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.”