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Episode Transcript:
Dealing with Hopelessness – Dr Christine Moutier
Transcribed by Kajsa Lancaster
PG: I’m here with Dr Christine Moutier who is a psychiatrist, and you are on the – well, more than on the board, you are the head –
CM: Chief Medical Officer.
PG: Medical Officer for the American Foundation for Suicide Prevention.
CM: Yep.
PG: So many questions that I want to ask you. How do we support people who are suicidal? How do we support the people that care about them, not only when that person is suicidal but if that person does complete suicide; how do we support the people left behind…? But before we get to those questions, I want to know what led you to into this. Also, as a psychiatrist, we have so few guests that are psychiatrists, and not because I don’t want them – I don’t know if it’s just that they’re too busy, but it seems to be the profession that has the most amount of mystery around it, I think, because of the art and the science, the combination of it – that it requires empathy and human connection and seeing the person as a whole, but it also involves neuroscience and all that other stuff. And there are – I hate to say it, but there are a lot of a bad ones out there that don’t treat patients as if they are a person; they seem to treat them as if they are a disorder. Those are all the questions I want to get to, if you want to touch on any of those as we talk about your story. But let’s start with whatever details you’re comfortable sharing about your life and what led you to this passion of yours that you have.
CM: Sure, great. Thank you so much for having me on. It’s such an important topic that touches far more people than perhaps most people realize. It’s the majority of Americans who have been personally touched by suicide in some way. So, for the last several years, I’ve served as the Chief Medical Officer for the American Foundation for Suicide Prevention, which is the largest national non-profit organization fighting suicide and really trying to make a dent and turn this major public health crisis around. My journey starts with my own personal crisis that happened while I was in medical school, which sensitized me to the human experience and how it’s going to work for me as a trainee and going on my path – is medicine even for me? Fortunately I did stay, found psychiatry, love working with people with mental illness and really any kind of human struggle.
PG: Did you have a specialty in mind before you chose psychiatry?
CM: Yeah, I thought I would go into family medicine or pediatrics, and I thought, you go to medical school to treat patients out there in the community. I had no concepts of other types of work that one could do after medical school and after training. Starting with that personal experience related to mental health for myself – it’s one of those situations that you don’t wish that kind of experience on anyone, on your worst enemy, and yet, when you go through it and you come through it with new learnings and a new freedom about how to live your life, it gives you observational skills also about the culture around you. And other people who might be suffering and not having their needs met because of those unwritten rules about culture and the environment. And certainly within medical training there was a culture that was quite stifling of individual mental health needs, and a lot of fear around what will happen if I even talk about my experience, let alone get help or get treatment.
PG: Right, yeah. Kind of like the military in some ways – will I be placed? Will this hurt my career, I would imagine?
CM: Yes. There are several occupations – probably actually numerous – for whom the rules might be slightly different but the same principles apply. If I get treatment, if I take an antidepressant, if I get therapy or if I even talk about what’s actually going on inside my head, am I going to lose my gun if I’m a law enforcement officer, my medical license if I’m a physician? But things, at least in the field of medicine, and I think other fields as well are changing for the better, to treat mental health like the health issue that it is.
PG: There does seem to be a sea change going on right now. Are you comfortable sharing what your struggles were more specifically?
CM: Sure, yeah. I grew up in an environment – well, first of all, I have a genetically loaded family history on both sides, with mood disorders, psychotic disorders, schizophrenia, bipolar… and kind of didn’t realize that until I was in medical school and you’re learning about the genetics of mental illness, like, whoa! That actually wasn’t really part of the situation, but I grew up in a family where achievement is really everything; it defines the children in that family.
PG: It’s who you are!
CM: Yes, yes.
PM: Conditional love. Or at least conditional praise.
CM: Right, right. And so, I majored in piano performance in college knowing I was going to go on to medical school…
PG: You’ve said it all, right there.
CM: (Laughs)
PG: You have said it all. What’s the next thing? I did recital. Okay!
CM: Kooky crazy, yes!
PG: Yes! Perfectionist.
CM: Right, all of that.
PG: Worrier.
CM: Yeah, and you know, medicine draws a highly driven, perfectionistic, dot-every-i…
PG: Analytical.
CM: M-hm. But also caring, and identifying with being a caregiver; not needing help ourselves.
PG: Right!
CM: So, a lot of this is a setup for many, many healthcare professionals, and in my case it sort of culminated in that classic feeling of… I was so unaccustomed to being in the middle of my class in medical school, it triggered lots of fears and basically a growing, continuous panic that I’d be failing out at any moment.
PG: Based on anything in particular?
CM: No, I did very well academically, but that is what goes through a person’s head who’s in that situation. And it came to such a culmination that I took time off, and I actually was thinking I needed to leave and drop out of medical school, because this was certainly not – I didn’t think I was competent enough to become whatever it is that was happening and that you’re trying to become in medical school. Fortunately, I had a Dean who said, ‘No, take time off and come back and check in on a quarterly basis.’ Well, I ended up taking a year off and getting treatment, and that experience of therapy was life-changing because, essentially, when you figure out what those internal voices that are so punitive and perfectionistic, and you don’t apply them to anyone else but yourself…
PG: No. If somebody talked to you the way we talk to ourselves, you would get a restraining order.
CM: (Laughs) Right, right. And really, just getting some clarity about that… You know, they say that psychotherapy is more effective when there is a time constraint, and I had to make a decision about whether I was going back to medical school within a few months. So, it sort of accelerates the process and the motivation to figure things out.
PG: What were the specific thoughts and anxieties, and how did they present themselves? Was their suicidal ideation?
CM: Some, but not – that wasn’t the most prominent. It was more a feeling of, ‘If I am not – fill in the blank; in my case, top of my class, feeling secure, perfect – then I might not be worth breathing air and taking space on this planet. I mean, it’s that illogical and irrational. But I think, again, what I learned after my own experience is that these kinds of negative, distorted thoughts are incredibly common – and of course more common if there’s a mental health condition that’s shaping your brain and your thinking, that kind of distorted thinking. But it’s extremely common even without a mental health condition.
PG: Yes, and especially if we were raised in homes where there was – for lack of a better term – emotional poverty, where there was love but there wasn’t any kind of script for how to express feelings or feelings were deemed to be messy or uncomfortable or a weakness. Who wouldn’t run into their head if you believe that that is the truth?
CM: Yes, exactly. The amazing thing that happened was that there was some significant progress and resolution that allowed me to go back to school with a new set of rules that says, ‘You are a worthwhile person because you’re alive on this planet, and that applies to every human being on the planet, including myself.’ I hope that we all can embrace that if you struggle with that at all, because it gives you a new freedom to find out what you are supposed to be doing and what makes sense for you, as well as fulfilling your purpose if you believe in that kind of thing.
PG: Yes. And I want to add, for people who have made grievous mistakes – because a lot of people will look at their past and say, ‘I hurt someone’ or ‘I was selfish’ or ‘I did blah-blah-blah’… If you are seeking to become a better person, that is all that matters. I may take grief with this, but I believe serial killers deserve compassion. I think that society should absolutely be protected from them, but they’re still a human being, and I believe all human beings are worthy of love. I just kind of view them as dogs that bite and they need to be muzzled, but that’s kind of my take on it. Because, as you were saying that, I know that there were some people who were thinking, yeah, but I’m not worthy, because I treated my kids like shit or I was a burglar or, etc, etc.
CM: Yes, that’s right. We all could have our own reasons for making ourselves the exception to our otherwise compassionate view of all of humanity.
PG: That’s why you should always watch a Hitler documentary, because on a curve, you’re kicking ass.
CM: (Laughs) So, anyway. To fast forward what that experience gave me, was a new sensitivity to all of those things in the environment and other people who might be experiencing challenges, and lo and behold, challenges are ubiquitous in human beings, including among my colleagues at the time who were other medical students are residents and physicians.
PG: Hold that thought for one second. What was it specifically that helped you get to the place where you could go back? Was it anything other than just time and reflection – how did you get to this self-kindness?
CM: Well, for me, there was a very specific experience that happened in the course of psychotherapy where I figured out what that internalized voice that was so punitive was about, and actively rejected it for a period of time. I had to reframe it, recognize it, sort of fight it, grapple with it, choose to believe that I actually did believe about the rest of human beings for myself. It was a very active process.
PG: Was that CBT?
CM: Umm…
PG: You don’t have to name it, that’s alright, I was just curious.
CM: It wasn’t. I wouldn’t even know what to call it. I would love to give her a shout-out. She’s no longer alive, but my therapist was an incredible woman. She was the ex-wife of Jonas Salk of the Salk polio vaccine.
PG: Oh my god!
CM: Jonas Salk.
PG: As if that family hasn’t done enough!
CM: And she was a social worker and was in her older years at the time, and she would sit in a rocking chair, and I would think, ‘What is happening?! No progress is happening here!’ You know how psychotherapy feels – it’s slow! But in hindsight, in a few short months, that is quite tremendous that those discoveries and resolves were made that are forever with me to this day. When I see people who are being so self-punitive, and whatever is driving their struggle or distress or suicidal thinking, I do have this incredible compassion that is both based on my training as a psychiatrist and knowing about the neurobiology of the brain, but also having that empathy for the fact that anyone can suffer and can go to that place.
PG: Yeah. So it sounds like we need to tackle the nature and the nurture aspect of suffering.
CM: Yes, one hundred percent.
PG: So, back to where I cut you off. You came back with this new insight and passion?
CM: Right, and I got lucky, too, in my training program. My training director turned out to be my lifetime mentor and now friend, [“Ziz Izik” XXX 24:43]. So, over the years, psychiatry training was a good fit for me. I excelled and was able to also both teach, support more junior trainees… Nothing feels better than helping other people, for most.
PG: Yeah.
CM: By the time I was in my last year I was Chief Resident, and again, through many different opportunities and mentorship – I think no one necessarily forges their path alone. You’re lucky if it’s a good fit and you’re able to be authentic and honest, and there’s something about your work that you’re connecting to, and it leads onto the next thing. So for me, what ended up happening was, I happened to be joining the faculty at UCSD at a time when there wasn’t a lot of awareness about physician distress. It wasn’t welcome, necessarily, to talk about it, but some of us were talking about it and thinking about it. And then, as the medical center and medical school lost several physicians, about one a year over a period of years, to suicide, then there was this growing sense on the part of the top level leadership at the hospital and the medical school that we should really look at this and do something about it, if there is anything that can be done. Even though I was trained as a psychiatrist by then, by that point in time I had been a Residency Training Associate, Training Director in Psychiatry and then moved into the medical school as Assistant Dean for Student Affairs and Medical Education. So I was afforded this awesome role, to be able to be interacting with hundreds of medical students and residents and shaping curriculum culture and programming. Fortunately, like I mentioned, through the course of those terrible losses of colleagues, the leadership became ready to explore, what would suicide prevention even look like for physicians? Does the environment have anything to do with a population suicide risk? Which, to be perfectly honest, I didn’t know the science at the time, to understand that absolutely the environment and the culture have a lot to do with a population suicide risk. But I didn’t know that, so we went on kind of a search to look at what has worked for other populations, what does the science say… And one thing we found was the United States Air Force suicide prevention program that had used a thirteen-pronged approach to train every level of the hierarchy in the military, in the Air Force, about mental health needs, about the warning signs of suicide risk, to teach that these are human struggles, really destigmatizing the experience of distress…
PG: It’s not a weakness. It’s a normal reaction to stress.
CM: Yes. So, it’s training that works to address stigma; it’s also some skills training about how to have caring conversations with people in distress, and it’s learning and figuring out which policies in your system are actually inadvertently discriminating against people who are struggling, and keeping them silent. You have to create pathways for accessing support and mental health care that ensures that there’s no punitive consequence.
PG: Wow. I did not know that about the Air Force.
CM: Right, well, in the case of the Air Force, one of the reasons we decided to model our approach after theirs, is they had a successful outcome of reducing the suicide rate, which had been on the rise at the time in the Air Force members, by 33%. So that’s a very significant reduction in suicide prevention. Suicide prevention is hard because it’s multi-faceted and requires reaching people at moments when they are more likely to withdraw from any programming and messaging that you’re trying to do as a leadership.
PG: Yeah, it so often reminds me of a wounded animal that just wants to go hide and lick its wounds because it feels like even more pain to, you know – when we can’t even put into words what it is that we’re feeling, other than not wanting to be alive, to have to sit down and expose that part of ourselves and the fear that ‘I’m going to misdescribe it’ or ‘I’m not going to be able to do it and then I’ll realize that I’m just an exaggerator,’ or whatever the thoughts are that are swirling. It’s just this oppressive, grey blanket that is so overwhelming and yet so hard to describe.
CM: And, I would add – I agree with everything you’re saying – and if you keep it locked up internally, it tends to spiral around and become, sort of grow in its level of distortion. Whereas if you’re sitting with somebody who is caring, generally supportive – they do not necessarily have to be an expert, but that can hear you, just listen and tolerate it at a minimum and not judge – there is something that happens in that process of bringing it out into the open, even with one other person, that can be incredibly helpful and therapeutic on its own, let alone what might happen next to further explore or address anything that’s underlying those distortions and self-punitive feelings.
PG: And I would imagine, too, for people who are perfectionists, the idea of going into something that is so grey and nuanced, it’s terrifying to be able to do this thing that you don’t know how to get a leg up on before you go to it. There’s such a leap of faith and a feeling of underpreparedness that, of course, once we’re in it we realize, well, there’s no preparation for it; it’s just about the dynamic of letting what’s inside of us out and having another person help us with it. It’s not about intelligence.
CM: Yes, absolutely. You’re reminding me of a more generalizable experience which I certainly feel like for my own life, and I think others who have experienced trauma or crisis and come through it will talk about, which is a new-found freedom. We also see this in our network in the American Foundation for Suicide Prevention – people who are advocating for change and for saving other lives after they’ve been touched by the loss of their own loved one’s suicide. It’s such a game-changer. You’re so freed up to do what really matters to you that, in many ways, that usual way of feeling anxious – which we all still feel at times, all those human things – there’s something else that drives you past that, and it’s an incredibly freeing experience; especially if you find that it’s positive and it’s working in whatever way that means for your life and your work, your volunteerism, whatever.
PG: The feeling of meaning and purpose is the best muscle relaxer I have ever discovered. I don’t need a prescription to get it. There’s a part of my brain that battles it; that wants to keep me isolated in my recliner, but having a support network where I’m reminded that I matter and that I can help other people, and by helping other people I’m helping myself, because I’m deepening a sense of what it means to be alive and it’s beyond the culture of materialism and success. It’s hard to put into words but I know you know, you’re not in your head – is there a way that you can elaborate on that, or have we completed the idea?
CM: No, I think there could be. I love what you’re saying about there is something in this experience that’s incredibly counterculture, the prevailing at least superficial norms around what being a successful person amounts to. Because the truth is, none of that external stuff gets you this internal experience of joy, purpose, meaning, focus, peace. And again, this is not to say that it doesn’t include other human experiences of suffering. The amazing thing that I’m seeing in, to some extent my own life but especially as many advocates in suicide prevention speak about their experiences, they talk about their daily struggles, their chronic recurrent struggles with whatever it might be – an anxiety disorder, chronic suicidal ideation – but they have this new perspective that uses tools and discoveries that knows how to manage it, and they’re actively doing that. It’s a day-to-day, moment-by-moment sometimes, experience, and when they draw on a network of others to help them with that, it’s incredibly empowering.
PG: It’s beyond words!
CM: Yeah, it really is. One thing that you said made me think of something that I really want to talk about, which is, for that person out there who’s thinking, ‘Well, what is talking to somebody else going to do for my problems which are real problems; I have financial problems, I’m under this tremendous amount of strain, and talking about it does nothing for those things…!’
PG: Right, maybe ‘I have chronic pain’ or something that, yeah.
CM: And this is both, I want to say, talking about it with a therapist can help shape this mediator that is the layer of your mind. It might not change your financial debt, but it will change the outcome of how you choose – and how you’re able, not just choice, it’s the actual ability to address it in a different way.
PG: Resilience.
CM: Yes. You will get a different outcome, actually. An objectively different outcome through that change, small but significant changes that you can do through psychotherapy or other modalities. But I also want to speak to just this idea of, ‘Why would I tell anyone about these kind of embarrassing experiences I have with where my thoughts go, and my moods and my problems – who wants to hear about it, and it’s nothing I want to talk about…’ Many people – we all, probably – have been so socialized to keep that locked up and under wraps, and just present the happy face.
PG: Mm. That’s what Facebook is for.
CM: (Laughs) Yeah, really. Although Facebook is getting used for these kinds of disclosures, too.
PG: Yes, I’m just – yes, it can be very powerful.
CM: Yeah, it can be amazing, but it’s both ways. I just have to tell you, I don’t know there’s anything we’re going to say to convince you, but you just have to try it. Take one person you trust and try going deeper, and see what you get back. Just let that be a genuine experiment, and then you can decide whether you want to pursue that further. But I will just tell you that, for myself, it’s a game-changer; you feel connected, you know you’re not alone, and you also get new ideas, because people love sharing what worked for them. Just that experience of connecting is so important and powerful on the most primitive level for us.
PG: Yes, and it may feel terrifying at first – my experience has been, especially with support groups, is it begins to feel like a jacuzzi. My support group meetings, I feel safer there than I do any other place on the planet. I feel connected, I feel purposeful, we laugh, we cry, we support each other. I’ve shared my darkest secrets and it’s been met with love and compassion and other people have opened up to me about their things. When you see somebody once a week that you share that bond with, and you hug each other, or you make a fucked-up joke and you both laugh your ass off – it’s what I wanted my whole life. I used to think that a safe future was going to come from me being exceptional in what I did professionally, and it led me to being the most despondent, suicidal, financially successful as I’ve ever been, and I’m glad I hit that dead end, because I didn’t realize that there was a spiritual – not religious, but a spiritual – emptiness inside me, because all I cared about was myself. I needed this cross to bear, I believe, to be able – to have to – connect to other people and learn how to be vulnerable. It is the most beautiful gift in the ugliest wrapping paper.
CM: Right. I mean, you’re talking about a deep, dark crisis can change a person, their course, so fundamentally and lead to positive things that you never could have imagined. The way I see it is that many people suffer and have that crisis but keep it so closed-up and think that ‘If I just brush it under the rug and try to move on as if it didn’t happen, it’s a new day so I don’t have to go there,’ that you miss out on that opportunity and maybe worse. So it doesn’t necessarily always go that way; I think it depends on what happens during the crisis and after that crisis in terms of talking about it openly. That’s really the key to everything else that can come next.
PG: Yes. And having patience with the process and realizing that it’s not linear, it’s a lot of ‘two steps forward, one step back,’ but the overall momentum will be forward. And a lot of times what feels like the ‘mistakes’ along the way, can be a learning experience that can not only benefit us in the long run because we gain wisdom about maybe how to decide who to let in, who to be vulnerable around, but we’re able to share that with somebody else and say, ‘Gosh, that person in your life that feels like your best friend, the way they talk to you is really kind of mean, or let’s look at their actions, I would call this a toxic person, you might want to rethink your relationship with them.’ And if you hadn’t opened up to somebody who was toxic and you had a bad experience with it, you wouldn’t be able to share with them, ‘God, here’s this moment in recovery I had that felt like, oh, recovery doesn’t work, but in hindsight, no, it just refined my ability to get a gauge of who’s safe and who isn’t. Does that make sense?
CM: Yeah, absolutely. Right, that is the key thing that I would say – if you’re somebody who has been thinking about talking about your experience of either being suicidal, of an attempt, or of losing someone to suicide – or other mental health experiences for that matter – I would say take it slow, and pick individuals who are very trustworthy, and you know that they can handle it, and they have a level of understanding that is probably different from the average person. We at AFSP, we actually even created a resource to help people prepare, especially if they were going to start speaking publicly about these experiences, so that they were emotionally ready for it. Because there can be a bit of an unexpected emotional experience later, if you’re not quite ready for it. So, just being sort of understanding, that big picture. And also understanding some of the pragmatic implications. If you talk about your experience with depression or PTSD or a suicide attempt, and your workplace isn’t yet ready for that, doesn’t understand that mental health is a part of health and therefore should have the exact same approach as any health condition would.
PG: The flu or diabetes, whatever, yeah.
CM: Yep. We’re in a time of transition, so some workplaces are amazing that way and others are not quite there yet. So, you want to just set things up in a way that it’s going to go really well for you and, of course, that you provide a safe and effective hopeful message for other people.
PG: What are some tips for that, or where is a resource where people can learn tips for that?
CM: If you go to AFSP.org you’ll find a whole lot of resources, including how to tell your story. It’s a resource, that’s what it’s called. But some of the tips in there are just, kind of, taking some time to reflect and think through, what is it going to feel like on the other side of that public speaking event? Am I going to be okay with a level of disclosure – especially if this is the first time. Many people get very accustomed to speaking about it.
PG: So you mean, this could be just a one-on-one with your boss, when you say public speaking? You don’t mean at a lectern in front of two hundred people?
CM: Well, it could be both. The resource we made was specifically for speaking at public events, because we have so many out-of-the-darkness walks and opportunities to elevate the conversation about suicide and mental health through the combination of personal storytelling along with some chunky education about what the science tells us and what’s actionable, what anyone can do to play a role in suicide prevention. There is a hunger for this like never before, it’s really amazing.
PG: Yeah. Any other tips for somebody who is afraid to open up, be it in the workplace or just in general – they’re suffering, they’re replaying the idea of suicide over and over in their brain, maybe they’re getting close to making a plan?
CM: Right. If you’re in a place where you’re actively struggling with whether you’re going to stay alive or not, I would not go into this space of talking to anyone who is risky at all.
PG: Non-crisis people.
CM: Exactly – find healthcare professionals or people who have proven themselves to be very trustworthy and capable of going to that place with you and tolerating it, and just checking back in with you.
PG: How about the guy who operates the Tilt-A-Whirl? Would he not be somebody to open up to?
CM: (Laughs)
PG: What if he looks trustworthy, and he runs a nice ride?
CM: You never know! He might have his own experiences, in all likelihood, as our data shows!
PG: He works at the carnival? Yes! There is some fucked-up shit in his background?
CM: (Laughs) No, well, I’m really talking about the whole population. We did this Harris Poll at AFSP along with the National Action Alliance for Suicide Prevention. We surveyed two thousand American adults and it turns out that 55% of individuals have either had an experience of loss to suicide – not necessarily in their close family but in their community or in their network – or they have thought of suicide, or they have attempted, or a loved one has struggled in those ways. So we are talking about the majority of individuals.
PG: Yes.
CM: The prevalence of these experiences of having a thought about taking one’s life – the prevalence especially among youth of suicidal ideation, it’s about 1 in 5 within a twelve-month period that will think of suicide. It doesn’t mean that they take it any further, but it could indicate that there’s risk of suicide there. In a way, to me, what suicide prevention is all about, is facing these facts that are all around us, whether we want to go there or not, but those of us who are equipped and wired to do it can help lead into a space where everyone can get comfortable enough. Just like you would do, hopefully, if you saw somebody bleeding, like general first aid, that people would know how to have this kind of caring conversation that’s essentially like mental health first aid.
PG: Okay, so, there were times when I, more common than the ‘I need to kill myself’ was the ‘Oh fuck, I didn’t die in my sleep again, I just don’t want to be alive, I don’t want to kill myself.’ Address that space, which I think so many of us live in. It’s such a prison.
CM: Yeah, you’re really talking about – the clinical term for it is passive suicidal ideation, that wish that something could just end my life without me having to actively pursue that.
PG: I used to love turbulence on planes, because I would think, ‘Oh, please do it for me.’
CM: Right, and that turns out to be as serious as thoughts that are more active about finding your own method.
PG: So you’re suicidal and lazy, that’s what you’re saying? (Laughs)
CM: (Laughs) No, I think our minds just do certain things based on lots of different factors, and it is really fascinating – I mean, the most encouraging thing to me is that that does exist, that does exist for many people. For some people it will be a short experience and for other people it will be a longer term experience, but there is a way through that, beyond that, to something new and different. For many. Now, for some, their brains will keep on that path, and again, then it’s more the question of ‘How do I manage that? How do I remind myself that that is my brain taking me there, but that does not have to be the way I choose to respond or to see myself?’ Very hard to grapple with your own internal machinery of your brain, but people can do it.
PG: Yes. And that is the heart of the thinking of an addict or an alcoholic – it is a way of viewing reality that is warped and will be there forever, but we get better at catching it and seeing, ‘Oh, okay, this is not reality, this is one of my thousand fears warping this situation and I just need to let go right here and not try to future-trip and be a control freak.’ Which I think is hard for people who have had their trust violated as children. It’s very hard to let go and say, ‘Okay, this is just my mind or my central nervous system in fight-or-flight mode, or whatever it is.
CM: Yes, and I think people learn different tools of how to respond to that in the most effective way that makes sense for them, and those are tools that people sometimes find on their own, or they find through cognitive behavioral therapy, since you brought that up. That is the quintessential evidence-based treatment that helps people, empowers them with their own cognitive tools. And it’s not just – it could be what you think and say to yourself; it also could be what you do to reboot your brain into a new space that is more healthy and seeing the big picture. People learn what does that for them.
PG: Right. And dialectical behavior therapy, another huge, huge tool, especially for people with borderline personality disorder.
CM: Yes, yes, absolutely.
PG: Can you talk about that a little bit?
CM: Sure. DBT is so remarkable and so powerful, certainly for people with borderline personality disorder, certainly if somebody has attempted suicide, DBT is one of a handful of the most powerfully suicide-risk-reducing treatments. It’s been studied for, like you mentioned, people with borderline personality disorder but also people with substance use disorders, eating disorders… It’s been studied in adolescents who have attempted, and now there’s even a study of DBT for pre-pubescent children aged 7-12 who have dysregulated mood disorder. DBT not only works with the person so that they can learn new emotion and behavior regulation skills –
PG: Instead of outburst or withdrawing or self-hating in isolation.
CM: Yep, there are some strategies that involve mindfulness and just pausing before reacting, and then beyond that, other strategies and actual skills that they’ll practice and use. But the beautiful thing, especially in the case of these adolescent and children approaches with DBT, is that it’s all about that with the person and with the family unit, and with parents, and skills-based.
PG: Communication.
CM: Right, so that you leave therapy and you go back to your home environment, and can you be in a place that is also supporting those same types of skills and practices, or is it actually the space that triggers you more? Because, of course, as the parent is extraordinarily stressful to have a child or a teen who is thinking of suicide, who’s reacting emotionally in outbursts or attempting suicide. There’s nothing more stressful than that. So, that requires working with the parents as well. So, anyway, DBT is phenomenal.
PG: From what I understand, some policemen even use it in attempting to deescalate situations where someone is being potentially violent. From what I understand, it’s a way of letting that person know that you hear them, you understand where they’re coming from, but here’s a different point of view or here’s how I want to help you. It sounds like you’re inviting each other to be a part of your team when this conflict is happening, rather than there’s going to be a victor and a vanquished in this situation – which, I would imagine, is where all escalation happens, is feeling like we are pitted against each other rather than, ‘Hey, let’s make sure that there’s not a misunderstanding here, because I think I might understand where you’re coming from more than you think I do,’ or if you’re the person who’s upset, instead of lashing out and saying ‘I hate you, you’re the worst person in the world,’ saying ‘I’m feeling frightened right now, I’m feeling really frustrated, I feel like nobody cares about me or that you’re not interested in me,’ etc. I know in my own life, that has helped me in relationships when I just want to explore or isolate, to be able to express what I’m feeling rather than pointing fingers.
CM: Yes. I’m so glad you brought up that ‘coming on the same team’ and working together, because even in treatment you’d think that therapists or counselors are trained that way, and many are, but when it comes to the suicide topics, sometimes that can go in a different direction because it’s so anxiety-provoking for the therapist and they go into the mode of listing out their questions of the suicide risk assessment. Well, the person has just shared something incredibly private, maybe risky, and now they’re being grilled with a series of questions.
PG: Which is not what they need in that moment!
CM: Right, and so, there are approaches that are really coming out now into the clinical space to help therapists and doctors understand that there’s a better way to allow the person to tell their story and then to do the suicide risk assessment. There are even some brief, short-term treatment modalities, I’ll mention one called CAMS, Collaborative Assessment and Management of Suicidality, which was meant to just bridge a brief period of time between the time of discharge from a psychiatric unit or the emergency department, let’s say after a suicide attempt, until they have time to get connected to outpatient care. It was designed for this bridging period, which is actually a very important timeframe for people who are at risk for suicide. But it’s turned into a more broad-reaching treatment approach, where the therapist literally sits next to the client and they work through reasons for living and reasons for dying, they use a series of things that they look at together. The idea is that the patient, through some motivational interviewing types of approaches, can engage with that part of them that is holding on to hope, that wants to stay safe, and they can engage in that process together and work on, what are you triggers? Can we use a safety plan? That’s a very common practice these days that’s very important that everyone should know about, a safety plan. If you’ve never heard of it and you’re somebody who does hit some crisis points or suicidal thinking, it’s something you could even learn about yourself. But therapists could use it, other peer-to-peer – it’s been used in all sorts of different ways where the person engages in, what are my triggers? What are my best practices that I can use skills internally? Who can I count on outside of myself? Who can I call? And how do I keep my environment safe? These are things that individuals will engage with. It seems so basic, and yet in the treatment scenario that has not always been assumed, that a person is willing or able to do that. And certainly, in some circumstances, people aren’t when they’re acutely at risk, but it’s far more than people may have realized.
PG: You know, as you were sharing the image of the therapist sitting next to the person, the other thought that occurred to me was, it is a fact on the ground for that person that they matter. Because I think when people are at their most suicidal, the belief is that we don’t matter, or even worse, that we’re a burden, which I understand is a really common thought for people who attempt. What a great idea to have somebody – I mean, it’s such common sense that in your moment of need. If you are injured on the battlefield, people wouldn’t shout to you, ‘Hey man, I hope your leg gets better!’
CM: Right, yeah. It’s absolutely so true, everything you’re saying. Therapy is supposed to be therapeutic, but family members can also facilitate and be part of creating an environment that, number one, has to be aware that suicidal thoughts are happening. That’s the first thing; we need to get rid of that stigma so that we can talk about these things in our homes and in our friendships. And then to know that just a little bit of basic knowledge about where the mind can go, because I think many people, they’re open-minded to the idea of mental health being real, but they don’t understand necessarily that that means it’s common for people when they get into whatever space it is – crisis, depression – that their mind will play tricks on them. They will convince themselves that people are better off without them. A lot of those myths that are out there, hopefully diminishing, about suicide, just simply don’t make sense if you understand some of these basic things about what a person is actually going through when they’re in that state of crisis.
PG: Is there a different game plan for someone who is in suicidal ideation because they are future-tripping and extrapolating their fears in a vague kind of way, and someone who is in the present moment perhaps dealing with chronic pain or something that has nothing to do with them thinking about the future – the present, not based on future thoughts, the present is so painful?
CM: You bring up the fact that people come to think about suicide in an infinite number of pathways and ways that get them there. I think if you are a pain specialist working with people with chronic pain, a starting point would be to realize that suicidal ideation is very, very common in people who live with chronic pain, because it is a load to carry and to process on a moment-to-moment basis for those individuals. So, resilience does get worn down, by definition. It’s not a matter of strength or of character; we’re human, we’re very dynamic in that way. I think the approach ideally should be customized to what the person – again, back to the narrative, allowing people to tell their stories – that you have to actually understand how they got there rather than just thinking, ‘Oh, suicidal ideation –‘
PG: ‘How do I fix it?’
CM: M-hm. This monolithic thing. That’s really not understanding how to help the person best.
PG: So how do we, let’s say with a loved one, when somebody comes to us with suicidal ideation. How do we know the difference between somebody who’s like, ‘Man, I’m so tired of being alive,’ to ‘I just want to let you know that every day I’m out standing on a bridge, and really close.’
CM: Usually, people won’t hand it to you on a platter quite that clearly. They might, certainly, but any hint around hopelessness, feeling trapped, overwhelmed, or like a burden, or if you’re living with the person, you know their day-to-day patterns of sleep, eat, energy, socializing, their favorite activities… As much as we do have free will as autonomous individuals, our behavioral patterns are kind of like our biological patterns in our body; they tend to stay in a narrow range unless something significant is causing a shift. So, I really encourage people, just trust your instinct – if something seems off, what is going to be the harm in having a caring check-in type of conversation? And really, even if they don’t tell you everything that’s going on, starting the process of inviting it, that’s part of the deal. Many people aren’t ready to talk about these deeper things because it has not necessarily been part of the pattern of your friendship or your relationship with them. But you can go there, and I think we oftentimes don’t go there because we don’t know what to say, we get nervous, and we’re not sure if it’s going to offend the person. So the next thing we do is we rationalize not even saying anything. We say, ‘Oh, they’re just stressed because something’s going on in their life.’ Well, guess what? There’s always something going on in life, but if you notice something, it’s probably significant enough to ask about.
PG: Yeah. It seems like the things that you share, the hesitations that the person has, that it would be fine to preface with those things and remind the person that you care about them. ‘I care about you, and I could be making it up but it seems like you’re withdrawing a lot, and forgive me if I’m being nosy, I just – is there anything you want to talk about? I hope I’m not being rude or offending you, but again, I care about you and I just want you to know I’m here to listen and help you in any way that I can.’
CM: Absolutely, a hundred percent. The key thing, I would say, is, as you said, be direct, say ‘I care about you and I’m here to support you. I want to understand if stuff is going on in your life, because I’ve noticed X, Y and Z.’ Just be that direct, because if they are in distress, and now you’re approaching them in this new and sort of weird, different way, their mind is going to start going, ‘What’s happening here?’
PG: ‘Are they judging me? Are they going to tell other people?’
CM: Yes. So if you just lay it out clearly – and you have to say the things that are in your head, like ‘I’m not going to judge you, I am really interested in supporting you because I care about you.’
PG: ‘I’m not trying to embarrass you.’
CM: Exactly, right. But I think we would probably apologize more than we need to. It’s almost the kind of thing that you need to just kind of make your little talking points and just stick to it and be direct. Say, ‘I really want to have this conversation with you because I care about you, and I’ve noticed X, Y and Z. Would you feel comfortable talking to me about what’s been happening in your life?’ And it’s really that, this is not going to be the language of mental health symptoms; this is going to be the conversation of what is going on in their life, and it’s going to be the way that they talk about that. You have to be listening for those cues of, as I mentioned, hopelessness, feeling trapped or like a burden, or that the stress is affecting their physical body, that many of us – we all have physical bodies, our brain is part of the physical body, and we do experience stress, depression, anxiety, PTSD, addiction, in very physical ways.
PG: Which then affects the thinking and the actions and it’s this big circle.
CM: That’s right, it is. You have to realize that the person, if they’re in a state of distress or crisis, they’re not necessarily having access to all of their usual sense of humor, creative problem-solving… Those things might be dismantled and put off, locked up in a room that they will access later, but right now, understand that there is something different, a force at work that, just by being a listening ear and being supportive, you can help normalize what they’re going through in a sense – at least normalize the experience of talking about it, and possibly be a stepping stone that helps lead them to the next positive thing that’s going to help them. I would continue to be a friend, just like you would check in with a friend who’s going through a hard time about anything – grief, financial hardships or whatever. A good friend tends to remember that and asks about it when they see the person next, or might go out of their way to reach out and ask about it. We absolutely need to remember to do that when it comes to these deeper sharing conversations, because when they do happen, and the person never checks in again, it’s a very weird message that that sends to the person. Like, ‘Ooh, maybe that wasn’t okay with them,’ and again, all those negative distortions – the person is left to spin that out into a different place.
PG: Something that I’ve heard people share as well is, if that person is stuck in that place of immobility and hopelessness, to offer to help find a therapist. To drive them to their first appointment. To sit in the waiting room and wait for them. To aid them in a way that isn’t you trying to ‘fix’ them.
CM: Right. And in a way, if you are that kind of friend, if they had a broken leg or were going in for same-day surgery, that you would offer to drive – it is exactly the same then for this mental health piece. I think that can be a guidepost. People often wonder, especially in the workplace or in friendships, in a family – ‘Well, how do I approach this, because it’s all so tangled up and it feels very overwhelming,’ and the family member’s emotions are getting triggered as well. I think a very grounding principle is, what would you do if they were in an acute physical health crisis right now? You would come around, you would support, you would make sure that they’re immediate medical needs are being met, and then you would follow up. Whatever your relationship allows for in that kind of space, same thing for mental health. And I would say the same thing applies for people who have lost a loved one to suicide. So often, even in this day and age when things have changed dramatically, or at least that movement is growing in huge numbers in terms of people being so much more open and taking the stigma out of suicide, and if that’s the cause of death, calling it what it is. People even use a term, by the way, of ‘I lost my loved one to his depression or to his addiction,’ and going there in terms of the root that they believe drove the suicide, that’s helpful, too. But again, for the community and friends, to not support that person in a moment of intense, complex grief is just, it’s frankly inhumane.
PG: And probably shame. There’s survivor guilt of ‘I shoulda shoulda shoulda…,’ which is never the case, correct?
CM: Yeah, that search for ‘Why?’ is a given after a loss to suicide has occurred, because of course your mind is going to try to reconstruct everything that happened, what did I miss? And here’s the deal with suicide death – all of us see one slice of the pie, and we only see a very limited portion of that slice. The truth is very hard, which is that no one will probably ever have access to the full story, certainly not internally what the person was experiencing, nor the possible long-term risk factors that were starting to erupt and come to bear based on an interaction that happens between multiple risk factors that lead to that death. So, the ‘Why?’ search can be extremely obsessional and excruciating for many, let alone the shame, the self-blaming, the blaming all around… But, needless to say, it’s a time with lots of mixture of emotions, and so, as a friend, you don’t have to figure all that out; you don’t even have to go there. You can just say, ‘I’m here for you.’ You can bring them food like you normally would if somebody loses a loved one, and you can say the person’s name who died. Oftentimes people just don’t touch it! And the family members, some of them, some loss survivors really want to remember their loved one; they want to talk about their life, they want to remember them for what they were in their life, not just by the way they died.
PG: Yes. Something that we did when I was married – my mother-in-law died, and after the funeral we watched home movies of her, and it was so soothing to just remember how much she made us laugh, how much she laughed at herself. It was really great.
CM: Yes, yes. And that same thing can happen after a suicide death, even though for a period it will be very complicated and wrapped up around the way that the person died.
PG: Yes, and address – ‘God, I don’t know what to say, because I don’t want to say the wrong thing. I can’t imagine how much pain you’re in.’ The biggest mistake that I hear people make is, they want to try to change what that person is feeling. ‘Well, you know, you still have three other children,’ or ‘You have this beautiful home,’ or…
CM: Yes, yes. These platitudes, people trying to come up with something. I think it is far better to say, like you said, ‘I can’t imagine what you are going through, but I do want to be here for you. I’m not going to stay away, I’m going to be here.’ Just showing up is a key principle for suicide grief, that period, as well as for after a suicide attempt. That’s another period where sometimes family members and friends don’t know what to do and they’re so afraid of triggering them into a bad place, they don’t know what to talk about. But come around, sit with the person, talk with them, be silent – follow their cues. Ask them, ‘How do we have conversations that are helpful to you, where you are right now and whatever you need?’ Many people who are in a place to be able to actually process, what happened and how did I end up attempting? Their path, while not linear, is something of a recovery experience, and if you’re – look, no one’s going to be perfect as the family and friends around that, because you can’t read the person’s mind; but you can communicate in a loving and non-judgmental way that’s respectful of their space, while you take care of yourself too, because again, this is very triggering for family members. But to try to be intelligent about, what is your boundary of taking care of your own needs, and not really putting that on each other – both ways.
PG: Right. The other common mistake that I hear people make – and I know I’ve been guilty of this – is, ‘Let me know if there is anything you need.’ Which is really our way of giving ourselves an out, making ourselves look like a good person – I should just speak for myself. Something that I try to do instead now – because I know as the other person, I already feel like a burden, so I’m not going to pick up the phone and say, ‘I haven’t been able to cook for myself’ or ‘I’ve been crying all day and I just need a shoulder to lay my head on.’ What I try to do now is I say, ‘I would love to bring you food on Tuesday afternoon. Would it be okay if I did that?’ I think things like that are helpful – concrete things with a day in mind, and letting the person know that you want to do that.
CM: Right, right. You’re taking the initiative, they’re not having to expend the energy to try to decide anything other than say ‘yes, thank you, that would be helpful.’
PG: Yeah, and ‘I’d like to hang out with you.’
CM: Yeah. This is hard, but I think these are definitely the guiding principles, show up and not avoid, to ask ‘Can I do such and such, and do please feel free to tell me if that’s not what you need…’ To just be open to that kind of dialog but understanding that this is a moment where the person is not – their energy is being taken up by something else, especially if this is suicide loss grief. It’s a very, very intense grieving period.
PG: And resist the urge to make it about you.
CM: Yeah, right.
PG: Which, for narcissists like me, is very hard.
CM: Well, I think it’s hard for everybody. Everyone lives in their own heads and walks in their own shoes and, you know, you want to be helpful but we haven’t always been conditioned by our families or our cultural norms in our neighborhoods, wherever we are in the world, to know what that looks like. We’ve lost the art of just connecting! And we have to find ways to counter that. I think that’s why, in part, this conversation around deep authenticity with this human experience that can intersect with mental health, can intersect with a lot of things, is so important that we model that, that we promote that, that we help people who don’t, they want to but they’re not sure, and it’s so much easier to just stay with the status quo and stay locked up… But to invite that change to happen, that is such a beautiful thing. And it is amazing to see that happening around the country in so many different ways.
PG: How do we know, if somebody we care about is considering suicide, how do we know when to just be the ear, to listen to them, and when to call for help, as in 911 or, what are the resources that we should do?
CM: I think if you are having this dialog and the person is not just having thoughts of ‘I’d be better off dead’ or ‘I’m thinking of this method’ and you know that they have access to that method and they are not giving you any indication of a different way of thinking or coping. In that moment I would be very seriously trying to make sure that either that day or very shortly thereafter, they’re getting connected with a mental health professional, or even their primary care doctor. That’s another way that you can go – it’s hard to get in with a mental health person right away, which is true in so many places. I would reserve calling 911 for a period where they are actively harming themselves or they are in the process, because what can happen when the police show up, that process can be so traumatizing –
PG: And shaming, yeah.
CM: Yes, and there is a time for it, because certainly, you want to save a life. That’s first priority. With the caveat in all this being that even clinicians can’t predict suicide risk. There’s no science that tells us how to do that. The suicide risk assessment helps, but it’s more like just connecting and following up and getting them onto a long-term path of deeper recovery. So I really would encourage people that getting the police involved is to be avoided unless there is an imminent, current threat to life and to safety. Now, bringing them to a local ER can be an option if you’re just really not sure and you’re very, very worried, especially if they’ll go with you.
PG: Oh, okay. If they won’t go with you, obviously you can’t bring them to an ER.
CM: Right, if they won’t, then what I would do – if they’re not actively harming themselves right now and are not about to, momentarily – I would call the National Suicide Prevention lifeline as the helper or friend, and get their guidance. They’ll talk to you, they’ll talk to the person of concern, if they will talk to the trained counselor at the lifeline, and they will help you figure out, where is this at, what needs to happen now? The lifeline, the crisis text line – let me give you the ways to access them.
PG: And we’ll put out the links to all of this under the show notes for this episode.
CM: Right. The lifeline is 1-800-273-TALK, and the crisis text line for people who prefer to text over getting on the phone is, text the word TALK to 741 741. 24/7, these systems are actively having dialog.
PG: So they will respond to you, ‘I’m such-and-such, what’s going on?’
CM: Yes, and as I mentioned, you can be the helping person, to get some guidance in an acute moment where you’re not really sure, like you’re saying, is this an imminent threat to their safety or not? In the vast majority of cases, if that conversation has been helpful and they’ve shared with you some, and there’s a plan moving forward and ways to check in with each other, that is the way to go. Certainly if they’ll take a referral or if you can drive them to see their doctor or to a therapist, help them find one – all those things are excellent. And if you’re not sure how to find a mental health professional, there are links on our website for that as well. Go to AFSP.org and find Support. There are a couple of treatment finder links, both for mental health conditions and one specifically for substance use problems.
PG: Okay, great. There are so many other questions that I want to ask you about psychiatry and medication, but I think I’m going to wait until you’re in town and we’ll do a return episode if you’d be kind enough to come be a guest again.
CM: Sounds great.
PG: I’m so glad that we were able to do this and thanks for taking the time out and sharing such great information.
CM: Thank you. Thanks for what you do and your work, it’s amazing.
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