John Donne’s classic poem unexpectedly resolves an impasse between doctor and patient.
by JP Sutherland
No man is an island,
Entire of itself,
Every man is a piece of the continent,
A part of the main.
If a clod be washed away by the sea,
Europe is the less.
As well as if a promontory were.
As well as if a manor of thy friend’s
Or of thine own were:
Any man’s death diminishes me,
Because I am involved in mankind,
And therefore never send to know for whom the bell tolls;
It tolls for thee.
John Donne, 1624
‘What is the meaning of life?’ was a question that I looked at and then rapidly discarded as I was growing up. As a curious student I inevitably came across the issue, chatted about it with friends (mostly late at night after one too many drinks), and even started to read around the subject. But I was young and in a hurry, so I wanted a clear answer, preferably without much work, and this was obviously not forthcoming. I got disheartened with the truly enormous number of different explanations being offered, and I also became frustrated with the details of philosophical discourse. One day I came across a whole chapter in a philosophy book addressing the meaning of the word ‘meaning’ and after that I really gave up on the subject. I went off to play sport and have another beer, and I went on to study to be a doctor, and I might never have thought about it much again.
Once I became a practicing psychiatrist, I found the issue returned, though in a much more urgent and practical manner than any late-night musings on pop philosophy. I inevitably spent a significant portion of my working life talking with patients about suicide and trying to help them avoid killing themselves. This meant that the meaning of life – the meaning of their life – became extremely important and would be one of the factors that helped determine how safe they would be as they passed through their period of despair.
I didn’t meet Ingrid in the emergency room, where one of my colleagues assessed her after an overdose, but I took over her care once she came to our unit. She had tried to die by taking a large amount of acetaminophen, having just been dumped by her boyfriend in a text message. She had been alone at home, and might have come to great harm, but fortunately her mother was alert to her distress and when she couldn’t raise her daughter on the phone, she called by in her lunch break to see if all was well.
What an unusual teenager, I thought, actually liking Shakespeare.
Ingrid was seventeen and as such shouldn’t have been on an adult psychiatry unit at all. Under the age of eighteen we admit people to an adolescent unit on the other side of the city, but they are often full. In fact, all the inpatient units are often full (and have been routinely throughout my career) but the adult psychiatry units open up spaces more often than the adolescent unit. Had Ingrid been a ‘young’ seventeen we would have moved her at the first opportunity, but she was mature, and serious-minded. Another concern about female adolescents on an adult unit is that we usually have a small contingent of male patients with antisocial personality traits, and a vulnerable young girl can be the focus of their unwelcome attention very easily. Our psychiatry nurses are vigilant about the care of such young people, and on the first morning of Ingrid’s stay with us I was chatting with Colleen at the nurses’ station about a different patient. As she spoke with me, she continued to survey the unit in her role as charge nurse, and I suddenly saw her eyes frown, and she was quickly but quietly gone. She had spotted a couple of our young men moving over towards Ingrid, and had wanted to be within earshot of whatever was going to happen. She was back again within a couple of minutes and chuckling.
“There’s no need to worry about Ingrid.” She said. “She handled those two with no difficulty.”
“The adolescent unit says they’ll be full for days,” I replied, “do you think we can manage her here?”
“I think we can cancel the transfer request, but we’ll have to see how you get on with her. She sounds like she could be a little feisty.”
I have never been particularly strong at interviewing teenagers, and I usually get around it by having a medical student with me who takes the lead in the discussion and rapport building, after I’ve covered all the basics. As luck would have it, I was without a trainee when Ingrid was admitted, and so she was stuck with me alone. She started by being quietly uncooperative, and was obviously ambivalent about having survived her suicide attempt. Sitting bowed and unhappy in her chair, she made no eye contact with me. There was a marked reluctance to discuss her personal matters, which made our early meetings feel rather mechanical.
Our third interview started in the same stilted fashion, and then came an opening.
“You’re so old,” she said, which didn’t seem very promising. “Are you English?”
“Yes, I am.”
“Hmm. We’re doing a Shakespeare play in English. He’s cool.”
What an unusual teenager, I thought, actually liking Shakespeare.
“Which play?” I asked, happy to have some avenue of potential mutual interest to engage her with.
“’The Merchant of Venice’. Do you think Shakespeare was racist?”
I could feel her reserve dropping a little and I just wished she might have chosen a play that I knew better.
“I think it has a lot of anti-Semitism in it, but maybe that was just the times he lived in.”
“That’s what our teacher says, but then Shakespeare writes the lines ‘Hath not a Jew eyes, hands, organs…’?”
“‘… if you prick us do we not bleed’?” I finished, relieved at remembering the quotation. “So maybe he wasn’t so racist after all.”
“Maybe not.”
And then from nowhere came an idea, which I spoke before fully thinking it through.
“If you like Shakespeare, have you ever read John Donne?”
“No, who?”
“John Donne. He was alive around the same time as Shakespeare, and he wrote a famous poem about death called ‘No Man is an Island.’”
“I’m not talking about death.” She said, slumping back into her original posture.
I tried to explain, and offered to bring a copy of the poem, but her tone told me that we were done for the day, and that the window that had briefly opened was now closed tight again. Kicking myself for my clumsiness in not thinking it through in advance, I returned to checking her safety, and the lack of need for any psychiatric medication, and then I closed the meeting.
By this time, we had spoken with Ingrid’s family and one friend, and we understood her better (though not as well as we would if she fully opened up to us). Her suicide attempt was definitely serious, and she had been a little lucky to survive. However, there didn’t appear to be any psychiatric diagnosis underlying her problems, such as major depression or psychosis. The rejection from her boyfriend, and in particular the unthinkingly cruel way it was done (by texting!) had made her suicidal. This was a hopeful sign for her future since the pain of a broken relationship rarely persists at a suicidal intensity indefinitely, and so one of our jobs was to keep Ingrid safe while we helped her grieve for her loss. Which meant that one of the tasks we had in the meantime was to decide how suicidal she still was.
In my experience the three most common reasons for avoiding suicide are family and friends, religion, and fear of pain or disability from a suicide attempt.
As we assess a patient’s level of danger, we want to hear their story, and we are on the lookout for any risk factors for suicide and any withholding (or ‘protective’) factors. The risk factors include some pretty obvious ones. Having access to guns or a supply of pills is a risk, as is the presence of a recent and severe stressor such as a job loss or a relationship breakup. And drug and alcohol misuse are a concern, because however much someone may appear to have their suicidal risk under control when sober, anything might happen if they become intoxicated and lose their inhibitions.
Parallel to our questions about risk factors, we are also asking about withholding factors. These are the reasons why someone might not carry through with dying, even if they have some suicidal thoughts. And these are the psychiatrists’ clinical equivalents to the philosophers’ library-based thoughts about the meaning of life. In my experience the three most common reasons for avoiding suicide are family and friends, religion, and fear of pain or disability from the suicide attempt.
These days it is the fear of hurting family or friends that holds most people back from the brink, and I always think how selfless and decent that is. Here are people suffering about as much as is humanly possible, so much so that they would consider ending their lives, and what stops them is the thought of how it would hurt their mother, or little brother.
What makes these withholding factors particularly important is that a period of suicidal risk is usually quite time-limited. Stressors fade, psychiatric illnesses improve with treatment, and people adjust to their situations in life. For all these reasons there are usually only a few weeks of heightened suicide risk, and if we can help a patient stay safe during this time then their future safety is often assured.
The next day Ingrid surprised me by opening the conversation.
“I read your poem.” She glanced at me uncertainly from under worried brows. “I found it online.”
“By John Donne? What did you think?”
“Jorn Dorn,” she mimicked my accent, “you sound funny.”
Her tone wasn’t the most encouraging, but at least we might be able to finally talk about death.
“‘Never send to know for whom the bell tolls; it tolls for thee’ – do you believe that?” she asked.
“I think Donne was saying that all of our lives are intertwined with others, and that we can’t die without affecting them. I think I do believe that.”
“I bet Justin wouldn’t be affected by my death.”
“Maybe not; dumping you by text message didn’t show a lot of feeling. But how about the others in your life, your parents and your brother?”
She paused and looked down. “I wish I was an island. They don’t understand.”
I paused too. “I think most of us want to be an island at times. But your parents do sound like they want to understand.”
“I want them to understand. I just don’t want to have to talk to them about it.”
“Would they understand the poem?”
“They don’t get Shakespeare, so I don’t think they would understand John Donne.”
So began the psychotherapeutic process that would help her minimize her time on an inpatient psychiatry unit. Her concern for her parents and brother, even when mixed with the inevitable disagreements she had with them, turned out to be one withholding factor from suicide that would keep her safe. But it wasn’t the only one.
Also on the ward at that time was Trevor, an all too frequent visitor to our unit. He still looked like the strongly-built sheet metal worker that he had been before his life was derailed by a much more severe diagnosis than Ingrid’s – schizophrenia. But now his arms were muscular from propelling himself around in a wheelchair, rather than bending metal into ductwork. Antipsychotic medication brought him relief from the auditory hallucinations that told him to kill himself, but after a period of stability he inevitably discontinued his treatment and became ill again.
“It’s the voice of God,” he had once told me.
“Surely not.” I replied, “God wouldn’t want you to kill yourself, would he?”
“I know it’s not the voice of God now,” he clarified, “but when it happens it’s definitely God, and if God tells you to jump then you have to do it.”
Unfortunately and tragically, ‘God’ had told Trevor to jump off an eleventh-floor balcony a few years ago. His survival was extraordinarily lucky, but came with the price of having to have his legs amputated above the knee. Now he spent his days in a wheelchair.
His hallucinations continued to come and go depending on whether he took his medications, and we had learned to admit him to hospital promptly when he started to hallucinate in order to avoid another suicide attempt. Once medications were restarted he was a cheerful and sociable individual, and before long I saw him chatting with Ingrid.
“Is Trevor your patient?” she asked one day, “He says he is.”
“Yes.” I answered, hoping that she wasn’t going to ask me details about him or his illness that I wouldn’t be free to share.
“And he’s like that, disabled, because he tried to kill himself?”
Nodding was the best way to answer this and give no unnecessary detail about him.
“Could I have been disabled by what I did? I didn’t jump but could I have damaged my body?”
Her mood had lightened since admission, but now she looked seriously worried.
“So – I’m never doing suicide again, ever, no matter how bad things get.”
“Ingrid, the medication you took could have badly damaged your liver. Do you remember that you were connected to an intravenous line for a while? That was to flush the drug out of your body before it could cause your liver to fail. Your liver tests now look good, so you got away without injury.”
“But I could have damaged myself?”
“Yes, you could have.”
“So – I’m never doing suicide again, ever, no matter how bad things get.”
“I’m very glad to hear it.”
“And I’m glad that Trevor didn’t die – ‘for any man’s death diminishes me, because I am involved in mankind.’”
After that, I decided that she was safe from further suicide attempts, which allowed us in turn to give her some time off the inpatient unit, and gradually start some passes home with her parents. Her mood continued to pick up, because of the passage of time and the therapy she was now engaged with. Before long we arranged her discharge, and she agreed to a period of outpatient follow up to check that things continued without any slip back into suicidal thinking.
On the day of her discharge, I was away from the ward for a while, and only got there just in time to see her leave with her parents. No longer bent over or slowed, she waved and called out as she went out through the unit’s doors.
“See ya later, ‘Jorn Dorn’.”
I smiled, and as I waved goodbye I silently thanked the seventeenth century poet, and the twenty-first century amputee, for their help in her care.
All names and other identifying details have been changed to protect patient confidentiality.
This story was first published in the journal The Examined Life.
JP Sutherland 