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"I am hearing voices telling me to kill myself," said a weary woman's voice on the other end of the line. The telephone had awakened me out of a deep sleep. I was new in residency training, and at 3 a.m. it was not easy to bring to mind the techniques for handling psychiatric emergencies. I asked background questions: Who is your usual therapist? What medications are you taking? What happened yesterday? What has worked in the past? What brings you to call at this particular time?
She dutifully answered my questions, then came back with the question I had been avoiding and dreading: "What shall I do?" Giving advice was something I had not been trained to do. In fact, I was learning to do the opposite: help people solve their own problems by carefully listening and being neutral. After many minutes, it became clear that this was not working. Here was a seriously suicidal woman who wanted advice from me.
I gave in and gave advice. She met everything with negatives. She had heard it all before. She had obviously talked to many other psychiatric residents before me, collecting suggestions to counter the deadly voices. It even crossed my mind that she was hired by the residency program to test me, and I was failing. Finally, in exasperation, I threw off all professionalism and said to her, "I don't suppose it would help just to tell you not to kill yourself." To my utter amazement, she said, "Oh yes, that would help a lot. You see, with all these bad voices telling me to kill myself, what I need are a few good voices telling me not to."
Those words have stayed with me through years of practice, reminding me that I am a voice for life, helping counter the voices of destruction.
The draft of a recent General Conference Mennonite Church statement on violence says, "We call the church to name violence against self as sin." When I first heard about this statement, it seemed to me that the wording was too negative and too simplistic. How can the church call suicide a sin? It is a symptom of a biological illness. The question reopened the pain of being part of a family that has grieved suicide more than once.
Then I went back to work. In my work as a psychiatrist, suicide is the enemy. I battle against it every day. I talk to people about suicidal thoughts; I read about suicide prevention in medical journals; and I am made aware at professional meetings that suicide is one of the leading causes of malpractice suits against psychiatrists. I must document in my charts that I have asked about suicidal tendencies. Whenever I write a prescription, I must think about whether the amount of medication I give could become a lethal weapon.
When I counsel people who are struggling with suicidal thoughts, I try to help them sort out the forces for and against suicide, then reinforce the reasons they have for staying alive. I have come to think of them as the "good voices". They range from mundane ("Who would take care of my cat?") to sacred ("I'm afraid I would be committing the unpardonable sin") and from temporary ("I want to stay alive long enough to see Harrison Ford's new movie") to permanent ("I don't know if I could do this to my family"). I help the person listen to each voice: None is considered too trivial or guilt-producing. Here is one situation where I do not try to minimize guilt; rather, I reinforce it to buy time to help the person over the crisis. One of the strongest voices and thus my most positive ally—is a person's religious belief that suicide is wrong.
I must here make a distinction between suicidal thoughts and the act of suicide. I do not believe that suicidal thoughts can be named sin because they are usually involuntary. They are symptoms of severe medical or emotional illness. On the other hand, the act of suicide is more deliberate, done after much agonizing, ambivalence, thinking and planning. It is in this stage that the suicidal person most needs to hear the voices saying, "No, don't do it." But is that any reason to call suicide a sin?
Karl Menninger, well-know psychiatrist and founder of the Menninger Clinic in Topeka, Kansas, wrote a book called Whatever Became of Sin? (1973). He believes we have turned sins into symptoms of illness, quieted the voices of clergy who used to speak out against sin, and thus given up individual and social responsibility. He says, "If a dozen people are in a lifeboat and one of them discovers a leak near where he's sitting, is there any doubt as to his responsibility? Not for having made the hole, or for finding it, but for attempting to repair it. To ignore it and keep silent about it is almost equivalent to having made it. Thus, even in group actions, there is a degree of personal responsibility, either for doing or not doing or for declaring a position."
Church statements on suicide do what Menninger is talking about. By adopting such statements, we are saying as a church, "We are all in this boat together. We accept personal and corporate responsibility, and we agree to do something about it." Calling violence against self a sin is the first step toward destigmatizing conditions that for years have been hushed up.
I hope such statements will be taken not as a condemnation of people who have acted on suicidal thoughts but as a consolation to people who feel they struggle alone. I am convinced that it is important that we speak out about suicide. Being part of a church that is able openly to take a stand such as this makes my voice stronger when I am helping someone through the night.
Janet Toews Berg practises psychiatry in Seattle, Wash. and attends Seattle Mennonite Church. This article is reprinted, with permission, from the Oct. 28, 1997 issue of The Mennonite.
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