Will, lightly, with a brief flash of humor, said, “Mom, I hope you aren’t thinking of buying me a puppy because of this?” The two of us knew full well that a puppy wasn’t going to solve this problem.
“No, sweetie, but I am thinking of getting you a pony,” I joked.
He chuckled and then remarked offhandedly, “I feel like I’m in someone else’s body.”
Wow! His admission caught me off guard: it was hauntingly reminiscent of my first major bout of depression, when I confessed to a colleague that I felt as though I were no longer at home in my body.
“So, whose body do you think you’re in?” I teased. I hoped to stretch the levity of the moment a little further.
“Ummmm, Christina Aguilera’s.” We both giggled.
Like a condemned man who has run out of reprieves on his way to the gallows, he offered up a humorous parting shot. God bless him for his humor. He was going to need it.
Will was housed on the same floor, same corridor, in the same room I stayed in during my hospitalization at PIW ten years earlier. At seventeen, Will was the youngest person on the unit by several years. My heart tore open seeing him there, but I trusted Salerian’s judgment. At least he was safe in the hospital while we tried to sort out why the medication wasn’t working.
While he was there, doctors conducted a complete physical and a battery of psychological tests. Bob flew out from San Francisco and everyone in the family spent some part of visiting hours every day with Will at PIW. Will spent most of his time writing descriptions of the other patients on the unit in his journal and putting in all the time he could on the pay phone in the corridor outside of his room, talking to Megan.
At the end of seven days he was released. There were no surprise findings, no breakthrough. We already knew the diagnosis: major depressive disorder.
This is the first PIW admission for this 17 y/o WM. He has been treated for depression for the past 2 months. No prior history of psychiatric problems. No specific precipitating events. No physical complaints at this time. Patient confided in mother and g.friend of suicidal intent.
On January 23, when Will was released, I asked Dr. Salerian, “Do you think Will’s suicidal?”
“I think he engages in suicidal thinking, but I don’t think he will act on it.” Hardly reassuring. Dr. Salerian’s words carried far less confidence than I wanted to hear.
Back at home, it didn’t seem to me that Will was getting better—the new drug regimen was not providing him any relief yet. I think he felt trapped. I doubt if he believed we would find a remedy for him. Furthermore, I am convinced that his first hospitalization gave him a window to the garish landscape of mental illness, which both terrified and embittered him.
In his journal from that first hospitalization, he captures an encounter he had with an elderly female patient named Gene. The uniqueness of their exchange seemed to have haunted him for months to come.
Gene was at the hospital. The Psychiatric Institute of Washington. She was at the age where her age could no longer be determined. She could be 60, 70, 80…I really have no clue. She was old. She walked quickly, but with a slight limp and dressed in blue paper-fabric hospital pants, rolled up to the ankles, a large bright blue sweater, and white tennis shoes. She was a small woman, accentuated by the size of her sweater. Her hair was black and hung to her shoulders, wide eyes, small black whiskers above her upper lip and under her wrinkled chin. Her eyes, so wide, almost sad. I had noticed her before but hadn’t paid attention. But now she sat across from me in the lounge and talked to herself, mumbled words I couldn’t begin to understand, as was her custom. I was used to this and paid no particular attention to it, but then something strange happened. She started to cry. She wasn’t bawling, rather crying as she spoke. I sat uncomfortably for at least a half-minute. I felt so terrible because for the first time…I looked at her, a woman so beautiful, so precious in her own way or maybe in my eyes, I looked at her and she was crying. Until now she had remained another homeless, faceless elderly schizophrenic woman, who I occasionally smiled at and tried not to stare at obtrusively as she talked to unheard voices. But now, for the first time, I opened my eyes to give her a name and a face and she was crying. I didn’t know what to do. I wanted to sit, but I couldn’t just sit, could I? I wanted to leave, but I couldn’t just leave her to cry, leave with only her overpoweringly sad face in my mind. Could I close my eyes? I stood up and walked across the room. I pulled a small coffee table towards her chair and sat down, took her wrinkled hand, gave it a squeeze and told her in the most comforting voice I could find, not to cry, everything is going to be all right.
What happened next surprised me. She took my hand and held it to her cheek and continued to cry. I tried to console her as best I could, not knowing what to say. But then she stopped. She stopped and looked up, taking my hand in hers and shaking it. She smiled at me and nodded, holding onto my hand. I’ve never been so happy in my life.
Sitting in a neighborhood café on a winter’s night in 2004, I was finally able to pose the question that confounded me most in the three years since Will’s suicide attempt. I arranged to meet Dr. Salerian to talk about this book and a writing project he himself was engaged in about the effect of major depression on the decisions made by President Franklin D. Roosevelt shortly prior to his death.
Alen Salerian had become, over a dozen years, a reliable friend. Not socially, but professionally. I remained his patient after my initial diagnosis in 1991. I have since learned that not everyone is adept at the practice of psychiatry. Dr. Salerian exudes compassion for his patients. I trust his judgment, and over the years he has helped me interpret the pharmacological conundrum surrounding antidepressants.
But a particular question haunted me ever since our conversation upon Will’s release from PIW after his first hospitalization. “I think he engages in suicidal thinking, but I don’t think he will act on it.” I played Dr. Salerian’s statement over and over again in my mind and I wanted to ask him candidly if he thought he had erred in his judgment about Will—or, worse still, did he assume all along that I would know better than to let Will handle his own medication? Had he failed to instruct me to do so? Had I missed something? Had he? As uncomfortable as it was to raise the issue without appearing to cast blame or seek an excuse for my own failure, I needed to know what Salerian thought had happened.
“Alen, I finally got all of the records from Will’s file at PIW and I went through them with a fine-tooth comb. There’s one thing there that really bothers me; it’s awkward and I’m uncomfortable asking, but I need to know.”
He put down his coffee cup; I had his focused attention. “There’s a note in your handwriting on the initial admission assessment which says something like ‘preoccupation with suicidal thoughts including OD.’”
Dr. Salerian did not appear startled or uncomfortable. I sensed I was touching on a puzzle he had already thought through.
“What should we have done differently?” I continued. “What should I have done? Should I have known better than to let him take his own meds? Did you warn me? If he mentioned an overdose to you, then he certainly had the means available. God, I hope I’m not putting you on the spot here—”
“No, no, Gail,” he interrupted. “All these are the right questions. And, no, you’ve touched on some very critical ways in which I look at patients—especially teenage patients. No, it was my fault. Let me explain. First, there are two things going on, really. I usually assume, because you are trying to build trust, trust and responsibility with your patient, I have them assume responsibility for taking the meds. It’s an important part of what they need to do.
“Second, these newer drugs, the SSRIs, have a greater degree of safety—they’re much less lethal, so you don’t think about a patient being able to kill himself with an SSRI. But I realize now, it was a mistake. I don’t ever let a young person handle his own meds anymore. I give them to the parents to give out. Will surprised me. It was a wake-up call. I had to r
ethink the risks.”
Salerian sat back in his chair. I nodded and neither of us said anything for several seconds.
“So, how’s your Roosevelt project coming along?” I asked after a decent interval. I took a sip of coffee. I wanted to get the conversation back on a lighter track.
I was grateful for his candor and his honesty. Was Will’s depression so severe by early 2001 that he posed a suicide risk? Yes, indeed. Were we all, his family, his doctor, his therapist, doing everything in our power to see that he got better, that the risk dissipated over time? Yes, I believe we were. I, like Alen Salerian, never imagined Will would “act” on a suicidal impulse. He fooled us.
By definition, adolescents are perturbing. They do things to disturb us. They are illogical and erratic and engage in risky behaviors that should be left to professional acrobats and NASCAR racers.
Will had always had a girlfriend. Girls were drawn to him like ants to a glazed donut. So when he and Megan began dating in the fall of 2000, I didn’t think there was much going on that was out of the ordinary. The relationship passed for your garden-variety teen romance—at least on the surface.
But what I didn’t know was that Megan was a cutter.
Dubbed by high school counselors and therapists “The New Anorexia Nervosa,” self-mutilation by cutting has reached epidemic proportions. According to a number of sources, as many as ten percent of American teenage girls cut themselves. Why? Again, there is no one answer. You have to assume our current culture, where kids, overwhelmed with adult issues, growing up too fast, is the petri dish in which these aberrant behaviors flourish and mutate. The culture of violence, the media, disintegrating families, abuse, neglect, and so on. It is a litany all too familiar.
But cutting? I have to admit, wanting to die is something I understand, something, in my most dastardly depressions, I have found alluring. But I do not understand cutting.
“A cry for help,” is the way most clinicians characterize cutting. A symptom of an underlying psychological problem. And since physical pain is easier to tolerate than emotional pain, cutting becomes a way of coping, of flirting with a public declaration: “Look at me! I’m in pain!”
Cutting is the method of choice by which adolescent girls express self-loathing. And it’s contagious. Most girls begin cutting after seeing a friend do it or through popular culture, and they harbor the illusion that they can control their habit.
Few adolescent boys routinely cut themselves. Psychologists theorize that women internalize anger, men act out. Hence girls are more likely to cut themselves than engage in strenuously edgy behavior such as excessive drinking, driving too fast, or fighting. But cutting should not be dismissed as a gender-lite pathology. All cutting needs to be treated seriously. According to the Web site informedparent.com, studies show that thirty percent of girls who cut themselves eventually develop a psychiatric disorder—depression, bipolar disorder, or borderline personality disorder. And the longer the cutting goes untreated, like with any addiction, the harder it is to stop.
Megan and Will, Will and Megan—caught in a downdraft of teen depression. They supported, fed, and reinforced each other’s illness. And in certain respects, they were each other’s salvation in time of need.
Megan writes:
The cutting started with the beginning of high school. Cliques began to form against the backdrop of harsh fluorescent lights glaring off linoleum. Several other middle schools fed into my high school, creating a population of about three thousand. I had been popular in my middle school, part of the group of girls to be feared. In high school, however, I met the classic and tragic fate of slipping from favor. My old friends quickly began forming groups with the new kids and I was left behind.
One day I realized that I was unconsciously dragging a short, jagged fingernail across the vulnerable flesh of the underside of my forearm. The resulting pain was so raw and refreshing and a few hours later my work resulted in a neat line of bright red welts. Part of me hoped someone would see it—preferably one of my old friends. The appealing fantasy had them all rushing back to my side with worry and concern.
No one ever saw the marks, and eventually I made my way back up the social ranks. I found a boyfriend who was acceptable and everything looked great in pictures: I was pretty, well-liked, got good grades and felt powerful again.
But even though I was outwardly happy, the cutting had become a habit. It wasn’t too physically destructive yet, mostly scratches with thumbtacks and shards of metal. I didn’t really focus much on it; it had just become something that I did sometimes. The marks would usually fade within a few hours. On the surface, everything was fairly stable, so I felt no reason to acknowledge my underlying unhappiness. It just hung there, a dull, familiar sort of pain that had been with me as long as I could remember.
High school was certainly not the beginning of my depression. At eight or nine I distinctly remember throwing myself on the ground and banging my head against the hardwood floor when I got in trouble. I would scream things like “I hate myself,” or “I want to die.” Once I even took the corner of a marble soccer trophy and slammed it against my temple.
In middle school I would make detailed suicide plans in my journal, scratching out diagrams of jumping off the roof. Normally this was in response to punishments that I couldn’t talk my way out of. Losing control triggered the impulse and provided the reason for my self-destructive fantasies. Cutting gave me momentary release from my misery and a sense of control.
At the end of ninth grade I cheated on my boyfriend and when I came home from an idyllic time away at summer camp, I discovered that my ex-boyfriend had found out what happened and sought revenge. He called my house in the middle of the night with some friends, and when my parents angrily answered the phone the boys unloaded the details. Upon hearing such crude language in the middle of the night about their teenage daughter, my parents called the police. I had to talk to a police officer, have repeated conversations with my parents about appropriate sexual behavior for a tenth grader and accept a forced apology from the ex-boyfriend all in the week leading up to the start of my sophomore year of high school.
Now I had an excuse, I had permission to be unhappy, and this tore the floodgates open. I spent hours in a heap on the floor, my body wracked with spasms of sobs. The only thing to relieve the desolation was cutting, and I did it constantly.
At summer camp I had begun using pushpins, which excited me because it drew a thin string of ruby drops of blood behind a slight line of shining metal. My arms were covered in neat rows of red and brown scabs. They were perfection to me—my new pastime and saving grace.
School started and I was completely alone. A few of my closest friends still put in the time for short courtesy calls and rushed hallway hugs. The unrecognized depression that punctuated my late childhood was taking over though, and I spent all my free time dragging the pushpins across my arms and crying.
In public, however, it was not sadness, but cynicism that defined my personality. I was a constant tirade of biting remarks and eye rolls. No one was allowed to see the new truth of my existence and my arms were covered in public and eye make-up took care of the constant puffiness around my tired and tear-flooded eyes. All this cover-up managed to alienate the few friends I had left. People did not know what to do and grew more jaded and more bitter; most were so perplexed or weary of me that they gave up.
I made the field hockey team that fall and was required to wear short sleeves. I upgraded from a pushpin to a miniature Swiss army knife and confined the cuts to the thin section of my left arm covered by my watch. The knife was new and sharp and yielded far more satisfying results. Since I was cutting around the curve of my wrist and against the bone, it required much less effort. I barely had to push down and my blood would spill out of the opened skin in amounts that, at first, even I found shocking.
I would hold my arm up and watch the steady stream of drops cascade down the smoothness of myself, falling to my lap with a m
ixture of tears. When I was finished I would soak the blood up with a pair of white tube socks, monitoring the patterns created as the redness seeped into fibers of the cotton. I stowed the socks in the back of my closet behind old sweaters and would occasionally take them out and finger the crispness of the browned blood. Their metallic smell was calming. It was satisfying to know that many of the cuts were probably deep enough to warrant stitches, or at the very least, a butterfly bandage. The scars would be beautiful, I thought.
Everything made sense when I could localize the pain to my arms. I was quiet and calm when I did my routine afternoon cutting, feeling wonderfully dramatic and free, as the misery balled up in the pit of my stomach. Tears fell down my cheeks as I stared up at the spinning ceiling fan and then back at the redness. The deeper I went the more control I possessed. Shutting my eyes, the gleaming blade replaced the images of the day and my emotional pain with pure and ephemeral serenity.
I took myself seriously, but at the same time I never really believed I was hurting myself. I never thought that I had to cut myself. It was more like I was emulating the stick figures of teenage angst on television who locked themselves away and tore at their skin in this new self-destructive fad. Cutting was becoming the new breakout trend, edging up to the status of anorexia and bulimia. “You are completely full of shit,” I would tell myself. “You can stop this when something more interesting comes along. There is really nothing wrong with you.”
My parents began to notice the cuts. The wounds were not well hidden by the watch anymore because cutting everyday only allows you to go over the same wound a few times. They took me to my room and told me I would start seeing a therapist. I wouldn’t let them see my arms. I didn’t have the energy to deal with people who were scared of what I was doing. The thought of my mom crying or feeling sick to her stomach was just too much for me.
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