On a recent Monday, clinical staff at Massachusetts General Hospital had gathered with a patient as she prepared for discharge from the psychiatric ward. After nearly everyone had said their goodbyes, the patient turned to Dr. Stuart Beck, the soft-spoken psychiatrist who runs the ward.
“Hey you, Dr. Beck,” the patient blurted out. “You got anything to tell me?”
The Boston hospital has 1,011 beds, only 24 of which are reserved for the psychiatric ward. Vacancies on the ward are rapidly filled, and Beck and his staff are always busy, moving from one bed to the next as they make decisions about medications, treatment plans and whether it’s safe enough to let a particular patient go. Still, Beck tries to build a connection with his patients and uncover the deeper issues that brought them to his ward.
This woman had arrived about a week earlier with a depression that left her unmoored. She had trouble sleeping and eating. There were days when she couldn’t get out of bed, and suicidal thoughts plagued her. Beck had seen her nearly every day, and the two had bonded quickly over their mutual gray hairs and curmudgeonly sensibilities. Beck learned that she was estranged from her children but had a doting husband and many friends who loved her, people she cared about as if they were family.
So as she was departing his ward, Beck debated what to tell her, knowing that she was still at risk of suicide. He decided to say what was really on his mind: that she had to acknowledge that her cultivated family could sustain her and to stop dwelling on the children who were no longer in her life. “You are looking for love in all the wrong places,” he told her.
“That’s not a very shrinky thing to say,” Beck admitted to HuffPost. “I find myself at discharge dropping those pretenses and saying something that I hope has some use to people.”
Beck hopes his patients leave feeling more sure of their place in the world. But some are still mysteries, and survivors of suicide attempts are often the biggest mysteries of all.
In the aftermath of the high-profile suicides of Kate Spade and Anthony Bourdain, I wanted to talk to Beck about what it’s like to treat suicidal patients. The suicide rate rose across the U.S. between 1999 and 2016, according to a Centers for Disease Control and Prevention report released in June. Beck works with suicidal people every day, and I wanted to know how he coaxes them back from the brink.
This interview has been edited for length and clarity. It includes a frank discussion of suicide that could be disturbing to some readers.
Did the deaths of Kate Spade or Anthony Bourdain remind you of people that you’ve seen come through your ward?
Absolutely. I think there’s some patterns to these people. There’s the person that says nothing and then they die. And then there’s the person who says a lot and doesn’t die. There’s the person who sees the world as a horrible place to be and is chronically at risk and does do multiple suicide attempts and experiences depression a lot.
Kate Spade is interesting. It brings up that whole notion that it cuts across money, it cuts across gender, it cuts across socioeconomic and racial lines. Suicidality is ubiquitous.
A lot of them are men, actually, now that I’m thinking about it. Men tend to shut it down and hold it inside and then burst. Men also have, as you probably know, the higher risk, especially middle-aged men over women, and they commit suicide in more violent, abrupt ways than women do.
It’s interesting because a lot of them tend to be a little blasé about it. “Yeah, I was thinking this. I’ve been thinking about it for 10 years. Then one day I just got fed up and decided to do it.” That kind of thing. Very abrupt. Unprocessed. Almost with some detachment. I think actually those people are probably even higher risk, the ones who are emotionally detached from it, more numb.
We know on inpatient, the ones who kill themselves are the ones who look fairly good. They’re actually at peace. There’s a calm about them. They’ve already decided they’re gonna kill themselves and they’re not gonna tell anybody. And you can’t tell unless you know them really, really, really well.
I think the ones who are safer are the ones that actually talk a lot about it. “You know, I’ve thought about this, but then what if I killed myself? My mother would be so upset. I don’t want to cause a mess, but I’m really desperate.” People who verbalize have a door open for us to help them more than the ones who don’t.
How do you reach the patients who fall in the detached category?
If I can tell that that’s what’s kind of going on, it doesn’t work to ask them directly, “How’s your mood? Are you suicidal? Do you have any thoughts of killing yourself?” They’ll say, “No, I’m fine. No. No. No.”
So usually the first-line approach is to make a leap into the unknown and assume that they are thinking about suicide and they are gonna kill themselves, just to kind of leap in there. Then you say, “Well, when you’re thinking about killing yourself, what images come up?” You don’t even ask them if they’re suicidal. You just assume that they are. So it’s a gentle assumption, and you leap into the questions from the other direction.
It’s like you’re building an instant rapport because if it works, you’ve intuited something deep in them, and they recognize that, and then maybe they respond because you understood them, or at least a little piece of them.
Some patients really appreciate that. And also, it stops them from feeling shame because you’re doing it in a way that’s nonjudgmental. They don’t have to confess anything.
Sometimes, the attempt itself is a release for them. They didn’t die. They survived. And sometimes that just breaks it all open and they’ll say those things. “Ten years I’ve been thinking about it. I’m so sad about this, I’m sad about that and I can’t tell anybody. I’m so ashamed.” And so sometimes just having survived opens the door and they start talking.
Some of them don’t, and they come in and say, “Yeah, I did it, but it’s OK.” And we kind of start just chipping away at that, because somewhere inside they’re extremely sad ― really, we see many times, angry. We have to just start working on those things and work it through.
It’s scary though ― they’re scary patients because they remain in the high-risk category. When you discharge them, one of the predictors of suicide is past attempts. So the previous risk factors are there. Plus, they’ve already tried to kill themselves and failed, and they’re not very emotionally available. So what we do is try to do high-risk discharge planning around safety [a safety plan is essentially a patient’s lists of things they can do to ward off suicidal thoughts before they reach a crisis point] and see if we can get any agreement.
Is there a patient or two that’s really stuck with you?
There are a lot of them. I’m thinking about a young man who’s married with a small child. He actually went off in a secluded area and [made an attempt]. His wife got some sense of it and found him and brought him in. He was in the medical surgical floor for a while and came over to us.
I’m remembering the most about that kind of case is the level of disconnect he had from the love that he actually had in his life. We spoke about rekindling his heart to a certain degree, like restoking the fires, trying to pursue connection and meaning. And at the same time, getting over the humiliation and shame of this act.
Had he not realized how much he loved his wife?
He had these thought distortions, which are so common in depression, that “of course I love my wife and that’s why I’m killing myself because she doesn’t deserve to have a miserable man next to her for the rest of her life.” Or “I guess you’re better off without me because I’m a horrible father and these are the reasons why I’m so bad.”
Their thoughts get so bad it’s almost psychotic. They’re not hallucinating, but they’ve got really negative, almost bizarre, cognitions floating around. So we work on those things.
Did you have a session with his wife?
We had family meetings. We do that a lot. We start small because they feel guilty, of course, and they’re traumatized and they’re terrified of the patient ever coming out of the hospital. There’s a lot of repair work to do with them.
We’re also trying to get the patients to be alive again, like life is worth living, trying to pull together the little threads in their life that still might be there. “Tell us about your wife. What’s she like? Where did you guys meet?” We just have to pull together these little threads.
It’s astonishing. It’s almost like you’re just telling the story of their relationship before this hit. So you ask people, “How did you guys meet?”
Yeah. If they have kids: “Tell me about your kids. What’s the thing you love about your son the most? What’d you do for your last birthday?” Just things that might bring joy to them. They don’t produce it, so we have to kind of poke around, and the family meetings help with that, too.
We try to instill in the patient, “OK, bad event, OK, very sad, but there’s still tons of love. There’s still options and opportunities for joy and connection. This is not a thing that’s gonna hold you back. It’s going to only deepen your relationships and bring more meaning to your life.”
Do you get a sense that people have held onto their despair, their suicidality, for years? I’m wondering how common that is, that they’re sitting with it because of shame, and they won’t seek help until it explodes and they come to Mass General.
Well, I think I deal with a skewed part of the population. These are the sickest people, and so I often hear stories and we often document it. They’re chronically suicidal, they’re chronically self-harming, they chronically think life isn’t worth living. And then something tips them into acute. So that’s a common theme all the way through. I do think people think about it for a while.
There’s usually much more to the story. They may not be aware. That’s the other thing I’ve been struck with is how little they are aware. “I don’t know what triggered me. I have no idea.” Then you start talking.
And they have been thinking about it for years. It may not be in the right words, but they’ve been thinking about it.
But it’s there. It’s insidious. It’s a dark force. It creeps into the bones. I think people think either suicide is a symptom of a disorder that could be treated with medications, which it may or may not be, but I think the human experience is a story. It’s a storyline, and it’s a dark thing that takes people over and it happens to their bodies and their souls.
I think about it from almost an existential viewpoint. They’re playing with one of the big existential issues for all of us, which is death. And it just doesn’t pop out of nowhere.
It’s such a serious issue that they have to live with it a little bit at first.
We can’t just go, “Let’s do your safety plan, let’s increase your Prozac, let’s get you an [outpatient] program.” I think we fail them. I feel like if somebody does die, we would have been partially negligent if we didn’t try to get under their skin, get into it deep, as much as they’ll allow us, and pull for the existential problems and try to show a pathway out that’s not just the resolution of symptoms, but a true recovery into a different way of being.
What worries you the most about people leaving the ward? Is there a type of patient that you worry about the most?
The ones that don’t have family, don’t have housing, don’t have resources. They don’t even know what it’s like to be normal or live a life that we would recognize as meaningful. I think those people are just set up for something horrible. And I don’t think they get better that easily. There’s nothing to get better to. There’s not many strings to pull together to try and help them. I think they’re at risk.
Can you tell that there are people that leave who are going to end up white-knuckling through it ― who are not going to go to the referral for outpatient therapy?
I was just talking to our outpatient urgent-care clinic. We refer a lot of people there for next-week appointments, and we have a no-show rate of 95 percent. They don’t show up.
And the outpatient clinic is in the same complex as the hospital?
Yes, it’s just over in another building. We’re aware that there’s a big cliff for all patients that leave. They have a choice. They vote with their feet, and I don’t know all the factors that go into it. They won’t tell us many times. But we kind of know. We can kind of tell by their attitude when they leave. Many times, we’ll actually confront them about it and say, “Listen, it looks to us like this is not your cup of tea. It has been hard for you on the unit. You may not want to take the medications, but let’s look at the consequences of not doing that, let’s talk about it.”
When was the last time when you discharged somebody that you really worried about?
I would definitely say within the last week. It might even have been this week.
What were the circumstances?
Last Friday, a patient came in with bizarre behaviors, psychosis. He was nonverbal. We finally got him to talk to us and we actually went through a formal depression inventory and he scored very high on it. We started an antidepressant. He left, but he never fully talked to us. He kinda laughed us off a little bit. He wouldn’t come to rounds. He looked very, very depressed. But he had a group home to live in, he had family and providers, and he was on medication. But he clearly was in that gray zone where further time in the ward could have been very helpful.
Another patient who was discharged earlier this week, we met with his family several times. Psychology was seeing him and he left with a question mark on his lips: “Well, I’m not sure if I’m gonna be safe or not.”
So we went through the safety plan and he says at the same time, “Yeah, there are a lot of things ― I got family, and there’s things I want to live for. But when it comes upon me, I never know what I’m gonna do.”
We discharged him to his family, who are keeping him in their home. He was a little uneasy.
That’s actually not uncommon. People leave feeling at times somewhat suicidal. We won’t let them go if they have a plan to kill themselves that day. If they’re actively, acutely suicidal, we just won’t discharge them no matter what.
How can you tell when you’ve made a connection with a patient? Who are you best with?
I don’t know who I’m good with. The people 60 and above, they respond to me better because there’s a sea of youngsters running around here. They’re probably the age of their grandchildren. I’m probably the oldest one on their team. And sometimes age matters for them. I can talk their talk a little bit better. I also do think I’m fairly OK with people who are about the age of my sons, so late 20s, because I know those people.
What is that like to see patients that are the age of your sons?
Oh my God. You’re going to make me cry. Seeing people who are just like my boys on the unit ― it is really difficult for me because I feel all sorts of strong paternal urges to take care of them and parent them and do things that are not necessarily part of my professional role. But I also think, on the other side, I’m much more, much, much more impassioned about trying to help, which I think is a good thing.
I think it’s very hard for people in my business to manage the feelings that come up. But I think it’s particularly hard with patients your own kids’ age.
And then is there any patient that you take home with you in a way that you’ve thought about after work? I know you try not to, probably, but does that happen?
It used to happen a lot, longer ago. I think the ones that stick with me are the ones that are really traumatized, have been really traumatized, and I think probably they stick with me because I’m also now traumatized by them and I have to work through that. The ones that bother me the most are the ones that are really badly traumatized by people who are supposed to care for them.
Those are the ones that get under my skin and I have nightmares about. It’s not necessarily the ones that kill themselves.