Expert: Libby Bonner - 10/8/2008

Question
Dear Libby,

I want to make it very clear that I did not chose you randomly. I read your description and want your take on this question. This is very important to me and I've chosen who I wanted to ask with precision.

A dear friend of mine has suffered a lifetime of mental illness. She was diagnosed with schizophrenia at a very young age and has dealt with it her entire life. She has tried every medication known to man. Herbal too. It’s gotten to the point where her psychiatrist is suggesting she undergo electro shock therapy. Though they have told her very clearly that if that doesn’t work – there is nothing more they can do for her.

As a friend – I don’t know what to do. Help and support can only go so far when the entire psychiatric ward of UCSF is saying “if this doesn’t work, there is nothing we can do.”

Kate has made it very clear that she plans to end her life if the ECT doesn’t help. She has tried everything. She’s tried every drug, every remedy – and after years and years of patience, she’s run out.

Honestly, Libby – I don’t disagree with her. I don’t think I could have made it this far. I don’t think many people could have.

I’ve watched her suffer for 20 years. I’m certainly not going to encourage her to commit suicide – but at this point, I don’t think I could bring myself to talk her down from it either.

Does that make me a bad friend?

Thank you for your time.

Answer
P.S. to my long answer, below.  I have asked this in several ways, but this is a better question:  what would she wish for, what change or improvement, that might give her a reason to continue on a bit more?  Has she enunciated this to herself, to you?  ---- And is this suicide intention new and based largely on 'nothing else to do?' If so, it may be a sudden response, as I mention below, to the complete loss of hope...and she needs something new to realistically hope for.  Not new meds, probably....something un-medical.
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I usuually begin my answers w/ questions, and so I may need to hear from you again.

Her disorder has been continuously, unremittingly terrible all this time -- in what way/s?  She hears voices daily? - or what exactly has made this completely unbearable?  --  Is it a loss of former competence?  Is it unemployment and poverty?  Struggling to buy meds?

Has she been under expert care from the start, or only since _______ ?
If the expert care has come belatedly, that could mean that some damage occured during undertreatment that the right drugs, right doses, can't necessarily overcome now.

When under what would assume to be expert care, and using the best meds available throughout that time, did she take the meds for long enough periods to be sure of benefit/no benefit....and were there frequent enough contacts between her and the docs to get meds tweaked and dosages and/or drugs adjusted as needed.   [Necessary frequent contact is more likely w/ a private doc than w/ public doc...not always, but ....]

Besides your own steadfast loving support throughout, were there others providing a loving supportive network?  Does she have regular contacts w/ others?

AND - a hopeful thought that might change this picture some:  has she had semi-social contacts w/ other patients?  I am thinking on "clubhouses" or recovery groups or just drop-in informal places.
If she has not, you should see if that could change.  These other patients are her peers, in fact, and they are at very different stages of illness/recovery and w/ differenct diagnoses.  She could see how she functions relative to others, might find some persons who enjoy her company, might find herself reaching out to help anyone in emotional need.

[I hope also that she has had regular visits from helpful social workers over the years.....]

OK - much of the former is retrospective and maybe doesn't move us off dead center.  But maybe there will be a clue in there somewhere.

NOW to the only question that you asked.  Of course you would not be a bad friend...in fact, without giving her permission, you can certainly be overtly empathetic and say that you understand entirely how discouraged she is now, how discouraging it all has been.  

BUT.  Depending on the exact circumstances that prompt her NOW to do this, or think about it, one would not wish to have the clumsy docs' Nothing We Can Do be THE reason - the complete withdrawal, w/ their words, of Hope.  For instance, my suggestions, above, about greater contacts w/ others suggest a life beyond pills and ECT...   

That there is nothing more that psychiatry can do doesn't necessarily mean there is nothing to be done.....there is everything to be done [depending on exact circumstances, e.g., 20 years of horrid horrid Voices would defeat me] beyond and outside of medical care.  Can her environment be changed - better/different place, and/or where there are others around?  Could she care for, does she want, a pet?  Could/should she relocate? Does she have any hobby - craft - that interests her; is she in any shape to find an interest and pursue it?

And now - a personal note.  Early in my daughter's illness, when she was terribly depressed and distraught, and then confided her suicidal thoughts/intentions, I was so distressed by her pain that I asked a question very similar to yours.  Mine was, what sort of mother would beg her child not to do this, but to remain in terrible terrible pain, and I questioned where my truest, loving duty lay.  What I decided was to only listen to her ideas, saying only that I hoped she wouldn't carry them out...but no pleading on my part.  And, as events have proved, there were other, different days and years ahead for her, and for us....and she does very well now in her umpteeth year of illness.

However, I didn't just listen to her.  I did point out that not all intended suicides result in death, and that she could end up in a condition, for years, far worse that her present pain.  I don't know if you want to use that or not.  But I myself wouldn't care to have my 'suicide' end in paralysis or a severe head injury or unending physical pain and drastically limited mobility.

Oh - a bit more.  Have you been w/ her to hear the 'nothing more we can do?"  And/or - I hope she has signed a Release of Information naming you as the person to whom providers can talk plainly.  Should have one for every provider [not individual docs at UCSF, but assorted other entities whom she may still see.]  I would perhaps, w/ or w/o her, question the person who has pronounced Nothing, as to what, then, is she to do - live where, live how.  Put the person on the spot.  Has she told them of her suicide thoughts?  You and I can talk more about what, if anything, to do w/ that and the med staff.

I hope that both you and she understand that 'shock' treatments are today quite common, well-controlled, and very successful for many.  There will be some memory loss - maybe not all bad in this case? - but it is a good, valid, mainstream treatment today.

Write again whenever.