Normalizing Talking About Suicide

This is one in a series of short discussions of the myriad ways our society in general, and the mental health field in particular, fail to understand the veteran culture. That there is a such a thing as a “Veteran Culture” as something unique is itself a hotly contested when not summarily dismissed concept.

Writing about suicide on a public forum can be lethal to the careers of those in my profession. Unless all the same ideas and theories are supported and the appropriate platitudes are repeated, of course. Dare to say that conversations about suicide need to be normalized and you may as well start practicing for your next job by smiling into a mirror as you say, “Do you want fries with that?”.

If you have ever been to a VA hospital, any behavioral health facility, an emergency room, most private practice crisis centers, or even your GP, in other words, just about any mental or medical health care facility or provider, you’re well familiar with the National Institute of Mental Health’s (NIMH) ASQ, though probably not by that name. It is four simple questions, with a fifth follow-on, depending on your responses to the first four.

The direction to those asking the questions is to be matter of fact and ask the questions as written. What to do with the responses is delineated as well. I don’t follow any of that advice when working with a veteran or First Responder. In truth, I don’t follow that advice with pretty much anyone, at least not since I moved into private practice. Even back when I was required to read them verbatim, I was quite clear that I expected to be lied to, and their actual responses were the smallest part of the conversation. Even back then, when dealing with veterans or First Responders, since they often knew these questions and the NIMH advised course of action based on the answers, to say this was a pointless exercise is an epic understatement. Still, the four golden questions are:

• In the past few weeks, have you wished you were dead?
• In the past few weeks, have you felt that you or your family would be better off if you were dead?
• In the past week, have you been having thoughts about killing yourself?
• Have you ever tried to kill yourself?

An answer of “yes” to any of the above requires the follow-on of,

• Are you having thoughts of killing yourself right now?

An answer of “yes” to any of the questions is directed as a “positive screen” and particularly in the case of a hospital emergency room or VA appointment, the prescribed course of action states the patient/client cannot be allowed to leave until further evaluated for safety. Even if a patient/client does not say “yes” directly, a refusal to answer, or if in the clinical judgment of the provider the negative responses or denials are deemed not truthful, it is directed as a “positive screen”, followed by the same prescribed course of action.

More often than not, veterans I’ve had the pleasure of working with laughingly respond to question number one along the lines of, “Just in the past few weeks? Not particularly”, or “What would make the last few weeks different from the last few years (or decades)?”, or something equally sarcastic.

Question two generally gets a similarly caustically delivered response, to include the exact dollar amount their family will get. An opposing, but equally acerbic answer would be along the lines of, “the primary reason I’m alive today is I’m not going to let that (insert inappropriate word for a former spouse) get their hands on or control over that money.”

I have never asked the third question as written. Instead, I ask “when was the last time you thought of killing yourself”, not because I believe all veterans and First Responders are suicidal, but because this phrasing elicits a more honest and useful response. Particularly after I laugh – genuinely – at the creativity of the first two answers. To me, those are more ice-breakers than real questions.

Regardless of any previous answers, non-answers, and on one memorable occasion, name-calling, that fourth question is asked straight, as is. But it is not a stand-alone. I say, “Have you ever tried to kill yourself or cause yourself harm?”. Generally, by that point, we are having a conversation and there is sufficient rapport that I get an honest response. This is not because I am asking these questions, it is because of everything that came before.

I related my spiel before, but a quick recap is called for here. When I meet a client for the first time, I explain what they can expect from me, that I am straight-forward and direct, that I will challenge them, that therapy is hard work, but it is worth it because it works. I go over the limits of confidentiality and emphasize that talk of suicide or self-harm does not mean I’m immediately calling for the guys with white jackets; it means we’re going to have serious conversation. I stress there is a world, a literal life-and-death-world, between a thought and an action. All of this and more is laid out before I get anywhere near those NIMH ASQ-type questions.

This is the way I operate, which is admittedly outside the norm. But, I am relating my technique, if you want to call it that, because as a client, you can steer your therapy onto the same or a similar course. If you try and the therapist doesn’t instantly get on board, you may be better served with a different therapist. Suicide is serious, the most serious topic you can discuss in therapy, but that doesn’t mean it has to be intoned with the stoic reserve of a Puritan minister.

Thoughts of suicide are much more common than most people, therapists and clients alike, care to admit. There are exceptions, of course, particularly amongst those with a strong religious conviction against suicide. Most people have at one point or another in life faced the abyss. Ever dealt with life-altering, blinding, unrelenting pain, physical or emotional? Face the unendurable heartbreak of the death of a loved one? Financial ruin? Nearly every person on the planet has experienced one or more of the above, and had even just a fleeting thought of a permanent escape. The difference between that thought, even one that is not so fleeting, and the decision to act, then the following through with the act is the difference between honesty and self-delusion.

In this very limited sense, thoughts of suicide need to be normalized as merely thoughts. So they are talked about. Still, there is an inherent risk in those thoughts crossing over from this normalization into acceptance; that is the edge of a treacherous, steep slope. But, the alternative is not to talk about it, to keep the mere thought so stigmatized that the very real issues that could be drivers are minimized to the point of being dangerously ignored and unaddressed. That is the oil that makes the slope so slippery, that lets one careless step lead to the ultimate fall.

The real and telling questions are not then the NIMH ASQ’s. The real questions revolve around what is driving those thoughts? That life-and-death-world I refer to exists between the statements,  “I am tired and just can’t do this anymore”, whatever “this” is, or “I’m looking forward to dying someday, hopefully sooner rather than later but certainly before I end up in diapers and forget my own name”, or “I’m done, I don’t have anymore in me and there is no possibility, no hope of it ever getting better”. In the hands of a skilled clinician, particularly one with experience in the veteran or First Responder communities, a desire for a continuation of life can be cultivated in each of those statements.

Each of those are actual statements I’ve heard. None of them ended up with either a voluntary or involuntary commitment. None of them has ended in suicide either. In each case, my task was to understand and respect, and help the client find and understand that driver of desperation. Once recognized, that driver can be put in perspective, even if it takes a lot of metaphorical wrestling and screaming. At that point the client can begin to see, or at least accept for the moment the possibility that hope can exist. Even when they can’t see it. Even when they don’t believe it. Just for the moment. Then the next moment. Then the next, and the next, and the next.

Life is, after all, a series of moments. Many of them we’d rather forget, some we can’t remember, but they all have one thing in common. They happen, then they are in the past and a new moment follows. Then another and another and another. And we can choose, are we the drivers, or are those past moments.

The single biggest reason to normalize talking about suicide is the support and comfort those conversations can offer to those who are on the precipice of that steep, oiled, slippery slope. Letting those who need the words and experiences of others become the tether to the terra firma that exists just one step back may be the all the difference. Just one step back.

If you are struggling, reach out to a buddy or call 988 and press 1 if you want to identify as a veteran. If you are not struggling, reach out and be the buddy to someone else.

 

Category: Mental Health