Dead patients live on in my mind. My relationships with them continue in quite different ways than when they were alive, much more one-sided, but still with considerable similarity. They are with me even as I am without them in the outside world. In some cases, I get to know them better or at least differently after they have entered the past tense .
While I was on vacation one summer a number of years ago, a patient of mine, a young man in his twenties, hung himself. Suicide had been a preoccupation of his for many years as a way out, as a total solution to vexing problems. His death was a shock and also not a surprise because he had been on the verge of it many times.
After I heard I swam all the way around quite a large pond on Shelter Island. It was hard to assimilate what had happened, horrible to think of his resolve, of his last moments. I was very grateful to the fresh water for how it held me and still let me move. I could not believe that it had happened and also did not have the luxury of not believing that it had happened. I thought of all the things I might have done differently. I thought of the futility of this thinking.
Shortly after I got back from vacation, I met with the patient’s parents. We had already spoken on the telephone, but this did not make the meeting any less difficult, any less heartbreaking. They had other children but the loss of this one was the loss of an entire world. The mother said little. I thought she was too upset to say much. The father was a complex mixture of devastated grief and reactive rage. He told me that he hoped something like this never happened to me.
The last thing he said to me came in the form of an intense injunction just as he and his wife were about to walk out the door of my office.
“Keep thinking about him. Don’t ever stop thinking about him.”
I have obeyed the injunction which I took to mean many things wrapped in one bundle. If we keep thinking about someone we have lost, that seems to keep the person alive, particularly in the early days. The person lives by the light of memory’s pale moon rather than the dazzling sunlight of life.
Also, this patient represented a set of clinical problems that we had not adequately understood and certainly had not been able to solve. How did his neurological problems and his psychiatric problems interact? Never to stop thinking about him proposed a research agenda, one that remains with us.
As time goes on, I have seen more clearly how much trouble he had settling with being himself with all the differences that he carried. He was so competitive and so bitter, more and more radically disappointed in himself. He was tormented by the instability that his neurological difficulties imposed. Memory was hard and a word that surprised him would undo him. He had a tenderness that he abhorred, as if he felt the only hope was for him to be hard, not just a little hard either.
In my now more than thirty years of being a psychiatrist, I have been around a certain number of suicides. I have observed a recurrent pattern. Somehow the process leading up to suicide involves a subtle distancing of others, so that after the event others reproach themselves. They tax themselves with not having intervened, with not having moved closer, with not having seen the pattern that in retrospect is so clear.
I think it is as if the person about to suicide emits a gas that moves those around this person back, that gets them leaning the wrong way, that puts them crucially out of position. Or, to put it another way, the person involved in the process of turning his back on life, subtly turns his back on his human contacts before he does the definitive deed.. This is an observation. I do not know how to push further towards a deeper understanding of the workings of suicide.
The deaths from natural causes of patients, especially younger patients, are hard to take as well. I was on the way down to the hospital to see a patient, a young woman with an exotic genetic metabolic disorder with whom I had worked very closely. She had been very ill. It was my understanding that she had gotten a good bit better and would be discharged the next day.
When I got to the room, there was an ominous silence and a curtain drawn around her bed. I peeked through the curtain. There was her still, lifeless body. She had bled out unexpectedly in the night, probably an effect of the drinking she never could or would curb.
I drove away from the hospital in internal disarray. Years of suicide talk punctuated by a few attempts and this silence was the end. The last time I had seen her she had hugged me as she left and then planted a shy kiss at the base of my neck, something she had never done before and would never do again.
Was that goodbye and thank-you? I wondered how much she knew then. She had survived an enormous amount with pluck and humor and then she was not surviving any more. In my mind, I hear her singing and playing her guitar, whose case was emblazoned with a sticker – “I survived Catholic school.”
And then there is cancer…
I have rarely fought as hard with or for a patient, rarely met anyone as armored against the softer parts of her character, as if to say that it is a tough world and unless you were hard you would just be crushed. She had grown up in a chaotic family charged with much too much responsibility much too early. She took care of her younger siblings and was abandoned both by her mother and by her father, each in his or her own way
She was an athlete. In fact, the way she described the results of her long hospitalization was that she had gone from swimming instead of thinking to being able to think while she swam. I suppose this would be what is now often called “mentalization.” She stopped drinking and maintained her abstinence after she left the hospital.
When her mother was very ill with cancer, she moved to take care of her , this after years of excoriating her and declaring that she would never have anything to do with her again. She became a grief counselor. She took care of a boy friend who was diagnosed with cancer near the beginning of their relationship.. Her great consolation was the outdoors. She became a triathlete out on the west coast. She worked outside the country.
I heard from her once a year, warm and friendly bulletins. There were a few visits in person, too. Then there were a few years when I did not hear from her. I initially interpreted this as meaning that she had taken another step towards independence from me, a step of which I approved. She was her own person and she had her own life.
After five or six years, this explanation started to wear thin. It was not exactly in her character to stop communicating like this. Or at least that was the thought that nagged at me. So I did something that has only become possible in the last decade or so. I googled her and discovered an obituary that let me know she had died a few years earlier of breast cancer. I felt very bad that she had not reached out to me when she was ill. She was only in her middle forties.
As I assimilated the shock of this strange discovery strangely made I began to see this patient, this person, in a different light. She gave more than she had and then was in extremis. She took care, except for herself. She experienced taking care of herself as transgressive. She was such a tough character, even an impossible character, because she was such a soft character. What was hardest for her was any form of settled intimacy, because she could never feel secure enough to let that be, to let someone else know what she needed in depth and detail.
I have installed her in my mind and heart as a consultant on the care of other people, as a consultant on how to live. This is, I suppose, what we do with all former patients, but I believe that I do it in a special way with those who have died.
Their race is run. They ask nothing. They have given and taken what they could. They leave us with regrets and rewards but are not in a position to have any themselves. I honor them by how I work and how I live, by how I use what I have learned, what I would not know to feel or think without them.