[Content note: Suicide. May be guilt-inducing for people who feel like burdens. All patient characteristics have been heavily obfuscated to protect confidentiality.]
The DSM lists nine criteria for major depressive disorder, of which the seventh is “feelings of worthlessness or excessive or inappropriate guilt”.
There are a lot of dumb diagnostic debates over which criteria are “more important” or “more fundamental”, and for me there’s always been something special about criterion seven. People get depressed over all sorts of things. But when they’re actively suicidal, the people who aren’t just gesturing for help but totally set on it, they always say one thing:
“I feel like I’m a burden”.
Depression is in part a disease of distorted cognitions, a failure of rationality. I had one patient who worked for GM, very smart guy, invented a lot of safety features for cars. He was probably actively saving a bunch of people’s lives every time he checked in at the office, and he still felt like he was worthless, a burden, that he was just draining resources that could better be used for someone else.
In cases like these, you can do a little bit of good just by teaching people the fundamental lesson of rationality: that you can’t always trust your brain. If your System I is telling you that you’re a worthless burden, it could be because you’re a worthless burden, or it could be because System I is broken. If System I is broken, you need to call in System II to route around the distorted cognition so you can understand at least on an intellectual level that you’re wrong. Once you understand you’re wrong on an intellectual level, you can do what you need to do to make it sink in on a practical level as well – which starts with not killing yourself.
As sad as it was, Robin Williams’ suicide has actually been sort of helpful for me. For the past few days, I’ve tried telling these sorts of people that Robin Williams brightened the lives of millions of people, was a truly great man – and his brain still kept telling him he didn’t deserve to live. So maybe depressed brains are not the most trustworthy arbiters on these sorts of issues.
This sort of supportive psychotherapy (ie “psychotherapy you make up as you go along”) can sometimes take people some of the way, and then the medications do the rest.
But sometimes it’s harder than this. I don’t want to say anyone is ever right about being a burden, but a lot of the people I see aren’t Oscar-winning actors or even automobile safety engineers. Some people just have no easy outs.
Another patient. 25 year old kid. Had some brain damage a few years ago, now has cognitive problems and poor emotional control. Can’t do a job. Got denied for disability a few times, in accordance with the ancient bureaucratic tradition. Survives on a couple of lesser social programs he got approved for plus occasional charity handouts plus some help from his family. One can trace out an unlikely sequence of events by which his situation might one day improve, but I won’t insult his intelligence by claiming it’s very probable. Now he attempts suicide, says he feels like a burden on everyone around him. Well, what am I going to say?
It’s not always people with some obvious disability. Sometimes it’s just alcoholics, or elderly people, or people without the cognitive skills to get a job in today’s economy. They think that they’re taking more from the system than they’re putting in, and in monetary terms they’re probably right.
One common therapeutic strategy here is to talk about how much the patient’s parents/friends/girlfriend/pet hamster love them, how heartbroken they would be if they killed themselves. In the absence of better alternatives, I have used this strategy. I have used it very grudgingly, and I’ve always felt dirty afterwards. It always feels like the worst sort of emotional blackmail. Not helping them want to live, just making them feel really guilty about dying. “Sure, you’re a burden if you live, but if you kill yourself, that would make you an even bigger burden!” A++ best psychiatrist.
There is something else I’ve never said, because it’s too deeply tied in with my own politics, and not something I would expect anybody else to understand.
And that is: humans don’t owe society anything. We were here first.
If my patient, the one with the brain damage, were back in the Environment of Evolutionary Adaptedness, in a nice tribe with Dunbar’s number of people, there would be no problem.
Maybe his cognitive problems would make him a slightly less proficient hunter than someone else, but whatever, he could always gather.
Maybe his emotional control problems would give him a little bit of a handicap in tribal politics, but he wouldn’t get arrested for making a scene, he wouldn’t get fired for not sucking up to his boss enough, he wouldn’t be forced to live in a tiny apartment with people he didn’t necessarily like who were constantly getting on his nerves. He might get in a fight and end up with a spear through his gut, but in that case his problems would be over anyway.
Otherwise he could just hang out and live in a cave and gather roots and berries and maybe hunt buffalo and participate in the appropriate tribal bonding rituals like everyone else.
But society came and paved over the place where all the roots and berry plants grew and killed the buffalo and dynamited the caves and declared the tribal bonding rituals Problematic. This increased productivity by about a zillion times, so most people ended up better off. The only ones who didn’t were the ones who for some reason couldn’t participate in it.
(if you’re one of those people who sees red every time someone mentions evolution or cavemen, imagine him as a dockworker a hundred years ago, or a peasant farmer a thousand)
Society got where it is by systematically destroying everything that could have supported him and replacing it with things that required skills he didn’t have. Of course it owes him when he suddenly can’t support himself. Think of it as the ultimate use of eminent domain; a power beyond your control has seized everything in the world, it had some good economic reasons for doing so, but it at least owes you compensation!
This is also the basis of my support for a basic income guarantee. Imagine an employment waterline, gradually rising through higher and higher levels of competence. In the distant past, maybe you could be pretty dumb, have no emotional continence at all, and still live a pretty happy life. As the waterline rises, the skills necessary to support yourself comfortably become higher and higher. Right now most people in the US who can’t get college degrees – which are really hard to get! – are just barely hanging on, and that is absolutely a new development. Soon enough even some of the college-educated won’t be very useful to the system. And so on, until everyone is a burden.
(people talk as if the only possible use of information about the determinants of intelligence is to tell low-IQ people they are bad. Maybe they’ve never felt the desperate need to reassure someone “No, it is not your fault that everything is going wrong for you, everything was rigged against you from the beginning.”)
By the time I am a burden – it’s possible that I am already, just because I can convince the system to give me money doesn’t mean the system is right to do so, but I expect I certainly will be one before I die – I would like there to be in place a crystal-clear understanding that we were here first and society doesn’t get to make us obsolete without owing us something in return.
After that, we will have to predicate our self-worth on something other than being able to “contribute” in the classical sense of the term. Don’t get me wrong, I think contributing something is a valuable goal, and one it’s important to enforce to prevent free-loaders. But it’s a valuable goal at the margins, some people are already heading for the tails, and pretty soon we’ll all be stuck there.
I’m not sure what such a post-contribution value system would look like. It might be based around helping others in less tangible ways, like providing company and cheerfulness and love. It might be a virtue ethics celebrating people unusually good at cultivating traits we value. Or it might be a sort of philosophically-informed hedonism along the lines of Epicurus, where we try to enjoy ourselves in the ways that make us most human.
And I think my advice to my suicidal patients, if I were able and willing to express all this to them, would be to stop worrying about being a burden and to start doing all these things now.