A Letter from Dr. Harold I. Schwartz

The novelist Paul Beatty writes of our tendency to “…preen in the mirror, so as to avoid looking in the mirror and remembering where the bodies are buried.”

For a psychiatrist, the process of looking in the mirror comes most profoundly when a patient commits suicide. More than half of psychiatrists will face that loss at some point in their careers. Unlike an oncologist losing a patient to cancer or a cardiologist losing a patient to heart disease, the loss of a patient is not inevitable and psychiatrists are always left questioning whether there was something more they could have done.

Then comes the defensive preening. “I’m a smart psychiatrist and I asked the right questions,” we say. “It was the patient’s choice and I can’t be responsible for what I can’t control.” It’s protective, but it’s a type of preening that prevents a deeper look in the mirror.

For me, this experience came early in my career in the form of a very depressed middle aged man. In the course of an hour he gave me every assurance that he would not kill himself—until he suddenly got up from his chair and said, “You know, doc, I really could do it.”

He quickly sat down and returned to his denial. When I pressed him, he said all the right things to placate my concern. Balancing all his denials with that one admission, I concluded that he was safe and let him go. But an alarm had gone off in my gut, an alarm which I ignored to his peril and my regret.

When a new movement in suicide prevention arrived, Zero Suicide, I initially protested. I resisted the idea of holding ourselves to a standard we can’t meet. It’s counterintuitive, I thought, and if we accept such a standard we will be held accountable when we fail.

My experience showed me what failure felt like and I resisted the thought that suicide could become a never-event. But the suicides keep coming: 44,000 last year and rising. They keep slipping through our fingers and I have gradually come to realize that zero should not be seen as a hard metric but as an aspiration that will lead us to do more and do better.

Looking in the mirror means being willing to stretch, to think outside the box, to accept the risk of being held accountable and, indeed, hold ourselves accountable. If we take this opportunity to look hard in the mirror, we can summon the courage to change—and save many lives in the process.

Dr. Harold I. Schwartz
Psychiatrist-in-Chief, Institute of Living
Vice President of Behavioral Health, Hartford HealthCare