Tuesday, December 23, 2008

That is the Question

"There is only one really serious philosophical question, and that is suicide."

Albert Camus

Morbid though it is before the holidays, I feel obliged to finish the thought from last post, about how the ultimate ethical issue of suicide is similar to other grand queries (why be moral? why grow up?) that lack a fully satisfying theoretical answer. And in practical and clinical terms, is it possible, or even advisable to try, to dissuade someone who is seriously suicidal?

But this gives me a chance to touch on "holiday psychiatry" in general. As many hopefully are aware by now, the notion that the suicide rate increases around the holidays is a myth (it actually has a spike in the spring), although some have expressed concern that the dramatic economic downturn may generate more risk this particular year.

While many people complain about the increased stress of the holidays, and certain individuals do indeed fare worse this time of year, in my clinical experience the net effect is positive. In my years of inpatient work the unit census always dipped dramatically the latter half of December. And outpatients--again, on average--seem to coast through holiday time reasonably well.

My hypothesis is that while many may gripe about tedious or irritating family time, the social support of sheer enforced togetherness is usually a good thing (time off from work doesn't hurt either). In this way, family time can be like, well, a very different but well-known kind of social encounter: it may be far from perfect, but it is better than none at all.

At any rate, let's suppose someone is in fact driven to the brink by depression plus the holiday fanfare. As hinted above, philosophers have had a hard time coming up with solid justifications for why suicide is generally an evil. Presumably, the reason is that in order to work, such arguments have to assume too much of what they're trying to prove, that is, the absolute value of life itself.

Any philosophical argument presupposes an adequately rational auditor, and that is the problem--a seriously suicidal person, virtually by definition we say, has lost sight of his or her own vital interests and therefore cannot be considered fully rational. That is why we have involuntary commitment procedures and locked psychiatric hospital wards, because for suicidal individuals reason has broken down.

Fortunately of course, most people make it through life without being constitutionally disposed to seriously suicidal thoughts or behaviors. So native biology is our first and primary protection, but not the only one by far. What are the most common reasons not to commit suicide? The following is not scientific, but based on my clinical observations:

1. Cowardice--Fortunately most people are sufficiently averse to violence, pain, and blood that this in itself will keep many in the land of the living; there is also the associated fear of doing something halfway and winding up brain-damaged. If some absolutely painless and definite means of suicide were widely available, that would make the psychiatrist's job considerably harder. This is a visceral factor that few potential suicides need reminding of.

2. Threat of damnation--Whatever else one might say about religious belief and psychiatry, hell serves--among believers obviously--as a mighty deterrent for many would-be suicides. This consideration is also the basis for one of the most famous passages in English, Hamlet's "To be or not to be" soliloquy. However, most people for whom this rationale has force will have arrived at it long before they talk to a psychiatrist, so I wouldn't usually bring it up (if I know a suicidal someone to be a believer and yet he doesn't volunteer the damnation concern, I will usually ask something like "Have you shared this with your minister, etc.?"). In fact, suicide is such an absolute ethical issue precisely because death is, so far as we know, so final; in the broadly secular context of psychiatry, to emphasize considerations of the afterlife would be positively counterproductive for this reason (again, if someone already has a belief in hell or whatever that protects against suicide, that's great with me).

3. Effects on family--Many potential suicides will already have this preventive concern in place. But sometimes not--depression is, almost by definition, a state of self-absorption such that the ramifications for children, parents, etc. will have been overlooked. For this reason I often try, sensitively and without imputation of a "guilt trip" for their own suffering, to convey the devastation that suicide can wreak in families through the generations.

4. This too shall pass--This is the consideration that seriously suicidal people are least likely to have perceived, and therefore one that I most emphasize. In most cases depression is an episodic illness; when it flares it can be awful, but relief is likely to come (even without treatment, although treatment obviously hastens recovery). And yet the deeply depressed person, by the nature of the illness, cannot imagine this--all they can see is darkness (that's what true hopelessness is). So the way I usually think of it is that suicide is a permanent solution for a temporary problem, and I remind people that their own values and their attachment to life will recover if they will only give it time.

Okay, I've had my say on that, and will come up with something appropriately rosier tomorrow.


Retriever said...

Good. We are (hopefully) helping with some of that enforced togetherness for a suicidal member of the family right now. Of course consulting all the required witchdoctors er medical professionals and the minister as well. The person in question is painfully shy and the family den comforts we hope.
As a recurring family issue, I've often wondered if the holiday feasting didn't also help a little. Nutrient dense meals (nuts, fruit, eggog, roast meats, etc. help more than yukky sugar cookies or booze which makes them worse--isn't booze involved in 60% of all completed suicides?). And most people, even desperately depressed, can usually respond to PRESENTS and spiritual music, albeit only briefly.
IMHO,you missed out one brutal argument that has to be advanced with tact and skill to the would be suicide: that their killing themself will NOT make the rejecting lover finally love them, or make eveyone feel sorry for them. One has to get across the Scriptural insight that tis better to be a living dog than a dead lion. That people will hate and be devastated by one's self-destruction, and will not admire or be impressed by it. This kind of message is better presented by a supposedly neutral shrink than a perceived-as-snarky relative,obviously

Novalis said...

Thanks for reminding me that martyrdom for love, as I suppose one would have to call it, is not usually a winning strategy in the LONG term.

However, I have been discomfited to note that in the SHORT term, a modest overdose seems pretty effective for bringing the quasi-estranged significant other rushing to the ER or the bedside. But presumably that kind of drama only works once. If it works more than once (with the same significant other), you probably have two patients on your hands and not just one.

Anonymous said...

This too shall pass is hard to swallow when your experience is that of having it pass briefly, only for it to return again and again and again. What do you do when virtually every drug has been tried, inumerable ECTs have come to pass and therapy is a weekly reality?

Anonymous said...

Let us suppose a situation where the would-be suicidal person has his/her mental faculties intact (and is not clnically depressed), and is thus, by society's definition, sufficiently rational to be able to reason about suicide and its consequent implications. What if, upon analysing the pros and cons of a life badly spent (by design, choice, circumstance, misfortune etc.), the scientific unknown equates to less than zero, and reprieve in death for the subject and their connections is the only rational response; that life's continuation, in the face of available evidence, would be morally repugnant (euthanasia also fits somewhere here). Is suicide still unjsutified?

Or what about someone who has lost everyone/everything and hence has no sphere of consequence? I'm thinking maybe someone quite old, whose partner, realtives, friends have all died and they are left completely destitute, having reached the limits of life's bearability. Are they wrong to choose not to go on?

And the point dworthen touched on --the repetitiveness of the assault that only temporarily relents, and then keeps viciously replaying like an evil loop. Is suicide still not justified, when reprieve is the only temporary situation, and the persistent sickness, that ebbs and flows, the only constant thread?

The ethics of suicide make for an uneasy conscience. It be the truth that life is not always the desired acme, and death the repellent nadir.

Anonymous said...

Just let me emphasise --to pre-empt any accusations of irresponsibilty and general irrepressible gloomy pessimism -- that I'm not pro-death, just pro-reason.

Novalis said...

I see no irresponsibility in your comments; it is a serious question, and brings us back around to some of the concerns of the assisted suicide issue of a few posts ago.

Apart from the ethical issues in the abstract (if that even makes any sense), there is the question of whether any decent society would want a medical branch such as psychiatry, which routinely deals with suicidal people, that was anything but staunchly opposed to taking one's own life. "Opposed" needn't mean blaming or demonizing those who contemplate or even attempt or carry out; it can merely mean, well, opposed. Similarly, whatever one's views on assisted suicide, I think most would agree that we wouldn't want a medical profession that lightly and nonchalantly "assisted" suicides by request.

I don't think I minimize the devastation of severe and chronic depression; I have seen too many people with it. But the problem is that we still don't know how to forecast individual prognosis well enough; in that respect it is not, say, like end-stage ALS where we know recovery just isn't possible. Whatever its horrors, depression does have strange and unexpected remissions, and this alone should make us opposed, at least in principle, to "permanent solutions."

Anonymous said...

I would like to say this; Suicide is selfish; if you have loved ones- it is selfish of you to kill yourself.

For those whom nothing works, do something (yes, I know you don't feel like - make yourself.) By this, I mean, move to another state and start a new life; start a difficult hobby like learning an instrument; volunteer at a YMCA; host softball. DO SOMETHING that is time encompassing. When you are depressed; time is your worst enemy.

Or… you could join the military! Unless you have been admitted, just don't disclose prescriptions and off you go. If you are going to kill yourself anyway, you might as well put a little meaning in to it.

Also, ease off the meds; dulling the brain will not set you free- they only hinder and placate. Though, if you have issues with obsession or bipolar, you do need something to balance you a bit~ in order to make you functional.

I have extensive experience with this as my mother has various mental deficiencies as do two of my brothers, my grandfather and my aunt. Lastly, DON’T get electroshock therapy- it is just frying your brain (your memories in particular)

On the other side of the coin; who are you to waste such a biological triumph; whereas who am I to say what one can waste.


Anonymous said...

Except when medical is keeping you alive; when you would prefer to die. I am pro-assisted suicide in certain circumstances.


Anonymous said...

Novalis at 3:05 AM: spot on. That's the nobility in psychiatry, right there. It made me think of the p-docs I've had who could fling the gloomy romantic horseshit with me, finish my Nick Cave and Dostoevsky references, which gained my respect and created a bond. Because they didn't turn away from the dark I imbued those docs with authority, in the original sense of the word. The ones I shared my secret plans with and they had zero tolerance for the argument that I was "destined" for self-destruction. The zero tolerance was of course the surprise I secretly needed at the time. I shudder to think how things might turn out if your aforementioned "role opposition" succumbed to reasoned argument. And Anonymous is right of course, people always have their reasons.
I do believe this blog is aptly named.

Anonymous said...

Sometimes, it's paradoxically the absolute height of selfishness to NOT suicide. It's only superficially and politically correct to scratch around for a microscopic speck of worth that would render the plan regrettable; but underneath the psychological niceties lies an eminently fulfillable wish --from all perspectives.

Let's not be fools and pathetically hold the broken shards of a once invaluable urn up to the light and make-believe we see a flying pig...We're all carved up f@#in' meat in the end anyway -- get over it!

There is a beginning and there is an end. All things move toward their end.

Sorry, let me balance my response:

Cheerfulness, optimism, happiness, joy, chocolate, wine, good company, arguments that resolve with a kiss and hug...gee it's great to be human! Some pretty thoughts to end on -- being Christmas and all ;)