Fuggeddiboudit

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Previously I noted that disparate studies suggest that incessantly assessing suicide risk without providing distressor relief may actually kindle – make worse – suicidality.  Over the recent past this has been my experience. The chief source of “treatment” such as it is, is by serving as a lab rat in studies.  I have been subjected to incredibly intrusive and distressing assessments on a very frequent basis.  I haven’t responded to any of the treatments and have instead had side effects including a liver injury from one – where the CRO (for profit contracted research organization) and IRB disappeared into the ether and left me to my own devices.

Last week I served as a subject that I thought wouldn’t involve distress or harm because I needed $$ to pay for treatment I received as a result of the liver injury.  Well, the assessment was awful to the extent that I called a crisis hotline – was treated to a rude and dismissive response and then the crisis provoker hung up on me. “Just read a book,” she commanded.  And,
“I’ve never been suicidal,” she crowed.

I lost time after that – a few days at least.  Apparently I threw the phone away, which makes sense.  No one calls me, and it isn’t needed since no one responds to calls for help, either.  One cost reduced.

I’m withdrawing from the other studies.  I can’t tolerate the distress.

I used to blog to try to stay current in health policy and clinical practice, but I’m too far gone to do that or to care.

So I’m signing off at this juncture with a link to what looked to be a thoughtful and fairly comprehensive report about the state of suicidality “treatment” in the US with some Western countries’ best practices thrown in.

And a plea to offer a humane death for those of us ostracized by you.  There’s a difference in wanting to hurt oneself and desiring a peaceful death. I failed at finding a means to the latter, and am forced to resort to the former.  That is cruel and unusual punishment for being deemed a worthless freak.

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Predictions

Honestly.  In the conflation department, I keep reading comments about how much a need there is to have a reliable tool to predict suicides.  Well, that ain’t happenin’ until there is effective, available and safe treatment which reduces distressors.  Otherwise, all of the rewards and incentives are lined up squarely against anyone admitting suicidality, let alone seeking incarceration quaintly and deceptively referred to as containment and hospitalization, applied emotional trauma, humiliation and intrusiveness which is all the “standard of care” does in the US, at least, when someone admits to suicidality.

I have been explicitly instructed by three psychiatrists on how to dodge a suicidality assessment in order for us to play charades:  me, so that I escape imprisonment and them to escape legal risk and actually intervening to alleviate my distress.  So why in the world would I seek out any “help” at all when it is clear that there is none to be had?  Sheer lunacy, (irony alert).

And so, the world goes on without me. Silence punctuated by external noise. Unending hell. No reason to get up, go anywhere, do anything. There is no intervention for ostracism.  Untouchable, literally untouchable. Enduring social death until physical death.  Hurry up, already.

For those who have friends and family, a recent large scale study examined some of the factors involved in them not intervening or providing help when people close to them are suicidal:

As the suicidal process unfolds, significant others are required to make a series of complex decisions about what is happening and what, if anything, they should do about it. They must collect and weigh evidence from a range of sources, correctly decipher and assess the significance of both signs and countersigns, identify the appropriate actions to take, and then summon the courage to take them. Risks are involved at every stage; cherished relationships are at stake. Significant others must weigh the danger of doing nothing against the perceived dangers of saying or doing “the wrong thing.”

Experts agree that a clear and unambiguous warning message is a prerequisite for effective disaster planning and crisis management.29 Our data suggest that, in a suicidal crisis, members of the family and social network may not always receive a clear and unambiguous warning message. This may be because the person fails to give out a clear enough distress signal or because distress signals are given but significant others cannot decode them correctly at the time  Equally, they may not be able to bring themselves to accept that anything is seriously wrong or that suicide is a possibility. Writing in another context, about clinical identification of child abuse, one author comments: “[It] is a difficult intellectual and emotional exercise. . . The biggest barrier to diagnosis is the existence of emotional blocks in the minds of professionals.”30 The emotional blocks that can operate in clinical practice are magnified many times in close personal relationships, where every word or action may be emotionally charged and gauging the right response is critical. Our findings suggest that those very relationships, generally believed to be a protective factor for suicide,31 32 may sometimes heighten risk by acting as barriers to both awareness and intervention.

….critical errors in judgment often result from the so-called “normalcy bias,” defined as the tendency of people who have never experienced a catastrophe to disregard ominous signs and behave as if nothing is wrong. The strong desire for everything to be normal inclines people to believe that it is, even in the face of evidence to the contrary.33 Our findings suggest that this same principle may operate at the private level, particularly in the context of family life. The cycles of avoidance model, proposed by Biddle et al to account for non-help seeking for mental distress, provides an alternative framework that also fits our data well.   Our data show that lay people may go to considerable lengths to avoid pathologising the distress of those close to them; their thresholds are repeatedly pushed back by powerful emotions, especially fear of the consequences (for themselves, as well as for the distressed person) of acknowledgment and intervention.

Confound Conflation!

In dipping into the literature on suicide and suicidality, two conflations appear over and over again.

  1. Assessment equals treatment
  2. Distress equals depression (alternatively that the treatment for symptoms of depression will alleviate suicidality)

As far as I can ascertain through my jaunts through the journals, there is no standard of care and treatment for suicidality.  The treatment as usual for imminent suicide is to remove the stated means from the person, to keep them in visual contact until they are deemed not at risk to take suicidal action, and to incarcerate them – in a hospital room, jail cell or home until an external authority figure decides to release them from confinement, voluntary or otherwise.

Today’s latest suicide research press release contains the same errors of conflation:

“We know that asking teens about suicidal ideation does not worsen their problems,” said Dr. McCarty. “It’s absolutely crucial for a teen who is having thoughts of self-harm or significant depression to be able to tell a helpful, trustworthy adult.”

 

“These findings underscore the need for clinicians to be aware of the potential for suicide in adolescence,” added Dr. McCarty. “Primary care physicians and healthcare providers should be specifically assessing suicidal ideation in the context of depression screening for teenagers. Effective screening tools are available, as are effective treatments for depression.”

 

It seems to me that this will result in not much.  Instead, why not invite adolescents to share their thoughts and concerns about belongingness, self worth, and their views of their developing futures?  Joiner’s work – the interpersonal theory of suicide – is largely based on work done with adolescents and young adults.  The two greatest risk factors expressed by people who attempted suicide are the percpetions of thwarted belongingness and perceived burdensomness.

If distress is assessed in those domains, it can lead directly to interventions that can help alleviate acute short term distress and to build social skills for navigating the complicated and complex path to successful adulthood.  Instead of simply affixing a stigmatizing and problematic label of self harm, suicidal, clinical depression, etc. to a troubled youth, why not instead, guide, counsel and eventually partner with that person-in-progress to explore, discover and build character strengths, behavior strategies and social skills development?

Who should be assessing and intervening?  Parents, teachers, coaches, counselors, spiritual leaders/advisors, physicians, nurses – all of the usual cast of adult characters in adolescents’ lives.  Just because teens are trying on independence for size and fit and so most likely won’t initiate these discussions doesn’t mean that they should be held.  And it certainly doesn’t mean that they aren’t important.

I suspect that it would uncover a lot of perceptions of social exclusion, of externally imposed loneliness (cliques and bullies, exclusive teams, clubs and competitive organizations’ closed memberships) and of feeling of failure, inadequacy and uncertainty.  The adults can help youth to identify where actual and potential social connections lie and coach strategies to achieve them. They can monitor and intervene in the situations where youth are at risk (bullying, discrimination, sexual/gender identity, learning problems, disabilities, violence), and they can be stable and predictable lifelines in a world that is neither.

A long time ago a very wise animal trainer explained to me that if “you want the puppy to come to you, quit hitting it on the nose when it does.”  We need to find ways which encourage, entice and reward people for sharing distressors and for engaging in the very hard work it takes – often a lifetime’s worth – to alleviate distress to tolerable levels and find at least minimal satisfaction in belonging and contributing.  The last thing that adolescents need is to have their distress offloaded onto mental health providers who will only intrusively assess and confine them (talk about ostracism!) while not addressing the underlying distress and distressors and who really aren’t the right folks to treat problems of living.