Misconceptions about Suicidal Thoughts

My publicist seems to think people have a lot of misconceptions about mental illness (she's right), because many of her questions go there. You are very open about discussing your own struggles with suicidal thoughts. What do you think are the biggest misconceptions about people going through similar experiences? So today's post will focus on suicidal thoughts or suicidality.

Suicide is not a choice


The way people talk, you'd think we sit down and make a list, pros and cons of suicide. Then based on our calculations, we make some kind of decision. She chose to end her life. Or, How could he have been so selfish.

This is called the volitional theory of suicide, suicide as an act of will. The suicide prevention approach that addresses it is to weigh in on that list of pros and cons, like Jennifer Michael Hecht's book, Stay.

You know -- Suicide is a permanent solution to a temporary problem. Or, Think of what you'll miss out on. Or, whatever. In other words, how dumb or short-sighted or irresponsible or selfish you must be to decide to kill yourself.

Edwin Schneidman, father of suicide prevention, subscribes to the volitional theory of suicide, that it is an act of will. But the suicide hotline movement that he started does not use it. Schneidman recognized that persuasion, trying to talk somebody out of suicide, does not work. Rather, The most effective way to reduce elevated lethality is by doing so indirectly... Reduce the person's anguish, tension, and pain and his level of lethality will concomitantly come down, for it is the elevated perturbation that fuels the elevated lethality.

In other words, people don't commit suicide because they can't figure out it is a bad idea. They do it because they are in pain. Arguments may reduce the arguer's pain, because the arguer is right. And sure, the arguer is right, at least the arguer thinks so. But arguments miss the point of prevention. They miss it be a mile.

Suicide happens when pain exceeds resources for coping with pain


There is another way of looking at suicide, the non-volitional theory espoused by David Conroy. At some point every weight lifter drops the weight. Maybe it's a really strong weight lifter who can lift a lot of weight. And let me tell you, people who struggle with suicidal ideation are a lot stronger than they get credit for. Or maybe not. Maybe the suicidal person for whatever reason is more fragile and can't carry a lot of weight. But just like death from cancer, at some point the burden of the illness is more than that person can carry. The lifter collapses. The weight drops.

A strategy of suicide prevention proceeds naturally from the non-volitional theory of suicide. In Schneidman's own words, The most effective way to reduce elevated lethality is by doing so indirectly... Reduce the person's anguish, tension, and pain and his level of lethality will concomitantly come down...

In other words, to prevent suicide, reduce pain and/or increase resources. It turns out:

You can help prevent suicide

While calling in help from a professional can be a good idea, you don't have to be a professional to make a difference. You don't have to be a hero, either. You don't have to patrol bridges to stop people from jumping. You don't have to put your teenager or depressed friend under a microscope searching for "signs."

You can mentor a young person. You can look a homeless person in the eye. You can call a friend you know is ill. You can share a pot of soup. You can volunteer at Habitat for Humanity. You can pay a living wage. You can vote for health care for all... It's a long list, not only acts of kindness but also anything that addresses the structural inequalities and oppression that press down on fragile and even not so fragile persons. You can help mend the world. Judaism calls this work tikkun olam. That is how you prevent suicide.

You can do anything on any day to reduce pain and to increase resources to help heal this tattered world.


Series

So this has been a short series coming from questions my publicist has asked me to answer. I was struck that three of her questions related to misconceptions about mental illness, the first about antidepressants, the next about therapy, the third, prompting today's post on suicide. I will probably continue to blog on her questions. They have focussed for me my mission of which the book is a piece. Google lists that mission as information, provocation, entertainment, and an occasional rant. As more people become aware of the book, I get more feedback about how it addresses a widespread need for all of the above. I am grateful to my readers. I also feel a responsibility to you.

Every morning I pray the Serenity Prayer, with its phrase Grant me the courage to change what I can change. I tend to say do what I can do. This is what I can do. This is my part of tikkun olam, to heal the world.

woodcut of scales by Johannes Regiomontanus, 1512 in public domain
stained glass window of the Tree of Life by Tiffany in the public domain
photo of weightlifter from the Bundesarchiv (German Federation Archive) in the public domain

What People with Depression Need to Hear

Depression is one tough condition. Contrary to those cheery ads on tv and friends who want you to get over it, it is not easy to recover. Doctors also, in their eagerness to get you to do something that will help, sometimes oversell their solutions.

Chris Aiken's recent article in Psychiatric Times presents a more helpful picture.

Five Things to Say to People with Depression

You can expect, and do deserve, a full recovery. Aiken's point is that people with depression have a hard time believing we will ever feel any differently. (This is true. Boy, is this true.) Nevertheless, chances are, we will feel better. There is a rub here however. Most people get to full recovery, not all. As a patient, I'd like to hear up front that even if it comes back, chances are that things will get better again. So many of us feel like failures when depression recurs, when actually both remission and recurrence are part of the natural course of the illness.

You don't have to do a lot to make your medication work better, but you do have to do a little. Here's a line I want to shout from the rooftops. 70% of patients will not recover fully on antidepressants. Antidepressants are not magic happy pills. When doctors fail both to acknowledge the odds up front and to alert the patient of the process ahead (of which antidepressants are only one piece), patients feel betrayed and more hopeless than ever.

Simple changes help. But there is so much more that we can do to improve our health. When we are depressed, we don't have much motivation to do all that self-help stuff. But one change, just one, helps a little, and helps us tackle the next change. Aiken's Mood Treatment Center website has a whole menu of things to try that are evidence-based. Pick one that seems doable, that fits your life and your goals. Start there. Bonus: many of these strategies help our medication work better too.

Depression is not an emotional illness. Damn whoever came up with the DSM chapter heading Mood Disorders. The feeling of depression is not the illness of depression. The feeling of depression is not the illness of depression. Learn that line. Chances are, you'll need it a lot for friends and family who tell you that everybody gets depressed. The illness of depression attacks parts of the brain that address motivation, energy, sleep, appetite, memory, and a variety of neurological functions. In fact, some people with depression don't feel depressed at all -- we feel nothing. The feeling is not the illness.

Recovery means you can function: Prioritize, figure out what's important and act on it (not all the time, but enough to get by.) How we feel is not a good measure of how we are doing. That may seem odd, especially if we went into treatment because we wanted to stop feeling so bad. But action is where the action is. I'll never forget the day when I played with the water caught in the rocks on the shore of Lake Superior. I stuck my hands in the water and compared the temperatures in different sized puddles. The light shone on the water, the sky was blue, the breeze was gentle. And then I realized, I was not thinking about how I was feeling! I was playing! I was living! The way out of the morass is to do something that so captivates you, you are lifted out of the morass.

Now one day playing in puddles did not cure my depression. But it turned a corner. And it gave me a day of joy. Wouldn't that be nice again, even one day of joy?


See, the truth really works better than hype in the long run. Let's hear it for the truth, which sometimes is good news, sometimes not so good, but always more helpful than promises that cannot be kept.

I will add a sixth thing to Aiken's list. Recovery is a process. Pills are a part of it, one part of it. But it's a whole change in your life, step by daily step. It's a trip worth taking.

photo of Chris Aiken from Psychiatric Times
book cover from Amanzon.com
photo of rocky shoreline, Apostle Islands by Yinan Chen and in the public domain

Misconceptions about Therapy

Continuing the press kit-inspired series...

No, therapists aren't like friends that you pay

Therapists make you work. The work you do depends on the kind of therapist you see. Interpersonal therapists get you to examine your relationship patterns. Are they working for you? Are you sure? Social rhythm therapists make you track your schedule. For people with bipolar, an off kilter schedule results in an off kilter brain. (The chart I use is here.) Cognitive behavioral therapists even give you work sheets! Mostly this homework involves learning to examine your thoughts. Just because your brain tells you something doesn't mean it's true.

No, therapists don't give advice

Not like your mother. Not in the sense of, should I break up with my boyfriend or how do I get my mother off my back. Therapy is all about the tools you need to make these decisions on your own. Your therapist may give you information, or ask you to examine motivation or anticipate consequences. But honey, your life is your own.

No, just because one therapist didn't help doesn't mean the next one won't

Maybe it wasn't a fit. Maybe you weren't ready for what that therapist was doing. There are all kinds of therapy. And what might be helpful to you at one stage might be less helpful at another. Most therapists have a number of techniques up their sleeve. If you have a good relationship with yours, but you don't find what you're doing to be helpful, you can say so. You can say so! Maybe the two of you can steer in another direction. Or maybe it's time to move on. But have the conversation.

Case in point: One way to treat past trauma is to tell the story again to somebody who is safe. Every time you retrieve a memory from your long term memory, it goes into short term memory. There, something new is added, the experience of telling it to the other person. When it returns to long term memory, it is changed. I don't mean the details of the event are changed. But the emotional energy around it is changed. This process is called memory reconsolidation. That technique works slick for me, as long as we are talking about past sorrows. But for real trauma, it was a bust. There is supposed to be some closure at the end of the story-telling. But it never stuck. Every time I repeated a trauma to my therapist, I left the office in a hyper-aroused and re-traumatized state. So, I told my therapist. We decided to stop doing trauma work. Now we focus on the present.

Three takeaways: 1) There are lots of therapies, more than the three mentioned above; 2) Therapy is work; and 3) You can negotiate about what kind of therapy you are going to do.

Actually, the process of negotiating with your therapist is practice for negotiating other parts of your life. That also is how therapy works. It's practice for your life.

book cover from Amazon.com
Wooden file cabinet by Pptudela, used under the GNU Free Documentation License
clip art from clipart-library.com

Misconceptions about Antidepressants

What do you think are the most common misconceptions about antidepressants?


Prozac Monologues: A Voice from the Edge is at the press kit stage with Q&A in development. My publicist wants me to answer questions that interviewers might ask. My responses should be in the three to seven sentence range, she says.

Three to seven sentences are not my forte. I am doing my best and taking comfort that in an interview format, there might be a follow-up when I can say more.

They are good questions and worth a blog series, I think, where I can expand to three to seven paragraphs. Mostly seven. Maybe more. Plus, you know, pictures. So that's what you get for a few weeks.

No, antidepressants are not happy pills

Nor do they change your personality. It's depression that does that. Having depression is like getting cast in concrete. You don't notice it at first, but slowly it sets, locking your thoughts, your emotions, your movement in place.


via GIPHY

Okay, so it looks like there's a lot of movement in a hamster wheel. It may feel like your brain doesn't stop. But it doesn't really get anywhere, does it.

People for whom antidepressants work (that's not everybody who takes them, but that's another post...) say, I feel like myself again. Your self may not be happy. In fact, your self might be a jerk. But antidepressants get you off that hamster wheel so you can feel your feelings, the whole range of feelings. My therapist used to call it all eighty-eight keys, referring to the full keyboard of a piano. On antidepressants you can think clearly again, get out of that negativity loop that keeps confirming your hopeless/helplessness. On antidepressants you can make choices again -- you know, therapy might help with that jerk-thing.

No, antidepressants don't "fix a chemical imbalance"


Oh, I know that's what you were told. Zoloft sold a lot of ADs with its cute little cartoon that took an overly-simple idea and turned it into a heartwarming sales pitch.

The chemical imbalance thing was an early hypothesis, trying to figure out how antidepressants work. One problem with the hypothesis is that they take so long to work, four to six weeks usually. If you just need more serotonin in your synapses, (check out Zoloft's video) then why don't you feel better in a couple days, as soon as the "balance" is restored?

Nowadays scientists think the synapses are not where the action is anyway. But it is fixed in the public imagination as the fault-free explanation for depression and why you shouldn't be ashamed for having to take medicine.

Dr. Ronald Pies has written several articles about this controversial phrase, the problems with it, and a better, albeit longer, discussion of the causes of depression. Try Doctor, Is My Mood Disorder Due to a Chemical Imbalance? if you'd like to know more.

Do Antidepressants T(h)reat(en) Depressives?

Well, that issue is complicated. Zolt├ín Rihmer and Hagop Akiskal wrote this cleverly titled article on the subject that gave fits to the design people for my book. (The computer program kept thinking that t(h)reat(en) was more than one word.) But I digress...

The bottom line is, if you truly have unipolar depression, then antidepressants are the thing for you. They save lives of severely depressed people.

On the other hand, if you have a bit of unrecognized bipolarity, and it doesn't have to be the screaming wild recognizable mania of the movies, then antidepressants can create what are called "mixed states," the misery of depression combined with the agitation, insomnia, irritability, increased suicidal ideation and maybe a dash of impulsivity of mania or hypomania. You want to die and you have the energy to do something about it. That's a dangerous, sometimes deadly combination. Most people who attempt suicide do so while experiencing mixed states.

Those terrible side effects that give you pause usually happen to those of us with unrecognized bipolarity. If doctors did a better job of diagnosis, then we wouldn't get what are for us the death pills, the effectiveness rate of antidepressants (which now hovers just a tick above the effectiveness rate of placebo) would rise, and antidepressants would get cleared of the charges against them.

That's my story and I'm sticking to it.

What to do about antidepressants

Before you pop those pills for whatever diagnosis, check out these screening tools: the Mood Disorder Questionnaire and the Bipolar Spectrum Diagnostic Scale. If you are taking antidepressants and it's not going well, check out those screening tools. If they give you an all clear, then happy day! Or, happy day to come... If they raise further questions...

I'm over my seven paragraph limit. Further questions will be next week's post.

photo by author
gif from giphy.com
cartoon from depirrogarrone.com
flair from Facebook.com

Trauma, COVID-19, and Cutting Yourself Some Slack

Are you failing to build your abs while social distancing?
Or learn that new language?
Or clean out that closet (you know which one)?

Are you utterly exhausted while getting nothing done and beating yourself up for it?



STOP. Just stop.
And read on.

You are experiencing trauma, a deeply distressing and disturbing experience. How's that to describe a pandemic, "deeply distressing and disturbing experience"? Your experience does't have to be unique or worse than anybody else's for you to have genuine feelings about all this, nor for you to take care of yourself.


SAMHSA is a federal organization, the Substance Abuse and Mental Health Services Administration. Now those words may have nothing to do with you generally. But they produce materials that are helpful to all of us in this weird universe to which we all have been transported by the deeply distressing and disturbing experience called COVID-19.

The following are excerpts from Trauma-Informed Care in Behavioral Health Services, one of their resources.

Trauma affects your body, your thinking, your emotions, your sense of self, your soul. Here are some of the consequences of trauma (your results may vary):


Immediate Emotional Reactions:

  • Numbness and detachment
  • Anxiety or severe fear
  • Guilt (including survivor guilt)
  • Exhilaration as a result of surviving
  • Anger
  • Sadness
  • Helplessness
  • Feeling unreal; depersonalization (e.g., feeling as if you are watching yourself)
  • Disorientation
  • Feeling out of control
  • Denial
  • Constriction of feelings
  • Feeling overwhelmed


Immediate Physical Reactions:

  • Nausea and/or gastrointestinal distress
  • Sweating or shivering
  • Faintness
  • Muscle tremors or uncontrollable shaking
  • Elevated heartbeat, respiration, and blood pressure
  • Extreme fatigue or exhaustion
  • Greater startle responses
  • Depersonalization

Immediate Cognitive Reactions:

  • Difficulty concentrating
  • Rumination or racing thoughts (e.g., replaying the traumatic event over and over again)
  • Distortion of time and space (e.g., traumatic event may be perceived as if it was happening in slow motion, or a few seconds can be perceived as minutes)
  • Memory problems (e.g., not being able to recall important aspects of the trauma)
  • Strong identification with victims

Any of these sound familiar? I'm getting hit with anger, sadness, GI distress, faintness, extreme fatigue, difficulty concentrating, rumination. And time, what day is this? What about you?

These are not good circumstances for undertaking ambitious schemes of self improvement. If you can, great. Go for it. You may have a plan that channels any of these reactions into something positive. There's a lot of banana bread being baked right this very minute, so much that they are writing articles about its psychological benefits.

But if you are stuck in a "should" storm, it's time to cut yourself some slack. You are not alone, as this article about 17 Totally Normal Things to Feel Right Now will demonstrate.

Things will get better. Well, I don't know about the universe. Me, I am expecting the whole show to go over a cliff and us with it. But we will get better. We will adapt to whatever this new world will dish up. We really will.

These also are consequences of trauma, what resilient people do eventually:

  • Increased bonding with family and community.
  • Redefined or increased sense of purpose and meaning.
  • Increased commitment to a personal mission.
  • Revised priorities.
  • Increased charitable giving and volunteerism.

So take a deep breath, drink some water, stretch and get whatever exercise you can, once you can, enjoy your banana bread. Move on when you are ready. You'll be okay, even if you have banana bread abs and don't speak French.

logo in the public domain

Frazzled Cafe and Ruby Wax - Yes, I am a Fan


Ruby Wax is the founder of Frazzled Cafe, a peer support group for anyone who is overwhelmed by the stresses of modern life. As Ruby says, our brains just don't have the bandwidth. If that describes you, check it out. But bring your own coffee. The meetings moved online, a Zoom meeting on account of... you know.

Ruby is an American-born long time television personality in Britain and comedienne whose career pivoted when mental illness caught up with her. She went back to school to study the brain and got a masters from Oxford on mindfulness based therapy. Since then she has written books, toured, lectured, using her prodigious brain and her comic chops to entertain and educate about brain health.

So I'm not the only one whose career pivoted to brain nerd in response to the question, What the hell happened here? and then makes that information available to the general public using humor and plain English. Ruby's was one of my most coveted and not-secured blurbs for Prozac Monologues: A Voice from the Edge. I could spend a lot of time ruminating about that. But in the video below, she teaches me how not to.

The following was first published in April 2014. If you want more, here is another post with another video. Can you tell I'm a fan?

How to Tame Your Mind -- Ruby Wax

It's like training a dragon, only harder.

Ruby Wax nails depression: when your personality leaves town, and suddenly you are filled with cement.

She nails the problem: our brains don't have the bandwidth for the 21st century. Nobody's brain does. Yours doesn't, either.

And she nails the solution: learning how to apply the brakes.



photo of coffee cups from frazzledcafe.org/
photo of Ruby Wax used under the creative commons license

The End of Miracles - A Review

What is it like to have depression with psychotic features?

What is a day like inside a psych ward?

What is the psychiatrist thinking?

Sometimes the best way to explore questions like these is in a story. So here is Prozac Monologues' first review of a novel.

Monica Starkman is a psychiatrist at the University of Michigan whose expertise includes psychosomatic disorders, stress, and women's issues around fertility, miscarriage, and obstetrics. In her debut novel, The End of Miracles, she turns her clinical experience to the story of one woman, Margo Kerber, a long-infertile woman who finally conceives, tragically miscarries, and then... unravels.

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