Serotonin is a chemical often associated with mood and happiness. A lack of serotonin can sometimes contribute to mental health issues such as anxiety and depression. Helping the body produce or maintain its level of serotonin can alleviate depressive symptoms.

Many people use psychotropic medications to adjust their serotonin levels. But there is such a thing as having too much serotonin because of medications. This phenomenon, called serotonin syndrome, can lead to extreme health issues.

What Is Serotonin Syndrome?

Serotonin syndrome occurs when someone has an excess of the neurotransmitter serotonin in their nervous system. The condition’s symptoms generally fall into three categories:

• Altered mental status (irritability, agitation, restlessness, and anxiety)
• Neuromuscular hyperactivity (tremors, shivering, muscle rigidity, and muscle spasms)
• Autonomic hyperactivity (rapid heartbeat, high blood pressure, sweating, and fever)

Because serotonin is produced primarily in the gastrointestinal tract, digestive problems like nausea and diarrhea are common. A person experiencing serotonin syndrome may also be confused, dizzy, or disoriented. In severe cases, an individual may develop hallucinations and seizures.

Serious cases of serotonin syndrome can be fatal if left untreated. However, serotonin syndrome is usually very treatable. Recovery often occurs within 24 hours of seeking medical help.

What Causes Serotonin Syndrome?

Serotonin syndrome is ultimately a bad reaction to medication. It most often occurs after a person takes multiple drugs that increase serotonin. For example, someone who uses antidepressants may take cold medication. Both drugs can boost serotonin, raising the neurotransmitter levels much higher than either medication would alone.

Serotonin syndrome can also happen if a person starts a new medication or increases their dosage. It can be difficult to predict which medications or dosages will pose a risk though. A certain level of serotonin may be therapeutic for one person and toxic for another.

Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are the most common drugs linked to the condition. Other substances that can increase serotonin include:

• Other antidepressants (such as MAOIs)
• Triptan migraine medications
• Over-the-counter cold medicines that contain dextromethorphan
• Certain herbal supplements (St. John’s wort and ginseng)
• Certain recreational drugs (such as cocaine or LSD)

Symptoms of serotonin syndrome typically appear within the first 24 hours of starting or adjusting one’s medication regimen. There is currently no one medical test for serotonin syndrome. A doctor would likely perform several specific tests to evaluate organ function, check for hormonal imbalances, and rule out other potential conditions, such as drug overdose.

How Common Is Serotonin Syndrome?

With around 13% of Americans taking some type of antidepressant medication, many people could be at risk for serotonin syndrome. However, the vast majority of people who take antidepressants do not develop the condition. There are no known demographic risk factors like age or gender.

Historically, the number of people who experience serotonin syndrome is quite low—only several thousand per year. Just over 8,000 people were diagnosed with serotonin toxicity in 2004, the most recent year with data on the topic. Researchers acknowledge this statistic is likely an underestimation, as mild cases often go undiagnosed. Yet the average person taking antidepressants does not need to worry for their safety.

Serotonin Syndrome or Neuroleptic Malignant Syndrome?

Neuroleptic malignant syndrome (NMS) has many similarities to serotonin syndrome. Both conditions are adverse reactions to psychotropic medication, and their symptoms can look identical.

If you have any adverse reaction to taking any medication, it is very important to contact your doctor immediately.However, there are important differences. Both the onset and recovery period of NMS are much longer. Plus, NMS can be treated with a medication called dantrolene. (There is no equivalent medication for serotonin syndrome.) Thus, it can be important to distinguish between the two conditions.

Often clinicians can determine which issue a person has by evaluating their medications. Unlike serotonin syndrome, NMS is linked to drugs that affect dopamine levels. If a person’s medication history still leaves doubt, doctors may need to perform clinical tests. Clinicians can diagnose NMS by looking at white blood cell count, serum iron levels, and other physical markers.

How Is Serotonin Syndrome Treated?

In most cases, serotonin syndrome can be resolved within 24 hours. Treatment can be as simple as stopping the medication that was causing an increase in serotonin. Mild symptoms can be cleared up very quickly in this way.

If an individual has mild symptoms but requires the medication (for example, a severely depressed person taking antidepressants), they may discuss the risks and benefits with their care provider. Often a compromise can be found by reducing the medication dosage. If the current dosage is necessary, then a clinician should closely monitor the patient for any worsening of symptoms.

More severe symptoms of serotonin syndrome may require hospitalization. Doctors will likely monitor a person’s vitals and watch for any withdrawal effects. In extreme cases, someone with serotonin syndrome may require a breathing tube, feeding tube, or sedation. If the person is experiencing muscle spasms, a doctor might use a medication that temporarily paralyzes muscles as a preventative measure. This helps guard against damage to the muscle tissue and kidneys.

How to Prevent Serotonin Syndrome

While serotonin syndrome is not always preventable, you can stay safer by paying close attention to any negative reactions to medication. It is especially important to pay attention if anything changes in your prescription or dosage.

Always be transparent with medical professionals about the medication(s) and supplements you’re taking, as well as any recreational drug use. Stay in communication with your psychiatrist or health care team to help monitor the effects of medication. Communication is essential if you have a combination of prescriptions.

If you have any adverse reaction to taking any medication, it is very important to contact your doctor immediately. Left untreated, symptoms may worsen and become incapacitating. However, quick intervention can help prevent any more discomfort.

If serotonin syndrome has interfered with your medication regimen, you may be able to get relief through therapy. The right therapist can treat your mental health issues and may help reduce your need for medication.

References:

1. Ables, A. Z., & Nagubilli, R. (2010). Prevention, recognition, and management of serotonin syndrome. American Family Physician, 81(9), 1139-1142. Retrieved from https://europepmc.org/abstract/med/20433130
2. Cafasso, J. (2017) Serotonin syndrome. Healthline. Retrieved from https://www.healthline.com/health/serotonin-syndrome
3. Cooper, B. E., & Sejnowski, C. A. (2013). Serotonin syndrome: recognition and treatment. AACN advanced Critical Care, 24(1), 15-20. Retrieved from http://acc.aacnjournals.org/content/24/1/15.extract
4. Hiraga, A., & Kuwabara, S. (2017, October 15). Neuroleptic malignant syndrome and serotonin syndrome in general hospital settings: Clinical features, frequency and prognosis. Journal of the Neurological Sciences, 381, 606. Retrieved from https://www.sciencedirect.com/science/article/pii/S0022510X17322062
5. Lawrence, L, (2013). Be prepared: The ins and outs of serotonin syndrome. ACP Hospitalist. Retrieved from https://acphospitalist.org/archives/2013/04/serotonin.htm
6. Perry, P. J., & Wilborn, C. A. (2012). Serotonin syndrome vs neuroleptic malignant syndrome: A contrast of causes, diagnoses, and management. Annals of Clinical Psychiatry, 24(2), 155-162. Retrieved from https://www.researchgate.net/publication/224916051_Serotonin_syndrome_vs_neuroleptic_malignant_syndrome_A_contrast_of_causes_diagnoses_and_management
7. Sifferlin, A. (2017, August 15). 13% of Americans take antidepressants. Time. Retrieved from http://time.com/4900248/antidepressants-depression-more-common
8. Volpi-Abadie, J., Kaye, A. M., & Kaye, A. D. (2013). Serotonin syndrome. The Ochsner Journal, 13(4), 533-540. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865832

More and more Americans with mental health concerns are becoming incarcerated. This population of has reached “crisis proportions,” according to the National Alliance on Mental Health (NAMI).

Evidence shows incarceration is likely to worsen mental health symptoms. Most institutions do not have the resources to treat such a great number of people. Reduced mental health can lead to recidivism, meaning a recurrence of criminal behavior. When more people are rearrested, the population of imprisoned people stays high.

However, there are ways to reduce recidivism in these populations. People who receive mental health treatment during and after their sentences are less likely to reoffend. Alternatives to imprisonment can also reduce recidivism.

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Mental Health in the Criminal Justice System

In the United States, around 2 million people go to jail or prison each year. In general, jails are run by local forces. They hold inmates for terms of one year or less. Prisons are run by state or federal forces. They typically house prisoners for longer periods.

Many people in prisons and jails have a mental health diagnosis.

• A 2005 Department of Justice study found 64% of inmates in local jails have a mental health concern. The rates were 56% for state prisoners and 45% for federal prisoners.
• Around 50% of incarcerated people have a dual diagnosis. A dual diagnosis occurs when someone has both a mental health concern and substance addiction.
• According to NAMI, 20% of incarcerated individuals been diagnosed with “serious mental illness.” Someone with a “serious” condition may require daily assistance. This category includes conditions such as schizophrenia, major depression, and bipolar.

Estimates on recidivism rates vary. Most studies show offenders with diagnoses have higher recidivism rates than those without.

• The 2005 study above found 75% of incarcerated individuals with a diagnosis had been arrested before.
• A 2017 study showed offenders with diagnoses have a 9% greater chance of rearrest one year after release. Five years after release, the difference increases to 15%.
• The same 2017 study found people with severe diagnoses are 4% more likely to be rearrested than those with milder conditions.

How Jails and Prisons Became Mental Health Facilities

The criminal justice system has not favored people with mental health concerns in the past. From straitjackets to lobotomies, history is full of inhumane attempts to manage mental health. Pervasive stigma impacted nearly every step of incarceration and treatment.

In the 1950s and 1960s, the government closed many mental institutions and psychiatric hospitals. The intent was to serve people through community resources instead. Yet a lack of funding and commitment left many states with few treatment options.

In a Stanford Law Report, Senator Darrell Steinberg and Professor David Mills write, “Although deinstitutionalization was originally understood as a humane way to offer more suitable services … in community-based settings, some politicians seized upon it as a way to save money by shutting down institutions without providing any meaningful treatment alternatives.”

Many prisons and jails are ill-equipped to provide adequate mental health care. But for some people, these facilities are where they first encounter treatment. In the 1980s, the “war on drugs” complicated matters. The government began assigning mandatory sentences for drug-related offenses. More people with substance addiction were put behind bars. Many of these people had co-occurring mental health concerns. In the last 40 years, the rate of incarceration has increased five-fold in the U.S.

People with mental health issues are more likely to be the victim of a crime than commit one. Yet research shows living with untreated conditions can be extremely damaging to individuals. An untreated condition may affect a person’s judgment and lead to criminal behavior. This likelihood increases if other large-scale stressors (poverty, abuse, etc.) are present.

Many prisons and jails are ill-equipped to provide adequate mental health care. But for some people, these facilities are where they first encounter treatment. A person may not get a diagnosis until they are already behind bars.

The Incarceration Cycle for People with Mental Health Concerns

Today’s criminal justice system treats individuals more humanely than in the past. Yet offenders with mental health concerns still face discrimination. Someone with a diagnosis is likely to get a longer, harsher sentence than a neurotypical peer convicted of the same crime. They are also less likely to be granted release.

Incarceration itself can worsen mental health. Offenders often experience a drastic drop in agency. Strict rules and isolation can exacerbate stress. An individual may develop additional mental health concerns as they adjust to the transition.

Incarceration itself can worsen mental health.The Bureau of Justice Statistics held a survey asking offenders about their mental health in the prior 30 days. Fourteen percent of state or federal prisoners reported having severe psychological distress. The rate was almost double (26%) for jail inmates.

Compromised mental health and relative isolation can promote substance abuse. Andrew Archer, LCSW explains, “American incarceration operates as a perfect recipe to perpetuate habitual patterns for individuals. Extreme isolation and societal alienation demoralize the person to the extent that often times substances are the only form of self-regulation.”

In this way, alcohol and drug addiction can spread through populations of offenders. The sale, trade, and consumption of drugs can broaden one’s criminal network. Being insulated with other offenders can also reinforce attitudes that encourage further crime.

After years of incarceration, prisoners tend to struggle once they are released. Trey Cole, PsyD, says, “Relationally speaking, incarcerated individuals often become accustomed to the externally controlled environment (i.e. when to eat, sleep, etc.). When released, then, usually with few resources, becoming accountable to oneself and internally motivated become more difficult.”

Released offenders may find themselves without any resources or support. They may struggle to find housing or employment due to stigma. Reduced mental health can also impact one’s ability to make a living.

In other words, the factors which led a person to crime may be even stronger after release. Their ability to survive within the law may have been reduced. In this context, a person can easily be drawn into recidivism.

Compassionate Solutions for Lowering Recidivism Rates

A report by the Council of State Governments (CSG) Justice Center calls for an overhaul of the way U.S. criminal justice systems address people with mental health issues. Special attention was called to the way such people are released from jail and prison.

According to the CSG, a successful system of reentry into society would:

• Combine a range of services and professional efforts.
• Coordinate treatment for substance abuse and other mental health issues.
• Integrate both mental health care and primary healthcare.
• Provide housing for individuals with mental health issues.
• Draw upon family connections and community resources for treatment.
• Ensure people can access the full range of government entitlements for which they are eligible, such as Social Security Disability Insurance.

Some states have already begun to implement these measures. Colorado, Texas, and North Carolina have used grant money to expand mental health care and substance abuse treatment for offenders. These states also saw large drops in recidivism.

• North Carolina had a 42% reduction in people sent back to prison after probation violations between 2006 and 2015.
• Texas had a 25% reduction in the 3-year reincarceration rate between 2004 and 2013.
• Colorado saw probation revocations and the 3-year reincarnation rate reduced by at least 23% in around the same time frame.

How Diversion can Reduce Recidivism

Diversion has also been shown to reduce recidivism rates in people with mental illness. Diversion is a practice of placing offenders in mental health treatment instead of prison or jail. It often takes one of two forms.

The first form is forensic hospitalization. Offenders who have been found not guilty by reason of insanity are typically sent to forensic hospitals. These facilities do confine people like prisons and jails do. Yet their aim is typically rehabilitation rather than punishment. Less than 1% of people in the criminal justice system qualify for the insanity defense.

A 2005 study found offenders released from forensic hospitals had very low recidivism rates. They were less likely to reoffend than released inmates with mental health concerns. They were also less likely to offend than inmates without a diagnosis.

It is often cheaper to send nonviolent offenders to mental health treatment than jail. The other path of diversion involves mental health courts. These courts are for offenders who have mental health concerns but don’t qualify for the insanity defense. Judges may offer defendants reduced sentences in exchange for getting treatment. In many cases, a defendant may not go to jail or prison at all.

A 2007 study found participation in mental health courts cut the risk of violent offense in half. People who had gone through mental health courts also went longer without reoffending than those who went through traditional courts.

NAMI strongly supports diversion as a more humane and cost-effective approach to incarceration. According to NAMI, the cost of jailing adults with mental health concerns is two to three times the cost of keeping other inmates. It is often cheaper to send nonviolent offenders to mental health treatment than jail.

Just as psychotherapists who practice good therapy see people as whole beings independent of any mental health issues they may have, NAMI’s compassionate justice system would see all individuals as worthy of treatment and change. This system would classify mental health concerns not as moral defects, but as results of adversity or strain. Prioritizing treatment over punishment could have lasting benefits for the criminal justice system.

References:

1. Agnew, R. (2001). Building on the foundation of general strain theory: Specifying the types of strain most likely to lead to crime and delinquency. Journal of Research in Crime and Delinquency, 38(4), 319-361. Retrieved from http://journals.sagepub.com/doi/abs/10.1177/0022427801038004001
2. Bales, W.D., Nadel, M., Reed, C. & Blomberg, T. G. (2017). Recidivism and inmate mental illness. International Journal of Criminology and Sociology, 6(1) 40-51.
3. Bloom, J. D., & Novosad, D. (2017). The Forensic Mental Health Services Census of forensic populations in state facilities. The Journal of the American Academy of Psychiatry and the Law, 45(4), 447-451. Retrieved from http://jaapl.org/content/45/4/447
4. Bronson, J. & Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011-12. Bureau of Justice Statistics. Retrieved from https://www.bjs.gov/content/pub/pdf/imhprpji1112.pdf
5. Criminals need mental health care. (2014, March 1). Scientific American. Retrieved from https://www.scientificamerican.com/article/criminals-need-mental-health-care
6. What is the difference between jails and prisons? (n.d.). Bureau of Justice Statistics. Retrieved from https://www.bjs.gov/index.cfm?ty=qa&iid=322
7. Lerman, A. E. (2013). The modern prison paradox: Politics, punishment, and social community. Cambridge University Press. Retrieved from https://gspp.berkeley.edu/research/selected-publications/the-modern-prison-paradox-politics-punishment-and-social-community
8. NAMI warns senate about criminalization of mental illness; Supports Cornyn bill. (2016, February 10). NAMI. Retrieved from https://www.nami.org/Press-Media/Press-Releases/2016/NAMI-Warns-Senate-about-Criminalization-of-Mental
9. The new asylums: Some frequently asked questions. (2005, May 10). PBS. Retrieved from https://www.pbs.org/wgbh/pages/frontline/shows/asylums/etc/faqs.html
10. Reducing recidivism: States deliver results. (2017). The Council of State Governments Justice Center. Retrieved from https://csgjusticecenter.org/wp-content/uploads/2018/03/Reducing-Recidivism_State-Deliver-Results_2017.pdf
11. Steinberg, D. & Mills, D. (n.d.) When did prisons become acceptable mental health care facilities? Stanford Law School: Three Strikes Project. Retrieved from http://law.stanford.edu/wp-content/uploads/sites/default/files/child-page/632655/doc/slspublic/Report_v12.pdf

With greater access to treatment, more people find they can take on the monumental venture of earning a degree. Yet once they are in school, their risk of mental health problems increases. Graduate students in particular may struggle to manage school, finances, and self-care. The combined stress can be devastating to mental well-being.

The American Psychological Association says the need for mental health care on campuses is increasing. A 2015-2016 report from the Center for Collegiate Mental Health surveyed college counseling centers across America. The report showed an increase in student hospitalization, medication use, and suicide. More than 55% of the centers saw increases in salary budgets to meet demands for care. But some clinics still face challenges in meeting students’ needs. They may have limited hours of service or high costs of care.

Meanwhile, almost a third of PhD candidates may be at risk for mental health concerns. Around 34% of graduate students may already experience moderate to severe depression.

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Researchers continue to study the specific differences between undergraduate and graduate students’ health. Further surveys may determine how to improve psychological care for each population. The goal is to promote mental well-being in colleges and universities.

Risk Factors for Mental Health Concerns in Grad School

Some populations are more at risk of developing mental health concerns. As the population of graduate students grows more diverse, so do mental health needs. Minority and international students may need help with multicultural issues. LGBTQ+ students can also face discrimination.

These populations can benefit from seeking mental health treatment on campus. Yet not all students may feel represented at their school’s counseling center. Around 71% of counseling center staff members are white. The number of openly LGBTQ+ counselors is limited. Counseling centers could better serve minority students by hiring more diverse staff.

Another risk factor is academic performance. Students who feel they are behind in their classes are more likely to report stress and anxiety. The Graduate Assembly of University of California, Berkeley rates academic performance as one of the top three predictors of depression in graduate students.

Yet catching up may be easier said than done. Many graduate students have responsibilities outside school such as childcare or employment. In a 2014 survey, graduate students cited job outlook, financial stress, loneliness, and alienation from mentors as contributing factors to depression and negative well-being.

Graduate students can help improve mental health outcomes by learning what signs to watch for. Any of the following symptoms may indicate a larger mental health concern:

• Irritability
• Sleeplessness
• Panic attacks
• A dependence on drugs or alcohol
• Inability to complete daily tasks
• Feelings of worthlessness
• Suicidal thoughts

How Grad Students Can Use Counseling Centers

Psychological care addresses diagnoses that affect students as well as the general population. For example, cognitive behavioral therapy can help individuals cope with anger or anxiety. Acceptance and commitment therapy can help busy students focus on their priorities.

Graduate students are a population with unique mental health needs.

Counseling centers can also introduce students to alternative treatments to complement traditional therapies. Some therapists might assign internet-based worksheets to help reprogram harmful thoughts. Others may direct students to mindfulness practices like yoga.

Treatment can be especially helpful for students whose diagnoses impact learning. When a survey asked students if campus counseling services helped with their academic performance, over 70% answered positively. These results suggest counseling can help both mental health concerns and academic issues.

Preventing Mental Health Issues During Grad School

Self-care practices like sleep and exercise can promote more positive mental health outcomes. Students who limit their schedules and have a social life have less risk for burnout. Experts encourage students to find a therapist before their symptoms become overwhelming.

There are several ways graduate schools can reduce students’ risks of mental health concerns. Schools can accommodate students’ schedules, aid their career preparations, and improve campus mental health care. Schools can also help by educating students about time management and self-care. Close mentorship is also linked to improved mental health and academic outcomes. Academic advisors are particularly helpful for international students.

Graduate students are a population with unique mental health needs. If schools improve their campus mental health care, they can not only lower the rate of mental health concerns, but also promote academic success. Mental health care on campus can improve all aspects of graduate student life.

Lifelines and Further Resources

• Jed Foundation is an advocacy group for teen and young adult mental health. Students can find information about their legal rights related to mental health.
• The National Grad Crisis Line provides suicide prevention services specifically for graduate students. Individuals can reach the hotline by calling 1-877-GRAD-HLP (1-877-472-3457). People studying abroad can access the hotline through a Skype number.
• ULifeline.org is a service of the Jed Foundation. It offers self-assessment tools to evaluate mental wellness and suitability for counseling. There are also resources for those who need immediate help.
• American Psychological Association has an online section of articles especially for graduate students. Helpful pages include self-care tips and advice for seeking mentorship.

Resources:

1. Barry, K. M., Woods, M., Warnecke, E., Stirling, C., & Martin, A. (2018, January 19). Psychological health of doctoral candidates, study-related challenges and perceived performance. Higher Education Research & Development, 1-16. Retrieved from http://www.tandfonline.com/doi/abs/10.1080/07294360.2018.1425979?journalCode=cher20
2. Bershad, C., Reetz, D. R., LeViness, P., & Whitlock, M. (2016). The Association for University and College Counseling Center Directors annual survey. Association for University and College Counseling Center Directors. Retrieved from https://taucccd.memberclicks.net/assets/documents/aucccd%202016%20monograph%20-%20public.pdf
3. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31. Retrieved from https://www.sciencedirect.com/science/article/pii/S0272735805001005
4. Campus Mental Health. (n.d.). American Psychological Association. Retrieved from http://www.apa.org/advocacy/higher-education/mental-health/index.aspx
5. Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine, 81(4), 354-373. Retrieved from https://journals.lww.com/academicmedicine/Abstract/2006/04000/Systematic_Review_of_Depression,_Anxiety,_and.9.aspx
6. Eisenberg, D., Downs, M. F., Golberstein, E., & Zivin, K. (2009, May 19). Stigma and help seeking for mental health among college students. Medical Care Research and Review, 66(5), 522-541. Retrieved from http://journals.sagepub.com/doi/abs/10.1177/1077558709335173
7. Graduate Student Happiness and Well-Being Report. (2014). Graduate Assembly of University of California, Berkeley. Retrieved from http://ga.berkeley.edu/wp-content/uploads/2015/04/wellbeingreport_2014.pdf
8. Grappling with graduate student mental health and suicide. (2017, August 7). Chemical and Engineering News. Retrieved from https://cen.acs.org/articles/95/i32/Grappling-graduate-student-mental-health.html
9. Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169-183. Retrieved from http://psycnet.apa.org/record/2010-05835-004
10. Hyun, J., Quinn, B., Madon, T., & Lustig, S. (2007). Mental health need, awareness, and use of counseling services among international graduate students. Journal of American College Health, 56(2), 109-118. Retrieved from http://www.tandfonline.com/doi/abs/10.3200/jach.56.2.109-118
11. Ickes, M. J., Brown, J., Reeves, B., & Martin, P. D. (2015). Differences between undergraduate and graduate students in stress and coping strategies. Californian Journal of Health Promotion, 13(1), 13-25. Retrieved from http://www.cjhp.org/volume13Issue1_2015/documents/13-25_Formatted_Ickes_CJHP2015_Issue1.pdf
12. Karyotaki, E., Riper, H., Twisk, J., Hoogendoorn, A., Kleiboer, A., Mira, A., … & Andersson, G. (2017). Efficacy of self-guided internet-based cognitive behavioral therapy in the treatment of depressive symptoms: A meta-analysis of individual participant data. JAMA Psychiatry, 74(4), 351-359. Retrieved from https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2604310?redirect=true
13. Levecque, K., Anseel, F., De Beuckelaer, A., Van der Heyden, J., & Gisle, L. (2017). Work organization and mental health problems in PhD students. Research Policy, 46(4), 868-879. Retrieved from https://www.sciencedirect.com/science/article/pii/S0048733317300422?via%3Dihub
14. More and more students need mental health services. But colleges struggle to keep up. (2017, May 4). USA Today. Retrieved from http://college.usatoday.com/2017/05/04/more-and-more-students-need-mental-health-services-but-colleges-struggle-to-keep-up
15. Why do so many graduate students quit? (2016, July 6). The Atlantic. Retrieved from https://www.theatlantic.com/education/archive/2016/07/why-do-so-many-graduate-students-quit/490094

Editor’s Note: This article contains description of childhood abuse, which may be triggering for some readers.

“I have an image in my mind I can’t seem to get rid of,” I tell Dr. Erickson. “A snapshot of a memory that’s always there, and I can’t stop looking at it.”

His office is dimly lit. On the wall facing me are two pictures of shamans, medicine men who heal spiritually. I had thought a psychiatrist might decorate with pictures from the masters—Van Gogh, Monet, or maybe a classical artist like Michelangelo. Below the shamans, on an end table, is a Kokopelli statue set in a dish of smooth stones. Next to that are two huge bookcases filled with copies of publications from the American Psychiatric Association. At least he seems well-read.

“Are you sure it’s a memory?” He sits near the opposite wall, filing my evaluation form into a folder. Today he’s wearing a shirt and tie. If it weren’t for his long hair and ponytail he would seem every bit a doctor.

“Yes. It’s something the attorneys brought up during the deposition. Something I haven’t thought about in a long time.”

He stares at me and says nothing. I realize he isn’t going to prod. It seems a strange way to communicate, not asking questions.

[fat_widget_right]“When I was nine I told kids at school that I’d seen my father’s penis,” I tell him, “that I’d touched it. Only I didn’t know to call it that. They stared at me in shock. That’s when I realized there was something wrong with what I was doing. You only know what you’re told when you’re a child. I didn’t know that other kids weren’t touching their fathers that way.” I pause. “They stopped playing with me after that.”

He’s quiet for a moment. “That’s the image in your mind?”

“Yes, swinging on the playground, laughing. I remember the looks on their faces when I admitted what I was doing. It was all so … innocent.”

“How does that make you feel?”

How does it make me feel? The memory is so old, almost thirty years have gone by, but it still seems like yesterday. It’s the kind of memory I store in one of those chests at the bottom of my mind, but now I can’t seem to put it back.

“Ashamed, sad, like I’ve done something wrong.”

“Do you feel that in your body?”

Another strange question. The memory is in my head. My emotions are in my head, glued to that image of swinging happily, chattering with my friends and having no idea of the impact of my words. My emotions are not imprinted in my body. But I think about the question anyway because I have so much anxiety these days, a tightness in my stomach that feels like a descending roller coaster. Even my nightly dose of Seroquel isn’t alleviating it.

“In my stomach,” I say.

“Images come forward in your mind to help you get what you want. Your subconscious wants to heal. This is its way of communicating that to you.”

“There’s something for me to learn from this memory?”

[EMDR] is very effective for trauma and posttraumatic stress. Once you process the memory, the picture goes away, along with the emotions associated with it.

He nods. “There’s something called EMDR—eye movement desensitization and reprocessing. It’s a therapy like hypnosis that can help speed the processing of memories. It’s very effective for trauma and posttraumatic stress. Once you process the memory, the picture goes away, along with the emotions associated with it.”

I’d like to get rid of the snapshot memory, and the sadness and shame it brings with it. It was different before; it was a private memory I could easily tuck away. I could convince myself it was a single incident barely worth my energy to consider. But I had admitted it during the deposition; I had exposed my shame to a team of attorneys who simply stared at me, stoic and apathetic. I had mirrored their apathy, determined not to allow them to see my pain. I can still see their unimpressed expressions.

“How do I do that?” I ask Dr. Erickson.

“I move my hand in front of you and you follow it with your eyes as you think about the memory. Emotions will come to the surface. As you process the emotions, they will be released. The memory will lose its emotional charge.”

“Will the image go away then?”

“It should.”

Is that what the memory wants—to be felt? Have I tucked away so much of my life that it stubbornly refuses to be hidden any longer? Or is this just a byproduct of the deposition, the aftermath of stress?

What I know is that the memory bothers me. I don’t like looking at those faces of my schoolmates staring in shock, and the memory of realizing I did something wrong. I don’t like being made to feel bad when the onus should be on someone else. Maybe that’s been the problem; the guilt belongs to someone else and not me.

“Okay,” I say.

“Okay what?”

“Okay, I want to try that. I want the image to go away.”

He moves our chairs closer together, so his left arm will be next to my left arm. We’re sitting side by side, but facing in opposite directions. He lets me sit close to the door so I don’t feel boxed in. “An escape route,” he says. Then he stands back from the chairs like an artist appreciating his work.

I know his deliberate manner is meant to make me feel more comfortable, but his ceremonial style has the opposite effect. I hesitate and glance at the door. Am I going to need an escape route? Do his patients routinely flee the room and he’s learned to anticipate it? Or is this merely a psychological strategy?

I take my seat, knowing that I would rather feel part of the scene than an observer.

Nothing will happen with me standing in place, and if it’s all been set up by design then I’m failing and the image will remain. Unwilling to leave and uncertain of how to move forward, I take my seat, knowing that I would rather feel part of the scene than an observer.

He gives me a moment before taking the seat next to mine. We’re too close for my comfort. I have pretty strict boundaries; I’ve never been able to allow people to get very close to me physically. It always feels like they’re suffocating me with their proximity, as if they’ve wrapped their arms around me in a crushing embrace.

I can see the ring he wears and the tiny hairs on his arms, and it makes my body tense. He’s sitting only a few inches from me; I can feel his gaze studying me, and I become self-conscious and begin to fidget in the chair.

“Think about the image,” he instructs. “Think about being on the playground with your friends. Hear their laughter. Think about how you feel as you talk to them. You feel ashamed, sad.”

I hate this already. What kind of therapy begins like this?

He moves his left hand horizontally in front of me. I follow it with my eyes, but I don’t see his hand.

The playground is noisy. I’m swinging with my friends. It’s a Catholic school, and we’re all in uniforms: replicas of one another.

“I’ve never seen a boy’s wiener before,” Kathy says. Her voice is filled with laughter.

“I’ve seen my father’s,” I say. “It looks like a bratwurst.”

“You have not!”

“Yes. I touched it.”

“That’s right,” Dr. Erickson says in a soothing voice. He’s reading the emotions that play across my face. “Stay with it. Let the emotions build and then let them go.”

I don’t know how to let go. I don’t know what I’m supposed to learn from this. It’s all old news, pain long past. It doesn’t belong with me. I’m an adult now, a grown woman who’s made her own way in the world and crafted her own successes. I’m a million years from that little girl on the playground, but the pain is so fresh.

The transformation is rapid. The expressions on the girls’ faces morph from playful amusement to confusion, settling on prudence. They’re judging me. They know something I don’t know. For the first time in my memory, I feel like an outsider, a pariah.

Dr. Erickson stops EMDR. I can feel his eyes on me, but I don’t look at him. I stare, without seeing, at the carpet.

“I have a question,” he says gently. “Whose shame is it?” He moves his hand in front of me, and the image switches.

I’m touching one of my sisters, kissing her on the neck. On Wednesday nights we played a game my father made up, where we had to select small pieces of paper from a hat. On each piece of paper was written something we were supposed to do: kiss a butt, lick a breast, touch a crotch. Each of us would then choose one of our siblings and go into a room with them.

“Where are you?” Dr. Erickson asks. He’s stopped his hand movement and is studying me.

“With one of my sisters.”

“On the playground?”

“No.” Pause. “Every Wednesday my mother would go away and my father would have us sit in a circle, naked. He made up this game.” When I finished explaining the bizarre game, I said, “I’m with one of my sisters in a room … kissing her.”

“Go with that,” he instructs, and begins EMDR again.

It’s all giggles and little-girl fun. It doesn’t feel sexual, just playful. We’re both naked because that’s the way our father wanted it.

I don’t like touch. It’s a mantra I say to myself and it has defined my life. I don’t have relationships and I don’t let people near. But some part of my brain is wondering why I’m not afraid with my sister, why I don’t feel apprehension. I say as much to Dr. Erickson.

“You’re judging her as an adult with rights and wrongs. She’s feeling the comfort of her sister.”

“I liked when we were touching.” It’s the only time I can recall liking touch, when caressing was comforting and nurturing. What happened to that feeling? Darkness falls on me as tears well in my eyes. An enormous sadness overwhelms me.

“I like touching my sister, but I don’t like touching other people. Men. What kind of a person does that make me?”

“Human.”

What I hear is “different.”

The memories fade, but they don’t disappear.

I like the softness of my sister’s skin and the sense of freedom, and I like the closeness as if nothing were going to separate us. Sitting in a psychiatrist’s office, trying to come to terms with my life, liking to touch my sister seems wrong.

I’ve never had a sexual relationship with anyone, male or female. I stopped dating a decade ago; I long since gave up trying to let someone get close. And yet there I was at the tender age of nine, exploring my sister’s body. Was that what was wrong with me?

“I want you to think about the healing white light,” Dr. Erickson says softly. “It’s coming from high above and surrounding you. A brilliant white light taking away all the pain.”

The light bathes me with a warm glow. It calms my breathing, eases my tension and, like a drug, dulls the pain the memory created.

“Let those images go. You don’t need them anymore.”

The memories fade, but they don’t disappear. I like the light surrounding me. It takes me far away from my feelings of guilt and shame.

Laureen Peltier is the author of Hungry For Touch: A Journey from Fear to Desire. She focuses on educating others on the possibility of making a full recovery from PTSD, as well as the benefits of healing past trauma. A passionate speaker for RAINN and other organizations, Laureen is sought-after for medical and nursing schools, and has participated in several online and DVD documentaries focusing on PTSD recovery.

It took a long time before I finally decided to see a psychotherapist—and for reasons that are probably very common:

• I wasn’t sure I had “issues” that warranted help. With nothing to measure against, how was I to know if my angst wasn’t exactly what everyone else felt?
• I grew up hearing family members say people should be strong enough to handle problems on their own. Seeing a therapist or asking for help was a sign of weakness.
• I had no idea what psychotherapy actually entailed. My biggest frame of reference was the film Ordinary People. I loved the therapy sessions depicted in the film, but surely the problems of the boy were far greater than my own.

It took a long time before I was able to acknowledge that my childhood had an effect upon my adult life. Again, with nothing to measure against, how was I to know? I took for granted that my self-doubt, low self-esteem, anxiety, irritability, and desire to be on my own were simply who I was. I didn’t even realize I kept people at a distance and shared nothing of myself because I had been that way all my life. It was simply my personality. I was an introvert. So what?

But thankfully, I began to piece together that negative patterns in my life were emerging and repeating. I recognized the depression I felt had begun in high school, continued and got stronger in college, and then became a recurrent theme in adulthood. After several failed relationships, the depression continued and grew intolerable. I had no idea my own self-imposed barriers against people were actually making things worse.

[fat_widget_right]At 34, I knew something was wrong because I was drinking more, not less. I could see I had always pursued relationships that were destined to fail from the outset, and if they weren’t, I would sabotage them so they did. Through either cheating or losing interest in sex, we would simply drift apart and become friends. For me, the concept of intimacy was repellent.

I give myself credit for recognizing I was stuck, unhappy, and highly unlikely to improve on my own. I was concerned about costs, so I searched and managed to find a therapy organization with a sliding scale fee. I forced myself to the initial consultation meeting, and was caught off-guard when the therapist fairly quickly asked me about my childhood. What would that have to do with anything? I managed to tell her it wasn’t happy. I had snippets of foggy, bad memories.

Over the next two months, I dared to open up to her. I told her about my mother, who had beaten me over the course of six years. It wasn’t my mother’s fault, I explained, because she’d experienced much worse: her father had committed suicide. After a particularly difficult session, I broke down for the first time. I told the therapist about a horrible beating and the announcement from my mother that she hated me.

But I was very fearful, and that would be my last session. I returned the next week and told the therapist I couldn’t afford to come anymore. My finances were too tight. She said I was always welcome to come back, and she was proud of the progress I had made.

While my first attempt at therapy ended prematurely because I was still unable to face painful, buried memories, it proved to me that something mattered about my childhood. I’d hidden it away for a reason. There was something inside me, because I’d never cried like that before.

It took about another 10 years before I dared to try therapy again. By then I’d become a poster child for dysfunction: anonymous hook-ups, juggling sex with multiple partners, heavy binge drinking on weekends, and depression. Thankfully—again—I recognized my patterns were not going to stop without outside help. I had proven myself powerless to make changes on my own.

Searching the internet, I found GoodTherapy.org. I liked I could explore psychological topics, and could find a large, supportive community.

Searching the internet, I found GoodTherapy.org. I liked I could explore psychological topics, and could find a large, supportive community. I located a doctor near my home with a specialty in childhood trauma. Though I had no idea what trauma meant, I thought back to my first experimentation with therapy, and surmised a childhood focus would probably be what I needed.

I was very nervous on the first meeting, but the therapist put me at ease. I felt an immediate rapport with him. When prompted, I told him about the “childhood” part. I showed him a scar just below my right eyebrow. My mother had thrown me and I’d caught my face on the corner of a wooden bookshelf. I wanted to be worthy of his time and was afraid he might find my case frivolous and refuse to see me. At the end of the session, I asked him if he thought we would be a good fit, and he said, “Very much so.”

About two years later I began a book, Grandson of a Ghost, as a therapeutic exercise. I still had difficulty comprehending that my childhood impacted my life, and the book helped me see—literally, in black and white—the ramifications. Here is an excerpt, taken from the moment when I was able to articulate how the abuse poisoned my sense of self:

For Scott, it was now clear that with no one to talk to, and with no frame of reference—in isolation—he grew up fearful of people and had a low self-image. The low self-esteem as a child made the world a scary place. It was terrifying before and after a beating. He was helpless and lacked any shred of control. Everything was potentially dangerous and threatening, laced with a fear of getting in trouble. Fear of making a mistake. Fear of others discovering he was actually something awful. The secret had to be hidden so that no one would find out. It would interfere with learning, because of the amount of mental energy required to keep the secret. He daydreamed constantly, lost in a fog. It made sense. He was ashamed, because he misbehaved and always made his mother cry. He didn’t deserve love, because he was the horrible dark seed somehow planted within the family and disrupting it.

Generational abuse—abuse passed down from parents to children—is a widespread problem, and it impacted my family after the suicide of my grandfather. It’s a difficult topic, and I hope my book can help people.

Three and a half years later, I am still with my therapist. My life has been transformed. The fog has lifted. I’ve learned not to overreact to threats, both real and imagined. I’ve learned to question and quickly parse an alarm. I’ve learned my abuse did have lasting repercussions. I’ve also learned that love means something. It matters. And before working with my therapist, I was closed to it. Now I see connection to others as the key that sets me free.

Scott Depalma is the author of the forthcoming book, Grandson of a Ghost. He grew up in Vermont and fled to New York City when he turned 21, unsure of anything except the need to run and disappear. Scott hopes his story helps others recognize that abuse has a lasting impact, but also that a new perspective (a rebirth) filled with joy and connection is possible at any age.

We all have things and ideas and ventures that we turn over in our minds, sometimes on paper, maybe with other people who share our inconsistent commitments—projects that, even in their incompleteness, still have some hold on us. Our interest and our thoughts keep circling back to that place. We come back to them again and again, and we work on them in fits and starts. Unrealized projects we have yet to find the space or time to help become something concrete in our lives.

My unrealized projects are the fragments I have been writing for years about my mother. The Book (probably an overly optimistic way of seeing it, but we’ll go with that for now), or A Thousand Illegible Scribbles (I have the title, at least), that keeps flipping me on the back of the head, insisting that I pay attention. For almost a decade, my mom has struggled with a mental health condition. I’m still not sure what it is. It’s easier to describe symptoms than state a diagnosis. She cycles through the day between extreme emotional states—through anger and frustration, through sadness and a deep, deep stasis. She doesn’t think she has a head. She stares in the mirror to locate herself, brushes her hair ritualistically. She struggles with self-care; the shower hurts. She knows that I’m her daughter, but no longer cares for me as one. Her script has been unchanged for years: “I’m a bit nervous.” “I just worry about my sleep.” “I was a good mum, wasn’t I?”

[fat_widget_right]To gather the fragments of the book, my own unrealized (or maybe unrealizable) project, I decided to sit down with Amber Cady for an Office Hour on Unfinished Business. This was part of the program that day at Storefront Institute, a cultural and learning organization I recently launched with Kate Griffin in the San Francisco Bay Area. Amber is both a practicing artist and therapist, a combination that drew me to her (my own background is in contemporary art curation). She brings together the high-level ideological language of the art world with the empathy, compassion, and openness of the wellness industries. She’s my unicorn.

Amber’s Office Hour, then, sat between these two seemingly opposing but actually quite complementary worlds: she had designed a session that would take on a creative project that is loved and obsessed over, but that we don’t actually work on or don’t work on enough to actually make happen. Amber’s Office Hours would try to help us figure out why that particular project—that artwork or business, that blog or zine— keeps mattering, why it keeps insisting on space in our lives. She’d bring to our creative endeavors an emotional life and give them validity.

I started writing A Thousand Illegible Scribbles four years ago. It started with an article that was published in The Independent newspaper in the UK. There was a story that my mother couldn’t tell herself, but I could. And through telling it, I thought that I could do more for her, and others like her.

Would you put your mental health story, or that of your family, down on the page? Do you talk about it? Do you share your anxiety, depression, break-downs?

I’ve dealt with my mother’s struggles in various ways: spending time at home. Spending time away. Seeking out people to help her, to help my dad who is home with her, to help me. I have researched and discussed her condition. I have planned and argued with and for her. And I have written (in bursts), since I realized the condition that began the year I got engaged, like my marriage, had the promise of a life-long commitment.

I now have 40,000 words, pages and pages of fragments. I sit down and write when there’s no outlet for what I feel about her condition, or when she’s having a bad episode and I’m back in the UK living alongside her every day, or when we have any interaction that throws me back with her and less in California, where I now live.

“I suggested a walk. Mom asked to feed the ducks at Marbury Park. She’d collected scraps of bread which, it turned out, meant dad had pulled together almost a whole fresh sliced loaf. She didn’t notice. Too cold outside for us in April, we walked straight from the car park to the lake. She broke off the bread in handfuls, almost like pulling out hair, and chucked it at the ducks. Bits so big they should have choked. Ten seconds to tear through a loaf, then back to the car.”

Having done my own time on the couch, I know the structure of weekly therapy, but my Office Hour with Amber was different. The orientation of the session, its focus on unfinished business, meant that I had a clear, definable framework in which to work. Though going into it, I had thought that we’d talk about words on the page, about how to get the book going, about how the pieces I write occasionally can come together into a coherent whole. Plotting and planning its progress, making it take shape, setting goals. But this was therapy-of-sorts, and we lingered in that space of the emotional content that makes up the book.

Over the course of an hour, as we sat in the cozy booth at Makeshift Society where these sessions were held, Amber took me through four different ways of thinking about the project. We covered the strengths that the book represented for me and with that, the daily build that would support it, the obstacles for working on its daily pages, the allies and supportive forces to fortify progress, and the self-care necessary for keeping it a reality. Amber talked with me about how our creative projects are not just carefully contained goals, but real relationships, with all the complexity and messiness that those entail. Especially this one.

Talking with Amber, that’s where I got—this project is so much more than building chapters and momentum. It’s a deeply meaningful and emotional project that is about connection. Connection with my mother and the family I left behind.

“Mom paces. Dad was 40 minutes late for coffee, but we were together in a nice café, with warm drinks and each other’s company. Not so bad, but she slipped off her chair and shuffled from side to side, looking around for dad, though when he appeared she didn’t see him.”

But Amber also helped me realize the reason that this book languishes in that “unfinished business” category. She helped me identify the huge emotional roadblock, the one that would and does keep me away from the book: the threat of conflict. As much as it touches on urgency and meaning, the book also touches on points of contention and denial. It’s about connection, but holds the promise of its opposite: disconnecting me from those I care about.

When you talk about mental health, you very quickly enter the language of stigma; when you talk about mental health in your own family, you very quickly get to your own family’s biases and fears around the subject. To write to this subject means opening up our lives in ways that are terrifying and complicated to those involved, to admit to a problem that we don’t want to identify. I see writing as the invitation to connect, as an opening to a conversation, and I believe that we need to talk about the reality of mental health in our society.

But writing can end relationships too. As soon as I write a sentence, any sentence, there’s the possibility that the conversation I want to have around my mother’s situation may end in silence. Family members may shut down and turn away, or accuse me of airing our dirty laundry in public, acting on motivations that have more to do with fame and money than impact and value.

“By day three she is angry. She’s already at the breakfast table when I come down for a shower. She wears a ridiculous fluffy peach sweater that accentuates her size and attracts my baby daughter’s curiosity. She says nothing. No acknowledgement of the new baby, no acknowledgment of her old daughter. No good morning. Dad makes slightly burnt bacon butties. He asks Mom again and again if she wants one. Always ‘no.’ Her rice crispies are already stuck to her sweater. ‘No.’ I put the baby down for a nap, then hear ‘No,’ louder this time. My husband shuffles our son out of the house. I hear them chatting. More ‘No’s. Voices starting to rise.”

The book, even just lingering in the idea stage, contains the power dynamics in my family, the lingering shock of losing people I have loved, the pain that confrontation can bring. I’ve been framing the project as a way of making meaning from an awful situation, of researching and thinking and processing ways beyond how we currently think about mental health. Done in the right way, it may help my mum, my family, me, and others like her. But received wrongly, it might go the other way.

We are all touched by mental health issues. We know that now. We know that one in four people lives with mental health issues. We know someone who has a mental health condition. We’re starting to learn that we need to take care of our psychological well-being as much as our physical selves. We’re increasingly comfortable going to therapy or seeking help when we’re in crisis. What we’re less able to do is tell our stories or share our experiences or stand out as that someone who is, in fact, struggling. We’re not there yet. My mum is not there yet. My family isn’t. Maybe I’m not, either.

So this is what we do: we hide her away, we deal with it in private, hoping the neighbors don’t call the police with another outburst, that the local coffee shop doesn’t get tired of her rants and ask her to leave, that people don’t continue to turn away from our family, to give up on us. And we don’t get the help we need because we mistrust, we’re afraid, and we don’t talk about it, don’t know how to, and actually don’t want to.

That’s the real reason for the book—the belief that we need to tell our stories, to ourselves and each other, to make sense of our mental health. We need to talk about what preventative care looks like, what we do when someone “gets sick,” and resources for how to care for someone with a mental health condition. But it’s also a threat. Would you put your mental health story, or that of your family, down on the page? Do you talk about it? Do you share your anxiety, depression, break-downs?

Yeah, that’s where I am, too. Right in that space of knowing that to reach out is necessary, but to do so, in the words of my mother tongue, is bloody terrifying. That fear can silence us, even when we need those words on the page more than anything. That’s not just my unfinished business—it’s ours.

Claire Fitzsimmons is the Founder and Co-Director of Storefront Institute, a co-learning space based in San Francisco’s Bay Area that delivers discussion-based public programs facilitated by innovative practitioners – writers, artists, designers, teachers, and thinkers. Our programs provide the practical, social, and intellectual connections to open up new perspectives that help us better navigate our lives. Claire is a curator who has worked internationally and has spent more than a decade as an exhibition-maker and explorer of ideas and cultural practice.

Editor’s note: This article contains mentions of suicide. Details have been altered to protect client privacy.

Bill promised not to kill himself, as long as he could continue to see me. Despite his severe depression, this 67-year-old Vietnam veteran showed up at my office each week at 1 p.m. on Tuesday wearing the same stained beige t-shirt, torn jeans, and a faded baseball cap with the words United States Air Force embroidered boldly across it. His sour body odor choked the room as I listened to the horror of his nightmares and gauged the degree to which he wanted to kill himself that day. The hour before he arrived, I spent readying myself for his whirlpool of despair and avoiding the obvious fact that this person wasn’t getting better. In my 20 years as a psychotherapist, I had never encountered someone in therapy who worried me as much as Bill.

I was his third therapist. Before he reached me, Bill had already spent years in weekly therapy at our facility. His previous therapist ended treatment because he believed Bill was “not interested in getting better.” Still, I was optimistic that I could help this stubborn, but fragile, man. Bill reinforced my aspirations at first by leaving our sessions lighter. His depression soon reappeared, however, like a disturbed old friend who comes for a visit, somehow moves in, and requires a police escort to leave. But no matter how depressed Bill felt, he would always make it a point to end our sessions with, “I really appreciate our work together, and thank you for your time.” This gave me hope.

[fat_widget_right]Bill was angry, bitter, and resentful about many things. At the top of his list was his sister, Kate. What likely started as sibling rivalry in childhood simmered into a putrid sludge of jealousy, betrayal, and abandonment so thick that Bill’s irritable bowel syndrome flared up whenever his sister’s number flashed across his cell phone. Unfortunately, Kate was the only other consistent person in Bill’s life.

The only way I seemed to get through Bill’s anger was to connect with him as a person, not as a therapist. Whenever I strayed from my clinical persona and mentioned that I enjoyed a certain book or movie, he came alive. Bill would recommend certain books or DVDs and loan them to me like a devoted uncle. These exchanges touched my heart and showed me the thoughtful and caring man below his embittered exterior.

Over the first four years of our work, I came to recognize that Bill might be getting worse. There were ups and downs, but the downs came more quickly and stayed longer. His melancholy started to weigh me down, too. I began to feel burdened by our sessions and had trouble tolerating his misery. I knew it was my professional responsibility to work through my resistance, but I struggled. At times, his pain was almost too much to bear.

Somewhere around the middle of his fifth year of treatment, Bill blurted out that he found a “foolproof” suicide method on the Internet. His eyes twinkled as he shared that the suicide would mimic some other form of death.

Somewhere around the middle of his fifth year of treatment, Bill blurted out that he found a “foolproof” suicide method on the Internet. His eyes twinkled as he shared that the suicide would mimic some other form of death. “No one would ever know,” he mouthed his excitement. His demeanor frightened me so much I changed the subject. Later, once we had both calmed down, I asked him to tell me more about this method, but he had moved on. “I don’t want to talk about it,” he insisted. So, I assessed him once again for suicide risk. No, he reminded me, he wouldn’t kill himself as long as he could continue to see me.

After that, I started to question whether I’d be able to keep Bill alive. The gravity of my increasingly impossible duty sat on top of me in session, as I drove home, and at night while in bed. I felt so powerless. The truth was, I couldn’t secure Bill’s safety unless he verbalized intent to kill himself—only then could I hospitalize him. Bill knew this. He knew exactly what words would have him locked up in the psych ward, and he carefully avoided them. He had been hospitalized once before, a number of years ago, and wished never to return.

A few months later, Bill came to session particularly upset. He was being evicted from his flat where he’d lived for the past 30 years. His landlords had sold the property. Bill decided he was going to fight it. His determination seemed to embolden both of us for a few weeks. Bill secured a lawyer and showed up to session bathed and wearing clean clothes. I began to believe that if we could win this fight we might finally lift his depression. As it became clearer that Bill would be forced to leave, I changed course. Not Bill, though.

Bill started missing sessions. At first, I was secretly relieved that I didn’t have to spend the hour arguing with him about finding a new place to live. These disputes wore me out. But I was also worried about him, so after a couple of cancelled appointments I insisted he come back in. Things were not going well at all. Eviction was imminent. As a last resort, Bill had called his sister to ask if he could “crash” for a couple of weeks. Kate refused.

Bill sobbed in my office. I felt crushed, too, as I assessed for suicide and he promised, as always, not to hurt himself. His mood improved as we talked over his situation, and he felt supported. Toward the end of session, he promised to see a doctor about his IBS and attend a stress management group before our next meeting.

When I arrived at work the following Tuesday, I had a voicemail waiting for me from the site manager of our clinic. Bill’s sister, Kate, had contacted him. She hadn’t heard from Bill on her 40^th anniversary and found this strange. Nor was he answering his phone. Kate decided to call the police to check Bill’s apartment, where they found him found him on the bathroom floor, dead. The message ended by informing me Bill’s body would be sent for an autopsy to rule out suicide.

I cherished Bill and felt honored by his trust. Then I remembered the words he had used about a year ago—“foolproof suicide.” My grief turned to panic as I began to question whether he killed himself or not, and if so, could I have prevented it?

I locked the door to my office, put my head on my desk, and wept. I was devastated. I cherished Bill and felt honored by his trust. Then I remembered the words he had used about a year ago—“foolproof suicide.” My grief turned to panic as I began to question whether he killed himself or not, and if so, could I have prevented it? Why hadn’t I pressed him more for details? My thoughts jumped down that dark black hole, until I remembered I could only take Bill at his word. He had promised not to kill himself that day, as well as the gazillion other days I had asked him.

The coroner’s report came back a month later. It determined the cause of death to be a myocardial infarction—heart attack. I was relieved. Bill’s death was due to natural causes. But to this day, I still wonder if he may have used the “foolproof suicide” plan. He had come to the end of his road: he was elderly, physically impaired, soon to be homeless, and completely alone. His last remaining pleasure might have been to make sure he would ruin his sister’s anniversary each year by dying on the same day. Yet I can’t be fully certain. If he had taken any actions to bring about his death, they left no trace.

Bill’s death had me asking some very painful questions. Was there more I could have done? Was the therapy unsuccessful? And, most damning—was I to blame for his demise? Thankfully, the uncertainty around his death left many of these questions unanswerable and spared me from the agony I would have felt had I known for certain that he committed suicide under my care. In the end, after I tried so hard to protect Bill, he in his death may have, in fact, protected me. I will never know for sure, and I’m pretty certain that Bill intended it that way.

Susan Oren is a clinical psychologist who has been treating clients and training psychology pre-doctoral interns for over 25 years. Her writing has appeared in professional journals and books as well as in the Huffington Post and three anthologies.