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Loneliness, Depression, and Suicide

Barry Greenwald, Ph.D.

SESSION GOALS:

  • To define the "depression continuum" from normal to psychotic manifestations of depression.
  • To point out both the obvious and subtle symptoms of depression.
  • To point out the relationship between depression and suicide
  • To provide some suggestions for ways of dealing with depression, suicidal preoccupations, and suicide in progress.
  • A UNIVERSAL EXPERIENCE
    Few, if any of us, have escaped feeling depressed. We may have different words for it, e.g., "I feel down," "I'm so blue," "I just don't seem to care about anything," "I've no energy for anything," "I just want to crawl into bed and pull the covers over my head" but the underlying emotional experience is essentially the same. Feeling "down in the dumps" from time to time seems to be a part of the human experience. It is never a pleasant feeling; but it is usually endurable because it doesn't go on forever. At least, in normal depressions, it doesn't go on forever. Some people, however, seem more prone to depression. They have more frequent experiences of the "moody blues" and the duration of these feelings often last for long period of times. Both duration and intensity are key factors in determining the difference between "normal depressions" and depressions that are the expression of unresolved psychological problems. Depression is really a collection of symptoms and can be thought of as a symbolic communication that there is something wrong in an individual's ability to maintain a comfortable psychological balance.

    SYMPTOMS AND COMPLAINTS
  • Feeling sad, lonely, down,
  • Feeling excessively self critical, worthless
  • Loss of self esteem
  • Unexplained teariness or weeping
  • Feeling tired, energyless, exhausted
  • Changes in sleep patterns; i.e., insomnia, wanting to sleep too much or not at all.
  • Changes in eating patterns; i.e., eating too much or loss of appetite
  • Loss of weight
  • Feeling empty, hollow, lifeless, dead
  • Disinterest in everything and anyone
  • Irritability
  • Concentration problems
  • Vague complaints about bodily symptoms, e.g., backaches, headaches
  • Decrease in communication
  • Withdrawn behavior
  • Highly agitated behavior (in an agitated depression)
  • Exaggerated excitement; person looks as if he/she is trying to hard to appear happy
  • SOME ATTEMPTS AT EXPLANATION
    Biological

    Some theories propose that clinical depression in caused by a biological problem. Sleep and eating (vegetative functions) problems are often used as evidence for the biological theories as is the fact that people who are depressed often respond to anti-depressant medication. Recent research made possible by non-invasive techniques (MRI, CAT) have shown that the brains of people experiencing depression show marked variations in the absorption of serotonin and norepinephrine. giving greater credibility to the biological bases for depression. Both the older and newer generations of anti-depressant medications deal directly with these neurotransmitter, often preventing their re-uptake making them more available at the synapses. If, ultimately, depression as we know it turns out to be a "biochemical disorder," the temptation may be to overlook the psychological components that are a part of this illness. Psychological reactions are a part of every illness and need to be addressed if the suffering individual is to be helped.

    Psychological: Failure to live up to ideal

    Psychological theories have traditionally explained depression as "Anger turned inward against the self." If you fail to live up to some internal standard of who or what you are supposed to be, some internal watchdog notes your failure and begins to let you know that you haven't been all that you could be--depression. People often talk about being angry with themselves because they have not accomplished or achieved or done what they think they should have. This explanation accounts for the diminished self esteem depressed people often report.

    Psychological: Problems expressing anger

    Often depressed people report having great difficulties expressing any kind of anger. Instead of becoming angry with someone who has provoked them, the anger is turned inward against some part of the self. They don't even kick the cat; they kick themselves. These people have a way of making everything their own fault so that no matter what happens, they can blame themselves. Others talk about anger as a useless emotion, i.e., "What good does getting angry do anyway?" Intellectually, they attempt to convince themselves and others that anger accomplishes nothing so why bother. What they don't realize is that this style drives anger beneath the surface and forces it to find a more indirect avenue for expression.

    Psychological: Empathic failures

    Depression also seems to be the reaction to empathic failures on the part of others. When important people fail to understand, recognize, acknowledge, appreciate, or respond in a way that we hoped they would, that can be a sufficient injury to produce a depression. It is as if their failure delivers the message that we are not good enough, worthwhile or important. It is a slight to our self esteem and it does not even have to be of major proportions. Some people are more sensitive to this kind of injury because of their personal history, so a small slight may well have the same psychological importance as a major rebuff

    Psychological: Reactions to life events

    Certain events that occur as a part of life carry depression as a component. Endings, separations. losses, and death elicit strong emotional reactions in those who are experiencing them; depression is often a part. More specifically, divorce, moving to a new place, graduations, the end of a romantic relationship, a good friend moving away, the completion of a major project, the death of a loved one are examples of normal events that can evoke strong, reactive depressions. These depressions are a part of a more global emotional state known as "mourning" when an individual withdraws his energies from other activities and seemingly reinvests them in himself. Loss is experienced as a wound and the individual needs time to heal, to restore his psychic equilibrium. The period following loss is a time of reassessment and revision. Loss requires a new adjustment, a learning to do without whatever has been lost. It is a slow process and often a confusing time as people try to work out how their life is going to be now. Periods of mourning and its attendant depression that stretch beyond three years, however, should be carefully assessed. This otherwise normal process may have taken on some pathological elements.

    THE CLINICAL SPECTRUM
    Depression runs the gamut from mild to severe and at the severe end of the continuum, it is a profoundly disabling disorder. The more common forms of depression are currently labeled Dysthymia (Depressive Neurosis). A more severe version is considered to be a Major Depression. At the severe end of the continuum are the Bipolar Disorders which are characterized by depression or mania or a combination of both mood states. Milder forms of this disorder are called cyclothymia. Depression may exist with or without psychotic features (markedly impaired reality testing, peculiar or highly idiosyncratic thinking). It may be chronic (of long standing) or episodic (intervening periods of normal moods).

    Psychotic depressions are paralyzing, often characterized by complete withdrawal, the absence of speech and the absence of movement. It is as if the person returns to an exclusively vegetative state where only bare existence is maintained. Depressions that reach this level often require hospitalization and are treated with antidepressant medication or electro-convulsive therapy (ECT).

    The manic side is quite a different picture. It is characterized by high states of agitation, driven behavior, stream of consciousness thinking, emotionality, a need to be doing something all the time, an exaggerated sense of well being, poor reality testing, poor judgement, and irritability. The person who is in a manic state gives the impression of being incredibly "high" on something. They are uncontainable, off in a million different directions simultaneously. Often, hospitalization and medication is required in order to treat the person. Lithium is often prescribed as the drug of choice since it tends to dampen the manic state and prevent future episodes when taken properly.

    It is not uncommon for a person suffering from a bipolar or cyclothymic disorder to move back and forth between depressed and manic positions. Some theorists believe that the manic phase is really a defense against depression. The person is struggling mightily to keep from becoming depressed by maintaining this exaggerated mental and physical activity level. It is also possible for people to show only the depressed side or only the manic side.

    In the more moderate range are the depressions that are not so profound but nevertheless painful and troubling to the people who experience them. Hospitalization is seldom required and usually psychotherapy will provide sufficient insight so that there will be relief from the symptoms of depression. It is not unusual to discover that people suffering a moderate depression are also being treated with antidepressant medication. What is important to remember is that talking is often a very important means for the depressed person to find out why he/she is depressed. What are the triggers in his/her life that sets the depression into motion.

    STRATEGIES FOR DEALING WITH A DEPRESSED CALLER
    (Because depression depletes the energy level of the person, the liner may need to be a bit more active than usual in order to elicit material and move the call along.)

    Once the caller has identified him/herself as feeling depressed or has offered some of the symptoms listed above, find out as much as you can about the complaints, when they occur, how are they affecting the person's life, i.e., just how disabling is the depression.

    1. Find out how long the symptoms have been going on and as much about the time they began as possible. Listen for "significant others" so you know who is important to the person. Listen for "significant events" so you know what is important to this person. Then listen for disappointments, slights, failures, a feeling of having failed someone important, losses, significant changes in the person life.
    2. As the person reveals his/her history to you, be sure to ask about the feelings that surrounded the people or events that are described to you. "What were your feelings?" "How did you feel about that?" "You didn't say what you felt about that." You want the person to talk in feeling language as much as possible.
    3. Be alert to omissions. If a person describes something to you that could well have evoked hurt, anger, insult, frustration and it is not mentioned, wonder about it. "Were you hurt about that?" "You might have been angry?" "Sounds as if its difficult to put your finger on what you were feeling. What was going on inside of you?"
    4. Listen for problems dealing with anger. An important part of your strategy is to help the person discover, if appropriate, that his/her depression has something to do with unexpressed angry feelings. "It sounds as if you work very hard not to be angry..." "What became of the hurt feelings?" "Where do you put your anger when you don't express it?" "It seems much easier for you to be angry with yourself than to be angry with someone else."
    5. If unexpressed anger does not seem to be the pivotal issue, listen and explore for the other possibilities discussed above.
    6. Our goal is to help a person understand what might have been the event and the emotional interpretation placed on it that triggered the depressed response. Keep in mind the "event" does not have to be major in order to trigger the depression: "He didn't call" "I'd hoped she would remember." "I can't believe that just forgetting my name could be so upsetting to me."
    7. Helping find the "trigger event" is easier when the depression has had a recent onset and seems more like a mild to moderate reaction.
    8. Our goal with a person who reports a depression of long standing is likely to be different. It is possible that this not the first time the person has been depressed and when that is so, this is probably a pattern. Our ultimate goal with a caller who evidences repeated, prolonged depressions is to refer for psychotherapy so that the person may explore the significant issues in the context of a long term relationship.

    SUICIDE

    A BRIEF "TRUE" AND "FALSE" EXERCISE...
    Take the following test and see how well you do.

    1. People who talk about suicide don't commit suicide. True or False (circle)
    2. Suicide happens without warning. True or False (circle)
    3. People who are suicidal are fully intent on dying True or False (circle)
    4. Once a person is suicidal, he or she is suicidal forever. True or False (circle)
    5. When a person reports feeling better after a suicidal crisis, the suicidal risk is over. True or False (circle)
    6. Suicide strikes much more often among the rich or, conversely, it occurs almost exclusively among the poor. True or False (circle)
    7. Suicide is inherited; it "runs in the family." True or False (circle)
    8. All suicidal individuals are mentally ill and suicide is always the act of an extremely disturbed person. True or False (circle)
    The answers for this exercise will be provided at the end of this section on Suicide.

    BY WAY OF INTRODUCTION
    Not everyone who is depressed is a suicidal risk. Not everyone who has ever thought about suicide is a real risk. From time to time, we have all considered the possibility that things would be a whole lot easier if we weren't alive. These are the moments when we want relief from the seemingly overwhelming pressures that make life extremely difficult. Suicidal thoughts, in these instances, is the wish to be "out from under" the enormous burdens or disappointments or hurts we are carrying.

    On the other hand, depression and suicide are related and suicides and suicide attempts are usually preceded by a period of serious depression. For some people, death becomes preferable to life. It represents a solution to what seems to be the insurmountable problems in their lives. For some people, it is a last, desperate plea to have acknowledged the incredible and interminable pain they are in. And, for some people, it is an angry assault on those people who will be left behind who must deal with the emotional aftermath of a suicide. And, when alcohol enters the picture, the increase in risk becomes substantial.

    Of all the emotionally loaded situations faced by crisis workers, suicide is the most frightening and the situation most likely to be mishandled. The urgent life and death nature of suicide brings out the RESCUER in all of us. We harbor the belief that we can be responsible for saving the suicide. We also harbor the terrifying belief that we may push the person "over the edge" and become responsible for the death. Neither belief, while understandable, is likely to promote appropriate clinical interventions.

    Before continuing with interventions, let us look at some of the signs that indicate high suicidal potential.

    SUICIDE INDICATORS
    1. Previous attempts; 50% to 80% of those who commit suicide have previously attempted it.
    2. Lethality of attempt: The more violent and painful a previous attempt (gunshot wound, hanging) the greater the risk.
    3. Age: The highest risk age group is 75-79; the second highest is 55-64 and the third highest age group is 15-24.
    4. Depression: This symptom combined with problems sleeping and eating increases the risk approximately 500 times. People are more likely to be at risk when they are coming out of a depression rather than when they are profoundly depressed.
    5. Lack of future plans: No plans for the future and talk of what people will do when they are gone increases risk.
    6. Recent Loss: A person who has experienced the death of a loved one, an important separation, or divorce can be at higher risk.
    7. Giving away personal property: If cherished items are being given away, there is increased risk.
    8. Unemployment or financial difficulty: Economic problems due to lack of employment or increased financial burden increase risk.
    9. Substance abuse: Barbiturates and alcohol can be a lethal combination. Alcohol is involved with 90% of all suicide attempts.
    10. The presence of psychotic thinking: Often severely disturbed people believe death to be a temporary rather than permanent state. They fully expect to return tomorrow after committing suicide today. Confusion and disorientation also adds significantly to the risk factors.
    This list of indicators is not exhaustive. It is the 10 most common indicators of high suicide potential. In working the hotline, you will become familiar with your organization's suicide assessment form that you fill out as you are taking a call. By answering a series of questions, you will come up with a numerical score that gives a quick reference for just how suicidal the person is. Of course, no test can take the place of your judgement (nor can you abdicate responsibility to the test). It is a helpful instrument in that it focuses your thinking on dimensions relevant to determining risk potential.

    POLICY REGARDING A "SUICIDE IN PROGRESS"
    The rationale for this policy is the conviction that some part of the caller wants to live. That's why he or she called. As with all psychological conflicts, ambivalence is an important component. This policy sides with the part of the person who wants to live even if the death choosing side seems to be in ascendance.

    MANAGEMENT OF THE SUICIDAL CALLER
    Some people call because they are contemplating suicide. It is something they are thinking about doing in the near or distant future. It could be as soon as they hang-up or it could be weeks or months from now. Suicidal thinking should be taken very seriously. It is important, however, that the liner not panic. The absolute essence of good suicidal management is maintaining a sense of calm when everything inside of you is pushing you in the opposite direction emotionally. Handling suicidal calls is SCARY. Good technique and comfort with that technique helps. But a liner should never get to the point where handling a suicidal caller becomes easy or a matter of routine. It is a demanding, exhausting job and it tests you more as a person than it does as someone who has mastered techniques of crisis intervention.

    People hold differing views on suicide and the right of anyone to take his/her own life. The state is very clear. Suicide is against the law. Although people who attempt suicide are seldom prosecuted, it is certainly within the state's purview to do so. Individuals, however, vary enormously about this question and it is not difficult to find proponents for the polar extremes of this question. In recent years, there have been groups formed to provide information about effective means for committing suicide for those who seriously plan to take their lives. The media is full of coverage about doctor-assisted suicides. Regardless of your personal beliefs, you need to know and understand the policy of the organization for whom you work or volunteer and be sure that you are objective in its implementation.

    It is important that you have come to grips with your own emotional as well as intellectual positions on suicide. The hotline is not a place to impose your point of view no matter how convinced you are of its ultimate "rightness" and "benefit to person kind." Our interventions and strategies are to be for the caller's benefit, not to make ourselves more comfortable or to enhance our self view as the "adequate crisis worker."

    THE CALLER CONTEMPLATING SUICIDE
    1. Listen for the symptoms of depression listed earlier and for the indicators of risk also previously discussed. Listen with your "gut" as well as your head since the suspicion of suicide often is conveyed between the words. If something inside of you is sending up the "suicide red flag" pay attention to it.
    2. It is important that you communicate in a calm manner that you are not afraid to talk about suicide as very personal issue; as a very personal choice. This is not the place for a political or philosophical treatise on personal rights. It is important that you convey a sense of neutrality to the caller. To convey anything else is to make it impossible for the caller to be as fully self disclosing and open as may be needed for your discussion.
    3. If the caller brings up the topic openly, be prepared to follow his/her lead. Our usual open ended questions are useful in gaining more information about the circumstances that have led a person to be seriously contemplating taking his/her own life.
    4. If the caller conveys that suicide is an issue but does not bring it up directly, it is likely that the liner may have to introduce the topic. "I have the feeling your thinking about suicide but having trouble bringing it up." "Are you thinking about killing yourself?" "It sounds as if suicide might be on your mind." INTRODUCING THE TOPIC, SAYING THE WORD SUICIDE WILL NOT MAKE A PERSON COMMIT SUICIDE NOR WILL IT PLACE THE IDEA IN HIS OR HER MIND CAUSING THEM TO COMMIT THE ACT.
    5. Because suicide is so frightening to most people, being able to talk about it openly and forthrightly is often experienced as tension reducing. Most people respond to the possibility of someone killing himself with reassurances that things will get better, that life is worth living, and that he shouldn't be thinking or saying things like that. None of those remarks reflect good intervention technique. They are designed to make clear that the listener does not want to hear such terrifying ideas and feelings. We do! We want to hear it all. We want the caller to talk in great detail about the pain in his life, the things that s/he has tried, the things that have failed, the people s/he has turned to, the disappointments s/he has experienced, the desperation he lives with. And then, we want the caller to tell us in detail about his/her plans for the suicide. Saying these things out loud may permit the caller to actually hear them for the first time. That, in and of itself, can sometimes bring a new perspective to the situation.
    6. Keep in mind that the threat of suicide galvanizes people into action. If people have become bored or disinterested in you and your problems and have begun to withdraw from you, threatening suicide seems to breathe new life into the deteriorating relationship. As such, threats of suicide can be used as manipulative strategies to get something that might not ordinarily be given under ordinary circumstances. Assessing whether this is a real suicidal caller or a caller who is using suicide as a manipulative strategy is amongst the most difficult judgement calls you will ever have to make.
    7. While there are no hard and fast rules that work every time, paying very close attention to your own emotional reactions can provide information. If you begin to feel manipulated by the caller; if you begin to sense a lack of genuineness or sincerity; if you have a sense of being milked for all your worth; if the call becomes circular and you have a sense that this is really going nowhere, then you may be dealing with someone who has learned to use suicide as a way of making people jump through hoops.
    8. If your judgement is that this is not a real suicide call, you can begin to test your hypothesis by checking it with the caller. "I Have the feeling that people really respond to you differently when you are feeling this suicidal." "It seems as if you've found a way to make people pay attention." You may meet denial at first, but if your gut still feels right, stick to your guns.
    9. While talking with the caller, you will be filling out a suicide assessment form in order to determine the risk potential. Whether high or low risk, it is important to take the caller's concerns seriously. The suicide form will help point you to questions you should ask in order to get a more complete picture of what is going on.
    10. Suicide is a decision. Its consequences are irreparable and the devastation it leaves behind is enormous. Nevertheless, if you want to be effective in managing a suicidal caller, you need to approach this issue as a decision that can be discussed. If you come down "pro" or "con" the caller will be forced to play to your position or to abandon the call. You need to be able to discuss this option and to explore other options with the caller. You need to discuss what the caller feels will be the impact of this act on others in his life and you may even need to correct unrealistic expectations ("Nobody will care. Nobody will even miss me") You will want to encourage the caller to take his/her time reminding him/her that if successful, there are no second chances.
    11. While a call to the line may have an immediate, calming effect, it should be our goal to refer this caller to an agency or private practitioner who will provide long term assistance. Once the suicidal issues drop from immediate concern, there are many other issues that the caller would profit from exploring and understanding.
    A SUICIDE IN PROGRESS
    1. This is a call in which the caller has made it clear that he/she is in the process of committing suicide or has the means (e.g., a gun) at hand and is planning to make use of them at some point in the call or immediately thereafter. LINERS WILL FIND THEMSELVES MORE ACTIVE DURING THESE TYPES OF CALLS.
    2. It is important to attempt to find out the name and the exact location of the caller so that help can be sent.
    3. It is also important to find out if there is anyone with the caller, a neighbor, or a friend who might be helpful should such help be needed. Callers are often reluctant to provide this information. It should be actively sought and if not successful, the liner should return to information gathering questions at other times during the call.
    4. If the caller refuses to provide the information needed in order to send help, it will be necessary to begin a TRACE. Enlist the aid of a second liner in the office to undertake the trace. If you are alone, ask the caller to hold on because you must attend to a second phone. Keep in mind that traces are not instantaneous. They often take a good deal of time. You will need to keep the caller on the phone if the trace is to be successful.
    5. Some hotlines now have Caller ID. While this new technology gives rise to important ethical questions about "caller anonymity," the management of the "suicide in progress" caller can be made enormously easier if a phone number is immediately available. Be sure to check on your organization's guidelines and policies regarding this.
    TRACE PROCEDURES:
    Each local phone company may have different procedures for beginning and carrying out a trace. In some places, a liner can start the process. In other communities, the police need to be called first and make the request for a trace. Be sure to be informed about the "how-to's" that apply to your crisis service in advance of actually needing them.

    A trace can take as long as 45 minutes; sometimes longer. Ultimately, it is the police's decision whether or not to send assistance. Keep in mind, the police often will not break into the caller's home. The caller needs to be encouraged to open or unlock the door to his home or apartment so that the police can gain entry. In many places, the fire department is not governed by the same restrictions as the police and may be a better choice when help is needed.

    A trace is only successful if the line remains open. Should the caller hang up, the trace is no longer possible. KEEP THE CALLER ON THE PHONE. Use any measure necessary short of making the caller so angry that he/she hangs up.

    This type of call is probably among the most difficult we handle. The feelings stirred by the suicidal caller have both immediate and long term effects. No one handles these calls without being stirred up. In fact, the absence of an emotional reaction should be viewed with real suspicion. These calls should be processed with other liners, with your supervisors, and with the directors of the line so that closure may be achieved.

    NO ONE KEEPS ANYONE ELSE ALIVE. The person intent on killing him/herself will most likely achieve his/her goal. Our job is to buy time in the hope that the help we provide will allow the person to reconsider and, perhaps, come to a different decision.

    If the caller is prevented from completing his/her suicidal attempt by police intervention or by a friend, do not expect to be thanked. It is very likely that the caller who calls again will be very angry at you for what you have done. The rewards for managing this call come from inside of you; the knowledge that you have done everything possible to provide a person time to reconsider the most important decision of his/her life.

    THE ANSWERS TO THE "TRUE" AND "FALSE" TEST

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