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.