Unfortunately, 2018 has become a year notable for our loss of well-known public figures to suicide. The deaths of Kate Spade and Anthony Bourdain (among too many others) drive home the point that fame and fortune are not elixirs for psychological pain. As therapists, we know all too well how common suicidality is among our clients, with 71 percent of psychotherapists reporting at least one client who’s attempted suicide, and 28 percent having had at least one client die by suicide.
Helping distressed clients who are teetering on this particularly precarious edge is one of the most important interventions we can make as therapists, and it’s one of the scariest aspects of our work. While the current media push toward suicide awareness is a welcomed effort, I’ve been working with suicidal clients since the earliest cases in my training, and still I wonder, how do we give hope to the people who feel hopeless? How do we provide help to those who feel helpless? I’ve found myself asking more probing questions with clients than I once did. But while heightened vigilance and awareness is critical, is it enough to save lives?
Kay Redfield Jamison is a professor of psychiatry at the Johns Hopkins University School of Medicine, a MacArthur Fellowship “Genius Award” recipient, and author of several bestselling books that touch on her own struggles with bipolar disorder and suicidality, including An Unquiet Mind, Night Falls Fast, and Touched with Fire. Her most recent book, Robert Lowell, Setting the River on Fire: A Study of Genius, Mania, and Character, explores the life and mind of a Pulitzer Prize–winning poet whose bipolar disorder colored much of his career.
Here, she shares her thoughts on Lowell’s life and work, as well as how the fields of medicine and psychology can work to better understand and treat severe mood disorders and suicidality.
RH: High-profile suicides trigger a greater focus on the issue as a public health crisis, yet rarely seem to propel meaningful action. What can be done to reduce our rising suicide rates?
Jamison: Some groups, like the military, that have a significant suicide problem in their ranks have made a lot of important strides, but it remains a pretty intractable issue. And there are so many things that compound it: societal problems, access to guns, and increasing availability of opiates, to name just a few.
For people who have a mood disorder, especially when there’s an impulsive component, having guns readily accessible amplifies the risk. I think having opiates easily available creates a similar problem. Other medications that people have commonly overdosed on in the past weren’t as lethal, or as lethal so quickly. And now you’ve got people, many of whom have mood disorders and other difficulties, who are addicted to these drugs and have them on hand.
It’s just a hugely complicated problem. There are 45,000 people a year who die by suicide, which is many more than those who die from breast cancer. Also, these people are disproportionally young. You’d think the general public would be horrified enough to trigger an immediate response.
RH: So what can we do?
Jamison: I think funding more research will ultimately pay off. We need more studies to better ascertain who’s biologically at risk, so we can at least protect some vulnerable people a little bit more. And we need to help more people understand mental health issues that are associated with a high suicide risk, especially general practitioners. There should be more awareness in the schools as well.
One of my colleagues at Hopkins has a great program that started in the Baltimore public and private school systems and is now in many states. It involves educating the teachers, parents, and kids about the symptoms of depression, saying, “This is a really common issue, and it’s really important to be able to recognize it and keep an eye out for your peers, because it’s treatable.”
We talk to our medical students every year at Hopkins, and say, “Look, a lot of you are going to get depressed. You’re at risk, given your age and stress level. We’ll do everything possible to get you well, and there’s every reason to believe that you will get well, but we can’t have untreated doctors.” You can change the motivation to seek care and look out for friends and classmates this way. And we’ve got to start in psychology and medicine, or what’s the point? After all, physicians are so often the front line for suicide intervention—and they have a much higher suicide rate than the general population.
RH: Does suicide always correspond with mental illness? I know there’s a bit of debate around this.
Jamison: Nothing is always, but if you do psychological autopsies, or you do epidemiologic studies, 90 percent are tied to mental illness, generally mood disorders (depression and bipolar disorder) or schizophrenia or borderline personality disorder. Of course, what determines when somebody kills themselves is usually more complicated than having mental illness. What are the economic circumstances? What are the relationship issues? Are you depressed because you broke up with somebody? Or did you break up with somebody because you’re depressed or manic?
It’s often very complicated so maybe the most effective thing we can do to help someone struggling with suicidal thoughts is to ask questions and to keep talking about it—and to get educated. I think that suicide research is outpacing practitioners’ knowledge. People aren’t aware, for example, that there are probably 50 studies showing that lithium has a very strong anti-suicide effect. I think it’s important for therapists to know that when working with someone who has a mood disorder.
RH: What lessons have you learned from working with suicidal people that you’d like to pass on?
Jamison: After somebody has attempted suicide or been very suicidal, meaning they’re not in the middle of the crisis, I always ask patients, and teach residents to do the same: “What did I do that was helpful to you in any way? What did I do that may have made you feel worse? What would be helpful for you with your family?” I’m very willing to work with family members. I also help patients draw up advanced directives. For example, if I get suicidally depressed or manic again, I want to be hospitalized, even if it’s against my will. I want to be hospitalized at Hopkins and have consultations with specific doctors. I want this medication. I don’t want that medication. That kind of thing.
RH: That’s very proactive.
Jamison: How legally binding those directives are varies across states, but it does give your doctors and family a sense of what you think is in your best interest. And I think it gives people a sense of agency, rather than everybody just waiting for a crisis, which is when so much of this thinking tends to be done. It’s really hard to know what people want when they’re depressed, because everything they see is through that hugely pessimistic and helpless lens. It’s hard to make rational decisions then. I know from personal experience.
RH: You say you chose the poet Robert Lowell as the subject for your latest book because of your admiration for his work and life. Can you tell me more about that?
Jamison: Well, the book is reviewed as a biography, but I think of it more as a psychological account. It focuses on how Lowell thought and approached his work: how his life and work and illness came together. And I chose him for a lot of reasons. Mainly, he’s just an extraordinarily interesting and courageous person, who’s also a great poet.
When I was 17, I had my first breakdown, and my high school teacher gave me a few volumes of Lowell’s poetry, saying, “I think you might be interested in this.” I was completely hooked and fell in love. It wasn’t so much that he was writing directly about having a mental illness, but through his poems he seemed to take this uncontrollable, galelike force, and marry it with a sense of beauty. An early poem of his, “The Quaker Graveyard in Nantucket,” is a good example of that.
RH: Wasn’t he most prolific when he was having his manic episodes?
Jamison: Yes. He’d generate a lot of fragments, some of which he’d scribble down. Then he’d revise and revise and revise. He was a hugely disciplined man, and his process was to revise his work when he was depressed, or feeling normal. In other words, that’s when he’d work on the writing he’d created when he was getting into full-blown mania.
RH: He was hospitalized about 20 times, right?
Jamison: He spent a great deal of his adult life in a hospital. He first went when he was about 40, but he’d been ill long before that, just not psychotic enough to land him in a hospital. One of the very few treatments available then was electroshock therapy, which he actually responded well to. But it doesn’t stop future occurrences; it just works acutely. When he was hospitalized quite a few years later, he was given Thorazine. Again, he responded well, but it didn’t prevent his manic episodes from coming back, and he lived in abject terror of going mad again. Then in 1967, he was given lithium for the first time. That seemed to help the most, but it wasn’t a silver bullet, of course.
I suppose part of my fascination with Lowell is how you can still get up to teach, to create, to have relationships, to serve on all sorts of professional boards, and even to win the National Book Award and the Pulitzer Prize for Poetry, knowing that, even if you do everything you’re supposed to, it’s just a matter of time until you’re psychotic again. It’s just in your nature, beyond your control.
RH: He lived in terror of psychosis, but there must have been a love-hate relationship with the mania in some way, because that’s when he was most prolific?
Jamison: He spoke to his doctors a lot about that and believed that the early stages of mania were very related to his imagination and creativity. Still, he was unequivocal in wanting to treat his illness. He had a very bad form of it; there was nothing romantic about it at all.
RH: You’ve always had an interest in studying the relationship between creativity and mental illness. I’ve had many artistic clients with mood disorders express their worry that treatment and recovery will mean losing their artistic edge. Is there any truth to that being the case?
Jamison: I think that’s an important and legitimate question, and the answer, like much in life, depends on the individual and the nature of the illness. Bipolar disorder may give some individuals a creative edge, but it’s progressive, so it gets worse over time and takes a toll on one’s life and brain. The advantage of lithium is that it’s quite effective at reversing some of the damage in the brain, preventing suicide, and getting people back to a position of being able to work and write again.
If you have a severe mood disorder, you’re likely to be spending a lot of time sick, and very few people are creative when they’re sick. I think it’s important not to frame it as an either/or for your patients, so much as a matter of what they can do to maintain their creativity and productivity and not be sick. In this day and age, that can be done; it didn’t used to be the case. When I was first put on lithium, for example, it was given at very high doses, and there was no question that it had a dampening effect.
Now there are a lot more options, and I think one of the many advantages of psychotherapy is that it allows some people to function on a lower level of medication than they’d otherwise require. And it’s important to intervene early, when someone first begins to get either depressed or manic, because it’s obviously much harder to treat somebody once they’re in the midst of it all.
RH: What’s the role you see for psychotherapy in treating bipolar disorder, which is so often genetically and biologically based, as well as environmentally triggered?
Jamison: It’s typically more environmentally triggered toward the beginning of the illness, and tends to form its own rhythm after the initial attacks. Not everybody needs psychotherapy, but it saves a lot of lives and makes the quality of life better. And I think it’s hugely important to have a psychotherapist who truly understands the nature of the illness, the biology, the progressive course it can take, the treatment options, and the role of positive experiences in how people perceive the illness. I couldn’t have lived without lithium—and couldn’t now—but I also credit my therapist for saving my life. He was intelligent, empathetic, humanistic, and medically knowledgeable.
RH: After writing your first book, you stepped away from your own psychotherapy practice. You’ve said that you felt like with clients knowing so much about you from the book, they might not feel like it was their space any longer. Do you still believe that?
Jamison: I’d always made it a point to tell anyone I was practicing with at UCLA or Hopkins about my illness. If there were any concerns, I wanted them to let me and my doctor know, to let my department chair know—that was okay with me. But I feel patients have a right to go into a therapist’s office and deal with their own issues. After I’d written such a terribly personal book, I wasn’t sure that could happen. I regret closing my practice in the sense that I loved being a psychotherapist: it was incredibly interesting and challenging and rewarding. That’s why I end up doing a lot of informal consultations, mostly with medical students, graduate students, and faculty at Hopkins.
RH: Lowell died of a heart attack in 1977. How do you think his treatment would be different today?
Jamison: I think he’d still be on lithium—it remains the gold standard as a treatment for bipolar disorder—but he’d have more information about his illness than he did then. In terms of therapy, he had a convoluted relationship with it. Probably his greatest book in his poetic legacy was a result of the suggestions of his psychiatrist in Boston and his work with that doctor. But therapy didn’t keep his illness from coming back. And when he was finally put on lithium, after many, many, years of psychoanalysis and psychotherapy, and he responded so well and so quickly, he got pretty jaded.
My guess would be that he would be more responsive to psychotherapy these days because his illness would be more in control. We can’t do much great psychotherapy work when people are sick all the time. He was a highly verbal man and incredibly smart, and I think he’s exactly the kind of person who would get an enormous amount out of psychotherapy under the right circumstances.
RH: You believe that often psychological and medical treatment need to blend in order to create ideal circumstances?
Jamison: Yes. I think it’s tremendously unfortunate that just because medications do work well in many instances, complex, interesting psychotherapy work has been downplayed. Both are vital.
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