Tag: psychotherapist

Building a Therapeutic Alliance

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

Building a Therapeutic Alliance with the Suicidal Patient. Eds: Konrad Michel and David Jobes

This book is a work of genius among the top suicidologists in the U.S. and Europe. The editors actually want to help suicidal people get better and try to make their life worth living. Like most of Drs. David Jobes and Konrad Michal work, they have done an excellent review of the literature and made the book easy to read without a lot of psychological jargon.  This book should be used as a handbook for anyone dealing with suicidal individuals.  As someone who has been through many suicidal episodes with many different therapists, this book is groundbreaking.  It lists his classic work of CAMS (collaborating and managing suicidality) which is a tried and true way of dealing with lethal suicidality in an outpatient setting. The other evidence based therapists will enhance therapy around this work.

The Chapters are broken down easy enough and progress from good to bad in my opinion, of the treatments that work.  The conclusion was brilliant by Dr. Jobes. He has stated with clarity the hardships that are faced with suicidality such as the IRB approvals for research, clinicians wanting to work with this population, and the need to try and keep these people in therapy.

The brilliance surrounding this book is the alliance part of it. Without a therapeutic alliance, you cannot have a good report with a therapist and the therapist cannot have a good report with the client. The essential element is having a good working relationship that builds on trust and collaboration. The therapist must want to know the client’s story in a non-judgmental, non-criticizing way. By listening to this story, the therapist engages the client and the client feels validated and understood. This is a central element to helping any client in psychotherapy, in any discipline.

This book covers most of the therapeutic disciplines and how it relates to treating someone with suicidal ideation. It also offers empirical evidence that supports treatment of suicidal individuals, from psychodynamic to cognitive therapies.

I believe this book should be read by every graduate student and post graduate in the mental health field. This book can also augment education for those that are already in the field and practicing psychology or psychiatry.

what do you say

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

I have been asked to write about what you say to a person who has just attempted suicide. The answers are many but there is a song that I have in mind, another one by the Fray, that I think helps to explain it if only I can get the words out. You try and be supportive and not be a smart ass with things like I’ll kill you if you try this again. It is one of the WORST thing you can say to the person. Being there and hearing the person’s story of why they did what they did will be invaluable. It might even prevent another attempt. If this was a one time deal, the person will say this was the stupidest thing I ever did in my life and may not try again. If this was not and the attempter says, how could I be so stupid that this really was going to work, that they seem harder on themselves because they survived or are wicked PISSED OFF they did survive, there is a likely chance they will attempt again and again until they succeed. I know this from experience. I first overdosed when I was sixteen, April 12, 1992. I remember the day as if it was yesterday. I had carefully planned out my pills, the day, how I was going to do it. I even went to confession the day before (I was a practicing Catholic at the time) and went to church on this sunny Sunday. It was my Aunt’s birthday and I knew that the house would be all to myself. All I had to do was wait for it to be. I knew by the time I got home from church, my family would be heading over to Somerville and be down my grandmother’s house celebrating my aunt’s day of birth, not knowing meanwhile back home I was planning on ending my life. Except it didn’t work. I got wicked sick, puked everywhere, my eyes were dilated for days. And when I woke up Monday morning, I WAS FRICKEN PISSED OFF like no tomorrow. To my dissatisfaction, I went to school in a very pissed off mood. I couldn’t tell anyone what I had done nor could I tell them why I was so pissed off.  There was one person I did tell. It was not the school nurse or a friend but my therapist at the time, a social worker who a month or so before told me she was leaving the state and I would have to find someone else to take care of my mental health needs. I don’t remember what happened too much the day after, I was still drugged up and out of it but I remember being so mad at everyone, most of all myself for failing. I then fell into one of the worse depression of my life. This got really bad. I didn’t go into the hospital as I said I was never going to do it again and all the lying it took to avoid being in the hospital because I just was so PISSED and was not going to get help. The hell with the help. It failed me and I was really really angry. This therapist was my third and I figured strike three was called and I was out. I later did go into the hospital that year, in the summer. I lost another twenty pounds, had no appetite, thoughts on killing myself were great, I felt like the biggest asshole on the planet because I failed to kill myself and that kind of pain is hard to describe. You have no idea what failure is until you try and take your life and fail at it. It hurts and that is what I was feeling. This big hurt that no one knew because who would want to know how much it hurt to fail at killing yourself when you thought things out so perfectly, or you thought you did. Nobody knew I had done what I did and when I did it was met with over concern and I was left feeling more like a burden than I ever did before the attempt.  I also felt like who would listen to me. I was a pretty good student and who would believe that I was having problems holding things together after my parents had a massive argument that ultimately ended their marriage.  I felt that I should have been smart enough to sort through this all by myself.

 I remember that day the phone just kept on ringing. I couldn’t understand why. Didn’t the world know this was my day to end things? I’m not sure if the phone constantly ringing was a good or bad sign. It was my best friend wanting to play and I was half in the bag so to speak so there was no chance of me leaving the confines of my house to play ball. But I wonder if the panic of what I was doing forced me to throw up all that I had taken. I remember right before falling asleep that this was it, I was going to sleep for the last time. YEA RIGHT…

There have been at least ten times I have tried to end my life. Unfortunately, I don’t always remember what was happening with me when I was just about to take my life. I do remember and it is still the case today, that most of my attempts have been planned attempts and not an impulsive one which most are. I did have an impulse the first time I truly wanted to die as I was digging with a pair of scissors to draw out a vein and die that way but that was a lot harder than it seemed. I was introduced to the self-harm of cutting which can also look like suicide attempts, especially when the cuts are deep enough to cause stitches.  Though I am a former self-harmer, that is not the subject of this paper and will defer commenting on this for now.

The reason I had first cut was because I had wanted to die. I had tremendous stress with a parent that day and the day after and I just snapped. All I could think about was death. Up until this time, I was the perfect student in my high school freshman year. I was getting all A’s and nearly had a perfect attendance record. After this blowout, and that I put mildly, I didn’t care too much about anything. My grades slipped and my attendance faltered. I entered therapy and discovered more than what I bargained for. My psyche was exposed and I could not let anyone in on the hurt I was feeling.  I had grown up with the what goes on in the house stays in the house.   I just wanted the pain to end and so I had cut to end it. Fortunately, I wasn’t a good cutter and all I did was cause scratches on my wrist.  It wouldn’t be until a year later that I would take my first serious suicide attempt.

Like my pain that I tried to hide, I also kept my scars that were visible, hidden. Today they are a reminder of how bad things were and that I survived. I know it may sound strange but they are truly what saved me from attempting more serious attempts at my life.  Planning an attempt is not as easy as it sounds but it is what has kept me going. It is my escape hatch and though a lot of researchers have written about suicide as an escape, it truly can be as well as I know it to be. I have thought of many plans but have not acted on any since before 2001.  That makes over a decade of planning yet no action. You might think that I have been lucky but in 2005 I came close to acting on my plan. Things were going pretty sucky for me emotionally and I was still struggling with my nerve injury. Chronic pain and depression do not mix.  Seemed that both like to feed off one another and I was swimming in both physical and mental anguish. I could barely keep above water so created this wonderful plan, set a date, and all I had to do was get my affairs in order by Nov 5th, 2005. Except the one thing I was counting on, fooling my therapist in thinking I was “well”, failed horribly.  The way she recounts it today and is always be aware of someone making an effort at feeling good. This is true. The moment someone in a deep depression like I was in suddenly starts to feel better is the crucial time to ask about suicidality.  The reason being is that this provides the sufferer that they are no longer going to suffer. The so called “warning signs” of suicide can be just that, feeling better after a deep depression and suddenly giving away possessions.  With people with suicide careers such as mine these warning signs are not so subtle to the outside observer. Even a trained professional could miss them. I was under siege with suicidal thoughts yet no one knew until the day my therapist asked what was really, really, going on.  If not for her insight into my care, I probably would not be here today writing this for you to know. It is important to realize that the attempter does not want people to find out about their plan, especially when they have been thwarted many times in the past with hospitalizations after hospitalizations. Statistically, I should not be here yet as my therapist points out, I am the exception. Why I do not know. But holding my thoughts to myself was my haven. I thought carefully about my plan  every day and that brought me some reprieve from my pain.

Constant vigilance is key after someone attempts suicide.  If they are intent on ending their lives, they will try and try again until they succeed. If the suicide was a “wake up call”, and if they truly get the help they need at this time, they may not try again. But these types of preventions are not always sound. What holds true for one may not hold true for another. The biggest thing to worry about with attempters is the amount of guilt and sense of failure after the attempt that makes another attempt all that more eminent.

As mentioned earlier, hearing the person’s story is the most important thing you can do after or before an attempt. Just listening without being judgmental and criticizing can be important for the person and might be just the thing to prevent another attempt that will succeed. There is a book called building a therapeutic alliance with a suicidal patient by Konrad Michel and David Jobes, two of the foremost suicidologists in the world. They have written an awesome account of how to build an alliance with a suicidal person. It should be the textbook guide to anyone in the mental health field. It gives case studies of clients and the therapist’s reaction, good and bad. That is crucial to see how one person can be understanding and helpful and another not so helpful. If you are reading this and are a mental health professional, I STRONGLY urge you to get this book. I have studied the works on David Jobes for several years now, you might even call me a professional stalker as all I do is do a literature search on him at least every month to find out what new study he has done with his works on collaborating and managing suicide (CAMS). In this works, the SSF (Suicide Status Form) is the key element to help a survivor or someone who is about to attempt suicide to help work through their issues on why they think ending their life is the key to solve their problems.  But without knowing the story behind the pain, no one will be able to help this person that has just attempted to end their life.

My story mentioned above, and you can see how much pain I was in that caused me to think ending my life was the answer. While being in this bubble of hopelessness and despair, no good feelings can penetrate it. I guess that is why my therapist crossed the boundaries and told me she cared and when she started crying, I knew that to be the true. Hearing the person tell you why they are thinking about ending their life is so essential to saving that life.  To reassure this person that they are not a burden, not a bother, not a dipstick is the most important thing you can do to try and help bring some hope and ease the pain. There is really nothing more than you can do to help this person in need of help but just knowing you are there and that you are not going to leave or think less of them can help save this person from making another attempt. I have been through some very close attempts. One attempt was medically serious and I was forced in the hospital for three months because a previous therapist (who was more than pissed off at me) was so very certain I was going to try again. And I would have had I not given myself some time to heal while under the hospital’s care. I was in a very dark place and there was no other way out of my abyss other than suicide. I had tried all the medications, and they didn’t help me. I tried therapy for years and it didn’t help me. Still after all this time and energy of trying to plan the end of my life I still try and hold on to some hope that there will be a better tomorrow. Sometimes there is and sometimes things are just the same. This hurts. Knowing day after day that there is no way out other than suicide is a very lonely place. A place that is filled with hurt. I had tried and I failed again. There is no greater pain than that.

Today I read on facebook a quote, “when you fail, you learn from the mistakes you made and it motivates you to work even harder.—Natalie Gulbis

This is the worst thing you can say to someone who has just attempted suicide and is hell bent on suicide like I was. Yes, I have learned from my mistakes, I have learned not to trust people, especially mental health professionals, to speak of telling them of my suicidal plans because they will try and stop me from achieving those ends. I honestly have no idea how my therapist can deal with me sometimes because I am hell bent on ending my life and she I think lives in a fairy tale world where suicide doesn’t exist so when I tell her, the answer is always a NO. But then, could it really be a yes? If all therapists were to green light their client’s suicide there would be no hope for prevention. But therapy still is supposed to help those in need and yet after more than 15 yrs in therapy with different modalities, I still remain depressed and suicidal. Though I might get a respite every now and then it is far and too in between to really count and I have learned not to hold on to it because that usually means a big downfall and another hospitalization.

Now I find myself writing about every attempt I have made in my life and the consequences of those actions.  I don’t know if that is what people want to read about but I write about the aftermath and how it felt after each failed attempt.  Maybe I have just given up on trying to attempt again and that is why it has been so long since I have. True I feel like the biggest failure in the world knowing this but how can I not. This is deeply personal talking about the lowest point in my life and wanting to end it all and then by some grace, still be forced to live on afterwards because of some kind of divine intervention. Of the many attempts I have tried, only 1 was medically serious to warrant a hospitalization. The others were not so serious but did lead me to hospitalizations. Since the age of sixteen I have had close to 30 hospitalizations. Most have been involuntary as I posed a danger to myself and it is law to hospitalize for that reason. I just wonder why I have survived this long. Am I suicidal if I don’t attempt and just plan? We can go into the whole what makes a person a suicidal ideator vs. an attempter but most would agreed prevention lies in before the attempt not after. We hear stories about suicides and their survivors but what you don’t hear at all is about the attempter that survived. These truly are the ones that need the most attention to but because their world is so private no one really knows. Unless someone survives a shotgun wound or immolation or hanging attempt, you often don’t see the scars of attempters. True those that slice their wrist leave scars but most do survive to eventually tell their tale. There are countless overdoses every year that get under reported or if successful get ruled as accidental poisonings rather than suicides mostly to either spare the family the “shame” or because there was no clear indication that the poisoning was intentional. Most people believe that unless there is a suicide note, it is not a suicide because he or she wouldn’t do that. I would say that the majority of people who attempt and fail feel too ashamed to admit what they have done and so cover their asses by saying it was an accident or just a foolish impulse but for those that succeed we will never know.

Talking about an attempt is difficult for the survivor. They really need support after the attempt, to know that they matter and are not a burden to their friends and family. I know not all family members are supportive when it comes to mental illness and when someone they love and care about just tried to take their life, fear of losing them overtakes the care and compassion that they might feel.  I know with my family I did not have that kind of support but then I felt like a burden to most of my family because I had this illness I could not control that was causing me to feel like the scum of the earth. If you are reading this and truly want to help someone after and attempt, whether it be a friend, coworker, or family member, do not shy away from them. Let them know how much you mean to them and look them in the eye when you do. There is a lyric from Sugarland’s song Just make me believe that says “if you look in my eyes and tell me we’re going to be alright, if you promise never to leave, you just might make me believe.” This person feels so out of it they do not want to come back to the land of the living and the shame of what they have done and the guilt is killing them in ways the attempt never did before. If they thought that killing themselves was the answer, they may now know that it is not.  If the attempt caused an injury, that will be harder to deal with. Not only have they failed to kill themselves properly, they injured themselves without taking that into consideration. That will be hard. Words like saying they have their whole life in front of them will only make them feel worse or that they were “lucky” to survive. I still don’t feel lucky to have survived my attempts. I still feel ashamed of myself and worse like the biggest failure in the world.

ramblings 4

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

My blog had quite a lot of views and comments yesterday which made me happy for a little while but I was in a deep funk and still am in a deep funk. I don’t know why but I should stop reading about suicidal stuff because it is giving me ideas. I know I already have them in my head but I keep thinking, if I am not suicidal, then should I kill myself? As the saying goes, you should NOT kill yourself when you ARE suicidal. Mostly that is because you are thinking irrationally. But if you have been thinking irrationally for so long, does it become rational at some point? That is where my thinking is heading. I tend to think about killing myself nearly every day. I have yet to act on it for various reasons. Usually it is an in the moment type of thing but lately I have been thinking of a plan and a date. I KNOW it is because of the time of year. Every late September/early October I get seriously depressed, more so than anything. Since 2005 I have planned my death every single year without fail. I don’t know what it is about this time of year that makes me want to kill myself. I know that baseball season is over and that saddens me to no end. I no longer see pitchers on the mound and balls and strikes being called. Right now it is Postseason but I know that baseball will truly end by mid-October. Around that time is when I always think of ending my life.

I don’t know why this time of year brings me to my knees. I just don’t feel like life is worth living anymore. It is a seasonal pattern but doesn’t fit the usual SAD (Season Affective Disorder) criteria (mostly because I have recurrent depression throughout the year anyways). If it did fit, I probably would not be so crazy this time of the year. I’d get a light box and be done with it. But this is something more. I call it the black dog as I show more signs of depression than at any other time of the year. I just feel so worthless and guilty that all I can do is think about my own demise. The physical symptoms I get is more psychological pain, lethargy, fatigue, loss of pleasure and loss of interest (also known as anhedonia), loss of appetite, crying for no reason, worthlessness, guilt, etc.

I don’t know what takes me out of the black dog. Sometimes it is just perseverance, sometimes it is just means extra support from my therapist and psychopharm. I also have the hospital when it gets too much to bear, but I only use that as the last resort. Some people would say that is not right but I have had over thirty hospitalizations over the past twenty years that I know when I need to be in and when I don’t.  Though there is some literature saying that the hospital is under-utilized for suicidal patients the same can be said that it is over utilized as most clinicians do not know how to treat suicidal clients. And that bothers the hell out of me because there is (going on my Jobes soapbox) there is an assessment form easy to use and is applicable to all modes of therapy called the Suicide Status Form (see Jobes, 2009). If more clinicians used this, there would be less hospitalization and suffering and possibly less suicides. Granted my therapist tries to use this during each suicidal crisis but I wave her off. Not because I am a hypocrite, but because it was my idea and not hers mostly. Could this save my life? Possibly but the thing that bothers me is that she only uses one piece of the form. If you are going to use the form, use the whole of it. It will make your notes easier and all you have to do is have each person sign it (it is a collaborative effort on both the client and clinician parts). I love this ingenious form but I hate it when it is not used properly. But then my therapist has known me for upteen years now so knows what information to get from me to get me away from my suicidal thinking. Another form that is NOT used at all that should is the psychache form by Richard Holden at Queen’s University in Canada. That I have used to monitor my psychache and even modified the form for my needs. Every journal I have has the psychache scale in it. I would reproduce it here but it’s not kosher and I don’t want to get in trouble with the web police for copyrighted information. Holden wrote the article in 2001 and it is printed in the Canadian Journal of Behavioural Science, 33(4), 224-232. I find Jobes and Holden to be the best suicidologists in the world because they have come up with assessments that are clinically useful and empirically validated.

a little of this, a little of that

by Midnight Demon, posted in depression, medical, mental illness, suicide, suicide attempt

To write or not to write, that is the question. Been trying the past few days to write something, anything and I came up with nothing. I had jotted down one of my statuses as a starter to write but it too has not gone anywhere. Right now as I am writing this I am becoming exhausted. I was hoping my therapist would call me tonight but it doesn’t look promising.

Been thinking the past few days about needs. Everyone has some need that is not being fulfilled at any given time. Shneidman, the father of suicidology thought there were 20 needs that lead to suicide. I talk about him a lot in my writing so people know this sweet man that called me out of the blue one day. I was actually shaken up by his phone call. To me, he was as famous as Richard Gere. I was so honored that I didn’t know what to say to him when I called. Time was of the essence because his health was frail and if he died before I called him, I would never had the courage to talk with him for a half hour that truly was the highlight of my life. Now if Dr. Jobes ever calls me, I will have a heart attack. He is another person I deeply respect because he writes about suicide and what it is like and not only this but developed an assessment that can be used to help save someone’s life. I will write about his works until my dying day because he has the knowhow of what it is to be suicidal. I am not saying that he is or ever has been suicidal, but he has lead the way in the collaboration of so many professionals for one goal, to end suicide. Granted not all suicidal people can be saved, but he is willing to try, which is more than what I can say for some of the top professionals in Boston. I had my doubts ever since I tried getting a new therapist and failed, ten times!! No one would take me on and then the one, the last one that did was afraid of me. I couldn’t be in that therapy if someone is afraid of me because I am high risk. Sure, statistically I should be dead. But by the grace of some higher power, I am not.

That brings me back to the needs. I have been thinking about what my needs are that are not being met that drive me suicidal. I know that I am not loved, I have a need to feel important because I think I am nothing, I have a drive to succeed but yet I know I will fail. That truly is my biggest thing. I failed at killing myself and feel terrible at that loss. It is a loss that I have yet to get over. I still truly believe that I am meant to die by my own hand though there still is a drive to keep me going. I was asked recently on what it is that keeps me here. To tell the truth I have no idea. Some part of it is faith and hope, others is a pesky therapist that will “die” if I die. The aftermath of a suicide is not pretty. I sometimes wish I could be a part of Jobes world for a little bit and see what he sees in a hopeless case like me. What he would say or do to try and ease my suffering and then I look at my therapist who is doing all she can to keep me sane and alive. There is nothing more that she can do that what she is doing. Suicidal thinking has become a part of me that I can’t let go. I read about it every day to try and ease my pain, I work with my therapist who is a pain in the ass sometimes and she is open to my ideas of what treatment is and does not have the “I know it all you know nothing” attitude. If she did, I doubt that I would have stayed with her for this long.

The twenty needs are abatement, achievement, affiliation, aggression, autonomy, counteraction, defendence, deference, dominance, exhibition, harm avoidance, inviolacy, nurturance, order, play, rejection, sentience, shame avoidance, succorance, and understanding. If I was to fill out the model of the needs, my highest would be affiliation, achievement, succorance, nurturance, and understanding. As I have written in a previous paper (https://midnightdemons7.wordpress.com/2012/09/03/is-suicide-caused-by-psychological-pain/),  the twenty needs are weighted on the sum of 100, though Dr. Shneidman does not say what the scale is for each of the 20, and as much as I have tried to ascertain this information through his research, I have not been able to find it. Everyone has these needs in some way shape or form. And when they become blocked or frustrated, suicidal thinking occurs. I know my need for affiliation is great at times that sometimes I get frustrated. I don’t necessarily become suicidal all the time because I have not been friends with someone but I’ll admit that it is lonely when you don’t have too many friends that call you anymore or that just keep in touch via email. I am a loner by nature but that doesn’t mean that I am friendless.  My online contacts mean more to me than my non-online friends. My family does not know too much about what I write, if they read my blogs at all. But this is my livelihood, writing about suicide because it means so much to me. It is the biggest demon I have had to face in my life and sometimes it gets the better part of me.

This past April I went to the annual conference of the American Association of Suicidology and found out some things I already knew. I met my favorite suicidologist and his trainees again. One of his trainees has become a good friend of mine. I also found out that I am a hopeless case that no one in their right mind would want. I am high risk, psychotic and delusional at times, and have multiple suicide attempts. I asked one of the guys from Mayo about this “case” I was working on and he wouldn’t touch it with a ten foot pole. Thanks dude, you really shown me how much hope I have for my future. It was an exhausting trip. Next one is in Texas and I am not sure if I am going to go. I have never been that far out west. I really don’t know anyone close by. I would have to stay at a hotel for the few days. But it might be fun to meet up with my co-author and discuss my book that she wants me to write. She is the biggest proponent in my writing right now. She had me publish my blog and it has done well so far. Since I started it in July, I have had almost a thousand views. I hope that I am able to meet up with her in Texas but I don’t think I will have the financial resources to pull it off.

I got notification this week that I am found to be disabled. My social security disability has gone through. I now can collect a check every month while I write and not have to worry about how I am going to pay for my Starbucks coffee habit. Starbucks is truly what keeps  me going some days. It is a chance for me to go out of the house, even if it exhausts me. To have that one cup of joy a day is usually all I can get out of my day. Instead of my mocha, lately I have been enjoying the Blue Java of Indonesia. It has a full bodied flavor that I like. I have tried the Panama but wasn’t too thrilled with it. It was a little too earthly flavored. I am going to try the blue mountain as it seems like I will like it. But none of this would be possible if I was not deemed disabled due to my mental illness. Since I found out I have been more depressed. I find it more exhausting to do tasks. Even my writing as dwindled to what it was. I try journaling to keep the ideas going and sometimes I will write something I think worthy of a blog but mostly I keep my personal thoughts personal. There was a time when I used to share my journal with my therapist as a sort of therapeutic processing, but seeing as I don’t see her physically anymore, I might end up sending her an email about my thoughts on certain things. Like my suicide attempt paper I wrote that was extremely difficult for me to write. It stirred up a lot of emotions, some of which I had no idea I was still carrying around.

The reasons I am still around are many but sometimes that is not so obvious in a crisis. It truly is up to the individual to make the choice and no one can take it away. But if they let a professional know they are hurting and thinking of taking their life, they might be able to get the help they need. I just hope that with that help the person finds someone who is understanding and asks, “where do you hurt”?  Because otherwise it is going to be a long road for that person to find the help they need. Not all professionals are alike. They have different disciplines and treatment plans. But if they are able to find a therapist who is willing to take them as they are, that therapist is worth their weight in gold.