The Nearest Exit May Be Behind You

Andrew Miller


sky and clouds

My new bride and I had two transfers before our final flight to Copenhagen. We caught a small twin prop plane from Columbus to Toronto, then transferred to a 747 headed for Frankfort, before a short jaunt over the mainland and sea into Copenhagen. Even with several connections breaking the flight into smaller segments, it was the seven-hour Toronto to Frankfort flight that concerned us the most.

Preceding the trip, a number of bizarre incidents involving commercial air travel had left hundreds dead. There were the two lost flights under command of Malaysian Airlines, one over the Indian Ocean that took over a year to determine even where it had been lost, much less determining any cause. The other had ignored warnings about hostilities between Russia and Eastern Europe, leading to it being shot down over the disputed territory of the Ukraine. Then in May of 2015, a German co-pilot who suffered mental illness took advantage of being left alone in the cockpit, and deliberately crashed a Lufthansa operated German Wings flight into the French Alps.

That co-pilot, Andreas Lubitz, waited for the commanding pilot to leave the cockpit before closing the door and locking it. Flight recorders captured the sounds of the flight crew pleading with him all the way up to the point of impact. With a post 9/11, reinforced, bullet-proof door sealed, no one could alter the course Lubitz chose.

All 144 passengers and the crew of six were killed. Lubitz had been declared “unfit to work” during a health check due to his suicidal ideations; but he chose not to share those thoughts with anyone beyond his personal physician. No one else deserves the blame for the terrible decisions made, yet to simplify Lubitz choices leading up to the fatal final decision would be unfair.

Physicians have many barriers preventing the dissemination of information crucial to their patients ongoing care. Far beyond mere concerns over the exchange of health records – electronically or otherwise – there are the ethical concerns, privacy concerns, and a myriad of other legal and cultural issues. Specifically, cultural stigmas about suicidal ideations, or even more mundane mental health malaise, can lead to very real and very negative consequences. Lubitz knew that sharing his issue with Lufthansa could ground him, possibly costing him his career.

Consequences such as losing your job, friends, family and even basic autonomy can exacerbate the mental health issue, as opposed to improving the stability and health of the ailing. Lubitz life story is written in pursuit of flight. He’d joined an aviation club right out of high school, eventually earning a position in Lufthansa’s flight training school. The only break in his training was during a forced hospitalization due to depression. He was later cleared to return to training, but for a time was unable to earn his U.S. pilot license due to licensures concerns related to his hospitalization.

Ironically, although we’d booked Lufthansa, it wasn’t tragedy that caused our concern. Instead it was our own mental illnesses.

A year earlier we’d taken our first overseas trip together. Our Paris trip was the first-time Gail had travelled trans-Atlantic in years. On a crowded direct-flight from Columbus to Frankfort, she became unexpectedly claustrophobic. Anxiety took over. Anxiety which became so overwhelming that all Gail’s color had left her face — she was shaking and feverish. I had been wholly unprepared for this reaction, left depressed and bewildered, not knowing what to do.

Fear of Gail suffering this claustrophobia once again led to the choice of the Lufthansa flight, subtracting about an hour from the long trans-Atlantic segment.

When we landed in Toronto heading to our Danish honeymoon, our worry rose. Prior to leaving we’d invested in various sleep aids and distractions for preventing another fevered arrival. We continued to make plans right up to boarding for how we might deal with not just Gail’s anxiety but my own. I wanted to know I could provide Gail comfort, but instead felt that there would be little I could do beyond empathizing. My own mental health was prone to moments of deep depression over feelings of shame and inadequacy; the inability to comfort brought both to bare.

Certainly this wasn’t a normal day. We’re not part of the jet-set no matter how ungrounded we often find ourselves. On a normal day our relationship seems to work so well specifically because both Gail and I have suffered significant un-grounding mental health struggles. Shared struggles allow us to share both sympathy and empathy for one another.

Family and friends struggle to understand, but never really know what’s wrong with us. We see doctors and therapists who do their best to probe for answers, hoping for the right word or drug combination to magically appear.

The grand lie of the US mental-health-care system is that there truly is a system of care at all. Instead we have disconnected doctors and diagnoses. The once iconic ideal of the psychiatrist has been wiped away. Psychologist, the therapists with time to talk, but rarely the ability to prescribe medication, are the ones inviting the suffering in to talk through their issues. Psychologists strive to understand the individual struggle and root cause. Psychiatrists have no time for talk-therapy, instead they write prescriptions and the pharmaceutical manufacturers reward them well for it. The MD associated with their name may as well mean Medicine Distributor instead of Medical Doctor.

This is not to say that medicines are ineffective in the treatment of mental illness. After years of incorrect, and at time detrimental prescriptions, I’ve finally found some relief through medication. A variety of therapists over the years have been forced to draft short letters to an MD to request a course of medication. A paragraph, a full page at best, explaining the therapist’s best interpretation of the DSM-5 (Diagnostic and Statistical Manual) in hand, I then might get ten minutes face time with the doctor responsible for re-interpreting my symptoms and suggested diagnosis. The MD plays connect-the-dots with possible prescription options which are often selected from the pile of medications most recently regaled to them by their pharmaceutical sales staff, possible over a free lunch.

A World Health Organization (WHO) study, America’s State of Mind, shows a decade long increase in mental health disorders of 23 percent. The rate of increase for various psychiatric medications has shown an even higher upward trend, such as second-generation anti-psychotic prescriptions tripling according to the WHO. This despite the numerous professional organizations’ studies that show how often these mind altering prescriptions are made with an educated guess based on a computer algorithm or pharmaceutical brochure. The aftermath of an incorrect medication can be deadly.

An American Journal of Psychiatry analysis, titled, “Suicide Rates in Clinical Trials of SSRIs, Other Antidepressants, and Placebo: Analysis of FDA Reports”, concluded: “These findings fail to support either an overall difference in suicide risk between antidepressant and placebo-treated depressed subjects in controlled trials or a difference between SSRIs and either other types of antidepressants or placebo.”

In my youth I rotated through various medication cocktails and therapists, with an eventual suicide attempt made while on that era’s SSRI “miracle” drug, Prozac. During the late 80’s Prozac was being prescribed to teens in record numbers, ironically resulting in record numbers of those same teens committing suicide. Memories of that period for me are deeply melancholy, including the complete emptiness I felt on lithium and the rubbery smell of the stairwell in the Battle Creek psychiatric hospital. To this day that odor transports me back into those confining walls.

In early adulthood I self-medicated with horrifying results; including incarceration, repeat career failures, and two failed marriages. In later adulthood I gave in to trying prescription drugs once again, and after some trial and error, did settle on one – with mixed results so far.

The American Psychological Association published an article titled “Inappropriate Prescribing” in their June 2012 journal Monitor on Psychology which documents the rising profit for pharmaceutical companies and MDs alike in this environment. According to the article, quoting associate clinical professor of psychiatry at Tufts University, Daniel Carlat, MD, “Health insurance reimbursements are higher and easier to obtain for drug treatment than therapy, which has contributed to the increase in psychotropic drug sales and a shifting of psychiatry toward psychopharmacology.”

“There is a huge financial incentive for psychiatrists to prescribe instead of doing psychotherapy,” he says. “You can make two, three, four times as much money being a prescriber than a therapist. The vicious cycle here is that as psychiatrists limit their practices primarily to prescribing, they lose their therapy skills by attrition and do even less therapy.”

Amidst my negative experiences and research, it was Gail who inspired me try medication again. She has had reasonable success overcoming anxiety, obsessive-compulsivity and attention deficit disorder, with a combination of medications and therapy. Until meeting her I hadn’t know anyone (willing to admit it, at least) who had a positive medication experience.

Gail has had her setbacks, but generally moves through life with grace, determination, and confidence. Where I grew up with constant passive-aggression, she did not shy away from expressing her feelings. Experiencing an emotional honesty which I hadn’t before, expressed by someone suffering many similar issues as me, still wasn’t explicitly what led me to try medication again.

A series of episodes spread across a year or two of our relationship where I found myself feeling out-of-control and subjugated, primarily at my job, led me every few months to increasingly dangerous situations of self-medication. I was drinking myself into oblivion in the hour or two between my leaving work and Gail coming home. Once Gail found me passed out next to a roaring bonfire; another time laying face-down in vomit just inside our front door, house keys still dangling from the lock.

Regardless of these episodes she’d inspired me to embrace life in ways I hadn’t. Gail reminded me of what I had to live for, and what she wasn’t willing to live with. Therapy alone wasn’t working so I looked at her example, and gave in to psychopharmacology. Sadly, her inspiration wouldn’t hit me until a few months after our honeymoon. A year would pass before my medicated mind felt mostly normal. It would be even longer before my therapist and I felt we had a handle on what triggered me to near-suicidal alcoholic self-medication.

* * *

As we found our seats on the Frankfort-bound plane, we were relieved to realize we would be at the front of the coach section, sometimes referred to as “peasant first class”, providing us with just a few more inches of space between ourselves and the galley wall. No seats reclining into our laps. No bouncing trays as a forward passenger shifts in their chair.

With a small jerk, we felt ourselves moving. The tug pulled us off the jet way. Fortune shining on us, we’d been left with an empty seat to our right and left. Gail’s anxiety was subsiding, but at this time I was still white-knuckling my mental illness, neither medicated nor taking my talk-therapy seriously at all. I was barely holding myself together, much less paying Gail the attention I’d intended to.

The mania side of my manic depression took over. I shifted uneasily in my seat as we awaited takeoff. I knew that once we leveled out I would be free to use the microscopic bathroom to splash water on my face, cooling myself with the ceilingounted air vent evaporating the beads of water. If possible I’ll find some other distraction, a book, drawing, the ridiculous sky-mall offerings. Anything to refocus my miserable one-tracked mind.

Taxiing toward our position on the tarmac we’re given a floor show by the flight attendants, a Macarena like dance of locking and unlocking seatbelts, grabbing an oxygen mask, and learning to inflate a life vest. The pre-recorded narrator bellows out instruction after instruction, including a reminder that: “The nearest exit may be behind you.”

This phrase finding a seat in my mind, securing itself there for the duration of the flight.

The nearest exit may be behind you.

There’s a misperception a cure for mental illness has been found. Or that mental illness, specifically suicidal ideation, is something distinctly different from a deformed limb, or an affect such as dyslexia. That mental illness is more akin to the flu or an infection; that a short period of suffering or a strong prescription is all that’s necessary to get through.

Given the pharmaceutical industry’s efforts, I can understand why so many people believe that simply taking a Xanax will solve your anxiety, or that the ability to live without hallucinations is just one Abilify a-day away. The Canadian Medical Association Journal found the U.S. “drug industry tripled its spending on marketing, including a five-fold increase in direct-to-consumer advertising … American patients were more than twice as likely to request advertised drugs than patients in Canada, where most direct-to-consumer advertising is prohibited. Patients who requested advertised drugs were nearly 17 times more likely to receive one or more new prescriptions than patients who did not request any drugs.”

Furthermore, the industry has been responsible for billions of dollars in settlements over prohibited off-label marketing of their drugs. Aggressive marketing in this way leads to, in particular, general practitioners not specifically trained in mental health disorders prescribing drugs not specifically approved for the issue.

When I was 11 years old, I lost my cousin Luke to suicide. This was ahead of the Prozac era, ahead of there being but only a few psychiatric medicines, ahead of even talk-therapy being widely accepted.

Luke had found his exit plan from years of anxiety and depression at the end of a gun. On that 1986 Thanksgiving eve, he locked himself in a bathroom, and no pleading from the other side of the door could divert him from what he saw as his only option. While I hadn’t understood exactly what it all meant in my youth, I had already known the highs and lows of manic depression. The once foreign concept of suicidal ideation had found a seat in my mind, and belted in for the long haul.

Open to the possibility that I could control my own fate, I attempted suicide twice as a teenager; but my weak constitution and outside intervention prevented success. Being alive should have felt like a second chance. Instead the failures felt like insult upon injury.

Hospitalization helped keep me from myself, mostly through cocktails of sedatives and anti-psychotics, 24-7 supervision, and learning some socially acceptable coping mechanisms such as meditation, and scrubbing my forearms with bristle brushes. Rubbing my skin raw replaced other mechanisms, like beating my head against walls until my hair matted with a stream of warm blood, or cutting my skin in artfully placed slits ala the film Syd and Nancy.

My current therapist helped me realize my need to let my feelings out as a trigger for my drinking; as opposed to most people who use alcohol to avoid feelings. The psychiatric hospital seemed less concerned with causation and more interested in correction. Rubbing my forearms was meant to deaden my physical revulsion to being touched. The sedatives and anti-psychotics deadened my revolting emotions.

On visits to the hospital my parents would inquire about whether or not I’d been cured; feigning ignorance about what I was up against. Only recently, now in my 40s, have I had a conversation with my mother about my father’s own mental health issues.

Shortly after the release of my most recent book, If Only the Names Were Changed, which is a broad examination of my mental illnesses, mom drove down from her home in Michigan to visit. She asked if we could take a walk alone together. I was happy to oblige, assuming we’d talk about the book. I knew she’d read it not because I sent it to her, or even mentioned it had been published, but because I noticed she had left me a review on Amazon titled: “4 out of 5 stars.” A fitting commentary on more than just my writing for sure.

“I don’t know if you remember when you were a kid, and you and your sister were learning the theme to M*A*S*H,” she inquired.

I did. I hated piano lessons even though I enjoyed playing the piano. With a tin ear and no natural talent however, I’ve resigned myself to being an aficionado as opposed to being a musician.

I would’ve been about 9 years old at that time. I remembered how we would play that song over and over on the piano. In my teenage years I learned the words to the song – “Suicide is painless, but brings on many changes…” – certainly an odd theme for a sit-com meant for the whole family. Originally M*A*S*H had been a film, and a much darker commentary on the Korean War. To this day, I remember watching the TV show each week with my family and crying a little after the episode when character Henry Blake died in a plane crash returning to his civilian life.

Mom continued, “One day while you and your sister played it over and over and over, I was in the bedroom with your father trying to convince him not to commit suicide.”

Neither my mother nor my now dead father (cancer, not suicide) had ever suggested to me that he suffered from mental illness and suicidal ideation. At no point after Luke’s suicide or my own attempts had this ever been brought up.

From them there was no attempt at empathy, just an attempt to cure me.

We talked further about how she didn’t recognize the stories I’d written in the book; how she accepted the fact it was my perception (a point I make throughout), and reiterated a recurring theme of our conversations about my writing – “I really hope someday you’ll write about happy things.”

I think what works in my marriage to Gail that hadn’t worked with my previous two wives, that hadn’t worked with my family in general, is our acceptance of one another with all our differently functioning mental states. A big part of mine being the constant calculating of whether the time to exit is now – never – or, if I’ve missed it altogether.

The nearest exit may be behind you.

Sitting shoulder to shoulder in peasant first class, I squeeze Gail’s hand and she squeezes mine back. I consider briefly what would happen if in-flight I used the newly garnered knowledge of how to open that emergency door a few rows behind me. Although an oft-reported story of passengers attempting to kill themselves this way, they never succeed and I didn’t suspect I would either.

Like an amputee who occasionally feels phantom limb syndrome, my suicidal ideations can take hold at any moment; even in a moment of love, of happiness – my best friend and new bride next to me – even in that moment. My ideations come upon me as easily as clouds drifting through the atmosphere or as rapidly as a jet bursting through them.

The nearest exit may be behind you.

Gail holding my hand tightly.

Her hand holding me in the moment.

Releasing only long enough to latch our seatbelts.

Strapped in for the long haul.