Healing the Wound to My Soul

Natalie’s Light:

Healing The Wound To My Soul


                         Hope is the thing with feathers that perches in the soul,

                         and sings the tune without words, and never stops at all. 

                                                   ---Emily Dickinson


Readers of this blog will recall our fundamental belief:  the soul is dwelling within each of us, as the place and spirit where we find purpose and meaning in our lives. And it follows, at the heart of Natalie’s Light, is the belief the soul has been gravely wounded when a person considers ending their life.  How do we heal this wound to the soul?


The process, which enables healing of the wounded soul, is embodied in the word Hope. Writing in their outstanding book, “Motivational Interviewing,” Miller and Rollnick describe hope “as the belief that change is possible….Finding hope is a matter of calling forth that which is already there.”


                        And nothing to look backward to with pride.

                        And nothing to look forward to with hope.

                                                   ---Robert Frost “The Death of the Hired Man” (1914)


For some reason I recalled these words of Robert Frost when I first encountered James while working in Boston. James refused to talk about his past and he said to me, “I have no hope there will be any change in the future.” He was homeless, only occasionally taking refuge in the Pine Street Inn for homeless men. A Social Worker had referred him to the West End House of Massachusetts General Hospital (MGH) where Addiction Services are located. He had scared the hell out of the staff at the Inn as he went through his most recent episode of withdrawal from alcohol. He admitted he simply did not have any money to buy some cheap wine to keep “the monkey off my back.”  They delivered him to MGH in the van the Inn used to gather homeless people off the streets of Boston in the winter.  He told me, that first day, “they did not trust me to come on my own.”


James was emaciated (looked like he was just liberated from a concentration camp), unkempt to say the least and foul smelling.  While he did not want to be there with me, or anyone else, he made good eye contact and was engagingly forthcoming about his current situation. He initially described himself as “just a good ole Irish boy.” Actually, he was 38 years old and was not from Ireland or Boston. He came from Nebraska in hopes of getting a gig playing bass guitar. He laughed as he denied being Catholic, but agreed his last name would be heard frequently on the streets of Dublin. He told me there was no hope he would ever stop drinking: “It is my soul juice.” Despite this, James agreed to see me again the next day. Perhaps he could tell I liked him.


                                  There is no such thing as false hope.

                                                                          ---Mary Piper



For brevity purposes I will skip my long and arduous efforts to learn how James’ soul was so deeply wounded.  It all started to come out about 3 months into our alliance when I joked with him about his last name: “Are you related to the famous guy with your last name?” Anyone reading this who is older than 50 years would instantly make the connection with the name.  I was truly surprised when he told me the famous man was his father.  However, It is fair to say his father had disowned him about 10 years before we met. James had dropped out of college after his sister committed suicide by overdose. James did not demonize his father, for he truly believed his father’s words to him, “You are hopeless and worthless.”  But James did describe the longtime pattern of verbal abuse he experienced throughout his childhood. James did continue to have sporadic contact with his mother, but his father told James he was ashamed of him and did not want to ever have contact with him. James was an “embarrassment” according to his father.


Ultimately, James told me he had a 9 year-old son from his then dissolved marriage and his ex-wife made the vow he would never see his son again. Paraphrasing the words of Dr. Stephen Rollnick, James had no hope and was filling the hole in his soul, with alcohol.  The official diagnosis in his clinic record was Alcohol Dependence and Major Depression.  I ventured in my notes to mention chronic PTSD. But it was useless to document he was suffering from a wounded soul; the MGH coders would have sent the chart back with the statement, “No such diagnosis.”



                        We have always held to the hope, the belief,

                        the conviction, that there is a better life,

                        a better world, beyond the horizon.

                                                   ---Franklin Delano Roosevelt


Evoking or summoning Hope from a wounded and damaged soul is a formidable task demanding some essential prerequisites. The first and most important requirement for awakening Hope is self-acceptance. Miller and Rollnick describe self-acceptance in the following way: “Ironically, it is when people experience acceptance of themselves as they are that change becomes possible. Causing people to feel bad and unacceptable usually entrenches the status quo.” It is wrong to expect them to be anyone or anything other than who they are. This does not require approval or concurrence of their actions, but demands an honest and committed acceptance of what they bring to this alliance, so healing may begin.


                              You are never too old to set another goal or to dream

                              a new dream.

                                                                                             ---C.S. Lewis


In the Spirit of Motivational Interviewing (MI) there are things you and I can do to evoke HOPE and healing. Not only must the person with the wounded soul accept who they are, we must be a model of acceptance for them. The noted psychologist, Carl Rodgers, described four aspects of acceptance for us to help others find hope: Absolute worth, Autonomy, Accurate Empathy and Affirmation.  I borrow liberally from Rodgers, Miller, and Rollnick in detailing these aspects.


Absolute Worth is the first step in healing the wounded soul. Miller and Rollnick describe this aspect of acceptance: “First, acceptance involves prizing the inherent worth and potential of every human being.” Rogers emphasized “an acceptance of this other individual person, a respect for the other as having worth in his or her own right.” It is essential we do not place or project our own expectations on them. We must respect and accept who they are and where they are; not where we are or where we expect and want them to be. Rogers dealt with the seeming paradox: “When people experience themselves as unacceptable they are immobilized. Their ability to change is diminished or blocked. When, on the other hand, people experience being accepted as they are, they are freed to change.” I would paraphrase this statement with the words: acceptance allows the soul to heal.


Autonomy means “honoring and respecting each person’s irrevocable right and capacity of self-direction.” I am very pleased to repeat the quote of Miller and Rollnick used to describe the importance of autonomy. It is from Viktor Frankl (Man’s Search for Meaning 2006):


                        We who lived in concentration camps remember the

                        men who walked through the huts comforting others,

                        giving away their last piece of bread.  They may have

                        been few in number, but they offer sufficient proof

                        that everything can be taken from a man but one thing:

                        the last of the human freedoms—  to choose one’s

                        attitude in any given set of circumstances, to choose

                        one’s own way.


The opposite of autonomy support “is the attempt to make people do things, to coerce and control,” according to Miller and Rollnick. “Directly acknowledging a person’s freedom of choice typically diminishes defensiveness and can facilitate change. This involves letting go of the idea and burden that you have to (or can) make people change. It is, in essence, relinquishing a power that you never had in the first place.”


Accurate Empathy is described by Miller and Rollnick as an active interest in and effort to understand the other’s internal  perspective,  to see the world through her or his eyes…An ability to understand another’s frame of reference and the conviction that it is worthwhile to do so.  Rogers described empathy as the ability “to sense the client’s inner world of private personal meanings, as if they were your own.”  The opposite of empathy is the imposition of one’s own perspective, perhaps with the assumption that the other’s views are irrelevant and misguided.


Affirmation is the final necessary element of Acceptance and the way to evoke hope and healing of the soul. Affirming overlaps the other elements of acceptance as it supports and encourages the efforts of the wounded person. Miller and Rollnick state, “To affirm is to recognize and acknowledge that which is good including the individuals inherent worth as a fellow human being.” The opposite of affirmation is searching for what is wrong, rather than searching for positive values, strengths and efforts. One of my ways to offer affirmation is to ask the wounded soul to HELP me. Most often they are astounded that I am asking for and need their help. They sit up taller as they understand I respect what they have to say. I need their help to understand how we can work together.  


For hope to flourish and begin to heal the wounded soul, there must be some measure of confidence in their ability to change and appreciate the real possibility it can happen. In the language of Motivational Interviewing (MI), it is harmful for a person to believe and imagine a future when it is not possible or beyond their reach. For example James could not ever have confidence his father and ex-wife would find value in him and seek reconciliation. But we did focus on the real possibility he could have a fulfilling relationship with this son sometime in the future. He did find hope in his goal to return to his music career. These were important goals for him; realistic hopes and a strong incentive for him to remain sober and healthy.


                        It is astonishing how elements that seem insoluble become

                        soluble when someone listens, how confusions that seem

                        irremediable turn into relatively clear flowing streams when

                        one is heard. I have deeply appreciated the times that I have

                        experienced this sensitive, empathic, concentrated listening.

                                                                                                 ---Carl R. Rogers


In summary, accepting the premise that an individual who is contemplating ending their life has an injury to the soul; and thus, healing that wound involves instilling a sense of hope. Indeed, we have a way to use our skills and compassion to help heal the wounded soul.  This endeavor is not rocket science and does not require a PhD.  It requires committed acceptance of the individual as manifested by our building a sense of worth, autonomy, empathy and affirmation.  Edward Tick, PhD, in his book “War and the Soul” describes the importance of our doing “Soul Work.”



                        The soul  is the great cry of I AM awakened in the

                        individual. It is the seat of joy, the great affirmation,

                        the inner breath that shouts  “Yes” to life, no matter

                        what.  From the soul comes the baby’s first cry of

                        life, the athlete’s victory shout, the singer’s house-

                        shaking performance, the scientist’s “eureka!”

                        Every great spiritual teacher and religious leader

                       has taught first not from doctrine but from this

                       primal affirmation of existence.


James tried to fill his wounded soul with hope. He tried to maintain contact with his son. He sent cards and letters. He called many times. His son’s mother was able to get a no contact court order.  He tried to get his bass guitar from his home but his mother told him his father had thrown it into the garbage. For two years I saw him weekly and he stayed sober, and was able to get temp work episodically. But he began to miss appointments as I was preparing to leave Boston. There was an open door policy for James. He could come in any time and he would be seen. He was a “Free Care” patient and there was never a charge.  He did not show in the last month of my time at the West End House.


I maintained contact with the Staff in Boston and during the Winter, January 1981 James was found by the Pine Street Inn van as it searched for the homeless on the streets of Boston during a snow storm. He died on the way to the Emergency Department of MGH.  We believed in the worth of this man, but he did not value himself and he died without hope due to fatal wounds to his soul. 


Natalie’s Light:  Imagination



                                       Whoever you are, no matter how lonely,

                                        the world offers itself to your imagination,

                                        calls to you like the wild geese, harsh and exciting---

                                        over and over announcing your place

                                        in the family of things.

                                                            Mary Oliver  “Wild Geese”



Early on in my life as a psychiatrist I was part of a Fellowship in Boston devoted to Addiction Psychiatry. While I struggled to weave a comfortable perspective on the nature of substance dependence, one of my patients told me she could not imagine life without alcohol. She was literally, and deadly, serious.


Her words were a shadow following me as I began to build a new conceptual Model: All substance dependence is a disease of the imagination.


My patients could not imagine life without their substance. This was because, somewhere along the line, they lost the ability to form a mental image of something not immediately present and rewarding. They could not conceive of a different reality. They did not expect or believe in a different life or future.                                    


This loss of imagination is not just the result of a substance causing neurochemical alterations in the brain: waiting for the next jolt of dopamine to the nucleus accumbens.  For my patients it was the way they viewed the meaning and purpose of their life; they could not perceive and believe in beauty, kindness, honesty, or even love for anything other than their substance. Often they could not imagine the fundamentals of life; like what life would be like without food or water.  Many told me, even after detox, they could not see beyond the next drink or dose. A few were able to understand their loss of imagination; and knew this loss started well before they began using a substance. Early physical, sexual or emotional abuse, as well as other forms of trauma and loss, numbed them to the possibilities in life. They learned a substance was a way to deal with the trauma and later the painful abyss of a blank imagination.


In the Fellowship I learned the neurophysiology and pathology of addiction and became an expert in the medical management of substance abuse and learned all the accepted techniques of psychotherapy to reduce the risk of relapse. However, building or resurrecting a new imagination was a different and far more difficult challenge. Helping people learn how to feel again was not an intellectual process. It was an emotional excavation: digging for the gold of imagination.


However, no great surprise, my conception was too narrow and naïve. Loss of imagination is also a fundamental feature in many other mental health disorders. This loss is like a vacuum, a space devoid of matter. It is also hallmark of those who suffers from depression and all forms of anxiety. In my experience lack of imagination should be one of the essential criteria in the diagnosis of Major Depressive Disorder published in the DSM-5. Somewhat paradoxically, all anxiety disorders are fundamentally the imagination run amok: where there is psychic tension and apprehension over potential, often imagined, threat.  More important, and pertinent to the mission of Natalie’s Light, is the fact, or may be my personal belief, that suicidal ideation is fundamentally a loss of the ability to imagine different possibilities of a new or different life.


It is our own fault the word imagination is not part of any description in the DSM-5 and is not measured in any meaningful way in a Mental Status Examination or psychological testing. The ability to use imagination is one of the most, if not the most important, eloquent and sophisticated abilities of the human brain. It is a profoundly complex process for us to imagine and plan a future full of possibilities, but our children have wonderful imaginations; before we train them to suppress expansive and sometimes fanciful ideas.  Among all creatures, we humans are born with the wonderful capacity to imagine a future. I love our dogs Juliet and Elliott and I do not want to denigrate their understanding, but I must admit their ability to imagine the future is limited to when Mama is coming home and when the next meal or treat will arrive.


 Yet, imagination is often termed an enigma, an amorphous inexplicable skill that is generally not marketable for most of us. Or, more commonly, imagination is a fancy, or fantasy, lacking definite form or substance. Of interest, we admire the use of imagination in the creative arts, while at the same time the arts and music, which most appeal to the imagination, have largely been diminished or eliminated from our schools.  We teach the fundamentals of reading, writing, and arithmetic, but we do not teach and practice the fundamentals of Imagination. There is no doubt the average 10 year old, can and frequently does, embarrass an old fogey like me with their computer skills. Yet, by the age of ten most children I have seen are perplexed when I ask them to tell me a story about themselves in a painting of a South African landscape I have on my wall.  They can certainly do it with some encouragement and a little practice. Are we breeding, in the sense of training or educating, the imagination out of our young people? Why imagine, when you can have it produced for you on the Internet.


Before I let my imagination arise and fly on how Natalie’s Light can promote the resurrection of the imagination and prevent suicide, it is of value to look at some psychobabble fundamentals. Actually, it is just a brief review of the fundamentals of Cognitive Behavioral Therapy, which I dare to describe as a euphemism for Imagination Training. I will borrow from the on-line Newsletter and book “Barking Up the Wrong Tree” to explain. We have to go back a couple of thousand years to the philosopher Epictetus to learn “It isn’t events themselves that disturb people, but only their judgments about them.” This is the core of Cognitive Behavioral Therapy (CBT).


More recently, 2011, a guy named Beck, a psychologist of considerable note, described CBT as “based on the principle that thoughts influence feelings, feelings influence actions, and actions influence our results, or life circumstances. In other words, situations don’t make us feel certain ways. People don’t make us feel certain ways. It’s how we interpret (or think about) situations or things people say or do that influence how we feel.”  In full disclosure, I totally agree with this statement. But for our purposes in Natalie’s Light, I must add the caveat, it is not just the thought that paralyzes and punishes, it is the inability to imagine a different thought, different scenario, or different result. For example, when someone calls me an “ugly, old, stupid f…” I can own that thought and the inevitable feelings that follow. However, I can imagine a very different scenario: I may be old, but history indicates I am not stupid and my wife and children love me. I can and do imagine my life with my family and the vacation we will take in the Spring. Unfortunately it is not that easy if you are depressed, anxious, abused or abandoned. 


Marcus Aurelius, a really old philosopher said: “Today I escaped from the rush of circumstances, or better put, I threw them out, for the crush wasn’t from outside me but in my own assumptions.”  I have taken ownership of a somewhat similar aphorism that says, “Stress is inevitable; the struggle is optional.” Unfortunately we all struggle, some more than others, particularly when we can not imagine a different story.


Of course, it is easy to say:  Just ignore or get rid of negative irrational thoughts, and just think in terms of sweetness and light. It takes practice and more practice; after gentle education, training, support and validation. It also takes some reality testing: after all, life is full of stress, it’s inevitable. But we can do something about it, and it will change lives.


I follow a veteran who has survived life threatening trauma and has Chronic Post Traumatic Stress Disorder. He is very intelligent and I admire him a great deal. He is also a prisoner to the chaos of his own thoughts. The feelings that result from distraught and sometimes irrational thoughts are explosive and he always regrets his outbursts later. Yet, because of his illness it is very difficult for him to imagine a life not filled to the brim with threats and overwhelming stress. But I know we can help him and he will be able to imagine a different life. He has already made the hardest steps: he is willing to examine his thoughts however painful it is sometimes. Now we can begin working on his imagination.  There is a formula for this. It is easy to write out a plan, but very difficult to accomplish because he did not learn the power of his imagination early on in life. But it is not too late. Our brain is very flexible, adaptable and the power of the imagination is limitless.


Actually, Natalie’s Light is the product of the imagination. At its most expansive we imagine a community where suicide is not a major public health epidemic and totally preventable. At a more practical application we imagine ways we can make every person aware of the threat of suicide and knowledgeable in the very real steps each of us can take to make our imaginations reality. In short, we must use our imaginations to recognize distorted thoughts about life in each of us. We must open our imaginations and challenge what we believe. It takes courage and perseverance to question our personal beliefs. And it takes imagination to entertain an alternate reality and a new life. I believe in the power of metaphors, in establishing routines and rituals: daily reminders of our values. Seneca wrote thousands of years ago: I will keep constant watch over myself and—most usefully—will put each day up for review…Let us balance life’s books each day.”


Each of us should always have a little card or ledger where we fertilize our imaginations and harvest them when we are distressed by some external thing. For years I carried a small card that said, “These are the things and people that will give me S… today.” Everything else is optional. Marcus Aurelius also said, “When you are distressed by an external thing, it is not the thing itself that troubles you, but only your judgment of it. And you can wipe this out at a moment’s notice.” At Natalie’s Light, at that moment, we want to help you imagine an alternative life, full of possibilities.    


                                       You do not have to be good.

                                       You do not have to walk on your knees

                                       for a hundred miles through the desert


                                       You only have to let the soft animal of your


                                       love what it loves.

                                       Tell me about despair, yours, and I will

                                       Tell you mine.

                                                                                    Mary Oliver



Honor Thy Self: Defeating SHAME

Not withstanding the importance of the book by Jay Asher and television series entitled “Thirteen Reasons Why,” the most common question I am asked as a psychiatrist is why a beautiful, intelligent, multi-talented, deeply loved and supported young woman, such as Natalie, committed suicide. Sadly, there are no simple - undeniable - answers or explanations. At this time, no contemplation or dramatization of the infinite number of possible reasons why, will alleviate our profound sense of anguish and loss. Still, we compel ourselves to examine emotional factors, which are inextricably and universally tied to the act of suicide.


 For the purpose of our mission to prevent suicide it is essential we explore how Natalie, or any person, feels about her or his self as they consider ending their life.  It is fair to say, if they have a vision of who or what they are, it is a picture of disdain, scorn and contempt for their self; for whomever they perceive themselves to be at that moment. This state of emotion is not guilt:  It is not a matter of feeling sorry for something they have done, or not done.  It is not having done something bad. And it is not the stigma placed on them by someone else.  Rather, it is a sense and cognition: “I am bad, unworthy, inadequate, and contemptible.”  The overarching emotion to defining this state of mind is the word SHAME.  The origin of this word describes being covered over with something that cannot be washed away. When chronic and unrelieved, shame becomes toxic, debilitating, ultimately poisoning the soul. Ultimately shame evokes destructive and fatal thoughts and actions.  Our job is to fight and defeat this sense of shame.


To understand this battle, let me describe the true story of a young woman I was honored to see while serving at a hospital in Massachusetts nearly 20 years ago. We will call her Carolyn.


She described our first encounter as being “under duress.”  Carolyn was pressured by a number of her friends, all young women, including a physician at my hospital who referred her. They “threatened me,” in Carolyn’s words, if she did not keep the appointment. They brought her to the clinic, after hours, and waited with her until she entered my office. It is safe to say Carolyn considered me somewhat akin to a snake handler and a member of an evil conspiracy with her friends.  Still, she began to talk when I simply asked her: “Tell me your story, from the beginning.”

While Carolyn did her best to be defensive and adversarial, she was not good at being irritable and angry.  Before she started she apologized for being rude. Then, her first statement was a revelation: “What can I tell you so you do not think I am some kind of crazy lunatic?” It was crucial, to Carolyn, for me to think well of her.  I have since been reminded of a statement from the book “Transit” by British writer Rachel Cusk: “It was as if she was trying to intercept my vision of her before I could read anything into what I saw.” No doubt my reflection, back to her, was much more important to her than her own thoughts. When I asked why her friends were determined she see a psychiatrist, she responded: “I guess it is because I have screwed up every relationship in my life.”


Carolyn is the only child of a marriage between two very obsessive, highly educated and insecure people. Her father left the family when she was 7 years old and Carolyn never had a relationship with him. “In fact, I don’t even know where he lives.” Her mother was a lawyer and it was Carolyn’s ongoing impression her mother felt the father left mostly because of Carolyn. Though Carolyn admits her mother never said those exact words, she was convinced her father abandoned her, and not her mother.  Carolyn was 30 years old at the time I first saw her, 23 years after her father disappeared from her life. She was sure she could never meet the expectations of her non-existent parent and her victimized mother.  Still, she was desperate for her mother’s approval, but afraid of this person she wanted to please.  


Carolyn was the Valedictorian of her high school class and graduated from Harvard at the age of 20.  She was a star in her Harvard MBA class and accepted one of many offers in the financial world, accepting a job with a financial institution in Boston.  She dated only sporadically from high school through graduate school and never had a sustained relationship.  She told me she was always “too busy” to get involved.


At age 23 she was on a fast-track in her career and was described to me by the friend who referred her: “brilliant, pretty, personable, energetic, conscientious and a fun and loyal friend.”  Soon after entering the business of high finance Carolyn was on the scope of most single - and some married - men in her company; and throughout the financial district in Boston.  She was overwhelmed and embarrassed with the attention and compliments; like statements she was “wonderful.” At the end of her first year on the job she found the “love of her life” in a handsome young stockbroker.  They were soon married in a destination wedding in Bermuda; her mother did not attend. Carolyn did not invite her.  She did not want to risk her mother’s disapproval.  


Not long after they returned to Boston from their honeymoon the “love of her life” slapped the hell out of her. She had been 20 minutes late getting home on an evening when they were scheduled to have a dinner with his boss.  Later he told her she had embarrassed him in front of his boss and emphasized his displeasure with several slaps to her face.  Carolyn minimized this, to me, with the statement: “He did not hit me with his fist and there were no marks.”  The next day he asked for forgiveness, but this was the beginning of a pattern: he could not control his anger and even minor irritations rapidly escalated to slaps, violent pushes, bruises.  Carolyn did not exactly accept responsibility for his violent outbursts, but even 5 years later, in conversations with me, she felt she was inadequate because she could not help him stop his “aggression.”


While Carolyn’s friends did not witness him hitting her, they did witness his repeated explosive anger. Carolyn did a good job of covering up any bruises, but also had to avoid her friends some days.  The one and only time she suggested counseling or therapy to her husband, for his anger, she suffered a particularly vicious beating.  Never the less, she was convinced she could figure this out and make the marriage work.  However, her husband had other plans. He beat up and seriously injured a co-worker in a financial district bar. He lost his job and spent a year in jail. At his trial Carolyn refused to testify about his domestic violence. And for her support and loyalty she was rewarded with his accusations about her deficiencies. He filed for divorce.  Carolyn refused her friends’ help in finding a therapist for her self.  In her words, “I was ashamed.”


Now approaching age 26 Carolyn was young, bright, pretty, personable, energetic, conscientious, and a fun and loyal friend.  She was promoted at her job; making a good living in an exciting city.  She never revealed to anyone she sometimes had suicidal thoughts when she was alone. She only felt good when she was with her friends. For nearly a year she steadfastly declined constant pressures to go out with men.  Finally she accepted coffee with a lawyer who contracted with her firm. After several months she finally accepted an invitation for a dinner out with him. This time she was convinced she was safe. At least that is what she told her friends, who saw some ominous signs Carolyn did not recognize.  Nearly 28 at the time, Carolyn married for a second time, a destination wedding in New England. He mother and her friends did not attend. Carolyn did not invite them.  But a few of his friends were there. Unfortunately, he got drunk each night and beat her up on the second night of the honeymoon.  He was never apologetic, to her or to anyone else. Three months into the marriage he got physical with the wrong person in a bar and he was shot in the head.  In the melee the shooter was not identified and never found.


Carolyn, of course, took all this very personally. In fact, when she first saw me she asked, “What is wrong with me?”  But at age 30, she was still young, bright, pretty, personable, energetic, conscientious, a fun and loyal friend, and a rising star at the firm.  She was even more determined to not make the same mistakes and the younger men at the office wondered if she was just frigid or maybe had turned into a lesbian, according to Carolyn.  Subsequently, when the president of the firm introduced her to his 32 year old son and suggested the two of them get dinner together, she felt pressured and accepted the invitation. Over the next year he pressured for more of her time and her resistance slowly weakened.  Her friends became alarmed and began the plot that finally resulted in Carolyn sitting in my office for an hour at least one late afternoon a week; for over a year. She also continued to date the son of her boss, barely resisting his pressure to get married. 


Carolyn was happy to talk about her friends, all women of course. In fact she was quite animated, humorous and insightful in discussing their relationships, and marriages.  While validating and supportive with her friends’ stresses, she was also very strong in expressing her observations and thoughts to her friends: their values, strengths and autonomy. Many times she would laugh with me, finishing a story about a friend’s relationship with the statement, “you don’t have to take crap from that slime ball,” or words to that effect.  It was difficult to apply the same sentiment to her own relationship.


Slowly, she adapted to my beginning each session with the request: “Tell me the details of the last week in your life.” The conversation always gravitated to her relationship. “Why do I feel there is something missing? What is wrong with me? Sometimes I feel like there is no use in all this.” Occasionally she had suicidal thoughts but never had a plan.  She could never identify a single thing he said or did that made her feel good about herself. He told her she was pretty and smart but never asked for her thoughts or opinions on anything. When I asked what her plans were for the weekend, she would always say, “What ever David says; he always makes the decisions.” Paradoxically she expressed “shame” for not standing up to him.


She was always hypersensitive to personal slights or lack of value experienced by her friends. But when I asked her about her boyfriend’s habit of keeping her waiting for extended times in a public setting, or ignoring her opinion on people, places, things—or anything—she was not able to identify why she did not set some limits.  While rapidly recognizing lack of respect towards her friends, she did not sense the lack of respect directed towards her self.  In fact, at times she would volunteer she did not earn or deserve more consideration. “My record in relationships suck.”  How she felt about her self was dependent upon the behavior of David.


Carolyn was exhaustively contemplative. She would analyze our conversations in great detail. Often returning to a comment or question made weeks or even months before.  Gradually she took control of the agenda of our sessions, expressing her thoughts and asking for my reaction.  She retuned again and again to my question: “Don’t you feel you are worth more than such treatment? Don’t you deserve to be treated better?”  For a long time she could not answer the question.


After about a year into this therapeutic endeavor Carolyn called me to ask about seeing her earlier in the week than our usual Thursday evening session. She wanted Monday but settled for Tuesday.  She declined to tell me what was going on but told me she was just fine. When she arrived I saw a very different person. She was actually pleased with her self.


On the previous Friday night she was supposed to meet David at 7:30 for dinner at a Sea Food Restaurant on Boylston. She made the reservation.  He had not arrived by 8:30 and she was forced to give up the table. But she waited in the restaurant vestibule, a glass of white wine in her hand; managing an embarrassed smile as diners came and went. She also fended off being hit on by young men trolling for some action. Finally at 9:30 David showed up. He had been drinking with some of his lawyer friends and was immediately angry with her for not having a table. 


I asked her what she did then. With the biggest smile on her face I had ever seen, Carolyn said she told David, “I don’t have to take any more crap from you; I deserve better than you.”  She threw the contents of her wine glass at him and walked out.  Then Carolyn cried for the first time in front of me, and said, “What took me so long. I have nothing to be ashamed of.”


What Carolyn finally learned was she had real value and was worth so much more and deserved to be treated with respect, honesty, kindness and generosity. She had been covered with her self-perceived shame and she could not see or feel her value.


When I left Boston a year later, Carolyn was no longer in therapy but kept me posted on her life.  She called her mother who came for visits in Boston and they were able to talk and discover each other for the first time.  On her last visit with me she said she wanted to share what had become her favorite song. It was by George Benson:  “You know, the one about learning to love yourself is greatest love of all.”  

From Stigma to Strength

From Stigma to Strength


She lives on the reflections of herself in the eyes of others.

She doesn’t dare to be herself.



A baby girl was born with a cleft palate. There was no cleft lip and no other craniofacial abnormalities. Her mother did not smoke, did not take medications known to affect the nervous system or cause such birth defects.  There was no family history of early fetal development abnormalities. Why the palate failed to fuse during the second to third month of fetal life is unknown.  Of course, the baby had feeding difficulties, but the parents lived near a city with a special children’s hospital with highly dedicated pediatric surgeons. They repaired the cleft palate at age 14 months. There was no need for any cosmetic surgery. Other than this problem the baby thrived, met all developmental milestones ahead of schedule. She was bright, energetic and beautiful. For this true story we will call her Sara.

The only mark or sign of Sara’s developmental problem was the quality of her speech. Despite a team of providers being aware of a potential speech impediment, providing intensive—essentially exhaustive—therapy, Sara had a hollow nasal quality to her speech. Sara’s speech was not difficult to understand at all. It was just different.  Sara did not appreciate that she was different until children told her there was something wrong with her.  Over time she acquired a series of nick-names: like echo or garble mouth; eventually she was constantly referred to as “Garble.”  Sara felt the pain of this stigma, but learned to not show the anguish she experienced. Her parents were devoted, but did not learn about the label and anguish Sara experienced until the 10th grade when Sara was not chosen for the debate team.   Sara had only a few friends; most of her activity was solitary. She was her school’s top cross-country runner. Taking some pride in being considered a “dweeb,” she did not date, but attended her senior prom with a boy who would now be considered a real nerd. She was designated the Valedictorian of her high school class, but she declined to give a graduation address. However, during the ceremony she was recognized as having the highest grades ever recorded at the school. When asked to stand a student called out, “Way to go garble.” The standing ovation she received did not soothe or cover her pain.

As expected, Sara persevered. She graduated from college with honors, attended medical school and trained as a pediatric surgeon. She is now on the faculty of the same medical school; She is known as a world expert on craniofacial surgery in infants. Sara recognized her mood disorder when she was in high school, but did not seek evaluation or treatment for her chronic depression until she became pregnant. She then sought help because she did not want her children to be like her.  She placed one condition on entering therapy:  No one, except her husband, was to know. She told me, in what I considered a completely normal manner of speech, “I have accepted and overcome the stigma of my speech problem, but I will not be able to handle being marked as a head case.”  Since early childhood she had the strength to overcome the stigma of a physical impairment. Then, as she entered therapy she was stigmatizing her self for having a mental illness. She was convinced, even within her own medical community, she would be shunned or avoided if it was learned she was depressed.

In the years since Sara’s childhood our culture has matured and come to accept and understand physical problems and defects are normal aspects of the human condition.  Today, HIV patients are hugged in public and even Leprosy is understood to be an infectious disease to be treated, and not a mark of evil.  But when it comes to mental illness we are still in the dark ages.  Mental health is still in the shadows and in most situations the open discussion of feelings and emotions is still considered a taboo. The mental health disciplines—psychiatry, psychology, counseling, and psychotherapy—are, in many cases confused with Exorcism or black magic. This stigma remains a major confounding factor for patients, families and the public in general.  For example the President of the United States, in conversation with Russian diplomats, referred to the former Director of the FBI as a “nut case.”

In my youth, just out of the Bronze Age, I may have heard the following children’s rhyme a thousand times: Sticks and stones may break my bones, but words will never hurt me. This rhyme, a rose colored but foul smelling aphorism,  is described by Wikepedia asan attempt to persuade“the child victim of name calling to ignore the taunt, to refrain from physical retaliation, and to remain calm and good-natured.” Unfortunately this cautionary advice is totally and ludicrously wrong. In fact, words do hurt, and can penetrate deeply into our identity; leaving, most often a festering boil of emotion, injuring the soul. Or, if there is some form of healing, there remains a scar, a mark, a label; often a symbol of disgrace or infamy. This is an ancient process: “And the Lord set a mark upon Cain”-Genesis, in other words, a stigma.  This branding constitutes the ongoing social stigma of mental illness and often leads to suicidal ideation. Without confronting and transforming the shame of stigma we will not impact the growing epidemic of suicide. Our goal is to turn the stigma into strength.

A word originating from the Latin, stigma, was a mark or brand, especially one that marked a slave; a stigma indicated a person as inferior and flawed:  a set of negative and often unfair beliefs that a society or group of people have about another person. In all its various manifestations, stigma is a form of discrimination. And, in regard to mental health impairments the stigma is particularly invidious and often deadly.  Stigma is a major part of the silent and secret epidemic of suicide.  Stigma is not genetic, congenital, infectious, or contagious; it is not the result of a weakness on the part of the victim. Stigma is a malicious and malignant form of cultural discrimination. From adults children learn to project malevolent malice on others as a means of avoiding fear of the unknown. Stigma is a way to wish adversity and even evil upon others based on the misguided belief that being different, particularly in regard to thoughts and feelings, indicates a damaged defective soul. Stigma is always negative, implying an insidious  contagious character flaw in another person. Multiple aspects of the branding or stigmatizing process must be understood so we can change stigma into strength.

First there is double jeopardy in the projection of a stigma upon an individual with a mental illness. For various reasons, quite often multiple explanations, the person has lost a sense of self-worth. Most often this is due to some form of trauma: physically or emotionally, and compounded by medical, social or psychological predisposition. Then, this struggling person is traumatized again, or re-traumatized, by being marked, labeled or stigmatized as being weird, crazy, a head case, unworthy, worthless, possessed or even demonic. Unfortunately, a person who is the object of these various designations is defenseless and begins to believe they are, indeed, worthless and hopeless. They lose their voice to express their anguish.

Second, within the process of stigmatizing, there is a strong element of a psychological phenomenon called “projective identification.”  This important mental interaction, often inappropriately relegated to the psychobabble trash bin, is a challenge for both the accuser or projector, and the individual who is the object or target of the accusation. The projector, if you will, is motivated by their own dysregulated emotions related to ignorance, fear, envy, shame, despair, guilt, abandonment or loneliness, resulting in resentment and retaliation upon the vulnerable.  Unfortunately, the target of the stigmatization, struggling with their own tenuous sense of value, purpose and meaning, mistakenly take on the projected identification and own it; adding the weight of the branding to the baggage they carry.  For an experienced psychotherapist the concept of projective identification can be a valuable therapeutic process. For our process, turning stigma into strength, recognizing the devious features of projective identification can turn confusion and bewilderment into clarity and determination.

Third, to turn stigma into strength, it is absolutely essential we understand stigma is a cultural—societal--and community rooted phenomenon. It is closely related to shared values and behavior of a society. Unfortunately this is a universal human emotional process that is gaining strength by the estrangements of our modern technologies and the poorly understood consequences of our wavering lines of communication.  In his book, “The Better Angels of Our Nature—Why Violence Has Declined,” Steven Pinker writes “By the late 20th century, the idea that parents can harm their children by abusing and neglecting them (which is true) grew into the idea that parents can mold their children’s intelligence, personalities, social skills, and mental disorders (which is not). Why not? Consider the fact that children of immigrants end up with the accent, values, and norms of their peers, not their parents. That tells us that children are socialized in their peer group rather than in their families: it takes a village to raise a child.”  Thus, the effort of Natalie’s Light to change stigma into strength is focused on promoting and changing cultural and societal perspectives within the community.

Dr. Pinker, a Harvard psychologist, makes a fascinating and cogent case for the decline of violence: “Today we may be living in the most peaceable era in our species’ existence.”  However, despite his distinguished psychological qualifications, in his 802 page book he does not mention the epidemic of suicide and the continued growth and power of cultural stigma which is a major factor in how our society views mental illness. Dr. Pinker does discuss, at great length, the influence of empathy in reduction of violence. “Empathy has surely been historically important in setting off epiphanies of concern for members of overlooked groups. But the epiphanies are not enough. For empathy to matter, it must goad changes in policies and norms that determine how people in those groups are treated. At these critical moments, a newfound sensitivity to the human costs of a practice may tip the decisions of elites and the conventional wisdom of the masses…the ultimate goal should be policies and norms that become second nature and render empathy unnecessary. Empathy, like love, is in fact not all you need.”   In fact we must vigorously attack the stigma of mental illness in all its manifestations: through awareness, education, legislation and through our moral and spiritual institutions.

The power of stigma is evident in all the demographic categories where mental illness and suicidal ideation occur. The process of stigma very often begins in childhood, but insinuates itself, often progressively, into the self-worth of all ages, races, economic classes, genders and religions.   Perhaps the most painful example of the malignant power of stigma is the experience of veterans of the Vietnam War.  As a veteran of that conflict the following data of that shameful era is particularly painful, but demonstrates the insidious power of stigma.

Over 2.5 million American military service personnel served in the Vietnam conflict. 1.5 million experienced in combat.  58,200 were killed in action; 300,000 were wounded which included 74,000 quadriplegics and those with multiple amputees. It was estimated in 2005 there were 1.5 million military personnel who sustained PTSD due to their experience in Vietnam. In 2005 it was estimated there were greater than 100,000 suicides in Vietnam veterans. There were at least 382 “in-country” suicides by active duty military in Vietnam. By 2014, Dr. Edward Tick, in his book, “Warrior’s Return- Restoring the Soul After War,” estimated three times as many veterans committed suicide as were killed during the conflict. 

Thus the rate of suicides is being replicated, if not exceeded, for veterans from conflicts since 9/11/2001.  Dr. Tick notes between 2005 and 2011, there have been 49,000 veteran suicides. By 2014 “more than 6,500 veterans kill themselves everyyear, which is a far higher tollthan the total number killed in the full length of the Iraq and Afghanistan wars combined…..Many veterans die in violent ways after violent service. Accidents (unconscious suicides) and criminal activity (death by cop) may have military or combat-generated components.  Iraq and Afghanistan veterans have a 75 percent higher rate of fatal motor vehicle accidents than nonveterans….Accidental deaths may mean that the terrible veteran suicide rate is even higher than we know.”

What is going on here? What is the stigma we place on our veterans?  Following Vietnam we shamed those who were already racked with guilt over the failure of their efforts and the loss of their brother warriors.  Thousands were accused of being fakers for exhibiting the burdens of PTSD. Tick describes this with the following words: “Veterans know that, having been to hell and back, they are different. We expect them to put war behind them and rejoin the ordinary flow of civilian life. But it is impossible for them to do so---and wrong for us to request it…When the survivor cannot leave war’s expectations, values, and losses behind, it becomes the eternal present.”

What profound burdens we place on our fellow strugglers by our insatiable and unreasonable expectations for perfection. And if they do not meet our mercurial and unpredictable cultural standards, we place a stain, brand, or stigma upon them, missing their real strengths; the values that should sustain us all through the inevitable stress of our lives.  It is our moral responsibility to lift the stigma and turn it into a strength. 


Listening / Connecting by Patrick Lillard


As a Junior in high school, some 60 years ago, I was privileged to have a class titled Introduction to Philosophy.  My most enduring memory of the class is the recurring discussions centered around the topic of “the existential dilemma.” That is, what is the meaning of life and where do we find our purpose in living? As a naïve, obsessive and concrete adolescent I argued, “So what?”


The wonderful teacher, Dr. John Kennedy, (no, not that John Kennedy) was an insightful and gentle man who remarked to me back in 1957, he was quite sure I would change my philosophical view on the existential dilemma in future years.  Thus, I began an ongoing life long journey in search of this question: what is the meaning of our existence? What is the answer?  Or is there no answer at all.”


 The question about the meaning of life is universal and eternal, but the answer is ultimately individual, very personal and immediate.  We may choose to say, “so what,” but the inexorable pressure and inevitable stress of life, forces us all, sometime in our journey to ask, “What is this all about?...Where do we find meaning in our lives?”  Natalie’s Light suggests an answer.


For Natalie’s Light the answer to the existential dilemma is engagement, connections, relationships.  Purpose and meaning are found by making positive connections with other beings who have a soul.  You may recall our definition of the soul: the place within us where we find meaning and purpose.  This is found almost exclusively through our relationships with others—all relationships, including family, friends, classmates, teammates. And yes, romantic relationships, as well as our connections with our dogs, cats, horses, or what have you. And, of course many find meaning and purpose in their religion; their private relationship with God, however and wherever, they may find their own personal spiritual being.  Nothing comes close to providing authentic meaning and purpose other than our connections, our relationships.


While this is a simple concept, unfortunately  making connections and sustaining relationships is often very difficult; some would say messy or not worth the effort. Relationships often make us vulnerable.  Connections can be high risk.  But the reward in sincere relationships is sublime, and transforming.  Perhaps Natalie’s Light can help in this process.  It may help you save a life.


Before discussing the booby traps we all fall into when trying to connect with others, please read this poem or prayer written by William R. Miller, the author, along with Stephen Rollnick of a powerful book called Motivational Interviewing.  Miller explains this prayer was inspired by Native Americans of the Southwest, and the personal pronoun can be easily changed from her to his. Please read this slowly and carefully: it may bring meaning and purpose to your life.


Guide me to be a patient companion,

to listen with a heart as open as the sky.

Grant me vision to see through her eyes

And eager ears to hear her story.

Create a safe and open mesa on which we may walk together.

Make me a clear pool in which she may reflect.

Guide me to find in her your beauty and wisdom,

knowing your desire for her to be in harmony:

healthy, loving and strong.

Let me honor and respect her choosing of her own path,

and bless her to walk it freely.

May I know once again that although she and I are different,

yet there is a peaceful place where we are one.


The first step in establishing long lasting and meaningful relationships is the process of engagement.  Miller and Rollnick define this as the process of establishing a mutually trusting and respectful helping relationship. This sounds simple and easy. Unfortunately relationships represent the most complex and difficult cognitive and spiritual transfers of psychic energy in our universe; while also being the most meaningful and purposeful transactions of our lives. Engaging in this process is high risk, but the rewards are transforming.  Natalie’s Light feels this is a very spiritual activity, but there are some concrete and practical guidelines.


Natalie’s Light believes suicide is preventable. It can be prevented by awareness, education and training, and by direct intervention.  AND, at the most elementary level the most powerful preventive force is making connections:  establishing positive supportive relationships. We all are capable of doing this, if we have the right spirit and motivation. However, it requires what we call a center of gravity. That is, a sense of moral responsibility to have an open mind, a level of self-knowledge that accepts we do not have all the answers, and a continuing engagement with a process that asks, “How should we live our lives?” To borrow again from Miller and Rollnick, the spirit of Natalie’s Light is partnership, acceptance, compassion and evocation: “You have what you need and together we will find it.”


The first and indispensable step in engagement, connecting and finally in a sustained relationship is sincere listening and actually hearing what another person is saying. That other, the person we are trying to connect with, knows their feelings, their emotional state, even when they are not able to express it to others.  They are the expert on how they feel and the listener does not know and should not judge how they feel.  But the listener can help with the expression of emotions and feelings, by the very manner of listening. Listening is the key to understanding another person’s dilemma.  Jiddu Krishnamurti describes the art and skill of listening with the following words:


“So, when you are listening to somebody,

completely and attentively,

then you are listening not only to the words,

but also to the feeling of what is being conveyed

to the whole of it, not part of it.”


Good listening is not a passive process; you have to work at it. Miller and Rollnick describe this as “reflective listening.” And another expert, Thomas Gordon, writing in 1970, Parent Effectiveness Training, calls this skill “Active Listening.” Gordon recommends we first learn what good listening is not. Here is a list of 12 kinds of responses that we commonly give to each other, that are not good listening. It may surprise you.


1.     Ordering, directing or commanding

2.     Warning, cautioning, or threatening

3.     Giving advice, making suggestions or providing solutions

4.     Persuading with logic, arguing or lecturing

5.     Telling people what they should do; moralizing

6.     Disagreeing, judging, criticizing or blaming

7.     Agreeing, approving, or praising

8.     Shaming, ridiculing, or labeling

9.     Interpreting or analyzing

10.    Reassuring, sympathizing, or consoling

11.     Questioning or probing

12.    Withdrawing, distracting, humoring, or changing the subject.


Remember we are trying to engage and connect with others.  The best way to do this is to listen and not tell them what to do or how to feel.  If a friend or acquaintance tells you they are in pain or distress, it is not listening to say to them: “You look fine to me,” or “ I don’t see what the problem is.”  It may be appropriate to say nothing at all, and just be there with them. Also, a simple “tell me about it” will connect.  They may not have the words, but they are not the person putting up roadblocks to connecting.  In fact, if you are being the expert, the fixer, the analyzer, you are the roadblock to engagement and connecting.


Miller and Rollnick emphasize the value and power of“Nonverbal Listening.” Undivided attention is essential to active / reflective listening. Making eye contact is also important but keep in mind sustained eye contact can be intimidating to people who are in distress and anxious. 


Reflective listening provides even more power to the process of engagement. “Reflective listening focuses on the person’s own narrative rather than asserting your own understanding of it.” This can be simply done by just repeating the statement of the person, while only inserting the pronoun you. For instance, the person admits “I have no friends and often feel lonely.” An appropriate reflective statement is to merely state, “You are feeling lonely.”  This is validating the feeling and represents true empathy.


If the engagement and connection is not happening, it is often possible to breech the blockade with the magic word: HELP.  That is, using the following phrases. First, “How can I help?” Or, “Can you help me?”  Understanding, that they may not have the words and after listening carefully, you may be able to reflect back to them what they may be struggling to express.


“What people really need is a good listening to.”

----Mary Lou Casey

A Culture of Caring

Natalie’s Light:  A Culture of Caring


In a stunning essay published in the January 11, 2017 edition of the New England Journal of Medicine,  Rana L. A. Awdish, M.D.  described her own agonizing near death story. This is a personal “Perspective” article titled “A View from the Edge—Creating a Culture of Caring.”  While describing her own multisystem organ failure, stroke, hemodynamic collapse and loss of the baby of her 7 month pregnancy, her astonishing primary message was the change now occurring in her home medical center; the transformation to a Culture of Caring.  She writes,  “My experience changed me. It changed my vision of what I wanted our organization to be, to embody. I wanted the value of empathetic, coordinated care to spread through our system. I shared my story openly. I wanted the system leaders and every employee to know that everything matters, always. Every person, every time.” 


In its own way this model of change is the core mission of Natalie’s Light, though our task may well be more challenging. It is more difficult because we seek to not just alter the culture of a medical center, but to spiritually change the culture of our entire community. It is not just a system or organizational transformation, it is a change of how each individual cares and treats others.  To paraphrase Dr. Awdish, we must learn to recognize different forms of suffering and to find ways to diminish pain and anguish, and avoid inflicting or exacerbating suffering. To do this we must come together as a community and create a Culture of Caring.  She concluded her essay with the following statement: “ In the wake of painful experience, we all seek meaning. It is the human thing to do…The stories we tell do more than restore our faith in ourselves. They have the power to transform.”


Our transformation to a Culture of Change will require redefining or reframing the very idea of suicide; in fact all manner of selfharm. It is not an individual problem; it is OUR problem. The solution involves a change in how we all recognize our connection to others. To paraphrase the poet John Donne (1631), any person’s death diminishes me, because I am involved in all Mankind.  


Suicide is a unique challenge because it is such a paradox.  It is born in the indescribable pain of an anguished soul, causing unspeakable pain in those who survive such an event. And yet, we hide from this horrible event and fail to recognize how it is slowly wringing the life out of our community. It is becoming more common, and we have become inured or numb to its creeping presence within our community and country.  For many reasons, the number of people committing suicide has increased dramatically in the last decade.  It is shocking to read some of the statistics, but we must face the facts.   


A report in the October 2016 Journal of the American Medical Association (JAMA) indicated for all age groups suicide is the 10th leading cause of death in our country with the overall rate of suicide increasing by 28.2% since 1999.  The number of suicide deaths shot past the number of deaths by traffic accidents in 2009; the 42,773 suicides reported in 2014 are more than double the number of homicides at 16,324.  Of interest, compare this with decreasing death rates over the same period for cardiovascular diseases, cancers and human immunodeficiency virus (HIV/AIDS). The JAMA article was titled, “Are There Still Too Few Suicides to Generate Public Outrage?”  I speculate, if there were 43,000 deaths per year from an infectious disease, would it not be considered a plague, a public health disaster, and Congress would declare a national emergency?  However, suicide is just a shadow on the wall we choose to ignore.  Our prevailing culture is obviously not ready to talk about such unpleasant facts.  


Or, we can talk about suicide among younger age groups, where suicide is the second leading cause of death.  For instance, in 2014 the highest percent increase in suicides was 200% in females age 10 to 14.  In 2014, in the United Sates there were 425 suicides in the age group 10 to 14; 5,079 suicides for the ages 15-24, and 6,589 suicides for the ages 25 to 34. In these age categories, suicide was the second leading cause of death.  For age group 35 to 44 there were 6,706 suicides, and for 45 to 55 the suicides numbered 8,767.  These later two groups were the fourth leading cause of death for the age groups.  As we get older more people die of “natural causes” and thus the suicide percentage drops, though the overall rate of suicides continues to climb for all ages. 


We can parse the numbers even more, with ever more discouraging, mind numbing conclusions. In another JAMA article in May of 2016 Christensen et al. concluded the following: “Preventing suicide is not easy…our current approach to the epidemiologic risk factors has failed because prediction studies have no clinical utility—even the highest odds ratio is not informative at the individual level. Decades of research on predicting suicides failed to identify any new predictors, despite the large numbers of studies. A previous suicide attempt is our best marker of a future attempt, but 60% of suicides are by persons who had made no previous attempts.”


Christine Holland, a behavioral scientist at the Center for Disease Control summed up the state of the medical concern with the following words: “We do not have enough resources directed at suicide prevention, especially compared to funding behind other leading causes of death…If this was a finding of some other problem that results in death, it would be on the front page of every newspaper. People would be pressuring the politicians to come up with solutions.”  In fact there is no public outcry, and seemingly no public concern.  Politicians currently are more concerned with enabling the means or cause of the highest rate of suicide in men: through the use of firearms. Millions, if not billions of dollars are spent extending our right to collect firearms while the rate of suicides continues to climb.


While I am a strong advocate for more research into the causes and prevention of suicide; for more mental health professionals who are trained in suicide detection and prevention; for more education in medical schools and all branches of medicine, I do not think the answer to the problem of suicide will be solved by the medical professionals or organizations or even government. This problem is not a failure of the professional providers. It is OUR failure, as a community, to create a Culture of Caring.  I accept, as a psychiatrist, this is my business to help those who are lost souls and I want to play an important role, as do all those providers I know in mental health. But it is clearly not enough.  At Natalie’s Light, we are asking for your help, whoever you are.  There is clear evidence that you can help.


In a “Viewpoint” article in November JAMA, Michael Hogan, PhD, sounded an optimistic note, “Better Suicide Screening and Prevention Are Possible.”  While acknowledging more research, education and training are desperately needed, he feels we can make progress now. He does site the need for screening, such as seeking out risk factors and having more intensive assessment tools. He notes the need for better safety planning with reduction of lethal means and restriction (i.e. of firearms) at a community level is a valuable measure; more direct treatment of suicidality with more available treatment facilities; and a public health systematic implementation of screening and prevention measures.  But there is more, much more. This is where Natalie’s Light will be a game changer in this community.


Dr. Hogan describes this additional measure as “Supportive Contacts.”  He admits “One of the most effective and widely studied interventions with suicidal patients is simply contacting them with messages of support and encouragement.”   However, he does not go nearly far enough with this idea. He limits the nature of “contacts” to those who have been identified in emergency department visits and following up with interventions. Unfortunately he ignores the vast numbers of people in distress who never get to the ER or a mental health provider, or reach any provider who is sensitive to the problem and is not too busy to ask the right questions. But I give him credit for being in the ballpark. 


The answer is much, much more powerful and all encompassing. And the answer is not grandiose or delusional; it is just so self-evident we take it for granted: the power of our caring.  The scope of connecting, caring relationships is everywhere and overwhelming, when we all begin the process of reaching out, making contacts throughout the entire community; in schools, churches, community support groups of all types; one on one and in groups of all sizes. The answer is in making a Culture of Caring. We can do that.


Finally, to bring this concept home, I ask everyone who reads this post to seek out and watch a movie called “Pay It Forward,” or at least log on Google and watch the trailer.  This drama is based on a novel of the same name by Catherine Ryan and stars Kevin Spacey, Haley Joel Osment and Helen Hunt.  The story is about a seventh-grade teacher challenging his students to do something to change the world.  One student imagines a different world where we care about others and do something for them, however small, to help. The only request is for the person who receives the gift to pay it forward to others.  If each person does something for three others, and each one of them does the same for three more, before long there is a chain reaction with thousands, perhaps millions of caring people: a culture of caring. The challenge of Natalie’s Light is to begin the chain reaction: For each of us to connect with others: with people who will then continue this journey of human caring. It will be transforming.  







The Secret Power of Empathy

Natalie’s Light:  The Secret Power of Empathy


                        “The healing power of even the most

                        microscopic exchange with someone

                        who knows in a flash precisely what

                        you’re talking about because she

                        experienced that thing too---

           cannot be overestimated.”


I borrowed this quote from a little book by Cheryl Strayed called “Tiny Beautiful Things: Advice on Love and Life from Dear Sugar (2012).” Ms. Strayed is describing the awesome power of the thing we call Empathy:  the compelling human value which tells us to share the secret private space of the feelings—the emotions-- of another person; to know their pain and anguish, love and joy, as if it is our own. To understand the cloistered halls of empathy with another is to understand the meaning and resolve of Natalie’s Light.


No, we are not talking about Sympathy, which is the weak cousin of empathy. Sympathy is an inclination, or disposition, perhaps a tendency to feel some despair or grief yourself when another person is suffering. Sympathy does not share the emotions of those in pain and does not condescend to know the inner anguish of others. The sympathizer feels bad for themself, and perhaps there is a glimmer of sadness there, a superficial understanding of the suffering; but it is more a process of feeling pity or a shame such a thing has happened to “them.” While empathy applies to all emotions, joy and love just like sadness and pain, sympathy is reserved just for the dark side, like: “It is such a pity, a shame, a loss, that she died.”


One rather cold and emotionless definition of empathy was published in JAMA in 1991 by Bellet and Mahoney, as the capacity to understand or feel what another person is experiencing from within the other being’s frame of reference, i.e., the capacity to place oneself in another’s position. Better said, empathy is seeing with the eyes of another, listening with the ears of another and feeling with the heart of another.” This still does not get to the core of what empathy means in human relationships, and even our connections with animals. Psychologists have tried to systematize and quantify empathy by designing an “Empathy Quotient.” This is a series of 60 questions we all can take and allegedly come up with our capacity for empathy. I came up with a grade of 48, and the on-line interpretation of that score is: I am not on the autistic spectrum. Thank God for such a penetrating insight into my psyche. Clearly this scale does not define the power of empathy in human connections. I think we learn about empathy by opening up our minds and hearts to others, giving and experiencing empathy in our lives. Empathy is, in this writer’s experience, the secret power to all sustaining,  fulfilling, and  intimate relationships.


Despite 51 years as a physician, including 20 years of graduate professional training, I learned more about empathy from my children than any textbook or Buddha figure. I must confess before fatherhood I was very pragmatic: the fixer, the solver so to speak; what ever came along, “I will handle it.” But I soon learned, with children, they don’t want or need the parent to fix everything; they want someone to feel their pain, anguish and joy with them. And surprisingly, I began to understand, because when they were in pain, I actually was in pain too; right in there with them. It became an absolute: I had to validate their feelings in a real way, or I was not ever going to connect emotionally with my own children. I learned that feelings are never bad; it is what we do and how we act on those feelings that gets us into trouble. Let me share a personal story about this. We discover the power of empathy in our very personal stories.  


When my mother died 16 years ago, I traveled from the East Coast to California, as the only remaining member of my family of origin. She had died alone after another heart attack and the only family member close by was my daughter, Elise. Elise and I have a special bond as I delivered her in an  Air Force Hospital in South East Asia, and 14 years later, at a Thanksgiving Day dinner, I diagnosed her with a particularly mean cerebral arteriovenous malformation, which subsequently required 32 hours of neurosurgery. She is the bravest person I have ever known. In any case, soon after I arrived in Santa Monica, Elise came with me to the funeral home to make the various arrangements. This process took only a short time, as measured by the clock but seemed like hours. We did have to wait for 20 minutes, sitting together on a small couch in the funeral director’s stuffy Victorian reception room. I had moments of bittersweet reflection; sadness mixed with relief; and frankly trying not to be too emotional. We did not talk at all, Elise and I, during the wait. What was there to say? But then, slowly Elise slipped her left hand into mine, locking fingers with me. We did not speak, but there is no doubt she could feel all the emotions roaring inside me, and that empathy allowed me to feel emotions I had buried over a life time. I am a very emotional man at this stage in life, thanks to the empathy of my children and wife. 


Psychologists say there are different types of empathy, including cognitive empathy, emotional empathy, and somatic empathy. It seems there is a need to push or package all aspects of human interaction into Diagnostic Criteria, and to state who has the capacity and who does not. However, they have not precisely located the specific group of cells in our brains where empathy is born. This attempt at minute dissection of empathy diminishes the secret power of our capacity to reach out and connect with each other. 


During my years as a Psychiatry Resident, I was assigned to a community mental health clinic as the psychiatrist who would provide medication management. I was the only male among this group of about 15 psychologists, social workers and counselors. In their wisdom, the leaders of the clinic decided my experience with them should include time doing individual and group therapy. Almost all the patients were young women and one of the first patients assigned to me for therapy and medication management was a tenuous and reticent  appearing young woman, a lesbian, and a chef. No doubt she was depressed and initially very uncomfortable with me, and I was working much harder than she was in trying to establish a therapeutic relationship. Perhaps some of this was due to her father being a physician, who was not comfortable with the person she had become. She was a highly intelligent, honest, kind, generous and hard working woman. That was not enough for her father.   


Some weeks into our relationship I prodded her to tell me about her childhood.  Reluctantly she told me about an experience that defined how she handled stress in her life. When she was about 8 years old, she was with her father in a Department Store in a large city where the floor was wet, and she slipped and fell. Later, she understood, she had a fracture dislocation of her right elbow. To this day, after all these years of dealing with the most severe trauma you can imagine, her injury still makes me cringe. She was laying on the floor of the store with this injury, and her father leaned over her, close to her face, and told her not to cry; he said he did not want to make a scene in public. Being true to the psychobabble process, I asked her how she felt about al this. Her reply was simple: “I don’t feel anything about it and I don’t want to talk about it.” I tried to connect in some way, but she left the session cool and emotionless.  When she returned the next week she initiated the conversation with the statement: “I have to talk to you about something.” She wanted to know why I was so upset when she told me about her injury. “I thought you were going to cry,” she said and  “I don’t understand what this is all about.” I told her I could not imagine the pain she experienced with her injury, but I could imagine the pain she experienced with her father’s words. I told her about my children and the actual pain I feel when they are suffering, physically or emotionally. She told me it was the first time anyone had ever told her how much they felt her pain. Time went on, she gradually felt better about herself, and I moved on in my career. Still, to this day, this experience was the most important in my professional life. It is unclear who was the therapist in this situation. But it clearly was a manifestation of the power of empathy.


Thus, the first goal of Natalie’s Light, is very clear, and in its way quite pragmatic. We must find a way to be empathic with all those who suffer. It does not matter where they are or what the circumstances, first we go where they are, in body, mind and spirit. We do not start with where we want them to be. In my various readings I ran across a quotation in a book called “The Taming of the Queen” by Phillipa Gregory.  It is historical fiction about the life of Kathryn Parr who became the wife of King Henry VIII, after he had buried four wives. In her struggle in dealing with the pathologies of the King, she wished for the most precious thing:


                        “The most precious thing is a place where you can

                        be as you are, where someone can see you as your

                        true self.”


And that is our first goal. To be that someone who can see you as your true self.


A significant part of the motivation for the writing of this post to the Natalie’s Light blog is a statement that Leslie, Natalie’s mother, has said to me a number of times: Natalie was an empath. Meaning she had a natural capacity to reach out and feel the mental and emotional state of another individual. Indeed, I believe there are those among us who have the capacity to actually feel the pain and anguish of others and their goal is to be there for others; be with them, wherever they are, in their suffering. As with the LAMED VOV, this is a gift, truly a gift from God, if you will. And sometimes the burden of this gift may become too much to carry. At Natalie’s Light we wish to help carry and share such a burden.



Patrick Lillard





NATALIE'S LIGHT: Imagination and Rediscovering the Soul

Imagine what it would be like to lose all awareness of who and what you are. What would it be like to lose the ability to conceive of your  self as an autonomous, self-reliant, self- directed, self-governing organism? What is it like to be entirely disconnected from your conscious self, as a human being?  You struggle but ultimately you fail to connect with your self;  and finally you are unable to feel or define your self as man, woman, or child.  You are bombarded and controlled, even paralyzed, by a hurricane of thoughts and emotions outside of your self.  Or, you are disconnected from those elements—love and compassion—previously holding you together like a gravitational field; and thus you are slipping away, from the earth, feeling abandoned but unable to identify those unknown forces of separation. Your soul has been so damaged or lost you have forfeited your reason for living.

The soul is at once the ephemeral enigma we seek to capture and define-- like gravity, or moonbeams, or love. Ultimately, out of fear or frustration we give up our search for a concrete, objective, mortal entity we may call the soul. And yet, at the same time we recognize the soul as the most powerful, inevitable and irresistible ingredient in our identity as human beings.  To lose your soul, is to lose your sense of self and you no longer know who you are.

A caveat to this conundrum of the soul is the fact all creatures, and perhaps even plants, have a soul. Fortunately, the others—those creatures we love-- they do not have these troublesome frontal lobes, which make us fret, stress and struggle over our true self. We have a puppy, a three year old apricot miniature poodle, who prances about her territory, barks at all manner of noises, but then runs to jump in our laps, to snuggle, knowing her real connection and identity, as a dog.  Juliet may sometimes think that she is human but blissfully accepts her true self curled up in bed with us at night.  We, her humans, meanwhile constantly search to define our soul, and fail to see it in our love for her.  And some of us, particularly those of us connected to Natalie’s Light, try to help those who struggle to rediscover their damaged or lost souls.

This writer, having studied the brain in all its eloquent states, for over 50 years, has reached a reconciliation with neuroscientists, religious gurus and cloistered philosophers, so I define the soul in a very simple psycho-spiritual manner:  the soul is that place and force within us, the anatomical location still not on our GPS, where we find the meaning and purpose of our lives. Thus, I believe the lost or damaged soul is no longer conscious of who they are; there is no awareness of self.  Now, more eloquent statements about the soul are available and should be shared. Edward Tick, PhD., writing in his book “War and the Soul” attributes the following traits to the soul: “How we perceive how our minds are organized and function; how we love and relate; what we believe, expect and value; what we feel and refuse to feel; and what we judge as good or evil, right or wrong….The soul is the awareness of oneself as a discrete entity moving through space and time. It is the part of us that contemplates our own existence. ” 

Regardless of how you conceive of the soul, it is the fundamental belief of Natalie’s Light that it is the lost and damaged soul that succumbs to the event we call suicide.  While it is our mission to prevent suicide though awareness, our extended goal and method to prevent suicide is helping those who struggle in the darkness torediscover their soul. This belief will help us design the strategies and detailed curriculum of Natalie’s Light and at the same time we will energize, redefine and rediscover the soul of our community.   

Imagine living a life that is without feeling. That is like asking what it would like to live without thought.  The simple and easy response is to say, “You can not live that way; it is not possible.”  Well, there are conditions where it is possible to be alive, but just not functioning as a human being.  We assume a person in a persistent vegetative state is a biological being but without the psycho-spiritual capacity to feel, think, reason or understand. In other words they exist without a soul.   Dr. Tick reminds us “many philosophers consider reasoning as the highest function of the soul…reason allows us to know ourselves—and to KNOW that we know…it allows us to rise above our animal nature; to control our instincts, to shape our world and to create things that did not exist before…through reason, the soul contemplates the order of the universe and searches for meaning in our lives and in all existence.”  Of interest Socrates explored similar concepts when, facing death, he stated, “A life left unexamined is not worth living.”  It seems Socrates was not willing to sell his soul and live his life in exile.

There is also a psychological state most commonly associated with severe physical and emotional trauma, where the soul is so damaged or lost that the mind dissociates from all feelings and rational thought.  In this setting, described as mind numbing, the soul separates from the body and the meaning of life is lost.  Still, there are many more souls lost for reasons we do not understand, but is the determination of Natalie’s Light is to help those people rediscover their soul.

Imagine, if you can, you have totally lost the ability to imagine.  You cannot imagine a future for yourself or your family.  Previously there had been unlimited possibilities; now there are only impossibilities.  Without imagination there is a gaping hole in the heart of our soul.  However, the first indelible pillar of the soul is found through imagination.  It finds some organization and meaning in the seemingly random and arbitrary events and stresses of our lives.  Again, Tick eloquently describes our imagination as our ability to “create images both to express the intangible and to help us manipulate the tangible world…We could say that the act of creating Is one way we resonate with the Creator, no matter by what name we understand divinity. In this sense, the use of the imagination is inherently life affirming. “   Thus, rediscovering the soul requires the use of the power, and yes the magic, of the human use of the imagination.  The illness that leads to the unfathomable abyss of suicide is a disease of the imagination.  So it follows we must use the power of imagination to rescue and rediscover the soul.

Traditional medicine and psychiatry mandate the identification of a sharply defined diagnosis, followed by a tightly structured evidence based treatment program.  Clearly there is a place for psychotropic medication and various forms of psychotherapy, even a place for electroconvulsive therapy.  But statistics tell us we are not making any progress, not only in reducing the incidence of suicide, but in the persistent misery of a wide variety of mental health disorders.  It is time for a different perspective and alternative interventions.

There is no diagnosis, no DSM code, for a lost or damaged soul.  Insurance companies will not reimburse for a soul diagnosis no matter what may be the overt cause, such as severe trauma.  So, to make an impact we must use our imagination and create a different model to repair and rediscover the souls that have been lost.  This will require a must broader and dedicated effort.  It requires participation of the entire community.  Preventing suicide through awareness demands we, as a community, be aware of our selves and our souls.

To borrow—paraphrase-- once again from Edward Tick, this journey of rediscovery will require imagination, nurturing, forms of purification, storytelling, healing journeys, grieving rituals and soul retrieval.  This demands the participation of our entire culture.  It will ask the question: is this a community with soul?

Natalie’s Light and the Lamed-Vov

If you are searching for the heart, the soul, and the spirit of Natalie’s Light you can find much of it embodied in the parable: the Legend of the Lamed-Vov. This storytelling is powerful and compelling: for the person telling the story is searching for his soul, which is the place within each of us, which brings meaning and purpose to our lives. But equally important in this process is the person who listens to the story and shares the pain, anguish and meaning of the tale. Natalie’s Light will be there to listen, to let those in pain know they are not alone. We know the soul of others only by what they disclose about themselves. 

The Legend of the Lamed-Vov originates in the Jewish Religion or Kabbalist tradition.  The writer Sheldon Kopp notes the Jewish aphorism: whenever two Jews meet, if one of them has a problem, the other automatically becomes a rabbi. Please note, I am a goy and claim no knowledge of the Jewish religion or Kabbalist tradition. However, the following brief story is the most important narrative in all my learning as a psychiatrist and as a physician, as well as in all my relationships with others, regardless of context. I have told this tale to hundreds of soldiers who have lost their souls, their sense of identity, of self, after experiencing severe trauma. I have read variations on the details of the legend, but the power of the story remains unchanged.

The terms Lamed and Vov represent the value 36, with lamed equal to 30 and vov equal to 6, in the traditional system of Kabbalist numerology. In Jewish legend there are always living 36 “Just” men, the Lamed-Vov, spread throughout the Diaspora and according to the tradition, the continued existence of the world depends on these anonymous men. When one man dies, another is immediately appointed by God. The thing that distinguishes the Lamed-Vov from other men is their unquenchable capacity for caring. A new member of the Lamed-Vov may not even know of his appointment for this chosen task. Part of the mythology is that a true member of the Lamed-Vov possesses such humility that he can not conceive of himself as being a member of this order. Sheldon Kopp describes these men in more eloquent terms: “So inconsolable are the Just Men in their anguish about human suffering, that even God himself cannot comfort them. So it is, that as an act of mercy toward them: From time to time the Creator, blessed be His name, sets forward the clock of the Last Judgment by one minute.” So, to our story. 

Thus, in the spirit of this legend is the story of a young boy who has lost his parents and lives with his aging grandfather.  The grandfather learned that one of the Just Men had died and the boy was chosen to be the successor and will take the place as one of the Lamed Vov. The boy was told he would come to know the spirit and strength of this honored position. Though the boy knew of the legend, he did not understand the reality of his task and was bewildered by what he should do as a Just Man. His grandfather told him he did not have to do anything to fulfill his destiny but continue to live his life as good little boy.

But the child was initially frightened and worried that he would not be able to meet the requirements of his appointment to the Lamed-Vov. He felt he must meet the unknown requirements so that God will be satisfied and spare his grandfather from dying. It became his obsession that great self-sacrifice and suffering will be necessary for him to fulfill his responsibility.

While terrified, he was ready to do whatever was required and he made the decision to test his ability to withstand any pain or torment. He started by holding his breath as long as he could, but soon learned the need to take in air overwhelmed him. He then failed in his attempt to go outside in the bitter cold of winter without a coat, and to go without food and water for long periods. He failed all these tests of his strength and devotion. Finally he put a flame to the palm of his hand but then could not hide the pain and scar from his grandfather. The boy sobbed because he knew that he could not save his grandfather.

The grandfather was extremely distressed and profoundly touched when he learned the boy was testing himself in order to save his life. Despite his misunderstanding of his mission as a Just Man, the boy was in fact acting in the spirit of the Lamed-Vov. The grandfather explains:

He teaches the boy the nature of his monstrous error by explaining that as a Just Man, he will not be able to change anything. Ultimately he will save no one. A Just Man need not pursue suffering. It will be there in the world for him as it is for each man. He need only be open to the suffering of others knowing that he cannot change it. Without being able to save his brothers, he must let himself experience their pain, so that they need not suffer alone.

While the goal of Natalie’s Light is to somehow save lives, we know our ability to make a difference is in our ability to let those in pain know, we will be there for them. This is heart, soul and spirit of Natalie’s Light.

There are many variations of this simple story of the Lamed-Vov.  We all have personal examples of the power of just being there. Let me share briefly how the power of this legend affects my personal history. 

Of all the people I have met in my life, the soldiers I encountered in the last 5 years of my life understood and identified with this story the most. They lived the concept of “I’ve got your back; never leave a fallen comrade.” The reason D-Day, the 6th of June, 1944 was successful in WWII was not because of some general’s brilliant plan of attack. The allies ultimately prevailed because of the profound perseverance of the troops on the ground who were there for their brothers; they were not alone. Those Soldiers, Marines and Seamen were not going to let their battle buddies down. I recall this same spirit in my father’s work as a fire fighter. His crew of men loved him and each other because they were always there for each other, in dangerous situations, off duty and at the end of their lives. It took me years to finally understand my father’s allegiance to those men. My father did not know it, but he was a Just Man. Therefore, I tried to always let soldiers know that they would never be abandoned; they would never suffer alone. I could not change the trauma they experienced, but I could be there with them, through their pain and suffering. Sheldon Kopp expresses this more eloquently when he states, as a therapist, he must feel vulnerable to the pain of his patients and he wants them to become personally important to him.

Natalie’s Light takes this mission very personally. 

(The story of the Lamed-Vov came from the book by Dr. Sheldon Kopp called If You Meet the Buddha Along the Road, Kill Him! The audience for this slim volume is meant to be psychotherapists, admonishing them to be careful: if you are looking for the master, the guru, the therapist, the Buddha--- or any person who proclaims they have ALL the answers to everything--- you will never find your soul: the meaning and purpose of your life. The search for answers is to be found within the self, by searching the narratives, the stories of your life.

Dr. Kopp states that the therapist, the guru, the Buddha, instructs by metaphor and parable, but the pilgrim learns through the telling of his own tale.)