What kind of setting are you working in? I wonder if this has a lot to do with your patient population.
I would say in my (albeit short) experience dealing in outpatient with primarily patients on medicaid, very low income, high homeless population, tons of trauma, SMI, dual-diagnosis, tons of subsequent PD but also just bad primary psychotic disorders, etc., and I would put this number closer to the single digits (1-3% - and I mean realistically these are about 1/3 of people that end their lives most consistently). Even if the number of people not experiencing remission by "therapy" and psychotropics is much greater, most of the time there is waxing and waning of the conditions and they can still identify some things they either enjoy or look forward to (if asked in the right way).
I wonder if perspective would be improved by reframing your goal here. It is not your job to make people happy about their crappy life circumstances. You try your best to identify ways in which the system can help them be more comfortable or functional whether by psychotropics, therapy, groups, IOP/PHP, inpatient, residential, social programs, ACT teams, etc. Your goal is not purely remission of all depression or even of all chronic passive thoughts of death/SI.
I will also say that maybe we aren't classifying people the right way. A true depressive disorder inherently clouds judgement and disrupts memory. I would not trust a person with a true depressive disorder to make the sound determination that ending their life is the best option for them. I'm not even against the idea of autonomy in this area, but the cases I've seen and reviewed where I felt it was justified involved a thorough appraisal of their mental states and did not demonstrate true depressive disorders as a driving force for the wish to die. That is often why these determinations are rarely done without a thorough psychiatric evaluation and the involvement of many specialists.
I think part of my problem with the idea of creating a line where we say "yup, you should kill yourself" is that we are all subject to our own biases of what a life worth living looks like, so I'm not making a determination that someone has reached that point for them unless I know their logic is sound based on their own priorities, interests, and beliefs (which in and of itself is insanely difficult and not a job I would want).
Good post.
One of the things I learned early in my training by a very good psychiatrist (who was also a very good psychotherapist) was that psychotherapy is not 'the power of positive thinking.' If anything, it is the power of
rational thinking. This is also definitional with respect to our very concept of mental disorder. If someone is
not experiencing substantial distortions influencing their way of thinking about their position (or future prospects for alleviation of suffering) then--by definition--they aren't suffering from a 'mental DISORDER.'
I believe that two very odd (from an historical perspective) societal developments in the 'modern' world are responsible for the conditions that, perhaps, caused the original poster to ask this question:
(1) the all-but-complete elimination of a specific religious/spiritual shared framework within society itself (at least with regard to giving it serious attention at the academic/professional level of society) which was the original framework within which we tended to understand and conceptualize problems of existential suffering that was--at least hypothetically--refractory to medical/technological intervention or cure; and
(2) the societal elevation of 'happiness' (whatever that is--some form of hedonistic pleasure maximization? (Kierkegaard had the concept of 'The Asthete' which I think he considered the basest form of existential stance) above other all values in one's hierarchy of values. Things that
may be more important than 'happiness' [or one's average degree of 'gratification' or the temperature of your personal dopamine sauna] depending on your deeper philosophical moral framework could be things like (gasp, classical 'virtues') like truth/authenticity, love (in all its forms), duty (of various kinds) honor, loyalty, integrity...you name it. In fact--mindblowing, I know--the religious doctrine that had been the foundation of Western civilization for at least several hundred years (until recently) basically taught the credos of 'loving your neighbor as yourself' and acting in accordance with your understanding of a 'Power greater than your individual self' (basically, don't consider yourself to be omnipotent/omniscient) when making decisions to act in particular ways. The elevation of personal 'happiness' or 'satisfaction' to the top of the value hierarchy would have struck most people (historically) as rather odd and out of place. Sure, life is full of suffering but there are
reasons we keep going (that have little/nothing to do with pleasure/hedonism). Now, we can agree/disagree with the logic/illogic of particular religious doctrines but I think it probably goes without saying that it's impossible to orient yourself in the world and figure out
how to act in any given situation without a set of guiding overarching principles (philosophical or religious) helping you decide how to respond. I mean, in a sense this is what
schemas are (from a cognitive therapy perspective). I would assert one of the most important guiding principles to have when faced with various catastrophes of human suffering is 'I'm not God...therefore, it is not my responsibility to 'fix' God-level 'problems. I'm a human being (limited, flawed, biased, imperfect, stupid, selfish--you get the idea)...therefore, it is only my responsibility to address problems within the ambit of my abilities and the 'reach' of my personal efforts.' To have any other position is a recipe (ironically) for creating your own personal Hell (suffering) and to distract you from the task of doing any actual little bit of good you
could do during your brief journey of existence.
TLDR: It's not the job of a mental health professional to 'solve' existential problems of human suffering. It's only our job to use our tools, skills, and education (and compensated time) to try to assess, conceptualize, and intervene around disordered psychological (and perhaps medical/physiological) processes.
Another thing is that--just like other forms and positions of official political power--the likely answer to the question of 'Who's going to do the job of deciding whose lives are so hopeless that they don't deserve to live (or, it's better if they just die rather than keep living)?' is THE PERSON THAT YOU WOULD LEAST LIKE TO BE IN THAT POSITION. Basically, someone unsophisticated, narcissistic, and blundering enough to think that they would be capable of deciding who gets to go on existing and who doesn't.
And, just to be a little playful with these heavy topics...I'll just leave this here (believe it or not, I think that this clip is an excellent example of the ability of 'art' to illuminate and comment expertly on such questions...I really think it is THE answer to OPs original question:
