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Paula Joan Caplan's Authors Guild Blog

Suicidal Thoughts, Psychiatric Diagnosis, and What Really Helps: Part Two

Originally published at https://www.madinamerica.com/2020/09/suicidal-thoughts-part-two/ on September 25, 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.


Part 1 of this essay was about the absurdity and dangerousness of pathologizing suicide as "mental illness" and about the ways traditional approaches either do not reduce suicide or risk actually increasing it. Now we consider some factors that tend to inhibit suicidal people from reaching out for help, and that is followed by description of what actually can be helpful.



What can get in the way of reaching out for help?
Barriers to asking for help—and there are good kinds of help—include:

(1) Fear of being called mentally ill and all that follows from that, including losing support from friends and family, who want you to confine your talk to a therapist behind closed doors, just take psychiatric drugs, and/or agree to be hospitalized.

(2) Belief that only a therapist can help—this often keeps others from reaching out to someone who is suffering, because therapists' guilds have taught the public that only therapists can help reduce human suffering, that we have special knowledge no one else has, when that is almost never, ever true

(3) Feeling unworthy of taking up the time of a family member or friend. This can differ depending on one's sex-role socialization, since traditionally, women are not supposed to ask for anything for themselves, and men are not supposed to need anything.

(4) Believing one ought to be able to manage on one's own—whereas, in contrast, in some cultures the community considers it a community responsibility to reach out to and support those who have been traumatized, those who are feeling despair.

(5) Being labeled mentally ill because of having suicidal thoughts or made attempts to kill oneself, even though these are more common than widely assumed, and the masking of many of the causes of such thoughts or attempts, because "mental illness" is assumed to explain them.


What therapists and many others can do to help
(1) Realize that it can be very hard to predict who, even among people deemed to have risk factors, will attempt suicide (https://www.ajpmonline.org/article/S0749-3797(19)30506-9/abstract). So begin by not taking responsibility for what the suffering person ultimately does.

(2) Related to (1), stop assuming therapists can prevent suicides. The truth is, we therapists don't know how to do that, certainly not based on our clinical training. In a USA Today article (https://www.usatoday.com/in-depth/news/nation/2020/02/27/suicide-prevention-therapists-rarely-trained-treat-suicidal-people/4616734002/), Dastagir wrote this: "experts say training for mental health practitioners who treat suicidal patients is dangerously inadequate….There are no national standards that require mental health professionals be trained in how to treat suicidal people, either during their education or their career." Keep in mind that therapists are not supposed to work in fields in which they have not been trained.


And too often, those that do receive training are "taught" to send people who are considering suicide to the ER, get them on psychiatric drugs, and/or have them committed to an inpatient facility.  Many clinicians spend most of their time trying to treat a patient's allegedly underlying mental illness, rather than asking the person, "What makes you want to kill yourself?


Dastagir wrote: "Stacey Freedenthal, a suicide attempt survivor and associate professor at the University of Denver Graduate School of Social Work, says a common feeling among therapists when they realize they're sitting across from a suicidal person is panic. Their reflex is to send the patient to an emergency room.


'You've got this person who has taken weeks or months or more to work up the nerve to go to a professional and the professional is saying, "I can't help you, you have to go somewhere else." And that can be very harmful,' Freedenthal said."


(3) Stop using psychiatric diagnostic terms everywhere. Instead, tell suffering people you don't consider them mentally ill. Teach them the truth about psychiatric labels, because just being told one is mentally ill can lead to despair. In a recent Mad in America essay (https://www.madinamerica.com/2020/02/pathologize-eating-problems/), Jo Watson and I mentioned a New York Times essay by a woman who had been body-shamed by her ballet teacher for years, but it was only when her therapist told her she had an "eating DISORDER" that she said she fell to the floor and was despondent.


(4) Broaden the field of what we consider might be helpful, not just therapy and/or psychiatric drugs. Over the decades, as people have told me what helps them, I have seen two categories of helpful approaches: connection and creation.


Connection can be with people other than therapists, so the suffering person will know they won't be labeled mentally ill or treated as though they are, and this can be anyone who will be a willing listener. That is why the Listen to a Veteran listentoaveteran.org (LTAV) project is so powerfully effective. A Viet Nam veteran who had become a counselor and listened to others' suffering for decades had just one session in which a nonveteran truly just listened to whatever he wanted to say, and that ended his intense wishes to die.


I have referred to "The Astonishing Power of Listening" (https://www.madinamerica.com/2020/09/suicidal-thoughts-part-two/), which cannot always prevent suicide but sometimes can. And on a recent episode of "CBS Sunday Morning," a person whose suicidal despair had been stopped because of receiving occasional, simple post cards from someone said, "It wasn't about my mental illness.  It was isolation"—having someone reach out and show they cared.


When Hom et al. asked 329 suicide attempt survivors what they wanted, they said reducing stigma of suicidality, expressing empathy and active listening, a range of treatment options, including nonmedication treatments, addressing root problems, bolstering coping skills, and using trauma-informed care (https://www.madinamerica.com/2020/09/suicidal-thoughts-part-two/). Connection with service animals and with something spiritual or religious can also be helpful. This makes sense, given the crucial roles of isolation and hopelessness in leading to thoughts of suicide.


Creation can be in the form of involvement in the arts, doing volunteer work, gardening, etc., and many forms of creating also involve connection, whether with other beings, with the earth, or something spiritual. This website has more than two dozen very brief videos of nonpathologizing approaches to reducing isolation and suffering and providing real help (they come from a conference focused on veterans but are useful for anyone).


And keep in mind that another part of destructive labeling includes not just psychiatric labels but also "art therapy," "music therapy," etc. People find meaning, connection, enrichment, and creativity through the arts, so it harmfully sets up some people as belonging to the category of Other to say "I paint a picture, but YOU need art therapy"?


(4) Reduce or get rid of psychiatric drugs whenever possible, because it is known that they increase suicidal thoughts and suicides (https://www.madinamerica.com/2020/03/open-letter-va-secretary-wilkie-deprescribing-veteran-suicides-plan/).


(5) Get rid of firearms, since they are known to increase suicide risks substantially (https://onlinelibrary.wiley.com/doi/abs/10.1521/suli.2010.40.5.421).


(6) Provide real-life help getting safe places to live, jobs, healthcare, community connections, and a sense of meaning.


(7) Without being Pollyana-ish, help the person consider the strengths within themselves and their external resources.


(8) Help the person look realistically at the structural factors that may cause their despair, such as various kinds of violence, sexism and sexual harassment, racism, classism, ageism, ableism, homophobia and transphobia. CALL THESE FORMS OF OPPRESSION AND EMOTIONAL VIOLENCE BY THEIR NAMES, say they are all forms of abuse, and tell the person they are of course upset and feeling powerless in the face of such treatment. Help them consider ways to fight against these, including but not limited to political action and use of the arts.


(9) Be careful what you wish for. Don't give up your critical thinking and think the problem has been solved when someone or some entity says it cares. For instance, the American Psychiatric Association has recently professed alarm about the lack of mental health care given to Black people. I am sure some of their members are aware of racism as a cause of suffering and would not ignore it and attribute suffering caused by racism to an alleged chemical imbalance in the brain. But given that the APA is officially a lobby group, not a service organization and not an anti-racism one, one has to wonder to what extent they are looking for new markets.


The Congressional Black Caucus rang the alarm about increasing rates of suicide by Black youth (https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf). Although this is cause for alarm, it is worrying that they attribute this to "depression" rather than to being targets of racism, and they call for more mental health research funding, reducing barriers to mental health treatment, increased use of "depression" screenings, and getting more mental health professionals into Black schools.


These recommendations are worrying, because too little traditional mental health work involves calling out racism—or other forms of oppression and violence—as a cause of deeply human responses, not of "mental illness."


(10) Try to avoid suicide hotlines. Instead, use warm lines (see below). When I asked the directors of the Army suicide program what happens when someone calls their hotline, they said they are told to get "mental health services." Those are nearly always the labeling, drugging, and hospitalization referred to above.


I investigated many high-profile hotlines and crisis lines and some that are not well-known. I want to describe the experiences I had when calling them. One of the best-known services, the one most often mentioned by colleagues whom I asked for recommendations, has toll-free numbers and several numbers with various local area codes that turn up in online searches. Over a period of several hours one evening, dialing one of those local numbers consistently elicited nothing but a busy signal. Over those same hours, another of the local numbers in a different location consistently elicited an automated message instructing the caller to dial 911 if it was an emergency and otherwise to call back.


A third local number in still another state also rang busy for hours, but a man finally answered. I asked what they do for suicidal callers. I said I hoped to find a line where people would listen, be supportive, and try to maintain a meaningful and helpful connection with the caller. He replied that what they do is send people to get "mental health care." When I asked whether they have been trained at least to offer callers information about alternative, nonpathologizing, low-risk approaches that have been shown to be helpful—such as physical exercise, meditation, volunteer work, involvement in the arts, other kinds of human connection, and having a service animal—he said that they have not and that he himself does not suggest them.


When I called the main toll-free number for that same crisis line group, the automated answering message immediately gave an option to press 2 if you are a veteran. I pressed 2, and a man answered right away. I told him about a dear friend who is a veteran who takes three psychiatric drugs and has attempted suicide several times, each precipitated by a change in the drugs. I asked what the people answering their line would say if I persuaded him to phone them. He told me that he would tell him to go straight to the VA. I expressed dismay, saying that it is well known that at the VA, veterans are often put on psychiatric drugs, even up to a huge number at once, and that even some top VA people have expressed alarm about the ways the drugs so often lead to deaths. I got nowhere.


Around the United States and in other countries, people who have themselves been through difficult times and who do not rush to recommend psychiatric diagnosis, drugs, and hospitalization are creating "warmlines" for people who are having suicidal thoughts or other kinds of upset. Many such lines have small budgets and can only provide people to respond a few hours a day, usually in the evening, but from what I learned by contacting some, they are staffed by compassionate people who respond in helpful ways. Although some do not have toll-free numbers, they can be phoned from anywhere in the U.S.


When providing someone with numbers to call, it is important not to overreact to their having mentioned thoughts of suicide. A simple and kind, "Here are some numbers for you if you continue to have thoughts about suicide. They are staffed by warm and caring people who will not rush to recommend psychiatric care, diagnosis, drugs, or hospitalization. I am providing them in case you decide you would like someone to speak to about these feelings."


The primary aims of this two-part essay are to save everyone time and worry when trying to help prevent suicides by describing the absurdity and even the harm caused by psychiatric labeling and drugging of people who are thinking of killing themselves, by providing a list of "What Not to Do" and providing concrete suggestions for "What to Do." I hope this is of use.


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Suicidal Thoughts, Psychiatric Diagnosis, and What Really Helps: Part One

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.


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