Saturday, June 27, 2009

Suicide Prevention for All of Us

I end this month's focus on suicide with what we can do. Remember, "Suicide is not chosen; it happens when pain exceeds resources for coping with pain." (David L. Conroy, Out of the Nightmare: Recovery from Depression and Suicidal Pain)

So the way out of the nightmare is laid before us: reduce pain and increase resources.   Somewhere below is something you can do for yourself, for those you love and for those whom you have been commanded to love, if you believe in that sort of thing.   These lists are from Conroy, pp. 300-302.  My remarks are in brackets.


physical and/or psychological pain

death or terminal illness in family
mental illness
alcohol and/or drug abuse
sexual assault or abuse
crime victimization
stress, confusion, anxiety
vicious circle problems
eating or sleeping disorders
loss of esteem, security, health, talent, status, job, money, relationship, home, social isolation and loneliness

physical or mental capacity
physical and/or emotional abuse
disruption or dysfunction in family
feelings of hopelessness
prejudice and stigma for suicidal pain
other forms of prejudice and stigma
loss of any resource for coping with pain

[preventing access to resources]

fear, ignorance, silence
stigma and prejudice, denial, minimalization, belittlement
negative moral attitudes

blame the victim
the non-suicidal's uses of the suicidal for their own purposes [e.g., focus on teen suicide to exercise denial of adult concerns about suicide]

myths: just wants attention
motives of revenge or escape
suicide is rational, a solution
blame the family
suicide prevention is a last minute activity
suicide is romantic and dramatic
being suicidal is good for you
attempts to get it out of your system
it must have been something more [some deeper, hidden motive]
suicide is voluntary
they can't be stopped
the suicidal need an inner light
suicidal pain is psychological pain [ignoring physical manifestations and causes]

service providers who will not provide or continue with services [when suicidal condition is made known]
inadequate referral systems, quick referrals
too little
confidentiality: breaches that cause more pain
too much confidentiality: secrecy, limitations on access to resources
being trusted with possession of the means [get rid of the goddamn gun! and the pills, and...]
pressure to hurry up and get better
inappropriate language: "threat, confrontation, success, failure" [more on these in later OMG! awards]
ignorance and false beliefs about the effect of suicide on survivors
false conceptions of themselves and each other that are had by both the suicidal and their counselors
lack of information and education for both the general public and professionals
lack of public and private support for education and research
theories of suicide that ignore much of the pain
esoteric theories of suicide, single cause theories
caregivers' perfectionism and fear of blame [that cause them to withdraw, so they don't "do something wrong"]
false conceptions of self-reliance, ride it out strategies
no words for one's pain
no role models for recovery
denial on the existence of recovery


patience, acceptance, understanding, compassion, tolerance
no-fault theory of suicide
comprehensive examinations for physiological causes of suicidal pain
improved models of what suicide is
improved theories and treatments for depression
ordinary language theories [e.g., "when pain exceeds resources"]
decomposition of suicidal pain
new conceptions of the rights and worth of suicidal people [e.g., the right to treatment]
studies on suicide self-prevention
role models for recovery
hope appropriate for a condition with a high recovery rate
recognition for recovery [where's my cake?! my six month pin?]
efforts to help others with their pain
willingness to give and get help sooner rather than later
support groups
professional treatment
improved support for survivors
improved policies, support, and referral systems for caregivers
legislation on discrimination against the suicidal

legislation on access to means
education for the public and caregivers about suicide
increased support for research

I will add your contributions by comments, if you permit. 

God bless you, Willa

book cover by
photo by RN Marshman, licensed under the Creative Commons Attribution ShareAlike 2.5
photo of man in shadow by Cornava, permission is granted to useunder the terms of the GNU Free  Documentation License
Tiffany window Tree of Life in public domain

reformatted 6/4/2011

Friday, June 19, 2009

Out of the Nightmare: Recovery from Depression and Suicidal Pain

Suicide is not chosen; it happens when pain exceeds resources for coping with pain. 

David L. Conroy had me at the opening sentence.  I read it first at and knew it came from somebody who had been there.  I recommend the website for help and insight from the insider's perspectiveIf you are thinking about suicide, read this first. 

Conroy, a psychologist knew his subject personally for ten years, and came back, and wants to help others recover.  With the opening sentence of Out of the Nightmare, he establishes his theoretical framework and forecasts his strategy. 

Involuntarism -- Suicidal People Do Not WANT To Die 

Conroy is an unrelenting involuntarist.  Suicidal people do not want to die.  We want to be in less pain.  Conroy takes on the theorists who speculate about the inner psyches and spin the thought processes of those at risk of suicide.  He rejects any language that supports the notion that it is a decision, an option, a choice.  The way I have come to understand my own illness is this: MDD is a disease with a 15% mortality rate.  Other diseases have other mortality rates. 

Voluntarism -- Edwin Shneidman 

Conroy cites Edwin Shneidman, the founder of the nation’s first comprehensive suicide prevention center.  Shneidman recognizes that the cognitive processes of the severely depressed are impaired, but he assumes an unencumbered volitional capacity when he argues, Never kill yourself when you are suicidal.  It takes a mind capable of scanning a range of options greater than two to make a decision as important as taking one's life. (from Definition of Suicide, p. 139.)

Clever, isn't it?  If it were a debate, Shneidman wins.  But he might lose the war.

In fact, Shneidman cautions that neither his argument nor any other attempt at persuasion prevents suicide.  Rather, The most effective way to reduce elevated lethality is by doing so indirectly; that is, by reducing the elevated perturbation.  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. (ibid., p. 230.)

Shneidman's practice is the foundation of suicide prevention centers across the country and has saved lives.  That is because his theory and his practice do not match.

Suicide Prevention -- Matching Theory to Practice 

Conroy's theory, Suicide is not chosen; it happens when pain exceeds resources for coping with pain, gives us a practical program for suicide prevention.  It invites us to consider the whole range of human pain and its accumulation as contributing factors.  Counselors, friends, survivors don't have to waste energy on questions of motive, whether they know the real reason or whether the purported reason is reason enough.  Every single pain is on one side of the balance.  Every single resource is on the other.

Cut to the chase.  Just get about the business of reducing pain and increasing resources.

The killer, so to speak, in suicidal pain is the pain on pain, the pain that is heaped on by stigma, by disrespectful attitudes, by fear, avoidance, horror, that make people withdraw from the suicidal, that shame us and deprive us of the resources we did have. 

Deconstructing Suicidal Pain 

If you could treat your suicidal friend as a normal human being, that simple action would remove pain from one side of the balance and place yourself in the resource side. To do that, you may need to come to an understanding of what suicidal pain is.

So Conroy deconstructs and normalizes suicidal pain.  It isn't any different from anybody else's pain.  It's like somebody, anybody standing while weights are placed on the person's shoulders.  Some people can carry a lot of weight.  Some can carry less.  It doesn't matter why.  If the weight keeps piling on, at some point, everybody will collapse.  Everybody.

Most of us never get to that point.  Even those who have major depressive disorder, 85% of us survive the disease.  But that point exists.  It is not a matter of moral weakness or will power.  It is a matter of how much a person can carry and how much is on his/her back.  When you get toward the limit, that is suicidal pain . The observer who wants to help doesn't have to figure out the heaviest object.  Remove any part of it, and you will have helped.

Conroy notes that his theory includes physical pain, that suicidal people with chronic pain often recover from their suicidal issues when their pain issues are resolved.  This week I met a friend in the grocery store parking lot.  We were talking about hats and skin cancer.  I commented on how melanoma is a lousy way to go.  He said he would just get a gun.  He mimed putting it in his mouth.  He is not suicidal.  Would he be, if he had melanoma?  Maybe, maybe not.

We all have ways we would prefer to go, and ways we would prefer not.  For pretty much all of us, including those in suicidal pain, suicide is low on the list.  Nevertheless, all of us have a limit to the pain we can endure.  All of us. 

Treatment For Suicidal Pain 

The book includes self-help suggestions for components of depression pain, including issues that are not typically raised in therapy: envy, shame, self pity and grandiosity.  Here, too, Conroy normalizes depression pain and places these issues in the context of every person's experience with these issues.  He notes that most suicides are self-prevented, and provides a road map for recovery.  Special sections are included for survivors, for counselors, and for social policy.

If you would read one book for a friend in suicidal pain, for a family member, for yourself, for me, this is the book I recommend.

photo of scales from Deutsche Fotothek of the Saxon State Library
shame image in the public domain
Tree of Life by Tiffany in public domain
photo of weightlifter from the Bundesarchiv
(German Federation Archive)

reformatted 11/30/10

Saturday, June 13, 2009

OMG!!! That's What They Said!

First, how did I ever start reading so much about depression, medication and the brain, the topics of Prozac Monologues?  Well, it was after I took two antidepressants that made me crazy and one that made me sad.  Then I was back in a psychiatrist's office, and she said, You have to weigh the costs and benefits.  And I took her seriously. 

But the information she gave me and that I found on the prescription information sheet wasn't very much information at all, not the kind that would have helped me when I was taking the antidepressants that made me crazy.  I knew this because I had read them, and they didn't help me.  I will write more about this some other time. 

The Language Of Doctors And Scientists 

So then I started looking for the information that is written for doctors.  I discovered this other language, the language used by scientists when they communicate with other scientists, when they publish and build their reputations.  And in this language, they are not talking to me; they are talking ABOUT me. 

This information is much more informative.  When I am not so sick that I am too desperate to process it, it does help me weigh the costs and benefits.  And because I know I need to get this information before I am too desperate, I read as much as I can find while I am relatively healthy.  The real information, the research, not the sales brochures.

But it is, what shall I call it, disorienting, like OMG! to read what scientists say ABOUT me.  I presume they have their reasons to maintain an emotional distance from their subjects.  It makes them more scientific.  At least it makes them sound more scientific.  At least they think so.  It's really just my problem that I am reading stuff that was not written for me.

Nevertheless I am. 

Reframing Offensive Language 

In order to protect myself while I dabble in thoughts that my therapist wishes I would not, I have established the OMGThat'sWhatTheySaid Award.  I am confident of my subject -- there will be enough material for a monthly award.  Maybe we can hold a contest once a year and let readers vote on their favorites.

To start us off, drum roll please, the first OMG!! Award goes to David Dunner, Major Depressive Disorder, The Medical Basis of Psychiatry, (3rd edition) S. Hossein Fatemi, Paula J. Clayton, Norman (FRW) Sartorius, editors, (Humana Press, 2008) page 74, and I quote: 

Suicide and suicide attempts are unfortunate complications of MDD -- David Dunner 

Now there is good information in this chapter about epidemiology, clinical picture, biological theories, lab studies, presentation, principles of treatment, pharmacotherapy, though not near enough information to weigh the costs and benefits of Electro-Convulsive Therapy.  So it's a starting point.

But still.  When somebody reads that statement who is at risk of suicide and suicide attempts, the thought process goes something like: 

Suicide Is Complicated 

Complicated for whom? For the victim, aren't the complications pretty much over?  Granted, those who manage to survive a self-injury find that the act creates many complications, some of which will be the source of another OMG!! Award at a later date.  But The Medical Basis of Psychiatry is written for the professional.  So I take it to mean that suicide creates complications for the professional whose patient has disrupted the professional's life by bringing up (whether by words or deed) an issue about which the professional has some issues.  Complicated issues. 

Suicide Is Unfortunate 

Unfortunate is the only adjective used in the entire chapter that is not neutral, even clinical.  This is the one word that indicates the author has feelings about his subject.  And that's the word he chose to describe suicide, unfortunate.  It's that one word that is jarring, suggesting that even scientists have feelings.  For example, they find suicide to be unfortunate.

Okay, so he wasn't writing for me. He was writing for the people who take care of me when I am at risk of suicide.  He was reminding them how unfortunate my suicide would be.

Like I said, I need an interpretive frame to protect me while I dabble in thoughts that my therapist would just as soon I would not.  So there it is, the OMGThat'sWhatTheySaid Award. 

Send Your Nominations Via Comments 

Thanks to the reader of Prozac Monologues who brought this quote to my attention.  Do please send me your own nominations for future awards!

flair from Facebook

reformatted 11/29/10 

Saturday, June 6, 2009

Fact of the Month -- Suicide

It's June, the month with the highest suicide rate for persons with major depressive disorder.  So my posts this month will be on the topic of suicide.  Note to friends: This is not a coded message.  I personally am okay right now.

Today's post introduces the "Fact of the Month" feature.  And today's fact comes from David L. Conroy, Out of the Nightmare, who gets his information from the Statistical Abstract, 1989. 

Statistics -- More Suicides Than Homocides
In 1986, out of 2,105,400 deaths from all causes, 30,904 were suicides, 21,731 were homicides, and 47,865 were motor vehicle accident fatalities. [Conroy, p. 279]

These are the official counts.  They don't include the number of single car accidents that were suicides but not recorded as such, nor suicide by cop nor other accidental deaths of suspicious nature.  They do not include diabetics committing suicide by donut, nor overweight people with high blood pressure committing suicide by bacon.

After consideration of public funding priorities, or a night of typical TV viewing, would you have expected that 50% more people die of suicide than homicide?

Five Million People Alive In The US Today Will Die By Suicide

Conroy continues, Absolute numbers may be a more effective way to present the public health problem of suicide than percentages.  It does not seem very substantial to say that officially 1.4% of all deaths are suicides or that the real rate may be 2%.  A different way to present the information is to use the 2% estimate on the 250 million population estimate for the United States.  Five million people now alive will die by suicide.  Twenty-five million more are, or will become, suicide attempters.  Suicide has been, or will be, seriously considered by more than 50 million people. [p. 280]

It's uncomfortable to read, let alone talk about this subject.  For the sake of 50 million Americans alive today, isn't it time we get over it?

flair from facebook

reformatted 11/29/10 

Monday, June 1, 2009

Cognitive Behavioral Therapy -- aka Cake or Death

Cognitive-Behavioral Therapy (CBT) is a... treatment that focuses on patterns of thinking that are maladaptive and the beliefs that underlie such thinking...  In CBT, the individual is encouraged to view such beliefs as hypotheses rather than facts and to test out such beliefs by running experiments.  Furthermore, those in distress are encouraged to monitor and log thoughts that pop into their minds (called "automatic thoughts") in order to enable them to determine what patterns of biases in thinking may exist and to develop more adaptive alternatives to their thoughts. -- 

Books on Cognitive Behavioral Therapy

A lot of self-help books for depression, anxiety, panic, Post Traumatic Stress Syndrome (PTSD) include CBTHomework is central to this therapy.  They give you worksheets to fill out, to monitor automatic thoughts, identify negative beliefs and test them.

Those work sheets remind me of my first experience of therapy, in the "Mental Hygiene Department" of Health Services at Yale University.  Every time I walked in that door, I thought about flossing between the lobes.  The thing is, CBT homework strikes me as even more tedious than flossing.  Once I realize I am having a thought that my therapist will not like, I would just as soon not dwell on my failure long enough to do the worksheet.  So I have three of those Depression/Anxiety/PTSD for Dummies books on my shelf.  But I have never, ever done my homework.

I used to do my homework all the time.  Pleasing people in authority was very important to me, and I was very good at it.  It still is, and I still am.  In fact, that’s the issue I am working on in therapy right now.  So I am not going to please my therapist by doing worksheets.  I think this is progress.

Computer Game for CBT?

I wonder.  If the CBT people could come up with a computer game, would that get around the homework aversion that some negative thinkers have?  What about Frogger?  Your avatar tries to cross the road while cars (“you’ll never make it”) and bicycles (“nobody even sees you”) and eighteen-wheelers (“come to me, come to me, you’ll never feel pain again”) whiz by.  The little frog gets points for dodging, depending on the speed and lethality of each vehicle.  The median could be a safe zone to rest and power up, like the therapist’s office.  But once across, there is another day, another road to cross.  Too many glancing blows from bicycles and Minis, or a single direct hit by a bus, and your little avatar keels over with x’s for eyes.

I don’t know.  That death scene might be mesmerizing.  You could end up practicing the wrong thought!

The other day I was reading the Crazy Meds blog.  Which directed me to Cake Wrecks.  Which is how I found Cake or Death.  Though for the life of me, I can't reconstruct how I got from the second to the last.  Cake Wrecks is fun.  But Cake or Death is my new venture into correcting my maladaptive thought patterns.  I figure if I watch this video two or three times a day and practice choosing cake, then a new thought pattern will hack its way through the kudzu in my brain, and I will create a different automatic thought.  When I see the eighteen-wheeler bearing down on me, I will step aside to find out if it's from Hostess or Sarah Lee.

What do you think?

Like Moses said, Choose Cake.

homework photo by Arvind Balaraman

edited and reformatted 11/27/10