Looking over the recently released suicide statistics from the World Health Organization, I wondered how to account for the remarkable variation in rates between different countries, and different demographic groups within each country. What are the cultural influences? The economic pressures? The family issues? The possible genetic factors? The availability of means to kill oneself—and on the other side, of help to deal with the suffering, desperation and hopelessness that motivate suicide?
In the interviewing course that I teach at BGSP, an important topic is how to deal with a patient who reveals, either by statement or by action, that ending their own life is a real possibility. When I speak of the responsibility that an intake interviewer has to take reasonable measures to ensure that the patient will not die, one or more students will ask: doesn’t a person have the right to kill himself or herself? And if someone states a desire to die, what right do we have to interfere?
My answer is: You are entitled to the opinion that your body belongs exclusively to you and not to anyone else (even though your death, by whatever cause, is certainly a matter of concern to others, and not a “victimless” action). However—if you are in my office, I know that you are ambivalent about your death. If you really were of one mind, with no doubt or hesitation, then you would either already be dead, or in the midst of your planned exit. The fact that you are in front of me means that you have mixed feelings. And it is my job to find out what those feelings are, both the ones impelling you to die, and the ones keeping you alive for now. Obviously, if you stay alive today, you can still decide to die tomorrow, but the reverse is not the case!
There are many questions that need to be asked in determining the seriousness and immediacy of a suicidal threat, but the single most important one is, “What stopped you?” (or “What is keeping you going?”). I have heard a wide variety of answers, including fear of bungling the attempt and ending up worse than before. The most common response is children. If someone says that they think their children will be better off if they are dead, I know that the impulse to die is very strong.
We also need to understand exactly what has brought the person to see us. Will the connection with us help to lift them out of a state of isolation? Are they looking for an excuse to live—or to die? Are their statements—or actions—a “cry for help”? An attempt at revenge? An impulsive response to frustration?
I once received a call from a woman completely unknown to me, who shouted into the phone: “Dr. Goldwater, I’m an alcoholic, and a paraplegic, and I want to kill myself!” When I asked her if she could stay alive long enough to meet with me the following week, she laughed and said she could. This woman simply wanted a connection with someone who could accept her.
Actions may be harder to interpret than statements. One young woman told me that one day she had gotten it into her head that she wanted to jump off a building. She said she was not depressed and had no desire to die. It was only after she jumped that she realized that she had made a terrible mistake. She desperately tried to maneuver her body so that she would not be killed, and succeeded, although she did sustain serious injuries. I have now known this woman for 25 years, and to my knowledge she has never made a deliberate suicide attempt. But she is frequently psychotic, and in that state is vulnerable to dangerous delusions and impulses.
People without proper training in dealing with psychosis can make astonishing mistakes. At the (world-class) hospital at which I was trained, a man was brought to the emergency room one night after having jumped out of a third-floor window. His leg was broken and he was seen by the orthopedic resident, who set the fracture and put the leg in a cast. “Why did you jump?” he asked the man. “The voices told me to”, was the reply. “Did you want to kill yourself?” “No.” The resident wrote in the chart, “Not suicidal. Will get psych consult in the morning.” He sent the patient up to the orthopedic ward on the fifth floor of the hospital, where the patient waited until he was alone, hobbled over to the window, and jumped to his death.
Far more common than these examples of psychotic behavior are people who are depressed, overwhelmed, or in terrible physical or psychological pain. Often enough we listen to their stories and think, “if it were me, I’d want to die too.” Chronic depression in particular threatens to wear us down, just as it does the person who suffers from it. But we must remember: something is keeping them going. What is it? Exploring–and accepting–the ambivalence of the suicidal person, and offering them connection: these are the tasks that I hope to teach my students to accomplish.
–Dr. Eugene Goldwater, M.D., Cert. Psya., Adjunct Faculty, BGSP