Editor’s note: We publish this article with a content warning due to discussions of suicide, suicidal ideation and depression in this contribution.
A medical student, to whom I will refer as X, posted on their social media page they were going to kill themselves. Their letter was direct, raw and, as many suicide notes tend to be, apologetic. They explained they felt they no longer had the strength to keep fighting; it was simply “time for them to go.”
Yet the responses to this letter, as many responses to such notes tend to be, were well-intentioned but incongruent relative to the honest words in the original post. X confessed they were exhausted; people replied, “But we love you…” X painted a detailed and deliberate picture of internal suffering; people said “But you’re so handsome…” X said they were going to kill themselves; people answered with “We hope everything is okay.” The next day, a friend updated everyone that X was doing “great” and reassured us that X is an outstanding person who enjoyed their life, felt bad about writing the suicide note, and would never really kill themselves.
What strikes me in this situation is the stigmatized societal influence which results in feelings of guilt by the person who is already in a vulnerable position. Overwhelming and varying emotions after a suicide attempt are expected; however, I think guilt ought not to be part of this array. It is not my intent to encourage suicide or suicidal ideation; on the contrary, I write this with the aim of offering a defense for X and to contribute to destigmatizing the issue.
Being an outstanding person and wanting to die are not mutually exclusive. Suicide should not be referred to as a terrible, abstract act that is shameful and unspeakable. Dr. Beth Brodsky, associate clinical professor of medical psychology in psychiatry at Columbia University, has commented on the high rate of physician suicide as “alarming” and affirmed that “suicide is an illness and not a crime.” There is a difference between discouraging someone from ending their life and making them feel guilty or ashamed of their feelings and actions especially since this is not an uncommon occurrence.
According to the Centers for Disease Control, suicide was the second leading cause of death after unintentional injury for people between the ages of 10 to 34 in 2017. This means suicide is a more common cause of death in this age group than homicide, malignant neoplasms, congenital abnormalities or heart disease. Importantly, medical students have been reported to have higher rates of mental illness, burnout and depression than the general population; they are less likely to receive treatment, with stigma as one of the barriers to treatment utilization. Thus, there is a need to reduce the stigma associated with mental illness.
Sylvia Plath was terrified of what she described as a dark thing that sleeps in her; Elizabeth Wurtzel fell in love with her all-consuming depression because she felt it was all she had, all she was. She described that she wished she could walk through a picture window and have the sharp broken shards slash her to ribbons so she could finally look how she felt. A majority of suicides and suicide attempts are associated with psychiatric disease and are estimated to be at least 10 times higher risk than the general population. Causes of suicide in the general population are extremely varied, including issues with finances, relationships, chronic disease diagnoses, discrimination, violence, terror and war. Suicide is a tormenting and pertinent issue regardless of the specific etiology or risk factors.
We must take care when trying to be supportive to avoid unintentionally perpetuating stigma and guilt. Referring to the well-established “but people love you” response is not effective; usually, suicidality is independent of a person’s family, friends and peers. In fact, this response is more likely to externalize guilt and shame. Commenting on how “beautiful the person is” pointedly ignores their pain and is more likely to undervalue their feelings during a crisis. Posts expressing hopes that “everything is okay,” when they are clearly not, might be perceived as insensitive.
Regardless of the situation and your connection to a person like X, it is difficult and frightening to witness someone you care for in anguish. This fear may be the reason for a kind of paralysis of not finding the “right words” to say what you feel: I am here for you and I want to help. While trying to express this caring sentiment, we ought to stay away from responses, well-intentioned as they may be, that allow stigma and guilt to flourish and solidify. Instead, aim to validate feelings, listen patiently and provide connections with community resources and treatment options.
If there is a need for urgent care, seeking help at an emergency department is appropriate. If you feel comfortable, remind them that you are there for them and ask how you can be supportive. In an ideal world, no one would feel compelled to post such a message on social media; I hope anyone in a similar situation feels able to reach out for guidance from trained specialists, using resources such as a suicide or crisis hotline, the American Psychiatric Association, the World Health Organization or the Suicide Prevention Resource Center.
Lastly, dear X, I can only imagine how difficult it was for you to be vulnerable in front of your loved ones and peers. If you felt bad after the incident, I hope it was solely because of the nausea of the antidote, the IV in your arm, or maybe the hospital’s uncomfortable pillows, but not because of the burden of feeling that you need to apologize or redeem yourself. In a world filled with deception, your words were genuine and your choice to embrace help in the midst of your struggles was heartening and brave. I hope you are able to access the support you need to work through this, and I am excited to see the virtuous impact you will have on our communities and the medical field.