Knowing Who to Call – Commiseration with the Right People Four weeks ago I met with a patient who told me that the night before she met with me she was an “11” on a scale of 1 to 10, with ten being the highest degree of suicidality. She was trying to do it all alone. And she has severe chronic pain. We talked about the psychobiology of suicide1 and how she can start being in the driver’s seat of her life. In order to do that she needs to ask for support from the right people, hopefully from peers who can relate to what she is going through. The following is a definition of peer support paraphrased from the article, “Peer support: A theoretical perspective” by Meade, Hilton and Curtis2. Peer support is reciprocal empowerment achieved through giving and receiving help from those sharing respect, responsibility, and mutual agreement of what is helpful. There is no basis in psychiatric taxonomy, labels or diagnostic treatment. It is the shared empathic experience of emotional and psychological pain that creates the therapeutic connection. The mutual affiliation affords an equality in status without the constraints of traditional (expert/patient) relationships. As trust develops over time peers are able to challenge each other’s old behaviors and encourage new ones. There is more information about peer support at www.jsp3.org. Understanding that this patient needs to develop peer support is vital to retraining her brain and creating new behaviors based on those new concepts. We discussed how she needs to realize who in her life actually supports her and who does not. But, more importantly, at pivotal times in our lives we all need to figure out who in our lives might want to support us but simply can’t because they don’t know how nor do they have the capacity to learn how. And the hardest lesson of all is realizing the people we think should be able to help us (like our blood kin or long-term friends) are either overwhelmed in their own worlds, living in fear of anything shaking their beliefs or holding on to their own preconceived notions that prevent them from opening their minds and hearts to new information. Hard to know what really stops people from having compassion for us when we need them. But it sure hurts when you need it and don’t get it or worse get derision, shame or blame instead. So we talked about how you actually figure out who might be supportive. The best indicator is past behavior. If a person has been supportive of you in the past or if you know someone who might be supportive of you if you build a relationship based on mutual honesty, you have a good prospect. But probably the most important aspect of finding supportive people is finding people who have been through what you have or have some intimate knowledge of a similar situation. Research indicates that peer support from troops who have had similar combat stress or other trauma can provide for each other mutual compassionate support that can actually prevent post-traumatic stress disorder3. So it seems if you can find someone who personally knows something of what you have experienced, you have a better chance of receiving “emotional support, informational advice, practical assistance, and help in understanding or interpreting events” (p.14)3. I know this for a fact. I have certain friends I call for certain kinds of support. I emailed a colleague last week after I worked diligently on a conference proposal for 5 days. I thought I had 2 hours leeway in submitting it. But after I entered it into the proposal portal, the date/time stamp on it revealed it was 2 hours too late. I had not noticed that the proposal deadline was midnight EST, not PST. All that work seemingly for nothing. I could only tell that to someone who had been there and knew what that kind of research and prep really meant. Few others would have fully understood how disappointed I was in my own stupidity. One thing that makes my chronic pain patients (and me, too, because I have chronic pain) frustrated is doctors that eschew the psychological effects of unrelenting pain. They treat the physical pain the best they can but usually spend no time dealing with the devastating mental effects of intractable pain. This is sometimes obvious when the patients gets the blame from the doctors who are relegated to just treating the symptomatic pain because they cannot successfully solve the causative health problem. I’ve learned when fibromyalgia lays me out for days, unable to walk but haltingly on my walker, there is nothing I can do. Day follows day and upon awakening each morning perhaps after a disturbed, pain and fit-filled night, comes the realization this day is no less debilitating than the day before. I do everything I can to mitigate the effects of unmitigated pain. I switch around my obligations as best I can, reschedule patients, ask for favors from husband and friends, reassess priorities, and accept this is how it is. I handle it the best I can by myself but sometimes I need help from others who know what this is like. I call my friend in Florida who has Chronic Fatigue and Fibromyalgia. She is one of the funniest people I have ever known and can make me laugh even when we are both in serious pain. We’ve known each other for 45 years. We’ve had our ups and downs and we’ve both gotten over disappointments in each other over the years. In contrast and in testament to our enduring friendship, we still celebrate moments of hysterical insanity from years of sharing work hours and the goofing off hours in between. But moreover, we can rely on each other for compassion in dealing with our chronic pain. I’ve been struggling all week with “through the roof pain” and broke down today, angry because I had to cancel another day of activity. I called her and make no mistake about it – this was not then nor is it at any time wallowing in distress. This was not misery loves company. This was and is vital mutual support for mutual suffering. When I call, she reminds me I’m not alone and that I do have much to be thankful for – but it’s the way she does it that makes it perfectly healing. I told her, “I’m exhausted from not being able to do anything.” This is what E told me. “I haven’t been in this much pain in years either. I think it could be the weather, but either way, this sucks. My house is a mess. There is so much crap on the coffee table I can no longer see the other side of the room nor the body from which my husband’s voice is emanating. I want to clean it up but I really only have the energy to think about it. When I’m watching our gigantic TV and I can no longer read the news crawl on the bottom of the screen, I know I have to start lowering the stack of crap in front of it.” We went on to talk about how we distract ourselves using different TV shows. I use stupid 60’s sitcoms. E uses true crime shows. She says, “whenever I start feeling really bad I watch a murder on ‘I’d kill for you‘ and then feel glad that’s not me.” She reminds me how grateful she is that she’s retired and does not have to work. She and I agreed that even in all of our pain, we need to be thankful that we do not have to spend our precious remaining days standing all day saying, ‘Hello, Welcome to Walmart’ or asking, “You want fries with that?”. See what I mean? P.S.: E called me the next day and asked me, “You didn’t think I was trying to “out pain” you, did you? Because I hate people when you tell them how much pain you’re in hoping to get some understanding, and they ‘one up you’.” She wanted me to know she heard me and that she wasn’t dismissing my pain with hers. She made me laugh again and really guffaw. I was grateful. The pain disappeared out of my consciousness for a few seconds more. There’s something special about knowing who to call. References: 1 Jensen, R. (2012). Just Because You’re Suicidal Doesn’t Mean You’re Crazy: The Psychobiology of Suicide. Smashwords. 2 Mead, S., Hilton, D., & Curtis, L. (2001). Peer support: A theoretical perspective. Psychiatric Rehabilitation Journal, 25(2): 134-41. 3 Defense Centers of Excellence. (2011). Identifications of Best Practices for Peer Support Programs: White Paper. Retrieved from www.http://dcoe.health.mil
How Suicidal People (and Others, too) Ask for Help, or not…
Why is it so dang hard to ask for help? What has happened in this world that we have become so self-sufficient that we no longer allow our friends or anyone to do for us? Well, I think there are 2 sides to this peculiar coin. “Heads” says we should be our own determiner. We should be independent because true independence means you’ve “made it” in this world. You don’t need anyone’s help. You can make it on your own. But all you need to bust that bubble is a situation where suddenly you can no longer “do” for yourself. You can’t zip up your pants, you can’t even get them on in the first place. You need help. And there you are at “Tails” – you are flipped in need on the other side of that coin. Now you have no choice but to ask for help or founder by yourself. Why is it that most of us feel shy in asking for help? Could it be that we fear looking weak, stupid, inadequate, incapable, or less than? Or maybe we fear being refused and thus looking vulnerable and embarrassed that we even asked in the first place? Perhaps even though doing it ourselves causes huge inconvenience, we still think no one can do it better. Sometimes former experience has created the fear that asking for help will lose us any control over the matter. In those cases you end up with someone who won’t stop helping you and you end up buried in obligation. One thing that suicidal people do seemingly routinely is ask the very people for help who cannot give it. We have a tendency to ask those who have never been helpful in the past but who we think should help either from familial obligation, reciprocation or some other duty or debt. We forget or refuse to acknowledge that past performance is the best predictor of future results. We habitually repeat the same hopeful yet humiliating routine expecting there to be a change in the people who continually shame and blame us. It’s uncanny but I’ve discovered it to be a universal pursuit among suicidal individuals. Probably the next most universal thing that happens, not exclusively with suicidal people but with almost everyone, is the use of sideways comments when requesting help. Sideways comments are ways of saying things without actually verbalizing them precisely. You hint yet circumvent the real meaning by making cryptic or euphemistic comments. I’ve asked for help from a supervisor before by saying, “I’ve had all I can take”; “I can’t do this anymore”; “I’m at my limit”; “I just don’t care anymore”; “I’ve had it”; “I can’t take it anymore”, and many more like that. Simply because I could not say, “I need help, please help me.” This supervisor did not recognize as true supplication my trite statements made in desperation. I explain in “Just Because You’re Suicidal Doesn’t Mean You’re Crazy: The Psychobiology of Suicide” that suicidal individuals most often ask for help in a particular sideways offhand way. We make comments that sound like extreme frustration but do not confirm true dilemma. People write off our statements also because we are more than willing to let them do just that. Almost at the very moment we release the words, we feel like we might have made a dreadful mistake. Letting the words out is opening yourself to shame and blame. The doom dawns immediately and while wanting to suck the words back in, we let you believe they were said in off-handed hyperbole. When people ask for help using sideways comments, they really can’t achieve the help they want because no one recognizes the request. This is the sad part. No help is forthcoming because the appeal is essentially written off. In this way the suicidal person unknowingly contributes to the conspiracy of denial around suicide. In addition, the veiled comments that scratch at the surface of hope for relief from suicidality also obscure the chance of it. Those who have never contemplated suicide develop a pervasive denial that anyone actually could. Compounding that, it also seems that people are not willing to hear more than what is explicitly said for fear of what might be asked of them if they do. Until the development of the Jensen Suicide Prevention Peer Protocol (The JSP3), aside from conveying the person to a mental health facility, no one knew on a day to day basis expressly what to do for someone who is suicidal. In other blogs, we discuss how to defy and overcome the conspiracy of denial and pick up cues to the real meaning behind suicidal sideways comments.
Suicide and Don Quixote
I just this week watched on TV the film, “Don Quixote”. I remembered in strange reverie that this was one story I could relate to in my struggle to stay alive in the early 70’s – the height of my suicidality. I would sing along with the movie’s song lyrics desperately in search of my own destiny, something faithful and worthy to follow. “I am I, Don Quixote, the Lord of La Mancha, my destiny calls and I go”. I longed for the knowledge that something besides death would call to me. I felt like Quixote did, alone on a quest that had no real discernible future. That music gave me something to focus on though, some knowledge that out there was a story punctuated by compelling melody written by someone who knew a deeper truth, a deeper yearning in the human soul. I was drawn because somehow I knew I could find solace there. I have found many of my patients find certain songs express the pain inside better than they could ever verbalize it. They listen to a particular song repeatedly, memorizing every word and inflection. I did exactly the same thing. And I felt a tremendous comfort in knowing someone had found a way to express my torment – that there might be someone else out there who felt my same way. Suicidality is so isolating. It seemed maudlin to any unsuspecting eavesdroppers but music and story always played a part in my slow path towards my healing and my destiny to heal others. I realized that the reason I spent 24 years in agonizing suicidality was to be able to discover the means to help others through my research and my own personal experience. Why it has taken so many decades for me to get here pains me because I feel the urgency of Quixote. I feel the loss of every spent moment and am compelled to jealously garner every second in retribution for that lost time. I’m going on vacation next week and I know how badly I need it. I’m going to a local quarry for 5 days to learn how to sculpt. I want to go and I need to go. I’ve always wanted to work with stone. It is a powerful healing metaphor. I’m looking forward to it. Yet, I feel precious moments ticking away. There are more things I could be doing to save lives perhaps in a more demonstrative immediate way. I wrote the book (Just Because You’re Suicidal Doesn’t Mean You’re Crazy, 2012) and I add to and am revamping my website (https://www.jsp3.org), but I am perpetually thinking, “What more, what more…”. In my meditation this morning the Lord spoke to me and told me my continued mission of preventing suicide in the world is at the quarry. “GO and wait on me”, was the clear and poignant message. So, you see, in watching Don Quixote this last time through new and enlightened eyes, I realized fully that my ministry is not necessarily in what I do, the deeds I accomplish. It is in who I am as a person – the essence of benevolent intent. The blessed entity that is who any of us are in the world surpasses all we could ever do. Today I am renewed. UPDATE: An unfortunate misunderstanding prevented me from continuing my sculpting plans. I spent only one day at the quarry, felt totally extraneous, unwanted and in the way… and left. I was overwhelmed with loss of expectation for most of the remaining week. I found myself in deep reverie and meditation, wondering what that experience was all about. I can only think of rare occasions when I have felt so disrespected and disparaged. Expecting the opposite, the reality hit me twice as hard. But life is filled with little disappointments and griefs like this. The best thing to do is put your big person pants on and move on. It took a while and I’ve moved on. I’m not worrying about deeper meaning or lessons learned – just movin’ on. Only thing that drives me crazy is that one of my most unfavorite sayings fits perfectly here: “It is what it is.”
I’ll cry if I want to…
Why do we try not to cry? Especially as a therapist we try not to get overly emotionally involved with our clients’ traumas. It looks and seems unprofessional. We should be trained, educated observers not participants. After all, if we delved into each client’s life, joined them in their emotions, feeling what they feel but not knowing really why but just feeling, we’d have no defense against it all piling up on us, burying us in our own as well as their despair. But I find myself welling up in tears routinely while counseling my veterans and active duty military members. I refuse to apologize or hide my tears. They are real and heartfelt and I’m not ashamed to feel what I feel when I hear a soldier reveal his or her pain at dealing with the mind-bending, heart-rending experiences of combat. After years of training to do what a soldier must do, then when required to do it, a soldier realizes that he has never killed anyone before. He has forgotten that his sergeant told him that it might be hard the first time. But he must not hesitate. Hesitating could get everyone killed. He tells me of his fear hidden behind his duty. He tells me of his trained instant reaction to pull the trigger as many times as it takes to stop the aggressor, no matter how small or vulnerable they look – no matter how unthinkable that this approaching young person could be so devoted to kill before he is killed himself. No matter how strange and unconscionable – how automatic and robotic that advancing body seems – hesitating to react is likewise unthinkable. Hesitating might kill everyone, not just the automaton facing him who begins to whisper, not a customary shout, but an almost inaudible utterance of a familiar Islamic litany. He does not hesitate. Suddenly the soldier finds himself pinned down, having to hunker down with his enemy’s limp bullet-ridden body there facing him. He did his job. He did not hesitate. This soldier tells me he is flooded with feelings of exhilaration and conquest then enveloped immediately afterwards questioning what he knows he must fully and completely suppress or go crazy. I reach down deeply into my soul to offer my patient my willingness to hold his pain and grief as he whispers over and over again to someone who is always with him, “I’m sorry, Mom, I’m so sorry.” His face betrays the deep moral damage he has endured. He continues to whisper only loud enough for me to barely hear, ‘You did not raise me to do this. I am not this person, really, Mom. I’m so sorry, please forgive me, Mom. I would have died not to feel this pain in taking out the person sent to kill me. I’m so, so sorry, Mom”. And as this soldier buries his head in his hands, he whispers in a slow guttural realization, “Mom, I know now…I know why I feel this pain…I know now that ‘He is me’.” So, I’ll cry if I want to…
WE ALL MUST HELP – DO WHAT YOU CAN
Journalist and military advocate, Lily Casura, went to bat for a young soldier who had lost all hope for help towards a livable life. She showed her dedication to the healing of our military suffering from the invisible and very visible wounds of the Iraq and Afghanistan wars. We will see more and more of “our” veterans who, like the young veteran Lily assisted, are far removed from DoD and VA service centers. I know I have seen military members who have had their trusted clinicians changed without their knowledge, their benefits altered without warning and no immediate provisions made for a warm handoff to another qualified clinician. It takes time to build trust and a therapeutic alliance. When a military service member feels like that trust is not honored, they do like many of us; they simply stop in their tracks. It is individuals like Lily who say, “No, this is not right. This will not do.” And they make sure that others outside the VA and DoD who can help, do just that. There are so many who need help, the VA simply cannot be everywhere. That means each and every one of us must take up the slack and make sure our troops and veterans get the care they need. Sometimes that means listening and asking questions, doing some research and asking more questions. Just don’t give up – on the process or on the service member. If you need to get more resources, the American Legion is a terrific source. Lily’s website, http://www.healingcombattrauma.com, has a plethora of blogs, books and resources. Go there and be informed. It takes all of us to heal this village of America. If you want to know how to form a suicide prevention peer support for anyone you are worried about, go to https://www.jsp3.org. Or you can read more about it in “Just Because You’re Suicidal Doesn’t Mean You’re Crazy”. If you need help, do what Lily did, step in and do it. This is going to take all of us getting involved. And thanks to all who do what they can.