Wednesday, September 9, 2009

Guest Blog - Trying to Comprehend Loss

At age four, Nancy Rappaport's mother took her own life. Her just-released In Her Wake: A Child Psychiatrist Explores the Mystery of Her Mother's Suicide (Basic Books) explores the author's own coming to terms from both a personal and clinical perspective. Dr Rappaport is a child psychiatrist and assistant professor of psychiatry at Harvard.

This week is National Suicide Prevention Week. Following is a timely excerpt from Dr Rappaport's important new book:

When I was a resident, a psychiatrist I knew killed herself, leaving me bereft. The gossip was that she was infatuated with another doctor, and that he rejected her affections. Humiliated, she barricaded herself in her apartment and downed too many pills. On a frigid winter morning, I boarded a train to New York for the memorial service. In an austere stone chapel filled with blue flowers, the doctor’s mentor stood up to pay his respects and commended her for her conscientiousness. He noted with admiration that the day before she died, this diligent doctor had assessed ten new patients in the emergency room – an impressive feat. One by one, patients had filed into her office, closing the door behind them. She had asked the same diagnostic questions ten times, the equivalent of the physician taking a pulse, about sleeping at night, having trouble concentrating, hearing voices, mood changes, loss of appetite, plans to commit suicide. I wished that she had interrupted her “mental status examinations” long enough to get help for herself. I was saddened by her fragility despite her having tried to put up a good front. I was frightened: Now I had to relinquish the fantasy that if I learned this profession it would somehow protect me from the forlorn legacy of suicide. Even if you are proficient in this craft, it does not inoculate against the forcefulness of depression.

At the memorial, my medical colleagues speculated on her state of mind just before she died, offering armchair analyses of why she might have killed herself and wondering whether it was premeditated or a passion of the moment. In the rush for an explanation and with the disturbing sense that things are not always what they appear, they had a morbid fascination and dread that she was able to function with apparent ease professionally while struggling with private anguish. And yet there was also a heaviness – as if we had failed her.

Over the next few days, I was irritable, haunted by disturbing dreams and a sense of foreboding anxiety. The psychiatrist’s suicide evoked the loss of my mother. My therapist told me that when someone kills herself it is as if she puts her skeleton in your closet. I did not want this skeleton, and I resented the intrusion. I could not do this work if it felt futile, but in the aftermath of this doctor’s death, I did not want to think with my patients about the urge to end it all. I wished that I could bag groceries, do any other job that did not involve making sense of suffering and sharing the responsibility for keeping someone alive. But my therapist reassured me warmly, with the intimacy that comes from years of talking with each other, that it is normal to be shaken to the core when a colleague kills herself; it did not mean I was unstable or destined for a free fall. I have cultivated a determination and a skill to recover my balance when life has unexpected detours. I was depleted and needed to give myself some time to be with the people I love and who provide me solace. After a cross-country ski trip with Colin, awestruck by the pink sunset etched into the silhouette of the branches in the sky, painting valentine boxes in Cory’s class and resuming the outward semblance of routines in my life, I felt less overwhelmed. My sadness would run its course not because I would avoid the flood of feelings but because I could replenish without drifting too far from my center.

I always find myself incredulous that when someone commits suicide – when my mother took the overdose, when a teenager hangs himself in the closet, or a man shoots himself – this person truly wants to die. When I was younger I often dreamt that my mother and I were careening down a hill in a car out of control and in the back seat I was valiantly trying to reach down for the emergency brake to avert disaster. For the tortured souls who are intent on suicide, there is no territory beyond the present. The “mind tumble” means that they are not thinking clearly, and their judgment is clouded as they reach for pills or jump from a bridge. As I investigate my mother’s suicide, with the stealth of someone who wants to break the code, the inexplicable mystery of why this was the moment that she lost her determination, I return to her diary. I wish that I could have shown her the sunset that I found so comforting or that she could see her grandchildren, anything to have her hold on to a fighting spirit, to find the invincible shield of self-preservation. To develop the wisdom that premature death will not bring the peace that she ached for. In her diary she is wrestling with her demons, trying to stay alive, to anchor herself in her love for us. Yet that was not enough to keep her grounded in survival.

As I read from her diary, I weep for her, wanting to hold her, give solace….Understanding my mother’s suicide matters to me – as a doctor I spend my life trying to avert disaster, to offer a safe retreat to find strength to stay alive….I actually feel better when someone is talking to me, figuring out how to ease his pain. Some of what I have learned about suicide, depression, and substance abuse in general has helped to define, yet has also complicated, the mystery of why my mother killer herself, and it guides my assessment of how to help my patients not take the lethal next step.

Purchase In Her Wake on Amazon.


Anonymous said...

Thanks for sharing, Nancy!

My mother was suicidal during my childhood and adolescence and I thought it was my task to keep her from killing herself. I did. It probably wasn't due to me, but I worked hard to keep her happy enough.

Because I didn't understand and wanted to learn more, I studied medicine and read loads of books about psychology and psychiatry. I ended up with a MSc in both medicine and health sciences, but I still did't understand.

Only because my own depression (probably part of bipolar spectrum disease) I've started to understand why anyone would take his/her life. When nothing matters anymore, you feel so extreme hopeless and extreme sad, you want the pain to stop. You don't want your life to end, but for the pain to stop.

Willa Goodfellow said...

I agree with the previous poster. I wrote a few years ago, it's like those people who jumped. If anybody at all could have shown them any other way at all out of that burning building, they would have taken it. We DON'T want to die. We want the pain to stop.