by Robert Duff
You know how fire extinguishers usually have that bold text on their storage cases that says IN CASE OF EMERGENCY BREAK GLASS? In this method, you make your own “in case of emergency” box. With my patients, I have often made this literal by using a display case with glass on the front. (If your means of suicide includes cutting yourself, please use your noggin and don’t include the actual breaking of glass in your method. Just make a box with a latch or something.) Anyways, the box itself is something that you fill up when you are feeling your best, most hopeful self. When you have some clarity about your desire to live. Fill it with pictures of people you care about, movie releases that you are looking forward to, clippings of grass, a Rubik's Cube, a list of 20 reasons to stay alive… whatever makes sense to you as a person. Think of this as the emotional version of the shot of adrenaline that action heroes stab themselves with in the movies when things are most dire, and they need to somehow get their broken body to push through another hour of over-the-top destruction. It is a quick shot of hope, reality, and reasonable thinking designed to postpone you taking action during the peak of your crisis, allowing you to reach out for emergency help if needed.
Talking to your friends or family about your suicidal thoughts is one thing, but telling a professional like your doctor or therapist is much more risky, right? Well, I wouldn’t call it risky. It is certainly a different experience, because most medical professionals as well as people in helping roles like psychologists, therapists, and social workers are mandated by law to report you if they are concerned that you might be a danger to yourself. However, this isn’t just an off-the-cuff judgment. The professional needs to evaluate you to see what your level of risk is. If you are just having thoughts, but have no intent and no immediate means, you probably wouldn’t expect any immediate action. However, after careful evaluation, if your doctor suspects that you are in serious risk of harming yourself, you can be held for your own safety. I know this sounds harsh, but I want to stress to you that this DOES NOT happen every time you talk about these topics.
Let me put it into perspective for you. Over the past year, I was working in a major healthcare setting, seeing probably around 15 new patients every week. I talked about suicide with probably 100 of them, and there was only one case that I ended up collaborating with to work out a voluntary hospitalization.
Just like I suggested with your loved ones, be honest and clear with any professionals that you tell about these issues. Help them understand that you need support and how confident you may or may not feel about your personal safety in the moment. It is SO important to keep your providers aware of your situation in terms of suicidality. In some cases, it could even be related to a medication side effect. In others, they will simply want to be checking in with you over time to make sure that things haven’t taken a downward turn.
When your doctor or helping professional evaluates you, there are a few things that they will be looking for. In addition to assessing you ideation, intent, and means, they will want to know if you have had any previous suicide attempts. Previous attempts are actually the largest predictor of future attempts, so that is something that would definitely to communicate to them. They also want to see what you are living for. I always ask, “On a scale of 0 to 10, where 10 is completely confident in your safety and 0 is the opposite, how do you feel today?” When the patient answers, I follow up with, “Why not lower?” Even if they are at a pretty low 3 out of 10 on this scale, their answer will tell me some valuable information about what is still keeping them alive at this moment. Clinicians will also want to look at things like your level of guilt, any substances that you might be taking, and what type of social supports that you have. Trust me, any doctor would be much happier to enlist the help of you family and send you home into their loving arms to keep you safe than send you to a hospital, if that is a reasonable option.
Let’s say that your doctor does determine that you are at serious risk of harming yourself and would like to put you on a hold to ensure your safety. What does that look like? This is another area that is hard to write about in generalities. I’ll tell you about what it looks like in good ol’ California, USA, where I practice. In my state, if a doctor, peace officer, or other qualified clinician determines, after their careful assessment, that you are at immediate risk of harming yourself, they may place you under an “involuntary hold” for a few days. This is a way to keep you safe in the short term and hopefully connect you to resources that will allow you to move forward with your life with support while lowering the risk of harming yourself. Let me be the first to say that I 100% understand that this possibility sounds terrifying. I know it does. However, it’s really super-important to know that being hospitalized for suicidality does not mean you are going to live out One Flew Over the Cuckoo’s Nest or wind up in Arkham Asylum. Let me paint a more realistic picture.
When you hear the term “hospitalization”, it makes you think of sanitariums and other scary clinical settings. While there is definitely some variability in quality between the different psych hospitals out there, in general they are designed to be as comfortable as possible. They will look much like any other clinic or hospital you’ve visited. When you arrive to the hospital, you will undergo an intake process in which your belongings will be collected and documented. You are usually allowed to have some personal items with you. However, they may temporarily confiscate any items that could be used in a suicide attempt. For example, you probably won’t be keeping glass items or clothes with drawstrings because an actively suicidal person could use those to harm themselves. You will most likely also undergo a short psychiatric evaluation. In many cases, they already have some information from the person or agency that referred you, but they will want to make sure that they get a good picture of your current state, medically and psychologically. After going through your intake, you will be given a room. This is where you will be sleeping while you are staying at the hospital, and frequently you will be cohabitating with a roommate. It’s no Holiday Inn, but it’s not a jail cell either.
At the hospital, you will meet a large range of people. There will be those who probably would not have actually killed themselves, but are just not completely confident in their own safety. There will also be those who are talking to themselves, yelling in the night, and convinced that the staff is trying to poison them. This can be jarring, but it can also give you some much needed perspective on your own situation. You will have a few different evaluations with therapists and doctors during your stay. Their goal is to help stabilize you, develop a plan for moving forward, and to get you back out into the world. You will also be expected to attend groups intended to help you build coping skills and learn ways to regulate your emotions. It can be a bit overwhelming and scary for sure. Luckily, you are usually able to speak on the phone at certain times of the day and may have loved ones come to visit you. Sleeping is usually a bit restless in the hospital because it’s unfamiliar, and you are checked on throughout the night to ensure that you are still safe. It’s annoying, but it’s necessary. You will be discharged from the hospital when your hold has expired and when the doctors feel confident in your personal safety. You won’t just be dumped out on the curb with no plan. The whole idea is to help ride out your crisis, give you some skills to take with you out the door, and to develop a follow up plan with mental health providers in the community to keep you going in a positive direction once you are back out in the world.
I won’t lie to you. Being hospitalized is tough. It isn’t a fun experience. However, sometimes it is absolutely the right choice. Looking back on her hospitalization, someone that I know in my personal life made a metaphor that has always stuck with me. She said that she hated going to the hospital. She felt guilty that she had to go, and she just wanted to come home once she got there. However, she said that she would never take back the experience, because it was a necessary step in her recovery. She described it like a broken bone. Sometimes when you break a bone, the doctors will have to
re-break it in order to set the bone in the proper position for healing. Being hospitalized for your safety serves the purpose of resetting you and putting you on the path toward healing. I hope it is something that you do not need to deal with. However, I hope you now have a better picture of what the process looks like if it does come to that. It’s nothing to be ashamed of. Sometimes it is just one important step on the path to overcoming depression.
The final topic I want to address in this chapter is self-harm without suicidal intent. In the field we call it non-suicidal self-injury (NSSI). NSSI is an interesting topic because it can serve several purposes. I think the most common reaction to NSSI (by people who have never been through it) is to interpret it, especially the cutting variety, as a “cry for help.” While that can certainly be the case, there is often much more to it. If you cut, scratch, slam, burn, rip, or engage in any other variety of self-harm, you know what I’m talking about. Many times it is used as a tool. Self-harm is often a coping skill. It’s not a good one, and it’s not safe, but it is a coping skill. Sometimes it occurs when things are too overwhelming and you want to feel like you at least have control over your own body. Other times, it happens when you are so numb and anhedonic that it seems like the only way you can actually feel something. I want you to think of NSSI as a symptom. That tells you that you need a coping skill that you haven’t been able to locate yet, and this is what you are using in the meantime. If you are in the NSSI camp, I do not want you to be ashamed, but I do want you to try to stop. A solid portion of completed suicides are accidental, and I do not want you to die. As you may have noticed, there is also often a diminishing return effect that happens with self-injury. It’s almost like an addiction where you need more and more physical feedback to have any emotional effect. That is a slippery slope.
If you engage in NSSI, the best course would be to get professional help. It is something that you can transition out of as you find more healthy ways of coping. Many people are scared about the prospect of bringing their self-injury up to their parents or to their doctors. I know it’s scary, but I will echo my sentiment at the beginning of this chapter by saying: your permanent health needs to outweigh your temporary discomfort or embarrassment at this time. Another worry is how your doctors will react when you tell them. I want to stress to you that they should not simply sweep you away to a hospital if you tell them that you cut yourself. If you want to be very sure that they understand, you will need to tell them why you cut. Tell them the purpose that it has served, that you don’t want to die, and why you need help stopping.
In the meantime, I would like to give you one tip that could possibly help you scale back on your self-injurious behavior until you can get in to see a professional. I absolutely need to mention that this particular approach has not been researched for NSSI in particular, but I think that it could potentially apply. There has been some research indicating that puzzle games such as Bejeweled, Tetris, or Candy Crush can help to reduce the strength of cravings. The reason this research may be relevant here is that NSSI is sometimes very much like an addiction. From what I have learned from people who self-harm, they are often fighting a losing battle with the growing thought of it. Even if they don’t want to do it, they can visualize themselves cutting, burning, or whatever method, and the more they try to push the thought away, the bigger and more vivid it gets. With these puzzle games, they basically override the portion of your brain responsible for temporarily storing visual information. It doesn’t mean that you won’t be able to visualize yourself going through with the self-injury, but now it will be competing for mental real estate with the puzzle you are working on. I’ll stress again that this is an extrapolation on the existing research and this particular method has not been supported yet, but it is essentially a zero risk strategy to try out for yourself. So, next time you find yourself starting to picture the process or the release of your self-injurious method, instead reach for your phone and play 10 minutes of a puzzle game. See if that brings down your urge enough to make a more healthy decision. I’m sure I don’t need to say it, but this is not a substitute for professional help. You still need to do that. This is just an in the moment coping strategy that you can try out.
Phew! We made it, guys. I know that was a tough chapter. It can be hard to hear these things. I’m proud of you for making it through. If this chapter really struck a nerve with you and you feel like there are some immediate steps that you need to take in order to invest in your own safety, please go do those right now. I will be here when you get back.
Ch. 5 On letting Go
One of the biggest roadblocks that has been shared with me by people actively contending with depression is the tendency to dwell on the shit that has already gone wrong. I totally get it. All of the strategies and tidbits of enlightened information are great, but what good are they if you don’t even have the mental real estate to put them into practice? You can’t begin your journey of a single step if you are too crushed by your feelings to get up off of the floor. All too often, guilt, frustration, and anger from the past keep you held back. Allow me to tell you the story of the annoying party guest.
So let’s say that you are having a party. Not a giant rager, but a sizeable get together with friends and family. Everyone arrives at your place, and you find yourself hopping around from group to group saying hello and joining in on the different conversations taking place. It’s a wonderful day and you are really enjoying yourself. That is until they show up. We all have one… the annoying co-worker or classmate that thinks they are your friend, but they most certainly are not. You didn’t invite them to this get together, but alas… here they are. Ugh! They are so annoying. What are they doing here? You don’t even like them! So you go over to them, try to politely express that you were not expecting them over, and drop some pretty non-subtle hints that they should probably leave.
Alright. Problem solved. You think you made yourself pretty clear and got rid of the unfortunate character. You go back to the party and get caught up in a new conversation about the latest blockbuster movies or something like that. Then, you hear it. That annoying-ass voice from the other room. They are STILL HERE. WTF?! You tell your friends that you will be right back and excuse yourself to the other room. This time you are a little more forceful and tell them flat out that they are not welcome in your home. You tell them that they need to leave. Good job! Peace is restored. A few minutes pass, and you think that your efforts were successful. Your moment of glory is fleeting, though. Before you know it, that persistent douchecanoe (technical term) is back again, trying to buddy up with the other guests. They are totally killing the vibe. This time you’ve had enough. You lose your filter of politeness and tell them to get the hell out of your house before there is serious trouble.
This relentless pattern is maddening and exhausting. You just want to enjoy your freaking party, but here you are managing this idiot’s behavior, and before you realize it… people start heading home. You just missed your own party, and that royally sucks. The worst part is that this isn’t the first time something like this has happened. Cue frustration, guilt, anger, and all of those other fun things. I’m sure you can see the parallels here between the party scenario and the battle going on with the thoughts in your own head. Whether it be a nagging self-doubt, a sense of guilt about something, lingering anger about some injustice, or an obsessive worry about something that hasn’t even happened yet, sometimes these thoughts seem to exhaust all of your mental horsepower. The more you fight back, the bigger they grow and the more disruptive they become, just like that annoying party guest.
Here’s another approach. Let’s go back to the party scenario. Imagine that when that obnoxious dummy came by in the first place, you didn’t fight back so hard. They may not be your friend, but they aren’t exactly your arch nemesis either. Sometimes, you can just let them be that annoying party guest. Sure, you still notice that they are there, but once you decide to let them do their own thing, it seems like they d
on’t quite have as much power over you. You aren’t constantly leaving your own fun moments to deal with them. It can even be amusing in a television sitcom sort of way. Oh, there’s the annoying party guest again! Look at them being lame and bugging the crap out of my uncle in the other room [Cue studio laugh track]. This does not mean that you’ve lost the battle. Let me say that again. This does not mean that you have lost the battle. It just means that you are not playing their game this time. You can have great conversations and thoroughly enjoy your party in the presence of this annoying party guest.