Among the most difficult decisions for any medical professional, whether psychiatrist or family physician, is whether to hospitalize when a patient is, as Ari Kiev puts it, “hot.” Increasing attention to patients’ civil rights has barbwired the issue; a clinician may be sued for putting a patient into the hospital or for keeping him out. “People often send people to hospitals not because they think they’ll do better there but because they’re afraid there will be a suicide for which they’ll be held responsible,” says Hendin. Such buck-passing is based on the belief that the hospital, where access to potential tools of self-destruction is limited, is the safest place for suicidal patients. “We tend to think we’ve solved the problem by getting the person into the hospital,” says Norman Farberow, “but psychiatric hospitals have a suicide rate more than five times greater than in the community.” (They are, admittedly, working with a high-risk group; the majority of inpatients are admitted because they have threatened or attempted suicide.) While acknowledging that hospitalization may be the only answer to a severe suicidal crisis, Farberow calls it “an expensive, frequently crippling, stultifying experience.” In the opinion of some psychiatrists, the hospital may literally be the last resort. “I rarely put suicidal patients in the hospital anymore,” says Maltsberger. “People need the hospital when they have nothing else to sustain them. If they can get a good therapist without going in, they’re better off. The hospital is the absolute end of the line.”
Certainly, even at the finest hospitals and despite the most stringent controls, patients find ways to kill themselves. Some 5 percent of all suicides take place in mental hospitals, nearly half of them within a week of admission. David Reynolds, an anthropologist who entered a California VA hospital under an assumed name and condition found “hundreds of ways”—nails; windows; razors; plastic bags; broken glass; high places; coat hangers; tonguing and accumulating pills; stuffing toilet paper down one’s throat; even clogging a sink, filling it with water, then banging one’s head against a faucet until, unconscious, one drowns. In a study of hospitalized patients who had completed suicide, more than 40 percent had been on fifteen-minute “checks” at the time of their death. Paradoxically, some in-hospital suicides may be a sign of a healthy environment; an exceedingly low rate of suicide in a hospital may mean restrictive measures are excessive. “Very often hospitals are dominated by the same mentality that may have brought the patient there in the first place,” says Hendin. “They don’t want to be blamed for a suicide, so they devote their efforts to monitoring the patient—preventing and controlling.” There is little evidence that seclusion rooms, surveillance cameras, twenty-four-hour observation, or removal of “sharps” and other ingredients of “suicide watch” are effective. Half of all suicides at Metropolitan State Hospital in Norwalk, California, over forty-two years took place in seclusion rooms. In fact, a study attributing a decline in suicides at Baltimore’s Sheppard Pratt Hospital to a decrease in such measures concluded that protective restrictions may increase suicide by calling attention to it. Susanna Kaysen, whose memoir, Girl, Interrupted, describes her stay at McLean Hospital, told me that after months of unshaven legs and plastic spoons, “people started thinking about committing suicide because the hospital makes such a big deal about keeping people from committing suicide.” Hendin shakes his head: “That’s what the problem is! Suicidal people are into control, the hospitals are into control, and it becomes a power struggle in which no therapy can take place.”
Therapy may not be the most important service a hospital can offer a suicidal patient. When William Styron, suffering from depression and beset by suicidal thoughts that seemed only to be exacerbated by the medication his psychiatrist prescribed, inquired “rather hesitantly” about hospitalization, his psychiatrist said he should avoid it “at all costs,” because of the stigma. When his condition worsened, however, Styron was admitted. Although he scorned the therapeutic agenda—group therapy was “a way to occupy the hours”; art therapy was “organized infantilism”—Styron believes that the hospital saved his life.
. . . it is something of a paradox that in this austere place with its locked and wired doors and desolate green hallways—ambulances screeching night and day ten floors below—I found the repose, the assuagement of the tempest in my brain, that I was unable to find in my quiet farmhouse.
This is partly the result of sequestration, of safety, of being removed to a world in which the urge to pick up a knife and plunge it into one’s own breast disappears in the newfound knowledge, quickly apparent even to the depressive’s fuzzy brain, that the knife with which he is attempting to cut his dreadful Swiss steak is bendable plastic. But the hospital also offers the mild, oddly gratifying trauma of sudden stabilization—a transfer out of the too familar surroundings of home, where all is anxiety and discord, into an orderly and benign detention where one’s only duty is to try to get well. For me the real healers were seclusion and time.
Time, however, is a luxury that few patients can afford. Styron was fortunate in being able to finance a seven-week stay in one of the best psychiatric facilities in the country. Most insurance policies cover only five days of inpatient care—down from thirty in the late eighties, ninety in the late sixties—hardly long enough to get started on a course of medication, let alone in-depth psychotherapy. (Medications are the primary—and, often, only—form of treatment in psychiatric hospitals today.) Hospitals across the country are under increasing pressure from insurance companies to make patient stays shorter, and under pressure from all sides to get patients “cured,” or at least functioning, before their coverage runs out. (The American Psychiatric Association boasts that most hospitals “begin planning for discharge on the first day of admission.”) Over the last several decades, with growing reliance on drug therapy and increased pressure to cut costs, the average psychiatric hospital stay has dwindled to twelve days. At private hospitals like Styron’s—of which there are not many left—inpatient treatment can run more than $1,000 a day, a rate at which extended care is available only to a select group. The alternative is a state hospital, where levels of staffing, training, funding, and treatment are far lower, making it “extremely difficult for state hospital staff to provide a true rehabilitative program to their patients,” according to psychiatrist Robert Okin. “Moreover, these conditions lead staff to conclude that they are neither expected nor required to do much more than provide a safe place for patients to spend their time.”
Today, even a “safe place” for patients to spend their time is difficult to obtain. When advances in psychopharmacology, press exposés of state hospital “snake pits,” and the Community Mental Health Centers Act of 1963 led to deinstitutionalization in the late sixties, the move was applauded as a reform in the tradition of Pinel striking off the chains at Bicêtre two centuries earlier. Beyond the great expectations, however, there was little planning. Thousands of patients were discharged annually to community facilities that were inadequate or nonexistent. The state hospital population plummeted from 558,600 in 1955 to 54,000 in 2000, setting adrift a flood of mentally ill people to fend for themselves amid a patchwork quilt of services that had neither the time, training, nor funds to cope with them. Many of the deinstitutionalized ended up wandering the city streets. Experts estimate the number of America’s homeless to be as high as 3.5 million—as many as 35 percent of whom suffer from untreated psychiatric illness. Many others ended up in prison, having committed petty crimes, acted threateningly, or just caused trouble once too often. Some 250,000 mentally ill Americans live behind bars—78 percent more than a decade ago and nearly five times the number in state psychiatric hospitals.
There has been no research on the effect of deinstitutionalization on suicide, but while state hospitals are crying out for qualified therapists (who can make three times more money in private practice), patients are crying to get in. “These days it’s easier to get admitted to Harvard than into the state hospital,” observes one psychiatrist. In most states, a pe
rson must be judged to be at risk of doing “serious harm to himself or to others”—homicidal or suicidal. But admission is often decided on the basis of bed availability rather than need. “They take only the most violent, the most psychotic,” fumes a community mental health center director in New York City who admits he has coached suicidal patients on how to act sufficiently disturbed when they present at a hospital. Suicide ideation no longer guarantees admission; people commonly attempt suicide to get in. Even then they may be refused. Investigating the suicide of a Los Angeles woman, a social worker learned that on the last day of her life she had tried to commit herself into three large hospitals with psychiatric units. She was turned away at all three. That night she killed herself.
Even if a person manages to get into a public psychiatric hospital, stringent admission standards have changed the hospital milieu. “You used to be able to send a depressed patient to the hospital for R and R,” says an Oakland therapist. “Now people in the hospital are very crazy, and if you are able to get hospitalized, you’re surrounded by psychotic patients. It can be very scary.” If a patient isn’t “crazy” enough, the hospital isn’t apt to let him remain. “You get into unfortunate situations because the state hospitals often don’t keep people who are suicidal unless they are incredibly suicidal,” says Stanford University psychiatrist Alan Schatzberg, who worked at McLean Hospital for nearly twenty years. “It becomes a kind of dangerous game of chicken.”
The patient is usually the loser. Repeated studies have shown that the suicide rate jumps in the weeks immediately after patients leave the relative safety of the hospital and return to the stressed environment they’d left, frequently without provision for follow-up care, and with the increased likelihood that they will stop taking their medications. “Often caught in the dilemma of being too well to be in the hospital but not well enough to deal with the realities and stresses of life outside, as well as having to contend with the personal and economic consequences of having a serious mental illness, patients sometimes feel utterly hopeless and overwhelmed, and kill themselves,” writes Kay Jamison in Night Falls Fast. Yet something as seemingly trivial as a piece of mail may help. A study by San Francisco psychiatrist Jerome Motto and epidemiologist Alan Bostrom of 843 suicidal people who refused follow-up treatment after discharge found that sending them regular letters expressing concern—as simple as “we hope things are going well for you”—resulted in a lower rate of completed suicide.
With treatment decisions increasingly based on legal or financial considerations rather than on patient need, the suicidal person is caught in the middle. At a time when the percentage of mentally ill people in this country has swollen, according to NIMH estimates, it is increasingly difficult for them to get care. The inability of the mental health system to cope with the demand has led to a practice that seems an unsettling symptom, as it were, of an underlying illness in the system. In the past several decades, more than a few overcrowded clinics and hospitals, frustrated by a particularly troublesome patient, have bought him a ticket and put him on a bus bound for a distant city, where he arrived homeless, friendless, and alone. “Greyhound therapy,” as it has been dubbed, seems a chilling end point to the humanism that, in part, inspired deinstitutionalization. It makes one wonder how far, despite our 250 different psychotherapies and our armamentarium of wonder drugs, we have come since the medieval days when townspeople loaded irksome madmen onto a boat and shipped them downriver in what became known as a ship of fools.
Because so much emphasis has been put on psychotherapists and dispensers of medications, it is easy to forget that suicide prevention has long had another genre of gatekeeper: the clergy. Modern suicide prevention programs were originated by religious groups, but despite strong evidence that religion plays a protective factor, with the medicalization of mental illness suicide has been secularized and the clergy’s role consequently underestimated and ambiguous. Studies say that 50 to 80 percent of people with mental health problems come first to the clergy. “Often the clergy are not aware of the problem and pass it off,” says Monsignor James Cassidy. “Most clergymen don’t realize their limitations and the importance of getting professional help.” Earl Grollman, a rabbi in Belmont, Massachusetts, and the author of numerous books on death and suicide, says, “I have to laugh when I read Ann Landers telling suicidal people to ‘speak to your clergyperson.’ There might be three people in all of greater Boston that I consider to be knowledgeable in this field. Clergypeople feel they have to give a religious orientation, not understanding that prevention consists of listening, caring, and touching.” Grollman pauses. “There’s a story told about Martin Buber. He is praying when someone knocks at the door and says, ‘Can I see you?’ Martin Buber says, ‘I’m busy. Come back later.’ The person never comes back—he commits suicide. And Martin Buber says, ‘Here I had a chance to be with God, but I lost God in prayer.’”
“I don’t think doctors appreciate the role of the pastor in counseling,” the Reverend Robert Utter of the Church of the Nazarene in Cambridge told me. “But that may be changing. They’ve come to realize we’re available every hour of the night or day, and we don’t charge a fee.” For the parishioner in crisis Utter prescribes a list of scriptures, extra prayer, perhaps an outing with the church singles group, and in emergencies the counseling center at nearby Eastern Nazarene College. “We believe in hell, so our people would think twice before taking their life,” says Utter. “There is an expression I use when counseling people who talk about suicide. I tell them, ‘You think you have problems now; wait until you end up in hell. You’ll just be out of the frying pan and into the fire.’” Prescribing the Bible rather than antidepressants can be a risky therapeutic approach. In 1980, a California church and its pastor were sued by the parents of a twenty-four-year-old man, in the first prominent clergy-malpractice lawsuit. After a previous suicide attempt, Kenneth Nally had been in pastoral counseling with the Reverend John MacArthur Jr. of Grace Community Church of the Valley, who referred to suicide as “one of the ways that the Lord takes home a disobedient believer.” Nally shot himself. Although Nally had been seen by several physicians and a psychiatrist, his parents claimed that MacArthur had tried to dissuade their son from seeking secular help and had made his condition worse by telling him that his depression was the result of his sinning.
Although the $1 million suit was eventually dismissed by the California Supreme Court in 1988, which ruled that as “non-therapist counselors,” the clergy had no legal duty to save lives, it underlined that in their response to suicide, clergy are often torn between viewing the person as a patient and viewing him as a parishioner. Religion and psychiatry work in an uneasy truce, as if psychological and spiritual dimensions inhabited different halves of the person. While counseling in the emergency room of the Cambridge Hospital, psychologist Nancy Kehoe, who is also a nun, realized that religion never came up in patient assessments. Kehoe sent a questionnaire to local clinics and found that of fourteen hundred suicidal cases, religion was broached in fewer than three hundred, more often than not by the patient. “In the face of suicide, which is a person’s ultimate statement about life and death, why do we separate mental health and belief?” asks Kehoe. Clinicians have found numerous reasons to do so. “Many of them were taught that science and psychology should be separate from religion,” says Kehoe. “Some are very uncomfortable with the subject. Others don’t know what to ask beyond ‘Are you Protestant, Jewish, or Catholic?’” Kehoe’s definition goes beyond what she calls “God talk”; it means thinking about a person’s spiritual life as part of the total picture. “Then when a person is talking about suicide, it’s natural to say, ‘What do you think you’re going toward? What kind of spiritual things keep you going?’” Clinicians in Kehoe’s study who did bring up religion found it useful. Says Kehoe, “Some even felt that if a person had lost faith, it was an indicator of suicidal risk.” (One wrote, “Highly religious people do not commit suicide.”) She sighs. “All I’m
asking is whether we’d learn something about a person if we brought up his spiritual beliefs, without judging whether or not it’s going to save lives.”
Kehoe’s findings are troubling. If suicide is purely a biological and psychological problem, then treatment is clearly the undisputed province of the physicians and mental health professionals. But the strands that combine to prevent a suicide are as numerous as those that combine to push someone to suicide. In the twenty-first-century perspective of suicide from the medical model, we risk excluding not only the religious or spiritual dimension of self-destruction, as Kehoe points out, but the social and existential dimensions as well. “Suicide can best be understood in terms of concepts from several points of view,” wrote Edwin Shneidman in Definition of Suicide. “It follows that treatment of a suicidal individual should reflect the learnings from these same several disciplines.” Shneidman suggested that optimum treatment might be effected by a “Therapeutic Council.” “Such a council would be concerned with the biological, sociological, developmental, philosophical, and cognitive aspects of its patients. It might include a biologically oriented psychiatrist, a psychoanalytically oriented therapist, a sociologist, a logician-philosopher, a marriage and family counselor, and an existential social worker.” While Shneidman’s proposal is, of course, impractical, the concept is sound. If suicide is caused by a variety of factors, suicide prevention should address each of those elements.
Even further, true suicide prevention might address the problem before people reach the point of crisis, before they call the hotline or appear in the emergency room. While not thought of primarily as suicide prevention measures, there are many steps that might help reduce the suicide rate: further developing our understanding of alcoholism, depression, and schizophrenia; routine screening for problem drinking in all patients; tackling such societal ills as unemployment, divorce, homelessness, violence, inadequate education, unwanted children, and neglect of the elderly; improving medical and social services and making them accessible and affordable to all; finding ways to promote ethical and spiritual values; and reducing the threat of terrorism. In short, one might lower the suicide rate by giving people more reasons to stay alive. Years ago psychologist Pam Cantor appeared on the television news show Nightline to discuss the causes of suicide. At the end of the program, host Ted Koppel said, “All right, we have half a minute left. You’ve described the litany of ills that exist. Is there anything that can be done short of changing our society inside out?” “Well, I don’t think you should say ‘short of,’” answered Cantor. “I think that’s what’s necessary.”
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