lives. He just didn't have the social skill to listen or to talk. There were four children. Four children, no contact. It really does happen.

Never had anyone discussed repairing his cut-offs with his children. The therapies, according to him, all addressed his relationships with his parents, his marriage, and his childhood problems, his lack of sexual/relationship attachment.

See, it's not that difficult, this case. There is a universal need to be loved by one's parents, and a universal need to be loved by one's children, and that can be repressed, of course. But it's there. And it has to be addressed if meaning in life is at all important.

Tiny steps, of course, he had to make the first moves, the calls, the visits, the toys for the grandchildren, the birthday cards and gifts. He didn't have to really talk very much at all to anyone in this therapy, but he eventually did, all on his own. It's a behavioral family therapy. Say hi, visit, go to the grandkid's baseball games. Quick guerrilla visits. Hi, Bye.

Put yourself on the map. You don't need to be a star.

No idea what those other therapies were about. Don't care. He did so well.

It's just an example, right? Anyone could see the need for that kind of intervention.

Was he still at risk? I thought so. You know how it is when people feel a little better. They have the strength to hurt themselves, whereas they hadn't before. But the thought of hurting the little ones like that, the grandkids, served as a deterrent. He said as much. And I lay on guilt big-time when it's deserved.

But I kept an eye on him over the years.

What's lovely is that I never even had to bring any of his children into my office to do that family therapy. The family system was in the room, everyone was in his head.

That's how you need to think.

Copyright 2007, therapydoc

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