Musings

Gloomy topics for Spring days; did you know we’re in peak season for suicide?

So, I'd like to take a few minutes on this lovely sunny day to talk about suicide, which you may not want to read any more about. There’s a limit to the scope for humour here, really, I’m afraid.

I've been having lots of chats with people recently mostly because someone they know has killed themselves, or they have some thoughts about it, or they used to think about it, and have questions, concerns, or things they’re really pissed off about like how the media presents it, and really, when you want to talk about death, ex-psychiatric workers with a bad case of gallows humour seem like a place to start.
A few issues have come up so many times I thought what the hell, Write A Thing. It is neither comprehensive nor referenced (you can complain later). It also Contains Swearing. No tales from work or personal life though, unless it's about sandwiches.

1) Suicide is the leading cause of death in men between about 18 and 50. This has been going up in England and Wales. So, you will probably be affected by it at some point within your extended network. It will be horrible. You probably theorised that already, but nothing really prepares people for the gut wrenching shock. The people you expect to do it are the known risks, and thus get help (or, it’s horrible when it finally happens but it’s like cancer; you sort of knew it was coming). It’s the people who don’t seem likely to do it that manage it. Hence the shock. it’s also usually pretty horrific as the available and most frequent ways to kill yourself are basically grim.

2) No-one really knows why there’s such a big gender disparity in suicide, though various reasons have been booted about and there's a few things the gap correlates with, like individualistic cultures, economic deprivation, self destructive use of alcohol, drugs, gendered ideas about not expressing feelings, and such. Don’t be fooled into thinking that means women are less suicidal, by the way - nope, we’re just much less effective with our choice of methods. This is probably not an area we should work to men’s standards on though.

3) Similarly, we also don't really have a fucking clue when it comes to assessing the risks of suicide in general. If you work in mental health you do risk assessments ALL THE TIME and basically just . . . it doesn’t work. And that’s people with 24/7 contact with people, in a controlled environment. For some people, it seems like a rapid process, they're managing life ok one week with nothing obvious and gone the next; even chronic and/or severe mental health issues are not in and of themselves a clear predictor (fuck all is a clear predictor. Screening doesn’t work). For other people, there are signs of distress or problems that are known about, but usually there's nothing obvious about when and how that tips into suicidal ideation (planning) or action. Very depressed people, oddly, aren't so much at risk - catatonic level depression makes you hard of thinking and slow to act, meaning you just can't do it. It's when people start to improve that professionals worry. Especially if someone goes suddenly very calm, as it can mean they have a plan and its soothing for them. Once people have reached the planning stage, they’re very high risk, so if someone tells you they have a plan, for gods sake don’t keep that secret.

4) There are some people who are so persistently suicidal/self destructive that they end up locked in hospital with staff at arms length at all times. What you learn when you are that staff member with them is that people can be surprisingly creative in their self-destructiveness, and that if we could just channel that level of determination and problem solving into something else, that would be awesome.

5) And in fact within two years of a suicide attempt the vast majority of folks are doing so; more than 95% are reasonably contently getting on with living, though I am buggered if I can find the reference for this. But basically, suicidal thoughts and feelings are usually temporary, within the scheme of a lifetime.

6) Can you stop someone killing themselves?
Not exactly.
If people with decades of experience and tons of research to hand can't work out when or how it will happen, whats your chances? Can you watch everyone with a risk factor for suicide (which, by the way, is most folks, pretty much everyone has some sort of vague idea about it at some point)) 24/7?). Are you actually a robot nurse with ninja caring skills and social work facilities? If so, your country needs you!
You CAN be the person who notices something is wrong and gets someone to talk at the right time. This is good. It’s worth doing. Maybe even learn some basics to deal with people for this kind of stuff. But it will be down to serendipity whether its you and your timing that’s right. And you can’t be there all the time - there will be things wrong that need sorting out, there will be aftercare issues, there will be life stuff that needs dealing with, trauma that needs working with, lord knows what, its different for everyone. You can’t do all of it. You just can’t.
You CAN be the person who happens to catch people at the stage where they are making plans, and somehow intervene. This is good, It’s worth doing. And then all the same things apply.
You CAN be the person who happens to catch someone at the right moment and you call 999 or do some first aid or whatever the situation requires. This is good. This is worth doing . . . and again, but then what?
I’ve seen people at all those stages. But whilst what I did was useful, even critical for an incident or however many, it wasn’t the be-all-and-end-all for the whole of that persons life. Lets take the worst case scenario, you intervene in an actual attempt. Good. Yes, technically, someone is alive because of you now. For now. But what about in an hour, or a week, or a month? People aren’t just that moment, that action. The important thing is the network and support on either side. The important thing is all of the care, to tackle as much as we can of what got someone to this place. You, alone, cannot fix someone or their life. They have to want to and there have to be the resources around for them to do it.

7) "But but but what if I had done this or that or the other wouldn’t it have been different then?"
People who go into mental health work usually get into it thinking they can make a difference, and then spend several years getting their incipient omnipotent complexes removed because they just cause problems later on (whilst simultaneously being insured to the hilt in case you do get sued after a suicide, so that’s a bit twisted). Here’s what my supervisor said to me, as politely and kindly as possible:
“You’re not God. People won’t live or die based on you alone.”
Obviously, we’re excluding folk that actually literally kill people one-on-one/leaders of countries that can take military action without mass consent, but you know, in the context of mental health workers that’s really should be a given. Basically, most of us just don’t have that much power or do that shit. We can have moments that impact massively on people. We can have relationships that heal. We can make the odd constructive suggestion that, for whatever reason, the person manages to hear , chooses to follow through on and it turns out to be useful, maybe even critical. But unless you’re engaged in abuse, attack, or certain types of healthcare, it won’t be your action or inaction alone that leads to someone’s death, and if you do something positive, it won’t have been the sole thing that made the difference to them living. We like narratives that make life that simple, so we tell the “and then someone talked them down off the bridge!” stories, but that bit isn’t the whole story.
It’s just the bit with the dramatic tension.

8) So what, you’re just saying I should do nothing?
No. I’m just saying don’t torture yourself about this and don’t simplify the issue down to single incidents, because neither of those things will help, really.

9) Well then what the fuck should I do?
Well, for starters, talk about it, and always take people seriously. If we can talk about suicidal thoughts, urges and plans we have a better chance of people not doing it, because then you can think about all the other things that could happen. So, if people want to talk about it, do so, if you want to talk about it, do so. No criticism, no bullshit, and a practical plan for what to do if things get worse/stuff to try instead/people you can go talk to in order of availability is helpful.
Important caveat; detailed methodologies can increase suicide. That’s why when someone kills themselves, the news doesn’t go into much detail, since you don’t really want to help someone thinking about it form a plan that will work.
Always challenge the notion that people are a burden. It’s bad for peoples mental health at the best of times, and at the worst, turns into “everyone would be better off without me”. Ditto ‘waste of space” and “nobody cares” ideas.
You can’t be responsible for someone else's life, you can’t monitor them all the time, but there are a few things you might notice that could ring warning bells - self destructive stuff like drink, drugs, food changes, sleeping all the time or not at all, being accident prone. Extreme fatigue (yes, I know that coming from me that’d be impossible to tell, but then, my illnesses DO put me into a higher risk category), tearfulness, isolating/isolation, absent/inactive, clearly not coping or agitated, withdrawing . . . obviously all of these things *could* be something else (and happily are likely to be) but whatever is behind them, you’re not going to burn in hell for asking someone if things are ok. Or saying hey, it seems like things are hard right now, can I help? Even if we are British. Just do it in private with a cup of tea. But be prepared for a REAL answer, not an "I’m fine". If you don’t feel emotionally equipped to handle a real answer, that’s ok. Work out who is, and ask them to help.
You can also learn basic counselling skills almost anywhere these days (NOT NLP), plus first aid. Useful life skills for pretty much everything. I also got made to do Food Hygiene, but that’s probably the least useful yet legislatively mandated course, and mostly just resulted in me being wary of reheated rice. But I am legally allowed to sell you a sandwich that I assembled.
In the UK, the Samaritans do an amazing job of listening. They also work on a wider level; they’re the people who collate the stats, for example, they analyse things like the gender gap, they say deeply radical things like “tackling inequality would really help” (it would really help. For like, so many things). Send them some cash if you have it spare, they do a bloody amazing job. And/or call them, if you want to or need to.
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Creative Rebellion

You can probably imagine that any place where lots of teenagers are, there's lots of rules. This is extra-true when it's a heavily regulated mental health hospital and specialises in eating disorders. At one point we had to scrap the dining room rules completely and start again because, due to a tendency to specifically write a rule against each new problem, we were onto 4 sides of A4. 

Sometimes, though, we can find amazing ways to rebel against things We used to take the people who it was deemed could cope for an afternoon out once a week. On one of these trips, I realised I'd absent-mindedly left my gloves somewhere. So many possibilities there for something to go wrong . . . I turned out to have put them in the dayroom, the communal lounge, where all the folk we had had to leave stuck inside were all afternoon.

Upon spotting them I realised one was suspiciously full. Oh dear. When you work with people who have issues with food, you learn to approach certain circumstances with trepidation and, ideally, hand sanitizer, because when you hate food, you will get rid of it anyway, and anywhere, you can. To this day I can't look a freusli bar in the face, having cleaned too many of them out of unexpected hiding places.

I pocked up the glove gingerly between one finger and thumb. It was heavy, clearly full of something dense that was shifting about. Oh no. That can mean vomit. Or worse. At this point I can see two sets of previously-bored eyes hovering over the sofa line, waiting for a reaction.

I peered inside.

It was completely and utterly packed with multicoloured glitter. 

It still makes me laugh to this day - and i hope you all find a happy, glittery solution to whatever constraints and frustrations you have to deal with!

(and no, I never did eradicate the glitter!)

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Online therapy

When I was a therapist, I loved working in person; it seemed so much easier to feel what people were feeling and  think about that (they hadn't invented mirror neurons back then, so I had to rely on psychodynamic theory instead, which was terribly upsetting for anyone with an enquiringly sciency mind).

But lets face it, most health problems mean we have extra problems managing to sort out appointments and get ourselves there on time and in a fit state to use them. In fact there's a whole brand of therapy theory devoted just to how to interpret such issues!

So what about support online? I saw a recent rash of posts about it and, of course, most of my life is now lived online. It's certainly got it's limitations - definitely no empathising with people based on their none verbal communication, so it's hard if someone can't or won't talk much (maybe snapchat therapy will become a thing for online art therapists?!) but it's clearly much more accessible in practical ways.

Do you use any online methods? I've always found twitter incredibly limiting, but in the Telegraph today there's a man who found it to be wonderful for his depression!

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A simple breathing exercise

I've spent so much time teaching and being taught relaxations, visualisations and breathing exercises . . . mostly because they're all good ways to manage when mind and body seem determined to cause problems!
But not all exercises work for everyone; I can't create a safe space these days and yes, I know that's worrying.
In the meantime I fall back on an old favourite from an American physiotherapist I worked with, to make you concentrate on breathing. But no counting, nothing complicated. Just imagine a candle, several inches in front of you, the flame burning bright and straight. When you breathe in and out it will waver and flicker - so you try to breathe slowly enough not to blow it out.

It's not for everyone, but it works for me. Do you have a favourite exercise to still the mind and body?
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Depression or anxiety - but does it really matter at all?

My  flatmate thinks I'm living with depression, I think it's anxiety (based mostly on the symptoms of "I really want to puke and can practically feel my adrenaline spikes').

Given that the recommended treatments are largely the same, at least since benzodiazepines fell out of fashion, and that I managed to work most days and see friends and keep on top of the laundry, it's not obvious that the diagnostic label matters much! 

We've got to the stage where the labels have such complications that they don't really communicate what the symptoms or issues are, what treatment is needed, or what might be causing the problem.  

Do you have a label? Is it useful to you?

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