Dogs that do not bark: ostracism, psychache and suicidality

The Way Out, or Suicidal Ideation: George Grie...

The Way Out, or Suicidal Ideation: George Grie, 2007. (Photo credit: Wikipedia)

1 boring old man referenced this historical and alarming analysis on the evolution of melancholia to major depressive disorder.  Science?  Evidence?  Fuggediboudit.

MDD, the most influential diagnosis of the past 30 years, emerged from intraprofessional pressures and the ability of research-oriented psychiatrists to gain dominance within the profession. Most importantly, psychiatry needed a credible classificatory scheme to maintain its legitimacy in both the broader medical profession and the culture at large. As prominent depression specialist Gerald Klerman (1984:539) succinctly summarized: “The decision of the APA first to develop DSM-III and then to promulgate its use represents a significant reaffirmation on the part of American psychiatry to its medical identity and to its commitment to scientific medicine.” Medical legitimacy required easily measurable and reliable diagnoses. The diagnostic criteria grounded in the Feighner measure that emerged in the DSM-III to resolve the many unsettled diagnostic controversies—and that have remained mostly unchanged until the present—did produce a far more reliable system of measurement than the amorphous criteria they replaced. Yet, this particular diagnostic system was not tested against the many alternative classifications that were available during the 1970s that might have been as good or even superior to the Feighner criteria. Instead, their adoption resulted from the shared commitment to a view of psychiatric diagnoses and the path that the psychiatric profession should follow among the research-oriented psychiatrists who controlled the development of the DSM-III classifications.

The developers of the MDD diagnosis did not foresee the profound consequences it would have. They inadvertently developed criteria that encompassed what had previously been viewed as a number of distinct types of depressive conditions. Endogenous, exogenous, and neurotic forms of depression could all meet the expansive criteria of the MDD diagnosis. Moreover, because it could incorporate short-lived responses to stressful conditions, MDD was the most suitable label for many of the heterogeneous and diffuse complaints that many primary medical care patients present. Likewise, depression became the most prevalent form of mental illness measured in epidemiological studies because so many community members suffer from common symptoms such as sadness, sleep and appetite difficulties, and fatigue that need only last for a two-week period to be considered disordered (Kessler et al. 2005). The sweeping qualities of the diagnosis also made it the most attractive target for the vastly popular SSRI medications that came on the market a few years after the publication of the DSM-III. Primarily through pharmaceutical advertisements, ubiquitous messages associated the most common forms of distress with major depression. This condition became psychiatry’s most marketable diagnosis, driving mental health treatment, research, and policy. Ultimately, the Age of Depression that has engulfed the United States and much of the Western world since 1980 resulted from relatively esoteric changes in diagnostic criteria.

It’s all about c.v. building by a chief resident of a backwater psychiatry program.

Then there’s this – relational ostracism – an unwanted enforced state of thwarted belonging.  It can take many forms, and its effects are severe, persistent and devastating.

The impact of stranger-ostracism is strong and painful,and has been shown to lead to aversive psychological responses (i.e., a threat to four primary human needs—belonging, control, self-esteem, and meaningful existence; see Williams, 2001), and a rangeof detrimental behavioral responses such as social susceptibility (e.g., Maner, et al., Carter-Sowell & Williams, 2007), inappropriate mate choice (e.g., Winten et al., 2006), risk-taking behavior (e.g. Daleet al., 2006), and anti-social behavior (e.g., Warburton, Williams, & Cairns, 2006).Despite the prevalence of ostracism in interpersonal relationships, ostracism research to date has not systematically investigated relational ostracism (i.e., the silent treatment, or ostracism carried out by one partner on another).

What’s missing in both of the above?  Their relationship to suicidality and psychache.

There is such a dearth of literature about ostracism – and virtually none about clinical intervention, treatment and support for people who are targets – that it isn’t surprising to find it absent.

But Kipling Williams, Thomas Joiner and C Fred Alford’s work can form a pillar by which to build a clinical and research model to aggressively address unbearable psychache, develop strategies (which may include public health and social justice policy and programming) to minimize and remove ostracism in all of its ugly forms, and to reformulate how suicidality is assessed and addressed.

The highest priority items for me would be to deep six “suicide assessment” in favor of distressors as described by Joiner’s three domains of perceived burdensomeness, thwarted belongingness and the capacity/rehearsal to tolerate self-inflicted death.

The second is to couple all assessment with immediate and adequate distress reduction which does not entail threats of or actual involuntary confinement, intrusive observation, forced medication, any type of restraint or anything other than active multi-sensory comfort, safety and mutually deemed appropriate and acceptable interventions, resources and supports.

One more thing that is never addressed in relation to psychache:  the extraordinary amount of physical and psychological energy toll it takes.  The relational ostracism study illustrates that for many, being a target is permanent as long as the “source” is present.

When one is powerless to escape ostracism, has no ability to affect a preferred future, and is effectively trapped, suicide becomes more salient as an alternative to put a permanent ending on an intolerable condition.

Here I discovered a study about people with severe/terminal illnesses who wish to hasten death – WTHD. Of course it doesn’t include people with psychiatric diagnoses (those people are nuts, donchaknow), but it fits right in with Joiner’s theory:

WTHD as a way of ending suffering

Among participants in the studies included, the WTHD also emerged as a way out, and in some cases [45][69] as the only way of ending their physical and psychological suffering. Death was not considered as an aim in itself, but rather as an escape. Indeed, the idea of putting an end to their life brought a sense of relief to some patients.

In the study by Schroepfer [71] the WTHD was regarded as a way out or as a means of relieving loneliness, fear, dependence, a lack of hope and the feeling that life was no longer enjoyable. The study by Nissim et al.[69] suggested that in the face of oppression and despair, death could be seen as the only alternative, with the WTHD being the essence of a plan to relieve suffering. Similarly, Lavery et al. [45] reported that the WTHD was seen by participants as a means of limiting disintegration and loss of self.

In five of the studies reviewed [14][46][69][70][71] the participants also described the WTHD as a way of reducing the suffering being caused to family and carers. Coyle and Sculco [14] interpret this as a gesture of altruism, since the WTHD is motivated by a desire to relieve the family of the burden of care and of witnessing their relative’s progressive deterioration. However, although the WTHD was driven by such a motive in some patients [71], in others (or simultaneously in the former patients) the desire to cause no more pain to their relatives led them to precisely the opposite conclusion, i.e. they repressed the WTHD. As such, their wish to protect their family took precedence over their own wish to hasten death [71].

And so we circle around to Alford’s “knowledge as disaster” concepts. See the About page for a listing.

Until the key elements of this circl(ing the drain) are interrupted permanently and predictably, suicidality will go on unabated, unaddressed and just as vicious.

The strangest part?  Psychiatry, with all of its disorders, doesn’t ever mention suicidality, psychache, thwarted belongingness, perceived burdensomeness and rehearsed capacity for self-inflicted death.

But suicide is on the Diagnosis and Statistical Manual of Mental Disorders (DSM5) radar – and of course, its proposed listing as suicide behavior disorder is nonsensical and is made up à la the Mad Hatter.

Chasing Tails

Thomas Joiner’s interpersonal theory of suicide is one I refer to often here.  However, even he doesn’t move upstream to look at distress causality.  Exhibit the last:

J Psychiatr Res. 2012 Apr 2. [Epub ahead of print]

Behaviorally-indexed distress tolerance and suicidality.

Source

Military Suicide Research Consortium, United States.

Abstract

Research indicates that distress tolerance exhibits a complicated relationship with risk factors for suicidal behavior. Specifically, low self-reported distress tolerance has been linked to perceived burdensomeness and thwarted belongingness. Contrastingly, high self-reported distress tolerance has been linked to the acquired capability for suicide. Given the frequently discrepant findings between self-report and behavioral indices of distress tolerance, we sought to expand upon prior findings by testing these relationships utilizing a behavioral measure of distress tolerance. Additionally, in an effort to further clarify the role of distress tolerance relative to painful and/or provocative experiences in the acquired capability, we examined whether distress tolerance serves as a moderator. Results revealed no significant associations between distress tolerance and burdensomeness or belongingness; however, distress tolerance was positively associated with the acquired capability. Furthermore, the interaction of distress tolerance and painful and/or provocative experiences significantly predicted the acquired capability, with the strength of the association increasing at higher levels of distress tolerance. Results highlight the potential importance of perceived versus actual ability to tolerate distress with respect to suicidal desire. In contrast, the results reflect the importance of actual persistence in the acquired capability.

Poor Put Upon Psychiatrists

Info from the English WP http://en.wikipedia.o...

Image via Wikipedia

MovieDoc is perturbed that patients who are contemplating suicide telephone.  Instead, he avers that they should be telephonally instructed to hang up and call another number.

Despite the ubiquitous “If this is an emergency, hang up and dial 911” message I wonder how many patients who are sufficiently ambivalent about ending their lives to call their psychiatrist would call 911 instead. There seems to be an expectation (standard of care?) that psychiatrists can somehow talk them out of it over the phone, or attempt to stop the patient by involving 911 or other resources. I find it ironic that many argue that video conference (eg, Skype) is inadequate for even routine psychiatric encounters and yet expect psychiatrists to, on the spur of the moment, handle a life or death situation over the phone. Why not send these calls to the people who handle them all the time, crisis lines, and stop trying to be the hero like one of those movie psychiatrists?

In Sybil Dr. Wilbur goes to her patient’s apartment to rescue her. How far should one go to stop the patient from killing herself? Why stop with a telephone call?

Should we pretend to do something we cannot do? Does providing access outside of an appointment encourage or reward dysfunctional and potentially dangerous behavior?

“If you’re suicidal, leave a message and you’ll get a free telephone session with your physician who wants to be your hero and rescue you and provide you with attention and make you cared for, warm and fuzzy.”

I don’t disagree that patients shouldn’t try to contact their psychiatrist, when they have one, but my disagreement is for different reasons. MovieDoc buys into many myths which have been exposed as such by Thomas Joiner. For example, the myth of impulsivity, selfishness and suicide notes are addressed:

To my knowledge, no study has reported a rate of note leaving among suicide decedents to exceed 50%. Moreover, most studies find rates between 0% and 40%4; a reasonable average rate would be approximately 25%.

 

Why are suicide notes so rare? Some have reasoned that because impulsivity is involved in suicidal behavior, suicidal persons often kill themselves before they have a chance to write a note. There are problems with this viewpoint, however. A major problem is that it draws on the distinct myth that dying on a whim is common. Another problem is the lack of empirical support that compares those who leave notes with those who do not. If it were true that note leavers are much less impulsive than those who do not leave notes, then this distinction should be easy to demonstrate in forensic studies that examine the lives, characteristics, and personalities of decedents. This difference has not been clearly demonstrated.

 

The relative rarity of suicide notes reveals the state of mind of those about to die by suicide. To say that persons who die by suicide are lonely at the time of their deaths is a massive understatement. Loneliness, combined with alienation, isolation, rejection, and ostracism, is a better approximation. Still, it does not fully capture the suicidal person’s state of mind. In fact, I believe it is impossible to articulate the phenomenon, because it is so beyond ordinary experience. Notes are rare because most decedents feel alienated to the point that communication through a note seems pointless or does not occur to them at all.

Suicide hotlines are staffed by people with all sorts of education, backgrounds and skill sets. There are no therapeutic standards of practice.  There is no accreditation, licensure or certification requirement for crisis hotlines or the people who staff them.  Caller beware.

As a caller, I’ve been treated to someone chewing his food and multiple hang ups (“I’m sorry I can’t help you. I have to go now.” Click. That was verbatim, and so must be in the script for getting rid of undesirable calls)

I refuse to ever have contact with any aspect of hospital based psychiatric services, as do I suspect a majority of people with past suicide attempts. The trauma and harm that caused is something I won’t expose myself to again.

But I would not contact a psychiatrist either since the power to force treatment is an ongoing threat. Suicidality is obviously not safe for me to discuss with anyone, and until euthanasia is “on the table” I can’t foresee trusting any provider enough to discuss core concerns. Moreover, I have no desire to distress someone else, provider or otherwise, with my concerns.

All this to get to the point that I hypothesize that there really isn’t a big patient population that would be likely to call their psychiatrist with lethal suicide intent.

Just as most people who commit suicide don’t leave notes, I doubt that they make impulsive “save me and be all warm and fuzzy about it” phone calls, either. I certainly learned that no one is interested, nor can help, via that route.

Indeed, I learned that there is no useful therapeutic treatment for suicidality. The current standard of incarceration (they call it containment), assaults and batteries (forced medication, restraints, isolation, refusal to allow patient chosen visitors to be present) and intrusive observation sans human interaction (unskilled people who do not speak to, touch or care for patients, but who literally remain in views at all times) is dehumanizing, demoralizing and confirms the extant hopelessness. It doesn’t ever address suicidality and its attendant concerns of thwarted belongingness and perceived burdensomeness.  It does nothing whatsoever to relieve the unbearable distress that predicates suicidality. It’s all about restraints, control and power.

Discontinuing mental health services and contacts was necessary to halt distressing assessments that were conflated with care and continuing trauma from a lack of effective care.  At least the iatrogenic harm stopped.

Like many others, I came out worse than before I received “treatment”.

So I find it ironic that the psychiatrist feels undue burdens in the theoretical situation of a patient contacting him or her with a perceived degree of unbearable distress.  Is it any wonder that the suicide rate is highest for psychiatrists?

When they remove the double speak and have that oh-so-critical insight into what will be done to them if they seek treatment for suicidality, psychiatrists, like most physicians, do not seek treatment and avoid seeking peer support or disclosing their “illness”.

The biggest walking, talking, suiciding ads for anti-psychiatry are distressed psychiatrists.

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.

Reading List

Cover of "Comfort Theory and Practice: A ...

Cover via Amazon

These are some of the books and published work which inform my thinking and reasoning.  Please add your own in the comments. I’ll make this into its own bib page when I figure out how:

C Fred Alford on whistle blowersWhistleblowers: Broken Lives and Organizational Power

David Jobes on collaborative assessment and management of suicidality – CAMS: Managing Suicidal Risk

Thomas Joiner on suicide: Myths About Suicide

Kathy Kolcaba on comfort:  Comfort Theory and Practice

K.Michel, D. Jobes, A.A. Leenaars, J.T. Maltsberger, P. Dey, L. Valach, R. Young Meeting the Suicidal Person

Understanding Aspects of Thwarted Belongingness – Humiliation

I think I’m going to use Thomas Joiner‘s work as a frame of reference for a while.  So back to the notion of thwarted belongingness.  What groups of people might that have applicability?

I think any stigmatized group might be affected.  In the US, that might be LGBT self identified people, whistleblowers, people who have visible disabilities, people who are bullied, and people who do not act in the proscribed ways of their communities. For example, religious denominations which practice shunning or repudiation.  Moreover, in the US immigrants are often targeted for humiliation and ill treatment.  Blacks and Latinos in the US, and people of minority races within their local communities are often segregated and excluded in significant ways.  Families can scapegoat vulnerable members and deny them belongingness.

There is an essay in Psychiatric Times by Jane B. Sofair about humiliation being a factor in suicidality.  That would be another example of intended exclusion with a result of thwarted belongingness. She lists signs of risk around humiliation, and they struck home:

TABLE: Near suicidal signs7,8

• Inability to form a working alliance
• Unwillingness to be known
• Intolerance of being understood
• Agitation
• Cogitation
• Detachment and despair
Social isolation
• Change in treatment compliance patterns
Suicidal ideation, plan, and intent with preparations
• Discrepancy between verbal self-report and actions
• Perceived environmental humiliation

Note that isolation is once again mentioned. It’s a recurrent theme, and it can be addressed in psychological treatment, but more important, as a public health issue and societal value, it can be addressed at all levels – individual resources, local, state and national policy and culture.

Thwarted belongingness can often not be self-managed. It requires external resources: people who voluntarily include and support the victim – mentors, coaches, champions and trustworthy, reliable and consistent people. Work regulations which do not allow for capricious harassment and at whim terminations, punishments and retaliation are key. Schools which assure that all students, teachers and staff are treated with respect, dignity and inclusion are vital. Communities which value all of their members with these same values are fundamental.

Does psychiatry have a role to play? I’m not sure. Certainly this is not a distressor which should result in medication, seizure induction or deep brain stimulation. And what else does psychiatry in its extant iteration offer?

Suicide

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Suicide remains an unmentionable in the US.  People who act upon suicidality are forcibly restrained, imprisoned (involuntarily confined), intensely and intrusively observed, and are subjected to treatment and conditions which make the already unbearable even moreso.

I aim to move upstream and address the conditions which lead toward unbearable distress, what Thomas Joiner has termed thwarted belongingness and perceived burdensomeness, and overwhelming despair.

I want to explore what people find helpful, how they are comforted and reassured, and what stops suicidality from developing to the point that the distress is incompatible with life – a phrase that is used in pathophysiology to describe a condition in which a living organism can no longer survive. I also want to go further and discover what prevents suicidality from occurring in the first place.

To that end, this blog is a safe venue in which to discuss the taboos, the precipitants, and all of the hidden and concealed facets around suicidality.  No one will track or monitor visitor identities.  There will not be online interventions responding to statements about intending to end one’s life. Your autonomy over your own life is respected.  To that end, comments that threaten harm as a manipulating device will not be published.

The overarching purpose is to address ways to relieve and to prevent feelings of intolerable distress.  People who would like to author around these topics are welcome and may drop me an email to discuss.