Saturday, October 4, 2014

Get Out!

    Many years ago, before cell phones existed, on a Friday afternoon about 2 PM, between patients, a CEO here in Portland, Oregon, called me.  After a hello he said, “Dr. Paltrow, I desperately need your help. One of my employees is in my office right now. He came to tell me he is going to commit suicide tomorrow or Sunday. Please tell me what to do.”
    I replied, “Ask him if he would go into a hospital to a psych unit?” I waited. “No.” “Ask him if he would accept antidepressant medication?” I waited. “No.” “Ohh…kay,” I said followed by, “Ask him if he would come to my office at 5 o’clock this afternoon?” I waited. “Yes, but he tells me he will get out of your office at 6 o’clock.” “Ohh…kay,” I replied, and then said goodbye.  To have a psychiatric emergency is not unusual.  But to have one hour to treat this particular emergency was really unusual and would really test my skills.
    Five o’clock came and with it my new patient.  As I ushered him into my office he was courteous and soft-spoken, but right off the bat he wanted me to know he had been in a state penitentiary and would not tell me why. And then because he must have known what I was thinking he said, “If you call the police to put me on a police hold I will flatten you, pull out your phone line, and I will get out of here.”  Odd, I thought,  “get out” was the same phrase his boss mentioned earlier on the phone.  “Ohh…kay” I said.  “I will not call the police.” And l emphasized, “Further, you will get out of here by 6 o’clock. So, why do you want to commit suicide?”  
    I posed one question after another, searching for an explanation, or even a clue or a lead. Then suddenly he looked at the clock on my desk and said, “Do you realize it is already 5:30 and you have accomplished nothing? I am wasting my time, but I will stay the full time because I promised my boss I would give you one hour.” I replied, “I know I have found nothing with all these questions. I still have some time. So, please tell me about your childhood.”
    “Okay. I never knew my father. I don’t even know if my parents were married. I never met my older brother. My mother had boyfriends who came to our house. They ignored me. Just after I turned five we went to live with her parents. I quickly discovered that my grandfather loved me and that my grandmother hated me.  About three years later my grandfather died of a heart attack. Almost immediately following, my grandmother told my mother and me, ’Both of you get out of here.’  So that’s where “get out” comes from I thought to myself.  We got our suitcases from the closet and placed them on the bed my mother used. As we started to pack them my mother turned to look at me. She said, ’You are a drag in my life so I’m going to put you in a foster home.’ She did put me in one foster home after another. I got into a lot of trouble; so bad in fact I ended up in a state youth authority institution where I remained until I was eighteen. Before I turned twenty one I got into so much trouble I ended up in court and then in the state penitentiary.” Suddenly he turned to look at my desk and exclaimed, “And now it’s quarter of 6:00 and you still have accomplished nothing.”  I felt incredible emotional pressure to find a solution. But if I were to succeed I had to keep my emotions on hold. A sentence from The I Ching or Book of Changes could describe my state of mind: “Passion and reason cannot exist side by side.” (1)
    Every situation involving the possibility of suicide is complicated, precarious, and so intensely personal. Many do commit suicide no matter what interventions are tried.  One insight I learned suggested that those who feel suicidal feel stuck in or despise one or more of their roles.  If this insight fit my patient I had just 15 minutes to find that role, which then might defuse his suicidal emotion.   
    I then said softly, “Listen closely; you will get out of here at 6 o’clock. But during the next fifteen minutes I want you to repeat everything I say.”  He nodded. “Okay, please look at the wall and slightly toward the ceiling and repeat.”
    “Dear grandpa, I am in a psychiatrist’s office doing this verbal letter to you. You might be looking down from heaven; you might even be in this room. I am sure you heard what I told the psychiatrist about my childhood but I will repeat it.  I never knew my father. I still don’t know if my mother and father were married. I never met my older brother.  My mother had boyfriends who ignored me. We came to live with you and grandma shortly after I turned five. And then you had a heart attack and died when I was eight. In my whole life you were… the only one…who ever…loved me.” He began to cry. I immediately stopped talking. Then he sobbed. I looked at the clock. I could not afford to wait very long. As he quieted down I continued. “Grandpa, I loved you…when I was a child; I love you…now; and I will always…love you. Thank you for loving me. And, grandpa, there is a place in my heart…just for you. And, grandpa, I hope God loves you and is taking care of you. I am going to sign off now. Love, _____.” Then I urgently and softly said, “Get out. Get out of here right now.  I knew I had to use that phrase. And you are to be back here Monday at 5 PM!” He seemed to be in a trance. He slowly got up from the recliner. He said nothing. He exited my office.        
    I could not relax over the weekend. I hoped he would stay alive.  I hoped he would return to my office. I heard nothing from him or about him over the weekend and nothing all day Monday. Fortunately I was available right at 5 PM.   And he did arrive right at 5 PM.  I was so relieved. I ushered him into my office.  
    He sat down. I said nothing. Finally, he said, “I wanted to find you and kill you over the weekend.” I asked, “Why?” He raised his right arm toward the ceiling. Then he mimed and spoke, “Nobody in my entire life ever went down into my throat and pulled out what you did on Friday. And by the time I got to my car I was not suicidal and I was not suicidal the whole weekend. I was so angry at you. I hated you for that.  What did you do to me?”
    I answered his question, “I found you suffering overwhelming grief from the loss of your grandfather. You were finally able to grieve.  Being able to grieve must have  stopped your feeling suicidal.” Then I was silent. After a few seconds he surprised me by saying, “So what happens now?” I replied, “If you’re okay with it, we’re going to carry out verbal letters to the other members of your family, so that you can have some resolution of your thoughts and emotions connected to them.” “Okay,” he replied.
    I continued with the Gestalt therapy, therapy that incorporates drama. One aspect of this therapy is the use of verbal letters to persons, places, and things. This therapy often accesses both conscious and subconscious thoughts and feelings, which greatly helps to wane passion and wax reason. Gestalt therapy was developed by Friedrich Perls (July 8, 1893-March 14, 1970), German-born psychiatrist and psychotherapist, and his wife, Laura Perls, in the 1940s and 1950s.
    We had a few more sessions.  He was totally cooperative and seemed to benefit.  He no longer had the desire to commit suicide.
    I am often gratified and amazed with the power of psychotherapy.  I did not know ahead of time that he had unresolved grief and it did not occur to me for some period of time after the therapy that he did cry for help and that his boss and my “loving” him must have put him in the role of “loved person” in place of the role of unloved person.  About two years later he called stating that he was fine and wondering if he could refer a friend.  

(1) Wilhelm, Richard, Cary F. Baynes. The I Ching or Book of Changes (Bollingen Series XIX). Princeton: Princeton University Press, 1971

All contents and writings of this blog are property of Kenneth Guy Paltrow, M.D.
Kenneth Guy Paltrow, M.D. is a psychiatrist practicing in Portland, Oregon.   This blog contains references to actual cases he has encountered over the years. Please note that names and other identifying characteristics have been changed to protect the privacy of those involved. This blog is not intended to be used as medical or psychiatric advice for the reader.  Use of information in this blog is at the reader's discretion and risk.  The reader should seek advice from consulting his or her own practitioner.