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?


  1. Excellent post.

    I have had Major Depression since the onset of adolescence four decades ago. I had a short break during the time I was pregnant and nursing my three children. But then it returned with a vengeance. I never considered suicide during all the years that I suffered.

    Then in 2004 I was diagnosed with Bipolar Disorder after the Prozac I had been taking for 12 years "pooped out". I promptly spent the next two years on the medicine merry-go-round until I realized that I would be unable to take any of the medicines long term that I was being given for my ever worsening depression and supposed Bipolar Disorder. In 2006 my psychiatrist delivered the final blow to my devasted self-esteem by confirming that I would never be able to work again. This is when the balance tipped for me, when the pain exceeded my resources for coping with the pain, and I began to plan my suicide.

    My plans were a simple acknowlegment of the reality that the medical profession could do nothing to enable me to be able to hold down a job, (Much less to pursue a career). The dominoes fell quickly after this realization, a never ending cascade of doom and gloom. Living on a small fixed income meant no more of the things in life that take the edge off the horrible aspects. The budget could no longer include birthdays, Christmas with loved ones, vacations, eating out, or even something as basic as health insurance. When enough dominoes fall, the pain is too great, the shame too deep, and death becomes a comforting refuge.

    So why am I still here to write this comment? Because at the end of the day I did not want to die. I just wanted the pain to stop. I allowed myself to use unorthodox ways to stop the pain (like by becoming a recluse). I accepted my reduced circumstances and stopped apologizing to myself and others. ("It is what it is" has become a favorite saying of mine).

    De-stigmatizing suicide is the first step in recognizing that everyone has their breaking point. This recognition puts us all on equal ground and ultimately is an acknowledgment of our shared humanity.

  2. David Conroy demystifies suicidal pain. It's like somebody standing while weights are added to the person's shoulders. If you add enough weights, eventually the person collapses. This is true for EVERYBODY. There is a limit - different limits for different people, but everybody has a limit. And no one weight is the "real reason." It's the totality of reasons. So suicide prevention is a process of reducing pain, any pain, any method.

    Most suicides are self-prevented, just the way you prevented yours. Congratulations! Somebody, bake this woman a cake!

  3. LOL

    I would love a cake, chocolate please.

    I have learned to be nicer to myself, and more understanding of the frailties of others.

    Love your blog BTW



  4. As a manic-depressive (they call it Bipolar II-I call that inaccurate) who struggles with suicidal thoughts through every several cycle of symptoms, I am finding myself withdrawing socially more and more, even from the people who claim they love me. Recovering from each experience has only become more strenuous and isolating. I still don't measure up in "normal" people's perceptions. I never bounce back fast enough or get well to standards that make other people feel comfortable. And stigmatizing suicide only serves to drive me deeper into the pit of shame, which will eventually claim my life. I only wish general population could grasp that. But why should anyone step outside their perceptual comfort zone and learn about mental illness if they don't experience it themselves?

  5. Contact with people who DO experience it themselves has been the most significant part of my recovery. (By "recovery" I don't mean that the illness has gone away. I mean a process of learning to manage the symptoms.)

    This contact began with the website linked at the top of my blog on the left, "why is it so hard..." which led me to Dr. Conroy's book, "Out of the Nightmare..."

    NAMI's Peer to Peer course was worth the weekly 120 mile round trip drive, even in winter weather.

    And then one day I simply called up a friend of a friend, whom I knew to have been in and out of hospitals. We struck up a friendship in which we can tell it like it is. Eventually that turned into a small support group of four friends with various diagnoses.

    I do have the support of people who love me. Even so, there are a number of reasons why sometimes we cannot cross the chasm. That is why support groups/meaningful contact with others who share our experiences is one of the four cornerstones of recovery.


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