Prozac is Talking -- Anybody Listening?

Anybody know this story?  You get a new prescription.  Responsible consumer that you are, you read carefully the PI [prescribing information] sheet.  It says, "If xx happens, call your doctor immediately."  Sure enough, xx happens.  You call your doctor, who does not call back.  After persistent calling over several days, the doc says, "Really?  We'll keep an eye on it."

The other day, I had a nosebleed that wouldn't stop.  The PI sheet says my new med can interfere with platelets, admittedly not very high on the list of side effects.  But I contacted the doc.  "Really?"  she said, "Where did you hear that was a side effect?"  My answer, "On the PI sheet you gave me."  It turned out, my blood work was fine, and the humidifier took care of the nosebleeds.

No harm done.  Right?

On the other hand, five years ago my GP had me on Prozac.  After a couple months, I couldn't sleep, was irritated, agitated, couldn't concentrate, had thoughts of harming myself and others.  The PI sheet said I should tell my doctor.  My doctor increased the dose.

Thus began a series of antidepressants, and a downward spiral that has ended with disability.

The Miracle of Gheel -- Humane Treatment for Mental Illness

It was seventh century Ireland.  The Queen died.  King Damon's grief was so deep that it moved into depression and then psychosis.  He thought his daughter Dymphna was his queen.  Rather than submit to his advances, Dymphna fled to Belgium, to the town of Gheel.  But her father followed.  When she again rebuffed him, he killed her, cut off her head.  Dymphna was buried in the local church.

Six centuries later, her coffin was found during renovations.  Signs on the coffin demonstrated her holiness.  She began to be venerated.  Cures of the sick were attributed to her.  She was canonized in 1247 as the patron saint of the mentally ill.

Okay, here the one last bit of unrecovered Catholic in me demands to be heard, to note Rome's fascination with girls who prefer death to rape.  Even as a nine year old, that made me uncomfortable.

Moving on.  People came to Gheel for healing.  Many brought family members who were mentally ill.  Sometimes they left them there.  The priest housed these abandoned ones next to the church.  When the job of caring for them became too much for him, townspeople started bringing in food.  They built a hospital in the 14th century.  When it was full, the real miracle of St. Dymphna occurred, or rather, began.  Townspeople took some of the patients into their own homes, reserving the hospital only for those most ill.

All across Europe, people with mental illness were thought to be possessed.  They were exorcised, tortured and burned at the stake.  But not in Gheel.

Imagine it!  A psychotic foreigner commits a terrible deed.  But the townspeople do not close the borders.  No, they open their homes.

And they still do.  Through plagues, wars, revolutions, recessions, depressions, during the Napoleonic "Reform," when all the mentally ill people in the country were ordered into one big hospital, during the Nazi occupation, with their "final solution" for mental illness, during the latest reform when the U.S. of A. was/is dumping all our mentally ill people out of the hospitals, onto our streets and into our jails, the people of Gheel developed and continue genuine community-based mental health care.

Today, there are 700 foster homes for 1000 people with mental illness.  A person will enter the hospital for evaluation and stabilization.  S/he meets the psychiatrist, psychologist, nurse, social worker and family practitioner who staff one of the five neighborhood community mental health centers.  Each of these staff people spends half a day each week in the hospital, so everybody gets to know everybody.  The potential foster family and patient meet at the hospital, then over tea at home, then over a meal, then over a weekend before placement.  Outpatient care, medication monitoring and therapy continue at the neighborhood center.  If possible, the biological family participates in the treatment plan.

Once part of the family, the person shares in family activities, chores and church.  The church doesn't have special bible studies, services or programs for the mentally ill.  They are fully integrated, regular readers, members of the choir, ushers, etc.

What if the person's symptoms flair?  "We say s/he is having a bad day."  Because the person lives in a family, not on the streets or alone in an apartment, problems are caught and addressed early, not after getting fired or evicted or arrested or in a bloody mess.  If needed, s/he can go back to the hospital for a while.  In fact, the hospital is not the place of last resort.  When the foster family has to go out of town, say, for a funeral, the person can stay at the hospital.  There is continuity of care.  There is care.

Three years ago I wrote a chapter for Deep Calling called, "If This Were Cancer."  I detailed all the ways that hospice patients receive the support of others, and that people who have suicidal depression do not.  "If this were cancer, there would be casseroles..."  I imagined the total collapse of care for the mentally ill, under the weight of our crazy health care system.  In fact, it's happening as I write.  I imagined that the Church would step in to meet a desperate need, to create hospice for the mentally ill, as the Church originally created hospice and hospitals.  I claimed that the Church has the resources to organize for such care on a local basis.  It has the faith to imagine such a thing, the love to cast out fear, and the values to demand it.  I will have to rewrite that chapter.  I didn't know it had already been/is already being done.

I am ever so grateful to Janet, whose last name I don't remember, who gave me Souls in the Hands of a Tender God: Stories of the Search for Healing and Home on the Streets by Craig Rennebohm, the source of this story.

Lord God, Who has graciously chosen Saint Dymphna to be the patroness of those afflicted with mental and nervous disorders, and has caused her to be an inspiration and a symbol of charity to the thousands who invoke her intercession, grant through the prayers of this pure, youthful martyr, relief and consolation to all who suffer from these disturbances, and especially to those for whom we now pray. (Here mention those for whom you wish to pray.)

We beg You to accept and grant the prayers of Saint Dymphna on our behalf. Grant to those we have particularly recommended patience in their sufferings and resignation to Your Divine Will. Fill them with hope and, if it is according to Your Divine Plan, bestow upon them the cure they so earnestly desire. Grant this through Christ Our Lord. Amen.
 

Dymphna's feast day is May 15.

The Best Health Care in the World

Rush Limbaugh says that he experienced the world's best health care in the United States of America, and it does not need fixing.  I am glad for Rush that he was staying at a resort near a world class hospital for coronary care last month.  I imagine he has insurance to pay for the hotel-like accommodations, the angiogram and several other tests that failed to find the cause of his chest pains.

Given his public platform and his wide influence on American opinion and public policy, I wish Rush would expand his experience of health care in the United States of America.  He could shadow Craig Rennebohm for a few days to find out how health care works for other people.  Craig is the pastor of Pilgrim Church (UCC) in Seattle and, as part of their ministry, "companions" persons who are homeless and mentally ill.  With David Paul, Craig describes their quite different experiences in Souls in the Hands of a Tender God: Stories of the Search for Home and Healing on the Streets.

The emergency personnel got Rush to the emergency room like that [snap!That's not what happened to Sterling.  Over months Craig built the trust of this man who camped in the church courtyard, surrounding himself with trash to protect himself from the evil spirits.  Finally, when the trash included highly combustible materials, Craig convinced him to go to the hospital.  Winter was coming.  The mental health professionals (MHPs) who showed up said they couldn't take Sterling in, because he was a voluntary patient.  They only picked up involuntary patients.  Sterling accused Craig of betraying him and fled the scene.  Craig couldn't find him until a month later, when he read of a homeless John Doe who died of exposure.

Rush was examined for days after they already knew he was not having a heart attack.  That's not what happened to Shelly, seven months pregnant, with bronchitis and in a state of euphoria and grandiosity.  Craig brought her to the ER.  But she wasn't a "good faith" voluntary patient.  They believed she would check herself out so she could go "accomplish her mission."  She didn't qualify for involuntary admission, because she wasn't a danger to herself or others.  What about her baby?  What about her bronchitis?  "Bring her back when she develops pneumonia."

Karl's story is the clearest example of how health care in the United States of America is not working just fine.  Karl is a vet.  He was arrested for resisting arrest for vagrancy.  He just remembers being attacked, and later that the people in prison were poisoning him.  He was transferred to the hospital for two years, then back to jail to be released, no money, no meds, nothing but the clothes on his back.

Craig had been alerted.  He was a total stranger when he met Karl at the jail that morning and took him to breakfast.  Karl was stymied by the question, "White or whole wheat?"  They continued to a clinic, where Karl couldn't understand or fill out the two-page form.  Since he wasn't in immediate danger, they sent him to the Department of Social and Health Services to apply for SSI.  Craig helped him with the six-page form there.  The social worker discovered he once received benefits.  So he had to get a statement from Social Security.  Social Security noticed he was receiving veterans benefits.  Next stop, the Veteran's Administration.  But the counselor there said they were a PTSD program and didn't take walk-ins.  He sent them a mile away to the Federal Building.  His file was in another state, so they had to get it transferred.  Meanwhile, the file was on computer, and said he was getting 50 cents a month, which was going to the hospital. (They could look up the information, but couldn't give him a copy until the file was received in a few days.)  Craig said, "He's homeless and needs medication right now."  So he was sent to the VA hospital, then to the outpatient clinic in the bowels of the hospital.  Several kind strangers helped Craig find the way.  To get help at the outpatient clinic, Karl had to be admitted through ER, where they determined his illness was not service-related.  The waiting list for outpatient treatment was six months, and he might not get in, because he had been hospitalized only once.  The social worker suggested they try the clinic where they had started the day.  By now it was 6:30 and the clinic was closed.  They covered miles that day.  Karl spent the night in a homeless shelter, still not able to remember Craig's name.

That's where I will end the saga, though it is still several days from completion.  Small wonder that 83% of psychiatrists want a national health insurance plan, a higher proportion than any other specialty.  So many of their patients are homeless.

And I thought I was having a hard time.  I have boatloads of people to help, support and advocate for me.  My salary is continued while I fill out applications.  I have a roof over my head and continued health insurance.  Most of all I have Helen, who asked me all the repetitive questions over several days, monitored my capacity, and terminated the work each day, usually after twenty minutes when I was getting overwhelmed.  My phone has been set to mute the disability company whose questions put me over the edge.  She screens my messages.  This process turned me into a pill-popping wreck last fall, and though my memory is not what it used to be, I do know my helper's name.

Rush, the system works well for you.  But not for the rest of us who live in the United States of America.

I commend to your reading Souls in the Hands of a Tender God by Craig Rennebohm with David Paul.  Craig uses his stories to help us see the face of Christ in these abandoned ones, and to frame his theology of God and what it means to be a human being in the sight of God.  We cannot make the journey alone.  None of us.  We are made for life together, made for community.  Those of us blessed with health and wealth may be tempted to forget that.  We may want to believe that we are self-made and assume that we have succeeded through our individual merits alone...  Illness - and especially mental illness - confronts us with the unavoidable truth of our frailty and finitude.  Illness underscores our fundamental dependence on the love and help of others...

Craig describes the work that his community is doing, "companioning" people who are mentally ill.  Companionship can be described in terms of four practices: offering hospitality, walking side by side, listening, and accompaniment.  Let's consider these in detail...

And he tells the astounding story of a very different kind of system in Geel, Belgium.  I will tell you about the miracle of Geel next week.  There is a different way to do this.

The image is from http://mentalhealthchaplain.org

Spiritual Practices for the Dark Night -- Forgiveness

Okay -- one more in the spiritual practices series.

But I don't put forgiveness in the same category as thanksgiving and tithing, practices I keep and commend to my readers. I can't say that I practice forgiveness. When forgiveness happens, it comes as unbidden as a gracious gift in a time of desperation.

I can't tell you how to forgive. I never learned.

What I mean by forgiveness goes something like this: This person has a relationship with me, in which I can expect this person to treat me well, AND this person did me some harm, AND I forgive this person and will carry the burden of not forgiving no longer.

I never learned that kind of forgiveness. I learned BUT forgiveness: This person did me some harm, BUT it wasn't that big a deal. Or: This person did me harm BUT there were extenuating circumstances. Or: BUT I just haven't figured out the bigger picture yet. Or: BUT he/she couldn't help it. Or: BUT I am the better person, and will let it go.

But the BUTs don't work. They hide a wound that does not heal. They disrespect me and how I deserve to be treated. And they cover with a fig leaf my disrespect for the one who hurt me.

The "I just haven't figured it out yet" thing is especially problematic. There are certain statements that simply can't be reconciled unless something gives. In my case, my brain. Rehearsing and rehearsing the same event, trying to comprehend the incomprehensible, experiencing that pain over and over -- this is called rumination, the bad kind of rumination, perseveration even, my therapist would call it when she was trying to scare me out of it.

Spiritual Practices for the Dark Night -- Tithing

Yes, I'm serious.  Tithing.

I knew about tithing because I am a Christian.  The concept comes from the Old Testament. I used to think it was interesting -- from a distance. Like fasting. Of course nobody except the legalists actually did it. Still, I suspected I was missing something.

Then two things happened within two months. I left the person to whom I had turned over all decisions that mattered. And I attended a conference about what was called the "Alabama Plan." We did bible studies about money, about tithing, about abundance and God's promises. And then we were asked, What is preventing you from claiming God's promises? I realized my answer was -- nothing. Nothing prevented me.

So I became a tither.

Now remember the context. Having just moved out on the chief money maker of the family, my household income had plummeted to 40% of what it had been. It occurred to me -- this was the perfect time to begin tithing. Instead of 10% of what I was used to living on, now it would cost me just 4%. The difference between living on 40% and living on 36% didn't seem like that bit a deal.

I was so excited by my new resolution that I decided to tithe for the previous two months as well. So I sat down with my checkbook. That's when the magic happened.

Suddenly, I had $300 to give to whatever cause I wanted.

I had never had $300 to give to whatever cause I wanted.  I was rich!

And I have never looked back. In the years since, I have purchased honey bees, rabbits, trees, a pig, a llama, a sheep, and this year a goat from the Heifer Project. I have purchased mosquito nets from UNICEF. I have fought hate crimes and taught tolerance through the Southern Poverty Law Project. I am helping secure marriage equality through the Lambda Legal Defense Fund.

My most satisfying sense of wealth was the opportunity to purchase four chlorinators for $300 a pop. They provide four villages in Swaziland with clean drinking water. The last time our diocese sent a team to partner with the Anglican Church there, they sent back word, "One elder welcomed us with great thanks. He said, 'Ever since you came, we have not buried a child.' It's a much bigger project than my contribution. Now the Swazis are making the chlorinators themselves.

And I have given lots of money to old churches in small towns. I make no apologies for paying heating bills of drafty old buildings. Hearts starve as well as bodies; Give us bread, but give us roses. In out of the way places, stained glass windows are the only art most people see. So I am glad to support the furnace repairs of my church home. We are family. Paying the bills is part of belonging.

I couldn't do all this if I hadn't made a commitment -- 10% on the first line item of my budget. If I had to decide each month whether I could afford it, well, of course there are other things I "need." But with that money already allotted, my only decision is where I get to spend it. Frankly, it's almost the only discretionary money I have. That there is so much of it makes me feel rich.

And what on earth does this have to do with Prozac Monologues: reflections and research on the mind, the brain, depression and society?  This:

Regarding depression: those of us with mental illness experience loss piled on loss, often including financial loss. We live in a world so programmed for consumption that it consumes us. We are surrounded by images of things we don't have. It hurts to feel poor.

Regarding society: the "Crazy Delusion" consumes all the rest of us, as well. Do you realize that of the almost 7,000,000,000 people on the planet, most of them do not have cable?

Regarding the mind: think of tithing as Cognitive Behavioral Therapy. First, pay attention to your feelings about money. Money is the quickest way into what we value. Examine the assumptions behind your feelings. Challenge your assumptions. Do they have a basis in reality? Explore and test options.

Nothing has ever matched the rush I got when I wrote those first checks. If you have to be careful about mania triggers, you might start slower. Figure out what you gave away last year. Calculate the percentage. Double it this year, and double it again next year, until you reach your goal. The trick is to make it a line item in your budget, as intentional as your light bill.

Tithing is a spiritual practice for the dark night, a way to push back your feelings of loss and your anxiety about the future. I am not going to promise that you will be rewarded by an unexpected windfall. Rather, it will occur to you that you already have enough.

So like thankfulness, tithing is a form of mindfulness, paying attention. The Torah has given us this great gift. Claim it. As Moses said, Choose life.

P.S.  I seem to have given a lot of advice lately. Too much.  There will be no third spiritual practice; the series ends here.

Spiritual Practices for the Dark Night -- Giving Thanks


I don't believe in New Year's resolutions. They tend to be such cliches. Quit smoking. Exercise. Lose weight. Well, if you are serious about losing weight, you gather information, you set goals, you plot a course, you prepare your house, you find a buddy (just like in AA), you plan each day, you think a lot and you practice. It's worth doing, and I did. The point of all of the above is to change the way you eat. Permanently. So I did all of the above and I feel great (at least about the way I eat). I wish you all the success in the world.

Christians get a second shot at the diet thing in Lent, which begins sometime in the middle of February. It doesn't fare any better than New Year's diets, because so few people want to change their life. They want a quick fix for that swimming suit or class reunion. That's why Lent. It's time limited, forty days, with Sundays not counting. Sundays are free days, for all the bad habits you resume once Lent is over.

Me, I am interested in changing my life. You may be, too, if you too have peered into the dark abyss and something still holds you back from the edge. We are tired of living on that edge. It's just too scary. It wears us out.

So I take advantage of whatever reflecting you might be doing on your life this time of year to introduce some spiritual practices that could change it.

Now don't get twitchy because I use the word "spiritual." Yes, I am a priest; and yes, I have a charge on my life; and yes, I do my best to follow Jesus. It causes me pain that many of you do not have access to that most powerful juju, because of how badly Jesus is represented by some people who have such strange ideas about how to follow him. And I ask him and you also to forgive me for how little I ever do about that.

But give me a hearing. I even changed the title for you. I could have called it "spiritual disciplines," which is how I think of them, and which connects these practices to their deep roots in my own and other religious traditions that have been around a lot longer than you or I, so that you might give them a chance to find out why they have stuck around so long.

Anyway, "practices" gives the sense that if you mess up one day, well, that's what people who are practicing do. Then they practice some more.

Having spent so much space on the title, I can't get to all three practices today. For which I am glad, because I do better when I don't have to figure out what I will write about, and now I know for three weeks, because I have just created another series. I hope I will remember the second practice, which I don't right this minute.

I try, I don't always succeed, but I try to start each day with three things for which I am thankful. I am not particularly profound, nor even moved.  I just notice three things. Today I am thankful that the sun came up. It didn't come out, but I can cut it slack some mornings. I haven't been out yet either. But it came up. That's a start, for which I am thankful.

I am thankful that I have a psychiatrist who listens to me. Let's not spend any time on the one who didn't. Let's focus on the present, for which I am thankful, because she listens to me.

I am thankful that my sweet Mazie is still alive. She has renal failure, and every day we notice more signs. It began with weight loss, then bad breath. Now she needs to go out several times a day, instead of three. I am the one who takes her for two long walks, and that gets me out, as well as up, whether the sun is joining us or not. Which is good for my mental health and for my heart, and so I am thankful.

Three things for which to give thanks makes me mindful, makes me pay attention to the present, which is a gift, which is why it is called the "present." For those of us who have peered into the dark abyss, the present is indeed a gift. Because we can imagine not receiving it.

Sometimes I forget to practice this practice. But I almost always give thanks at mealtime. That covers me three times a day. I give thanks for the food, for the hands that prepared it, and sometimes for those who grew it and picked it, and those who packed and delivered it. When appropriate to the menu, I might thank the chicken or the pig, and while I am at it, I apologize to them that I am not yet a vegetarian.

When I am in Central America, I hear my friends giving their thanks in quiet and rapid Spanish, so rapid that I can barely pick out a few words. But I hear them pray for those who do not have food, and for a world in which everyone will have food every day, like we pray in the Lord's Prayer: Thy will be done. Another word for this kind of prayer is mindfulness.

I was at a restaurant once on "A Day Without Mexicans," when lots of people from Central America stayed home from work to demonstrate how much the rest of us depend on them. I overheard a woman ranting at this demonstration, and how "they should go back to where they came from." All the while, she was eating a big beautiful salad.

Since that day, sometimes I pray, "Bless this food and the hands that prepared it. May it bless us or curse us, according to how we treat those who brought it to us." That is mindfulness, too.

I treat this practice gently. Once in a while I wonder who I am thanking, and that reminds me how mad I still am at God about this disease. I don't know how to give thanks for that yet. Part of my dark night is this alienation from God. Even alienation is a relationship. But it's not one I want to press too hard.

Don't press it too hard.  Thankfulness will do its work over time.  Treat it as an experiment, to find out what it will work in you.

Happy New Year.

OMGThat'sWhatTheySaid! -- Stigma

On November 26th, the New York Times published an article about the presidential policy not to write letters of condolence to the families of service men and women who commit suicide in a war zone.  These letters of condolence have gone out since Abraham Lincoln started writing them during the Civil War.  Given the upswing of suicides in the Armed Services lately and the attendant publicity, this policy of silence, which began in the Clinton era, is coming under scrutiny and challenge.
In response to this article, psychiatrist Dr. Paul Steinberg wrote an Op-Ed commentary titled "Obama's Condolence Problem," winning him this month's OMG Award for -- oh, it's hard to choose.  There are so many prize-worthy lines.  But let's call it for: Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts. I will deconstruct this sentence after putting it in context.

Dr. Steinberg is concerned that any recognition of suicide, even the reporting of it, glorifies it and makes the taking of one’s life a more viable option. If suicide appears to be a more reasonable way of handling life’s stresses than seeking help, then suicide rates increase.

Dr. Steinberg is clearly in the voluntarist camp, believing that people make a conscious, reasoned choice to kill themselves.  Suicide, in his view, is an option, a way of handling life's stresses.  He is in, if not good, then plentiful company, who believe that even while the thought processes of those who commit suicide are impaired, their will is not. They remain responsible for their choice.

Regular Prozac Monologues readers know that I am not in the same company.  Dr. David L. Conroy gave me the words.  From Out of the Nightmare: Recovery from Depression and Suicidal Pain, "Suicide is not chosen; it happens when pain exceeds resources for coping with pain."

Conroy describes the many ways that people who are suicidal attempt to reduce their pain and save their own lives.  Those who are suicidal sometimes use the language of choice and reason.  Conroy, who speaks from personal experience, says it is terrifying to have such little control over our own emotional state that it can shove us headlong over the abyss.  This lack of control is part of, and adds to suicidal pain.  To claim that we have considered the options and are making a reasoned decision is a grasping for the image of control; it is an effort to relieve pain.

Steinberg asserts that choosing suicide over treatment is deserving of shame.  Now that first-rate treatments for depression and post-traumatic stress have evolved and are readily available, and people with emotional problems do not have to suffer quietly, are we taking away the shame of suicide?  When he decribes depression treatments as first-rate, he parts company with the National Institute of Mental Health and many doing research in the field, who acknowledge the true state of treatment.  At least a third of those who seek treatment are not able to find a medication that is effective and tolerable.  Meanwhile, certain side effects of these first-rate treatments themselves increase the risk of suicide, doubling it in the case of insomnia, a frequent side effect of SSRI's and SNRI's.  Akathesia (called "inner restlessness" on prescribing information sheets) is one of the most under-reported side effects, due to euphemisms, and among the five top risk factors for suicide among hospitalized patients.  [Side note: when you read "inner restlessness" on your prescribing sheet, did you realize that "inner restlessness" could significantly raise your risk of suicide?]

Steinberg believes that letters of condolence to family members could be an inadvertent incentive to suicide.  In light of the condolence-letter controversy, the administration is appropriately reviewing the policy that has been in place for at least 17 years — and may indeed want to consider leaving it as it is. But as a country, let’s focus our energies on doing everything we can to diminish inadvertent incentives that might increase self-inflicted deaths.  And elsewhere: We need to find the right balance between concern for the spouses, children and parents left behind, and any efforts to prevent subsequent suicides in the military.

I feel downright silly answering this argument.  But here it is:

First, the shaming of suicide is indeed one of the resources that we possess against it.  But it is an even more significant reason why people do not acknowledge and seek help for thoughts of doing it.  Shame interferes with willingness to report symptoms.  And failure to report symptoms is a significant factor in failure to recover.  To think that we can shame suicide and prevent it at the same time is fanciful. There is no balance to be found here.

Second, it is well known that surviving family members are themselves at greater risk of suicide.  Shame increases their pain, including their suicidal pain.  It is a barrier that prevents them from seeking support and prevents friends from offering it.  A letter from the President could go some distance in reducing the shame of family members and providing comfort in the midst of their pain.  If prevention of suicide is the goal, here is the most direct intervention the President could make.

Now back to the beginning.  Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts.  Putting to one side the impossibility of de-stigmatizing the second while stigmatizing the first, let's take a closer look at what Dr. Steinberg wants to de-stigmatize -- the help soldiers need.  What help would that be?  Psychiatry, leading the mental health professionals.

Steinberg wants to stigmatize suicide and de-stigmatize himself.  That's natural enough.  Nobody likes to be the object of stigma.  People who experience suicidal pain can identify with him in his desire. But I took a fanciful direction upon reading this op-ed piece.  I imagined Dr. Steinberg as a chaplain taking a course in Clinical Pastoral Education.  Are my clergy readers following me here?  Think back to your CPE experience.  Imagine the conversation in group after Dr. Steinberg says Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts.  Somebody from my CPE group would surely have asked, "How does it feel to be the object of stigma?"  And if he returned the question with a quizzical look, "How do you feel to know that people would rather commit suicide than come to you for help?  What does that mean to you personally?"

To my psychiatrist readers (do I have any?), do you have any training like CPE, where you are asked to examine your personal feelings and consider how they affect your judgments and your treatment of patients?  Does it include your judgments about suicide?  How do you feel about yourself when one of your patients commits suicide?   How do you feel about that patient, and the next patient with suicidal ideation?  Can you acknowledge those feelings?  Is shame part of your own experience?  Where have you put your shame?  Your feelings are just that, feelings.  Can you use them to inform your understanding of your patients?

I posted a facebook status last week with a link to Dr. Steinberg's article, asking, "Do patients with any other disease face such disrespect from their doctors?"  I am going out on a limb here.  But I wonder if many psychiatrists have not yet dealt with their feelings about their patients' dying.  When oncologists did, the treatment of cancer patients changed.  Now, who even remembers that cancer once was shamed?

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