Role of Psychiatrist or Other Mental Health Therapist With Patients Who Have Thoughts of Killing Themselves and/or Someone Else.

Screen Shot 2015-04-16 at 2.48.39 PMAs details emerge various news stories of terrorism, and murder/suicide events, there are important questions being raised about how should a mental health therapist approach patients who may have the potential for violence towards themselves or others.

I would suggest that the following questions should be considered.

  1. What should a psychiatrist or another mental health therapist do when a patient says that they have had thoughts about killing themselves in a violent manner that could injure other people? Would the response be different if the self-destruction was only directed towards themselves in a non-violent manner such as taking an overdose as compared to potentially hurting other people as well? Should there be a different response to the above question if the patient is a school teacher, a bus driver, an airline pilot, or a scientist who works with Ebola?
  2. If a therapist knows that a patient has been suicidal in the past but is not so at present with therapy and medication, should the therapist be obligated to inform the patient’s employer if the job is a critical one such as those described above? Also, how we do factor in the fact that depression can be a recurrent condition?
  3. What are the possible consequences  if therapists were mandated to report patients who have had suicidal thoughts or violent fantasies?

General Discussion

Screen Shot 2015-04-16 at 7.25.57 PMJust having fleeting suicidal thoughts does not make someone a risk for hurting themselves. Similarly, having an angry murderous thought toward someone who you might resent does not make you a potential killer. There are many factors which a clinician must consider in evaluating the suicidal and danger potential of a patient. Is the patient psychotic? Is the patient having a severe depression which might include not sleeping or eating, crying, losing weight, etc ? Has the person acted on impulses in the past? Is there a history of violence towards self or others? Does the therapist and the patient feel comfortable that the patient would talk to the therapist if he or she felt that the feelings were intensifying? Does the patient have an immediate means to violence, such as access to a gun? Are there family members who can help monitor the patient in between sessions? These and many other factors enter into the evaluation of the seriousness of the threat that the patient may have to themselves or others. This is tricky business, but mental health professionals do it all the time.

The overwhelming majority of people with mental illness are not dangerous to themselves or other people. It should also be noted that mental health therapists do not have a sure method of predicting dangerous behavior in the future. We may be good in retrospect at explaining behavior and actions as the result of psychological factors (called psychic determinism), but we cannot claim the ability to predict behavior with great accuracy. We know a great deal about various forms of mental illness such as  schizophrenia where there is a break with reality. In most of these situations, the diagnosis is quite clear. Depression affects a very large number of people. There is a wide range of etiological factors of depression from grieving and situations involving loss and disappointment to biological types of major depression which can come on without any particular relationship to a loss or disappointment. There are also can be variations of mood such as bipolar or major depression which can even be at a psychotic level.Screen Shot 2015-04-17 at 12.50.56 PM

Suicidal thoughts often accompany various forms of depression. There can be passive thoughts such as a person who does not care about anything and might not want to eat or drink or take care of themselves. In such situations, a person frequently expresses the idea that they do not care if they wake up or not. Sometimes, persons may act suicidal or make suicidal threats or even try to hurt themselves as part of “cry for help.” In other words, the main thought of such person would be a desire to be stopped and given help. This doesn’t mean that they might not actually seriously hurt themselves.

People can become depressed to the point where they feel they cannot tolerate life or may feel worthless and that they do not deserve to live. Such a person might choose a suicidal method that would be more likely to be fatal. In some situations, this person, is intent on making a statement to someone else in their life, and they would want their suicide to have an impact on a family member or someone close to them. Sometimes, tremendous anger at themselves or others is part of the motivation for suicidal thinking.

Screen Shot 2015-04-16 at 2.51.07 PMAs it is well-known by police, some suicides are connected with a murder of someone else, usually a person well-known to the perpetrator. This may frequently be a family member or someone where there is an intense conflictual relationship. Sometimes, the suicide and the murder of the other person may involve a work situation such as a boss or a co-worker. The circumstances of someone being fired or humiliated at work or school might fit in to this category. These are not common, but they do happen.Screen Shot 2015-04-16 at 2.50.44 PM

This brings us to the situation of a suicide and multiple or mass murders. While such situations are extremely rare, they become very well publicized and well remembered. Sometimes they become examples for copycat acts by someone else. Limited research upon this group suggests that major depression is frequently present in the person who carries out this act. Also anger and rage and the feeling of being wronged may be present. There also may be some grandiose or narcissistic feelings where the perpetrator wants to become famous or remembered. While alcohol and drugs can always be a factor as it can loosen up one’s conscience and any inhibitions, it is not always present in this particular type of suicide connected with mass murder, since it often takes careful planning and requires a clear mind to carry them out. In retrospect, a study of each of these cases usually reveals particular stresses, rejection, and usually tremendous anger.

Can a therapist see the makings of a potential catastrophe and do something to prevent it? The answer is yes, we do that all the time when we work with people who have suicidal thoughts, but we can’t do it every time. Treatment works! But not all the time. There are many people who have experienced severe depression even with suicidal thoughts and even may have made a suicidal attempt and then recovered with treatment. Treatment can be psychotherapy, medication, or both. This is the reason that therapy has to be available, and a person should be able to enter the therapy and feel secure that they can express all their thoughts in a safe environment

But what if the therapist concludes at some point in the treatment that the patient is an immediate serious threat to themselves or someone else? At that point, there is an obligation for the therapist to hospitalize the patient. Hopefully, the patient would agree to such hospitalization. But even if the patient does not agree, there is a procedure (that varies from state to state) in which patients can be hospitalized against their will. In the State of California, it is called a “5150”, and if necessary, the police will assist a therapist based on the information provided from the mental health professional to take the patient  to the hospital. Then at the hospital, based on the information provided by the therapist and any family or friends available plus another evaluation by a mental health professional at the hospital, a patient can be legally hospitalized against his or her will. Then there can be subsequent legal proceedings to extend this hospitalization.Now, you may ask isn’t this breaking the confidentiality of the doctor-patient relationship? Yes of course it is, but this is obviously in the patient’s best interest. On occasion, during the course of therapy, the patient will ask me, “Is everything we say in therapy confidential?” I would reply, “Yes, unless I feel you were a true danger to yourself or someone else, and then I would act accordingly.”

Screen Shot 2015-04-16 at 2.47.41 PMThere is another situation to consider. What if the therapist becomes aware that the patient is seriously suicidal and/or a danger to someone else but they are not in present in the therapist’s office? Perhaps, they have left a message for the therapist or they do not show up for an appointment and the family described some behavior that the therapist understands means a danger situation to the patient or someone else. In such a case, the therapist is obligated to notify the police and have them attempt to find the patient and institute a “5150” based on the information that the therapist has provided. In California, the law further mandates that if the therapist feels that there is a clear danger to someone else , and the therapist knows who that person is, the therapist has to act according to the Tarasoff case. The Tarasoff case involved a situation at the University of California where a therapist knew that the patient would attempt to hurt another person. As a result of this case, in California, if a therapist believes that another person is in danger, the therapist must notify that person or be sure that that person has been informed by the police. Every effort must be made to contact the person who is believed to be in danger. So therefore, reflect on the thought, what if the therapist is treating an airline pilot and the therapist came to believe that the pilot who was not available to be brought to the hospital but might be flying a plane which he could be planning to  crash as part of a suicide murder. According to the Tarasoff precedent, the therapist would be obligated not only to notify the police and try to hospitalize the patient, but would also be obligated to be sure the airline was notified of the potential danger.

So now let’s return to the three questions which I raised at the beginning of this article.

My answers would be as follows:

  1. If the therapist believes that the patient is a serious threat to hurt themselves or someone else, he or she should act in a responsible manner to hospitalize the patient as soon as possible, even if this hospitalization has to be done on an involuntary basis. In California, if the patient has identified a threat to another person, every effort should be made to notify that person of the threat (in other states, there may be variation of this expectation). I believe the responsibility of the therapist is the same no matter what kind of work responsibility or employment the patient may have.
  2. If the therapist knows that the patient has been suicidal in the past but is not a suicidal threat to themselves or any danger to anybody else at the present time, the therapist is not obligated to inform the employer even if the job is a critical one, such as an airline pilot or a scientist working with dangerous bacteria, etc. The fact that depression is a recurrent condition does not change my opinion on this issue. An employer can make a decision that people with a history of epilepsy, or heart disease, or depression or suicidal ideation, should not work in critical positions. I would not necessarily agree with this position, but an employer certainly could make such a policy. Also, if a therapist is requested by his or her patient to provide information to an employer, the therapist should do that in a truthful manner.
  3. If therapists were mandated to report patients who have suicidal thoughts or violent fantasies, this would create a situation where people who had emotional conditions that might on occasion bring up suicidal thoughts or fantasies of violence would be quite reluctant to seek help. Therefore, people who would benefit by treatment would not be receiving it and I believe this would create, overall, a more dangerous situation.

Disclaimer

I am not an attorney nor do I claim expertise in legal issues which often differ from state to state. I also am not necessarily reflecting the ethical position of the American Psychiatric Association or other professional organizations. I am writing as one experienced psychiatrist who has confronted variations of these questions in clinical practice and has discussed such issues with my colleagues, mentors and students over the years.

I would also recommend a recent article in the New York Times by Erica Goode dated April 9, 2015 titled, “The Mind of Those Who Kill, and Kill Themselves.”

Dr. Blumenfield is the Sidney Frank Distinguished Professor Emeritus at New York Medical College. He currently is in private practice in Woodland Hills, California. For more information about Dr. Blumenfield go to  http://mblumenfieldmd.com/

 

Suicide: Main Theme of Meeting in San Francisco May16-18 2013

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Suicide is the 11th leading cause of all death in the United States. It is one of most important issues which mental health professionals are concerned about in their clinical work. The American Academy of Psychoanalysis and Dynamic Psychiatry of which I have the honor of currently being President, has designated the title of its 57th annual meeting as: Psychodynamics: Essential to the Issue of Suicide and Other Challenges to Modern Day Psychodynamic Psychiatry.  It is fitting that the meeting is being held in San Francisco which although not on the top 15 cities with the highest suicide rate does have the Golden Gate Bridge as its symbol which is the second most common suicide site in the world.(see previous posts on this subject)  Any mental health professional is cordially invited to register and attend this meeting (see AAPDP.org) which will take place May 16-18 2013.

images-1Mental health professional must always consider the suicidal potential of any patient especially when that patient is depressed or experiences significant distress. I recall as a junior psychiatry resident when I first was given the responsibility of making a decision to hospitalize  patients (even against their will) because I felt he or she was a danger to themselves (or others). As much as this is a heavy burden, it is likewise a major responsibility not to hospitalize a suicidal patientand face a situation where this person has ended their own life.  In the latter case there also is the possibility of legal consequences.

If a person is determined to end his or her own life, they will ultimately succeed. However when the desire to do it is due to a mental condition that we can treat, there is a good chance that we can prevent the suicide if we can intervene and facilitate proper treatment. Unfortunately this is not always the case since patients who are in treatment or who have had treatment do kill themselves.

Depression is the most common condition which has the potential to lead to suicide. This may be part of biological condition with genetic components which brings about severe bouts of depression. Depression may be part of the grieving process or it may be due to complicated psychological reasons which lead  some people  to be so depressed that they want to end their lifeimages-2.

Sometimes there is anger at a lost object (person) that gets turned inward leading to self destructive acts. When the ability to test reality is lost, the  reasoning for suicidal actions can be quite bizarre and may include internal voices commanding the persons to hurt or kill themselves. There are still other situations where a person does a self destructive act, not with intent to commit suicide but rather with an intent to suffer or manipulate others but inadvertently does die as a result of this gesture. There are certain personality patterns where there may be repeated suicidal gestures which have the potential to be fatal or very harmful. Drugs and alcohol and complicate the problems and may actually be the cause of suicide.

There are some special circumstances where a patient with a serious, very painful  or perhaps  fatal illness may want to end his or her life or may ask the doctor  to facilitate their demise. There are ethical discussions how should this be handled. In some of these situations, if pain and discomfort is better controlled this may not be an issue.

The treatment for a patient with suicidal potential is a delicate situation. First the decision needs to be made if the treatment is to be inpatient or outpatient (sometimes a combination of both). There needs to be a treatment plan that will almost always require psychotherapy frequently with a combination of psychopharmacology. In rare situations ECT (Electric Convulsive Treatment) will be utilized. Family and close friends often play an important role in the support of the person with suicidal thoughts. While psychotherapy needs to be confidential, the patient needs to understand that under certain circumstances where the therapist believes that the patient is an immediate danger to self or others, the therapist may have to break the confidentiality for the benefit of the patient. It goes without saying that there needs to be a trusting relationship with the therapist so the patient understands that there are two people working together in the best interest of the patient.

Many of these  topics and others  are going to be addressed at the San Francisco meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry  May 16-18 at the Westin St Francis Hotel which was mentioned at the beginning of this blog.  All mental health professionals are welcome to register  either in advance or onsite and attend the meeting . Go to AAPDP.org for more information or you can contact me if there are any questions. There will three plenary sessions by Drs Mardi Horowitz, Jeste Dillip and Herbert Pardes as well as  many panels and workshops. There will also be a very interesting documentary about suicide titled, Don’t Change The Subject  with a discussion with Mike Stutz,  the filmmaker after it is shown. A few of these presentations will be made available to Auto-Digest subscribers but if you are able to attend in person, I suggest that you  do so. I look forward to meeting any attendees at the meeting.

 

Let’s Talk About Suicide

Suicide is the 11th leading cause of death among persons over age 10. Patients with Major Depression or Bipolar Depression have a 20-60 fold increase of mortality rate over the general population. The role of medication and psychotherapy is can be important in preventing suicides. This topic will be discussed in future blogs and is the theme of the annual meeting of the
American Academy of Psychoanalysis and Dynamic Psychiatry which will be held in San Francisco Aug 16-18 2012.

Both attempted and completed suicides represent a major clinical and public health challenge. The CDC has ranked suicide as the 11th leading cause of death among persons over age 10 (33,289 suicide deaths were reported in the United States in 2009.

In a recent article in Psychiatric Times Dr. Tondo and Baldessarini  noted that 90% of suicides occur in persons with a clinically diagnosable psychiatric disorder. Patients with Major Depression or Bipolar Depression have a 20-26 fold increase of mortality rate over the general population. It was also stated in this article the fact than fewer than 1/3 of persons who commit suicide are receiving psychiatric treatment at the time of their deaths. The authors further state that there is only inconsistent evidence that antidepressants may help prevent suicides.

It was thought that the strong association between the rapidly expanding use of antidepressants and the moderately declining suicide rate in the US and in other countries were indirect evidence of effectiveness of antidepressants in reducing suicide.

Several recent studies have shown that mood disorders have been associated with increased suicidal behavior. This is especially true in patients with a mixed, manic-depressive, or dysphoric-agitated state, and perhaps also in those with anger, aggression, or impulsivity—all of which are particularly prevalent in Bipolar Disorder and may contribute to the unusually high suicide risk in persons with this disorder. In patients with such conditions (especially young patients), antidepressants may lack a beneficial effect or even increase suicide risk, at least early in treatment. Long-term treatment with mood stabilizers, particularly lithium, may be a more effective component of comprehensive clinical management aimed at suicide prevention.

From clinical experience we know that psychological conflict, psychological trauma, grieving, interpersonal conflict and other psychological issues can all contribute to self destructive behavior which can result in suicidal behavior. Suicidal gestures which may have been initiated to get attention or manipulate others can inadvertently result in a completed suicide. There are special issues concerning suicidal behavior in the military where recent studies have shown more soldiers are killed by suicide than in combat. There are special issues concerning suicidal behavior in children and adolescents. Bullying behavior including cyber bulling has been shown to induce suicidal behavior in young people.

Suicidal behavior can be quite complex as well deadly. It should go without saying that psychotherapy is usually necessary in treating patients who have suicidal ideation or who have demonstrated such tendencies or actions. Frequently, it may be combined with medication and sometimes it is the treatment of choice without medication.

Suicide prevention is a challenging issue not only for mental health professionals but for leaders in the military, teachers, parents and for us all. We also need to recognize that there are many mental health issues that have to be faced in the aftermath of a suicide.

We shall try to discuss many of these issues in future blogs. I am also pleased to announce that suicide will be a major part of the theme of the May 16-18 meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry (of which I am the current President) which will be held in San Francisco (just prior to the meeting of the American Psychiatric Association in the same city). A very interesting and informative program with outstanding speakers is being developed and will be announced shortly. I will also provide further information about this program in future blogs and you can contact me  if you have any questions at this time

New Documentary Film Highlights Rape in US Military

A new documentary film titled the Invisible War highlights Rape in the United States Military. A review of this movie is presented.

I recently previewed a new documentary film titled The Invisible War which I will be reviewing for FilmRap.net and which I felt was appropriate to reproduce in this blog..It highlights the serious problem of sexual assault in the United States Military. This should be of concern to every American but it also illustrates some major psychological issues about which mental health professionals in an out of the military need to educated and aware. Our colleagues in the military have to address this problem and as the returning soldiers seek psychological care as veterans, we need to be knowledgeable about this subject. We also have a duty as citizens to voice our objections to any policy which facilitates these criminal acts.

The Invisible War- Usually by the time we see a documentary film on a particular subject , we already have a pretty good idea of the nature of the issue being covered and the film provides some interesting documentation. In the case of this film, most of the audience had no idea of the great travesty of justice that has been taking place where there are violent sexual assaults against women serving in our military services by fellow soldiers, the vast majority of whom are not punished. Female soldiers in combat zones are more likely to be raped by fellow soldiers than killed by the enemy. In 2010 there were 19,000 sex crimes committed in the military. Because of the much larger number of men in the military many of these were directed towards men but percentage wise the women have suffered the brunt of this terrible injustice In fact, 20 % of women serving in the military will experience some kind of a sexual assault.

This movie is not just about statistics. Rather it is a very painful series of personal stories told mostly by dedicated women who entered various services, intent on being the best they could be in the service of their country. Not only were they assaulted and raped by fellow soldiers, even more outrageous, if that is possible, when they complained to their superiors in the overwhelming number of cases they were brushed off and not taken seriously. Heading up the team that put this film together are Kirby Dick ( nominated for an Oscar for Twist of Faith ) who directed it and Amy Ziering who was one of the producers and sensitively did most of the interviews with the several women and two men who were featured in this movie. Each personal story almost seems worse than the one before it. The traumatic impact of these assaults and in some cases the violence of them crushes these victims physically and emotionally. They go through stages where it seems there is no way out for them and therefore it is not surprising that some of them contemplate suicide. The attempts by the military to raise consciousness of the troops to this problem are almost laughable as well as deeply insulting to women. For example one such campaign exhorts soldiers to “ wait until she is sober before you ask her” A well thought out coalition of victims attempted to sue the government but their suit failed to gain traction as the first response of a federal court in West Virginia is to turn it down and state that this is an ”occupational hazard.”

The movie offers a glimmer of hope as one week prior to the opening of this movie, it was seen by the Secretary of Defense Leon Panetta, who takes the gigantic step forward by ruling that these assault complaints will no longer handled by the unit commander but rather will go up the ladder to higher ranking officer, presumably with less prejudice. Most probably there will not be justice until these complaints can be fairly dealt with by civilian police and courts. The film does something that many investigative documentaries don’t do well, in that it clearly provides a website (http://invisiblewarmovie.com/) and an opportunity to get involved in this cause by signing petitions and doing other things. This is the power of a documentary film and there is no better cause than the one put up the screen by this movie.(2012)

Don’t Change The Subject

This blog reviews a movie by Michael Stutz, a filmmaker who lost his mother to suicide when he was 12 years old . The film includes an exploration of his mother’s suicide as well as interviews with various people who have contemplated ending their lives. There are also creative dance and comedy routines which deal with this subject in a meaningful way. At the end of the review of this documentary there is a Q & A with the filmmaker.

I recently viewed this documentary which was shown to me by a good friend of the filmmaker. I thought it has great relevance to both professionals and others who care about people with mental illness and might be struggling with suicidal thoughts. It also might be helpful to anyone who has lost someone to suicide as did the filmmaker. The following is a movie review I wrote for my film blog Filmrap.net followed by a Q&A with the filmmaker which he agreed to do for PsychiatryTalk. If you would like more information about the film including where and how you can see it, please go to their website http://www.dontchangethesubject.org/

Don’t Change the Subject

This is a documentary about suicide, by a film maker who lost his mother to suicide when he was twelve years old. It seems to be his attempt to understand that tragic event in his life at the same time he is making film that he hopes will save some lives. Usually we don’t review films before they are ready to be released. In fact, the final edit on this movie has just been tweaked. It hasn’t hit the film festivals yet and a distribution deal has yet to be made. We hope in a small way, the availability of this review will help the process along as well as encouraging folks in the mental health community to consider using this film as a discussion tool at professional meetings and most of all to be used for educating the public.  According to the National Institute of Mental Health suicide is 10th leading cause of death in the U.S. and the 3rd leading cause in the age group 15-24. There are 11.3 suicides deaths per 100,000 people in this country. An estimated 11attempted suicides occur per every suicide.

While these and other statistics are important, this film is not about numbers and risk factors. It is about real people who tell little pieces of their stories. It is about people who came very close to killing themselves but for some circumstance or reason didn’t do so. It is about the filmmaker who comes across as a very likeable guy who is trying to figure out why is mother, who he believed loved him, would leave him by her own hand. He reads her letters, listens to tapes of her talking, looks at old film clips and ponders this issue with his older brother, aunt and step mother who married his father after his mom died. His brother never understood how she could have done this when she was in the music business and knew how important was his debut as an opera director that was happening the following week. His aunt, who was a psychiatrist, knew her sister had problems but didn’t see this coming. His stepmother only recently reveals her own special connection with suicide.

Sally Stutz

While the filmmaker may not have ever completely understood why his mother ended her life, he did realize that more then how she ended her life, she should be remembered for how she lived her life which included much love and support to her children. This message alone gives the film great value.

The filmmaker, Michael Stutz is also the director, writer and producer. He does go beyond just his own story and some close up vignettes of people who struggle with depression and have come close to doing this fatal deed. He follows a talented choreographer who is preparing a group of young dancers to perform a piece about autopsies. The result is as dramatic as is the meaning to young performers who had to come to grips with what their dance was about. We are introduced to a fairly successful comedian who has a team of writers help him prepare his material that daringly enough is going to be about suicide. It is always tricky business when humor is touching a potentially raw nerve. You have to understand, as a psychiatrist I usually don’t even like it when people use the word “crazy” in stories or in every day life but I appreciated the use of humor in this film. In fact the highlight was a piece by a comedian who did a monologue as a character who was leaving a video to his family prior to his suicide. He said just about everything a loved one would dread that their family member who was ending their life might say about them and how the suicidal person felt about them. It brought me to out loud laughter and will be for me one of the most unforgettable parts of this film about a very serious subject.

I said earlier that I hope professionals will view and use this film in their efforts to prevent suicide. It is not because this film will necessarily educate my profession about suicide. It didn’t really examine the difference between suicide attempts and suicide gestures nor did it attempt to show the different psychiatric diagnosis that people who attempt suicide might have. In fact there wasn’t much of a psychiatric presence in the film. However it has the potential to be very meaningful to anyone who has struggled with suicidal thoughts, had fleeting suicidal thoughts or has been close to anyone who has had these issues. Unfortunately there are a great number of people in at least one of these categories. This film can save lives so it deserves to be seen and will be a worthwhile experience for many people. I don’t know yet when and how it will be distributed but more information about it can be obtained on the following website: http://www.dontchangethesubject.org/ (2011)

Q & A with Michael Stutz

Shortly after I viewed the movie, I spoke with Michael Stutz, the filmmaker and he agreed to answer some questions for this blog.

MB: What made you decide to make this film?

MS: I wanted to make a film that I would have wanted to see when I was a kid dealing with my own mother’s death.  At that time I was struck by the typical adult reactions when talking to a twelve year old and how incredibly awkward they were.  Everyone seemed to be walking on eggshells.  If they talked about it at all it was in vague clichés or condescending attempts at “she’s in a better place.”  My mother was in and out of mental institutions for more than two years before she died.  I watched her sob and collapse and sleep for eighteen hours a day.  I also was the one who found her after her overdose.  I didn’t need clichés.  I needed honesty and a path to help me process my feelings and move on.  For me that path turned out to be theater and comedy and dance.  You can’t really capture all of the raw emotions going on in your head after something like this.  It’s surreal.  The arts helped me to work through images, fragmented thoughts and deeply conflicted feelings better than a straight on discussion could.  With this movie I wanted to suggest different ways of communicating beyond conversation.  It’s incredibly important to talk about it but not everyone is able to talk about it in the same way.  As I sit down to write this I am remembering the one adult who really helped me the day I found my mom.  It was a friend of my grandmother’s who came over to watch me while everyone else was at the hospital.  I was crying and she sat down and instead of clucking out soft meaningless words she showed me a book of watercolors she had painted over the years.  She said she normally didn’t show it to anyone but thought I might like it.  We just looked at the trees and lakes and various images that she had created and it calmed me.  I see now that’s a part of what I wanted to do with the film.  Share something private in the hopes that it might help somebody out in their own time of need.

MB:Is there a special audience that you had in mind when you made it?

MS: I made this movie for members of the suicide community who would cringe at being identified as part of the suicide community.  Over the years I’ve taught a lot of classes to various groups, teens in particular.  I’ve taught theater, comedy, dance etc. and I always find the kids I like the best and the ones who ultimately seem to get the most out of class are the ones who were the most resistant and cynical in the beginning.  The smartasses, the awkward shy kids, the kids who think they would rather be anywhere but in that class.  I made this movie for them.  Our movie is a punky, awkward, smartass, oddball little film for everyone who feels like they’d rather be anywhere but in a theater watching a suicide movie.

MB: Was it therapeutic for you to go through the process of making this film?

MS: Absolutely.  Though I have to admit when we started out my concept of the film was very different than the film that ended up on the screen.  I thought I’d interview several well-known people in the arts who had experienced suicide in some way and then see them creating their own artistic pieces.  After being turned down by everyone that I asked, I realized first how incredibly taboo this subject still is, and second that I’d have to be willing to step up to the plate and share my own story if I was going to ask others to do the same.  So then my family got dragged into it.  At the same time we were making the film my stepmother Judith was in the end stages of cancer.  Because of this she and I had been having a lot of conversations about family, including something that I didn’t know when I was a kid; her father had killed himself too.  She had held his head after he’d shot himself just like I had cradled my mother’s head after she overdosed.  Her father killed himself just before her birthday, just like my mother had done before mine.  It was amazing that we had lived under the same roof and never talked about this.  So, as Judith was entering hospice and going through her last year of life we were also filming this movie with family as they visited.  It was an incredibly bonding experience.  Judith was very involved with the whole process and always asked about its progress and was even able to see the first full rough cut three days before she died.  The conversations we had both on camera and off were some of the most rewarding and meaningful conversations I have ever been a part of and I think she felt the same way.  I will say it’s amazing that it took a camera to help all of us in the family to talk to each other in ways we never had before.

MB: How did the comedy piece of the character making the video for his  family before he killed himself, come about?

MS: There’s a comedic monologue called “Daddy’s Last Video” in the movie that I wrote several years ago for a brilliant actor named Ron Riegler.  He’s quite simply the funniest and most subtle actor I’ve ever worked with and I knew he could pull this off.  It came from my experience as a child where people would come up and say various versions of “this wasn’t your fault.” This is of course a very kind and reasonable and I’m sure in many cases very helpful thing to say.  But then again what is the alternative?  What if someone, in this case the daddy who killed himself, said in those same low and comforting tones, ‘well actually this is your fault.  You really were a lousy little kid.  Thanks for killing me.  Love Daddy.’ Now, out of context I’m sure this reads as horrifying but you have to see it to understand that I’m simply pointing out the ridiculousness of almost anything you say to a kid after a parent has killed him or herself. The situation is so bad it becomes absurd.  I guess I just hate low, hushed-toned speaking.  As a kid I thought, “Really, this isn’t my fault?  No kidding?  I just found my mom on the bed and that’s the best you can do?  Thanks.”  But, I was a weird kid.

MB: Were you concerned that this piece or any of the other humor would be found offensive by some people?

MS: I’m sure right now someone reading the previous answer is thinking ‘seriously you want me to see a movie where children are blamed for their parent’s suicide?’  I promise, it’s funny in context.  So yes, I’m sure it’s possible that some reasonable people could be offended by this or other parts of the movie.  But what I’ve found so far is that most of the people who have seen it who have experienced suicide up close and personal have laughed right along with it.  I’ve met with more resistance from those outside that world who worry that we may offend.  Gallows humor is what I do.  I’ve done plays and sketches about all sorts of issues related to mental illness.  I promise you they aren’t done to mock these very serious issues.  I was raised on Monty Python and Woody Allen.  I blame them.

MB: What kind of responses have you had from people who have seen the film ?

MS: We’ve gotten very positive responses so far, especially from folks in the psychiatric community.  I was somewhat worried that because the film is a little more “colorful” with its language in some places and does use humor to deal with very heavy issues that some folks might not be willing to take the trip with us.  But so far I’ve been very pleasantly surprised.  It’s also been great to see a broad range of people get something out of this.  A friend of mine pointed out that even though he hadn’t experienced suicide in his immediate family the way he felt after his parents’ divorce was very similar to how I felt after my mom’s death.  In some ways you could say that the movie isn’t primarily about suicide.  It’s about communication.  Everyone has had a time in their life when they felt misunderstood or unable to communicate their feelings.  That’s what we’re talking about.

MB: Do people “change the subject” when you discuss the content of the film?

MS: When I say I did a movie about suicide people usually drop their eyes and mutter something under their breath while trying desperately to inch their way away from me.  But when I say I did a weird dance comedy performance art movie with kids performing to autopsy reports and comics flipping out on rooftops and dark little animation sequences then the eyes sort of come back.  In the end many of the loveliest parts of the movie are actually the quiet, sometimes sad, sometimes funny little moments where survivors are relating their stories in this heartbreaking but incredibly inspiring way.  But since a lot of folks can’t quite wrap their brains around that we give them some other fun things to look at in between the stories.