Whenever suicide comes up—either because the patient or the therapist broaches the topic (bringing it up does not, as some worry, “plant” the idea in a person’s head), the therapist has to assess the situation. Does the patient have a concrete plan? Is there a means to carry out the plan (a gun in the house, a spouse out of town)? Have there been previous attempts? Are there particular risk factors (lack of social support or being male; men commit suicide three times more often than women)? Often people talk about suicide not because they want to be dead but because they want to end their pain. If they can just find a way to do that, they very much want to be alive. We make the best assessment we can, and as long as there’s no imminent danger, we monitor the situation closely and work with the depression. If the person is set on suicide, though, there are a series of steps to take right away.
Rita was telling me that she would kill herself, but she was very clear that she would wait out the year and not do anything before her seventieth birthday. She wanted change, not death—as it was, she was already dead inside. For now, suicide wasn’t my concern.
What was concerning to me, though, was Rita’s age.
I’m ashamed to admit this, but at first I worried that I might secretly agree with Rita’s grim perspective. Maybe she really was beyond help—or at least beyond the kind of help she wanted. A therapist is supposed to be a container for the hope that a depressed person can’t yet hold, and I wasn’t seeing much hope here. Typically I see possibility because the people who are depressed have something to keep them going—it might be a job that gets them out of bed (even if they don’t love that particular job), a network of friends (just one or two people they can talk to), or contact with some family members (problematic but present). Having children in the house or a beloved pet or religious faith can also protect against suicide.
But most notably, the depressed people I saw were younger. More malleable. Their lives might seem bleak now, but they had time to turn things around and create something new.
Rita, however, seemed like a cautionary tale: a senior citizen, utterly alone, lacking in purpose and full of regret. By her account, she had never truly been loved by anybody. The only child of older and distant parents, she had messed up her own children so badly that none of them spoke to her, and she had no friends or relatives or social life. Her father had been dead for decades, and her mother had died at ninety after suffering for years with Alzheimer’s.
She looked me in the eye and presented me with a challenge. Realistically, she asked, what could change at this late date?
About a year earlier, I’d gotten a call from a well-respected psychiatrist in his late seventies. He asked if I would see his patient, a woman in her thirties who was considering freezing her eggs while she continued to look for a partner. He thought that this woman might benefit from consultation with me because, he said, he didn’t know enough about the dating and baby-making landscape for today’s thirty-somethings. Now I knew how he felt. I wasn’t sure that I fully understood the aging landscape for today’s senior citizens.
I’d learned in my training about the unique challenges faced by older adults, and yet this age group gets short shrift when it comes to mental-health services. For some, therapy is a foreign concept, like TiVo, and besides, their generation grew up largely believing that they could “get through it” (whatever “it” was) on their own. Others, living on retirement savings and seeking help at low-cost clinics, don’t feel comfortable seeing the twenty-something therapy interns who predominantly staff them. Before long, these patients drop out. Still other older people assume that what they’re feeling is a normal part of aging and don’t realize that treatment might help. The result is that many therapists see relatively few seniors in their practices.
At the same time, old age is a proportionately larger percentage of the average person’s life than it used to be. Unlike the sixty-year-olds of a few generations ago, the sixty-year-olds of today are often at the top of their games in terms of skill, knowledge, and experience, but they’re still pushed out professionally for younger employees. The average life expectancy in the United States now hovers around eighty, and it’s becoming common to live into one’s nineties, so what happens to these sixty-year-olds’ identities during the decades they still have left? With aging comes the potential to accrue many losses: health, family, friends, work, and purpose.
But Rita, I realized, wasn’t experiencing loss primarily as a result of aging. Instead, as she aged, she was becoming aware of the losses she had been living with her entire life. Here she was, wanting a second chance, a chance she was giving herself only a year to realize. As she saw it, she had lost so much that she had nothing left to lose.
That part I agreed with too—mostly. She could still lose her health and beauty. Tall and slim, with large green eyes and high cheekbones, her thick naturally red hair flecked with just a few strands of gray, Rita was genetically blessed with the complexion of a forty-year-old. (Terrified of living as long as her mother had and running out of retirement funds, she refused to pay for what she called “modern beauty expenses,” her euphemism for Botox.) She also attended an exercise class at the Y every morning, “just to have a reason to get out of bed.” Her physician, who had sent her to me, said that she was “one of the healthiest people her age I’ve seen.”
But in every other way, Rita seemed dead, lifeless. Even her movements were listless, like the way she sauntered to the sofa in slow motion, a sign of depression known as psychomotor retardation. (This slowing down of coordinated efforts between the brain and the body might also explain why I kept missing the tissue box in Wendell’s office.)
Often at the beginning of therapy, I’ll ask patients to recount the past twenty-four hours in as much detail as possible. In this way I get a good sense of the current situation—their level of connectedness and sense of belonging, how their lives are peopled, what their responsibilities and stressors are, how peaceful or volatile their relationships might be, and how they choose to spend their time. It turns out that most of us aren’t aware of how we actually spend our time or what we really do all day until we break it down hour by hour and say it out loud.
Here’s how Rita’s days went: Get up early (“Menopause ruined my sleep”), drive to the Y. Come home, eat breakfast while watching Good Morning America. Paint or nap. Eat lunch while reading the paper. Paint or nap. Heat up frozen dinner (“It’s too much trouble cooking for one”), sit on her building’s stoop (“I like to look at the babies and puppies that people walk at dusk”), watch “junk” on TV, fall asleep.
Rita seemed to have almost no contact with other human beings. Many days, she talked to nobody. But what struck me most about her life wasn’t just how solitary it was, but how nearly everything she said or did conjured for me an image of death. As Andrew Solomon wrote in The Noonday Demon: “The opposite of depression isn’t happiness, but vitality.”
Vitality. Yes, Rita had had lifelong depression and a complicated history, but I wasn’t sure that her past should be our initial focus. Even if she hadn’t given herself a one-year deadline, there was another deadline that neither of us could change: mortality. As with Julie, I wondered what the goal should be in treating her. Did she just need somebody to talk to, to ease the pain and loneliness, or was she willing to understand her role in creating it? It was also the question I was struggling with in Wendell’s office: What should be accepted and what should be changed in my own life? But I was more than two decades younger than Rita. Was it too late for her to redeem herself—is it ever too late for that? And what degree of emotional discomfort would she be willing to endure to find out? I thought about how regret can go one of two ways: it can either shackle you to the past or serve as an engine for change.