November of the Soul

by George Howe Colt

  Others disagree. “Residents are trained as they get cases, by supervisors who were treated in the same haphazard way,” sociologist Donald Light told me. Light spent two years in the 1970s studying psychiatric residency training at the Massachusetts Mental Health Center in Boston, one of the most highly regarded psychiatric training programs in the country at the time. “So a lot of homemade ideas about suicide care are perpetuated from one generation of psychiatrists to the next.” Light recommended a specific training module to the American Psychiatric Association, in which each residency would have an in-house expert through which all suicide cases would be routed. Residents would be required to work at a crisis phone service and to attend regular seminars in suicide care, stressing availability, the need to relax confidentiality, the necessity of involving friends and family, and the importance of working in clinical teams. The APA’s response, according to Light, was “polite.”

  Alan Stone has been another advocate of specific training in suicide care. Years ago, after a rash of suicides at McLean Hospital, an elite, private psychiatric institution near Boston, where he was director of residency training, Stone concluded, “During the course of that epidemic, it became painfully apparent that many psychiatrists possess no systematic or comprehensive approach for dealing with suicidal patients.” In a series of papers, Stone and the late Harvey Shein, his successor and former student, proposed that “suicidal risk must be monitored in a way that is analogous to the current hospital management of acute coronary artery disease.” They suggested that suicidality be made an explicit focus of treatment and that the patient’s family be brought in and told. “Once the patient’s suicidal thoughts are shared, the therapist must take pains to make clear to the patient that he, the therapist, considers suicide to be a maladaptive action irreversibly counter to the patient’s sane interests and goals; that he, the therapist, will do everything he can to prevent it.” (Ironically, Shein, who campaigned for openness about suicide, couldn’t follow his own prescription; several years after the last of those papers was published, he took a fatal overdose of sleeping pills at the age of forty-one. The embarrassed hospital was hardly forthcoming itself; it reported that its promising young psychiatrist had “died suddenly” and persuaded the local newspapers to call the death a heart attack. At the next staff meeting, the hospital director didn’t mention Shein’s suicide until a grieving employee insisted on broaching the subject.)

  It is clear that some training is needed. There are therapists who still share with laymen simple misconceptions about suicide—for instance, that if you ask a person about suicide, you’ll plant the seed in his mind, or, conversely, that if he talks about suicide, he won’t do it. Or that if a patient really wants to kill himself, you can’t stop him. The most common fallacy may be the supposed distinction between serious and nonserious attempters. While it is tempting to assume, for example, that wrist-cutters are manipulators who don’t intend to die, they should always be taken seriously. Writes Maltsberger, “Some patients almost ready for suicide but as yet undecided may betray their ambivalence through a minor attempt. . . . We know of one young schizophrenic woman who ingested six Stelazine tablets, an event misunderstood at the time as a negativistic gesture of little significance. A few days later, her indecision resolved, the patient fired her father’s pistol through her head.”

  Sometimes, specific types of therapy may be harmful. One such approach involves what children call reverse psychology; while most therapy concentrates on the part of the patient that wants to live, “paradoxical technique” plays the flip side. The patient says life isn’t worth living; the therapist agrees. Light remembers a psychiatrist who claimed never to have lost a patient with this risky technique. He came close. “One girl had a blade at her wrist and he kept saying, ‘Go ahead, go ahead.’ He was pushing her down the hallway and she went screaming out of the hospital.” She made a small cut but recovered. Such brinkmanship requires an experienced therapist. Impressed with the jocular, Jewish-mother approach his supervisor used, a young resident tried it himself. “So already you should die” came out sounding like “you should die.” Two months into treatment his twenty-two-year-old patient put the plastic slip of a record jacket over his head and suffocated.

  Another therapist took the opposite tack. On learning that one of his patients, a businessman, had slashed his wrists, he rushed to the emergency room where the patient was being sewn up and gave him a right hook to the jaw. “How dare you do anything so stupid?” he yelled. “If you ever do anything like that again, I’ll kill you!” Perhaps encouraged by his therapist’s concern—or stunned by his Sunday punch—the patient did in fact get better.

  When Maltsberger was a resident, he had a patient who repeatedly slashed her wrists. “I was getting fed up,” he recalls, “and one day I said, ‘If you’re not interested in changing, we can arrange for you to be someplace else.’ I think that remark was motivated by hate. My basic message was ‘We’re tired of you; get off your ass or get out of here.’” On the next attempt the patient nearly killed herself. It was the first time Maltsberger had confronted countertransference hate—an emotional response therapists may have to certain patients. Such reactions can be particularly intense with suicidal patients. Extraordinarily demanding, they may attack the therapist, verbally or physically; they may shadow him or make anonymous phone calls. (Maltsberger knows of two instances in which patients telephoned suicide threats at the moment they correctly guessed their doctor was eating Christmas dinner.) The mere passivity—“almost a sucking quality,” says Alan Stone—of some suicidal patients is likely to inspire boredom, malice, even hatred, in a therapist. “When you deal with suicidal people day after day after day, you just get plain tired,” says James Chu, a psychiatrist at McLean Hospital. “You get to the point of feeling, ‘All right, get it over with.’”

  In one of the few papers on the subject, Maltsberger and Buie describe how therapists may repress such feelings. A therapist may glance at his watch, feel drowsy, daydream—or rationalize referral, premature termination, or hospitalization just to be rid of the patient. Sometimes a frustrated therapist will issue an ultimatum. Maltsberger recalls one therapist who, treating a chronic wrist-cutter, “just couldn’t stand it, and finally she said, ‘If you don’t stop that, I’ll stop treatment.’ The patient did it again. She stopped treatment, and the patient killed herself.” Reviewing the treatment of thirty men and women who killed themselves as inpatients or within six months of discharge, William Wheat isolated several patterns that he believes contributed to the suicide: the therapist’s refusal to tolerate a patient’s immature, dependent behavior; the therapist’s pessimism about treatment progress; and the therapist’s inability to recognize an event or crisis of overwhelming importance to the patient. “All of these processes,” wrote Wheat, “can lead to a breakdown in the therapeutic communication resulting in the patient’s feeling abandoned or helpless, thus setting the stage for the disastrous result of suicide.”

  Light contends that only certain therapists are able to withstand the demands of suicidal patients. “We should be candid about the fact that most psychiatrists are not built for suicide care. Let’s select about ten percent who have the stomach for it, who can handle the high anxiety, who might even like it, who have a kind of Green Beret outlook, and give them special training and then make it clear to other psychiatrists that when they get a suicidal case, they refer it to this person.” The late Bruce Danto, a psychiatrist who founded the Suicide Prevention and Crisis Intervention Center in Detroit, liked to talk about what he called the “psychiatric suicidologist,” which, in his description, seemed to be part social worker, part psychologist, and part cop. (With degrees in sociology, social work, and medicine, and a deputy sheriff’s badge, Danto was all of the above.) “The psychiatric suicidologist must have skills over and above those of psychiatrists in general,” he told me. “With these problems you can’t simply sit back in your chair, stroke your beard, and say, ‘All the
work is done right here in my office with my magical ears and tongue.’ There has to be a time when you shift gears and become an activist.” Support might involve helping a patient get a job, attending a graduation, visiting the hospital, even making house calls. “I would never send somebody to a therapist who has an unlisted phone number,” said Danto. “If therapists feel that being available for telephone contact is an imposition, then they’re in the wrong field, or they’re treating the wrong patient. They should treat only well people.” The psychiatric suicidologist must also pay attention to “the tools of self-destruction.” Danto kept a collection of guns and knives belonging to suicidal patients, who held receipts. “Once you decide to help somebody, you have to take responsibility down the line.”

  While many psychiatrists find such suggestions too gung ho, they admit that not all psychiatrists are equally fit to deal with suicidal cases. “There are many psychiatrists who don’t necessarily have great experience in treating people who have made suicide attempts,” Ari Kiev, a Manhattan psychiatrist, has said. “I would much rather have my social worker or even the receptionist deal with some suicide-prone patients than just any psychiatrist.” Herbert Hendin gets many referrals from uncomfortable colleagues. “A lot of people who do reasonably well with other patients cannot deal with suicidal patients,” he says. “The bigger tragedy is if somebody is not comfortable, you shouldn’t spend ten years trying to analyze his discomfort—let him treat someone else.” Robert Litman interviewed more than two hundred therapists shortly after the suicide of a patient. They expressed fears of being vilified in the press, of being sued, of being investigated, of losing professional standing, and of inadequacy. (Suicide is, in fact, the most common cause of malpractice litigation against mental health professionals.) Litman points out that therapists must understand that no treatment—psychopharmacology, psychotherapy, electroshock, hospitalization—can guarantee that suicide will not occur. When he lectures residents about suicide, he tells them that it is important to realize that they will undoubtedly have a suicide at some point in their practice. Indeed, it is part of psychiatry’s folklore that one is not a full-fledged therapist until one has had a patient who completed suicide.

  “These doctors who get so anxious when a patient threatens suicide haven’t settled in their own lives the question of who’s responsible,” says Maltsberger. “If there’s any blame to be assigned, it would be on the person who brought the patient into that plight in the first place. That might be the patient, the patient’s parents, or it might be God. Who knows? But it isn’t the poor therapist!” In forty-five years of practice Maltsberger has never had a suicide. Doesn’t that make him nervous? “All the time,” he says quickly. “But at this stage of the game if a patient of mine did away with himself, I would be very sad, but any self-reproach would have to do with how well I applied my art. It’s like surgery. If you operate on somebody and you don’t make any mistakes, and you tie off all the bleeders and the patient doesn’t make it, it’s sad, but that’s probably the way the ball bounces.”

  “I had a patient a couple of years ago who dropped out of treatment to go back to school, but he continued to come in periodically,” says Ari Kiev. “One night I got a message that he’d called at nine. I called back at ten, and whoever answered said he was asleep.” Kiev speaks slowly. “Next day his girlfriend called me and said she hadn’t been able to locate him. She’d tried at home and nobody had answered. I put two and two together and called 911. They went up there and he was dead. He’d gotten drunk and taken an overdose. So I was having second thoughts—since it wasn’t like him to call me, maybe I should have acted on the call and insisted that whoever answered the phone wake him up, which is when I would have found he couldn’t be wakened and called the police.” He riffles through the appointment calendar on his desk. “I don’t think I’m responsible, but you feel responsible. . . . I can answer these things from the point of view of the psychiatrist’s way of BS-ing the world and BS-ing himself—‘It’s the patient’s responsibility’—but you’re caught up with people, and it’s not as easy as all that.”

  Certainly, some suicides may be resistant to any intervention. In a study of schizophrenic hospital patients, Shneidman and Farberow describe a man who received psychotherapy but remained acutely suicidal. He was given a steady barrage of electroshock treatments for several years, but he repeatedly tried to hang himself. He was given a lobotomy. He was calmer, but remained suicidal. One day, despite the vigilance of hospital staff, he finally succeeded in hanging himself.

  Amid a glossary of possible techniques, clinicians sometimes overlook simpler approaches. “I had a slasher my first year in the hospital,” recalls one psychiatrist. “She kept cutting herself to ribbons—with glass, wire, anything she could get her hands on. Nobody could stop her. The nurses were very angry. They hate these patients, and they get very angry at the resident whose patient it is. I didn’t know what to do, but I was getting very upset. So I went to the director and in my best Harvard Medical School manner began in a very intellectual way to describe the case. To my horror I couldn’t go on but began to weep. I couldn’t stop. He said, ‘If you showed the patient what you showed me, I think she’d know you cared.’ So I did. I told her that I cared, that it was distressing to me. She stopped. It was a very important lesson.”

  Psychiatrists may be the bottom line for suicide care, but the ascendancy of HMOs and the proliferation of SSRIs have made it likely that most depressed and suicidal patients will never see a psychiatrist—or any other mental health professional. Between 50 and 75 percent of those seeking help for a psychiatric disorder are treated in a primary care setting; up to 10 percent of primary care patients suffer from major depression. Yet general practitioners, who are thus best positioned to help suicidal patients, are perhaps least prepared. Medical education is dominated by illnesses of the body, and the mind is relegated to a few lectures in psychology plus a four-to-six-week psychiatric rotation. Commenting on his 1997 survey, which found that fewer than half of primary-care-physician-training programs collaborated with departments of psychiatry—and that those that did, didn’t collaborate much—former APA president Jerry Wiener suggested that the current position of GPs as the frontline providers of psychiatric care “leaves them in the role of the emperor who rides naked through the streets while managed-care and cost-cutting health-policy gurus ask that we admire the emperor’s new clothes.” In another survey, 3,375 primary care physicians reported widespread lack of knowledge about the diagnosis and treatment of depression—which may help explain why more than half of patients with depression seen by primary care physicians are misdiagnosed. (NIMH data suggest that as many as 30 percent of people who walk into a general practitioner’s office use physical complaints as a smoke screen for depression and other mental health problems and that GPs miss 90 percent of those cases.) Even when depression is accurately diagnosed, the majority of patients are undermedicated, receive inadequate follow-up, and often fail to be given appropriate medication adjustment. Depressed children may be most at risk; a survey of pediatricians and family physicians found that 72 percent had prescribed SSRIs for a child or adolescent, yet only 8 percent felt they had received sufficient training in treating youthful depression.

  If few GPs are equipped to diagnose and treat depression, fewer still are equipped to assess and treat suicidal patients. The knowledge base has no doubt improved since 1967, when a survey of Philadelphia medical schools found that half the students believed that if a person talks about suicide, he will not commit it. (Half also believed that masturbation frequently causes mental illness; it is not clear whether this was the same half.) Yet in a recent poll reported in the Journal of the American Medical Association, 91 percent of physicians felt their knowledge of suicide assessment and treatment techniques was inadequate. One-third of people who kill themselves see a primary care provider in the week before their suicide; more than half in the month before, and nearly 75 percent in the previous ye
ar. “Many people go to physicians hoping to be asked about suicide,” says psychiatrist Alan Stone. They’re not likely to be. A 2000 study found that many physicians still believe the old canard—that if they ask a patient about suicide, it will plant the idea in his head. This may be why only slightly more than half of primary care physicians directly question patients about suicide during routine depression evaluation. Although the 2001 Academy of Sciences Report recommended that medical and nursing schools incorporate the study of suicidal behavior into their curricula, there is institutional reluctance. “We don’t pay enough attention to psychiatric aspects of medical education, so I welcome anything in that direction,” says psychiatrist Leon Eisenberg. “But specifically for suicide?” He shrugs. “We don’t even teach our medical students how to deal with stress in themselves.” Even if GPs had the training to assess suicidality, few have the time; the average visit to a primary care physician lasts 16.3 minutes, during which patients bring an average of six problems to discuss. “The worst thing about HMOs is that there’s no longer any time to spend with the patient,” says a GP with thirty years’ experience. “The drugs came along and really worked, but they’re so easy to abuse—a patient comes in depressed, and when you look out and see fifteen or twenty people in the waiting room, you don’t have time to do anything other than toss prescriptions at the fellow.”