Originally published at https://www.madinamerica.com/2020/09/suicidal-thoughts-part-one/
This piece is the first of a two-part essay about suicide, diagnosis, what doesn't help, and what does help. This part is about suicide, diagnosis, and some of what fails to help.
Paula J. Caplan, PhD
September 24, 2020
Portions of this essay are based on the Mad in America webinar, "Issues in Dealing with Suicidal People…and What Experience with Military Veterans Teaches about Nonpathologizing Approaches for All," April 2, 2019.
The arena of psychiatric diagnosis, "depression," and suicidal thoughts is a godawful…and dangerous…mess. And it just gets worse and worse.
Consider this development: On June 18 of this year, the American Psychiatric Association (APA) issued a news release that they were adding diagnostic codes and definitions for suicidal behavior and nonsuicidal self-injury to the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM).
It is already a serious problem that both having suicidal thoughts and killing oneself are, in a knee-jerk way, considered proof that the person has a "mental illness." When someone kills themselves, if they had a psychiatric diagnosis, the suicide is attributed to that alleged mental illness. If they had no such diagnosis, it is claimed that they had an undiagnosed mental illness.The circular logic of this is astounding. And it could not be farther from scientific thinking.
This is illogical, absurd, and dangerous, if we want to find out what really leads to suicide and how to try to prevent it. In this two-part essay, I am recommending a) intensively and sincerely validating the suffering of people who are suicidal, b) avoiding mental illness diagnosis and psychiatric drugs, and c) a great many things one can do instead of the traditional ones.
Consider what the DSM conveys about grief, which is often called "depression." When preparation started for DSM-5, the chair of the DSM-IV Task Force, Allen Frances, expressed alarm that what he called his edition's "bereavement exclusion" would be eliminated in DSM-5.This implied that in DSM-IV, he had said that Major Depression should not be diagnosed in someone who was bereaved.
In fact, however, DSM-IV includes the statement that Major Depressive Episode (MDE) should not be diagnosed if someone has been bereaved within the past two months. That is alarming enough, because bereavement does not end or, often, even diminish very much after 60 days, nor should we expect it to do so. Thus, it is hard to see what would justify the intensity of Frances' outrage about the DSM-5 authors diagnosing a depressive "disorder" immediately or after two weeks rather than two months.
But even in DSM-IV-TR, the instruction not to diagnose a disorder if the "symptoms" arose less than two months after loss of a loved one is followed by this: "unless they are associated with marked functional impairment or include morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation."
Note especially the word "or" in the foregoing. One need meet only a single criterion in that list to qualify for MDE even as soon as the first day of bereavement. It is hard to think of anyone who has lost a loved one and not met at least one of those. It is clear that even Frances' editions of the manual actually have no bereavement exclusion. To ignore that this was the case in DSM-IV is to render invisible the suffering and harm caused to grieving people whose bereavement was diagnosed as "mental illness" and often "treated" with psychiatric drugs.
What Causes Thoughts of Suicide?
The term "mental illness" is often assumed to indicate that the person isn't thinking clearly, is out of touch with reality—otherwise, suicide would not enter their mind. Those who make that assumption would do well to listen to people who have been suicidal. Many such people say that death is the only way they can think of to end intolerable emotional or physical pain.
Marsha Norman's Pulitzer prizewinning play 'night, Mother is a brilliant example of this. In the play, a middle-aged daughter tells her mother she is going to kill herself that evening. Her mother tries every way she can think of to persuade her daughter to change her mind, but the daughter explains: "I'm feeling as good as I've ever felt in my whole life." She recounts the many miseries of her life, saying she is worn out from trying to make her life better and never succeeding. She says she is "somebody I waited for who never came and never will. I didn't make it." She is at peace, because she finally feels there is something she can do that will end her misery. So, one kind of reason for wanting to kill oneself is to end what feels like unbearable suffering when there is no prospect of change.
Trauma of any kind can be a reason for wanting to die, in part because trauma by definition is a horrible experience, and sometimes suicide can feel like the only way to avoid another such experience or to escape from the effects of the trauma. In addition, trauma tends to be fragmenting and disorienting, which makes it that much harder to reach out and connect with others and with resources that can be helpful in dealing with the effects of trauma and avoiding further trauma. Trauma can come from violence, extreme poverty, and forms of oppression including sexism, racism, classism, ageism, ableism, homophobia, transphobia, and looksism.
In more than a decade of working with veterans, I have met so many who have been told they have "Post-traumatic Stress Disorder" ("PTSD"), an alleged mental illness listed in the psychiatric handbook. Elsewhere (https://www.amazon.com/When-Johnny-Jane-Come-Marching/dp/150403676X), I have extensively critiqued this term, but a major relevant point here is that it consists of a list of effects of trauma. It is a dangerous pathologizing of people's reactions to trauma.
What would be a "healthy" response to trauma, then? Not being affected at all by seeing a buddy blown to bits or being raped by one's sergeant?! Veterans often tell me that therapists have said, "You have this mental illness called PTSD and will have it all your life." Just being told that could easily lead to despair and thoughts of ending one's life.
In contrast, listening to veterans and other traumatized people when they are devastated, rather than thinking about how to label them, reveals that they variously feel grief, terror, shame, disorientation, moral anguish, loss of innocence. Do we want to say that someone who feels despondent when intensely grieving or deeply ashamed is mentally ill…and should be labeled and drugged?
As for moral anguish—the reasons servicemembers experience it are well known, but non-military people can also experience it when, for instance, a mother learns that her children's father is abusing the children, and she desperately wants to stop the abuse but is terrified that if she reports the abuse, the courts will consider her a lying troublemaker and give the children to him … as has been proven to happen 2/3 of the time in cases of child sexual abuse.
With regard to loss of innocence: Many people join the military when they are barely out of high school, maybe going from prom to basic training, and at that age to witness war or experience military sexual assault can clearly be overwhelming, causing despair and hopelessness from the shock of having such experiences while so young and unprepared (as if anyone could be prepared for war or military rape at any age).
This applies as well to nonmilitary people who experience trauma: Until the trauma, they have had a narrow view of what life is really like, and now a large proportion of their young life's experience has been horrific. Do we want to call all of this "mental illness" rather than experiences and feelings that seem intolerable and lead to thoughts of suicide?
In our death-phobic society, it is little known that many people—perhaps even most—in the course of ordinary lives think about suicide at some time. As soon as one becomes aware of life itself and of the inevitability of death, what could be more natural, more human, than to consider the possibility of choosing the time and method of one's death, whether in a philosophical way, or because one is afraid of how one might die if one doesn't take it into one's own hands, or because it makes one feel more in control? This is often common among adolescents and adults who are sensitive, artistic, and thoughtful. Then there are the people who either are desperately lonely and believe that will never change, or who have what feel like overwhelming burdens and problems for which they can see no escape.
Traditional Mental Health Approaches Don't Help Anyway
Susan Stefan, in her brilliant book (https://www.amazon.com/Rational-Suicide-Irrational-Laws-Psychology-Law/dp/0199981191) and in her lectures, urges that when we know someone is thinking of suicide, we offer to listen to whatever they want to say and ask them, "What would make your life worth living?" and then see if we can help with that. And of course, our offering to listen can help reduce their isolation. This could not be more different from traditional therapists' approaches.
Stefan has comprehensively reviewed the approaches to dealing with people who have suicidal thoughts in the traditional mental health system and has reported that these approaches tend to exacerbate the problem. That is a powerful reason for refusing to classify suicidal behavior as signs of mental illness. It does not belong in the DSM.
Does it help that the DSM staff say they plan to list it in Section II, "Other Conditions That May Be a Focus of Clinical Attention" so that it can have a numeric code? Of course that doesn't help. The book after all has "mental disorders" in the title, and its authors have zero ability to warn the world NOT to classify suicidal behavior as a "psychiatric disorder" even though it is in their book. What reason is there to give it a code to put on medical files and send to insurance companies if not to help therapists expand their territory, power, and income?
Although the rest of this section is about military servicemembers and veterans, the principle points about how traditional approaches do not help apply to people who have not served in the military as well.
In my book about veterans (https://www.amazon.com/Rational-Suicide-Irrational-Laws-Psychology-Law/dp/0199981191), I raise the question: If traditional mental health approaches are effective, why are veterans' suicide rates so high? When the book first came out in 2011, I warned about the ineffectiveness and harm from psychiatric drugs. And in two chapters called "What the Military Is Doing and Why It's Not Enough" and "What the VA Is Doing and Why It's Not Enough," primarily based on the Department of Defense and VA press releases, I found the following pattern: About every year, the DoD and the VA would issue press releases in which they expressed concern about high rates of suicide among active duty members and veterans, respectively. Each time, they would express mystification about these rates and mention ways they planned to reduce them. But that happened in each announcement, and in each subsequent one, the suicide rates had not declined. Strikingly, they tended steadfastly to avoid considering the role of war trauma and rape trauma in leading to suicides.
Concerned about this, Col. (Ret.) David Sutherland and I wrote an essay (https://www.inquirer.com/philly/blogs/phillypharma/Unseen-wounds-Psychotropic-drugs-often-intensify-the-veterans-suffering-and-isolation.html) about the four main reasons veterans kill themselves. These were:
The vileness of war (and rape, sexism, racism, homophobia, classism, and so on);
The soul-crushing isolation most experience when they return home;
Being labeled "mentally ill" instead of being told their reactions to trauma were deeply human responses…and the label often increasing the isolation; and
Psychotropic drugs, which can increase suicidal thoughts and suicides and which often dampen people's emotions, thus making it harder to form or maintain relationships.
Some years ago, I met with the two Army people (one a therapist, one an Army officer) charged with creating the Army's whole suicide prevention plan. It consisted of two things:
Persuading soldiers that the slogan "Army strong" can include "strong means asking for help"; and
Setting up a suicide hotline.
But without massive changes in military culture, the first wouldn't work. In fact, we need to look at toxic masculinity for men and the expectation for women to ask for nothing for themselves as barriers to decreasing disconnection and isolation. As for the hotline, more in a moment. But note that Jensen and Platoni (2018)(https://nationalpsychologist.com/2018/11/most-military-efforts-miss-target-on-suicide-prevention/105185.html) have written:
The military and the civilian community have missed the mark on suicide intervention and prevention. The truly intervening and healing elements are not treatment programs, not piles of pills, not being encouraged time and again to reach out…but community itself, in the context of compassionate, educated, reciprocal, PROACTIVE social support.
Suicide hotlines are often assumed to be important and effective, and that is a dangerous assumption. An Oscar-winning film about the VA's hotline, "Crisis Hotline: Veterans Press 1," illustrated (no doubt unwittingly) the massive drawbacks. The general audience with whom I watched the film gasped in horror when they saw onscreen "22 veterans kill themselves every day." (Note that that famous number is wildly inaccurate, because it was based on VA data from only 21 states, not including Texas and California, which have huge populations of veterans.)
But the audience probably wanted to believe that the hotline takes care of the problem. In the film, one sees no veterans but sees and hears what those who answer the hotline say. One of the most striking aspects was the almost total lack of warmth and connection displayed by the responders, who were described as having had "mental health training."
Tremendous focus was on keeping the veteran on the phone until the police arrived or ensuring the veteran got to an Emergency Room. It's frightening to be in a position of responsibility for people who are talking about killing themselves, so it's understandable that the responders may have been relieved to serve as little more than way stations, directing the callers to the police or ER.
Another astonishing feature of the film was the extended conversation a responder was having with a Marine whom we could not hear. Based on the responder's comments, the Marine was having flashbacks of seeing his buddy lying in a pool of blood. The responder said vigorously at one point (no doubt with good intentions, trying to forestall a suicide), "Your children NEED their Marine father!"
I would have hoped that whatever training the responders had had would have included the information that when someone is seriously suicidal, they deeply believe that the greatest favor they can do their loved ones is to kill themselves. I fear that that Marine may have felt that the responder utterly failed to understand them, perhaps increasing their sense of isolation and despair.
When I once called the VA hotline, because I had good reason to fear that a veteran I knew was going to try (again) to kill himself with the many psychiatric drugs VA personnel had prescribed, I asked the responder what they would do if I could persuade him to call them. The answer: "Get him to an ER to be committed to a psych ward where they could adjust his medications." My pointing out that the drugs were a huge part of his problem completely failed to elicit any other response.
In July of this year, the FCC approved the use of the number 988 (as of this writing, that is not a working number) which anyone thinking of suicide would be urged to call, but all callers to that number would be directed to the existing National Suicide Prevention Line, which has many of the same problems as the VA one, as do other crisis hotlines.
I have critiqued these hotlines in Chapter 6 of the paperback version of my book, When Johnny and Jane Come Marching Home (https://www.amazon.com/When-Johnny-Jane-Come-Marching/dp/150403676X), and have described the alternative: what are known as "warm lines" that are answered by people whose focus is to connect and be supportive.
Hopefully, it is now clear why it is so inappropriate to conclude that people who are considering suicide or have killed themselves are/were mentally ill. Traditional therapists' approaches simply fail to help them. In Part 2 of this two-part article, I will address some barriers that tend to prevent suicidal people from seeking help—and ways that we truly can be of help.