Meandering Musings

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Suicidal Ideation vs Intent

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Like my other psych-based articles this is not medical advice.

This is the viewpoint of someone that suffers constant ideation and has real intent now and again. It is also based on conversations with other people in similar situations. The intent of this essay is to give you some of the inner thoughts that will hopefully help you gain insight on something that can be unfathomable to those that have never had these thoughts and might need to help someone else get help. If you are suffering from this hopefully this will give you some measure of peace as it is something that can be learned to live with if you can not manage to rid yourself of it.

It is always consoling to think of suicide: in that way one gets through many a bad night.

Friedrich Nietzsche

Is there any meaningful difference between suicidal ideation and intent? There is, but that raises a few questions such as “How can I tell?” and “How do I react to each?”. Those are not easy to answer so the default advice you will find is to treat any and all suicidal comments and hints as serious. I am not sure that is useful or productive advice and sometimes can be damaging but I can’t come up with a better alternative. It is like my last year of taking classes in grad school, one or more sad clowns decided it would be fun to call in and post bomb threats on campus many times over several months. It was pretty obvious that they were pranks designed to get classes canceled on certain days or to just be as annoying as possible. Classes were actually only canceled once university-wide but a building would get randomly closed. The alternative would have been to simply ignore it and not close buildings but all it takes is one real threat in a sea of fake threats to get a horrible tragedy. Who wants to make that call?

So what do you do and what happens after that. The answer to that might be equal parts confusing and horrifying.

Let’s get to the basics. Suicidal ideation is simply thoughts of killing oneself. That is straightforward but the meaning is not. Suicidal intent is having plans and the mean and intent to carry it out. Is suicidal ideation part of that? Yes and no. Of course, to have the intent you need the thought, from what I have read a literal spur of the moment suicide with no ideation preceding it is extremely rare to impossible.

If someone has the intent, get them help. Full stop. They may or may not be incoherent and in obvious distress. Some people will make the decision to kill themselves and will take their time to get things in order and make a plan. Others will appear to be almost a spur of the moment thing. Think of it as the differences between a hurricane and tornado. One is slow-building and can be tracked over time, the other comes on very quickly and can also vanish quickly - but warning signs of a possible tornado are present for some time before it happens. Both are very dangerous and the difference in signs between a slow build-up and a quick onset can be subtle. Both typically have long term ideation but in the quick event, there may not be many obvious signs. Like the analogy suggests, the time to react is different. A slow build-up really is less critical but still needs immediate attention, it is just not a real emergency if that makes sense. If it is a quick onset, there is little time to react.

For myself a quick onset is that I get very quiet, feel very empty and numb and at the same time, my mind is chaotic. How that sort of thing is expressed outwardly can vary wildly. In my case, I think the only outward sign is that my voice becomes very soft and almost empty sounding and robotic. I tend to want to take a long walk and want to be alone way more than usual and will be uncharacteristically aggressive in seeking solitude. The morning of my birthday last year I was exactly this and unfortunately, I think that aggressive insistence scared my sister. Well, I was going to step in front of a rather large truck but sadly got dizzy and kind of fell into the ditch. It is sad how stupid little things can stop me.

Some signs of suicide

  • Withdrawal from friends and activities
  • Giving away prized possessions
  • Uncharacteristically poor hygiene
  • Uncharacteristically poor behavior or a change in personality
  • Unusual sleep patterns that can be too much or too little sleep
  • Change in personality that can be overly nice or unusually angry
  • Unusual drug or alcohol usage
  • Expressions of hopelessness, worthlessness or lack of a future
  • An overt conversation about death or morbid topics that is unusual for that person

Of course, this list is hardly exhaustive but it boils down to a negative change in that person’s behavior and outlook on life.

This new onset of depression for many people, especially extroverts is on the rise during this pandemic. Even introverts are not immune to this. This is coming from people with no previous history of mental distress and I think that is more dangerous since such feelings are new and something terrible and new is harder for people to deal with than for those of us that have lived with it for decades. People you might not have had to worry about may now find themselves in distress in these troubling times. Like the pandemic itself, no one is immune to the risk.

Ideation is much more complicated. Many if not most of the seriously mentally ill patients have ideation, often all of the time. This is typically not dangerous, in fact, it can be helpful which surprises many people. It is a pressure relief valve. When I used to see a shrink they always ask: “Do you have thoughts or a plan to hurt yourself or others”. A “no” answer usually ends it unless they see that is not true. I am not a fan of the profession, I hesitate to call them doctors, but they are usually pretty good at detecting deception, even if the patient is a good liar.

A yes response will draw out further questions. “Yourself or others?” and if you say “myself”, then they ask if you have a plan. A no response pretty much ends it and you can go your not-so-merry way. I am not sure what happens if you say “others”, probably something very similar. A yes response to whether you have a suicide plan will trigger more questions and possibly get you involuntary committed. If it gets to that point they will try very hard to get you to go voluntarily. Depending where you live, if they believe you are a danger to yourself or others, they can hold you for 48-72 hours, this is generally the case in the US. After that, the doctors need to see a judge or magistrate before you can be forced to stay longer and the bar for that is extremely high. That puts your shrink in an adversarial position against you and that is counterproductive, so they try to avoid it.

There are benefits and few risks to going voluntarily. The two biggest benefits are that you said yes so your attitude towards it will likely be better which will help you while you are there. I have seen involuntary patients when I was an inpatient and they were not happy campers. They looked at it as a prison and were antagonistic to everyone. The other benefit is that you walked in the hospital voluntarily so you can leave when you want to. Of course, you are giving them the ability to see you 24/7 which might give them more information to change it to an involuntary commitment if you try to leave before they think you are ready.

I was in the middle of a term at the university when I was committed and was in there for about 8 days. I do not remember specifically why my therapist pushed for me to go in. I do not remember what I said or did. Severe depression causes memory loss.

Luckily, I went in on a Friday and by the following weekend, I was out. The actual process to get committed was horrible and I was alone when I did it. They drew blood, did a very invasive physical exam, had me sign countless papers, and asked me over and over if I really am agreeing to it. It was easier to get through the paperwork and physical to join the military! I did not want to miss out on school anymore and it was a fight to get out, with my sister helping out. They threatened me with letting me go without meds, which is a cruel threat because withdrawal effects are extremely painful. Luckily for me, I had a lot of my meds at home, at least three months' worth because I always pay close attention to how things work so I could use the VA prescription mail-out system to my advantage. With psych meds, it is a comfort to have a buffer because withdrawal effects truly and utterly suck. Otherwise, that is a terrible threat to put over one’s head, it is coercive and if it works it is no better than kidnapping and should be prosecuted as such.

The head of the inpatient ward told me that there is no way that I could succeed in school right now. I finished that term on the Dean’s list, just like every other term.

I can’t say much about my stay because I have little memory of it. I just kept to myself and whenever a doctor or nurse asked me a question I think I answered in as little detail as possible. I am not sure it helped but it didn’t hurt either. If it helped, it was because I was able to unplug from my day to day life and not anything specific that they did. I also don’t know if I would be alive or dead had I not. Probably not, so I suppose that is good.

So, what if you observe suicidal ideation or intent in a loved one? What should you expect? If the person is doing poorly they will either passively give up or fight against getting help. Which one depends on circumstances. There are times I would be very passive about it, like when I did go in but I also fought it several times - it has not come up in 15 years, I am either really good at hiding it or can just deal with it better.

The thing to remember is that you are not a mind reader and it is hard to tell from the outside what is really going on in someone’s head. It is also true that they may get so angry at you that they may not talk to you for a while or forever. This isn’t to dissuade you, but rather to let you know what to expect. You might also be surprised about health professional’s reactions which is why I added personal anecdotes.

The big question is who to get help from. It really makes a difference but in an emergency, people tend to grab onto the nearest solution even if it is not optimal. That is not necessarily a bad thing but it could bring up issues and cause problems.

The best way is to get them to their therapist or psychiatrist. They know the patient and are in the best position to help them. There is hopefully some level of trust there and I can not overstate how that makes a difference. If it is during normal office hours, try to call and explain the situation. They are accustomed to this happening so they will have a protocol in place. They can be of great help over the phone. If it is after hours, they might have an emergency phone number where one of the staff is on call each night. The next best is an emergency room, they will have people trained in this and if this is after hours it is the best available option, but not optimal. Another option is to call a suicide hotline - there are some links to the right - and tell them you are calling for someone else, they will be able to offer guidance on defusing the situation and pointing you on options. If there is a hotline in your city, that may be the best way to go since they will know what is available in your area.

Depending on where you live, the worst is calling 911. Now, there exist some forward-thinking police departments that have officers trained well to handle a mental crisis, most are not and frankly they should not be required to do this. This is the end result of endless budget cuts on mental health services and is one of the points that the current ‘defund the police’ movement is trying to address. An ill-trained person who is armed is not a good solution. If they are not well trained it can end and sometimes does end very badly. You need to understand this. This is truly a last resort and a mental health crisis is not the time to learn if your local police department bothered to make sure its officers are trained in this area.

I have had the police called on me several times in my life over mental issues, luckily I am never violent and I lived in places that sent trained officers and social workers.

In the late ‘90s, my therapist would randomly call the police to do a 'wellness check’. She probably did this out of spite, she was not a kind person. Those visits were easy, they are simply making sure that I am breathing and not acting in obvious distress. A short talk at my door and they were off.

During this same time, a neighbor lady whose daughter was friends with my oldest called the police because I showed up at her door around 6 AM with my arms sliced up and dripping blood. At the time, I was so angry at her but she is a take-no-nonsense woman and simply said she did not care. I understand now why she did it of course. An officer showed up at my door with two social workers but the social workers were in charge of the interaction with the officer there only to make sure I didn’t get out of hand which is impossible since I am always very passive. They were not remotely interested in how bad my wounds were - it took over 10 years before the scars faded away enough to be mostly hidden and now only one or two scars are visible at all. I remember laughing at this proposed contract that they wanted me to sign saying I would not hurt myself and if I did not sign, the good officer would drive me to the VA hospital for evaluation. I thought it was the most ridiculous thing and said so and all he did was reach for his handcuffs so I signed it. I still think it is ridiculous and it is very coercive.

The last time was the day after my birthday last fall when my oldest daughter did it. Which was odd, I was on the other side of the state with two sisters. I was not angry at her and still am not. I am not sure what prompted her to do it, it was not done out of malice so why would I be angry? Two sheriff deputies showed up and they were obviously very well-trained in it so it went well, but having two armed men - something I am accustomed to being around - asking me questions when my mind was not right was not exactly a stress-free experience. I said very little and sat as quietly as I could so they would not try to take me into to be evaluated. They also told me if I really needed help I was in one of the best counties in the country for emergency mental services - which I have no doubt - and it might be good if I make use of it. I believe that they were truly concerned about me. They might have been right about the availability of the services there but getting back into the mental health system is the last thing I need. I have learned to control my illness even when it is working overtime trying to control me and I prefer to do things like this alone. I have had to learn to do everything by myself.

Despite my interactions going well, the police should be summoned only as a last resort. If you don’t believe me, there are plenty of news reports about when things go wrong simply because an officer was called on the scene. It may not be the officer’s fault that they are not trained well enough - I am not claiming malice on their part - but it doesn’t change the fact that they often are not. Woefully untrained officers often create serious and deadly problems when the issue was only a relatively mild one. If things are really serious, and you are out of options go ahead but make sure you tell the 911 operator if there are weapons present or not to help defuse the situation if the person in distress. This is important regardless if there are weapons present or not. If they are armed, letting 911 know can give the police time to calm down and think a little. If you are not expecting it, getting a weapon shoved in your face does add more than a little stress as I have found out once or twice. If they are not armed, it is good for the officers to know this in advance, although it will be unlikely that they take your word for it, but it will help to keep things from getting out of control.

That advice goes for every time you need to call 911 to summon the police, not just with someone with mental distress. Help them to help you.

So, now what?

If you ask your loved one if you can take them in or call a hotline for them, and they refuse, back off a little and try a different path to get them to agree. The idea presented properly can make the person agreeable and the proper presentation can seem random.

Sometimes, talking to you might be enough to defuse the situation and end the crisis. That is a difficult thing to tell but when that happens to me, I become more relaxed and more reasonable and amenable to trying to sleep. Everyone is different and even if you can calm them enough that the intent goes away try to get them in to see their therapist or psychiatrist as soon as possible. They may seem stable right now, but it might not take much to pull them back into the darkness and that can happen very quickly.

Let’s say your loved one has decided to get help by seeing their shrink or going into an ER or mental ward. Or the police took them in for observation. What happens next?

Someone will come to talk to the person and try to understand the current pressing problem and try to assess how serious they are. They will discuss plans, thoughts, and anything else that comes up. In an ER or mental ward where they do not know the patient, the visit could take some time and it can be very difficult to open up to a stranger, especially when in a crisis. If they only have ideation and no plan the odds are that they will be released within a few hours. This is the part that can be surprising and stressful for those close to the patient.

An ER’s goals are to ‘treat them and street them’, it is not a place to get treatment beyond stabilization. At that point they will be admitted or sent home. If it is their shrink or therapist, they will either make arrangements at a psych facility or send them home with similar instructions as the ER. Same for a mental ward. Meds might be prescribed so they must know what the patient is currently taking. Drug interactions can get nasty. If you do not already know what meds - not just psych meds - try to find out before going. Psych meds can take weeks to start working so it might be quicker acting meds like benzodiazepines and something else possibly in shot form.

A lot of times, a good conversation with the psychiatrist or social worker will be enough to relieve whatever pressure caused the crisis. If the person is a danger to themselves or others they will hopefully get admitted but that is not a given. In the US, and probably most of the world, psychiatric services are not great and availability is often terrible, especially with limited insurance or funds.

If they are sent home, that presents many problems from leaving them alone and having enough time to help them. You will likely be needed for quite a while after you bring them in, a circle of friends or family can be invaluable. If they are safe to be released, they hopefully do not need to be watched 24 hours a day and that is stressful for all parties involved and can end up counterproductive. See if you can get discharge instructions, whether they are there a few hours or even weeks.

Your loved one may be upset and try to send you away and sometimes being alone is a good thing and sometimes not. It is a difficult thing to give them time alone but try not to be suffocating.

Try to understand their viewpoint which can be difficult in these situations but always be gentle and not confrontational. If they do not want to talk about a certain subject, find something else to talk about. Sometimes, not talking about the incident is the most helpful. Trust me on this, it is very embarrassing to be in this position. It is difficult to even write about it here even though I am fairly anonymous. There is nothing better for them than to be loving and caring.

Trying to guilt or put blame on them can send the person into an even worse state. Don’t be judgmental, listen, and gently ask questions to try and get them to open up about what they are feeling and what caused it. I have a few sisters that can attest that I can get far from my normally reasonable state and this is a very challenging thing to do for everyone in the conversation.

What does your loved one want and need?

I would not try to speak for all mentally ill people who often have suicidal ideation and sometimes intent but I can tell you what I want when I am like this and well, actually all of the time. My list of ‘wants’ and ‘needs’ don’t change.

I need to be taken seriously and especially not have my issues minimized or dismissed or ridiculed. That would be super nice, I guess it is a difficult thing for others to do.

I also want to have someone to talk to without fear of losing that person or their respect. These thoughts and feelings do not define me nor do they control who I am. I need to know that those that love and care for me will not vanish on me. Not that day, or ever. They certainly do not need to be in constant contact with me but knowing beforehand that they won’t be around for the next day or week or two goes a long way to keeping me calm. Perhaps I don’t deserve basic consideration but it is still on my list of wants.

Most of all, I just want to be a normal person but no one can help me be that. I will go to the ends of the earth and beyond for my loved ones without conditions. I do not ask for anything close to that in return. In fact, I don’t really ask for anything in return and will accept various kinds of rejection and poor treatment and still go to the ends of the earth for them if they need it.

What I do to try to achieve that is I try to present very consistent behavior and in how I treat people to not only hide my issues, pain, and disappointment but to not scare them away. I will act the same and be polite no matter if I feel good or am sick or have severe headaches or if my mind is noisy or chaotic.

The fear of losing friends and family is pervasive across many psychiatric disorders. It is odd, losing people is one of the few constants in my life, yet I fear it. Maybe that consistent behavior makes me appear to be robotic or insincere. I am not sure but I have a feeling that this behavior is not that good even though I am always sincere. I do not lash out at others because I am upset or for any reason and very often they will not even know that I am upset. Even if I am doing very badly, I will deny it, which admittedly might escalate things. The reason I do that is that I need to be perfect all of the time just to be treated like a below-average person and feel like they will not abandon me. Showing emotions that are not positive makes me appear less than perfect so I go from below-average to simply nothing in their eyes.

It goes something like this:

When I do not get consistent behavior back - I never do because real people are not so consistent at all times - it really confuses me and makes it hard to know what I can and can not say. Mostly, the issue is not knowing where I stand with that person and that brings severe insecurity and uncertainty which in turn brings along feelings of rejection - even if I had not been explicitly rejected. I have the ‘skill’ of being with someone and having fun and that person wants to be there but I can interpret small, probably meaningless things as being abandoned and I get overwhelmed with a feeling of loneliness and it is very isolating. Ironic, since I am not alone, obviously. The feeling of loneliness is stronger in a room full of people than it is when I just spent the last two weeks completely alone. I am hyperaware of small things like facial expressions and body language, especially when in distress. I take those facial expressions and body language along with statements out of context often. I might be highly attuned to social cues but I have a pathetically difficult time interpreting them correctly and that is a serious problem for me.

It can cause a lot of problems during stable times, and worse when not stable. It is not fair to the person I am around whether they know what is going on and trying to help me or don’t know.

It is strange, a person can be with me and spend time with me and this fear causes me to feel utterly alone. That sort of thing makes trust difficult even though it is completely in my head. Reality can be very fluid in my mind and I have slammed the door on people INFJ style when that person did nothing overtly and possibly nothing at all.

All of this is usually at the root of my problems in this area and the reasons for my ideation and occasional intent.

I have never completely opened up to anyone about my issues and I am not sure I ever can. When I try to push towards that I get a negative reaction or worse, an indifferent one. Regardless if that person is my therapist, family, friend, or more there is a limit to what I can say without getting dismissed. I have been told by people to open up to them more and when I do, it is usually the beginning of the end of that friendship, or my family just gets mad and ignores me for a few weeks. It is much easier to be open with my physical issues but I even try to hide that because of the same reasons as my mental issues - it is expected that I will get rejected or abandoned because of it. Even if it hurts me physically, I will do something that someone else wants to do just so they do not find a reason to disappear because I couldn’t keep up with them.

The point of all this rambling is that personality quirks and insecurities are amplified during times of distress and effectively helping your loved one often involves recognizing that so you can help to diffuse the person. This is why the best help is their current therapist.

I have talked to some people with a variety of mental issues and it seems that they have at least a somewhat similar thought process and approach to opening up. They may not have a similar outlook on themselves that I have of myself but the fear and dread of being judged and possibly losing family and friends is similar.

Never underestimate the fear of rejection and the resulting insecurity that brings and is amplified when MH issues are involved. I think this is the core issue MH patients have in talking about their problems with loved ones.

Hopefully, that helps give you a way to approach this tough problem. It is a personalized approach that is needed.

What not to do or say to a suicidal person

Everyone is different and reactions to these hard situations differently, so it is hard to give a “to do” list. Such a list is personalized.

It is much easier to give a “don’t ever do or say this” list.

  • “It’s not that bad”
  • “Snap out of it”
  • “Stop whining”
  • “It is a sin”
  • “You are being selfish”
  • “Do you know how much you would hurt me and others”
  • “Don’t be a coward”
  • “Others have it worse than you and they aren’t trying to kill themselves”
  • “It is a permanent solution to a temporary problem”
  • “Stop seeking attention”
  • “You are crazy”
  • “Don’t do something stupid”
  • “Just keep busy”

I know it is difficult to not say these things, you will be shocked and hurt but remember that placing judgments, minimizing the pain they are feeling, and laying a guilt trip on them will make them worse and raise the risk that they do go through it.

It is not about you in the slightest even though you are hurting because of your loved one’s desire to end their life. Would you be so judgmental if a family member had cancer? This is no different.

Go the other direction: show love, concern, and understanding and gently nudge them towards getting help. Listen, but do not judge them or point out how ridiculous and illogical they are being.

“Just keep busy” is a wrong thing to say because these thoughts are always present no matter what the person is doing. While it is not judgmental or placing blame on them it shows a deep lack of understanding of what it is like to have these thoughts. They are all-consuming and almost constant and they can not be ignored by staying busy. For me, they are there when I am reading, working, riding my bike, falling asleep. Nothing removes those thoughts. Just listen and offer them a shoulder.

It is very easy to say the wrong thing. If you do say something that is upsetting apologize and tell them that you panicked and that you are here for them and are concerned about their well-being. Unless they are completely out of control they will likely understand and appreciate it. If you need to, take a few minutes to collect yourself. Do not double down on saying the wrong things even if you are angry and scared. Panic kills.

The goal is to show them unconditional love and get them the help they need.

In the US, most mental health services truly suck and that is without getting into the fact that psychiatry is mostly a pseudoscience, but when someone needs help it can and often does save lives.

Recognizing the signs and a simple question like ‘what is going on?’ is the start of what can be a long and hard journey.

They will likely tell you that they are not worth saving and leave them alone so they can end it, don’t heed that unless it is me that said it.

I didn't want to wake up. I was having a much better time asleep. And that's really sad. It was almost like a reverse nightmare, like when you wake up from a nightmare you're so relieved. I woke up into a nightmare.

Ned Vizzini