Friday, July 17, 2015

How to Save a Life (Part Three): Arguing with Suicide Intent

It is summer, and you wouldn't think people are too down, but maybe it hasn't been the best summer for everyone. Hopelessness doesn't always flip with the seasons.

A patient described panic symptoms, not knowing that she had suffered a panic attack. 
"But I told myself," she went on, "that everything will be all right. And it was!"
multiple meanings of spiraling BALANCE  

Therapists, friends-- we all say it with confidence: Everything will be all right.

The reply, "How, exactly, do you know?" is the tricky part. How do we know?

Emotions are temporary states, for one. We cannot stay in the same exact emotional headspace forever, wired as we are with homeostatic neurological and hormonal systems. Without therapy, we are changing all the time.

And therapy has improved exponentially in recent years.  Interventions are tested and have proven empirically effective. Change is so likely that when hopelessness spirals out of control and patients talk of suicide, therapists apply an adage,
Suicide is a permanent solution to a temporary problem.
There's so much else to do. But a body has to get there, has to get help.

There's a post on this blog (February 16, 2009) about a popular song, How to Save a Life by The Fray. The essay is long and winding, refers to the ballad, a lay-person's failed suicide intervention. The gist of the post (and one that follows, How to Save a Life, Part Two) is that when in doubt, when a friend talks about suicide, get him in for an evaluation, somehow, even a hospitalization, a visit to an ER with you. After that a primary therapist, and likely a psychiatrist, too, will shoulder the responsibility. As a friend you are a first responder, but not the last.

Fray has the right idea.
Step One
You say, 'We need to talk.'
He walks away, you say, 'Sit down, it's just a talk.'
The purpose of the talk, even between friends, is to evaluate the situation. How bad is it? Poke around the topic especially, as the song suggests, at the end of the evening, when everyone else has gone home, but just one person is still awake, prowling around grumpily after the party. Sleepless.

It's just a talk.

See if you can get to something really important, suicidal intent. The plans actually follow the decision. So sniff out intent, that's how you know the answer to the question, How bad is it? Add to the list items about thoughts and plans. Invade the privacy, pass through social stop signs to check out sad friends. The refrain . . .
Where did I go wrong, I lost a friend. 
is simply too sad.

It isn't easy, prying like this. Mental health awareness advocates spend their days organizing suicide awareness walks,  prevention months, weeks and days, to teach us how to pry. These are opportunities to bring up the subject, good times for the talk, perfect segues into a difficult subject.

As are podcasts. There's one by Cheryl Hamilton, totally worth a listen.. Teaching a wilderness search and rescue class in New Haven Connecticut, with no training in it, she accidentally stumbles upon a young man intent upon jumping off a ledge to his death.  She tries to talk him down, and the results, the effect upon her, and perhaps upon him, too, startle them both.

The difference between where I'm at now and where I was in 2009 is that I'm a lot more confident in having the talk. You see, even being a therapist, this is a difficult discussion. You can't be too confident when you are dealing with hopelessness, can't be too smart, and should never get too lofty or too glib. So having more confidence could be bad, and can come back to bite you. But when you learn more about suicide, you do get more confident, and if you can keep it in check, will be more effective at this whole saving lives endeavor.

At some point after writing the How to Save a Life posts, I had a very sick patient who had been suicidal all her life, and it was one of those things where you want to punt to someone smarter, but the patient already likes you, so you can't. And you like her, too, and can never be too sure, when you suggest someone sees someone theoretically more qualified, that that person, the one to take over for you, really is.

So I dig in, embrace the therapy, and one day happen to be checking out the University of Illinois Bookstore online. I'm there to see what the professors are teaching in clinical social work methods these days. I find gold, a reading requirement for a class in treatment, a text by Shawn Christopher Shea. Dr. Shea is a pioneer in a new methodology, the CASE approach, Chronological Assessment of Suicide Events for mental health professionals.

Shea's text, The Practical Art of Suicide Assessment is technical, and for therapists, but could be for anyone. Rock star Kurt Cobain's story, for example, and his suicide note, make up almost an entire chapter.

Just a few take-aways for now on the reasons, or triggers for suicide, and a bit on intervention. It isn't like we can stop here, but if we know what really causes people to make the decision, we might be more able, if not so confident, in having the talk, and yes, punting for help if desired.

Start by forgetting the myth that suicide is always an act of a disturbed, depressed individual. (That myth is in one of these posts somewhere). Suicide is a decision, a way to solve a problem. It is about feeling cornered, or trapped in a painful dilemma. Note the language, painful dilemma, not depression. Sometimes people perk up and feel just fine after making the decision.

Step One, therefore, is the same, the talk, talking about the triggers, the dilemma. Then when that is fully fleshed out, when no more words from our sad friend are forthcoming, we might begin to wind the conversation around the rationale for it, for that decision, the pros and cons of suicide as an intervention. It isn't the most rational solution, although it might work. But it might not. Even in our death, our problems continue to affect others. And maybe people don't want to do that, hurt others, saddle other people, people they love, with their problems.

The triggers according to Dr. Shea:
Every therapist should have them memorized before stepping into their first job, but again, everyone else should know them, too.

1. External stressors: deaths, rejection, public humiliation (a big one), and serious illness;
2. Internal conflict: psychological impasses, unconscious conflicts, cognitive distortions and binds;
3. Neurobiological dysfunction: exogenous toxins such as alcohol and cocaine, endogenous (already there before situational stress), and pathophysiology, the biology of depression, for example, or other illnesses.

Once we have the triggers on the table, the words are, Build on that.

Again, just for today, let's just look at the first trigger, external stress, a loss, perhaps a death.

Ask about the impact of that loss, how did it really feel? How did it affect the present, life today, practically speaking? What will be missing now that things have changed, now that there is no job, or now that someone has passed away? Can the loss be replaced. Is that even possible? Is there a satisfactory substitution, if not a replacement? And finally, can the patient see that the pain will lessen eventually, even end?

The answers to these questions clarify the direction of a friend's (or patient's) strategies for coping. Because at the end of the day, suicide is just one way to cope. There are others.

Once I asked a patient who had lost someone a similar barrage of questions, including her belief in an afterlife. She did believe in it, and contrary to that helping her feel better (her friend being in a better place), the belief had solidified her desire to hand out together in Heaven. She didn't believe God punished those who put themselves out of pain by suicide. So we had to discuss that, see if there were other ways to be together, like rereading emails, attending to surviving family members.

This is cognitive behavioral therapy, or CBT. with its focus upon thoughts, triggers, the dilemma with the potential to culminate in a deadly decision. The goal is to find alternative solutions and to debunk the rationale for suicide.

We ask a few good questions of the patient: Will suicide actually work? Will it end the pain? Really, who knows? Will it solve the problem? It might create new ones, worse problems for other people. Debts might be someone else's debts, insurance likely won't pay out.

Is suicide ethical? If it causes pain for others, maybe not.

Besides suicide, what's a person to do? Here I'm talking to that person who has suicidal thoughts, intent, even plans. Stay alive, for one, to keep the discussion, the conversation going. Be open to being talked out of it. You might be bored with the topic, your problems, your reasons to end it all, saturate your interest. Strangely enough, you might get bored, but not everyone else is. Talk about the dilemma when you have that gift, the opportunity.

There really are people who are interested. Find them. These are your people. One of them will find a way for it to be all right.


Monday, July 06, 2015


The Kotel, Western Wall
It was a fast day yesterday, meaning no food or water from sunrise to sunset (we have 25-hour fasts, but this one, the 17th of Tammuz is considered a "minor" fast, less intense). FD and I woke up at 3:45 am to get in some breakfast before sunrise.

This helps tremendously, a pancake or two, a cup of coffee, a couple of preventive Advil. But when you're fasting until 9:15 pm on a summer day, you get more than a little thirsty.  I traditionally tease my children with a text, a reminder of the joke about the old Jewish guy on a train in Europe. He continuously bemoans aloud, "I'm so toisty," until someone finally listens to him. (There are variations, all with the same punchline.). It is my final text of the long day.

Anyway by 9:00 that day I'm at work, where people are often talking about food, and their diets, how cutting out certain foods, white flour or sugar especially, helps them lose a couple of pounds and improves their state of mind. Abstaining from anything is empowerment, imho, in moderation.

A Jewish fast is an empowerment opportunity of a different sort, however. It is thought that the Old Mighty (my grandfather's nickname for Her) is more accessible, a little closer on these set days, that She's really listening, hoping we'll connect sincerely, and more often. And when we fast, we're more likely to tune into that side of ourselves, the side that communes with a higher power, people say. I like to call this part of us our religious life. We have many lives, all tucked inside, and this can be one of them, or not.

When we're depressed it can go missing.

As it is also the Muslim month of Ramadan; Jews are not the only ones fasting this day. This has to be an interesting month, psychologically, for the cousins, and the world over their effort is both baffling and admired.

There are two summer fasts for Jews, one the 17th of Tammuz, then another, more compulsory, on the 9th of Av, three weeks apart. The fasts remind us not only of the destruction of the Holy Temples of Jerusalem by the Babylonians (586 BCE) and the Romans (59 CE), but also the many bloody initiatives of other nations intent upon destroying the Jewish people.
mass grave in Belson

Since the experience with Germany in World War II is so close to us, and because there are still survivors of the war, some of whom are still around to speak about it, and cinematic footage of them in dirty striped prisoner pajamas, blank-eyed living skeletons, and footage of the dead, too, ominous mountains of real skeletons, mass graves, thousands of confused, terrified men, women, and children shoved onto trains for days, no food, no water, no toilets, on their way to the ovens, and death marches, miles in the snow in those thin pajamas, sub-zero weather, those who stumble and fall, if they aren't already dead, shot on sight. The Holocaust reduced the population of Jews in Europe dramatically from almost 17 million to less than 11 million. But what is 6 million Jewish people, after all. What do Jews even contribute to society?

Oh, never mind. It wasn't my intention to go here. It is too sad. For a look at photos of the Holocaust, mountains of Jewish shoes and eye-glasses, maps of concentration camps, emaciated bodies, look at or better, visit a Holocaust memorial museum, like the Simon Wiesenthal Center's Museum of Tolerance  in person. Any Holocaust museum will do. Anytime.

Fasting, if you do it six times a year, for many years, is still likely to be dreaded each and every time. But it isn't really that bad, and those of us who wouldn't, couldn't, miss a fast, know it. The less spiritual can point to the benefits, purging the body of all the garbage we've eaten the week before. When the fast is over, if we don't eat too much in breaking it, if we keep dinner moderate and healthy, we feel great, assuming we haven't a "caffeine headache." (Hence the early wake up before dawn for coffee).

And even the next day, today, at the pool at 6:30 in the morning, when the body has adjusted to the cool water, the jump in serotonin in this therapydoc's brain is measurable, words for this post swimming in the brain with every stroke.

It is paradoxical that the anorexia of depression functions to increase depression, makes it worse, denies a good state of mind. The treatment is to increase appetite, and certainly, make sure the patient sleeps a solid six, at least, which is one of the benefits of medication. Sleep and food are healing.

So unless fasting is one of those things your doctor tells you to do before a procedure, or your clergyperson really recommends as a traditional way to connect to certain events and your Higher Power (assuming the pri-care has signed off on it), take all this talk of fasting from food and water for many hours at a time with a grain of salt.

Preferably on a no-yoke omelet, half a bagel on the side. With butter, thank you, and at least a quarter of a cantaloupe. They're in season it just so happens.


Better Things-- Seeing Ghosts