Stigma Excerpts
"I am not okay."
? "You may feel
reluctant to ask a teen if they've been thinking about
hurting themselves.
Parent's Guide to Teen Depression For more information:
Suicide is the 8th leading cause of death in Oregon, and the second leading cause of death for 10 to 24 year olds. Still, suicide remains a taboo topic, is highly stigmatized and is surrounded by myth and mystery. Myth: Asking someone “Are you thinking about suicide?” or “Are you thinking about killing yourself?” will put that idea into someone's head.
"You may
feel reluctant to ask a teen if they've been thinking about
hurting themselves. What the experts say... Studies show that asking
at-risk individuals
Ask directly about suicide. Ask the question in such a way that is natural and flows over the course of the conversation. Ask the question in a way that gives you a "yes" or "no" answer. Don't wait to ask the question when the person is halfway out the door. Asking directly and using the word "suicide" establishes that you and the at-risk person are talking about the same thing, and lets them know you are not afraid to talk about it. Ask: "Are you thinking about killing yourself?" or "Are you thinking about ending your life?" How NOT to Ask the Question "You're not thinking about killing yourself, are you?" Do not ask the question as though you
are looking for a "no" answer. Asking the question in this
manner tells the person that although you assume they are
suicidal, you want and will accept a denial.
What’s the Harm in Asking
About Suicidal Ideation? What to Do When
You Think Someone is Suicidal One of the biggest — and most destructive — myths is that if you discuss suicide, you’re planting the idea in someone’s head, said Scott Poland, Ed.D, the prevention division director at the American Association of Suicidology and associate professor at Nova Southeastern University. Clinical psychologist and suicide expert William Schmitz, Psy.D., likens it to talking to someone who’s recently been diagnosed with cancer. By mentioning cancer, you’re not forcing the topic front and center. “If someone is diagnosed with cancer, it’s on their mind.” Bringing it up shows support and concern. Similarly, by talking about suicide, you show the person that you truly care about them. In fact, lack of connection is a key reason why people have suicidal thoughts; isolation contributes to and escalates their pain. In general, it’s important to take any suicide thought or attempt seriously. But what does that mean and then where do you go from there? Because we talk so little about suicide, there’s little awareness about how to help. Dr. Poland emphasizes that people don’t have to suddenly step into a therapist’s shoes and counsel the person. But there are important ways you can help. Drs. Schmitz and Poland discuss the best ways below. Take suicide seriously, and don’t minimize it. When talking to a person you think might be suicidal, it’s critical not to dismiss what they’re saying. While this makes sense, we might minimize a person’s pain without even realizing it. Poland even sees this when training professionals on suicide prevention. For instance, in a training example, if the person says, “My life is so terrible right now,” it’s usually met with reactions like “Oh, it’s not that bad” or “I know you’d never hurt yourself.” Even when the person mentions being overwhelmed, well-trained professionals dismiss the comments. For instance, they say: ‘Things were awful for me last semester, too, and I got through it. Let me help you with your studying.” Although help is being offered, this reaction still minimizes and discounts the person’s feelings and experiences. And both slam the door on communication. Know the warning signs. According to both experts, these are some of the warning signs to pay attention to: dramatic changes in behavior or weight; drinking more than usual; mood changes; anxiety; making hopeless statements about death and dying; and isolating or withdrawing, such as dropping out of activities. Ultimately, though, “trust your gut that something is not quite right,” Poland said. The American Association of Suicidology also features an in-depth list of warnings signs. It’s designed to help professionals detect risk for suicide, but it may give you more information. Approach the person. If you notice one or several red flags, don’t hesitate to talk to the person. Again, the worst thing you can do is to ignore what’s happening. Poland suggested starting the conversation by saying something like: “’I’d like to talk to you a minute, I’m really worried, you seem like you’re a little down. Could we talk about that? I’m here to help.” Also, during the conversation, consider your physical cues. You may be asking the person to share their feelings with you but your demeanor may indicate that you don’t really care, you’re rushing or you’re not open or fearful about hearing them. Importantly, never agree to secrecy, Poland said. For instance, you can say, “I really care about you, I’m here to help, and I cannot promise to keep this a secret,” he said. Be direct. Some resources suggest asking the person if they have thoughts of hurting themselves. According to Schmitz, such questions are “rarely beneficial.” That’s because “When people walk around the topic of suicide [such as the question of hurting oneself], it can send the unintended message that it is not OK to discuss suicide.” Also, he added that “for a lot of suicidal individuals, they have no desire to hurt themselves, they are striving to cease pain and want relief/death, and will often decide on the ‘least painful’ method of suicide in their ideations.” Ask the person directly if they’re considering suicide, Schmitz said: “You know, John/Jane, a lot of people with (insert warning sign[s]), can have thoughts of suicide or of killing themselves, are you having any thoughts of suicide?” Listen. “Too often we either don’t listen well or we say something that cuts off the conversation,” Poland said. But listening is one of the best ways you can help, both experts emphasized. Give the person the opportunity to tell you how they’re feeling and what they’re going through. Be genuine. As Schmitz said, “We can have so much fear in talking about suicide [and] we’re so scared about saying the wrong thing, that we say nothing.” Speak from the heart. Anything that’s said genuinely and directly, he said, ultimately can’t be damaging. Schmitz recalled working with a high-risk suicidal patient whose thoughts included killing himself with a gun. During one of their sessions, when talking about treatment, Schmitz unwittingly said to the patient, “we just haven’t found a magic bullet for this yet.” “Doc, ‘I’m not sure that’s the best analogy,” the patient responded, and they were able to laugh at the situation because of the connection they had. “It’s not about the right four words or two sentences, it’s about the connection,” Schmitz emphasized. There are no magic words. What’s important is conveying empathy, concern and a willingness to help. Help them eliminate access. If the person discloses to you how they’re considering committing suicide, eliminate access to those means, Schmitz said. For instance, if they’ve had thoughts of using a gun and there are guns in the house, either get the guns out or get the person away from the home, he said. Even if the person says in passing that they’re thinking about overdosing, it’s invaluable to see what kinds of medications are in the house and to talk about getting rid of them, he said. He added that you can tell the person, “I really care about you and I don’t want you to do something impulsive that you’ll regret.” This shows them that you genuinely care. Convey hope. “The next critical message after connection and empathy is that [suicidal thoughts are] treatable and there is help,” Schmitz said. Numerous studies have shown that treatment can reduce the severity, duration and frequency of suicidal thoughts. Let the person know that they’re not alone, that others have experienced suicidal thoughts and go on to lead fulfilling lives after seeking treatment. Help them get help. When talking to the person, the key is to get them treatment right away. As Poland said, “this isn’t something we want to wait on,” even if it’s checking back with them later that day or the next day. Avoid assuming that things will be better the next day. At their university, Poland encourages faculty members to walk students to the counseling center or call a provider together immediately after their talk. Together, the two of you also can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), which is free, confidential and available 24/7. (Here’s more information.) Call 911 in case of an emergency. In addition to calling 911, stay with the person until emergency services arrive, Poland said. It’s vital not to leave a suicidal person alone. You can show support and compassion by saying things like “‘I’m going to be there for you,’ I’m going to visit you’ or ‘Who can I call for you,’” he added. Unfortunately, suicide is largely
misunderstood in our society. But there are many things you
can do to help, including: paying attention to the warning
signs, approaching the person, being direct and empathetic,
truly listening and helping them find help right away. How To
Encourage Someone To See A Therapist Here are some steps you can take to tell your loved one about the benefits of seeking therapy. Show Support Misconception about mental health and therapy has intensified stigma in society. Your loved one may be aware that they need help, but may be afraid to seek it if they think you will judge or treat them differently. Therefore, it is essential to use non-stigmatizing language when talking with them about their mental health. Assure them that you will support them through the therapy process. Demi Lovato is one of the most vocal celebrities about her mental health issues. She mentioned on multiple occasions how important it was for her to have people around that really care about her wellbeing. She credits her support group for being able to go through everyday life. Demi asks for advice from her loved ones and asks them to let her know when they feel something’s off: "So whether it's with my management team or with my friends, every choice that I make, I run by people. And that's what's really helped me—vocalizing what you need." Be Sensitive To Timing And Place Talking to someone about mental health requires emotional sensitivity as well as physical sensitivity. The “where” and “how” the topic is presented may determine how a person reacts to your suggestions. Your loved one may not be as bold as Kesha when she shared her condition and struggles with the world while receiving an award. Don’t start this delicate conversation in front of other people or where others can hear as this may cause discomfort. And avoid grouping up in an intervention-style conversation as people do on TV shows. Allow the person struggling to decide whether they want others to know. This way, they feel respected and in control of their own treatment. Also: Avoid talking to someone when they are in a bad mood, tired, have tight deadlines at work or if they’re doing something important. They may dismiss you or disregard the weight of the topic. Approach the person when they’re in a good mood, relaxed and undistracted. Try as much as possible to keep the conversation private, friendly and relaxed. Prepare For Resistance Not all people who hear about therapy will be willing to try it out. You need to be prepared to make your case if your loved one resists your suggestion. Here are some ideas that you can use to highlight the importance of therapy:
Offer To Help You can try to embolden someone to go to therapy, but unless you are willing to offer meaningful support, it’s not going to encourage them. Some people do not know where to start when seeking help. Guide them in finding a suitable therapist in the area, depending on their preferences. You can contact offices on their behalf or research various professionals, their credibility and reviews. Some people are scared of seeing a therapist alone or signing up for group therapy. Offer to go with them until they’re comfortable. You can sit in the waiting room during their first few sessions. Make sure to assure them that you won’t ask prying questions about the counseling unless they want to share. Seeking therapy is one of the best
steps that a person with a mental health condition can take.
However, it’s an effort that requires great strength
and courage. Share your suggestions as openly as possible
and leave them to make the decision that best suits their
needs. Above all things, assure them of your continued love
and support throughout the process.
Many also face the stigma our cultures—and often our churches—assign to a death by suicide. For instance, I think it’s a terrible shame when families insist that the service not even mention the word “suicide.” Once, a mother whose son died by suicide reasoned that she feared his life would forever be reduced to that single act. She feared that all other aspects of his life, like the work he did and the friendships he enjoyed, would be forgotten. “If he had died of cancer, or in a car accident, that wouldn’t be all people talked about,” she argued. Inspired by this mother’s fear of how her son’s memory might be reduced and skewed, I began to characterize suicide in my funerals and memorial services as not a desire for death, but a cry for life—more life, better life. So often, our culture concludes that suicide is a rejection of life, a willful refusal to live any longer, but I believe suicide is a statement that life can and should be so much more than pain or despair. If a suicidal person only sees a future with days on end of pain, then that vision looks nothing like the sort of life we all long to enjoy. I remember in my own times of depression and thoughts of suicide, I often thought, “If this is all there is, if loneliness and meaninglessness and failure are going to be the sum of my experience, then forget it. This is not life. I am breathing, going through the motions, but I am not truly living.” I desperately wanted to live, but I couldn’t find a way to do so. Yet without realizing it, saying that I no longer wanted to live actually became a way to live. Having the courage to say how I was feeling and what I was experiencing—not pretending, but being honest even when what I was saying was difficult—was how I took my first steps away from a life that seemed no life at all towards a “real life” worth living. It’s a strange paradox: The more willing we are to be vulnerable and less-than-perfect, to ask for support when can no longer support ourselves, the stronger we become and the richer our lives become. Connections with others make the difference. Opening The Conversation When we bravely have open and honest conversations about mental illness and suicide, we potentially make life-saving connections—like what happened to me. Without those conversations, we only have loneliness, silence and unanswered questions. When I speak to those who attend the services of a person who died by suicide, I often discover that it’s not their first experience of grieving such a death. They reference family members, friends, colleagues or neighbors who died by suicide, and how the present death brought back those earlier losses. They talk about how they continue to struggle with their memories and questions. The shadow of suicide is long. Those who just experienced a suicide loss need comfort, and a religious service might provide it. However, that cannot happen if the manner of death is never mentioned. So, as we approach International Survivors of Suicide Loss Day, we might consider overcoming our reluctance to speak of suicide, to break apart the taboo that encloses it. Until we start talking, healing cannot happen. And as we speak more openly and honestly, we open the possibility that the cry for life suicide represents might be heard in time. International Survivors of Suicide Loss Day is Nov. 18 The American Foundation for Suicide
Prevention will be hosting gatherings in local communities
for those affected by suicide to come together and share
stories of healing.
Beyond my relationship with Andrew, I am also a mental health practitioner. Whether I’m caring for someone with schizophrenia or depression, I often walk the narrow, unforgiving line of when to push and when to administer a large helping of mercy. Though challenging people to improve their quality of life is risky, if we don't, those who are struggling may continue to struggle. People have asked me so many times when and how to encourage, or push, someone struggling with a mental illness. Here is what has worked for me: Practice Compassion And Mercy First An act of mercy starts with an open mind and a sensitive, understanding voice while communicating. I constantly challenge myself to see the bigger picture and put aside my own frustrations, so I don’t come across as judgmental or abrasive. As this type of personality can prevent an empathetic viewpoint. If I am open about my own problems around my husband, he might be more willing to talk about his own struggles. Assess Symptoms To push someone successfully, knowing when symptoms are flaring is helpful. Phone calls, text messaging or other forms of digital communication can make it difficult to assess symptoms. Body language and word choice, comparatively, offer a wealth of information. For example, anxiety can cause a person’s body to twitch and tighten. Show Love During Confrontation Unfortunately, caregivers often have to challenge struggling individuals during difficult times. Waiting for peaceful moments or willing ears is not always an option. That's where the art of confrontation and mercy merge into one cohesive act of love. However, yelling or speaking from a platform of self-assumed intelligence, pride, anger or bitterness typically results in a negative outcome. People tend to respond well to a loving presentation of information that reinforces equality. Build Relationships That Foster Equality Healthy relationships start with the understanding that mental health conditions have labels, but those labels don’t represent the person. Treat your loved one as a person who is equal to you, not as a lesser person because they have mental illness. If their relationship with you isn’t built on mutual respect and admiration, it will be very difficult for them to grow or be challenged by you. With all this said, keep in mind that
no one has absolute control over another human beings’
actions. Caregivers must let go at times to
remain healthy themselves
Expect to make mistakes as you grow
into your role as caretaker. Though I have often felt guilty
for making his life harder with my pushing, Andrew often
tells me he may have been lost to a permanent state of
delusion without our relationship. I know that my presence
in his life has challenged him to be the best he knows how
to be. Never give up on the person you love, and try to
remember the immense challenges that a person with a mental
health condition faces each day.
Dr. Nordal is a licensed psychologist experienced in treating adults, children and adolescents and has clinical expertise in the treatment of stress-related disorders. As executive director for the APA’s Practice Directorate, Dr. Nordal manages a variety of activities involving legislative advocacy, legal initiatives, efforts to shape the evolving health care market, and a nationwide public education campaign, including the Mind/Body Health Campaign, to enhance the value of psychology. Dr. Nordal is a recipient of the APA’s Karl F. Heiser Presidential Award for advocacy on behalf of Psychology. She was an APA/AAAS Congressional Science Fellow (1990-91) and served as a legislative assistant in the U.S. House of Representatives and with the House Select Committee on Hunger. Her clinical interests included: learning, behavioral and emotional disorders in children and adolescents; neuropsychological assessment; brain injury in children and adults; and civil forensic psychology. Do you think there is still a stigma associated with mental illness? Awareness of mental health issues has definitely improved in recent decades. When I entered practice more than 30 years ago, individuals in my semi-rural community would often travel 40-50 miles to get treatment because they did not want anyone to know that they were seeing a therapist. Many people were concerned about what others may think if they were open about their mental health. In many ways, we have taken great strides since then as more people talk about mental health publicly and as we see more positive depictions of mental health in popular culture. Yet, for many, stigma remains. A 2008 APA survey found that more than half of Americans saw stigma--and concerns about what other people might think--as barriers that could prevent them from seeking mental health treatment. And while an estimated 50 million Americans experience a mental health disorder in any year, only one in four will receive treatment. It is important to remember the impact that stigma can have. Because of stigma, people who need treatment may fail to seek it and they may face discrimination and problems at work or school or even encounter harassment or violence. Furthermore, untreated mental health disorders cost businesses millions of dollars in lost productivity, absenteeism and health care costs. Why does the public often have a different view of mental illness than physical illness? Traditionally, the medical model has separated mental and physical health. But this fails to take account of the strong links between the mind and body. Research shows that physical health is directly connected to emotional health, and millions of Americans know that suffering from a mental health disorder can be as frightening and debilitating as any major physical health disorder. Poor mental health has implications for physical health – for example, research has shown that people with depression are at greater risk for developing heart disease, and conversely, that people with heart disease are more likely to suffer from depression than others. Integrated health care – care that treats both the mind and body – is the key to breaking down stigma and providing the best care. Many psychologists already work in primary care settings with physicians and other health care professionals, often serving as members of multidisciplinary treatment teams and taking the lead when a patient has a primary mental health or substance abuse diagnosis. What can be done to combat stigma and stereotypes about mental illness? Congress took a huge step in tackling stigma when the Wellstone-Domenici Mental Health Parity and Addiction Equity Act was passed last year. This new law means that insurance policies can no longer discriminate against those with mental health or substance use disorders. We’ve long known that mental health disorders can be as serious as those impacting physical health. The new parity law recognizes this by mandating that coverage must be the same for mental health as for physical health including co-payments, deductibles and in-patient treatment limits. Events like Mental Health Month also
serve to raise awareness and decrease stigma. Mental health
disorders impact everyone – by talking about mental
health we can dispel stereotypes and raise awareness.
To be published on a quarterly basis, Stigma and Health (ISSN 2376-6972) serves as a venue for articles examining research representing stigma in its various guises (e.g., public stigma, self-stigma, label avoidance and structural stigma) as it impacts people living with mental and physical illness. Stigma and Health publishes peer-reviewed, original research articles that may include tests of hypotheses about the form and impact of stigma, examination of strategies to decrease stigma's effects and survey research capturing stigma in populations. Stigma and Health especially welcomes research studies on methods meant to erase the stigma of mental and physical illnesses. Theoretical reviews and pioneering reports on innovations are also welcome. The journal publishes regular articles as well as brief reports. As stated in the journal’s inaugural editorial, the true value of the research published in the journal lies in helping to replace stigma with affirming attitudes and behaviors that recognize the worth of personhood not diminished by illness or wellness and that acknowledge communal responsibilities for opportunities and accommodations that help people realize their goals. More information about the journal as well as guidelines regarding submissions can be found on the journal’s homepage. Prospective contributors and subscribers are encouraged to visit the site. The inaugural editor of Stigma and Health is Patrick W. Corrigan, PsyD, distinguished professor of psychology at the Illinois Institute of Technology. Previously, he was professor of psychiatry at the University of Chicago, where he directed the Center for Psychiatric Rehabilitation. His research examines psychiatric disability and the impact of stigma on recovery and rehabilitation. Currently, he is principal investigator of the National Consortium on Stigma and Empowerment (NCSE). Funded by the National Institute of Mental Health, NCSE is a collaboration of investigators from more than a dozen research institutions. He is also principal investigator of current grants from the National Institute on Minority Health and Health Disparities and the Patient-Centered Outcomes Research Institute, and he is conducting stigma research with support from the Department of Defense, the Veterans Administration and the Canadian Institutes of Health Research. Corrigan has authored or edited more than a dozen books, has published more than 300 peer-reviewed articles and is editor emeritus of the American Journal of Psychiatric Rehabilitation. Articles published in Stigma and Health will also be available through PsycARTICLES®, the most used full-text database in psychology and one of the most popular databases in all scholarly disciplines and fields. PsycARTICLES is available to a global audience of nearly 3,700 institutions and 80 million potential users. The American Psychological
Association, in Washington, D.C., is the largest scientific
and professional organization representing psychology in the
United States. APA's membership includes more than 122,500
researchers, educators, clinicians, consultants and
students. Through its divisions in 54 subfields of
psychology and affiliations with 60 state, territorial and
Canadian provincial associations, APA works to advance the
creation, communication and application of psychological
knowledge to benefit society and improve people's lives. How
The 5 Steps Can Help Someone Who is Suicidal Ask How – Asking the question “Are you thinking about suicide?” communicates that you’re open to speaking about suicide in a non-judgmental and supportive way. Asking in this direct, unbiased manner, can open the door for effective dialogue about their emotional pain and can allow everyone involved to see what next steps need to be taken. Other questions you can ask include, “How do you hurt?” and “How can I help?” Do not ever promise to keep their thoughts of suicide a secret. The flip side of the “Ask” step is to “Listen.” Make sure you take their answers seriously and not to ignore them, especially if they indicate they are experiencing thoughts of suicide. Listening to their reasons for being in such emotional pain, as well as listening for any potential reasons they want to continue to stay alive, are both incredibly important when they are telling you what’s going on. Help them focus on their reasons for living and avoid trying to impose your reasons for them to stay alive. Why – Studies show that
asking
at-risk individuals
Keep Them Safe How – First of all, it’s good for everyone to be on the same page. After the “Ask” step, and you’ve determined suicide is indeed being talked about, it’s important to find out a few things to establish immediate safety. Have they already done anything to try to kill themselves before talking with you? Does the person experiencing thoughts of suicide know how they would kill themselves? Do they have a specific, detailed plan? What’s the timing for their plan? What sort of access to do they have to their planned method? Why – Knowing the answers to each of these questions can tell us a lot about the imminence and severity of danger the person is in. For instance, the more steps and pieces of a plan that are in place, the higher their severity of risk and their capability to enact their plan might be. Or if they have immediate access to a firearm and are very serious about attempting suicide, then extra steps (like calling the authorities or driving them to an emergency department) might be necessary. The Lifeline can always act as a resource during these moments as well if you aren’t entirely sure what to do next. The
Harvard T.H. Chan School of Public
Health
Be There How – This could mean being physically present for someone, speaking with them on the phone when you can, or any other way that shows support for the person at risk. An important aspect of this step is to make sure you follow through with the ways in which you say you’ll be able to support the person – do not commit to anything you are not willing or able to accomplish. If you are unable to be physically present with someone with thoughts of suicide, talk with them to develop some ideas for others who might be able to help as well (again, only others who are willing, able, and appropriate to be there). Listening is again very important during this step – find out what and who they believe will be the most effective sources of help. Why – Being there for someone
with thoughts of suicide is life-saving. Increasing
someone’s connectedness
In the Three-Step
Theory
By “being there,” we have a chance to alleviate or eliminate some of these significant factors. Help Them Connect How – Helping someone with thoughts of suicide connect with ongoing supports (like the Lifeline, call 800-273-8255 or text "SOS" to 741741.) can help them establish a safety net for those moments they find themselves in a crisis. Additional components of a safety net might be connecting them with supports and resources in their communities. Explore some of these possible supports with them – are they currently seeing a mental health professional? Have they in the past? Is this an option for them currently? Are there other mental health resources in the community that can effectively help? One way to start helping them find
ways to connect is to work with them to develop a safety
plan. This can include ways for them identify if they start
to experience significant, severe thoughts of suicide along
with what to do in those crisis moments. A safety plan can
also include a list of individuals to contact when a crisis
occurs. The
My3 app
Why – Impact
of Applied Suicide Intervention Skills Training on the
National Suicide Prevention Lifeline
Follow Up How – After your initial contact with a person experiencing thoughts of suicide, and after you’ve connected them with the immediate support systems they need, make sure to follow-up with them to see how they’re doing. Leave a message, send a text, or give them a call. The follow-up step is a great time to check in with them to see if there is more you are capable of helping with or if there are things you’ve said you would do and haven’t yet had the chance to get done for the person. Why – This type of contact can
continue to increase their feelings of connectedness and
share your ongoing support. There is evidence that even a
simple form of reaching out, like
sending a caring postcard,
Studies have shown a reduction in the
number of deaths by suicide when following
up was involved
For more information, press/media
inquiries, or partnership opportunities, please contact
Frances Gonzalez at fgonzalez@mhaofnyc.org
It's ok to say, "I'm not ok.' A conversation could change a life
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