UNDERSTANDING SUICIDE PART TWO: The link to depression and the search for hope

According to the American Foundation for Suicide Prevention, 90% of suicides committed in the United States occur in persons with a diagnosed psychiatric condition. Over 50% of people who die by suicide are diagnosed with major depressive disorder. In any given year, 25 million Americans are suffering from depression. These statistics are striking, and they indicate a need for us to better understand how depression can lead to suicidal thoughts and actions. Based on the numbers, most Americans will have a friend or family member who is at risk at some point in their lives. The purpose of this blog post is to discuss the role of depression and suicide; how we may prevent some suicides by better understanding depression; and how to give hope to those with chronic depression who experience suicidal ideation before they attempt suicide.

While it is true that 25 million Americans meet diagnostic criteria for major depression, many of them never have suicidal thoughts. If suicide becomes an option, many of them change their minds or never seriously think about acting on their thoughts. How can we manage depression so that people don’t lose hope and decide there are no other options? What factors contribute to the decision that suicide is the best option? What factors may contribute to the loss of hope? Below are some points to consider to increase our understanding of the link between depression and suicide.

  1. Early Detection and Treatment Can Make a Difference: our goal should be to educate depressed people about their symptoms and the influence of biological and environmental factors such as genetics and stress. Helping people understand that having depression isn’t their fault decreases their shame and possibly allows them to retain some hope of improvement. The longer that someone has suffered from depression without treatment, the less likely they are to actively engage in treatment and believe that it will help.

  2. Social Support Can Make a Difference: educating spouses, parents, siblings, significant others, and anyone else close to the person could help in a couple of ways. First, the more family members and friends understand about depression, the less likely they are to blame the person, shame them, or lose their patience. The second reason to educate loved ones is to make them aware of their own need for emotional support. It is common to suffer from feelings of shame and blame when you live with or are often around someone who is chronically depressed.               

  3. Treating Substance Abuse When It Occurs with Depression: statistics show that when alcohol addiction is factored in, the rate of suicide in depressed persons increases from 50% to 75%. This significant increase warrants specific attention to treatment for alcohol dependence. The best treatment facilities understand the role of dual diagnosis and focus on treating both conditions since the depression may have been present prior to the substance abuse. 

  4. Focus on the Role of Hope: many people become suicidal when they believe all other options have been exhausted. People become suicidal when they believe they are a burden to others, and they have nothing to offer. In retrospect, the friends and relatives of those who have committed suicide recognized the possibility but did not know the gravity of the person's hopelessness. When people begin to withdraw from their life, we can begin to assess their level of hope. Missing work or quitting their job, spending most of their time alone, or giving away their possessions are more obvious signs. More subtle signs may be that the person avoids conversations with close friends and family, ends treatment with their therapist or psychiatrist, or loses interest in things they used to do regularly and enjoy. Noticing differences in the person’s affect (no smiles or laughter) and seeing them less at family gatherings or social events can be signs that are often overlooked. While family members and friends may realize the person is depressed, they may dismiss behaviors that signal the situation is getting worse. 

  5. Seek Treatment for Depression That Is Evidence-Based: it is very important that people suffering from chronic depression seek treatment that includes scientifically validated approaches. Talk therapy is not enough in these situations. The therapy sessions should be frequent, sometimes two or more times a week; include specific goals; include spouses or other loved ones as appropriate in some of the work; and should teach coping skills. People are more likely to regain hope if they see a clear vision forward of how they can experience relief from their symptoms. If a psychiatrist is part of the treatment plan, persons experiencing chronic depression should see their psychiatrist on a regular basis to determine whether the medication regimen is appropriate or sufficient to address the severity of the person’s symptoms. Patients who see their care providers more frequently and have clear goals are more likely to believe their providers care about their well-being. This can also be a factor in restoring hope during a dark period in their life. 

Preventing suicide in persons with chronic depression is a difficult process. There is no treatment or no treatment provider that can prevent every suicide from happening. But if we know the risks and the benefits of good treatment, we can restore hope to many who are contemplating suicide as their only option.

Photo by Joshua Earle on Unsplash

UNDERSTANDING SUICIDE PART ONE: Is suicide selfish?

In June 2018 two celebrities committed suicide in the same week. First, I was shocked and sad and to learn that Kate Spade, fashion designer and business woman, had taken her life. A few days later, chef and host of the show “parts unknown” Anthony Bourdain committed suicide. Both celebrities inspired others through their vocations and seemed to live enviable lives. However, as a result of their suicides, we learned that they both had struggled with depression for years.

When a celebrity, or someone in our own lives, commits suicide, we struggle to understand their decision. Some people, who may not understand mental illness or who have been personally affected by a suicide, think that suicide is a selfish act: Surely, the person must not be thinking of how others will suffer as a consequence of their choice. Surely, they must realize that their problems are temporary and that if they only seek help, things will get better.

That is likely true, to some extent. 

However, when someone is deeply depressed for long periods of time, their focus turns more inward. This doesn’t mean that people choose to focus only on themselves. It means that they are not confident that they have purpose or meaning, that they are worthy of being loved and supported by others, and that they deserve the support of others or even the help of professionals. Thus, by the time they contemplate suicide, they believe there is no other choice. They believe that others cannot help them because they are incapable of being helped. 

To better understand the mind of someone contemplating suicide, let’s explore the word “self.” When I Google the word, hundreds of terms appear, including self-love, self-compassion, self-esteem, self-confidence, self-worth, self-sufficiency, self-reliance. Our culture is obsessed with the concept of self. The word perpetuates a sense of autonomy, confidence, greatness, or the lack of these qualities and the importance of acquiring them. Thousands of media articles discuss how important it is to be ourselves, love ourselves, be kind to ourselves, forgive ourselves. The self-help section of bookstores is full of information telling us that we can become great and that we don’t need anyone else. We can become whatever we want, do it ourselves, and have it all without relying on others. 

Now, imagine a depressed person who has tried to believe these things. They have tried to believe they can do it themselves, and they have failed. They are not self-sufficient. They do not love themselves. They do not have self-compassion. Their definition of “self” has only negative implications.

The irony is that we can’t do it ourselves. Despite the cheerleading self-help books and articles, neuroscience supports that our brains are wired to be relational. We need others, and it’s OK to ask for help. It’s also acceptable to allow ourselves to be helped because it doesn’t mean that we are a failure. It doesn’t mean that we cannot achieve success, or become self-sufficient, or that we lack identity. Receiving support and help from others, even professional help, builds resilience. The best thing that we can do for those struggling with chronic depression is to take them outside of their selves. To help them understand that they don’t have to suffer in isolation. 

In closing, let’s help those at risk for suicide understand that they don’t have to figure it all out to feel better. Let’s help them develop a healthy sense of self that allows them to include others. They can experience relief from symptoms, bounce back from struggles, and experience love and support.  

Photo by Terry Tan De Hao on Unsplash

POLITICS IN PSYCHOTHERAPY: A Commentary on the Role of Therapists in Politically Turbulent Times

The holidays are over. The new year has arrived. It is a January following a mid term election, and many seats in Congress and the senate will change hands. Not to mention many local and state Government positions will receive new leaders during this inaugural month. Whether our chosen candidate won their election or not, we live in a contentious political climate in our country. The strength of friendships has often been tested due to political differences, and relationships in which partners have different political perspectives have experienced greater tension and conflict. This is especially true here in the nation's capital, where political ideology plays an important role in forming not only our values, but also our identity.

Late last year, Peggy Drexler published an article in The Wall Street Journal titled “Therapy Is No Longer a Politics-Free Zone” which discussed whether therapist and clients should exchange political view points, and whether or not that poses important dilemmas around the personal boundaries of the therapist. Drexler suggests that, if the client initiates the conversation, then it might be valuable for the therapist to share their politics because that validates the client’s concerns. Although sharing with someone you disagree with might be divisive in the therapist-client relationship, on the other hand, it could help the client navigate that experience in life.

This is an important conversation because the topic of politics is volatile enough that it has the potential to compromise trust in a therapeutic relationship if it is not handled well. To simply ignore the topic of politics in therapy seems unrealistic given how important it is in our culture. Research studies show that people who are committed to therapy are also more likely to be committed to their political beliefs. They are often socially conscious and think deeply about the candidates they choose to support. Thus, to leave the discussion of politics out of therapy not only seems outdated, but ill-advised. 

As a practicing clinical psychologist within 5 miles of the nation’s capital, I have a unique perspective on teaching clients to navigate political conversations they may encounter in different contexts. Below are four steps to support therapists and clients as they approach this discussion. These steps offer suggestions for how to sensitively address the issue with compassion and problem-solving. To me, this is essential to our distinct role as therapists advising others on how to lead healthy, enriching lives.

First Step: Empathize with clients who are anxious about the political climate. Your client comes in after a major election saddened because their candidate lost, anxious about what will become of our country and the important social and political agenda to which they subscribe. You may or may not be anxious about the future along with them. If their views are similar to yours, it’s easy to empathize. If you disagree with them, listen to their perspective and understand their reasons for feeling scared, disappointed, or hopeless. It’s possible to empathize without agreeing if you are empathizing with their underlying anxiety. Most of the time, we are empathizing with situations that we know nothing about from a personal standpoint, but part of being a competent mental health professional is to exert the effort to understand what we cannot personally experience. Clients can tell if we are genuinely empathic or not. They can also tell, most of the time, when we agree with them whether we speak it or not. We must remind ourselves that, in our unique role, we must give to them something they cannot receive from others in their lives. They may have plenty of others with whom to commiserate. We offer them a safe place to be heard and to better understand how they can respond to their feelings: first by owning them. Without receiving empathy in therapy, they may not feel that same ownership. 

Second Step: Keep your focus on your clients. If they are distraught over a candidate’s loss, or overjoyed by their victory, your role is to help the client navigate their relationships amidst the outcome. If they are delighted their candidate will soon take office, but family dynamics at home are difficult with differing viewpoints and contention, rejoicing with them and failing to help them understand those around them would be a disservice. The obvious example here is the election of 2016 when Donald Trump surprisingly became the president. The DC area is largely Democratic by party association, but thousands of people who live here now grew up elsewhere. They may have gone home to families who were happy about the outcome, which caused strife and stress not only for the clients but within those relationships. While you may align more with the client, your job is also to support them in bridging the gap between them and their loved ones to retain peace and compassion in the family system. 

Third Step: Respond, but do not offer unsolicited information about your political affiliation. Remember that the focus is on the client. If they ask you if you are happy about the outcome of an election or which candidates you plan to support in the future, you have a decision to make. The decision may be different depending on the client, the duration of your relationship, and how comfortable you feel in self disclosing with clients. Rather than feeling obligated to share because it is important to the client, consider the potential consequence on your relationship. If the client’s views or party affiliation differ from your own, it could affect rapport. If you agree, it could also turn the therapeutic relationship into one of mutual venting, rather than a productive relationship where you take a leading role in advising the client about how to deal with disappointing outcomes. If you find yourself caught up in your own grief, direct the conversation towards productive responses such as encouraging political and social activism. As a second strategy, educate clients to use active listening skills to better understand views different from their own. A third approach is teaching clients to avoid catastrophic thinking. While surprise outcomes, such as those in 2016, can impact millions of people in significant ways, we all need to be reminded that the political pendulum does swing in both directions. Historical reflection on how things ebb and flow can be a helpful and hopeful perspective to share. Clients who are in therapy because they already think negatively or experience cognitive distortions leading to depression must be reminded that things do change, and they can be an agent of that change if they choose.

Fourth Step: Remember resilience. Your relationship with clients can help them become resilient if you model for them what they may have trouble grasping after disappointment, severe anxiety, or depressed thinking. Walk alongside them in understanding that there is life after an election. This does not mean that you dismiss or minimize their concerns. Quite the contrary, you have a unique opportunity to understand the context in a healthier, more objective manner. Validating them in a gloom and doom perspective not only diminishes your ability to be effective, it may contribute to the greater anxiety and feelings of helplessness. Clients who already experience persistent anxiety and depression on a regular basis need a more balanced perspective, and one that many of us are losing sight of in recent years. Sitting elected officials have a limited term in office. They may weld great power for a period of time, but ultimately, others will assume the role, and things will change. The best thing we can do for our clients is to instill in them a sense of what they can control, and how they can proactively seek the kind of life they want, even if their favored leaders are not elected.

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Is it the Most Wonderful Time of the Year?: Solutions for Surviving the Holidays

It’s the most wonderful time of the year… So the song says. I’ve heard it at least a dozen times since Thanksgiving in shopping malls, the pharmacy, and on the radio while driving around. The holiday decorations, music, and festivities of the season surround us. Yet, for many, the holidays are far from wonderful or happy. Many of us had a difficult year, whether the reason was financial, family oriented, or some other challenge that prevents us from easily transitioning into the joyful spirit of celebration. We may have struggled with chronic illness or disability, unemployment, the loss of a loved one, or another tragedy. Or, perhaps, we just don’t feel like being festive. Whatever the reason we lack holiday spirit, it can feel forced upon us. I hope to bring you good tidings by letting you know that there are ways to get through the holiday season with joy, or at least some peace of mind. 

Don’t force yourself. You don’t have to enjoy the holidays in the same ways that others do. If you don’t feel up to buying personal gifts for everyone, think about what you do feel comfortable doing. Suggest a gift exchange, so you only need to buy a gift for one person from the group or family. If you don’t want to completely remove yourself from the festivities, choose events where you feel most comfortable. Attend parties for shorter periods of time so that you may enjoy yourself briefly and then excuse yourself before it becomes overwhelming. There are times when stretching yourself outside your comfort zone can be healthy and helpful. The holidays are often not these times, as the expectations that you experience or perceive may give you greater stress than is necessary. Let others know that you are struggling, even if you don’t want to go into details. Most people can be very compassionate if you give them the opportunity.

Figure out what you enjoy about the holidays. If nothing strikes you, perhaps you can explore. Do you enjoy the music? Do you enjoy attending religious services? Or do you enjoy quiet evenings at home sipping hot chocolate? There are simple pleasures you can find that do not involve the high energy festivities that our culture emphasizes. You can enjoy the holidays your way.

The expectations that our friends and families have of us during the holidays can feel overwhelming. Think about what you can manage, and talk with family members or loved ones ahead of time. Many people are unable to empathize with pain or grief. However, communicating our thoughts and feelings, regardless of the response, can still be a proactive step in taking good care of ourselves. Attending smaller family events or not staying as long can be an option. Keeping conversations over holiday meals to topics that do not engage in conflict is a good tactic for managing difficult relationships and personality clashes. Loneliness can be a major factor affecting millions of people during the holidays. Many people spend the holidays alone while watching others enjoy themselves with family and friends. If you’re going to be alone this holiday season, think about volunteering at a shelter or some place where other people would welcome your presence. People who volunteer during the holidays report greater satisfaction, not only in the act of giving time to others, but in the companionship and the gratitude they receive. If volunteering is too much for where you are, perhaps you can find others in your neighborhood or community who are not with family and have a small meal together or just gather for hot chocolate and conversation. Our world has become increasingly more isolated in recent years for many reasons, so we must proactively seek friendships and community. Sometimes this is extremely anxiety provoking, but you can start small with one or two people to see where it leads. Ultimately, people who find companionship in even the smallest of circles draw great joy from it and find that it can be a game changer over an otherwise dull and dreary holiday season.

Sometimes before we can enjoy others genuinely, we must appreciate time on our own: developing solitude is an important part of developing community. Take time out of your busy holiday schedule to enjoy moments of peaceful reflection. If you are alone, self reflection can be a great way to set goals for the coming year and to think about what you would like to be different in your life. Reading, meditating, praying, going for walks, and writing in a journal can be great ways to engage in much-needed introspection. I call it taking a break from every day life. This does not mean that you would exclude yourself from activities that you may enjoy or totally isolate. It simply means that you take time to be with your self in a meaningful way to rest, reflect, and think about how your future can unfold.

Gratitude is an important way to both reflect on our blessings and achieve personal growth. Being intentional about showing gratitude can make a huge difference in the way that our brains process the events of our lives. Think back on the previous year. Can you identify events or experiences that you appreciate? Are there people who you would like to thank or who you were glad to have in your life? Numerous studies have shown that demonstrating gratitude lifts our spirits almost instantly. When we recognize that there is good in our lives, despite the pain, struggles, and challenges, our brain develops a new perspective that improves our self awareness and contextualizes our circumstances within a bigger picture.

Regardless of what’s troubling you this season, I hope these strategies allow you to find peace and joy during the coming holidays and to look forward to a new year.

Photo by Annie Spratt on Unsplash

The Search for Peace in 2016: Can The Nation Heal After a Bitter Election?

The Search for Peace in 2016: Can The Nation Heal After a Bitter Election?

Regardless of our political ideologies, we can all agree that the 2016 presidential election was bitter and highly divisive. The nation woke up to a surprise on November 9, when the now president-elect Donald Trump gave the victory speech and prepared to assemble his transition team and his cabinet. Millions of Americans cheered alongside Trump’s team, while others wept or were out raged. Over the course of the past two weeks, there have been thousands protesting the election, and inauguration day will likely be a day of protests and unrest, along with those who will celebrate. However, even those who are happy with the outcome have much to fear, as protesters and other disgruntled voters have accused Trump supporters of many things and many insults have been exchanged on both sides of the party line. So, the question remains: Where does America go from here?

Turning Toward Empathy: A New Perspective on Depression

Turning Toward Empathy: A New Perspective on Depression

Depression is a complicated condition that can be chronic and severe. It can result in debilitating loss of functioning across areas of one’s life. But as is the case with most circumstances, one must take a series of steps forward in order to achieve freedom from the grip of depression. Many people may be surprised at how shifting the focus from an internal perspective to a more balanced view that includes others, and intentional acts of empathy and compassion can begin to change one’s perspective in positive and hopeful ways.

Finding Peace and Resilience When Tragedy Strikes

Finding Peace and Resilience When Tragedy Strikes

Whether or not we are directly affected by a tragedy in that we have lost loved ones, or we have been indirectly affected by the shock, fear, and intense emotions that follow, we have no choice but to find ways to seek comfort and support. In addition, we must bounce back – we have no choice in that. The only alternative is to give up, hide inside of our homes, and stop living a joyful and productive life. That is not an alternative that most of us want to entertain. This month’s article provides some guidance in how to survive and thrive when every day there seems to be a violent headline.

Redefining mental health: it's not just about illness

When the term "mental health" is used in conversation, most people tend to think of it in terms of diagnoses and disorders.

A discussion about mental health is not only about treating mental illness; it's also about a primary care approach similar to the model of physical health that has been encouraged by modern medicine. Taking care of our bodies, stimulating our brain, and managing our emotions are all important aspects of obtaining good mental health.  Perhaps we should call it "mental wellness.”