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Dr. Gordon is a consumer academic affiliated with the Department of Psychological Medicine, University of Otago, Wellington, New Zealand (e-mail: email@example.com). Jeffrey L. Geller, M.D., M.P.H., is editor of this column.
Copyright © 2011 by the American Psychiatric Association.
Approximately three years ago, a 34-year old woman killed herself. But the paramedics managed to revive her. Waking up from a coma two days later and being assessed as having no long-term mental or physical injury as a result of the suicide attempt, the woman was discharged from the intensive care unit to a psychiatric unit. After two months with this service, the woman asked to be discharged. She felt that this request was quite reasonable: her immediate acute mental illness symptoms had been addressed.
The psychiatrist refused to entertain any notion of immediate discharge, however, reasoning that the patient seemed to have no relationship with anyone or anything. You see, the psychiatrist argued, relating to people is absolutely fundamental to living well. So that is what the woman did with the remainder of her time with the unit, which was a further five months: she worked on relearning and practicing relationships with herself, her family, her friends, and her community. And this is what she is doing now: actively engaging in her roles as a mother and wife, working, dancing, writing, celebrating holidays, and shopping (something she particularly enjoys).
I often talk about my experience from the third-person perspective. Why is that? Because now, being well, I have no sympathy for that woman. Working in mental health, I am well aware of the trauma that results from people taking their own life. How could I have possibly done that to myself, my family, and my two boys? I don't think there is any easy answer to that question, but please let me share some of my ponderings.
In the two years prior to my last suicide attempt, I had been swinging like a pendulum, from being in an inpatient unit back to what had now become the chaos of my life, and back again to an inpatient unit. Each time I was assessed as reaching a reasonable level of “recovery”—sufficient to be discharged—I plunged head first back into the drinking, drugging, and self-harming. And each time I ended up back in the unit, there was another change of meds or more electroconvulsive therapy or another regimen of some sort, all in an attempt to get me well again. With each swing of the pendulum my mental illness presentation got more severe. Finally, I got to that place where my desire and actions for self-destruction overwhelmed any last remaining grasp at survival.
You might be surprised to hear me describe my drinking, drugging, and self-harming as equating to a last remaining grasp at survival. And yet, in hindsight, that is exactly what I have come to see them as. In fact this insight also came from that psychiatrist (the one who refused to discharge me). When I eventually was discharged, she admitted, with tears in her eyes, that she hadn't thought I would make it. My somewhat defensive response: “I don't know why you thought I was such a risk; look at everyone else 'round here—cutting, burning, starving themselves—I wasn't doing any of those things [anymore] when I arrived.” “Yes,” she said, “but at least when people are doing those things, no matter how unhealthy and maladaptive they are, they still have some fight, the energy of which I can then harness to support change.” This is a brilliant example of a strengths-based approach to practice.
I find it rather ironic that after I woke up from the coma, the medical professionals signed my heart off as being healthy and handed me over to the “head” specialists. And yet, ultimately, the head specialists also ended up working on my heart through relationships—what no pills or zaps could help me with and yet the key to a more positive long-term outcome.
To my mind there are two main barriers to relationship-focused supports. First, those interrelational factors are more intangible. For example, what does it mean to be “in a relationship,” and how do you go about supporting someone in that? Second, as reflected by my experience, it takes much longer to address those interrelational factors than it does to address anything else. Given that much of our system is designed and works, for a whole variety of reasons, in a manner that strives for the ultimate in efficiency, any “time-intensive” supports are difficult for services to work in to their programs. However, in the longer term, time-intensive supports are actually the most cost-effective. In my own case I have had no further admissions in the two-plus years since I was discharged from the service (which helped me attend to those interrelational factors in addition to others), compared with five admissions in the two years prior with other services (which did not).
In my present state of mind, attempted suicide would be an irrational action for me to take. However, back then, I had spent two years struggling and not getting anywhere. Furthermore, that struggle was not only mine; it was causing a great deal of distress to all of those close to me. In fact, during that time, my family used to be relieved whenever I was admitted to the unit. At least then they didn't have to worry what they may or may not have been coming home to. Yes, my death would have been traumatic for them, but the reality was that my living, at that time, was also traumatic for them. If I hadn't been able to access the help that I needed to get well (as I subsequently did), then attempted suicide could, in some ways, be considered quite a rational course of action. It's very sad that suicide becomes a rational alternative because the support needed in order to live well is not available or accessible.
In spite of everything, my family and friends steadfastly love and support me. That is not easy for them. Let me share with you some words from my parents:
“When she was in Ward 27, we visited Sarah everyday—sometimes twice a day—spending as much time as we could with her. After the initial sympathy for others, I soon began to think only of Sarah. I couldn't have cared less about the others. After a while, particularly when Sarah was under heavy sedation, I lost some of the sympathy and caring attitude for her. I just wanted it to finish and get out of there.”
I know there are people, for various reasons, who no longer have relationships with family and friends. And that makes those interrelational issues that much harder to address. However, it is still not hopeless. In these situations we need to look beyond what we could perhaps refer to as our more conventional relationships. I believe that peer support services can play a vital role in this regard, many of which exist purposefully to provide us with an opportunity to establish relationships with other people.
I think social isolation is also a by-product of how we are living as a community. For example, having two young children, I thought that their school community offered an ideal environment for me to establish relationships. Yet often I come away from their school events feeling like a big loser. You see, on asking another parent what he or she has been up to for the day, I often get a response like “Well today I have done three loads of washing, cooked and frozen the meals for the next five nights, and been for a 10-k run. What's more, I can't wait to take the kids home and spend some quality time playing in the yard and reading books. How about you?”
“Well,” I respond, “I have just been sitting around watching soaps and fagging. I am not looking forward to spending the next five hours with my kids. They have been little shits all week and will probably spend most of the afternoon in time out.” The interesting thing is the response I usually get; rather than ostracizing me, people seem to appreciate my honesty about my failings and vulnerabilities and then feel safe to expose and share their own—often, I believe, with a great sense of relief. The fact is that every one of us has struggles and challenges in life. The support we need to face them requires our being in relationships with each other. But those relationships will never develop while we are all full of pretense. Sometimes exposing our own vulnerabilities, however risky that may feel at the time, can serve to break down societal barriers and provide the foundation for developing real relationships.
You may think I have developed some profound wisdom as a result of my experience. I wish! When I was younger, after my first or second episode, it was much easier—“Never again!” I would loudly proclaim—but my now 20 years of experience have made me … what … a realist, a cynic, a pessimist, a harbinger of gloom, a defeatist, someone who likes to keep my options open. I don't know. In some ways I consider myself lucky that my illness manifests episodically; however, the reality is that each episode gets longer, more severe, and more difficult to recover from. So what is the best way forward? My family, friends, and I will continue to love, hope, and live one day at a time, facing any and all challenges the only way any of us can — together.
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