Yesterday Robin Williams hanged himself successfully, and passed on.  And America is in mourning, because come on, we’re about as heartbroken as a bunch of movie goers who grew up with his genius antics can be about a celebrity we’ve never met but whose voice we’ll hear in our heads until the end of time.

A few days before that, one of the inmates in the jail tried to hang himself, but he was cut down before he went unconscious, hit his face on a bed, shattered his jaw, and was knocked unconscious.  The next thing I know I’m on duty and he’s locked up in a safe cell with a smock on and his jaw wired shut.  Was he truly suicidal?  I don’t know,… but tying something around your neck is a pretty risky way to try to call out for help if you don’t really intend to die…

I had been meaning to write about suicide, suicidal gestures, and using suicidal threats as a desperate attempt at bargaining for something,…. I’m just pretty sad that I had been thinking about writing about it the same time a beloved actor plotted his own suicide, and now, I can reflect on not only my experience with my patients, but also the national conversation on suicide given his death,.. but I’m not grateful for that segue Robin, would have easily done without it.

Let’s just start with my experiences.  Suicidal thoughts, threats, gestures are so common, it’s frustrating.  In fact, it’s probably one of the things that riles me up the most besides patients yelling at me because they have to stomach tofu steaks.  It’s not just that the prevalence of suicide in our world breaks my heart, it’s that most of the patients I put on suicide precautions aren’t even truly suicidal.  Here are true examples of circumstances under which I have put patients on suicide watch:

“If you don’t give me my naproxen, I’m going to go back into my cell and kill myself!”

“If I have to go into segregation (isolation) I’m afraid I might hurt myself.”

“When he heard he was being transferred into another housing unit, he threatened to kill himself.”

“She was going totally crazy!  Screaming, yelling, threatening to hurt other people and threatening to kill herself!”

And then I sit and talk with them, and ask:

Are you having thoughts of hurting yourself?  Are you thinking of killing yourself?

And I am told:

“I never said that!  They lied!  I don’t want to kill myself!”

“Oh that?  That was just an act.”

“I didn’t really mean it, I just wanted to get out of my cell and talk to someone.”

“No I just got into an argument with the officers, that’s all, I never threatened to kill myself.”

And I respond:

well I’m glad you don’t want to hurt yourself, but because you made those threats, or people heard you make threats, or people thought they heard you make threats,  we have to take it seriously,, which means you have to go on suicide precautions in the safe cell.

And then the shit hits the fan once they realize that this is not going to go the way they were hoping, in fact, it’s going to be worse.  They are no going to get whatever it was they were hoping for.  I’m frustrated because I really don’t think they’re suicidal, the officers are frustrated because now they have to take the inmate’s clothing, personal belongings and get them into a cell with just a smock on- no mattress, no blanket, and they have to station an officer outside the safe cell to make sure they’re watched closely (so they are now down a man.)  

All because the inmate said the magic words, and if we don’t take every threat seriously, and someone ends up actually hurting themselves, guess who loses their license?  Me.  And guess who loses their shirt?  The jail.  

 

So, every time, without fail, we have to follow the protocols if that patient made any mention of suicide or self harm.  And it make me crazy- Don’t you realize you got yourself into this mess?  Don’t you realize you can’t say whatever you want, hoping to get something, without there being consequences?  Don’t you realize that you are in a JAIL and you have to play the game?  Don’t you realize how much time and effort you have wasted?  How many people are now going to have to jump through how many hoops because you said something stupid that you never really meant?

What exactly pushes someone to the point of threatening to hurt themselves in order to get what they want, whether it be a new roommate, or a tylenol?  I mean, it seems so stupid to me, but, I’m not in their position.  I’m not sleeping on a hard cot right now, without a pillow, listening to the noise of hundreds of other inmates, in a stifling hot cell with no air flow,…. I’m not wondering if my life and future and family are on the line for something I may or may not have done,.. I’m not wishing I was had more money so I could have just made bail,… or paid those bills.. or hadn’t felt driven to deal drugs.  I’m not the one who is wondering who’s taking care of my kids while I’m stuck in here trying to figure out my life.  I’m not the one whose own family members accused of child molestation because of a family feud.  I’m not the one pissed off at my lawyer because I told them not to settle over a crime I swear I didn’t commit, only to find out later that they negotiated a deal behind my back, virtually stamping guilty on my forehead in the process.  I’m not the one who feels humiliated and powerless.   I’m not the one who eats bologna and white bread every day.  I’m not the one who only gets to go outside in a concrete walled in enclosure for one hour a day, if the weather’s good.  I’m not the one who has to argue with yuppy bitches like myself over how many ibuprofens I can have when I’ve got five bottles under my sink at home.  I’m not the one who feels so overwhelmed by drugs, stress, life that I shook my girlfriend’s baby to death, stabbed my mom, stabbed my wife, jumped out the second story floor to escape the cops shattering my leg, accidentally tried to rob an off-duty cop and got shot five times, barely surviving with my organs patched together,… I’m not the one who was abused as a child and now has become the perpetrator suspected of multiple assaults at barely breaking 2 decades old….

I’m definitely not the one wondering how the hell this is my life! (ok,.. I do that sometimes but for vastly more trivial reasons than listed here)…. 

But I suppose if I was,… maybe threatening suicide would be the easiest, most natural thing to do, if I just want something that someone is telling me I can’t have right now, someone in power over me, and I am in desperate need for leverage.  Desperate for some measure of control over these humiliating circumstances that are legally humane, but drive many an inmate to exclaim “they treat you like animals in here!”  Well that’s what a jail is, Folks.  It’s you trading in your freedom because someone thinks you did something to deserve that loss of freedom, even if temporary.  And maybe you did, maybe you didn’t.  but if in your moment of madness, despair, desperation, attempt at cleverness, thinking you’ve found a way to circumvent the system, if you play that suicide card, you force my hand, and you don’t get to win in here.  

You don’t get to win the manipulation game.  

Can I just say how hard it is to write all these words?  I feel like I’m being honest, being real about how things really are, it’s my job and I have to do it, but to be honest, it sucks to know that some of my patients true stories, words and feelings are listed here.  And their stories are as important as mine.  As valid, as human.  Their behavior may be frustrating, unacceptable, and invoke consequences, but the sources of their behavior are often deep emotional damage.  A lack of coping skills.  feeling totally out of control.  Feeling pushed to the brink.  Sometimes, feeling like they were “left no choice” even.  And honestly, though it frustrates me when I have to put someone on suicide watch even when they may not be truly suicidal, I am mostly mad because I don’t want to punish anyone.  Suicide watch is not a punishment, but often it feels that way.  You wanna play hardball?  Well guess what!  We get to cork our bats.  It’s my job to keep people healthy and safe.  safe from even themselves.  And I want to do that WELL.  

And I don’t even like how it feels to put someone who really is suicidal on suicide watch either, because it’s like- you’re in the depths of the darkest pit you can imagine?  Bowing out of this circus is sounding like the best decision you can make?  Here, let me help make things worse by making you as uncomfortable as possible, sleeping on the concrete floor with a little velcro “safety” smock on, which, supposedly you can’t hurt yourself with.  It sucks.  You are rewarded when you aren’t suicidal anymore, you get to go back to your cell.  A lot of them will say anything to get out of there! but are they truly no longer thinking about ending it all?  I don’t know.  

We have a great team of mental health providers, God bless them, because most of the time, I just put someone in there, and they take them out when the person has passed enough suicide evaluations and deemed to be no longer a threat to themselves or others.  I know I’m licensed and qualified as a PA to practice mental health, there are tons of PAs working in psych, but because the burden of Mental Health is so great, we have a whole team of dedicated professionals, and I appreciate them very much.

 So I deal with suicide, suicidal threats, and suicidal protocols all the time.  It doesn’t make it any less sad when someone follows through and is successful in ending it, because I happen to believe that there is always hope, there is always a possibility of healing, there is always the chance that the despair you feel in one moment can give birth to new life and new dreams, new futures and new relationships.  I really wish that Robin Williams hadn’t lost hope completely.  I really wish he had listened to the voices that communicated love, joy, acceptance, appreciation and value to him.  I really wish the devil had not convinced him of the lie that his death would make everything better.  I really wish there was someone there to throw him in a safe cell, cold but alive.  There might have been a chance.    

I’m not going to go there about this raging debate about how “selfish” suicide is because it hurts those around us so much. Well ok, maybe just a  little.  Although I’m a person of faith, driven to care about others more than myself, it feels awfully arrogant to insist that someone ought to remain in their abject misery because  staying alive in misery, surrounded by loved ones, is inherently better than leaving those loved behind in their sadness, but knowledge that you may no longer suffering in misery anymore,.  

Is it not equally arrogant for those loved ones to insist that you remain alive, to appease their desire to having you around, despite your misery?  

As a Christ follower, I believe that there is no joy or life beyond this one without the saving grace of Jesus Christ, and that true “peace” once dead, is in question without Jesus,… but that is outside the scope of what I want to reflect on here.  I tend to be fairly sympathetic towards medically assisted suicide/euthanasia,.. and no, I don’t have all the answers to that debate either, but often I think we underestimate the mercy of it in our focus on suicide as the “ultimate” wrong.

There’s a lot of crap flying around on the internet, analyzing Robin Williams’ death, and discussing suicide in America.. I think that most Americans are woefully unaware of how common suicide is, that it’s one of the most common causes of death, and not always in young people- it’s quite common in older populations too.  Perhaps related to the loss of loved ones, the loss of health, the loss of vibrancy, the perceived setting of the sun and the desire to control one’s final destiny before discussions of nursing homes and depends take place.  There’s a lot of judgment towards mental health conditions- a lack of understanding of the disease that is depression, a lack of compassion for those spiraling down into it.  There’s a lot of exasperation from many who see things like celebrity deaths from suicide, overdose, mass shootings, murder suicides, and other violent assaults as the natural legacy of a society that has been blind to the undercurrents of mental disorders in our country.  There are many, myself included, that feel it’s time we poured the necessary resources into mental health resources in our country.  

The ideas that one just didn’t work hard enough, was too soft, too weak, to sissy, didn’t have enough control, didn’t pray hard enough, didn’t do enough, didn’t just ‘snap out of it’ will be shoved aside by the face-reality train that most Americans will clamor aboard.  I believe this is possible.  

In the meantime, I will continue in the trenches of the jail, praying that I not miss the patient who is suicidal but not saying.  Because who am I to say that my patient with the cracked jaw didn’t truly want to kill himself in that moment?  Despite saying at other times that he just wanted out of his cell?  He wrapped something around his neck!  He has abrasions under his jaw from his noose!  He could have snapped his neck in that moment, instead he only snapped his jaw (which I am sure he is severely regretting at this moment as he wishes he could eat that loathed bologna, not the pureed peas he’s eating now…)  Who am I to say that someone may not be driven to do something drastic over being refused tylenol?  When people are desperate, there’s no telling what seems “reasonable” in that moment.  Who am I to say what on earth I would do if I was in half the situations my patients are in?  or what I would have done if I felt the measure of despair Robin Williams felt the day before yesterday?  I dare not guess.