Saturday, 27 June 2015

Putting Myself in the Dock

Bereavement is almost always accompanied by a sense of responsibility and guilt on the part of those left behind. The relatives of people who have died of cancer agonise over whether they should have encouraged them to seek medical advice earlier or pressed for a different form of treatment, those who lost somebody in an accident find themselves wishing they had delayed them leaving the house that morning until the car with the drunken driver was safely elsewhere, or conversely, perhaps, not delayed them. The partners of heart attack victims spend the rest of their lives regretting that stressful argument they had the previous day. But the scope for guilt seems to loom even larger where the cause of death is suicide because, superficially at least, it seems so avoidable. This was an act of Man rather than God and thus it must follow that either in some way we were responsible for it ourselves or it was within our gift to prevent it.

This sense of control over events is, to some extent, an illusion since it presumes that suicide is an act of free will determined upon while in a rational state of mind. It presupposes that the individual can clearly, logically, assess the alternatives, determine the best course of action and seek out and accept help and support at the time of crisis.  

Some suicides may occur under these conditions. Perhaps, for example, in the case of somebody who has a terminal diagnosis and does not wish to suffer to the end. But most do not. Instead they happen amidst a desperate all enveloping darkness where a hunted mind fixates, perhaps for months, perhaps just for minutes, on one solution, utterly unable to see beyond it, to grasp the existence of alternatives, to understand that the outlook is not as bleak as they imagine it, or to recognise the impact on others of their intended course of action. There is no more genuine choice in whether to live or die here than that exercised by somebody suffering from cancer. Louise's life was at risk from her illness just as surely as if it had been a physical rather than a mental ailment.

Nevertheless there was nothing inevitable about her death. Any number of things could have prevented it, kept her safe until the crisis passed. So many, in fact, that its almost inconceivable that it actually happened. There were countless opportunities from the point when Louise fell ill right up to her last moments of life for the safety gates to slam shut, for her to be diverted onto another, safer course. Most of these events were beyond my control. But I was the one closest to her, I was the person who knew her best and had the most influence on her environment. It was my duty to keep her safe. I know beyond any doubt that there were many points at which different decisions or actions on my part would have kept Louise alive. 

Unlike many for whom suicide is the first, as well as the last, indication of their partner's mental distress I don't have the excuse of not knowing the risks. There were plenty of warning signs. Louise was the kindest, gentlest, most intelligent, fun loving, energetic and warm hearted person I have ever met and she enjoyed life with a passion which put me to shame. But she also suffered from periodic and highly distressing episodes of anxiety and depression. By the time that she took her life she had been battling a particularly severe attack of depression with incredible bravery and fortitude for several months and in the midst of this period also had to contend with the suicide of her father. Little more than a week before she died she had confessed, at the last minute, to a plan to overdose.

In the circumstances therefore an attempt on her life shouldn't have been a surprise. I attended the psychiatric consultations alongside Louise, talked to her about her illness endlessly and was confident that I understood, like no other person, the way Louise's mind worked. I now have to try to come to terms with the fact that despite this knowledge I still did not save her.

I was acutely aware of Louise's distress but made a series of judgement calls about her care which hindsight proves to have been wrong, or at least ineffective. I was too focused on giving her agency. Louise was extremely independent and I knew that she was distressed at the thought that she was becoming dependent upon me to keep her going. I wanted her to know that she had got better herself. I thought it would make her eventual recovery more sustainable. I therefore complied, reluctantly, with Louise's request that I return to work rather than stay by her side until she was better and accepted her reassurances, when pressed, that there was no need to alert her psychiatric care team when she went downhill again in the final few days. I tried to do what Louise seemed to want me to do rather than follow my own best instincts so that she would gain strength and empowerment from managing her own recovery.

I piled well intentioned mistake upon well intentioned mistake. I trusted in the robustness of the daily psychiatric monitoring programme. I trusted too much in Louise's ability as a doctor to do the impossible and manage herself as  a patient and objectively and rationally assess her own state of mind. I allowed myself to be lulled into a false sense of security by the fact that she had told me about her planned overdose. I thought that was the moment of crisis and it had been averted. Never in my worst nightmares did I contemplate Louise returning to the idea, and so soon. I lay in bed the next evening cuddling Louise, holding her for all I was worth, trying to come to terms with the thought that if she had carried through her plan she would now be dead and wondered how she felt about still finding herself alive. Relieved? Disappointed? Numb? I decided to wait, to give Louise time to recover before properly discussing the episode with her and telling her how much I desperately needed her to live. I feared that to confront her with such an emotionally fraught conversation when she was still fragile might be counter productive. Maybe it would have been better had I done so.

Confused by so many ups and downs over the course of the illness, I also failed to recognise the final, crucial, dip as being anything other than part of the normal daily fluctuations which had gone before it. Maybe this was partly because I was exhausted, physically and emotionally through coping over an extended period not only with this crisis but also another in the form of the simultaneous serious illness of my Mother. I was therefore not as alert to danger as I should have been.

Had the outcome been different all this would have been excusable. In the absence of a hospital admission I was in the front line of Louise's care. I knew that as the person principally responsible for creating the environment around her, every word and act on my part had the potential to influence whether she lived or died. I felt the weight of that responsibility. The mind is an infinitely complex instrument and there are no reliable manuals or pathways to surely fix it when it is broken. Even for practitioners psychiatry is more of an art than a science. Still, I tried hard to support Louise as intelligently and intensively as I knew how. Everything that I did appeared reasonable in context and my approach of giving her responsibility was endorsed by Louise's psychiatrist when I turned to him for advice in the final days.

Even the failure to recognise the real level of risk is understandable. Its difficult to bring yourself to seriously contemplate the idea that your wife might kill herself. The concept is too enormous, too obscene, to process. I knew that Louise had attempted suicide before but that was many years prior to us meeting. It seemed ancient history and was not something that we ever dwelt on.

People try to reassure me, to tell me that I could have done no more, that Louise was happier during our time together than at any stage in her adult life, that I may, without realising it, have helped her to survive or avoid similar moments of crisis in the past. I know that Louise herself doesn't blame me. She wrote in her farewell letter that ultimately nobody can fully hold another person. I draw some comfort from this.

But however hard I tried, however well intentioned I may have been, however tired I was, I either did not do enough or made the wrong choices when I could not afford to do so. Only the relatives of the living have the luxury of excuses. I have to deal with a sense of responsibility for what happened, the knowledge that I failed Louise in those final days. I replay over and over again what I could and, with hindsight, should have done differently. I still torture myself endlessly and ultimately pointlessly not only about the major decisions but also the smaller omissions. Why, for example, didn't I have the presence of mind to buy Louise flowers in the last few days? Or to tell her exactly much I loved her and needed her? It might just have lifted her mood the fraction that was necessary to get her through the immediate crisis.

I was Louise's husband. It was my responsibility to keep her safe. I was there to support her. I was her rock. No matter what I may have done before, on this occasion, when she needed me most, I failed her. I will have to live for the rest of my days with the knowledge that I might have been able to save the life of the woman I love so deeply, but didn't. I apologise to Louise every day. It is hopelessly inadequate but it is all I now have in my power to do. 


  1. Stu died of a heart attack in November 2013. He had three smaller ones in May 2011. I went with him to each appointment with the consultant, I cooked healthier food, we did more exercise than before.
    If love alone could have saved our loved ones we would not be where we are now - previous actions when they were younger (Stu's smoking) or a problem in their mental health (I suffer from depression) - and they are gone. As their closest person I do not think we would be human if we did not think of the what if's & blaming ourselves - however I also believe that they would not want us to be consumed with grief & blame.

    1. The guilt, as you say, is almost inevitable regardless of the cause of death, We always feel as though there must have been something more that we could have done. However, I've just come across the line 'you cannot save somebody, you can only love them.' I think that we can only hold on to that and know that we surely loved.

  2. Thanks again Gary for sharing these raw feelings. It is only 5 months. This is a normal reaction. It will be interesting to read what you feel in 5 years time

  3. Thanks Marion. Five years feels like a far distant horizon at present - but then so did 5 months not so long ago! And you are right, much has already changed even within that short time.

  4. Gary Thank you for your beautiful blog. I trained with Louise in London. We were good friends. I remember a wonderful afternoon laughing together preparing tabbouleh salad at her flat for a party at the end of our training. I remember the long conversation we had after her previous attempt. I moved house a lot. We lost touch. I regret that so much. I was so sorry to hear the news and sorry I wasn't able to come to the memorial. I disovered Louise's Facebook page only after she was gone. She looked amazing in the pictures. I am so happy to know from reading this blog what happiness she knew with such a loving husband. The joy is obvious in the photos. SB

    1. Hi. Thank you so much for posting. Its always lovely to hear from those who knew Louise before we came into each others lives. One of the things that pains me so much when talking about Louise's death is that it inevitably focuses attention on those times when she was unwell. For those who don't know her it creates an impression of somebody who was vulnerable and needy. But actually Louise was incredibly strong and self reliant, and the happiest and most vibrant person I've ever met. Its so odd how paths in life cross - her flat that you remember subsequently became our marital home, the place where I spent the happiest three years of my life. If you would like to talk more you are welcome to message me on Facebook.