Often, patients were admitted because they had attempted to harm themselves, or they were at risk of harming themselves, or they had begun to lose touch with reality in a variety of ways. As tragic as each of these individual cases was, there were certain similarities that kept returning as I read about more and more of them. In many of the cases the patient was a woman. There was often overt relationship conflict involved, either with a significant other or with family members. Frequently there was a fairly lengthy history of psychiatric treatment in the patient's file. Patients were also often strapped for resources and living at or below the poverty line.
One morning, in mid-winter, I picked up a chart that struck me as quite different from the very first page. Patrick was a white, middle-aged, married man with no history of previous psychiatric illness. His chart contained only a brief description of the events that preceded his admission to the hospital. Apparently, Patrick's wife was out for the evening, and his teenage son was supposed to be spending the night at a friend's house. However, following a change of plans, Patrick's son returned earlier than expected and discovered his father sitting on the couch with a loaded shotgun pointed at his head. His son called 911, the police came, and Patrick was taken to the E.R. When asked what he was intending to do with the shotgun, Patrick replied simply, "End it." In response to my question asking why he wanted to take his own life, he stated only "Enough is enough" and refused to elaborate.
That morning I interviewed Patrick one-on-one. When he walked into the room I immediately knew that it was going to be difficult to connect with him and to find out what was really going on. Although he was dressed in hospital clothes and apparently had neither shaven nor combed his hair for several days, I could immediately see that Patrick was (or had been) a handsome man who surely stood out in a crowd. His short salt-and-pepper hair, dark green eyes, tanned skin, and muscular physique made an impression even in his current condition. Patrick looked like someone who could have been a football coach, a banker, a politician, or a mountain climber. Yet now he was clearly half of a person; someone whose former life was a distant and painful memory, and someone whose current life wasn't particularly worth living.
Patrick looked down at his lap during the initial part of the interview. He answered my questions in a courteous fashion, but his tone was matter-of-fact and he did not elaborate on any of his answers. He identified no reason for wanting to take his life other than what he had stated previously ("Enough is enough"). All of my attempts to empathize with Patrick seemed to clam him up even more. I began to wonder if a sense of having failed in some way had played a role in leading Patrick to consider suicide.
Eventually, and partly out of frustration, I leaned forward in my chair with my elbows on my knees. "Patrick, I've got to tell you, I can't understand what got you to this point. None of this really seems to add up," I said. "Can we be straight with each other and cut out the BS?"
Patrick began to tell me about the events of his life over the previous two years. He had been running a very successful self-made company. Through hard work and a series of calculated investment risks, Patrick had built the business to a point where he was able to move his family into a larger house with a lakefront view. His family and friends were aware of Patrick's successes, which were a source of substantial pride on his part. People knew him as an easygoing guy with a good sense of humor who was, in many ways, a model of successful manhood as it has been traditionally defined.
Then a series of setbacks occurred. First, a major consulting job did not pan out. Then one of his previous clients developed financial difficulties and began spreading the word that it was Patrick's fault. Patrick's own business steadily slowed until he had difficulty making a mortgage payment on the new house. Things went downhill financially from there. Then the economy crashed. It was Patrick's response to these events that really struck me. Rather than letting his wife and close friends know about the struggles he was facing, Patrick kept it all to himself. Over time, the gap between what people thought was going on in his life and what was actually going on grew larger, and Patrick became profoundly depressed. He couldn't face working, but he also couldn't face telling people how bad things had gotten. Instead, he got up each morning, dressed as if he was going to work, forced a smile for his family, and either drove around the city or sat at a local coffee shop all day reading the newspaper. Eventually the depression became so overwhelming that he saw no other way out.
"How could I face them?" he asked. "What would they think of me? In their eyes I'd look like a has-been, somebody whose time had come and gone, only because he couldn't handle it."
"But those were extremely difficult experiences you had," I said. "Nobody could have foreseen the financial difficulties."
"I should have been able to. Besides, that's not what I'm talking about. I should have been able to handle it emotionally. Instead, I fell apart and turned into a sniveling little boy. What was I going to say, 'Oh, Mommy, please help me?' I couldn't let people see me like that."
On the one hand, it seemed obvious to me that no man would want to see himself like a little boy asking for Mommy's help. But then if you stopped and thought about it, is asking for help worse than dying? How far will a man go to hide his shame? How many Patricks are there who would rather take their own lives than try to break through the gauntlet of silence and invisibility that prevents them from finding the support they so desperately need?