My Friend Talks of Suicide

“Laura” writes:

Dear Dr. Einhorn:

I am a 13 year old girl with a friend that talks of suicide. She
refuses to tell her parents, and I live too far away from her to talk
to them. I know she needs help, but she will not talk to her parents.
Will you please see if there is anything you can do?
I realize you are very busy, but if there's anything at all, please
respond to this email.
Thank you so very much,
Laura D.

Dr. Einhorn replied:

Well, you could call her parents, Laura. Or you could talk to your parents and ask one of them to call her parents.

Laura replied:

Yes, however they don’t believe she is serious, and my parents have never met her before, as I met her at summer camp.

Dr. Einhorn discusses:

Laura’s concern for her friend and feeling of helplessness come through clearly in her question, and this is often the position that friends, family, and even professionals are in when caring for adolescents, or adults, who are, to any degree, suicidal. There is lots of help that can be brought to the suicidal person--including therapy, medication, outpatient and inpatient programs, and support from friends and family--but often the person herself, or, as Laura indicates is the case here, her family, don’t take the risk seriously enough. And it is a serious risk: suicide is rated as the third largest cause of death for adolescents.

Of course, we can only talk in generalities here, because we have no information about the people involved. We don’t know, for example, whether Laura’s friend is talking about suicide as a way of expressing her emotional overload, maybe blowing off steam, without really intending to do anything (in which case she still seems to be in need of help), or whether she is seriously at risk for self-harm. So, the question becomes, not what Laura can do for her specific friend, but what someone in Laura’s position might consider doing to follow through on her concern.

Laura feels like there’s nothing that she can do and she’d like me to step in and do something here. But this is a situation in which I have no “standing,” to borrow a legal term; I don’t know any of the people involved, and they don’t know me. Laura is the person who knows the girl who talks of suicide, so, like it or not, she is the person faced with the choice about what to do. She’s reached out to me, hoping to pass this “ball” to someone who can carry it better than she can, but the truth is that no one can carry it better than she can at the moment. That’s one of the problems and challenges of knowing someone who is suicidal. If you do something to try to help them, your attempt to help might be rejected as inappropriate, interfering, or silly. If you don’t, and the person does make a suicidal attempt, or, actually commits suicide, you might regret not at least having spoken up in some way to try to help. There is no easy way to deal with a situation like this.

I can think of a couple of options that Laura might consider, and readers might think of others. She could advise her friend to talk to a school counselor, who would then be in a position to evaluate the seriousness of her talk and call her parents to advise them to get treatment for their daughter. This might be the easiest path for all concerned if the girl would talk to the counselor. If she won’t, and Laura is still concerned, she can still talk to her parents and ask them to call the girl’s parents, even though they don’t know each other, to express parent-to-parent concern. That might help the friend's parents take a second look at their daughter's state of mind and risk for self-harm. Sometimes students will anonymously advise counselors in schools that a fellow student is making suicidal statements, but I don’t know that Laura would even know what school to send an anonymous letter to. And of course that could always boomerang on her, if it prompts intervention that the girl or her parents resent.

One issue that this raises is what the responsibilities and limits of friendship are. That’s a question that each one of us has to answer for ourselves, in different relationships, sometimes over and over again. It’s a real challenge, and no fun at all, to have to deal with this question in this relationship at this time, but that is the place where Laura’s life has taken her, even at her young age.

It’s a shame that adolescent suicide is such a problem in our society, and it’s worth our time to ask why that should be; what pressures are adolescents responding to? Answering that is beyond the scope of this Q and A, but I’ll appreciate any thoughts that readers care to contribute.

As for you, Laura, you are to be commended for your caring in raising this issue about your friend and reaching out for help, and supported as you seek within yourself for the wisdom to find, and the courage to do, the right thing; whatever, in this situation, that may be.

I've just read "The Writing On My Forehead," a novel by Nafisa Haji, and recommend it.  Written from the point of view of a feisty and questioning first generation American daughter of Indian-Pakistani Muslim parents, it covers a lot of ground about culture, family, morals, choices, and  traditions, within the context of a very readable story.  I was interested in the characters and, at one or two points, it bought a tear to my eyes.  

When a Privacy Guarantee Means You Give Yours Up

A colleague, on a professional listserve, reports that she was contacted by a hospital's development department after her daughter had been treated there.  "Hello Barbara," said the development caller (not real names).  This is Jonathan calling from ____ Hospital.  How are you tonight?  I'm calling because your 12 year old daughter, Laurie, was a patient here.  Is that correct?"  Jonathan went on to ask Barbara for a donation to the hospital.  

Barbara was appalled, and asked her colleagues whether this wasn't a violation of privacy laws.  Another colleague did some research and found this on the hospital's website:  "In the continuing effort to enhance _____ Hospital's mission of service, periodic communications and invitations to consider philanthropic support may be sent to patient families..."  This language must have been included in fine print on one of the required documents, probably the one that guarantees patient privacy.  

So a guarantee of patient privacy is actually a violation of it.  You think you're signing a privacy guarantee when you are actually giving up your privacy.

The linguist Geoff Nunberg, commenting on Terri Gross' "Fresh Air" program on NPR, highlighted a similar deceptive use of language when he said that most "guarantees" were actually "limitations of liability."  

This kind of misuse of language is actually a violation of trust.  And right now I am seeing violations of trust as being at the heart of many psychological problems in human relationships in our society.

Although the legal structure, pace of life, social decentralization, constant persuasion pressure from multiple sources, and technological sophistication of our culture bring it to a whole new level, the basic problem of violation of privacy is a very old one.  Idries Shah, in his "Caravan of Dreams," quotes a tradition of the Prophet Mohammed about this:  "Whoever invades people's privacy corrupts them."  

There's probably no more important psychological issue today than the reestablishment of public trust in institutions, and for that, institutions are going to have to become more trustworthy.  One of the chief changes that will require is the recognition of the importance of institutional honor in the relationships that institutions have with people at all levels; consumers, investors, workers, regulators.  

We have no trust in our institutions because they have no honor.  The hospital's treatment of Barbara is, in a word, dishonorable; not in that it asks patients for donations, but in that it slips the permission to do so into a document that purports to be a guarantee of their privacy rights.      

Clean Slate

We never start with a clean slate, because we always have a history that is embedded in the neurons of our brains and bodies.  We always start with a clean slate, because awareness is always now.  

Obstruction

Hanging my bathrobe in the closet, I felt a tug as the belt came out of the loops and fell onto the floor.  Looking to see what the belt had gotten snagged on, I discovered that I was, in fact, standing on one end of it.  And I wondered how many times we try to accomplish something that doesn't work out--in this case, hanging up my robe--and think that something in the environment is obstructing our success--whatever the belt had become snagged upon--when in fact the obstruction comes from ourselves.  We are, so to speak, "standing on one end of the belt while trying to hang up the robe."  Of course, it's because we haven't noticed in the first place that one end is longer than the other, and dragging on the ground...

Self-Respect and Self-Esteem

Some people equate self-respect with self-esteem, which is usually understood as having a good opinion of oneself.  But I would say that self-respect is saying what needs to be said and doing what needs to be done.  

Rear View Mirror

The temperature had jumped from -2F to +52, and a couple of feet of snow were rapidly melting as I drove through puddles and mist on Saturday morning errands.  A glance in the rear view mirror showed that the rear window was completely fogged, so I turned on the rear window defroster.  My car has a heavy duty rear window defroster, so I was surprised when nothing happened after a few minutes.  I wondered if the defroster was broken, or if the fog was on the outside of the window rather than the inside (although shouldn't the defroster clear that too?).  I opened the front windows a bit; perhaps air flow might clear the rear window.  Then I saw a clearing view out of a corner of the rear window.  But that was puzzling, because the clarity should have spread out from the defroster strips.  What was happening?

Then, as I looked in the rear view mirror and saw the clarity in the rear window spread, I realized that the fog wasn't on the rear window at all; it was on the rear view mirror with which I had been looking at the rear window.  

Surely, this is a "teachable moment!"

The shift of perspective--when I realized that what I took to be one situation, a befogged rear window, was really another, a befogged rear view mirror--shows brain at work in an unusually clear way.  Our perception of reality is in fact an interpretive construction that is part of the work of the brain.  The "Aha!" moment was the recognition of a shift in perception; this can often happen in humor, too.  This experience was especially valuable because it duplicates, in a low key and inconsequential way, what can happen in very much more consequential situations.  

There's a famous Welsh tale about Gelert, the faithful hound.  Prince Llewelyn heard the dog snarling in his infant son's nursery, rushed in to find the dog covered in blood and the infant nowhere in sight, and drew his sword and killed Gelert...only to discover, when he looked around again, his infant son alive and well in a corner of the room, surrounded by the remains of a wolf which had attacked it, and which Gelert the loyal hound had attacked and killed, saving the baby.  The same theme shows up in a Sufi story about a soldier who returns home after many years to see his wife walking hand in hand with a younger man.  He resolves to kill them for infidelity, but pauses, recalling the advice about pausing before acting impulsively that he'd begrudgingly purchased from a Sufi teacher years before.  Then he overhears his wife say, "We'll go to the harbor again tomorrow, my son, to see if your father has returned."  The story, as told by Idries Shah, has more context:  the soldier, many years before, paid the Sufi for a couple of pieces of progressively more expensive advice and then balked at the third, which would have saved him many years of suffering and deprivation.  So there's a theme about the value of advice here too, and whether we perceive the value, and more.  (I can't recall the book that story is in, and will be grateful to a reader who can tell me!)  

This theme--at its most basic, that things are not necessarily as they seem to be, and that perceptual mistakes can be very consequential when we commit ourselves to action--turns up so often in stories from different cultures and traditions that it must be part of the human inheritance of literature that shows us how the mind works. But that inheritance of literature itself is subject to befogging over time, as the folkloric elements come to predominate over the psychological and instructional ones.  Like my rear view mirror, the psychological content within the literature becomes befogged periodically and needs to be clarified if it is to become available again.    

Another insight has to do with how we understand ourselves and our lives.  Each of us has a narrative about who we are and where we have come from that is central to our sense of identity.  It provides us with some measure of inner stability and cohesion as we go about our lives, often buffeted by the impacts of events.  We look back, even as we go forward, and our understanding of where we have come from shapes our perception of where we are.  Sharing that narrative with others is part of becoming closer with them, and sharing particularly private episodes of our narrative is a sign of increasing trust and intimacy.  Yet the narrative, which we weave as we go forward in our lives, often incorporates perceptual mistakes, which can come from a number of factors:  lack of information, wrong information, mistaken beliefs, allegiances that shape what we see and how we see it.  

A large part of psychotherapy, at least as I and my psychodynamically oriented colleagues do it, is about understanding the patient's current situation and challenges in the context of the developmental history that has brought her to this point.  In order to do that, we have to reflect together on the patient's narrative of who she is and how she came to be who she is.  And in that process of mutual reflection on her (or his) narrative, we often discover the psychological equivalent of "fog on the rear view mirror."  Psychotherapy, then, when it works as it should, is to some extent the equivalent of "opening the windows so the fresh air can clear the fog."    

  

This brings us to two reasons that prevent people from coming in for therapy when they need it, and that prevent them from benefitting once they've begun.  First, they don't understand, at a deep enough level to make a difference, that part of their problems in living comes not from what has happened to them per se but from how they have perceived what has happened to them.  Helping people to understand this at a deep enough level to make a difference is a very important goal of therapy.  The second reason is that they are so attached to their narrative of who they are and how they became that way that they have confused it with their own innermost self, so they can't step aside from it to do the reconstruction necessary to bring their narratives more into alignment with reality.  Our innermost self, as psychiatrist Arthur Deikman points out in The Observing Self, is awareness; and with awareness, we can revise, re-view, reconstruct our narratives about who we are and where we have come from.  

We just have to have a clearer rear view mirror to look into.