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.


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

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