Saturday, September 23, 2006

Heaven Can Wait

The hospital where I volunteer doesn't have a psychiatric ward. Psych patients are held in our ER for medical clearance before being transferred to one of the local mental hospitals; this usually involves an evaluation by a psychiatric social worker, contracted by an outside agency, who comes in to talk to the patient.

The process means that psych patients often spend even more time waiting -- on gurneys, watched by a security guard -- than medical patients do. One poor soul spent a full day in our ER, waiting for a bed to become available at the mental hospital. Our security guards are very kind and compassionate to these folks; security guards may provide more pastoral care than chaplains do. A nun I know says that her best pastoral-care training was the ten years she spent as a bartender in New York before taking her vows, and security guards, like bartenders, spend a lot of time listening to unhappy people.

The psych population includes suicidal patients, and these cases always get referred to me. I think some of the medical staff aren't quite sure what chaplains do, and plenty of pastoral-care needs aren't obvious to them anyway: patients tell me about things -- family crises, recent bereavements -- that they won't mention to doctors or nurses. But if someone's dying, or if someone has come in wanting to die, I'll always get a heads up.

I have to be careful with these patients. I have plenty of personal experience with the issue, but I'm not a psychologist, and my old volunteer coordinator warned me that it can be dangerous to encourage patients to open up before they've seen the social worker, the person who most needs to hear what's going on with them. Many of these patients don't want to talk, anyway, and some who do are dealing with such overwhelming tragedy that if I were in their place, I'd probably want to die too. "All three of my children were killed in a car crash, and then my wife left me, and then I lost my job." In cases like that, I'm always intensely grateful for the professionals, and for the existence of hospitals that can keep people safe. I pray with such patients and tell them I'll be praying for them; I tell them that I'm glad they're alive, and that I want them to stay alive. I always hope that telling me their story has somehow made the grief a little more tolerable, but I'm rarely under any illusion that it actually has.

Over time, though, I have developed three strategies that are often helpful. I offer them here, in case anyone else can use them.

1. I always ask suicidal patients how they got to the hospital. Most of them either called 911 or called a doctor or therapist who called 911. In those cases, I'll say something like, "That means you got yourself here, and you should be incredibly proud of yourself for doing that. You did what you needed to do to get yourself somewhere safe, and you did that under really difficult conditions. When you're so depressed that you don't want to live anymore, calling 911 is as hard as walking to the hospital on a broken leg would be." If the patient's someone especially likely to feel stigmatized (homeless, an addict or an alcoholic), I'll add, "And you did what you needed to do to survive even though it meant coming to a place where you're scared people will look down on you. That takes a tremendous amount of courage."

Suicidal patients, by definition, are usually filled with despair and self-loathing; they consider themselves helpless, hopeless, and contemptible, and assume that everyone else sees them that way too. They often see being at the hospital as further proof of their incompetence. Turning that around -- telling them that getting to the hospital is an act of heroic strength -- often means the world to them. I can see it in their faces: they respond with wonder and gratitude. "I never thought of it that way. Thank you."

2. Sometimes suicidal patients ask me if I believe that suicides go to hell. Others have told me, "I know God loves me and won't condemn me, and I hurt so much, so why can't I go to heaven now?" I've heard quite a bit of anecdotal evidence that belief in a loving, nonjudgmental God can actually increase the risk of suicide. And many patients who've lost loved ones, especially children, want to rejoin them.

I don't believe that suicides go to hell; my personal theology is that we all wind up in the presence of God, and that our feelings towards and relationship with God will determine whether being there feels heavenly or hellish. So when this issue comes up, I say, "I believe that God loves all of us and welcomes all of us when we die, but I don't believe in leaving early. Heaven isn't going anywhere. If you die a natural death in another thirty years, surrounded by friends and family, you'll go to the same wonderful place you'd go to if you died now. But if you go there now, you'll never know what wonderful things might have happened here that you'll never get to experience, or what good work you might have done here that God needs you to do."

This is the theological version of that time-honored strategy, "Just stay alive for one more day. You can always kill yourself tomorrow." With luck and grace, some tomorrow will be better. As the hotlines say, suicide is a permanent solution to a temporary problem. This approach, like the first, helps patients turn the situation around, helps them see it a different way. They almost always nod. "I never thought of it that way. Thank you."

3. I always emphasize to suicidal patients -- and more generally to other psych patients -- that depression and other mental illnesses are real, physical maladies, not signs of personal weakness or wrongthink, and that they're treatable. "You're feeling so down right now partly because your brain isn't working right: you literally can't see any hope. That's not your fault. It's biochemistry, and you need to take medicine to fix it, just like you'd need to take insulin if you were diabetic. If you can just wait for the meds to start working, things really will look better."

With one patient, I used the "walking to the hospital on a broken leg" analogy and then said, "You're looking at your life with a broken brain right now, but the good news is that it can be fixed." A passing nurse gave me a very startled, disapproving look, but the patient reacted with delight. "A broken brain! No one's ever explained it to me that way. That's so helpful. Thank you!"

Another patient had gone off anti-depressants at the insistence of her AA group, which condemned all mood-altering drugs. I've heard this before, and it infuriates me. Nobody takes Prozac to get high, and most antidepressants aren't addictive. They just don't work that way. Most of the doctors I've talked to believe that addictions begin as self-medication for underlying mental illness: if that's true, telling people not to take their psych meds greatly increases the risk that they'll go back to alcohol or street drugs. I asked that patient, "If you were diabetic, would your AA group tell you that you couldn't take insulin?"

She nodded. "Yeah, you're right. That's kind of crazy, isn't it?"

As with all patients, the time I spend listening to suicidal patients probably means more than the time I spend talking to them. But I'm glad to have found some things to say that seem to be helpful, and I hope others can use them. As they say in twelve-step programs, "Take what you liked, and leave the rest."


  1. I was part of a "Yellow Ribbon" lifeline group at my junior high school. I never had the opportunity to help someone through that program, although I am sure there were kids suffering in silence. We had a few students commit suicide in high school, and it's one of the saddest things to me that they were hurting and no one was able to help them.

    I've often wondered what I would have said to one of these students if they'd approached me. Now, I wonder what I will say as a socialworker. Thank you for articulating these wonderful ideas!

    The medication issue is one I fight daily, since I need medication for pain (including an antidepressant).

    You are making a difference with your words, empathy and listening.

  2. I don't believe I've ever felt suicidal, not even when I've been depressed. I did go to sleep one night expecting to wake up dead, but I woke up to find I was still alive. When my time does come they will take me out kicking and screaming and saying there's been a mistake in the paperwork. But I'm lucky. I think I have enough imagination to empathise with those who find themselves lost enough and lonely enough to contemplate the end as being preferable to continuation. I say its electro-chemistry, that there is no brain/body dichotomy. 'Mental' illness is just illness. My experience is that it is amazing what a little love can do for any illness.

    That, and a good doctor.

    Keep showing them love. It can only help while the doctor is on their way.

  3. Nickie and Martyn, thank you very much for these comments. And Nickie, thanks for mentioning my post on your blog!

  4. I flinch from people who are drinking (particularly wine or beer, which have such strong odors.) That tends to push me towards social groups full of passionate recovering alcoholics and others with philosophical attachments to Sobriety. It can be uncomfortable, because I disagree with so many of them about medical use of drugs. I don't think your analogy to insulin works very well, with so many people getting type 2 diabetes they can control with diet and exercise. Someone who becomes insulin-dependent is likely to get a lot of pressure from doctor, nutritionist, and family, as well as 12-steppers. (Some of this is fat-shaming, rather than anti-drug pressure, but it overlaps in this instance.)

    My own drug use is for chronic pain, and a seizure disorder. There's a lot of pressure to minimize or eliminate drug use for chronic pain. (Especially for someone in her thirties.) I sometimes worry that my drug use is excessive. If I didn't work, or didn't travel to visit my sweeties, or didn't have sex, or didn't wear clothes with buttons...I could manage with less medication. How much can I justify as "necessary?" It really depends who I am trying to justify it to.

  5. Hi, Adrian! Thanks for your comment.

    When I use the insulin analogy, I'm talking about Type 1 diabetes. Surely Type 1 diabetics aren't pressured by anyone to give up their insulin? The analogy seems to work for the patients I talk to. Medication for a seizure disorder might be a little more scientifically precise, but it would probably be more obscure to most patients. In any case, if you can think of a better analogy, please let me know!

    Re medication for chronic pain: yes, if you didn't have a life, you'd need fewer drugs, but then you'd probably need other drugs to get over your depression at not having a life. If the drugs are helping instead of hurting, what's wrong with them? If they're making you feel better instead of giving you lung cancer or cirrhosis of the liver, how are they bad? Even if you were to become addicted to them, I think the question to ask is, "How is this harmful?"

    A therapist I know, another volunteer at the hospital, says that everybody's addicted to something. My addiction -- besides blogging! -- is coffee: if I don't get my two cups first thing in the morning, I become genuinely physically ill. This means that I do the classic addict thing of ensuring my supply by bringing coffee with me when I travel to places where it may not be available, like the wilds of central Nevada.

    Would I be better off without the addiction? Well, theoretically, sure. But my loved ones and my physicians don't seem concerned, so I'm not either.

    We're still way too Puritanical in this country.

  6. Adrian, as a Type 2 who has progressed from small amounts of metformin and diet to treat to maximum amountts of metformin and insulin to treat, I'm here to tell you that I have lost weight and do exercise more (but not enough of either) The reason for the deterioration in my condition is age, stress and the fact my pancreas is shot - it was probably shot before my diagnosis but hadn't yet decided to lie down.

    All the programs probably have something going for them but fall foul of us ornery human beings being individuals with very particular combinations of symptoms and reactions to treatment. One size does NOT fit all and most professionals - in my experience - try their best to find the best solution for the individual patient. They sometimes get it wrong. They are human.

    Which is the beauty of us all.


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