No easy answer: Anorexia and the right to die

A few people have asked about my opinion of this case in New Jersey where a judge ruled that a 29 year-old woman cannot be force-fed against her wishes; instead she will receive palliative care. Honestly, I have no simple opinion on this matter. It’s way too murky for me to say one way or another whether or not this is the best choice. I would love to be the optimist who says, “Anyone is capable of recovery, this woman included,” but do I really believe that? I’ll admit my overall opinion of recovery has shifted over the past several months. I used to think that everyone had a kind of a pre-destined “recovery potential” that dictated the maximum level of recovery they could ever achieve given the best case scenario. I now see things a little less black-and-white. I used to think this was about as good as it would ever get for me, and now I think differently. I believe I’m capable of more, and I hope to get there one day.

Some of my closest friends have severe eating disorders and I can’t imagine myself ever giving the “okay” for them to give in and settle for palliative care at such a young age. Part of this has to do with knowing the profound effect that malnutrition has on the brain. It’s pretty much impossible not to be intensely depressed when you’re starving. However, I’ve watched people I love make dramatic transformations through re-feeding– not just physical transformations but mental and cognitive transformations as well. I’ve also experienced this myself. When you’re drastically underweight and malnourished, simple food will have a much bigger impact on your mood and thinking than any antidepressant will (and actually, most antidepressants probably won’t work at all when your body is that compromised).

On the flip side, anorexia is an illness not unlike many physical diseases that, when determined to be terminal, have led to approved physician-assisted suicide. Have I ever felt defeated enough by my illness to wish death upon myself? Absolutely, more times than I can count throughout the course of  my eating disorder. However, I honestly don’t think any judge would have granted me permission to die (or to give up on treatment) had I asked for it at the time. As sick as I was at times, I had never done such irreversible damage to my body that it would have seemed warranted. Obviously I don’t know the details of this woman’s case, but I’m guessing her body has deteriorated to a degree that they believe she has little chance of ever making a full physical recovery. Re-feeding can be extremely dangerous when a person has gotten to such a grave physical state, so much that many hospitals won’t admit patients who are below a certain BMI. The places that can treat patients with single-digit BMIs or serious medical complications is very limited. For all I know, this woman may have exhausted all her options and is now just looking for any kind of relief– relief that only palliative care may be able to give her (I also can’t help but note that the article states she suffers from binge/purge type anorexia, which, at least in my experience, is like double the horror).

It’s depressing for me to even be writing about this. I’ve watched more than a few people die from this illness. Some of those people had clear wishes to die and others died very unexpectedly. I worry about my current friends and acquaintances with eating disorders every single day. I hate that this illness takes so many lives, whatever the circumstance, and I wish everyone could be as lucky as I’ve been to experience such a life-changing shift in perspective on the prospects of recovery.

Confronting suicide: Breaking the silence around one of mental health’s biggest taboos

A couple months ago I had the wonderful opportunity to participate in the Applied Suicide Intervention Skills Training (ASIST) through my workplace. This was an intensive two-day training designed for anyone (i.e., not just mental health professionals) who wanted to learn how to deliver “suicide first aid.” In the training we learned very practical intervention skills that were based on a scientifically-proven model. One of the best things about this training was that it also allowed for honest, candid conversation about some of the controversial aspects of suicide. We openly discussed questions like, “Is suicide morally wrong?” and “Is suicide always preventable?” The discussions had me reflecting back on a lot of the attitudes I’ve encountered over the years. People tend to have very strong feelings about suicide, and I’m not here to tell anyone their opinions are wrong. I merely want to add some more context, based on my personal experiences, to some common ideas.

“Suicide is a selfish (and even, malicious) act.”

Some people really do see suicide as a completely selfish and/or even malicious act. I understand this. I actually used to believe this before I ever experienced serious suicidal ideation myself. A girl I went to school with hung herself in her front yard; her parents found her dead that way as they pulled in the driveway. This event really rattled me, and I found myself really angry at this girl. How could she do that to her family? I knew she didn’t have a great relationship with her parents, but this? It seemed so… evil. 

Fast forward a couple years and my stance really shifted. Things with my eating disorder were not getting better. Actually, they were getting a lot worse, even after countless rounds of “treatment.” I truly felt like I was destined to suffer like that forever. In 2010 I made two serious attempts to take my life and looking back I can honestly say that hurting anyone but myself was the furthest thing from my mind. I actually wasn’t in any sound state of mind; I was at a breaking point with my eating disorder. I used to describe it as “not being able to keep up with my behaviors.” There comes a point when the disease really overtakes you and you feel entirely controlled by it. I was running almost completely on adrenaline, starving and exercising all day and then binge/purging all night until the early morning hours. I slept maybe 2-3 hours a night but only when I finally passed out from exhaustion. I hated every single minute of it, but it had become this compulsive interminable routine that I could not stop. My life as I once knew it was already over, because I had no time or energy to devote to any of the people or things that once meant something to me. I saw absolutely no way out other than to kill myself. I didn’t even feel like a person anymore. I was of no value to anyone anymore (so I thought), so there was no point in sticking around.

I don’t doubt there have been people who have killed themselves with the intent of hurting others, but this certainly isn’t the norm. Many people who attempt or complete suicide are under the influence of any number of things that have significantly impaired their judgement. I’m not only referring to substances like drugs and alcohol; it could also be severe depression, starvation, sleep deprivation, trauma, psychosis, etc. I can tell you that after a few weeks of improved nutrition, sleep, and medication adjustments in the hospital I could no longer identify with the person who had attempted suicide just a few weeks prior. My eating disorder hadn’t gone away, and I wasn’t cured of my depression, but my brain was functioning well enough to be able to see things more realistically. I could see myself as a person again, a real person with real people in my life who cared about me.

“People who are serious about suicide won’t talk about it.”

This may be true for some, but it certainly is not always the case. I know in the worst of my illness I was constantly talking to my therapist about death and wishing to die. I think I probably talked about it so much that she eventually stopped reacting like she had in the beginning. I think my attempts really took her by surprise because she was so used to me just talking about it but never acting. I don’t blame her at all for not “predicting it,” I just think it’s worth pointing out that just because someone has talked about suicide for months or even years without acting, that doesn’t mean they won’t at some point reach their breaking point.

Related to this, I think it’s important not to assume that just because someone has “failed” to complete a suicide once or even several times, this doesn’t mean they weren’t serious in their intent to die, nor does it mean they won’t “succeed” in the future. I’ll never forget the time I saw my psychiatrist for the first time after my string of suicide attempts in early 2010. “Well, you’re not very good at this are you?” He said this with an obnoxious grin on his face. And yes, he had a very odd sense of humor. “Well,” I replied, “I’m clearly not very good at this ‘life’ thing either, which is why I keep trying to end it. Maybe you could help me with that instead of mocking my very real suicide attempts?” Actually, I don’t remember what I said at the time, but probably not that. 😉 This response came to me after the fact, like the best comebacks usually do.

There is no “typical suicidal person;” some people openly talk about their thoughts and plans, whereas other people give no outward signs there’s a problem at all. A person who talks about suicide may not be in immediate danger, but he/she is giving you information that should not be ignored.

“All suicides are preventable.”

I wrote the following in December 2013, after a series of eating disorder-related deaths (mostly by suicide) occurred in one of my communities:

    Over the years I’ve unfortunately witnessed many friends, friends of friends, and acquaintances die from this disease, whether it be directly or by suicide. It is of course always extremely sad. However, I think it is misguided to say things like, “how many more people have to die from this disease until the world gets it?” This implies that if only the world “understood it,” it would go away, or people would stop succumbing to it, or even that the world is somehow AT FAULT for all the suffering. I’m all for (responsibly, in the right way) educating the public simply because it is FAR more pleasant interacting with people who have a clue than with the ignorant, but even everyone in the world “getting it” wouldn’t stop the suffering. Eating disorders are complex multifaceted mental illnesses without simple causes. Can’t we just accept that recovery is really f-ing hard and not easily or at all attainable for some, even after multiple attempts and lots of “knowledge”? I’m not discrediting the importance of having supportive people in your life–people who “get it”– this is incredibly helpful, but even the best friends/family members/therapists/mentors can only do so much. I can also imagine that reading something like “when is the world going to wake up?!?” could come off as insensitive to the people who HAVE been “awake,” supportive, and knowledgable and still unable to stop horrible things from happening to the ones they love.

Two and a half years later, although slightly less cynical than I was then, I still generally feel the same way. It’s a complicated subject and I’ll admit my views are likely very colored by my own experiences, particularly in the world of eating disorders. I’ve already blogged about my views on conventional treatment and how ineffective it is for many people, especially those with chronic eating disorders. A lot of the people I’ve known who have died by suicide had been through multiple treatments, had access to some of the best doctors and therapists, and had a slew of very loving and supportive people in their lives. It often isn’t a matter of the world not understanding or caring, it’s just the sad but true fact that eating disorders (or depression, substance abuse, etc.) are powerful, unrelenting forces that sometimes can’t be taken down.

This is a tricky subject because I don’t mean to imply that anyone should ever be deemed hopeless or untreatable. What I do want to convey is that we (friends, family members, therapists) are all only human, and we can only do so much. As great as it would be to think that with enough love, effort, and knowledge we can save everyone, that’s not reality. I also think it’s important to acknowledge that it is not always in a person’s best interest to continue to engage with a chronically suicidal person, for the sake of their own mental health. I unfortunately witnessed the dissolution of a very close friendship shortly after my suicide attempts in 2010. This person had to go through the trauma of finding me unconscious one night, not knowing if I would ever wake up. She had to watch me come out of the hospital a few weeks later seemingly “so much better” (my words) only to repeat the same series of events less than a month later. This was on top of having to deal with me as a very sick and unreliable friend for many years. After an awkward attempt to reconnect shortly after these events, our communication gradually dwindled until we were no longer talking. I still miss her, but I don’t blame her for anything. She did what she needed to do to protect herself and I’m glad she did.

The ASIST training focused on the initial interactions with a person at risk, understanding their situation, and keeping them “safe for now.” Sometimes that’s all you can do. As a society, I hope we continue to talk openly about suicide. Even though knowledge alone cannot save everyone, it helps break the stigma and forces people to confront the issue instead of brushing it under the rug.