I work in a helping profession for a living. As the deputy director of a case management agency for the mentally ill, I connect with people on the fringes of society. My clients typically are poor. They may not be the most educated, the prettiest or the most pleasant. But I successfully connect with them—most likely because I, too, was not always the prettiest or most pleasant of patients. I, too, have a psychiatric diagnosis, and like many of my clients I have at times been discarded by treatment providers who couldn’t or didn’t want to help me. In my job, I try not to judge, and that’s why the throw-aways keep coming back to me.
But the reality is, as non-judgmental as I try to be, I make judgments on a regular basis. Sometimes I catch myself making disparaging comments about my clients, and often I wonder if I can actually help them. Everyone places value on people, be it for their contributions to society, their wealth, their intellect or their looks.
Every now and then I like to take inventory of my judgments. One in particular that has troubled me for some time is my reaction to suicide. I am not alone in my complex response when another person takes his or her own life—most people experience a wide range of emotions, from grief and anger to helplessness and sometimes even relief. But out of fear of others’ opinions, we usually do not articulate our thoughts and feelings about suicide honestly. We often respond to the loss as we think we’re supposed to. Outwardly the good social worker professes that all life is valuable, and in an abstract sense that is of course the case. However, we all find ourselves affected differently by individual suicides. The question is, why?
I’ve tried to commit suicide countless times. I first tried before I was even an adolescent, before I was even sure how to complete the act. After my pre-teen years I tried again and again. I have thought about my own suicide with a frightening regularity. One of the recurring thoughts has been what others would think if I actually completed the act. Who would come to my funeral?
What would they say about me? My answers to these questions have varied over the years.
When I was in sixth grade, I struggled with the normal pre-adolescent BS surrounding a crush on a schoolmate. I thought if he didn’t respond to me the way I wanted, I would just die. Then my crush showed interest in a friend of mine. At the tender age of 11, this was more than enough to nudge me into thinking about suicide. I even told my friend about my plans. Would she miss me when I was gone, I asked? I got the uncensored answer of a peer, not yet old enough to know not to speak her mind: She told me quite frankly that if I killed myself, she wouldn’t miss me.
In addition to my own personal struggles, I have lost family members, friends and colleagues to suicide. One death that stands out is that of my friend Lorraine. I didn’t read about her death in the paper, nor did a mutual friend tell me she had passed. Instead, a colleague of mine called to refer a patient to me. This patient, an old acquaintance of mine, needed support relating to his friend’s recent suicide. As it turned out, his friend was my friend, Lorraine. I was distraught but also in some ways relieved. She had been trying for years to commit suicide. She finally got what she wanted.
The whole interaction was surreal. A colleague referring someone I knew, someone mourning the loss of a friend—someone else I knew, someone with whom I had gone through treatment. The situation was just one of the many quandaries of my job as a mental health provider. My personal experience with mental illness has given me an edge in engaging others who have mental illnesses. But there are awkward moments when the professional lines are blurred. I’m not often thrown, but this was one of those times. I took down the necessary contact information from my colleague and then went outside to have a cigarette by myself.
It was sad that Lorraine had left behind a son, though I wonder how much she was actually there for him when she was alive. She was miserable—days of agony broken up by flimsy overdoses and superficial slashes on her forearms. I couldn’t help but wonder whether her suicide was a slip, or whether she finally got her stuff together long enough to complete her destiny.
While Lorraine tried again and again to commit suicide, my friend Brian made only made one serious attempt. Unfortunately, he had beginner’s luck. Brian’s life appeared perfect to the outside observer. He was strikingly handsome, with jet-black hair, deep green eyes and milelong lashes. His family had unlimited financial resources, paying in cash for his year-long hospital stint. They loved him, and he loved them. Brian was brilliant, charismatic and popular. But most of all he was just so nice. Even the most cantankerous charge nurse was charmed by him.
But Brian was in constant pain. He paced the hospital hallways, pulling at his hair and pressing his ears as if to stifle a noise that only he heard. He tried once in vain to explain the pain to me, though even I couldn’t really comprehend it. But what I remember vividly were his pleas. He frequently appealed to me, begging for consolation: This will go away, right? Brian was on a 24-hour suicide watch protocol several times during his inpatient stay. The staff adored him, so it wasn’t a chore for them, and they probably afforded him liberties that others were denied: late night snacks, TV viewing after bedtime and things like that.
All the bedroom doors were kept locked on the unit in the evenings between seven and nine o’clock, when patients were out in the common area. But if patients had to use the bathroom, a staff member would let them into their rooms and then stand watch until they returned to ensure the bedroom door was again closed and locked behind them. The night Brian died, one staff member left this final step to a patient, who neglected to pull the door shut. In a short while, the staff member found Brian hanging from a pipe in that bedroom.
Brian had led a life of privilege, not only in material things. He had been loved and he had loved others; he had truly been rich. At the other side of the spectrum, there was Pam. Pam was, quite simply, a nasty person, unpleasant to the majority of people who came in contact with her. Were allowances made for her? I’m certain they were, as they are for many people with mental illnesses. It’s the double standard—treat us equally except when we have obvious symptoms, then attribute all bad behavior to the illness.
Pam was an amputee, the consequence of a failed suicide attempt years earlier when she had jumped from a bridge and lived. Her injuries had also left her incontinent, so her apartment—which was also home to a number of cats—reeked of urine, some hers and some from her feline friends.
Pam’s story was a sad one, and her prosthetic leg must have been a daily reminder of the severity of her difficulties. On some level, I believe she was aware that there was more and better out there, but she lacked the ability to transcend the obstacles to get to this better place. Still, it was hard to feel bad for her. She was unattractive, malodorous and mean. Though I didn’t know her prior to her earlier suicide attempt, I am almost certain she was mean and miserable long before she became disabled by her injuries.
Despite her difficult personality, Pam’s completed suicide sent a ripple through the community. Tears were shed, and friends were angry. In fact, after her death friends seemed to be in abundance—though most had in reality appeared to maintain contact with Pam either out of pity or because she had a car, a true asset in her social circle reliant on welfare and federal benefits. But her death touched the fear and helplessness that another’s suicide evokes in all of us. In a perverse twist, in death Pam was canonized. She was transformed into this kind, beneficent individual who struggled relentlessly, but in vain. Lacking another acceptable target, many blamed the hospital and the doctors for releasing her home. “She should have been kept under the watchful eyes of the hospital staff,” they charged. Others from the mental health recovery community mused about the spiritual potential she had never found: “She would still be alive if only she had found recovery.”
Sometimes even when the threat of suicide appears vanquished, it again rears its ugly head. The director of a New York City training program for people with mental illness, Julius, was the poster child for recovery from mental illness, and his face was showcased in picture ads all over the city. The caption beneath his confident smile read, Recovery from mental illness is working. Julius took his own life after relapsing on crack. Some close to him felt he couldn’t live up to his public persona, that in his mind this larger-than-life character he’d created was not allowed to still need treatment. Many wept and are still weeping for Julius. The recovery movement was stronger for his contributions, and his death was a tragic loss.
There are certain factors that increase the risk someone will commit suicide, such as a family history of suicide or a personal history of previous attempts. Also elevating the risk is the use of alcohol or illicit substances. But applying the predictors to the cases I have described would produce only moderate success in foreseeing the outcomes. Brian did not have a history of attempts, nor did he have a family history of mental illness, and he never abused illicit substances. Lorraine and Pam fit the model a little better, as both had a history of attempts, but both had struggled with suicidality chronically for years. How, then, could those around them identify the critical moment for intervention?
Recovery from mental illness seems to be polarized. At one end of the spectrum, the patient is expected to regain functioning at a level comparable to or better than that prior to the onset of the illness. He or she is expected to return to or attend school and meet society’s norms for work goals, becoming a productive, happy and contributing member of society.
At the other extreme, for some patients the concept of recovery—self-empowerment, a sense of mastery, meaningful activities, the experience of making choices—is never truly pursued as a goal. The objective of treatment is instead maintenance—i.e., an externally-imposed suppression of symptoms, sometimes at the cost of debilitating side effects from psychotropic medications. At times, these side effects prevent an individual from even contemplating the true goals of recovery. But for many mental health providers with the maintenance perspective, those goals are moot, as are the teachings of recovery. The bar is set exceedingly low, and the absence of symptoms or minimization of relapses and hospitalizations is deemed a treatment success, regardless of the individual’s subjective quality of life.
But if the goal is to prevent people from taking their lives, we have to do a better job of consider that subjective experience, putting ourselves in each individual’s shoes and considering his or her perspective no matter how distorted it may seem to us. To an outsider, receiving a C grade on an exam may not warrant death, but it may to the suicidal perfectionist. Rather than debate the logic of that viewpoint, we must approach it with understanding and empathy. In the end, the patient’s viewpoint is really the only one that matters.
Finally, I am curious about our rationalization of suicide in certain situations, where we feel that the suicidal individual—and perhaps also ourselves as friends and observers—seems exhausted by the struggle to keep living. How many times has news of a suicide met with the response, “Well, at least now he [or she] is at peace”?
I uttered that very statement in response to the death of a close friend, who died after 10 days in a burn unit with devastating damage to her body. I was consoling her mother and the others who knew her, and the statement just slipped out before I knew it. Maybe it was just a desperate attempt to believe that a troubled soul who had struggled in life, only to face a tragic and violent death, had found some reprieve. Or was this pat statement made to assuage my own guilt and pain? Is this the way we justify our helplessness in the face of violence and suffering?
Furthermore, why do we have this sentiment for some, but not all? I have lost many friends and acquaintances over the years—a disproportionately high number for a 32-year-old—and yet I haven’t uttered those calming words after every instance. For my friend who died in the burn unit they felt appropriate, heartfelt and salient. For Brian, however, they just didn’t apply, nor did the words ever pop into my head. Was that because I minimized his suffering? He had his own personal experience of suffering, but his life did not appear to be one of obvious struggle. Is there a different standard applied to those who seem to have potential? Do we value their lives differently? And in doing so, do we classify and respond to their suicides accordingly? Was it less palatable to stomach the notion that Brian was now at peace because we—those left behind—were not? Is the peace we refer to, the peace of the loved one or our own?
I sometimes wonder what would happen if I were to commit suicide now. I doubt my death would be greeted by comments like, “She’s at peace.” Instead, my premature death would likely be received with disbelief, confusion and tragedy. As with my colleague Julius, a sense of loss would be felt. But I have to wonder if the loss felt would truly be for me, or rather for my contributions to my field of work, or perhaps for the dashing of our collective desire to believe that mental illness can be transcended and left behind. By all objective measures I have recovered from a debilitating psychiatric disability, years of institutionalized living and a family history that almost destined me to a premature death. In fact, my mere survival might be considered miraculous. I am one of the success stories we so desperately need—only to the most cynical observers could suicide be considered my destiny (“Deborah couldn’t survive, couldn’t prosper with such an illness. Who was she kidding? With all she was up against, it was only a matter of time.” Is it proving these cynics wrong, in part, that fuels my will to live?)
I also think my death might be received with feelings of anger. I might even be called a coward. After all, I have all of my limbs; I have my physical health; and, most importantly, I am loved. So how dare I be so selfish?
But what if instead of contributing to society, I was taking away? What if I had not overcome the most debilitating aspects of my disease? I could have become anything: an arsonist, murderer, drug dealer, prostitute. In this alternate reality I might be addicted to crack. Perhaps I would have become HIV-positive and, unwilling to die alone, refused to curb my sexual habits, conveniently and without guilt choosing not to disclose my status to my countless partners. If I were this person today and stood before you, gun pressed to my temple, would you plead with me to put the gun down? Or would you dismiss me and turn your head while I pulled the trigger? After all, wouldn’t the world be a better place without me?
by Deborah Max
Deborah Max is the deputy director of CHOICE of New Rochelle, a peer-run case management and advocacy agency in New York state. She has presented at conferences for the New York Association of Psychiatric Rehabilitation Services and the United States Association of Psychosocial Rehabilitation Services (USPRA), and she provides consultations across the country about implementing non-traumatic, collaborative and patient-centered mental health care.