"It was a pretty amazing turnaround," said Sherry Pontosky, now a 35-year-old neonatal nurse from northeastern Pennsylvania who, at her worst, was so drugged on antidepressants and antipsychotics that she said she lost a year of her life.
"I never feared death," she said. "Even in the teenage years, I muddled through life. If I stepped off a curb and bus hit me, it was all right. I just thought that was how everybody felt and how people existed."
For years, before psychotherapy saved her, medications offered little relief and prevented her from getting to the root of her self-destructive behavior.
"I felt I wasn't worthy of happiness," she said. "I didn't know what that was."
The 'Subtle Suicide Zone'
Each year, 500,000 Americans try to kill themselves, resulting in 30,000 to 40,000 deaths, according to the National Institute for Mental Health, but far many more are living "on the edge," in what two psychologists have now labeled the "subtle suicide zone."
They may abuse drugs or alcohol, engage in risky behavior or, like Pontosky, sabotage their chances at happiness. Most are too afraid actually to kill themselves, but would have no problem if they didn't wake up in the morning.
"It's not a formal diagnosis, it's a state of mind that can co-occur with other things," said clinical psychologist Michael A. Church, who has co-authored the new book, "Subtle Suicide: Our Silent Epidemic of Ambivalence About Living."
"We think those numbers pale if we can measure subtle suicide," said Church. "We think it's a portal to overt suicide."
Church and his collaborator, research psychologist Charles I. Brooks, both of Pennsylvania's King's College, have developed the concept of subtle suicide, which is often misdiagnosed as bipolar or any number of other psychiatric disorders.
They have written the book for the average person and their families, but also as a "professional call to arms," said Church.
Together, they have developed a preliminary diagnostic questionnaire to help doctors and therapists better identify the characteristics of subtle suicide and work to end the cycle of self-anger and denial that typifies the behavior.
"Ultimately we want to measure it," said Brooks, a research psychologist.
"Why care about medications and psychotherapy if you don't care on a routine basis if you live or die," said Church. "Just to call it bipolar or alcoholism is to miss the point."
Emotional deprivation, sexual abuse and trauma in childhood can turn anger inward, according to the authors. Those with low self-esteem seem more vulnerable to subtle suicide.
Many stay in the subtle suicide zone for years, not killing themselves for fear of the act itself, of being sent to hell, botching the attempt or hurting loved ones. The key is that they avoid facing their real issues.
Often, the behavior begins in childhood. The book finds common threads in the self-destructive lives of celebrities Anna Nicole Smith, Marilyn Monroe, Evel Knievel and Jim Morrison: separation from parents or lack of empathy.
Some have "numbed" their pain since they were young.
"The percentage of students on psychiatric medications is absolutely frightening," said Brooks, who works with many overmedicated college students.
"When they are 14 or 15, their parents get upset and they go to see the psychiatrists. They automatically put them on medication and everyone buys in to the belief. Sometimes it allays the symptoms, but the underlying problems are still there."
"They don't want to kill themselves, but they have an ambivalence, thinking, 'Would it be so bad if I die?'" said Brooks. "It goes back many years, to the way they were raised, their interactions with their parents. They get into a cycle, a habitual way of not dealing with the problem. It's like a whirlpool sucking them down farther and farther and they get in that suicide zone and they are trapped."
Dysthymia: Just Going Through Motions
Church, who has treated more than 4,000 patients in his career, came up with the concept about 15 years ago after seeing self-sabotaging behavior in his patients.
The idea was not new. "Passive" suicide and had been described in other psychiatric literature, like Karl Menninger's landmark 1957 book, "Man Against Himself."
"I felt it was too important to put aside," said Church, after reading more books on the topic. He had seen the phenomenon in his own family: a relative who drove his motorcyclist too fast, "alcohol-ed up" and didn't take care of his health.
"I realized I have some unfinished business from my childhood and if I can't save my family, I can save others," he said.
Pontosky was one of them. In 2005, after her suicide attempts, she was referred to group counseling and met Church.
He discovered that Pontosky had suffered since junior high school with dysthymia, a mild depression that generally does not respond well to antidepressants.
Church likens it to "standing on one foot," where patients can be "more easily knocked down by the blows of life."
"They can go for years, have heightened feelings of anxiety and guilt, and avoid getting help," he said. "They go through the motions of life, underachieving. Sherry needed to want to live more."
Her first memory was of her parents announcing their divorce when she was age 3. Pontosky's father, unaffectionate and emotionally distant, remarried and had a child; her mother also remarried, then went back to school to become a nurse.
"She was working double shifts and didn't have a lot of time for me," said Pontosky. "I always had to have straight As and to be the star to gain some attention."
She went to college and married her high school sweetheart, an "unavailable man" much like her father, and resigned herself to being a submissive wife.
Pontosky was hospitalized and given electroshock treatment -- a "last resort" for those who repeatedly try to kill themselves, according to Church.
All memories from that year were wiped out by the electroconvulsive therapy.
A trigger for her depression had been a miscarriage after struggles with infertility. She was unable to work for nine months after her hospitalizations and couldn't face returning to the nursery at work, where she was surrounded by newborns.
All the while, her psychiatrist kept experimenting with her medications, which made things worse.
"After the second suicide attempt, a women psychiatrist at the hospital said she couldn't believe how many meds he had thrown at me," she said. "She basically said, 'No wonder you are in such a pit.' They didn't help and I had to get out of the zombie state so the therapy could work."
She changed psychiatrists and began with Church the hard work of finding out why she had been living so much of her life in the suicide zone.
"I wasn't very good to myself," Pontosky said. "He linked a lot to my childhood and the emotional deprivation I felt."
Suicide Notes Reflect Victims' Pain
Gregory Eells, director of counseling services at Cornell University, which had a string of student suicides this year, agrees subtle suicide needs more attention.
"We see it in through their [suicide] notes, comments about not finding meaning in life, having pain, but not knowing how to escape it," he said. But those with subtle feelings of unexplained loss of pleasure and meaning in life are the people we are often the most worried about."
"He, too, cautions against over-medicating when behavioral therapy may help.
"Therapy does work," he said. "The hard part is, it's not the narrative we want to hear. We think, give a pill and you'll be cured. The reality is nothing is that simple. Our experience tells us that a pill doesn't fix everything, it doesn't give life meaning or make sense of things."
He also emphasized that traumatic upbringing is not always an obstacle to emotional self-acceptance.
"To some extent we're all shaped by our past, but I have worked with people who have overcome amazing difficulties," he said. "Childhood is a determinant and it clearly sets us on a path, but we have an amazing potential to change and not be a prisoner of our past."
Luckily, Pontosky was able to surmount her painful past. After much therapy, she confronted her husband about her emotional needs.
"I was submissive," she said. "No independent person deserves to be unhappy. I need to be happy as well."
The couple separated, but they continued to work on the marriage and she eventually grew more confident of her self-worth.
In both suicide attempts, her husband had found his wife unconscious, and he needed therapy, too.
"He'd been through a heck of a lot," she said. "We just held strong and realized we could lean on each and accept each other's faults."
"It's hard to imagine what he and I were like then," she said. "We made a huge transformation. Though all of this we have held together and our marriage has flourished."
Today, they have a two-year-old adoptive son. "He is the light of our lives," said Pontosky, who has gone back to her work as neonatal care nurse. "For me, he was the missing piece which kind of brought everything full circle."
And Pontosky, who is now on a single medication and continues her therapy, is finally happy enough to be afraid of death -- "very much so," she said.
"A lot of the work is mine," she said. "But I thank Dr. Church for showing me what created these feelings and why I dealt with them the way I did. He gave me the tools to make it different."