Suicide, axis 2, and the Cow in the Kitchen:
Dear Dr. Brilliant Cliché,
I have heard that the highest risk for suicide is when a patient starts to feel better. That doesn’t make sense. Why is that?
-from Y. Sue Aside
Dear Y. Sue Aside;
In some personality disorders (axis 2) patients kill themselves when a medical professional makes them feel better because in doing so, we take something from them: their sense of self. For such a patient, their sense of self is intertwined with their suffering. Suffering is how they have learned to express themselves. If we quell their suffering they are entirely unable to express themselves; it’s as if they cease to exist. The act of suicide becomes an ironic way to take back a sense of self and control.
In dealing with this type of client I have found it effective to make them feel worse to begin with. This establishes that I am doing something, that I understand them and am talking their language. Over time I have found that they will make the choice themselves to shed the medication and treatment. Thus they are taking a step toward free will and getting better. This is what we call paradoxical therapy.
A great example of this principle is the story,’The Cow In The Kitchen.’
In this old fable a peasant woman complains to her husband about the noise, cramped space, and squalor they live in. The man prays to God and asks Him what to do. God tells him: “Take the chickens from the yard and put them in the kitchen.” The noise and squalor increase and the woman again complains to her husband, and he prays again to God. God tells him “Now bring in the pigs, then the donkey and then the cow!” When the wife and husband have had all they can stand of the squawking, braying, mooing, and squeals, God then says “Now, REMOVE the chickens.” With the birds gone, it’s not as bad, but still pretty awful. The wife complains and the man again prays. God says: “Now remove the pigs!” The donkey and the cow are soon to follow. As the animals leave, things get better. By the time the man and his wife are back to their original conditions, they feel such relief that their place seems spacious, clean and quiet. They are finally happy and cease complaining.
I hope that this answers your question.
-Dr. Brilliant Cliché
The Granny Dr. adds: that’s a very interesting idea- that patients kill themselves when a medical professional makes them feel better because it takes away their sense of self.
Believe it or not, this old granny trained as a black belt and this phenomenon you mentioned addresses a martial arts concept which we referred to in the dojo as “the guardian/gatekeeper”. In martial arts we learn that we hold ourselves back with inner weaknesses and negativity. Every negative characteristic that we need to overcome in order to reach our full potential comes with its own guardian/gatekeeper. When a person tries to change one of these patterns, the guardian convinces them that to change would be to die. The guardian can also convince the person that the person who is trying to help them is secretly their mortal enemy. This is easy to do because it is often authority figures whom we, as children, ought to have been able to trust but who were the very ones who hurt us and caused our aberrations to begin growing. Ironically, the person trying to help us through problems is very often an authority figure (such as a doctor or teacher) who must be trusted in order for help to get through.
No wonder it’s so difficult to change. We have built-in land mines that we tread without knowing.
How many people do you actually see change for the better in your business, Dr. Brilliant?
Dear Granny Dr.,
In School they taught us the rule of thirds: 1/3 get better with just medications, 1/3 with medications and counseling and 1/3 never get better. I have since found this to be about accurate.
-Dr. Brilliant Cliché
Medications to treat depression can rarely cause agitation or disinhibition thus increase the risk of suicide. They can sometimes aggravate an underlying illness in depression and cause depression to switch to mania. Also, antidepressants can sometimes increase energy levels; thus someone bent on suicide, but too lethargic from their depression to act at all, might suddenly have enough energy to carry through. These scenarios are rare but do happen so keep close tabs with your Dr. if you have one. If you don’t have one, should you harbor these feelings, GET ONE.
-Dr. Brilliant Cliché
A reader commented:
DocNeil- There is also the fact that severely depressed patients lack the cognitive skills to formulate and act on underlying suicidal ideation. In addition the last part of depressive illnesses to improve is the subjective mood portion.
Also some anti-depressants have activating effects that can make a patient more nervous and just generally dysphoric.
Take a patient who feels miserable who is now thinking clearly and has more motivation and add some further dysphoria and anxiety and these are other reasons for suicide in the course of improvement of depression.
Add Axis II control issues and I’d say the entire issue is at times predictably unpredictable.