Harvard/McLean psychiatry residency notes continued
Dr. John Maltsberger MD, a psychoanalyst and suicide specialist, gave us residents a lecture on September 20, 1991, a portion of which I described in a prior post. Here, I complete his lecture.
“What do you see in the mirror?” he asked.
The question stunned me. What a good way to ask someone about his self-esteem. Do we even look in the mirror much? I notice that I look less as the years go on than I used to look. Aging has a way of doing that; we turn our eyes away; we don’t want to see. Low self-esteem. That happens in people of any age for psychological reasons. It matters, as we’ll see, in its influence on suicide risk.
He continued:
“In treating a suicidal patient, be guided by the formulation not the mental state.”
Another pearl. We focus too much on the present: the patient is depressed, he’s anxious, he’s impulsive - or not. Either way, we worry about suicidality more, or less, than we should. The current mental state matters, but by itself it’s a poor guide to suicide risk. 90% of people who die by suicide have clinical depression at the time, but > 99% of people with clinical depression will not die by suicide in any single episode (about 5% eventually die by suicide in an eventual episode). What else should we do? The usual teachings are obvious: past suicide attempts, but one half of people die by suicide the first time they try; psychosis, but most people with delusions are not suicidal; and so on.
Maltsberger, using his psychoanalytic approach, boiled it down to two psychological features:
“In suicide assessment focus on two things:
1. Interior narcissistic reserve: producing the capacity to maintain self-esteem, soothe anxiety, and modulate rage responses when alone.
2. Exterior sustaining resources: self-objects (some aspect of oneself that we like)
a. Love – which can be to any object: a pet, God, even a delusion
b. Work
c. Self-aspects, like health
If there is poor interior reserve, then suicide attempt is often precipitated by failure of one of the three exterior supports.”
Nice: “A pet, God, even a delusion.” Anything that creates an attachment helps prevent suicide. Obviously the relationship with the clinician is an important one that is designed to help in this regard too. But don’t forget the dog, or the cat; and don’t forget God. Clinicians tend to be aggressively progressive, at least in the United States. There’s no room for God in the consulting room. You might invite a complaint to the state board if someone doesn’t like God and you speak of Him. But don’t resist: let the patient speak of God, even encourage it, Maltsberger says. Who are we to judge?
Even a delusion. Who are we to judge?
So the first step is that self-esteem, that look in the mirror. If there is something positive there, a person is protected. If there’s nothing, nothing at all, it’s dangerous.
And the second step is exterior supports, which clinicians commonly realize, but they don’t allow often enough for the pet, for God, and even for delusions.
We were reaching the end of the lecture. Terry Maltsberger turned solemn:
“You have to be prepared to lose patients if you want to treat patients, and you even have to be prepared to lose patients because you made a mistake. Learn to forgive yourself.”
Thirty years later, having lost at least five persons I treated, even realizing in at least one case it was because I didn’t know better at the time, doing something I wouldn’t do now - thirty years later, I know what he means. And I really appreciate what he meant.
Learn to forgive yourself.