Book Review: The Guardians -- An Elegy

Serious mental illnesses can be agony: They are as painful as physical illnesses but further bedeviling because there is no broken bone, no dead heart or lung tissue, no cancer or non-functioning organ to point to.
05/15/2012 02:06 pm ET Updated Jul 15, 2012

Harris Wulfson died July 23, 2008. He had walked for some 10 hours from midtown in New York City to the Riverdale Metro-North train station (north of Manhattan), where he jumped before an oncoming train to his crushing death.

His loss is beyond measure to family and friends who loved him and relished his abundant talent, energy and quirkiness. Because his death was from suicide while in the throes of an acute psychotic illness, likely bipolar disorder, his death is yet another preventable tragedy.

In this country, 35,000 people annually succumb to death by their own doing; there are no doubt more where the cause of death is less clear. Each is a life that need not have ended and inestimable grief for those who held that person dear.

Sarah Manguso delivers a tightly-written, powerful "elegy" to her friend Harris. She wonders:

"Why is it easier to think 'Harris killed himself' than to think 'Some unknown invasive pathology entered Harris without my knowledge and, while I wasn't looking, murdered him?'"

She asks a question that plagues my field: psychiatry. She asks what is the disease that extracts the ultimate price from its host. By inference, she also asks how we can learn to protect against its invasion and, if not effective in doing that, at least avert a fatal outcome.

The Guardians, an allusion I imagine to the angels of antiquity who look after we mortals, weaves Harris' and Maguso's often tormented, creative paths -- with his death seemingly to have permitted her escape from a similar fate. Manguso holds no animus to her friend for leaving her: She believes in "... the possibility of unendurable suffering." At once darkening and heartening to their stories is also her depiction of the catastrophe that befell New York City on Sept. 11, 2001 -- 9/11 brought horror, resilience and recovery to so many like them who lived through the attack.

Harris, who I never met, though I have known his father since medical school, was a spirited genius, a young man whose gift for creating music and computer software were head-turning. Scattered as he was, that did not matter; what counted was the way his remarkable brain operated and the ways by which he was a friend. Those were the treasures that Manguso enjoyed, and she dolefully laments their loss. We feel her pain since none of us is spared grief.

Serious mental illnesses can be agony: They are as painful as physical illnesses but further bedeviling because there is no broken bone, no dead heart or lung tissue, no cancer or non-functioning organ to point to. For some people with psychotic illness, their capacity to appreciate that they are ill has been pirated away by the "invasive pathology" that is mental illness. When intractable psychic pain seems like it will never end, without evident cause or hoped for remedy, the soul is taken over by a horrific state that Sartre called "no exit." Those are the conditions that drive a person to suicide.

Harris deftly escaped the psychiatric hospital where he had been admitted. He may have been on medication that made his distress even greater, so speculates Manguso. There is so much we cannot know since he is not here to tell us what feelings and thoughts preceded his irrevocable act. But we do know that suicide is preventable. Manguso herself is a lesson in how life can go on, despite illness and tragedy; her path shows that love, creativity and contribution can be achieved.

Suicide is a public health problem. Like other mortal and disabling conditions there are fundamental ways to beat it. Solutions begin with early detection of mental illness: 50 percent of psychiatric disorders begin by age 14 and 75 percent by age 24. Even before that are the behavioral problems that occupy more often in pediatric practices than for any other reason that kids and families are in the waiting room. Yet gaps as long as nine years are typical from the time symptoms appear to when a diagnosis is made. Another basic, yet often unmet, public health principle is to assure the delivery of effective treatments; sadly, in this country, less than one in five affected individuals receive treatments -- medications and psychotherapies -- proven specific to their conditions.

We know that early intervention and evidence-based treatments can prevent the progression of a disabling psychiatric condition. Offering accessible services is also vital; clinics and offices need to be welcoming and responsive to patient and family preferences and without unbearable wait times to appointments, insurance hassles and denials. The role of hope, persistence despite setbacks, and exposure to and support from others who themselves have lived through the "noonday demon" (as Andrew Solomon described) can never be underestimated. Mental disorders are highly prevalent and can be treated. The pain and cost of not doing so, which is too often the case today, is egregious and exorbitant.

We have Sarah Manguso to thank for her revelatory candor and the beauty of her prose. We have her to thank for this tribute to her friend, whose loss cannot be reversed but whose story can impel a health and mental health care system to do better from here on in.

Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.


Lloyd I. Sederer, MD

The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.

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