Thursday, June 30, 2011

Talkin' bout suicide

I used to work at a hospital program for people at risk of psychiatric hospitalization. I worked with a lot of people who were at risk of suicide or who had made an actual attempt. Part of this work involved talking with clients' family members and educating them about talking about suicide with the client.

Hopefully you never have to have this kind of conversation with someone you love, but with an estimated 750,000 suicide attempts in the US each year, this kind of talk is more common than you might think. Because it is a taboo subject, people often struggle talking about suicide. I pass on what I know here in the attempt to help with these conversations.

If you take one thing away from this post it is this: if you are concerned that someone you care about may be suicidal, urge them to seek care from a therapist or psychiatrist. It is beyond your role to be assessing someone's suicidality.

I am offering these guidelines because I know that in reality people who are thinking about suicide do talk to family members and friends. But as a friend or family member, your goal should be to urge the person you are worried about to get professional help.  

  1. The best way to know if someone is suicidal is to ask. You can say something like, "I know you have been depressed for a while, and this may be a weird question, but have you been thinking of hurting yourself?" 
  2. Sometimes friends or family are afraid to bring up the subject because they don't want to give someone an idea they have not already had. Don't worry about this; if someone is not thinking about suicide, your asking them will not make them suddenly think that killing themselves is a good idea. Bottom line: you do not increase someone's chance of suicide by asking them if they are thinking about suicide. 
  3. Plans, means, and intent help determine risk. 
    1. Plan: Has the person thought about how they would kill himself? A person with a plan is likely at greater risk than someone with no plan.
    2. Means: Does the person have the means to carry out their plan? Someone who has the means to do so (i.e., "I would hang myself, and yes there is a rope in the garage") is likely at greater risk than someone who does not have the means, or has no plan to get the means. Note: If someone who is thinking about suicide has access to a gun, this greatly increases the chances that they will kill themselves.
    3. Intent: Is the person actually planning on going through with it? When? Someone may have a plan and means but no intent: "If I killed myself, I would jump off the Golden Gate Bridge, but really I would never do this." Or they may be planning suicide but only if something they fear comes to pass "I will not kill myself unless my husband leaves." Obviously, someone who says they plan to kill himself in the near future is at extreme risk.
  4. Certain risk factors can increase the chance someone will attempt suicide. Consider:
    1. past attempt at suicide
    2. people close to this person killed themselves or attempted suicide
    3. drinking or drug problem
    4. history of impulsive acts
    5. hopelessness
    6. history of abuse or trauma
    7. isolation
  5. Certain protective factors can decrease the chance someone will attempt suicide. Consider:
    1. stated desire not to hurt friends and family by killing oneself
    2. stated obligation to care for others (i.e., "I would like to kill myself, but I need to care for my children.") 
    3. Religious beliefs against suicide
    4. Person talks about future events they are looking forward to
    5. Presence of family, friends, or mental health professionals who the person feels they can talk to and lean on
  6. The phone number for the National Suicide Prevention Hotline is 800-273-8255. The hotline is open 24/7 Give this number to the person thinking about suicide. Call it yourself for support or advice if need be.
  7. The emergency room or 911 is the right choice if someone is in immediate danger. If you are worried that someone is going to commit suicide in the near future take this person to the emergency room, or if they won't go, call 911. Having the police show up or going to the ER is a lot of drama, but far less than if someone kills herself. Err on the side of caution here. 
  8. People who are suicidal are sometimes ambivalent about killing themselves. This can result in a person jumping from saying they are going to kill themselves to saying the reverse. The rule here is if the person you are talking to cannot convince you that they will be safe in the near future at least, take them to the ER or call 911.
  9. People at risk of suicide need professional help. I am repeating myself here, but if someone is in a bad enough place to be thinking about suicide, they need to talk to a therapist or psychiatrist. Unless you are a mental health professional, you lack the training to be keeping this person safe. Urge them to get help. 

Tuesday, June 14, 2011

It's a process

I have this poster by the artist Nikki McClure in my office:

Despite its small size, clients comment on it more than any other piece of art in my office. To me, the word "process" has a dual meaning in the context of my office. One, people process or work through stuff in therapy. Two, therapy itself is a process.

The picture shows a process not unlike therapy. Pitting cherries, one cherry at a time. I imagine the hands belong to an old person who is patient and methodical.

It is a reminder to me that the work I do with clients and my own work in therapy is often this way. Big insights and dramatic breakthroughs do sometimes happen, but I find it is the change that comes bit by bit that often sticks.

For a long time, I looked for a cure for a part of my gut that gets tight. When I feel this way, it feels like the world is a scary place, and I would rather crawl back into bed. I have tried yoga, meditation, exercise, therapy, massage, and chiropractic to cure this problem. I imagined that I when I got rid of it, there would be no stopping me. I would be glowing with energy. I would be magnetic. I would accomplish twice what I normally do. 

What I realized was that hoping so hard this feeling would go away often makes it worse. It creates a split in me where one part of me hates another part.

I am learning to be more patient with my body. Now when I feel tight in my gut, I try to breathe with the sensation. I've found it important to breathe with the sensation - letting both my breath and the tightness be present - instead of breathing in an attempt to make it go away. I have also learned to expect ebbs and flows in my energy level. I would like to be high energy all the time, but that isn't how my life actually feels.

It has taken a number of years to learn to be more patient and gentle with myself. I have found that attitudes, especially attitudes about ourselves, change slowly. But it is this kind of change that actually makes a big difference in my life, actually makes me a happier person.

Do you agree? Have you found that change happens slowly or have you had more dramatic shifts that have stuck for you?

Friday, June 3, 2011

Breaking up is hard to do

I haven't written a post in a little while. I've tried, but I've either written diatribes against society or trite Buddhist wisdom.

It feels like I can only write with authenticity about one thing: the breakup of my long-term relationship. I haven't wanted to write about it because a. it is personal and b. I have qualms about talking about certain areas of my life given that clients may read this blog, but perhaps writing about it will help others who are going through something similar.

First, let me say that it sucks. It's just really painful and there does not seem to be any way around it.

And now for a closer analysis of this pain and how I am dealing with it:

Feeling: Self-blame
Every time I feel sad, there is a feeling that if I had done things differently then I would not be feeling sad right now. My general theory is that loss is inevitable, but we humans have an immensely hard time accepting this as part of life so we try to assign blame, hoping to feel more sense of control. 

Some people like to blame others. In keeping with my humble nature, I prefer to blame myself. I think about various points in the relationship where, if I had acted differently, we would still be together. I imagine going back in time and tapping myself on the shoulder and telling this version of me what I know now.  

Action: Stop it!
As much as I can, I try to short circuit this thinking. It is just not helpful and leaves me feeling worse. Also it is unrealistic: a. I can't go back in time. b. Even if I could, would this have saved things? I don't really know. It was a complicated situation and my fantasy of going back in time makes it much simpler than it actually was.

So, I just try to pull my mind out of this loop. Not always successfully. Sometimes I end up wallowing, but I try.

Feeling: Sadness
As I said, the self-blame tends to set in over a feeling of sadness. Sad because I miss her. I just do.

I think about times we had fun together or I think how it would be if she were with me in the moment. It's like I am reaching out with my mind and heart, but she is not there. Even though it hurts, there is something soft about this feeling, something tender.

Action: Feel it! 
When I actually let myself feel sad, and maybe cry it out a little, I usually feel better. This is often easier with another person - my therapist, my friend, my mom - than alone. I don't know why but it feels harder for me to get to a sad place when I am alone. 

For people who tend to spend a ton of time crying and feeling sad, I don't recommend staying in that place indefinitely. If this is you, you might need distraction. But if you are like me and getting to a sad spot can be hard, then I think it is good medicine to stay there for a little and let your heart be sad.

Feeling: Emptiness (depression)
This one sucks. It feels like there was a tube that supplied color to my life and now there is nothing on the end of that tube. My life feels like it is in black and white. 

I don't feel excited about anything, and there is the impulse to zone out, watch tv without really watching, even stare at the wall. My body feels heavy, and without energy.

For me, sadness has a feeling of movement to it, but this emptiness, this lack of feeling, feels heavy and stuck, like a stagnant pool of water.

Action: Keep doing my life!
I assume that time will heal things, and the color will return in time. I also find that when I actually do the things I am not excited about - exercise, hang out with friends, work - that I feel better at least during the activity. So, I continue to exercise, take walks, work, write (a little), meditate and see friends.

Action: Rest!
More than normal, I am allowing myself to spend time in bed, nap, and watch movies on my computer. I think you have to be careful with this one because too much bed time can exacerbate depression, but shit, I am going through something hard, and now and again, I let myself take it easy.

Feeling: Fear of suffocation
Ok, I know this may sound strange, but there have been several times when I have realized that a part of me is afraid I won't be able to breathe. It has happened during meditation and also when I wake up from a dream. It is like there is this fear that I will be stuck somewhere, somewhere I can't get out of, somewhere where I can't breathe but I don't die.

I have noticed that several times when I have woken up from a dream, I am a little afraid to go back to sleep for fear that I will get stuck in the dream world. I don't really know what this has to do with my break-up, but I think somewhere in me is the fear of dying and the sense that my relationship was a buffer against this fear. Like, ok here I am alone in the world and destined to one day die, but at least I have this loving person to hold onto, and now I am all alone.

Action: Be curious!
Even though this fear is terrifying, I am actually really curious about it because I sense there is something big here. So whenever it pops up, usually only briefly and on the edge of awareness, I actually try to feel into it more, so I can better understand what it is.

Action: Take a deep breath

Feeling: Jealousy
"What is she doing right now? Is she with someone else? What is she doing with them?"

This one comes on fast and hard, the images of her with someone else flying through my mind and my stomach tightening into a knot. It's a burning feeling, like I have swallowed a red hot lead ball, and I don't know how to throw it up.

Then my thinking mind kicks in - in a bad way. "What day is it? Tuesday. Shit, she doesn't have her daughter on Tuesday. She could be on a date. With who? There is that guy she mentioned being friends with a few weeks ago..." And so on.

Action: Get to the bottom of it!
Some deep breaths help me calm the crazy-making thoughts and feelings. From this place I ask myself what is beneath this and I find fear first and then loss. 

The fear is like an alarm bell signaling grave danger: "Woman about to go with other man! Woman about to go with other man! Act now to prevent loss of woman!" 

But the truth is we've already broken up. I've already lost her. I do my best to tell the alarm bell to calm down, the thing I am afraid of happening has, in a way, already happened.

I am also afraid that her being with someone else means she doesn't love me anymore. I remind myself that just as I will always have a place in my heart for her, I believe she will always have a place in her heart for me. I find this comforting.

That's when I get to the loss that has already happened. She is gone. 
If, or should I say when she goes with someone else, it will mark another stage in this loss, making it more final. This is inevitable. When I can calm down about it, I realize I am more sad than anything else.(see sadness above).
So what feelings have you dealt with when you broke up with someone, and how did you get through it?