Content warning: this essay discusses the mental health system - including in-patient care - and suicidality.
I am suicidal. To be specific, I have chronic suicidality. Which means that I think about suicide a lot, but don’t have a push to act on it. Basically, the thought is there – a lot – but the nudge into acting on it isn’t. That nudge, that’s classified as acute suicidality.
Some people don’t have chronic suicidality but do have a sudden, overwhelming nudge and they rapidly become acutely suicidal. Or maybe they had low level occasional thoughts about suicide, and those suddenly became Very Big And Overwhelming.
Everyone’s experience of suicidal thinking is different. I can’t talk about anyone else’s, because I can’t be inside their heads, I can’t feel what it is they feel. I’ve thought about killing myself on a nearly daily basis since I was 10, possibly younger. That’s 37 years of thinking, on a nearly daily basis, about how worthless I am. It’s exhausting.
Recently I’ve been thinking about my experiences in the mental health system. Let me say right now that suicide is not purely a mental health problem. A sizeable number of people who commit suicide aren’t in the mental health system, often because that nudge came out of nowhere. Suicide is a lot about our society and how we take care of each other. But there is, also – especially for a lot of us with chronic suicidality – the mental health side of things.
And in all this thinking I’ve been doing recently about the mental health system, I suddenly had this moment where a conversation I had with my hospital psychologist came back to me. I was in the shower – because a lot of my realisations come to me in the shower – and suddenly that conversation hit me fully in the gut.
Most mental health clinicians are afraid of suicide. And that’s not doing anything good for their patients who have suicidal thinking.
I can’t say what things are like at every hospital, but I suspect the things I’ve experienced at Palmerston North Hospital aren’t unique. But here are the things I’ve experienced, and which aren’t helping anyone.
Note: I’m using clinicians as an umbrella term to cover all those I’ve interacted with in the mental health system: psychiatrists, psychologists, key workers and nurses. Not all are afraid. But the vast majority are. I’m also talking about these interactions from the perspective of my own experience of having chronic suicidality, because I’ve never had interactions with clinicians while feeling acutely suicidal.
Maybe this does work and I’m just an anomaly in that I don’t share all the details of my suicidal thinking with a complete stranger the first time I meet them. But their approach does make it seem fairly unlikely.
I am, from my perspective, pretty upfront with mental health clinicians about my suicidality and that this has been part of my life since forever. I don’t hide it, I don’t pretend that I don’t think about suicide. When a complete stranger – who also happens to be a mental health clinician – asks me if I think about suicide, then I’ll always tell them the truth, that I do.
What follows is a spiralling interrogation that goes downhill fast. These interrogations mean I learnt to dread having a new mental health clinician. The only thing they want to know are the details: I have to tell them, why won’t I tell them, how can they help me if I won’t tell them, tell them! Tell them! Tell them!
For me, all that happens in response to this constant pushing for details is that I clam up.
My two most overwhelming experiences of this were having my keyworker (first time meeting her) spend forty minutes of our hour-long appointment demanding that I tell her the details of my suicide plan (more on that word, plan, later). The other was when I was involuntarily admitted to the psych ward a few months later, and after they had finished processing and admitting me, I ended up with three ward staff standing over me, demanding that I tell them the details.
My two best experiences of this: the second psychiatrist I had (who I always refer to as the nice psychiatrist) did the usual Do you think about suicide? Do you have a plan? Will you tell me your plan? stuff and did actually, briefly, push for details, before realising that I was shutting down and he changed subject. Later, right before our appointment ended, he said Really, if you tell me your plan, what can I do to stop you? I’m only going to see you once a month, so I couldn’t actually stop you and some part of my brain went Hmmm, he’s got a good logic going on there. And I did decide that I would tell him at our next appointment. Except he got transferred to another hospital and so, just like all my psychiatrists, I only saw him that once.
The other ‘good’ experience was with my hospital psychologist. I was dreading – I cannot emphasise enough how much I mean the word dread here – our first appointment and the inevitable interrogation. And then… he never asked me. He never even mentioned my suicidality. We talked about stuff – hard stuff – and he’d occasionally say It’s okay if you don’t want to talk about this now, we’ve got plenty of time and that was in stark contrast to the other clinicians who always highlighted how little time we had. Months and months later, I asked my psychologist why he didn’t do the whole suicide interrogation thing with me. He looked confused. But why would I? It was the first time we met. Your notes clearly stated that you have chronic suicidality, so why would I need to ask you about it the first time we met, if both of us already knew this is part of you? Why would I expect you to trust me to talk about something like that in a meaningful way, the very first time we met? It was more important that we started to build a relationship.
I know, crazy idea!, working on building a therapeutic relationship with a patient rather than fixating on interrogating them for their suicide plans.
The other thing my psychologist said was that he realised that my suicide plan is my security blanket, the thing that gives me comfort when I’m having a really bad day and my brain is telling me I’m utterly worthless. Clearly it comforts you he said to me. Why would I possibly want you to feel like I’m going to take your security blanket away from you?
One of the things I said to my psychologist a few weeks after I was sectioned – in which my psychiatrist’s fear of my suicidality played a big role – was Do they really think I’d show up here with a genuine plan and intention to kill myself within the next few hours or days and show it? Don’t they think I’d focus really hard on pulling my shit together to hide it, so that no one would stop me? Do they think I’d show up for an appointment and let that level of distress show? Because if they do, then they don’t know shit.
Assuming patients should trust you because you work in mental health
Let me make this clear: I don’t think mental health clinicians are – collectively – unworthy of trust. But there is a tendency for them to work on the basis that you should immediately trust them from the moment you meet.
And everyone I know who’s had to deal with mental health clinicians is, genuinely, wanting to trust them. After all, we walk in, tell you all our shit and trust that you’ll help us get things in a better way, whatever better might actually be. We do that even after the previous clinician was a bit of a dick and made us feel bad.
And talking with people who have suicidality – and I speak here from the perspective of someone with chronic suicidality; as I said before, I’ve never had any interaction with a mental health clinician while acutely suicidal – means recognising that you, as a clinician, haven’t earnt our trust. And that interrogating us is not a trust-building exercise.
My hospital psychologist was one of the few clinicians who recognised that trust isn’t guaranteed but has to be earnt. Now, I’ll admit, I freakin’ adore Harry, who was my psychologist for two and a half years. Part of that was that we immediately got along, as sarcastic, word-loving, overthinking introverts. And part of it was that he never presumed that he had my trust. And so every single week he worked to build trust.
I know this because, well, firstly I saw it. Little things, like always having the same appointment time (unless something unexpected messed up his diary), so that I’d know he was there for me. He never said You can trust me! like others did. And because he was always very much himself, not some professional façade of perfection. But also because when I read my clinical notes – yes, I’m the kind of weirdo who requests and reads their clinical notes; why? because I don’t trust the mental health service – when I read my clinical notes, in nearly every note for our sessions Harry had written something along the lines of Building trust remains essential for our therapeutic relationship, and so this remains a key focus.
One day – probably around eighteen months into us meeting weekly – I had just received the most recent clinical notes and Harry, as always, said that if there was anything in his notes that I wanted to ask him about or that raised anything, to say. I had previously asked him questions about the things he’d written. This time I said No, no, it’s all okay. And then I thought about it a bit and said I want you to know, I do trust you and Harry just very quietly – he’s a very quiet man – said Oh. Thank you. That means a lot.
And then he kept showing up and showing that he deserved my trust, that he didn’t take it for granted. And that was the last time I requested my clinical notes while I was a patient, because after reading them I’d realised that Harry wasn’t talking trash behind my back (there are a few notes from other staff who were nice to my face and then wrote not great things in my notes) and that I really could trust him.
After that, we started talking directly about my suicidality a bit more. But always with me in control, able to say Nope, I don’t want to talk about this today.
I realise that’s a really long time, and that that isn’t always going to be practical for a clinician who’s trying to get a sense of where a patient is at. But the basics should remain the same: don’t presume that a patient should trust you, but instead show that you’re willing to earn it; don’t be two-faced (we recognise this); let the patient have some control in saying no and back off when they do.
Because if patients don’t trust the clinicians, then we’re going to be wary, and then the clinicians are going to be on edge (read: afraid of what they might be missing) and push a little too much, and then… and then things don’t go well.
Clinicians are afraid of Missing Something (and the repercussions)
I’m going to say the thing that no one wants to say: people are going to commit suicide. You can set a goal of zero suicides til the cows come home, and yes, New Zealand’s suicide statistics are awful, but still. That’s the truth. There will always be someone.
And if that someone is a patient under mental health services, then yes, there will be paperwork. There will be questions asked. But rather than a confrontational justify-your-decisions style of reviewing cases… what if it was an open discussion looking for what lessons need to be taken away and implemented?
Because yes, undoubtedly, when a patient dies there needs to be a review. But the explain-your-clinical-reasoning-to-management style review – with the corresponding reports and why-are-we-failing-to-meet-targets and looking at charts of statistics – aren’t going to create a supportive environment for clinicians, which has flow on effects for patients. Because a cardiac surgeon can’t go into surgery thinking What if this patient dies, what if this patient dies, what if this patient dies because that’s going to cause problems. That cardiac surgeon needs to go into surgery focused on doing the best for that patient and not full of doubt. And a lot of mental health clinicians are so freaked out in thinking What if this patient dies, what if I miss something, what if this patient dies that they’re not paying attention to the patient. They’re juggling odds in their head. They’re caught up in their own fears. They become risk averse, which means they become incredibly conservative in how they deal with their patients. And the ones who end up taking on the burden of that risk aversion, that conservative approach, are the patients. I know that because I still carry the weight of my last psychiatrist’s fear and risk aversion.
What are the practical implications of this? As patients, we sense the fear. We have to deal with clinicians who are so busy trying to make sure that they don’t miss something, that they miss us. My last psychiatrist – who had sectioned me and put me in the psych ward – when we had mediation (which is, I’m told, a rare occurrence after a patient is sectioned, and also wasn’t his idea) said to me I couldn’t hear you that day. Fun fact: that psychiatrist had earlier that week assessed a patient as being okay who then went home and killed herself. The day he met me for the first time, he had to go in front of management to explain his clinical reasoning with that other patient. With all that weighing on him, of course he couldn’t hear me.
We use words in different ways, and no one clarifies what we’re talking about
When I was in the shower, having this whole revelation about clinicians and their fear, something else struck me. When clinicians asked me if I have a suicide plan, and when I said yes, what they meant by plan and what I meant by plan are two wildly different things. I meant I have a preferred method in mind. They meant a method and a timeframe and access to anything needed for that method.
Holy shit. These two things are worlds apart!! But none of those clinicians ever clarified what they considered a plan to be, and when I’m being interrogated for details, why would I think to clarify what I was considering a plan? All of those clinical notes of mine that mention my having a plan and not being willing to share it? Someone needs to go back and write Doesn’t have a plan, but has an undisclosed preferred method. Which is understandable in this situation.
Words and meaning are important. The first psychiatrist I saw, I told her I was having night terrors. I knew they weren’t nightmares, and from what I’d read online, they sounded like night terrors. It was night, I was falling asleep, I was terrified. She asked me what I was experiencing (this is a good thing!) and I told her and she told me that that wasn’t the clinical definition of night terrors. She then dismissed what I was experiencing because I didn’t use the right term (this is a bad thing!). In my notes she wrote that I claimed to have night terrors but wasn’t having them. Well, cool, but I was experiencing something. This feels like how a lot of things work in mental health (and in health in general) – the clinicians use this word this way, and that might not be the word you as a patient use, or it might be a word you use but in a different way, and we won’t sit and talk to see if we’re both using the same word in the same way.
Being relaxed doesn’t mean you’re not caring
About a year ago I was heading very rapidly towards being, as mental health clinicians like to call it, in crisis. Nothing in particular had happened, but I’d become overwhelmed and couldn’t cope and my head was filled with how incredibly shit I am and I was becoming increasingly suicidal.
I rang Harry to tell him that I wasn’t going to come to our session that day. Or ever again. Because I might’ve been suicidal but I’m polite and wouldn’t ghost someone. We actually said very very few words, but Harry quickly figured out where my head was at. What I remember of that phone call: I lay in bed, holding the phone, crying, unable to say much because of all my crying, and Harry very quietly saying over and over Please just come in and see me. I promise I won’t let them lock you up. Please come in.
Being locked up in the psych ward again for my suicidality is a massive fear of mine.
I did go in. I was fifteen minutes late and I looked like hell, but I went in. What I remember of that session: I cried. And Harry sat there. He didn’t try to fix it. He didn’t get me locked up. He sat there with me – I mean, as in giving me his focus without saying anything – and let me cry.
And it turned out that’s what I needed. Okay, I needed to vent a little bit too, about nothing in particular, just my shitty brain always being like this. About feeling so sad and lonely. But he didn’t panic. Maybe inside his head he was running through interventions or what to do next, but outwardly, he was simply sitting there with me, allowing me space to be sad.
I realise that Harry and I had a lot of time to build up that kind of relationship, but that relaxed acceptance of another person’s sadness is mainly about being there. When I was in the psych ward, most of the time when I was crying (I cried a lot – like depressed people often do) the nurses either ignored me or stood in my cell, arms crossed, watching me cry. It doesn’t make you feel particularly good, having someone stand a couple of metres from you and watch you cry, arms folded, like you’re messing up their schedule. One afternoon I was crying and my nurse was Pete; Pete came into my cell, crouched down near me so that he was in my line of vision, and then… he just stayed. At one point he briefly patted my knee to comfort me. But mainly he was simply there and showing me that he was there. And once I stopped crying he let me talk to get some of my sadness and anger out, and he was upfront that the psych ward was a shitty place to be. He didn’t panic. He didn’t frown.
Maybe inside his head he was running calculations as to what I might do. But outwardly, he was simply there with me, allowing me space to be sad.
In writing this, I decided to request the last few months of clinical notes from my sessions with Harry. Mainly out of curiosity as to how he recorded our final few sessions, before he left the hospital. And in those notes, in the session where we agreed to talk more directly about my suicidality – which included him promising not to get a psychiatrist to do an acute assessment if I said anything super confronting, and me trusting that he would stick to his word – he wrote this: My therapeutic stance must therefore remain stable (honouring Paula’s autonomy/personal control as a trauma survivor – while containing any anxieties that I may harbour relating to her suggestions of suicide at a future date).
When I read that note, I clapped in delight or relief or both. Here he is, saying the thing I’ve been thinking and writing about. Clinicians need to deal with their stuff themselves, and not let it seep out and weigh their patients down.
And yes, dealing with their stuff themselves means that clinicians might have to face their own bucket of grief and pain getting knocked over, face that they might feel a little or a lot when a patient does commit suicide, face that they can’t deal with their feelings simply by maintaining control over every interaction and patient that they have. Which is a lot. And the mental health system doesn’t currently have the focus to support the clinicians through dealing with all this. It needs to.
Suicidality is all around us
Most people – if not everyone – think about killing themselves at some point. It’s one of the most human things to do.
For the vast majority of people this will be a fleeting moment, a rough day when everything is going wrong, where for a brief moment they think I’d be better off dead and they maybe even think of a possible method and then the moment passes and they might forget even thinking it. By some medical definition that probably isn’t even considered suicidal ideation. It’s a moment of not wanting the life you’re in anymore.
I mean, when we’re talking about suicidality, we’re always talking about the more acute going-to-act-on-it type scenario or chronic suicidality where it’s always in your head or some point in between those. It is, however, that same thing, of not wanting the life you’re in anymore, but in a much more prolonged or overwhelming or intense way.
But most of my interactions with mental health clinicians have been about how this is wrong. It’s a flaw. I’m flawed. And I mean, they’re right, I am flawed, I do have mental health issues which include chronic suicidality. But they approach from a perspective of This is wrong and we need to fix it and you’ll only be better when you’re no longer thinking like this.
It’s not going to go away. And fixating on fixing it – on fixing me – is just setting those clinicians up for a world of disappointment, and for me a lot of frustration and feeling like a failure (and resistance when they’re doing that interrogation thing).
What if instead they viewed suicidal thoughts as something that most people experience. But just like everyone has red blood cells but having too many red blood cells is bad and needs medical attention, for some of us those suicidal thoughts will always be there, it’s a matter of supporting us when they become too much. Again, I realise this is a different situation that if a clinician is assessing a possibly acutely suicidal patient. But while I was in the psych ward, what was repeatedly – as in over-and-over, multiple times every day – said to me was We can’t help you until you tell us your plan.
No one could ever explain to me what knowing my plan (which, again, I didn’t actually have, I was using the word plan when I meant preferred method) would do to change things. How that would help them help me.
A general comment on talking about The goal is zero suicides
Is the suicide rate too high in New Zealand? Yes. Is this more to do with societal issues than mental health? Yes. Will we ever have zero suicides? No.
When working groups and committees and district health boards and politicians talk about Our goal is zero suicides, a big thing that happens is that a lot of us experiencing suicidal thinking disengage. We switch off. What that goal says is We have no idea what to do, so we’re talking about this unrealistic goal instead.
People have been committing suicide since ancient times. I don’t think modern society is going to magically change enough to change that. Just like when a goal is set to reduce suicides in a particular age group, what you’re telling us is that those outside that age group don’t matter (logically our brains know that’s not what’s being said, but in our suicidal thinking that’s what’s being heard).
People I know who have – or have previously experienced – chronic suicidality have the same feeling about this kind of talk. There’s a lot of eyerolling at that kind of talk.
What I would love was if someone had to balls to say the reality. If someone said Our suicide rates are too high and we need to act to get them down, but we also recognise that some people will always feel the kind of pain where suicide feels like the only way out I’d be a lot more likely to stay engaged in what they’re saying. I realise it’d be uncomfortable. But maybe being uncomfortable would be healthier for everyone.
Years ago I had complications after major, urgent surgery. My surgeon, Mike, was upfront that I only had a 25% chance of surviving the next surgery to investigate and repair whatever had gone wrong. It was one of those situations where at 4am a nurse had to phone my father and best friend to tell them to come to the hospital straight away, in order to say goodbye.
If Mike went into that operating theatre afraid of that 75% chance I was going to die right there, in front of him, then he never gave any sense of that. He clearly knew that things weren’t great – there was a quiet rush happening around me, while he sat next to my hospital bed and held my hand whenever he wasn’t organising his surgical team. I suspect that he isn’t afraid going into these surgeries – aware of the risks, aware of the chances, perhaps, but not letting it into his head to create noise there. He might be aware of the possible outcomes, but he focuses on what’s in front of him. If I thought Mike was afraid of what might go wrong, I don’t think I’d trust him at all.
And that’s what I want mental health clinicians to be like. I want them to recognise their fear and self-reflect on it and then figure out how to move beyond it. When they’re with a patient who has suicidality – in whatever form that presents itself – then they can know the statistics, the risks, the possible outcomes.
They can know all of that and put it aside and focus on the person in front of them. They can listen and hear the actual person, and not the outcome they fear we might be.
First published in paulaharris.co.nz (2021)