Leonardo Tondo: Brief History of Suicide in the Western Cultures
Barry Blackwell’s commentary
Recently, the epistemological metaphor of “the baby and the bathwater” has taken an interesting turn in Leonardo Tondo’s recounting of his career-long experience concerning suicide in patients treated for depression and more recently in his captivating Brief History of Suicide in Western Cultures (Tondo 2018).
Recently on INHN.org I described the lifetime experience of Martin Kassell concerning the frequency and psychopathology of impetuous suicide attempts (not associated with melancholia) and the therapeutic approach he developed in prevention of recurrence (Blackwell 2018).
This interesting turn of events encouraged me to reconsider my singular experience with the only completed suicide among the depressed patients I treated throughout my career and reported in the literature (Blackwell 1984). It was also included in my memoir, Bits and Pieces of a Psychiatrist’s Life (Blackwell 2011), in the section titled “The Bread and Butter of Psychiatry” devoted to a handful of patients that illustrated: “How, while I prescribed modern medicines, the essential ingredient to whatever success ensued was clothed in talk. Not always an hour long but sometimes brief and sequential; in my office, at the bedside, on the streets, in the clinic or in prison.”
A full re-telling of the singular events is followed by a brief conceptualization of them in the context of my essay, “The Baby and the Bathwater” (Blackwell 2017).
Reflections
The people we treat are mirrors to our own mortality, the images refracted by our readiness to perceive them. Sometimes the other person is a fellow physician and then the reality and its reflections are often distorted.
A few months after I became Chief of Psychiatry at Lutheran Hospital I received a call from the Medical Director of Children’s Hospital: “Would I see a child psychiatrist who was depressed… the staff were concerned about poor work performance and long absences… the physician had agreed to see me?”
In my office Paul was certainly dejected, but behind a hangdog appearance was an appealing and childlike charm. His gentle manner and quiet voice put children at ease; he had a reputation for rapport with the most disturbed kids and cared for more than his share of those with intractable or incurable diseases.
Paul took control: “Should I start taking that new antidepressant? It has fewer side effects and the others always make me constipated.”
Encounters with physician patients often begin this way; we are trained to take charge, diagnose, and treat. Paul was holding in check the underlying feelings of embarrassment and helplessness at being in my office. He was also telling me that he had a biochemical disorder and that drugs were the best solution. I side stepped by asking him to tell me more about himself and the events that led up to this visit.
The story traced a familiar path. Paul’s skill with the sickest children led to many referrals from colleagues and requests for consultation from house staff. He felt unable to say no and was seduced by his own success, the affection of the children, the gratitude of the parents and the approval of his colleagues. As work expanded he took less and less time for respite or refreshment; neglect of his wife and own son had made them angry and himself feeling guilty, so now he immersed himself in even more work to escape the tension at home. The strain had taken its toll. He was sleeping poorly, waking tired and coping poorly with daily routines and decision making. “I’ve become a lousy doctor and I’m not able to give the children what they need.”
I felt quite confident that Paul would respond rapidly and in the usual way to antidepressants and supportive counselling. As we met weekly over the next month, we tried to better understand events contributing to his depression.
Paul was a large and ungainly man. He looked cramped and uncomfortable on the sofa in my office as he traced his early upbringing. He described his mother as “probably schizophrenic”; she drank heavily, was unpredictable and often verbally as we’ll as physically abusive. She ignored his two sisters and focused her unpleasant attentions on Paul. His mild and ineffectual father provided neither a buffer nor a role model. Paul grew up insecure and with little self-confidence. The seeds of future depression were sown as well as a fear of sharing these feelings with others. The only redeeming feature of Paul’s early upbringing was his intelligence. His mother called him a “genius” and Paul learned to play on her better side by studying hard and bringing home good grades. His own stifled longings to be loved and held changed gradually into a desire to give others what he lacked himself. As soon as the wish to become a doctor was announced it elicited more longed for attention. Family routines were adjusted to accommodate his ambitions and for the first time Paul began to feel special. Medical school had not been easy. Despite his native intelligence, Paul’s psychological need to be a physician was so intense that success became a source of extreme anxiety and tests were a torture. He somehow scraped through the pre-clinical years and began to flourish with patient contact.
After graduating, Paul was drawn naturally to pediatrics and psychiatry. His intuitive understanding of children’s fears and needs grew out of his own early years. He was highly regarded, especially by the nursing staff who observed and appreciated his calming influence and clinical skills. Outside of his work Paul had few interests, he listened to jazz and enjoyed acting as a member of the local repertory group where he had a talent for assuming roles that contrasted with the rest of his restrictive life, but even this ceased after he met Cynthia. She was a second year nursing student. One year after they met they married; within six months she was pregnant and never went back to finish her degree after their son, David, was born. Paul described Cynthia: “She was so quiet and understanding; I felt I could protect her and that she would be a good mother. She was very patient and I don’t remember seeing her angry.” The contrast to Paul’s own mother was clear and the reasons he valued Cynthia’s nurturing, calm qualities were obvious. Their eager entry into parenthood was partly determined by Paul’s determination to repair his past.
Paul regularly visited my office during the several weeks it took to obtain this information about his upbringing and marriage. He seemed to benefit from the medication and sharing his feelings. There were a few side effects which he alleviated by adjusting his own dosage and regimen. Six weeks later, he was feeling so much better that we extended the time between visits. There seemed little remarkable about this episode of depression and response to treatment so I was not unduly concerned when Paul called to cancel his next appointment because he had flu and the one after because he was busy.
Three days after the second missed appointment I received another call from Paul’s Medical Director. Paul’s performance at work had deteriorated seriously; he seemed over sedated and incapacitated. It had been necessary to temporarily suspend him from duty. In my office next morning, Paul was untidy and disheveled. He blamed his worsening mood on the approaching anniversary of his father’s death and admitted to medicating himself with sedatives because of insomnia and nightmares. He had also increased the dose of antidepressant. He stated that “people at work probably think I am abusing drugs” but insisted that he was taking no more than the amounts we discussed.
We agreed that Paul should be hospitalized. He preferred to be admitted locally, even though he was known to our staff, because he wanted to be close to Cynthia and David. Having Paul in hospital would allow us to better assess drug dependency and provide an opportunity to involve his wife.
Paul was admitted the next morning. A dramatic emotional, physical and social disintegration ensued. I had decided to withhold all medication to obtain a clearer view of Paul’s mental and physical status. A few days later, after a visit home, a routine drug screen was strongly positive for benzodiazepines and analgesics; the plasma levels were far above therapeutic amounts. Confronted with this Paul equivocated; he admitted to low dose occasional drug use, argued about plasma half-lives and implied a lab error. But confirmatory evidence of impairment and drug dependency came from other sources, impossible to refute.
The information from the hospital, from several sources, was that Paul had been very effective when he joined the staff 10 years before. Five years ago, following an injury to his leg, he had periods of frantic activity followed by four or five days of complete letdown and several days off work. He spent considerable time with drug company representatives and took home large numbers of samples. In the last six months there had been memory lapses when Paul would claim to have dictated notes that did not exist. Had he entered the world of opiate dependency through the portal of orthopedics?
· Cynthia’s account of events at home was even more revealing. She sat in my office, tears running down her face and slowly shredding a tissue in her hands. Her manner vacillated between a pathetic helplessness and angry remorse. “When I first knew him he seemed so confident but it was only a cover. Soon after we married I knew he was taking drugs to cope with work. It was so important for him to do well but he wasn’t able to say no…” Early on Paul had taken amphetamines; the habit had begun in medical school and continued until the State Licensing Board had clamped down on stimulant use. For the past five years Paul used analgesics and benzodiazepines to blunt his performance anxiety without providing the artificial energy to meet his self-imposed demands. Cynthia had found drug samples hidden in the house, but when she begged him to throw out the pills he flew into rages. On two occasions he physically abused her and afterwards drove her to an emergency room in a neighboring city. Once he went berserk, tore apart the house and injured himself. Cynthia’s sadness turned to anger: “This last week while he has been away has been the calmest I can remember; David has stopped having nightmares and I haven’t had to take anything to sleep myself. I honestly don’t know if we want him back…”
Paul’s problems had been concealed by his own shame, his colleagues’ loyalty, the families fear and my own clinical naivete. The manner of unmasking was doubly damaging. He was deprived of the drugs that kept the self-doubts and insecurity at bay and he felt demeaned by the discovery. His depression became profound but clinically confusing; he refused to eat or dress. He lay in bed and quickly lost weight. At times he was confused and delusional. Paul’s physical condition deteriorated dramatically. There were several episodes of paroxysmal heart rate with evidence of previous myocardial damage and moderate hypertension. Liver function tests were abnormal suggesting damage secondary to prolonged drug abuse and a CT scan showed cortical atrophy possibly secondary to prolonged drug and alcohol abuse. Despite this, psychological testing showed no intellectual deterioration and his intelligence was in the high superior range.
Paul remained hospitalized for more than three months. His depression showed only moderate improvement on maximum doses of each of the major antidepressants. He refused to consider the excellent programs available for rehabilitation of impaired physicians, citing his reluctance to be away from Cynthia who would be unable to care for David alone as well as his poor health insurance. He had meager disability coverage and almost no savings. For most of his career Paul worked as a salaried employee and had lived up to his income.
Time ran out on our acute unit and the alternatives seemed barren. Several couples and family therapy sessions broke down in bickering and ended in silence. Children’s Hospital was willing to have Paul back on a trial basis and contingent on participation in an impaired physicians program but he could not function with even minimal clinical competence. Nor could Paul afford a lengthy stay in a private hospital. As a last alternative Paul agreed to go to a neighboring VA hospital; a second opinion suggested he might recover some motivation and self-respect in a less structured environment where he was not known.
Our final session before the transfer was bleak. To some degree Paul gave me his confidence but I had been unable to replace the chemical supports that had bolstered his past. In rare moments he reverted to his old self when challenged or stimulated; at other times there was a staged quality to his depression as if it were a part he played. We were both relieved to separate; if he returned we would try again.
Three months later Paul’s psychiatrist at the VA told me he was ready for discharge and shortly afterwards he came to see me during a visit home. As we chatted Paul smiled more than I had seen before. He seemed tentative but was taking some initiative in planning for his permanent return home. He had enrolled in an impaired physicians program and he would be subjected to random urine checks. There was to be open communication with the Medical Director at Children’s Hospital to monitor a return to work. Paul was now taking quite heavy doses of an antidepressant as well as a major tranquilizer; he seemed as convinced as ever that he could not function without chemical support.
Within a month Paul was having serious difficulty. He presented a zombie-like appearance and reported extreme difficulty at work where he was only responsible for two or three outpatients. He was reluctant to initiate any social contact for fear of being unable to sustain a conversation. He felt self-conscious and tongue-tied with great difficulty concentrating, A progressive behavioral program to extend his activity and restore his confidence failed at the first step. At home he became totally dependent on Cynthia and was doing little but watch television. Several phone calls confirmed this bleak picture. At work it had been necessary to transfer his patients to a colleague; at home Cynthia felt trapped, frustrated and angry at the complete role reversal in their relationship. The impaired physicians’ program reported Paul to be distant, remote and difficult to engage. Paul was one of the less than 10% of physicians they could not reach or help. His urine remained clear of addictive drugs but there were marked Parkinsonian symptoms with a shuffling gait and paucity of motor movement attributed to the high dosages of medication he was taking.
Paul’s inner world had become a ceaseless roundabout of painful thoughts which foretold failure and forestalled action. He had slipped back to that time in his life when nothing he could attempt was good enough or worthwhile. But now he was bereft of the inner regard and external rewards that came from medical practice. The drugs he had taken secretly to sustain his defenses were now part of his public and private shame.
There seemed no alternative but to re-admit Paul although there was little left to offer but a respite. Perhaps the massive amount of benzodiazepines Paul had consumed (equivalent to more than 100 mg of diazepam daily for several years) had permanently altered his brain chemistry to a degree only the addictive drugs could benefit. His hastening physical deterioration seemed to lend credence to this idea. Within a few days Paul had another severe episode of paroxysmal tachycardia during which his blood pressure and pulse were unrecordable. The medical resident on call administered diazepam and within 10 minutes he recovered. For the rest of his treatment Paul remained on the drug but it never restored his emotional or intellectual ability to function.
Paul’s general physical condition was appalling; his appearance had aged more than 10 years and he had Parkinsonian symptoms including hand tremors and a shuffling gait which persisted when drugs were withdrawn. The medications to remedy this worsened his depression and he lay immobile and silent in bed for much of the day. Yet another opinion suggested Paul be transferred to a nearby hospital for a course of ECT. When we parted I squeezed his hand and got back the glimmer of a smile.
Six weeks and 10 treatments later Paul was out of the hospital and back in my office. My notes from that visit read: “Better than I have seen him, wearing a suit and contemplating a comeback.” Later in the session Paul confided how at times he considered suicide but had rejected the idea as a poor example for his son. My notes comment: “Still there is a realistic risk… but not much to be done.”
The time of recovery from depression is always one of risk as the inertia lifts but the realities that provoked it remain. In Paul’s case the reality worsened. The corporation that employed him voted to terminate his contract and health insurance ended with it. Paul’s scanty assets were tax deferred and inaccessible. Cynthia was struggling to maintain a budget and considering a return to work but had no skills and did not trust Paul to provide childcare. Their house was on the market and they were selling their few antiques. Paul had filed for disability but there were clauses barring drug addiction and long delays in adjudication. The disability would need to be total and permanent to sustain them which meant Paul must relinquish medical practice.
Paul shared this darkening scene at our weekly sessions to which he came by cab; he had sold his car and Cynthia never learned to drive. Paul felt Cynthia had no respect and little liking left for him. His simple and softly spoken summary was “loss, loss, loss.”
At our last meeting Paul shared a small piece of good news; the insurance company had agreed to pay and the house could be saved. The family would be provided for.
Next week the weather was terrible. Paul called my secretary to say he was unable to get a cab and she reminded him of his appointment the following week.
Two days later Paul killed himself. He left no note, only a message. When Cynthia called to break the news, she asked if I had told Paul he should not come back because I had nothing left to offer. Sensitive to his core Paul sensed my frustration and impotence although, truth be told, I never gave voice to them and his next appointment was still waiting.
I was invited to Paul’s funeral and was surprised to find so many gathered to mourn the death of a man who seemed so friendless in life. Later, those closest to Paul invited me to a wake in their home and I learned about the man they knew but I never met, portrayed in this poem by a nurse on behalf of those who obviously cared long and deeply for him.
A giant and an orphan child he was –
Our paradoxic friend.
Bare head that almost touched the sky,
Big feet that tangled in the muddy nap of life.
He swayed between the mighty and the lame –
Our friend of times gone by.
Unto his friends he bared his soul,
And reading theirs he loved and angered with a mighty roar.
He played, made mischief, war and peace.
With not politeness or colleague’s grace
But from the psyche’s vibrant core.
Yet the child within was battered, naked and without a home.
For many years he bore the body of a man
and tried to be both son and father to his guest;
sang Blues full throated, played the frantic drum,
chased twisting fugue that tumbles here and there across itself.
The fugue will find its home, its rest,
The boy could not.
His frame began to fail beneath the giant’s weight
His bones began to break and fold,
The food once thrown the orphan boy
built flesh too frail for giant’s hold.
The fight went on for many a year.
The giant left,
The boy walked on alone
until at last he could no more.
Nor more be carried by his friends –
For that withheld in dawn of time
could not be taken by a soul long gone.
And so he took his body,
Paradoxic friend.
And as so often in times now past
He seeks one last forgiveness -
And bids we let him go.
Paul’s nurse Friend, Name Unknown
A contemporary reprise
Paul’s story is now a quarter century in the past. Carefully recorded, our relationship lasted almost two years, both inpatient and outpatient subject to many consultations and second opinions.
What seemed like a simple case of depression and possible melancholia quickly became complicated. In terms of our metaphor the “bathwater” became muddied by growing evidence of severe psychopathology and possible substance abuse. Early on my perspective was hampered by lack of collateral information. The referral made no mention of possible substance abuse.
At intake Paul’s own account of his troubled childhood revealed the psychopathology: denied love by a mentally troubled mother he described as “possibly schizophrenic” and a timid father who was “a weak role model.” Having grown up in Indian and British boarding schools during World War Two I recognized Paul’s loveless childhood might lead to caring for others while neglectful of his own needs - the so called “wounded healer syndrome” manifested in later life among impaired physicians with substance abuse, broken marriages and ruined careers.
The other missing piece of the puzzle was Paul’s wife Cynthia about whom he was silent. Where I trained at the Maudsley Hospital in London potential patients referred to our outpatient clinic were required to bring a family member who was interviewed separately. In America, confidentially concerns restrained me but when Paul relapsed and was admitted to our inpatient unit and Cynthia was interviewed the cat was out of the bag. The magnitude of Paul’s substance and domestic abuse of his wife became obvious despite his duplicitous denials.
Once the full story was known Paul’s physical and mental state both declined precipitously and were largely refractory to extended inpatient treatment, outpatient psychotherapy, behavioral modification, couples therapy as well as an impaired physicians’ program. Finally, a course of inpatient ECT secured a temporary respite before he committed suicide. Our relationship was always cordial and never contentious but complicated by an increasing existential burden including a deteriorating marriage, job termination, inadequate healthcare benefits and severe financial distress contributed to by lack of income, sparse assets, absence of a pension, a wife unable to work and his own inability to provide child care.
Earlier in the INHN series on “The Baby and the Bathwater” Ned Shorter suggested that when epistemological evidence for treatment modalities like Insulin Coma and Psychoanalysis was lacking or corrupt the remaining option was to fall back on traditional clinical wisdom. Paul’s case suggests this caveat may apply equally to treatment refractory individual clinical cases when overwhelming or obdurate therapeutic, personal or existential obstacles overwhelm therapeutic interactions and intentions.
In such circumstances patients may choose their own fate by suicide in the face of insuperable social, psychological and biological impediments to effective treatment.
Poetry as an aid to understand pithy and suffering
According to Greek Mythology Apollo, the God of Poetry was father of Aesculapius, the God of Healing
I was comforted at Paul’s wake by the anonymous untitled poem read by Paul’s friend and presumably a nurse who worked with him in earlier and better times.
My time with Paul coincided with my own midlife and becoming an amateur poet consummated in a slender volume (Blackwell 2016) which includes the poem “Wounded Healers,” influenced by my lived experience and time with Paul.
Wounded Healers
Infants born in orphanages,
torn from a mother’s breast,
die from a drought of love.
Kids abandoned or abused
at home or sent safe away
from bombs or city germs
are also divorced from love.
First they cry, then wonder why?
When feelings fade ideas intrude:
they ponder what to do,
ask what conditions love,
if self is not enough?
What soothes an aching void?
Kids compensate, choose who to be:
social workers, nurses, doctors,
care providers for a world of want.
Tendering kindness for kindred souls,
solace for unmet needs,
“Mother Love” by other names.
Late in life some burn out,
giving what they went without,
wounded, healing others, not themselves.
References:
Blackwell B. Reflections. Psychiatric Annals 1984;14:3-12.
Blackwell B. Reflections. In: Bits and Pieces of a Psychiatrist’s Life. XLibris 2011, 387-97.
Blackwell B. Wounded Healers. In: Naked Poems. XLibris, 2016, 24-5.
Blackwell B. The Baby and The Bath Water. inhn.org.controversies. June 22, 2017
Blackwell B. Martin Kassell: One of a kind psychiatrist. inhn.org.biographies. October 25, 2018.
Tondo L. Brief History of Suicide in Western Cultures. inhn.org.controversies. November 29, 2018.
October 3, 2019