You have such a unique career. Please tell us what steps you took to get to where you are today.
I knew I wanted to be a doctor, but I thought I was going to be a mission doctor in India as I had spent time in a missionary hospital there while I was in college. I received my BA from Princeton - I was an English major because I knew I also wanted to write. I also did some post graduate study in science at Columbia University. Before medical school I worked at an elementary school in Harlem (preschool thru 3rd grade) and I realized that a lot of what plagues American kids were things that happened in their lives (e.g., being exposed to abuse, having a parent with mental illness and/or substance abuse), even more than the fact that 20% are hungry. These issues were what I gravitated to, and that spurred me to work with schools. I knew from the work in Harlem what a hard job it was to be a teacher and I wanted to be able to support teachers. I had the idea to open a pediatric clinic in Harlem named after the chef I adored at that school, it would have been called the Lila Mae Carter Clinic, but I realized in medical school that I wasn't so fascinated by the antibiotics for ear infections, doing immunizations, etc., that make up the daily practice of pediatrics.
What I wanted to do was hear about kids' lives and try to figure out how to work with them when they were in pain. That's how I went into child psychiatry and I never turned back. I received my MD degree from Tufts and did my postdoc at Massachusetts General Hospital, followed by a Child & Adolescent Psychiatry Fellowship at Cambridge Hospital. I have been on the faculty at Harvard Medical School since 1996. I've devoted my professional career to fortifying kids and preventing and treating depression and suicide while decreasing the stigma that surrounds getting life-saving treatment. I've worked in a school-based health center for 18 years, collaborating with teachers, families, social workers, and school nurses in a concerted effort to provide an anchor for troubled teenagers. This is high-adrenaline, meaningful work. I know that if I can spare the families a loss of someone they love, it is immense.
So today's topic is also the title of your book. Can you tell us a bit about what you found out about your mother's death?
In my book, In Her Wake: A Child Psychiatrist Explores the Mystery of Her Mother's Suicide (Basic Books), I explore my mother's death by suicide from the perspective of a daughter seeking answers and desperate to know something about her mother, from the perspective of a very present mother of 3 teenagers, and finally, as a doctor working with teens confronted with deeply disturbing challenges.
The context of how this happened is that my mother and father had a 2-year custody battle. I was the youngest of 6 children at 4 years old (my oldest sister was 12). My parents were fairly prominent in the early 1960s in Boston so the divorce and custody battle were covered a lot in the local media. The beginning of my book introduces those articles (which gave a very polarized view - they really made it sound as if my mom was kind of a hysteric and my dad was rescuing the kids). On the day that we were supposed to be returning to my mother, the judge stayed the decision and my mother went home and took a fatal overdose. She had made a suicide attempt once before in 1961 and what we know about suicide is that once an attempt is made you are considered at risk for 2 years after. She died by suicide in 1963.
What were your reasons for writing your book?
What compelled me to write this book was the birth of my first daughter. When I cradled her in my arms I realized, 'oh my gosh, my mother loved me!' You might say, 'of course your mom loved you.' But I had been raised with this idea that my mother had abandoned us. This made some sense to me at the time, because she killed herself, and it occurred within a custody battle and certain stories were told.
But that first moment with my daughter raised my curiosity. I knew by how much I loved my child that something must have gone terribly wrong for my mother and I wanted to figure out what that was. I'm grateful to have all sorts of support, my husband, my family, I had my own therapist. I wanted to write the story for others who may not have had those luxuries.
Further, as a writer I was motivated by a desire to show my process of healing. Even though it was a somber topic in some ways, I wanted it to also be a memoir about hope and healing and to show how you may go about making sense of a complicated situation. I found that my memoir combined with my profession formed a powerful vehicle to reach people affected by suicide (or who may be suicidal). The message I try to get across is that when someone is suicidal, they truly believe they are expendable – they think 'no one is really going to care if I am not here.' I want them to understand how their families would be devastated by their loss. Some of my colleagues joke that I am 'out of the closet.' I like to think if it as my way of showing that we are all human and even from the darkest traumas, there is hope.
What would you diagnose your mother with?
I never interviewed her, so I don't know. Ten years in to writing my own memoir, a trunk of her belongings magically showed up and I found that she was writing a novel called The End of Freedom. It has a main character that kills herself – a woman who was running for governor. She also had journal entries that would suggest she was depressed and possibly bipolar. But again, I never interviewed her so I'm not sure. What I would say is that if she had bipolar disorder, I would have prescribed her lithium in a heartbeat. We know from the research that if you have bipolar disorder and you take lithium you are 8 times less likely to kill yourself.
Being that your mom had six children, a significant portion of her adult life was spent being pregnant or postpartum. Do you think postpartum depression may have had some role?
This speaks to my incredible sympathy for parents and how they talk with kids about suicide. My dad was shocked when he read the book and you will see toward the end of the book where there are 75 endnotes where my dad adds in different comments. He was shocked at what I had taken from his comment: "you mother was never the same after you were born." That I would have internalized that as "it would have been better if I wasn't born." Because clearly, not long after I was born, she killed herself. He didn't mean it that way, he was speaking to the fact the he thought that she'd gotten more depressed after I was born.
How does one try to break down the walls of stigma so that people are able to talk openly about suicide, get help (and feel better about it), especially on a college campus?
We know from CDC data that 20% of kids have thoughts of suicide each year, 5% make attempts, and 1% make attempts that warrant serious medical attention. So there is a reason for us to be devoted to trying to decrease the stigma. College campuses have approached it differently. Some campuses have students involved in psychodrama (i.e., they will act out certain situations that help to engage the viewers); some have a systemic outreach approach (i.e., there are leaders available on campus who are skilled to identify the warning signs). I think it's important to get the message to students that they shouldn't worry alone – share the responsibility. This can be difficult because they are young adults and they may feel like it is wimping out to tell someone about their worries or they may think that disclosing those details about a peer (or themselves) could jeopardize their academic careers. It's important for universities to be transparent and make students aware of what to do, how/where/who to ask for help. I have students from my freshman seminar who have gone on to become peer counselors and we have a designated space that is manned 12 hrs per day (i.e., 2pm – 2am) where students can go and get help. We feel this is an easier gateway of support for students to talk with informed peers, and this may open the door for them to get connected to a medical professional. Many colleges have also placed more emphasis on wellness centers, so the gateway to support may come from addressing how a student manages stress.
What is the psychiatry community doing now for outreach to families of suicide victims?
The American Foundation for Suicide Prevention [AFSP] and the American Association of Suicidology have made concerted efforts to have a place on the internet where people can go and get information and find support groups across the country facilitated by others who have experienced losses due to suicide. As far as the psychiatry community, I don't think it is happening very often. I'm just starting to work on a paper that explores the different interventions for families and so far there's not a lot of literature out there – most of what I did find began in the late '90s. We don't have 'evidence-based treatment.' But it's hard, how do you get a control group? I have been writing in various journals to raise awareness e.g., Psychiatric Times, Psychiatric News, the Journal of the American Academy of Child and Adolescent Psychiatry, because there are all sorts of places to intervene - think of the emergency room, where a family may have just experienced a family member's suicide (or an attempt). Some organizations like AFSP will have a volunteer go and meet with the family to provide support. And just understanding the importance of having that opportunity and information. One family therapy session could have saved my family a lot of time. We have 11 children in my family and 6 weren't talking before this book. What would have happened if we had all sat down with someone who could facilitate this 'ghost in the room'?
What about families who have experienced a suicide attempt?
In the instance of parents with mental illness, it is important for children to have an understanding of what's going on with their parents so they don't take the blame. When a suicide happens, many people feel like, 'oh it was because of that fight we had…," etc. There are terrible things that can happen that may make someone feel suicidal but it's important that families not play the blame game. The family should come together and talk about what may be a mental illness or substance abuse issue in the family and how to communicate about these things when in trouble. The National Alliance on Mental Illness (NAMI) Family-to-Family Program is a constructive program that gives families training when there is a crisis or mental illness.
How do you approach a situation where a suicide has occurred in the past and the family just does not talk about it?
It's amazing to me, we have such a talk-talk world, everyone talks about everything, but suicide still, is silent grief. In my family there was an implicit pact I had never been aware of that we did not talk about our mother. This kept us at a distance from each other. We had all grown up (each of us) dealing with her death in private, alone for 40 years. My understanding of why we don't talk about it is because it's so hard to find words to put to it. That's why I wrote my memoir, I was trying to figure out a way to be transparent about this journey. While writing my book, I started to ask my sisters and brothers questions that I had never felt permission to ask growing up. Was it a curiosity I cultivated as a trained psychiatrist wondering how a suicide affects an entire family? Or was it my relentless search for details about my mother? Through it I came to realize the enormity of unspoken and disavowed feelings. I was surprised by their willingness to share when I approached them and how different their perspectives were. Daring to ask forbidden questions can be transformative, or may cause tension or sometimes a little bit of both. The way that my brothers and sisters changed, from the time when I was 40 to the time when I turned 50 was really borderline miraculous. There is room for families to have enormous growth.
Are there particular screening tools that have been helpful to you in school systems?
According to Shaffer et al. psychology autopsies (i.e., interviews of relatives and friends after a suicide) show that mental illness and sometimes substance abuse is present, particularly in teenagers. Out of that research came the Columbia Teen Screen, which is given to the school system as a whole to identify any depression or other warning signs. However, what I have found over the years is that some schools will embrace questionnaires and some will be concerned that if they identify kids at risk, they have a responsibility to treat them. But I think it is important to identify children who may have depression or bipolar disorder and ensure they get treatment as it can be life-saving. I think the Beck Depression Inventory is another useful instrument and the post-traumatic stress disorder (PTSD) symptom checklist provides answers you may not normally get in an interview. What's important is to create an environment that nurtures kids - environments where caring adults are connected to students is incredibly preventive. You never want to have a false sense of confidence – that if you diagnose something, that's where the road stops.
How did the exploration of your mother's life and suicide change you as a clinician?
I am the youngest. Caretaker is a role I'm drawn to. I feel steady and sure when I'm near the dying, the psychotic, and the desperate. I'm ok when surrounded by the dread and eager to provide reassurance. A psychiatrist would say that this is a case of reaction formation. The man who's terrified of snakes becomes a snake charmer. One of the ways I have dealt with losing my mother's comfort is to provide comfort myself and to try and fix things. I am steady when my patients are in a free fall panic, reassuring them that they will not be swept away.
Some of my patients may never know that I too felt desolate at times as a teenager, and I too guarded my hurt – very slow to trust. Having this experience and examining my journey through it has added depth and dimension to my practice as a therapist.
We all have cases that are particularly evocative of our own challenges and for each of us this can give you a certain perspective. The act of examining my past has given me the energy to sustain my compassion, so that I do not flinch as I did in the earlier days of becoming a therapist. During that time I observed a play therapy case thru a one way mirror and I felt very uncomfortable. The patient was a 4 year old girl whose father had killed himself. I watched with absolute dread when this petite, pig-tailed girl entered the play room. She gathered up the dolls, pretending to flush them down the toilet while singing, 'London Bridge is falling down, falling down, we all fall down…" Session after session she threw the dolls on the floor. I watched as the therapist quietly witnessed the girl's combustible emotions and offered words to help order her chaos.
Before I had more fully processed my mother's suicide, it was unsettling for me to observe this girl. But now, I can be more fully open when my own patients (mostly teenagers) choose to reveal their deepest fears. When you're working with teenagers, therapy is like chess. The opening gambits are well known and follow a predictable order. Possible directions multiply quickly as the players seek to respond to each other's moves. Therapy for teenagers calls for ingenuity, spontaneity, devotion, and the ability to recognize those moments when they abandon their defense and reveal their truth. My job is to try to achieve a careful balance, staying curious and remaining patient (and I don't always succeed). As I grew more seasoned as a therapist, it became easier to appreciate that often, people avoid talking about what hurts the most, and to respect each person's pace of self-disclosure (particularly when you are working with families that have had suicide happen – families can grieve in very different ways).
Why do you continue to do what you do?
To me the powerful (and intimidating) part of being a psychiatrist is that you don't have some of the fancy lab tests that other health professionals have. We have the CT and MRI but that's not where the difference is made. There is a fair amount of sophistication in assessing whether the illness in question is biological or otherwise, types of medications to use, etc., but the art of being able to engage a patient is what's so key. It takes building yourself as a resource.
I love psychiatry. I like literature and I think psychiatry is the closest you can get in medicine to literature because you have people telling you their story, their personal narrative.
I feel like I am always growing from the work that I'm doing. The human condition is so challenging and always has different presentations no matter your specialty. I have a gifted job – it's meaningful. Think of it; first of all, I work in schools; I'm not working on the normal psychiatric inpatient unit where systems are a total bust. I have been working in the same community for 18 years and there's a whole depth of capacity to make a difference in kids. Overall, whether you are a practicing psychiatrist working individually with patients or working in a community as I am – you are able to contain people's anxiety. I like doing that, and that's why I continue to do this. And when I don't want to do that, I won't do this anymore.
It is wonderful that you use what you have experienced to focus the goals. However, it seems like it is something that takes many decades for people to learn…how do we teach this to newer clinicians?
If you don't have people skills as a doctor, if you don't really like people, that's a very hard thing to teach. You sort of have to have the basic ingredients that you bring to the table and then you can cultivate curiosity and encourage people. Sometimes we become so reductionist and many [psychiatrists] go through training never having had a therapeutic experience. I find that somewhat stunning to be able to work with patients without knowing (for example) why talking with someone can be useful. The necessity of self reflection in a psychiatrist's work is essential. We make ourselves more available to our patients through understanding ourselves and how our past affects us. After all, we cannot ask more of our patients than we ask of ourselves.
I don't know how to make it a cookie cutter process. But maybe that is what wisdom is about, it's not something that you can 'do' easily, it's something you have to really work hard at. It's not something you can prescribe for people, there has to be some initial curiosity and then we [the leaders] can give the tools to eventually do that.
We know that physicians and particularly people in the psychiatric field have a high incidence of suicide. How do we get to the point when we ourselves are able to overcome the stigma to better help our patients?
I don't feel that hopeless about it. Actually, I have a description in my book of an experience I had as a psychiatry resident: a consulting liaison ending up committing suicide. The training director always talked about what a hard worker she was, up to the day before she killed herself. I thought that it was so scary, this person was seeing consults during a time when she should have been home taking the time to care for herself. As doctors sometimes we get wired to get profound satisfaction from helping others while neglecting ourselves. There has been a lot of effort within the psychiatry field (and in medical residencies) to address the idea and to provide help, so I believe we are making headway. But, we also can't lose sight of substance abuse. Mental illness in itself is tough but the toxicity is mental illness plus substance abuse.
Do you have other publications that you would recommend to a psychiatry trainee?
Sure, there's one that looks at how kids make sense of taking medication and what it means to parents to have their child be on medication:
Rappaport N, Chubinsky P. The meaning of medication to children, adolescents, and their families. J Am Acad Child Adol Psychiatry 2000. 39: 1198-1200
And there's another one:
Chubinsky P, Rappaport N Medication and the Fragile Alliance: The Complex meanings of psychotropic medication to children, adolescents and Families. J of Infant, Child and Adolescent Psychotherapy 2006. 5:111-123
Also a book chapter on safety assessments as it relates to kids that may be violent or aggressive in schools:
Rappaport N. Survival 101: assessing children and adolescents' dangerousness in school settings. In: Esman AH, Flaherty L, Horowitz H, editors. Adolescent Psychiatry 2004. 28:157-181
Any last words of advice?
My mother overdosed on barbiturates at a time when they were prescribed very cavalierly. Suicide is also about access. In the United States, only 1% of suicide attempts are done by guns, yet they are 65% of completed attempts. That means that if you have an angry teenager or a policeman that comes in [as a patient], you want to always check on access to weapons. It is something that is done initially (e.g., during an ER visit) but may be forgotten over time, but it is a critical piece for us to remember.