Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, March 08, 2008

Answering the Real Question

I recently received an extremely moving email on the topic of suicide from a lurker. It turns out that my words, wrung from the pain of the deaths of two children, brought solace; truly a miracle of our times and the internet. Fat Doctor also had a post several weeks ago about how to answer the question, "Give me one good reason not to kill myself." (Back off, Grammar Nazis; the actual sentiment in the form of a question would be, "Why shouldn't I kill myself?")

My answer to that is to address the real question.

First of all, let me point out that it can take some skill NOT to answer what appears to be a question. It's not really hard to do, though it can take some practice. Here are some questions that are routinely not answered:
  • How yoo doin'?
  • Is the doctor there?
  • Why do I have to go to bed?
The first statement, of course, isn't meant as a question at all. It's Philly-speak for "Hello." The second is answered, Jewish-style, with another question: "Can I help you with something?" The third, usually asked by a pre-schooler, also isn't a question. What the kid is really saying is, "I don't want to go to bed." The wise parent learns this -- sometimes the hard way -- and responds with a non-answer like, "Because." But a mark of skillful parenting is learning to address "the real question," which is that the child wants to stay up because he doesn't want to miss interesting things (he perceives) going on without him. Of course he needs to sleep in order to be alert for much more interesting things the next day, and the wise parent learns to address this lovingly and explicitly.

"Why shouldn't I kill myself?" is, in my opinion, not really a question at all. It is an expression of despair so deep that the questioner cannot believe it will ever get better. In the case of a terminal illness with physical suffering, it is a statement that symptoms are not adequately controlled, and should prompt efforts to better manage them. This is also the case in the psychiatric version, but because the suffering is the belief itself, it is by definition resistant to intellectual logic.

The problem is that trying to answer these non-questions enters into a tacit agreement that an issue is open to debate. If you start trying to explain to a kid why he needs to go to bed, what happens if he makes a better argument than you can? Are you going to let him stay up? (Perhaps; but stay with me here.) Similarly, if you can't manage to come up with "one good reason" not to commit suicide, are you going to agree that the patient ought to kill himself? The flaw in the logic is that a suicidal person is unable to comprehend such a reason, just as a non-suicidal person doesn't need one.

Anyone who has contemplated suicide but not gone through with it eventually comes to realize that it was not a good idea, and that they were not thinking clearly at the time. What sense does it make to enter into a highly intellectual debate about life and death with someone unable to think rationally? I believe a better approach to the question, "Why shouldn't I kill myself?" is to recognize that what has really been said is, "I am in pain, and I am desperate." Expressions of empathy for the pain and reassurances that things will get better -- even (especially) if the patient doesn't understand or believe it -- strike me as a more honest approach than trying to come up with an "answer" to the wrong question.

And to my lurker: You cannot begin to imagine how deeply your words moved me. I can't even fathom the courage it took to write them, much less the courage it took to step back from that abyss. Please be assured that whatever my words did for you, you have returned the favor hundred-fold. Peace.


At Sat Mar 08, 03:11:00 PM, Blogger rlbates said...

Very thoughtful post. Thank you.

At Sun Mar 09, 08:53:00 PM, Anonymous Anonymous said...

Great post. (I read lots of blogs but rarely comment; however I had to comment on this.) This makes sense to me. I read Fat Doctor's post before, too, and I think most of the responders were coming from the wrong angle. You can't give a suicidal person a reason not to kill himself. People who are suicidal (and I have been, several times) are not thinking clearly or rationally. And kind of rational "explanation" is going to be wasted breath. It is comparable to trying to convince a delusional person that his ideas are not true. You can spout off wonderful logical arguments till you're blue in the face, but it won't touch the way that person is thinking/feeling. (And I have had delusions too, so I can make that comparison.)

At Tue Mar 11, 06:15:00 PM, Blogger Neumed said...

Wow! Just discovered your blog today. I've been reading for about an hour and I must say yours is one of the best medical-related blogs I've run across.

I especially liked the post on how to get pregnant. (However, in my case, instead of "doan' moove," I'll have to remember to tell my wife, "Quick, get up and run around.")

At Tue Mar 11, 11:30:00 PM, Blogger SeaSpray said...

I totally agree with you.

I also loved the "How to get pregnant".

I wish I knew that when I was having difficulty conceiving and undergoing infertility tests.

Thank God...did conceive 2 sons, but maybe it wouldn't have taken so long. :)

At Wed Mar 12, 03:47:00 PM, Blogger Kindyland said...

I attempted twice last year. Long story. No one could have talked me out of it. Now, I can't believe I did such a dumb was all I saw that could fix me.

At Thu Mar 13, 03:26:00 PM, Blogger Dr. Deb said...

I work with many individuals who fall into this abyss. And I agree with you: It's not a question as much as it is an expression of immeasurable pain and despair.

At Thu Mar 13, 11:25:00 PM, Anonymous Anonymous said...

Anyone who has contemplated suicide but not gone through with it eventually comes to realize that it was not a good idea, and that they were not thinking clearly at the time.

I have to disagree with this. I am not suicidal now as I'm on stabilizing medications, am attending therapy, and have no plans. But not once in the past 12 years have I ever thought that, if given the choice, I would choose to have been born. Now that I am born, it's too large a hill to climb over to die--the risk of not succeeding, the hurt it would cause my psychiatrist and therapist who genuinely care about me, and the natural animal instinct for suvival.

But as I said, not once have I ever thought that life has been worth living, even if I don't think that it's worth dying.

At Fri Mar 14, 07:03:00 AM, Blogger Kindyland said...

Anonymous, But you've still come to the conclusion that you're not going to die. I don't see that as being much different. You've decided suicide isn't worth it because it would hurt people around you.

At Fri Mar 14, 12:11:00 PM, Anonymous Anonymous said...

Nick, I am the one who posted the anonymous comment above. I haven't come to the conclusion that I'm not going to die. I've only come to the conclusion that at the moment I don't have the courage to kill myself, and that is the only reason that suicide is not worth it for me now--because it would require too much willpower to overcome everything that goes against it, even if I know that dying is a better state than living.

Every time I hear of a suicide, including of those I know, my first thought is, "Wow, how brave. I wish I could be that brave."

My point is simply that it's mistaken to casually dismiss suicidal longings by saying that you'll eventually feel better and be glad that you're living. That simply isn't true. For some people, depression is a lifelong battle that cannot be won. There may be moments of relief, but they are so fleeting before the next big wave hits.

Keep in mind that I'm writing this when I'm feeling 'okay' compared to how I've felt in the past. It's probably among my best times in the last decade. But this 'okayness' isn't enough for life to not feel like a torture chamber.

At Mon Mar 17, 01:27:00 PM, Blogger Dreaming again said...

As a survivor ... I know that nothing anyone said to my father could have changed his mind. Depression had taken over ...and he really, honestly thought he was making our lives easier.
The why's ... are not all that complicated but would take too long to write out here ...

The truth ... the destructive loss of his death ... the chaos his death sent our family into ...and the forever loss of his love, nurturing and understanding ... cannot be replaced. He did not understand that while he saw himself as a burden, he was in fact, the glue that held us together.

Recently, I've, for thereuputic reasons, listed the people I've lost to death ...6 of them to suicide ...not one ..NOT ONE ... realized the depth that they were loved, cared for and needed.

when someone tells you that you are loved ... they most likely mean it.

Life isn't easy, it wasn't meant to be easy ...but to make life more difficult, complicated, chaotic, and crushing by removing yourself so destructively from the lives of those who care about you .. is ... tragic, to say the least.

At Tue Mar 18, 03:04:00 PM, Blogger DDx:dx said...

In medical school I was extremely ambivalent about suicide. I thought if I could be convinced of a person's situation and if I were there and would consider suicide, then they were "rational".
Then I got into practice, but moreso, became the county coroner. Suicide is sloppy, selfish, desperate and wrong. Now I can understand wanting out. But to think only of oneself is very unhealthy. Inhuman. For we are all in this together. And it is our job, as physicians, to relate. To restore a sense of humanity.

At Tue Apr 01, 10:35:00 AM, Blogger Alison Cummins said...

I'd add something: "I am in pain, I am desperate, and I have lost hope."

Someone still talking is looking for a way to find hope again.

I'm with Anonymous 11:25:00. No, you don't always realise it was a dumb idea. Maybe when you are young and impulsive and you don't yet have a solid experience of the sun coming out tomorrow. Then you learn that even if you are feeling dramatic today, often all you need to do is hold on and life mysteriously becomes worth living again.

Some of us have been through that. Some of us learned in our early teens that episodes of clinical depression could be endured until they passed and life became good again. Most young people will develop resilience from this sort of experience and move on.

But by the time we are in our forties, some of us have become worn down. The disruption that recurring episodes cause, the fact that life seems never to become much good in-between any more, is exhausting. If we have tried repeatedly to haul ourselves out of the sludge of our lives and always fallen back in, after twenty years of trying why would we think that next time will be successful? Because frankly, that's quite unrealistic. Doing more of the same will almost certainly not help.

Someone in that situation is looking for assurance that there is something left to do. Something more that has not yet been tried. Some reason to hope. If there is nothing new, then we might as well accept that now and get out of it with as little mess as possible.

Of course, you are correct that a person who commits suicide typically underestimates the amount of "mess" their death will inevitably cause. Some of us, like anonymous, don't underestimate it. We endure suffering with no hope because we don't want to spread our suffering to others by causing them the kind of pain that accompanies suicide. But no, we don't ever look back and think that we were so glad we didn't end it then because life is so worth it now. Because it isn't.

*** *** ***
I write that in the present tense, but I have effective medication now. It took me years to get it, and paid huge prices for not getting it. I was losing hope that I would ever be effectively treated and wondering where I would get the strength to endure another thirty or forty years. If medication had not been available, whether because I was not able to get myself taken seriously or because I lived in a time or place it was not available, I would probably be dead by now. And it would probably have been the most realistic outcome.

At Tue Apr 01, 12:55:00 PM, Blogger Kim said...

Wow. I went back and read all three posts before this one. Powerful. And so are these comments.

Thank you, #1 and to those who commented for some insight into the issue of suicide.

At Tue Apr 01, 08:33:00 PM, Anonymous Anonymous said...

--Anyone who has contemplated suicide but not gone through with it eventually comes to realize that they were not thinking clearly at the time.

No, this is false. There is a difference between being MISTAKEN and being IRRATIONAL.

Many people who are in terrible suffering consider suffering. They are not IRRATIONAL. They want an end to the suffering. They are currently stuck in a belief that their suffering won't end. But that is not an irrational belief if you have terminal lung cancer and your pain has not been remedied. That is not an irrational belief if you've been in therapy for anxiety or depression or PTSD and your pain has not been remedied.

It's probably a MISTAKEN belief--the person believing it is mistaken that the suffering can't end.

But it's patronizing and ultimately, isolating to a suicidal person to tell them or act or even think they are necessarily irrational. They could be, but many are not.

--What sense does it make to enter into a highly intellectual debate about life and death with someone unable to think rationally?

Again, they can VERY WELL be rational. If you were in the pain THEY were in, you might consider it too. Because if you have not received treatment for your suffering, then it MAKES SENSE.

---I believe a better approach to the question, "Why shouldn't I kill myself?" is to recognize that what has really been said is, "I am in pain, and I am desperate."

Yes, THAT IS what they are saying. But that does not make it IRRATIONAL to want to end one's life, if every other attempt to end suffering has failed.

The part to concentrate on is to start a dialogue where you talk about suffering, and how they can come to believe that the suffering CAN END--be it with better physical treatment of their symptoms, or better emotional treatment.

but don't be so quick to assume the grossly awful nature of a painful terminal illness makes someone irrational for wanting to end their suffering, nor that someone spending years suffering emotionally shouldn't begin to doubt that they can get well.

At Tue Apr 01, 08:38:00 PM, Anonymous Anonymous said...

To continue: I do agree that arguing that the person is mistaken is not the way to go. The way to go is to work on remedying their suffering--and to make it clear to them that you DO NOT think that they should learn to merely "live with the suffering". You have to recognize its depth and its importance, and then you have to get them to believe you haven't tried every available remedy, and that you care to keep trying. That's important--that you haven't given up and assumed they will just suffer forever, or that this suffering is something they should learn to live with.

At Wed Apr 02, 07:14:00 AM, Blogger Lee said...

Thank you! I've got a friend who professes to be suicidal and has claimed to try twice. He just keeps doing things that reduce the likely hood of it too. But I've never known what to say when he says he wants to put a bullet through his brain. It hurts to hear it and I don't want to find myself withdrawing. So I really appreciate this post of yours. It will give me something to focus on besides the anguish of hearing a good friend talk like that.


At Sat Jun 21, 11:26:00 PM, Anonymous Anonymous said...

My opinion is that all depressed people who've found that SSRIs and therapy don't work should try an effective medicine like an MAOI. Talking therapy is pointless for a suicidal person IMO because the very nature of their situation and mindset nullifies anything you can say to them - as I think you were saying. Drug treatment can get someone to the talking stage.

At Fri Mar 06, 11:57:00 AM, Anonymous Anonymous said...

I work with alot of patients that talk about suicude and most truly want to hurt themselves. So people use suicide or saying "I AM THINKING OF SUICIDE" as an easy way out of a problem. Others use it like coffee and it is to get attention. But for those that are or have truly thought about suicide you must find that thing in their life that still holds meaning. They may have forgotten what it is!!!! I know that inside us all is the basic human instinct to survive sometimes we cannot allow our selves to get lost and forget that we do mean something to the people around us and to ourselves. Suicide is selfish and an easy way out as some of the people here have already stated, it takes a real man or woman to deal with what is going on, seek help and make the choice to do what is best for their family and in the end for themselves...... P.S. I am talking from personnel experience with the issue as well as PT interaction


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