On Suicide

Content Warning: Suicidal thoughts, self-harm

I first thought about killing myself when I was around thirteen. I had a plan, and I was going to carry it out as soon as my mom left the house. She never left the house that evening. Another point for mother's intuition.

A friend shared with me that she hurt herself and "it felt good," as it distracted her from thought of killing herself. We were twelve.

Another friend shared with me that she was "ready to join" a family member who had died by suicide a few years earlier. We were fourteen.

In high school I fell in deep obsession with a boy who cut himself all over his body with knives he "collected," and hardly ever ate. One night I became so depressed over this boy not reciprocating my feelings that I thought about cutting myself with a kitchen knife. I called a friend, who helped me through the wave of despair until it passed. The next day, she gently and patiently offered me different foods until we found something that didn't trigger nausea at the thought of ingesting. I believe that day it was canned pineapple and toast.

In college, I discovered a DSM casebook in the library and spent hours reading stories of painful and scary symptoms being assessed and organized into a definitive diagnoses and treatment plans, which invariably resulting in resolving the pain and fear of mental illness. Any research assignments in my classes with a flexible topic, I focused on schizophrenia, depression, and psychiatric treatment. I added this layer of understanding humanness onto my foundation of Mormonism, creating a map of life as complex and nuanced as one handed to a toddler in a restaurant with a handful of dull crayons.

I followed these maps, carefully staying in the lines of church attendance, temple marriage, the word of wisdom, higher education, and psychology, carefully listening to the wisdom and guidance of the men I was taught to trust with my mind, heart, wellbeing, priorities, life direction, and decision-making models.

As a counseling intern at BYU-Hawaii, I once responded to a phone call to the counseling center to approach a student who was crying and despondent outside the administration building. I walked across campus and found a young woman crying, with her face in her hands, and sat next to her on the cement steps, identifying myself and telling her that someone saw her and called, concerned for her. I listened to her and learned her story of pain and fear, and did my best to hold space for her as her waves of despair crashed over her. The demands of school and family in her home country were so overwhelming, she thought about walking into the ocean and letting herself drown.

About a year later, I was working in a psychiatric crisis stabilization unit in Dallas, Texas, grateful I had finally found a stable job as a new graduate with a master's degree in counseling. I stood in the doorway of patients' rooms and asked them a series of invasive personal questions, most of which they had already answered multiple times through the hospital admission process. One day I was interviewing a man who didn't fit the pattern - he was lucid, communicated clearly, and described a very standard life with jobs, kids, and a house. As I learned more about his psychiatrist appointment that ended with his hospital admission, I was shocked to learn that when his outpatient psychiatrist asked the textbook suicidal ideation assessment question of "Are you having any thoughts about killing yourself?" and he answered with a passive "well sometimes I wonder what death will be like" this psychiatrist decided to involuntarily commit him to the crisis stabilization unit for the weekend. Then due to bed allocation, he was placed on the high acuity unit, where most patients were what we call floridly psychotic - clinical terminology for crazy pants. I explained this disconnect to the hospital's attending psychiatrist in charge of assessing this man's potential for self harm, and luckily he listened to my perspective and discharged the patient. This doctor was so stressed and overworked, he mentioned he hadn't had a chance to eat lunch that day. I gave him a banana I had saved from my lunch that day, and he gratefully accepted it, peeling and biting into it while he clicked through more patient charts.

Sometime later that month, I wondered aloud to the nurses where that psychiatrist was, as he hadn't come by to do his rounds at his usual time of day. Phone calls and messages went around looking for this doctor, and a few hours later, our department director came to the unit and gathered everyone to announce his ex-wife had called her moments ago. He had taken his own life, and she found his body in his apartment that morning. We all fell silent and looked at the floor. Then we had to go back to work, caring for the two dozen psychotic or suicidal patients on the unit. One of my favorites from this hospital was a man whose psychosis included an audio track, so he was constantly dancing and moving, with hospital socks tied around his head and toothpaste smeared on his face, he would smile and greet me, "Hey Tanya. Hey Tanya. Hey Tanya. Hey Tanya" in rhythm with his involuntary dancing. He made me smile, despite the waves of pain and the absurdly tragic news I had just heard.

I worked at this hospital for about six months, then moved to Florida and transferred to another hospital there, remaining in the same general job - conducting assessments, group therapy, and case management for people with such severe psychiatric conditions they were often on disability, dependent on family members, or homeless. I was required to ask each patient every day, if they were having thoughts of suicide, if those thoughts were specifically about a plan, if they intended to act on that plan, and if they had any means to be able to carry out that plan. Over time, conversations about overdoses, self-harm, guns, swallowing foreign objects, and communicating with patients currently on another plane of reality became commonplace. I shared this weird universe space with co-workers, who were nurses, nursing assistant and technicians, social workers, and counselors, swimming in the symptoms and features of pain, anguish, rejection, and betrayal. The weight of this soon gave way to collective emotional distancing that allowed us to continue in the work. This defense mechanism is usually called gallows humor - finding the ability to laugh at the specific oddities of this corner of human misery we are engaged in.

This only worked for me for a short time, however, as I learned more about the system I was working within, its limits and failures, which seems to disproportionately affect those most vulnerable and downtrodden. As time passed and I continued observing these failures, I saw the resilience of those who had fallen through society's safety net - those "frequent fliers" who knew the psychiatric unit staff by name and commented on my weight fluctuations. They navigated the disjointed pieces of social services with skill. Many of them knew the policies of Medicare, disability services, and their legal rights better than I did. One particularly impressive man was on disability and opened an Aflac policy designed for upper-middle class worriers to receive cash for incidental expenses in case the worst were to happen - a hospital admission. This man took his policy and went to the emergency room, telling the staff and psychiatrist that he was hearing voices telling him to kill himself, and they would probably last until Thursday. This symptom meets the legal criteria for a hospital admission, and he happily shared his clever plan with the psychiatric unit staff, letting us know that he was at work, and currently making more money than most of us official hospital employees. He wasn't wrong.

The stories I read in that DSM casebook were not playing out as described. Doctors were giving diagnoses and prescriptions, but insurance companies and regulations and documentation and accreditation took so much time away from treatment, and limited so many options by placing them financially out of reach for most. I remember clearly having a conversation with a man old enough to be my father who risked losing his place in a group home. This group home was the only place he could afford with his pitiful disability check, and also happened to have some resources and supports that helped him stay functional and safe in the world despite his cognitive disabilities. I did my best to gently explain to this man what his group home manager had told me over the phone: that he was allowed to return home, but it was important for him to only masturbate in private, instead of in the front room where the television is, because it's considered rude to jack it to the Univision weather girl in a common area.

So I went back to school for a PhD, eager to expand my options for helping the countless people in similar situations and worse, who are not able to navigate a ridiculously complicated medical benefits system due to medical issues directly affecting their ability to do so. I finished my supervised licensed hours, received a prestigious fellowship, and was starting to feel comfortable and see more meaningful options in my future. Then one day I found myself using this license and my knowledge of involuntary commitment laws to stop my (now ex) husband from threatening to jump off the 9th floor balcony. Not long after that I looked over the same balcony, wondering if I could have done anything more to prevent the early death of one of my favorite patients at the hospital.

My PhD professors gave me a new lens for the world in post-modernism, or social constructionism. Instead of looking at a singular line of authority, located above me and out of my reach of my puny ability for understanding, I learned to evaluate what knowledge and reason are, how they are defined in our culture today, and other definitions of truth, reason, authority, and even reality. One of the most striking lessons for me was learning that an often-cited study claiming that couples who live together before marriage are more likely to get divorced has an obviously fatal design flaw: the participants of this study consisted of undergraduate university students, like most studies conducted by psychology professors at big universities. This study only showed that undergraduate college students (ages 18-22 usually) who live with a partner, then marry that partner, are more likely to get divorced. Well, no shit, Sherlock. Anyone from Utah could tell you that getting married in that early adulthood window doesn't always work well once those college students grow up and become fully formed adults. But by that time, there are usually a few children gluing the couple together, so whatever. I guess this is my life now.

I was lucky in that I didn't have any gluey children connecting me and my (now ex) husband who had become further and further away from the people we had jointly imagined we would become when we got married at 21 and 23. In the midst of my struggle with intersecting versions of reality, I went to Buenos Aires, Argentina, for three weeks with a group of counselors and counselor educators, for professional things and international collaboration and synergy and wine. One evening, around the middle of this trip, I bit my tongue while I watched one of the older men in our group, whose textbooks I owned, snapping multiple pictures of our young attractive waitress, and looked around the table at the wine drunk red faces of men I had placed on an intellectual pedestal for their career accomplishments and I saw their flaws, humanity, and blind spots clearly. I reflected on my other experiences on this trip, including a mind-bending approach to substance abuse treatment that actually includes the possibility of healthy relationships with substances instead of lifetimes of white knuckle abstinence, and a peer supervision approach involving acting out the patients' experiences, like actors stepping into the body of the patient, to attempt to experience their world and perspective. I was part of the group of Americans who had arrived in Argentina to bestow the gifts of North American counseling upon the poor isolated South American people who are still swimming in a sea of Freudian psychoanalysis. I had gained so much from learning how people from the other side of the globe are doing their best to empathize and connect with clients in their unique way, while at the same time I became disconcertingly aware of the plainness and humanity of the "experts" I had accompanied. I began to realize that the men I had been taught to believe and believe in without question in most realms - from the "heroes" in my history textbooks to the "prophets, seers and revelators," and the "researchers and professors" who literally "wrote the book" on any number of subjects are just people. People who get wine drunk and say stupid things, tell ignorant jokes, and through sheer luck find themselves at the top of the zeitgeist totem pole as white cisgender men in the United States, where opportunities for gaining knowledge and being paid to write a book about it are more abundant and likely. This does not mean that knowledge written in books and published in academic journals are the totality of human wisdom.

So if my textbooks' authors, my professors, and mentors are all just lucky bastards winging it, well hell I can do that. I had also been watching my (now ex) husband miraculously create a profitable business from the mines of garage band and gamer youtube out of sheer will and stubborn, unfounded confidence. The metaphor of throwing spaghetti at the wall and seeing what sticks comes to mind.

If the writers of the DSM Casebook and the Book of Mormon were just as stubbornly confident in their abilities, yet clearly flawed and human as these men I was drinking Malbec with, then why was I clinging to their words like indisputable, unquestionable truth, while downplaying my own intuition, confidence, and inner wisdom? What other perspectives and pieces of knowledge had I missed by only allowing a curated selection of written material into my mind?

Years later, I'm divorced and finished with my dissertation and interacting with people outside the small worlds of academia and mental health for the first time in... years. Turns out, most people have these inherent, natural social speed bumps and guard rails to guide them away from conversation topics like death, suicide, sex, addiction, pain, or even mild discomfort. My years of clinical training and study had worn my internal barriers away, and I found myself looking at horrified reactions in respectable folks' faces when I casually joked about or steered conversation into these forbidden territories. When I lecture on the subject of suicide assessment, however, my students seem relieved when I prefaced that passive suicidal thoughts are a normal human experience. Not only that, I find myself repeating ad nauseam that talking about suicide does not plant the idea in a person's mind, which is counter-intuitive for most. People are generally aware of the concept of suicide, and avoiding talking about it doesn't change that. If we avoid talking about uncomfortable things, and taboo concepts like suicide are never discussed, it leaves people to struggle with them alone. A wave of despair looms and threatens to overtake you, sucking you down into a riptide of ugly, nagging, intrusive thoughts, spiraling into hopelessness, despair, and disorientation. Soon suicide appears to be a sensible solution. Maybe the only solution. Instead of struggling so hard against the swirling, raging darkness of my own mind, I should just stop struggling. At least then this will be over.

But when we share, like my friends did when I was young, when I did, when patients did, it opens up the possibility of sharing the burden. Sometimes that backfires, like in the case of my patient whose outpatient psychiatrist reacted to his voicing passive suicidal thoughts as though they indicated imminent harm which the patient needed to be protected from by locking him away from his family for days. Most of the time, however, sharing our darkest and most vulnerable experiences leads to deeper shared connections, and more people available and willing to listen, hold space, gently encourage healthy coping, and pick up the slack where depression has sucked away your motivation. Today, those two friends (and even the object of my high school obsession), who shared their dark thoughts with me, post photos of their children, and share career and family celebrations and accomplishments on social media. When I remember who we were and what obstacles seemed insurmountable twenty years ago, I am overjoyed that my friends allowed me to help them surf their waves of despair, which showed me that I could reach out when my own wave knocked me over and pulled me down. Eventually I became strong enough to stay afloat and avoid the riptides, but I know I'm one of the lucky ones.

We need to learn how to talk about suicide and death, and all the other hard things we are collectively forcing people to face alone.

If you're having thoughts of suicide and you don't have someone to talk to, you can always text 741741, or call 1-800-273-TALK. You are not alone.

If you want to get better at talking about this stuff, I highly recommend this book