Tag Archives: edwin shneidman

My Thoughts on Zero Suicide as a Person with Lived Experience

My thoughts about Zero Suicide as a person with Lived Experience

There has been a lot of talk on Twitter about Zero Suicide and it’s mission to reduce the suicide rate to zero, because 1 is just too many. At first, I was appalled that clinicians think that is possible. I for one think that it is outrageous because there is always going to be someone who dies by suicide. Maybe not in their organization but outside their organization. But then I learned that it’s not an individual’s practice but an organization or health system that strives to achieve this goal. They have trainings and meeting with those in the suicidology world.

Something kept bugging me about this. I kept quiet because I didn’t want to anger those that are for it, though I think there are a few blogs that I wrote about it before I understood the mission. While talking to a friend that is a suicide loss survivor, the bells went off. She said that it goes against Shneidman’s questions, where do you hurt and how can I help?

I am a big supporter of Dr. David Jobes work with his framework called CAMS (Collaborating, Assessment, and Management of Suicidality). I don’t know if Dr. Jobes trains these Zero Suicide clinicians. And even if they are trained, I am not sure it will be used. Most clinicians have the attitude that their skills on suicide risk are good enough when it could be faulty. Worse, they go through the training yet don’t use what they are taught. That drives me up the wall. Why bother going to a training (unless it’s a mandatory thing) if you aren’t going to take away from it?

I really think CAMS is a tried and true framework to prevent suicide based on my experience of using it in my former therapy. I also used the Suicide Status Form. Unfortunately, my therapist did not want training in CAMS and we drifted apart, thus ending our relationship. We did, while we worked together, use the initial and tracking forms but unfortunately, we never got to the outcome form. She wasn’t committed enough to see it through and that kind of pissed me off. Every time I had a suicidal episode, she just wanted to know one question on the form, The one thing that would help me no longer feel suicidal. It is an open ended statement where the client fills in their thoughts on the matter. Unfortunately, I could never come up with a satisfactory answer as I really didn’t know the reason for my suicidality. I just wanted to die and that was that. I wrote a blog about CAMS if you would like more information about how it is formed and the use of the Suicide Status Form.

I went on the website for Zero Suicide but could not seem to find the specific training that they went through. From what I gathered on Twitter from their live tweets, some of it is CAMS and some of it is using risk factors for suicide. Unfortunately, risk factors alone are not predictive of a suicide attempt. CBT has been useful in reducing suicide attempts but not all clinicians are trained in this modality. The book by Craig Bryan on CBT for preventing suicide attempts is a good book to learn more about it. I also wrote a review on the book that you can see here.
The other thing that gets me is that no where among Zero Suicide is there talk of a person’s psychological pain. There are measures, if you look for it. Dr. Holden at Queen University in Canada has created a scale to measure what Dr. Shneidman calls psychache. See my review on the research article for more information. I think it is a good psychometric to gauge a person’s level of suicidality and pain, which ultimately leads to thoughts of suicide. This must be included in any talk of preventing or intervention of suicide and also postvention, should a suicide attempt occur.

My final thoughts of Zero Suicide is that it is a novel idea but as Dr. Shneidman says, “How many suicides do you want, and I say I don’t want any, but I want there to be the freedom to do it. I study suicide but I am not pro-suicide. I’m for suicide prevention.” I share his sentiments. I do not like the talk of “suicide is not an option”. To me, that is hindering free will. I do hope the rate of suicides goes down, but the way that health care and mental health are going, I think there will be more before it lowers, especially among the chronic pain patient population.

Shneidman’s greatest questions: Where do you hurt and How can I help?

Shneidman’s greatest questions: Where do you hurt and How can I help?

After I had a meltdown in late 2005 and was slowly recovering in 2006, I was taking a psychometrics class at college to earn my psychology degree. Psychometrics is a fancy name for psychological testing and validating tests and assessments on various things. As I was recovering from a deep suicidal depression, I was curious to see if there were any measures on psychological pain in suicide. I wrote my first draft of the term paper with 20 some odd articles all doing various risk assessments and testing of suicide ideation but none of them dealt with psychological pain, which was what I was aiming for.

The professor tore my first draft apart and even, however vaguely, accused me of plagiarism. I wanted to get a good grade in this class because it would help my further advancement in psychology. I went back to the drawing board. I searched for pain and psychological pain in the library databank. About only 5 articles showed up, at the time. I am sure I was doing it wrong. I looked up the articles and found Shneidman and Holden. Dr. Holden was based out of Queen’s University in Canada. He came up with a psychache assessment that I found useful in my therapy. I kept that article and shared it with my therapist. Then I queried everything on Shneidman and hit the jackpot. His work was in psychache, psychological pain. I read everything I could on him and his followers. I saw my idol David Jobes’s early work on the Suicide Status Form. It wasn’t appealing to me at that time. I was more interested in the psychache of the matter.

I read Dr. Shneidman’s book, The Suicidal Mind. Holy crap! This was about “me”. I knew I had to read everything this guy wrote but it measured in the hundreds so I focused on what was available now. I tried to read his books that were solely written by him but they were few and outdated. He wrote many chapters. The two questions that I kept coming across were “where do you hurt” and “How can I help?” No one had ever asked me those questions all my years in therapy. Not even my current therapist at the time asked until I brought it up to her.

These questions were the basis of how he helped suicidal people over his career. He brought them other options for suicide by learning things about their predicament. Then he ranked them in order of importance. As he slowly worked with them, suicide became less of an option on the list, which was good. It didn’t mean their risk of attempting was any lower but they could see that it wasn’t something that had to do right then and there as there were other options. That is what suicide prevention is, finding other solutions to the problems someone is facing other than suicide. Sometimes it works, sometimes it doesn’t. There was a case in which Shneidman talked to a Hispanic male who attempted suicide by gun shot. He blew off half his face and needed multiple surgeries and was in intense pain from his injuries. Dr. Shneidman counseled this man until he was well enough to leave the hospital. They kept in touch but as time went on, the contact got fewer and fewer. The young man died by suicide by that method a few years later. It was a sad case. The importance of the story is that contact is useful even after the initial attempt has passed, be it with postcard or phone calls or text messages. This isn’t an entire protective factor but it can be. Some people who think of suicide and even go to plan it, get through their circumstances never to think about it again. Others make an attempt and it is a kind of “wake up” call and they never think about doing something like that again. Then you have the people that are chronically suicidal, who make multiple attempts. These are the people most at risk of ending their lives by their own hand. It is these people that need the most help and patience. This is where the framework CAMS (Collaborating, Assessment, and Managing Suicidality) comes in handy. Check out their website https://cams-care.com/?pgnc=1

never ending. It just goes on and on

Never ending. It just goes on and on

I’m trying to settle down for sleep but a new pain keeps popping up when I lie down, when I sit up, when I take my meds, when I move it, etc. It is fucking never ending. I am not doing a damn thing tomorrow, least that is the plan for now.

I sent an email to my psychiatrist asking her if I was a difficult patient. I briefly discussed my therapy session with my therapist and that the therapy group down the hall from him contacted me. Unfortunately, it got filtered to my junk mail so I didn’t get it until I got home. My phone doesn’t get junk mail for they could be viruses embedded in what they send. Last thing I need is a virus on my phone.

I just sent an email to my neurologist asking her if she could help me out by confirming that I do indeed have CRPS as my PCP just wants to pass me off to another doctor. I am tired of seeing new doctors who aren’t helpful and then just want to pass me off or not treat/see me anymore. I see my neuro in two weeks. It was kind of a long email but I don’t care. My stupid phone kept on inserting different words as I typed, which annoyed the crap out of me. I should have just typed it on my laptop so I wouldn’t get aggravated. Lesson learned.

My foot feels like it is being strangled. There is such a pressure on it like it’s going to burst. I am so tired that I am reaching the over tired stage, which is dangerous because I could catch my second wind and then be up all night. I took an Ativan because along with the strangulation, my ankle is pulsating. The little muscles are twitching. This condition is so frustrating because there is never ending different kinds of pain. I wish I could see a doctor at this hour so they can see or I can try to explain to them what living with this condition is like. All I can do is send them an email and then not get a response. But at least by writing it out, it helps me because at least I have documentation that I wrote this to a doctor.

I still am shocked that in the great medical hub of Boston, I have not found a doctor that is willing to help me. Sure, my PCP gives me pain meds to alleviate my pain. I appreciate that. But he doesn’t want to stop there. Right now my diagnosis is in the air and it is making everything seem like we haven’t tried enough. I am tired of this merry go round. I want off. I asked my neuro if she could possible give me a concrete diagnosis and staple it on my PCP’s head. Well, I didn’t say that. But if she could send a note to him saying I have this dreaded condition, then maybe I don’t have to see yet another new doc. There is no treatment for this condition. I know this. My PCP knows this, my neuro knows this. But opioids help me and if I don’t have them, I am good as dead. I have exhausted physical therapy. I have tried injections. I have tried rest. This is no longer a case of tendonitis. It is deeper than that.

The pain is changing all the fucking time, all over my ankle, foot, toes, bones. It hurts every where. Normally, at this hour, I would be writing a morbid story about ending my life. That is what this blog was about. My suicidal thoughts in the cybersphere. But then one day someone took it too far and called the cops on me so I no longer talk about those things, even though it relieves the tendencies to act. Thoughts are NOT the same as feelings. And feelings does not mean act upon them. It is okay to feel. It is ok to think. Here is a quote from the father of suicidology, Edwin Shneidman that I had the pleasure of talking to him before he died.

“Never kill yourself while you are suicidal. You can, if you must, think about suicide as much as your wishes and let the thoughts of suicide –the possibility that you could do it- carry you through the dark night. Night after night. Day after day, until the thoughts of self-destruction runs its course and a fresh view of your own frustrated needs comes into clearer form in your mind and you can, at last, pursue the realistic aspects, however dire, of your natural life”. –Edwin Shneidman, Suicidal Mind, p166

I write these blogs because I still am struggling night after night, day after day. Pain increases my vulnerability to think of self-destruction. I have the means though no one talks about restricting them. I told my psychiatrist I have something that will end my life but still, she doesn’t ask about it when I see her. She never does. Poor assessment of risks. So does my therapist who knows damn well that I have chronic suicidal thoughts. It makes me angry that I am not treated the way I was with my former therapist, Bozo. She was annoying, I will give her that, but she fucking cared and if I had a method she damn well tried to take it away from me the best she could. I really miss her. Yesterday was her birthday. I wonder if I will be alive to see mine. I really am surprised that you CAN get anything off of Amazon. While I was searching for my method, they had machetes. Machetes!! I don’t think I would have the will power to use it to chop my ankle off but I know a chainsaw would do the job. I refuse to search for it because I know in my darkest of moments, I may just buy it. I’ll go all Scarface on my ankle and groin to sever my artery.

I am once again plagued by dark thoughts. All because I can’t sleep and I am in pain that is never ending. It just goes on and on.

Shneidman’s Psychache Theory

“From the view of psychological factors in suicide, the key element in every case is psychological pain; psychache. All affective states (such as rage, hostility, depression, shame, guilt, affectiveness, hopelessness, etc.) are relevant to suicide only as they relate to unbearable psychological pain. If, for example, feeling guilty or depressed or having a bad conscience or an overwhelming unconscious rage makes one suicidal, it does so because it is painful. No psychache, no suicide”. Edwin Shneidman, Suicide as Psychache p56

 

Psychache is the unbearable guilt, despair, hopelessness, shame, pain, depression, and press one feels when thinking about suicide. It is the corner stone of what this paper is about. The pain of the mind can cause constriction, a narrowing of view of things. It can also lead to perturbation (an unrest that causes one to feel like doing something to alleviate the uneasiness one feels) and also to press, which is also known as stress or the pressure and weight one feels under. The combination of these three things, press, perturbation, and psychache is what is known as the cubic model of suicide.

The cubic model of suicide is a 1-5 rating of the three things I just mentioned. The higher the rating, the higher the likelihood of suicide. The worst rating is a 5-5-5 scenario and suicide will be imminent. It is important to rate these items when dealing with a suicidal person. It will validate what they are feeling and make them feel at ease in talking about what is causing them to feel so pressured and hurt to make them think of killing themselves.

When dealing with constriction, the dichotomous thinking that a) suicide is the only way out or b) things are always going to stay the same, it is important to always bring in more options to the person so they can see things differently. In his book Suicide as Psychache, Shneidman gives the example of a young pregnant woman who was thinking of killing herself with a handgun. She couldn’t have the baby so therefore in her mind, suicide was the only way out. After discussing several options with her (calling her parents, having the baby and giving it up for adoption, discussing the situation with the baby’s father, etc.), it was agreed that the woman would call the baby’s father. Suicide was no longer the number one item on the list. To prevent a mishap, Shneidman did take the gun away from the woman. An excellent example about means restriction.

In almost every suicidal thinking, there is some measure of lethality and perturbation. You can have high lethality and high perturbation, but you don’t always have high perturbation with high lethality. Perturbation, as described above, is very much like anxiety. It is a perturbed feeling that causes one to feel pressured to do something. Lethality is the doing something.

Also in every case of suicidal thinking is the frustrated needs that bring about the suicidal feelings.

ABATEMENT The need to submit passively; to belittle oneself

ACHIEVEMENT To accomplish something difficult; to overcome

AFFILIATION To adhere to a friend or group; to affiliate

AGGRESSION To overcome opposition forcefully; fight, attack

AUTONOMY To be independent and free; to shake off restraint

COUNTERACTION To make up for loss by retrieving; get even

DEFENDANCE To vindicate the self against criticism or blame

DEFERENCE To admire and support, praise emulate a superior

DOMINANCE To control, influence, and direct others; dominate

EXHIBITION To excite, fascinate, amuse, entertain others

HARMAVOIDANCE To avoid pain, injury, illness, and death

INVIOLACY To protect the self and one’s psychological space

NURTURANCE To feed, help console, protect, nurture another

ORDER To achieve organization and order among things and ideas

PLAY To act for fun; to seek pleasure for its own sake

REJECTION To exclude, banish, jilt, or expel another person

SENTIENCE To seek sensuous, creature-comfort experience

SHAME-AVOIDANCE To avoid humiliation and embarrassment

SUCCORANCE To have one’s needs gratified; to be loved

UNDERSTANDING To know answers; to know the hows and whys

These twenty needs are what Shneidman has called the essential ones when people are suicidal. Most of them are not all twenty but five or six as it pertains to the individual. “The prevention of suicide with a highly lethal person is then primarily a matter of addressing and partially alleviating those frustrated psychological needs that are driving that person to suicide. The rule is simple. Mollify the psychache”. (p53) Shneidman believed that these frustrated needs are what caused psychache.

I believe there should be another need, validation. Everyone needs to be validated in order to feel secure and feel okay. Without this, most people feel shamed and dumb, that what they are feeling or experiencing has no meaning or purpose. They may also feel empty and alone as no one understands what they are going through. This need when frustrated or thwarted can lead to suicide.

Shneidman, Edwin. Suicide as Psychache. 1993. Jason Aronson, Inc.

Quote of the Day 7 Nov 2015

Suicide is not only a reaction to unmet needs, but also the need for important psychological freedoms, such as freedom from pain, freedom from guilt, freedom from shame, freedom from rejection,  and aloneness. When these freedoms are traumatically violated, an individual who realistically lacks “a court of appeal” may take matters into his own hands and remove his consciousness from the painful scene. Edwin Shneidman, Suicide as Psychache