Tag: psychology

A Drunken Ramble about fear of suicide

by Midnight Demon, posted in mental disorders, mental illness, suicide, suicide attempt

Most people have fears of death, but for those that are suicidal, they tend to want death because they believe death is the only way out. I emphasize the word only because according to the father of suicidology, Edwin Shneidman, “it is a very dangerous word in the world of the suicidal mind”. These people generally will only think of fear due to what Marsha Linehan calls fear of suicide, which is the belief that failure, cowardice, or fear of death that prevents someone from committing suicide.

Aside from these reasons for attempters to try, there is the fear of loved ones and friends of losing someone by death that has not been talked about. Mental illness in some form will affect someone you know more than you think. Even the most upbeat person can suffer from depression but no on knows this because they keep it hidden.

Most people shy away from suicide talk. They don’t want to hear it or will make stupid comments such as “people who commit suicide are selfish”, that “it’s wrong to take one’s life because only God can do that”. Despite these statements, hundreds of people attempt suicide every day. Suicide is the 3rd top killer of Americans more than heart attacks and cancer combined. How can people take their life is a puzzling question. It’s very difficult to kill the human body due to the fight/flight response. I know because on many occasions where I tried, my fight/flight kicked in and I made a call for help, much to my chagrin.  Prevention starts with seeking help but very few people in desperation will call for help before an attempt. They may call for help after or if they survive and don’t want to go through the survivor bullshit (the stomach pumping, hospitalization, stitching of wounds, etc).
Even therapists are fearful of suicide attempters or of the suicide talk. Most clinicians will actually pawn the client off to another therapist “more qualified” or outright refuse to see them. I have had this happen to me ten times while trying to find another therapist within a five mile radius of my house. 10 therapists!!!! TEN professionals refused to treat me because of my history of suicide attempts and current suicidal thinking. I could understand that they did not want to take me on as a multi-risk client and would have liked them to make at least one session with me before I lived up to their presumptions of me. But instead they decided to chuck me off to another therapist who referred me to another therapist who, well you get the picture. So for my therapy at the present time, I have to have phone therapy with someone who is thirty miles away from me because I do not have a car. She took a chance on me and we have been together for eleven years now. She stuck through the depths of my suicidal plans for the past eight years, my nerve condition, and my overall mental illness, which can at times include psychosis and delusions. I don’t know why she puts up with me but she does. Same could be said of her because she is the only therapist I ever had that talks more than I do. I have called her on it so many times that I lost count. Nothing like the analytical consultant I saw. He was strictly Freudian.

A Positive Blog

by Midnight Demon, posted in cauda equina syndrome, CES, depression, medical, mental disorders, mental illness, mood disorders, suicide, suicide attempt

I don’t know what to call these blogs that are just my random thoughts and think ramblings is better than just “random thoughts”. I tend to go off topic, if there is one or when I don’t think there is one so ramblings is more on target than another random.  But if it was just random, I would just call it random, wouldn’t I? But as the title suggests, I am rambling now as I am writing this…

today I get an email from a friend asking me to be part of an editorial board in the organization I am a member of. I am STOKED. This is my first attempt at this blog being a positive note as today was an extremely siked day. Not only did this person ask me to write for this column, soon to be named, but being part of the editorial board on suicide attempters is important to me on so many levels. I struggle on a daily basis with my suicidality, I would have what Maris would call a “suicide career” so to do some thing positive with my negative energy is HUGE. I just hope I don’t let people down with this opportunity. I have never edited any one’s work, just my own but I think I have the knack for grammar and the like. I am not an English major, never was as it is kind of boring, but I have picked up a few things with a creative writing course I took in college. I don’t remember if I finished it or had to withdraw. My college transcripts tend to be filled with more W’s than grades because depression would hit mid-semester and I had to choice which class of the 2 I could pass with a fairly decent grade. I was working full time and going to school part time and it was a struggle for me with my illness. It really killed me when I had to pull the plug in 2008 because my psychosis got so bad and the meds weren’t working plus going into the hospital because I was so delusional was not fun. The meds always made it hard to think so I ended up having to take an incomplete which is now an F because I never went back to school. Some genius I turned out to be.

the second positive thing today was that my psychiatrist asked me to be part of her 1st yr med student course. She has asked me to sit with a group of 1st year medical students and have them ask me questions about my medical condition. I find it fun. The first year I did this I told them about the chronic pain I was having and I think I made an impact on them with my honesty about chronic pain and depression that follows. These are going to be the doctors of tomorrow so it is cool to be a part of this learning process.

Then the nerve condition I had made my day suck! I had a little incontinence of the bowels that made all these positives go away in a heart beat. I just wanted to die with the indignity of it all. How could so many things go right and then this happen? Because I cannot feel myself go to the bathroom because of nerve damage to my cauda equina nerves, that is why. I have what is known as Cauda Equina Syndrome (CES), post. It really sucks because all the nerves that control bowel function and bladder function are affected. It sucked today because for some reason I had the runs and that is always *fun*.  I am literally afraid to fart for fear of Sharting myself. SO now all I can think about is ways of killing myself but then I re-read the emails from my doc and my friend and it kind of helped because if I do kill myself, I can’t be part of the learning process. I can’t be a part of the editorial board for this organization that means so much to me. And I would have let my friends down with my death and I am sure as hell sure that my friend in SA would be lost without me and take his life because I am not around to stop him. I really love you my friend and I can’t bear the thought of you ending your life because I ended mine. So maybe today is a new day where I have suicidal feelings but thinking of the positive helps me to see the light at the end of the tunnel despite desperately wanting to throw in the towel.

is suicide caused by psychological pain

by Midnight Demon, posted in suicide attempt

Since 1949, Edwin Shneidman has done extensive research in the field of suicidology.  He began his research by looking at suicide notes in the coroner’s office in Los Angeles (Shneidman, 1996).  During his intensive research, he came up with the term, “psychache” to refer to the mental pain, which, when intense, makes life so horrible and horrendous, that the sufferer can only think about suicide as the only option out of his/her misery.

Psychache can be defined as “hurt, anguish, soreness, aching, psychological pain in the psyche, the mind (Shneidman, 1996).”  Risk factors associated with suicide are only relevant as far as they can relate to psychache (Shneidman, 1993, 2005).  Dr. Shneidman believes that the true cause of anyone’s thoughts of killing themselves derive from this “psychache.”

During my research for this paper, I concluded that literature concerning the cause for individuals to resort to suicide is sadly lacking.  Most of the assessment scales for determining suicide risk focus on basically, two concepts as proposed by Rosenberg  (1999), action based and affective based interventions. 

Action-based interventions can include items such as a “no suicide” contract, increase sessions or phone check-ins, and, if appropriate, hospitalization. 

Affective based interventions focus on feeling and thoughts that are behind the suicidal ideation. 

Attempts have been made by several researchers for implementing a framework for something close to a “standard” for treatment care that is not determined by litigation (Brown, Jones, Betts, & Wu, 2003; Joiner & Rudd, 2000; Joiner, Walker, Rudd, & Jobes, 1999; Kral & Sakinofsky, 1994; Rosenberg, 1999; Rudd, 1998; Rudd, Joiner, Jobes, & King, 1999; Sommers-Flanagan, Rothman, & Schenkler, 2000; Walker, Joiner, & Rudd, 2001).  Discussion of litigation is not the objective of this paper, so if the reader is interested, Brown et al (2003) would be the work to which one is referred.

The frameworks provided by these researchers have provided many useful scales in determining risk and lethality of suicide, but do not include the assessment of psychological pain.  In Range and Knott’s (1997) analysis of twenty assessment instruments, not one of the twenty examined includes an assessment of psychological pain.  One reason for this is the subjectivity on the individual’s emotions, thoughts, mental state, and experience (Kral & Sakinofsky, 1994).  According to Kral and Sakinofsky (1994), suicidologists are in general agreement that “predicting suicide for a given individual is that, like many human states, the suicidal state has a temporal, fluctuating dimension”.  They propose that the evaluation of psychache experience, the psychological state of the suicidal person, is the key to accurate risk assessment.

Psychache is subjective.  A person is not going to feel the exactly the same way for any length of time.  However, if the level of perturbation (mental anguish) increases in intensity for too long, the individual is going to feel a need to escape from the anguish and despair by any means necessary, including by not existing any more.  If suicide is seen as the only option, the only form of escape, lethality of a suicide attempt is high risk.  Kral and Sakinofsky (1994) have stated that treatment of perturbation will reduce lethality and treatment of lethality ideation will reduce perturbation as these two states can feed off one another (Kral & Sakinofsky, 1994). 

A scale to the assessment of suicide risk would be to have a scale of the person’s needs and current psychological pain.  Dr. Shneidman believes, as do I, that when psychache is intense, perturbation is intolerable, and one or more psychological needs are thwarted or blocked, suicide is seen as the only option of relieving the psychache (Shneidman, 1999).  He has based these needs on described by Henry Murray’s (1938) Explorations in Personality. Shneidman has developed 20 psychological needs.  These needs are weighted and the total sum is 100 (see table 1 for an example).

Table 1

 

Murray Need Form

­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________
Subject: ____________________Sex: _______Age: ______Rater:________Date:_______

­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________

_____   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.

100

(Shneidman, 1999; used with permission)
References:

 

Brown, G. S., Jones, E. R., Betts, E., & Wu, J. (2003). Improving suicide risk assessment in a managed care environment. Crisis, 24(2), 49-55.

Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Counseling and Clinical Psychology, 68(5), 909-916.

Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30(5), 447-453.

Kral, M. J., & Sakinofsky, I. (1994). Clinical model for suicide risk assessment. Death Studies, 18, 311-326.

Murray, H. A. (1938). Explorations in personality. New York: Oxford University Press.

Range, L. M., & Knott, E. C. (1997). Twenty suicide assessment instruments: Evaluation and recommendations. Death Studies, 21(1), 25-58.

Rosenberg, J. I. (1999). Suicide prevention: An integrated training model using affective and action-based interventions. Professional Psychology: Research and Practice, 30(1), 83-87.

Rudd, M. D. (1998). An integrative conceptual and organizational framework for treating suicidal behavior. Psychotherapy, 35(3), 346-360.

Rudd, M. D., Joiner, T. E., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30(5), 437-446.

Shneidman, E. (1996). The suicidal mind: Oxford University Press.

Shneidman, E. S. (1993). Commentary: Suicide as psychache. Journal of Nervous and Mental Disease, 181, 147-149.

Shneidman, E. S. (1996). Suicide as psychache.New York and London: New York University Press.

Shneidman, E. S. (1999). The psychological pain assessment scale. Suicide and Life-Threatening Behavior, 29(4), 287-294.

Shneidman, E. S. (2005). How I read. Suicide and Life-Threatening Behavior, 35(2), 117-120.

Sommers-Flanagan, J., Rothman, M., & Schenkler, R. (2000). Training psychologists to become competent suicide assessment interviewers: Commentary on Rosenberg’s(1999) suicide prevention. Professional Psychology: Research and Practice, 31(1), 99-100.

Walker, R. L., Joiner, T. E., & Rudd, M. D. (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-Threatening Behavior, 31(2), 144-152.

Copyright 2013, Collerone, G

suicide paper, V1

by Midnight Demon, posted in suicide attempt

“You will not fail to see that I am suffering under a depression of spirits which will [not fail to] ruin me should it be long continued” -Edgar Allan Poe {{Jamison, 1993 #18}.    

Depression, left untreated, eventually leads to suicide.  In the United States, suicide is the 11th leading cause of death, accounting for approximately 30,000 deaths with an age adjusted rate of 10.7 per 100,000 persons (Gaynes et al., 2004).  Most clinicians have seen suicidal patients throughout their careers.  Researchers have reported that professional psychologists has a 1:5 or 1:7 chance of losing a client to suicide; for psychologist trainees, a 1:6 ratio has been reported.  To date, there is no known formalized training program for beginning or experienced clinicians designed to teach suicide assessment skills, nor is there a recognized model for treating suicidal thoughts and feelings in a systematic way (Rosenberg, 1999).  Furthermore, the current literature fails to accurately define what it meant by “suicide ideation” or “suicide attempt”.  O’Carroll et al describes in their research how one clinician can say to the other that they have hospitalized a client due to suicide attempt.  The other clinician often wonders what that means.  Does that mean the client actively attempted deliberate self-harm warranting medical attention, attempted self-harm but did not warrant medical attention, or ideated a plan for an attempt and was intent on acting on that plan.  Eg pg 238 on senate asking the question and responding.  Reasons for intent, how many came to the hospital how many didn’t, how many died.  Basic terms are not uniform among clinicians (O’Carroll et al., 1996). 

David Rudd has provided a conceptual framework based on clinical summaries and assessment tasks consistent with existing standards of care but not dependent on psychotherapeutic orientation.  This framework is divided into three categories: practical skills, self-image, and interpersonal relationship (Rudd, 1998). 

One of the essential goals to achieve treatment success is to emphasize psychodynamic approaches to developmental issues and the therapeutic relationship.  A strong therapeutic alliance is essential to positive outcome treatment with a depressed client (Klein et al., 2003).

Several studies have noted a difference between single and multiple attempters (Joiner & Rudd, 2000; Joiner, Walker, Rudd, & Jobes, 1999; Rudd, Joiner, Jobes, & King, 1999; Walker, Joiner, & Rudd, 2001).  It has been postulated that previous suicide attempts sensitize one to subsequent suicide-related thoughts and behaviors.  These individuals with a history of multiple attempts display behavioral and cognitive styles distinct from those of non-multiple attempters. There is also evidence that crisis intensity is related to negative life events for non-multiple attempters but not for multiple attempters (Walker et al., 2001). These same authors have stated that clients fall into three types of groups when assessing suicidality: suicide ideators, single attempters, and multiple attempters (Joiner et al., 1999).

The difference between them is the elevated risk in multiple attempters because of type, chronicity, and severity of psychopathology.  The authors also go on to define seven domains of factors in assessing suicide risk.  These are:

1. Previous suicidal behavior

2. Nature of current suicidal symptoms

3. Precipitant stressors

4. General symptomatic presentation, including hopelessness

5. Impulsivity and self-control

6. Other dispositions (e.g. history of abuse, environmental factors, substance abuse, etc)

7. Protective factors (e.g. suicidal writing, social support)

A history of previous suicidal behavior is an important domain for risk assessment.

In addition to these domains, the authors have narrowed down two main factors to summarize suicidal symptomatology risk: “resolved plans and preparation” and “suicidal desire and ideation”.

     Resolved plans and preparation is defined as the following symptoms: a sense of courage to make and attempt, a sense of competence to make an attempt, availability of means to and opportunity for attempt, specificity of plan for attempt, preparations for attempt (seeking gun, pills, etc), duration of suicidal ideation, and intensity of suicidal ideation.  Their view is that if the client shows such symptoms, they are in pernicious, moderate risk.

     The suicidal desire and ideation factor defines the following symptoms: reasons for living, wish to die, frequency of ideation, wish not to live, passive attempt, desire for attempt, expectancy of attempt, lack of deterrents to attempt, and talk of death and/or suicide.  These symptoms are clinically noteworthy but are considered minimal risk, unless the client has had previous suicidal attempts (Joiner et al., 1999).

References:

Gaynes, N. B., West, S. L., Ford, C. A., Frame, P. S., Klein, J., & Lohr, K. (2004). Screening for suicide risk in adults: A summary of the evidence for the United States preventative services task force. Annuals of Internal Medicine, 140(10), 822-835.

Jamison, K. R. (1993). Touched with fire.New York: Free Press Paperbacks. p.18

Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Counseling and Clinical Psychology, 68(5), 909-916.

Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30(5), 447-453.

Klein, D. N., Santiago, N., Vivian, D., Schwartz, J. E., Vosisano, C., Blalock, J., et al. (2003). Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics. Journal of Counseling and Clinical Psychology, 71, 997-1006.

O’Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the tower of babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26(3), 237-252.

Rosenberg, J. I. (1999). Suicide prevention: An integrated training model using affective and action-based interventions. Professional Psychology: Research and Practice, 30(1), 83-87.

Rudd, M. D. (1998). An integrative conceptual and organizational framework for treating suicidal behavior. Psychotherapy, 35(3), 346-360.

Rudd, M. D., Joiner, T. E., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30(5), 437-446.

Walker, R. L., Joiner, T. E., & Rudd, M. D. (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-Threatening Behavior, 31(2), 144-152.