Suicide is a terrible thing. It may – or it may not – end the suffering of the severely depressed person, and we are in no position to criticize. What Robin Williams did by hanging himself was a shocking thing, a horrible outcome, and yet, we don’t know enough to criticize him. That is a cliche.
But there is another reason to not criticize.
Williams, while clean and sober, recently checked into Hazelden. He was looking for help. Some clinicians will criticize him for that, since Hazelden is an alcohol / drug treatment center.
“Why not go to a top psychiatrist? Why not try . . . (insert your favorite treatment approach here)?”
There is a sad truth here. Treating depression is very unlike treating pneumonia or a broken arm. There isn’t a clear cut approach that always works. Many approaches work, and we don’t have a way to know ahead of time which one will work with which person.
Now some will be incensed at that statement. There is some justification. Not much, however.
Certainly there is some evidence in favor of using antidepressant drugs for severe depression. Did Williams get those at Hazelden? We don’t know.
What about ECT for refractory depression? That can help. Was it offered at Hazelden? We don’t know.
We do know that Williams looked for help. We don’t know much about what kind of help he was getting, so we cannot judge him.
But what we do know is that, unlike other areas of medical science, our treatments are not getting better over time. We can judge ourselves. With any treatment, whether psychotherapy or medical, when it comes to depression and other emotional disorders, about one-third to a bit less than one-half will get better. That means that on the Beck or the CES-D their score is below 10. On the Hamilton, they will score below 8.
Now, to be fair, about another third will improve. Their score at the end of treatment is at least half of what it was at the beginning. But they aren’t recovered, just improved.
Perhaps twenty percent don’t seem to improve, no matter what we do.
The truth is, that is the same pattern as it has been for at least the last quarter of a century. Cancer treatment improves. AIDS treatment has improved. In other areas things are getting better.
Our treatments aren’t improving.
There is one bright spot. Feedback Informed Therapy (FIT) does improve those base rates. Scott Miller is doing the most in that area.
What does FIT mean? It means that when therapists continually measure a patient’s score on a good rating scale such as the OQ-45 or something similar, the base rates are improved. We still have patients we cannot help. Fewer, but some. In the best therapies, the patient continually measures where he or she is functioning.
This is a good time to reflect on these facts: Depression is treatable. Continual measurement is the only modification to therapy that has been able to improve outcome. If you are a psychiatric or psychological patient and your therapist doesn’t measure progress each session, you need to ask why not? Or, perhaps, find one who does.
At the same time, bear in mind: suicide may or may not end suffering in the patient, and it certainly creates much more suffering in the survivors. Don’t fall for the idea that it is a solution. We cannot criticize Williams, but we can criticize those who are thinking that suicide is a solution. As Joe Banks asks in the movie, “Joe Versus the Volcano,” when Angelica Graynamore talks about suicide, “Why would you do that?” Angelica responds, “Why not?”
Joe says, with inspiring wisdom, “Well, because some things take care of themselves. Some things are not our business.”
It is not your business to decide when your life is supposed to end. That decision belongs to someone else, someone above your pay grade. Robin made the decision that seemed right to him. It isn’t my job to judge that. But I do take a position that suicide is never an option, and that there is always another way to do things. I have decided to believe that. Others do not. I have decided I do not own my life, it belongs to my family, my community, and, if you will permit it, to God. The playwright, John Patrick Shanley, who wrote Joe Versus the Volcano, is currently going through his own trials. Will he heed the wisdom he put into the mouth of Joe Banks in 1990? So far, the answer is “yes.”
Shalney doesn’t talk about his own physical (vision) problems in this NYT essay, but he continues to enrich our lives by confronting his own limits and pushing back against despondency and futility.
Life can be hard. Depression can cause incredible pain. No one knows which treatment will work with you. It is wise to keep trying, to not give up. Some things are simply not our business. Some things take care of themselves.