My first encounter with suicide was the death of a friend from medical school. Just a letter left to his parents with few words and no answers. No answers but many thoughts. I still knew very little if anything of the effects that the practice of medicine had on doctors. I, like many others, still ask myself if fear of the future was a trigger for his death, the secret thoughts that may have reflected his fears about a career where competition started to shape lives much more directly than a simple mark in an exam did in the past.
The consultant
When Alex was first admitted, he was fractured and confused.
Looking back and reading through the history, as is often the case, you could see the red flags, snapping and fluttering in the breeze, but no one had spotted them at the time. Taking hours to clerk one patient. Sending long, rambling emails to his consultant in the middle of the night. Increasingly bizarre behaviour, it said in the notes when he presented himself to A&E, stating he felt unsafe. Self-harm and self-loathing. The wandering, lonely journey of someone who was trying to survive in a landscape that eventually he was unable to tolerate. By the time he reached us, he was showing signs of paranoia – suspicious of everyone around him and refusing to communicate. There were persecutory delusions, perhaps even auditory hallucinations – hearing voices – although we couldn’t be certain, because he wouldn’t engage with anyone. There were times, though, when he seemed to respond to sounds or to people that no one else could hear or see.
He continued to believe he was working as a doctor for the ward on which he was now a patient. He was very convincing, of course. So much so, some of the other patients began to believe it too.
Slowly, over the weeks, with support and talking, and medication and kindness, Alex began to improve. He started to trust us more. He felt comfortable talking about his thoughts and reactions, and he gained back the insight into why he was there. We had long conversations, Alex and I. He talked about the stress he’d experienced as a junior doctor, how inadequate he felt and how much self-doubt filled his mind every day. I don’t think I have ever related more to a patient and their story. I’m not sure that I ever will again. This could have been me. I have always believed that the distance between a doctor and a patient is a short one, but never had it been shorter than with Alex. Most of all, though, we talked about his dog, Fletcher. In another strand that bound us together, he was completely and utterly devoted to his dog. A golden retriever with kind eyes and a goofy walk. He often took out his phone and showed me pictures and videos of Fletcher. While other patients would visit family and friends on a day’s leave, Alex would visit his dog in the boarding kennels. Through a tragic twist of fate and the impossibility of geography, he had no family and very few friends. Fletcher was everything to him.
Alex was discharged on a Thursday afternoon in the middle of a heatwave. Before he left, we sat in the shade at one of the benches in the patients’ garden and talked for the last time. We talked about different jobs we’d had and the consultants we’d worked for, and we laughed at shared horror stories from the wards. He told me he would like to eventually go back into medicine, because he loved the job and he missed it. He talked about how much he was looking forward to picking Fletcher up from the kennels. It didn’t feel as though I was talking to a patient any more, it felt as though I was talking to a colleague.
On the Saturday night, he hanged himself.
I was told at ward round on Monday morning. I had known suicides before, but the shock was so intense, so unbearable, I couldn’t find any words at all for a few minutes. When I finally spoke, the first thing I said was: ‘No, there must have been a mistake, because he would never, ever, have left his dog.’
Because I fell into a trap. I fell into a trap of believing that Alex had a choice, imagining that he sat at home on the Saturday evening and made a decision about whether he wanted to live or die that day, when in reality he had no more of a choice than someone who is killed by a heart attack or by bowel cancer. A disease ended his life, just like other diseases end the lives of people every day. I knew those thoughts were in my head somewhere, but it took me a few days to find them, to realise that choices are not black or white. Choices are coloured and shaded by our own thoughts and experiences, and our decisions are sometimes made – not only by us – but by the diseases that run through our minds.
It was only then I looked back and remembered standing in a mortuary as a medical student, and being filled with rage and disappointment, and realised, finally, what I should have realised then – that, just like Alex, neither the man who had had the car accident nor the man who took his own life in a garden shed all those years ago had been given any kind of choice.
In reality, what may seem like a choice can in fact be anything but, and it’s only when you visit a mental health ward that you begin to realise how small and how rationed those choices might be.
Perhaps, in psychiatry, this is the most important role of all – to restore choice – because the restoration of choice brings with it the return of hope. Many patients arrive on the ward with a complete absence of hope, and a space in their lives where the idea of choice used to live. Choices are born from the acknowledgement of our own emotions, because how can we make a decision about something if we aren’t allowed to explore how we feel? The registrar in the mortuary allowed me to explore my feelings about death and by doing so, she handed me the choice of staying or leaving, and the hope that I might be capable of this job after all.
In medicine, and outside of medicine, the need to preserve choice is vital, but perhaps it’s felt most keenly of all in psychiatry. A place where choice is so easily lost. A place where, in time, when that choice is found again, there is nothing more rewarding or more wonderful to witness than the restoration of a life worth living. Because the most important ingredient with which to mend a damaged life is hope, for the patient and for the doctor.