Letter Writing

FORGOTTEN LETTER LEGACY

A kind letter may make a difference!

By Stephen Wilson

 

'You will never know what your little note means to me. I always think that someone cares for me even if my family kicks me out'.

 

'Your note gave me a warm pleasant feeling. Just knowing someone cares means a lot.'

 

'You are the most persistent son of a bitch I've ever encountered so you must really be sincere in your interest in me'.

 

Those were three responses from former patients with mental health problems who had been discharged from hospitals and were deemed a suicide risk. They had, along with many other patients received a kind note or letter from a psychiatrist Doctor Jerry Motto and other staff as part of a research project to test whether sending an encouraging letter to a former patient could make a difference on whether this patient went on to commit suicide. To the surprise of many skeptical psychiatrists sending a kind note or letter expressing sincere concern about the condition of the patient did make a profound difference. Doctor Motto found that the modest act of sending a letter to patients who had previously attempted suicide reduced the rate of recurrence by half. This research was carried out between 1969 to 1974 but the full implications of the findings were never acted upon. It is only in the past recent years that psychiatrists, mental health workers and others have understood how they might have easily saved the lives of at least some patients through as simple a gesture as writing a short caring note to a patient!

 

The idea that writing a kind letter or note might help boost a patient's mental health was inspired by Doctor Motto's wartime experience. He found that his morale and that of other soldiers was boosted by receiving a letter from home. He reasoned that sending caring letters to patients might have the same 

result. It sounded such a simply crude idea that most of his colleagues were cynical! How could a simple note or letter make any difference? It was just a letter! But for Doctor Motto the main point was that the letter made the patient feel more connected, and less isolated proving he had at least one person who cared for him or her. That meant a lot in encouraging a patient to live on. It gave him or her hope! So Doctor Motto divided two groups of discharged patients into a contact group who would receive kind letters and notes, and a control group which did not receive them. Each patient in the contact group would receive four letters a year over the next four years and then in the fifth year. After sending those letters the researchers would contact the recorded lists of deaths from  the California State Department of Health, coroners' records and death certification clinical records to establish the rate of suicide. The result of the research was that after two years of leaving hospital only 1.8% of patients in the contact group had committed suicide compared to 3.52% in the control group. Sending kind letters proved to be a kind of effective suicide prevention influence in at least a significant number of cases. However, the psychiatrists cautioned that those letters should be sent over a long term period and that other forms of care should not be discounted.

 

Of course, it was important to send a short and sweet letter. The letter could not be too intrusive, or render the impression that the psychiatrists just saw the patient as 'mere material' to boost their research. The main point was that the letter had to be 100% sincere in caring for the patient. The letter would go:

 

Dear so and so,

 

It has been some time since you were here at hospital, and we hope things are going well for you. If you wish to drop us a note we would be glad to hear from you.

 

Motto later wrote, 'We were careful to avoid suggesting that we desired any specific information or action from the patient. By doing so we hoped to show that our intention was simply and entirely to let the person know we remained aware of his or her existence and maintained positive feelings towards him or her. One such letter was not expected to have much impact, but we believed the cumulative effect of repeated contacts of this kind might have considerable psychological force.'

 

Why did those kind letters or notes have an impact? It seems evident that many of the patients could be experiencing such isolation where they lack anyone who seems to care for them. They lived in profound isolation. Some of their families were not supportive ,and avoided them. They were stigmatized by their family and others who shunned them out of embarrassment. Just one friendly note of support or encouragement gave them hope to carry on. This note broke through the wall of indifference. I recently received a note from a patient called Jane {not her real name}, who lamented that her relatives no longer kept contact with her and her brother because they are embarrassed by their illness. Jane herself came across two fellow patients who had expressed feelings of wanting to commit suicide. One threatened to jump off the Erskine bridge in Scotland. But she talked and sent them kind notes, letters and cards. And it made a difference! They haven't committed suicide. Letters, in contrast to therapy, can appear less intrusive and intimidating. Many people can express themselves better in a letter than in face to face interaction. Hence a caring letter might be more cathartic and therapeutic. Jane, a 47 year old Scot who had received letters, wrote to me saying, "All those letters have been good therapy and a good help. Back in the 1990's people weren't taken seriously until things reached breaking point and they actually did have a breakdown. I send a handwritten message. I don't mind as it is good practice for my brain. Not many people even possess a pen or use a pen, let alone write letters by pen. How do they manage this? If I couldn't write with a pen there would be a massive void in my life. I think handwritten letters and going to a post office is good for you and it is also exercising your brain. You can say more in a letter than in an hour face to face'. 

Jane raises another issue. Could handwritten notes and letters be better than just an e-mail message or letter? A handwritten letter carries a more personal stamp. What if snail mail turn out to be faster and more effective than even a quick phone call or e-mail in helping patients?  

 

What is distinctly evident is that the sharp problem of suicide continues. According to the United States Center for Disease Control and Prevention, there were more than 38,300 deaths from guns in 2019 - of which 23,941 were from suicide. In Scotland, 2 persons kill each other everyday. According to the National Records of Scotland, from 2011 to 2015 the rate of suicide declined. Unfortunately, the rate of suicide has increased from 784 in 2018 to 833 in 2019. The study found a high rate of suicide among males, people of middle age, people who are not married or partnered, those who live in poverty, the homeless and among gypsies and travelling people as well as gay people.

 

Why not undertake small scale projects where responsible people write caring letters to vulnerable patients who have mental health problems? Such a project doesn't require much investment, space or equipment. All it requires is a trip to the post office, some stamps, a pen and an envelope and the will to write! There is a beautiful simplicity in doing such a project which was partly inspired by Doctor Motto's research. We have to turn his research into a living legacy! That is go beyond the academic. And as a grateful Scottish postwoman told Jane "Your are helping us to keep our jobs!"

 

 

For those who are interested they can find 'A Randomized Controlled Trial of Post Crisis Suicide Prevention by Jerome A. Motto and Alan G.Bostrum by clicking into the internet, and the publication 'Our Daily Bread' , Caring Letters, offers a distinctly religious perspective on Motto's work.{15 march,2021, Elisa Morgan, Dublin, and Carnforth.}