Tag Archives: suicide

A Blog About A Blog About Suicide

I’m going to keep this short.

On the eve of the second anniversary of the meta4RN.com blog we (guest writer Stevie Jacobs and I) have finally released her powerful, gutsy post “These words have been in my head and they needed to come out (a blog post about suicide).” I thought by opening up meta4RN.com to occasional guest posts I would save myself some time and effort. Ha! Stevie’s post has had the longest, most difficult gestation of all of the posts on this blog.

Why? It’s not because of Stevie’s writing – she writes very well – It’s because of the content.

It’s because we don’t know how to talk about suicide.

mindframe I remember as a 14  year old learning about suicidal ideation via the famous Hamlet soliloquy which starts: “To be, or not to be, that is the question…” Shakespeare didn’t seem to be as afraid as getting the tone/message wrong as Stevie Jacobs and I have been.

Luckily, we don’t have to navigate this tricky territory without a map. Mindframe – Australia’s national media initiative – have some very handy tips aimed (mostly) at media. They also have info for universities, the performing arts, police and courts. It would be silly to replicate all their information here – cut out the middle-man and visit the Mindframe website:
www.mindframe-media.info

The only thing I want to make sure is included here is that we, the health professionals, remain mindful of responsible use of language in social media, including blogs (and Facebook, Twitter, Instagram etc) . Melissa Sweet of croakey (the Crikey health blog) has used the term “citizen journalist” to refer to us non-journos who are active on social media. I have shied-away from that label because I have zero knowledge/pretensions of being a journalist. However, when it comes to talking about mental health and/or suicide, I reckon that those of using social media as health professionals should take some ownership of the “citizen journalist” tag.

Health professionals are used to being informed by evidence-based guidelines, right? That’s what the Mindframe guidelines are. They are guidelines for how language should be used by journalists. Those of us who are blogging/Tweeting/Facebooking/whatever can, if we choose to be safe and ethical, abide by the same code of good practice (here).

Let’s watch our language.

Let’s edit and re-edit.

Let’s reflect and think about our impact. Let’s do that slowly.

Let’s be safe. ethical and kind.

Let’s do no harm.

Let’s follow the Mindframe guidelines when we’re blogging about mental health and/or suicide.

End.

That’s it. Thanks for visiting.

If you haven’t done so already, visit Stevie Jacob’s guest post here: meta4RN.com/guest02 My favourite part is the middle part (the meat in the sandwich?) which is honest, powerful, raw and gutsy. I hope/think that the edits made have been in keeping with the Mindframe guidelines. If  not, that is my responsibility. Please let me know and I will fix it as soon as possible.

Paul McNamara, 23rd September 2014

Short URL: meta4RN.com/mindframe

These words have been in my head and they needed to come out (a blog post about suicide)

Trigger Alert – this blog contains info re suicide which may be unsettling for some people.

Guest Post: Stevie Jacobs has contributed this guest post to meta4RN.com

StevieJacobsStevie Jacobs is the pen name of a newly-minted Enrolled Nurse. The person behind Stevie is smart, experienced in life and has some awesome insight into the world of the student and new graduate nurse.

You can follow Stevie Jacobs on Twitter: @SJWritesHere

Stevie has contributed to other nurse blogs, including the excellent site Injectable Orange, by Jesse Spurr.

These words have been in my head and they needed to come out
(a blog post about suicide)

I am ‘Pro choice’.

I am a patient advocate.

I am a person advocate.

I support euthanasia.

I am pretty much of the opinion that if you have all the facts, figures and feelings figured out then you can go ahead and do pretty-much whatever you like. Even if it’s ‘bad’ for you. I can provide you with action plans and phone numbers and personal support, however ultimately, the choice my friend, is yours.

So when someone wants to kill themselves/suicide/take their own life (however you want to put it) what does my head feel about that? I’m not talking about obligations as a Health Care Professional, I’m talking about obligations as a human being. I can provide you with an ear to bend, a shoulder to lean on, I can find you professional help if you want, I can tell you that I don’t think you’re in a safe space and I want to get more support. For both of us. I can do all that. What I am stuck with is that if euthanasia is assisted suicide and I’m OK with that (OK meaning I won’t physically stop you nor judge you), does that mean I am ‘OK ‘ with someone’s suicide? Both have the same ending:, the removal of pain through the death of a person. I don’t know how my heart or my head feel about that.

Robin Williams was 63. That’s a long time to be living in pain. Yes, there are medications and therapies and support groups, but what if that starts to feel just all too much? That living is just all too much, a bit like ‘diabetic burnout’, where the person with diabetes basically gets fed up with ‘managing’ their diabetes and becomes unwell. That can happen with all chronic diseases. That can happen with mental health issues. Yes, some people have a depressive episode, it’s self-limiting and then they never have another one. Wonderful. For others, it just keeps on coming back, more painful than before.

To someone who is experiencing suicidal thoughts, suicide I can seem to be a rational method of pain relief. It’s the ultimate pain reliever for the person experiencing the thoughts.

For those left behind it can be devastating.

I can’t make up my mind. Do I have the ‘right’ to stop someone from suicide? I’m on the fence. The boundaries get blurred. I’ve experienced anxiety & depression, I’ve experienced suicidal thoughts & been ‘suicidally depressed’, I’ve had a family member suicide and I’ve known someone I followed on Twitter suicide. Which is a really fucking weird experience, quite frankly. Grief for someone who you ‘know’, but don’t ‘know’. 101 ‘What ifs?’. I could ‘see’ that something wasn’t right, but aside from checking in and offering an ear what else could I do? I’m at peace with those choices now, no longer haunted by ‘what ifs’. I’m sure that is not the same for their family and friends. I realised that what has stayed in my head is a photo of themselves they posted shortly before it happened. It’s their eyes. Their eyes haunt me. I can see something in their eyes I’ve seen time and time again. In my face. In the faces of others. I know those eyes so well. However good your mask is it’s in the eyes.

So, what to do? Who am I to tell anyone what to do? There isn’t really a clear answer. I think it’s really important to keep checking in on people: RU OK? I have RUOKed a few people and I will keep doing it. If it’s a ‘No’, and they express some ideas that worry you, it’s OK to ask “Do you have a plan?” If it’s a ‘Yes’, what then? Especially if you just don’t believe them. That’s trickier ground to navigate. I’m no expert on this. There are links at the end of this from people who are.

RU OK? It’s just a simple question. A simple, lifesaving question. I was on another planet from OK, and someone who barely knew me asked me that question.

It was like a thunderbolt.

It made me stop and think and choose to get help to make living less painful. Choosing to get help is hard. Getting help can be harder. What’s even harder is acknowledging that choosing to live is a conscious effort. It’s an effort. Accepting that medications and therapy and exercise and diet changes and avoiding triggers are now part of your life is an effort.

In time I hope that life will once again become effortless, but it might not.

Finally, after years of effort, I now think I am OK with that.

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Post Script 1:

I wrote the above post a little while back. Normally when I have said all I have to say on a subject it doesn’t pop back in to my head. This post did. If I am honest, I have only scratched the surface. I have more to say. The way I write usually is like a good vomit on a night out: it all comes out in one go and it’s done and dusted and you’re up and dancing again. The other way I write is a bit more like a gastro bug: on and off with a bit of dry retching when you just can’t get it out. Then you’re done and you feel better.

Paul told me the ‘meta’ point of meta4RN is ‘talk about what you’re talking about’. So I guess that’s what I’m doing here. Rereading the above, reflecting on it and trying to work out quite what it is that I still feel I want to say.

We need to talk about mental health. We need to talk about suicide. We need to do it in a safe, appropriate and open way, but we do need to talk about it. Talking about it is hard. Talking about it can be terrifying for anyone. Talking about it when you’re a health professional is really damn hard. There are so many ‘what ifs’. What if they ‘lock me up’? What if they don’t? What if they think I’m not fit to practice? What if I lose my job? What if my colleagues find out? What if I have to be treated in the same hospital that I work in? What if…

I want to talk about how it feels to have suicidal thoughts. I want to talk about how it feels to be suicidally depressed. I’m not sure how to do that. I know that there are media guidelines for discussing suicide. As someone who is trying to describe a ‘lived experience’, I decided the best way for me to write was to let it all come out uncensored, and then give it to Paul to edit it using some of those guidelines and make it ‘safe’. I am in a safe enough space now to be brutally honest about how those suicidal thoughts feel, and far away enough from those thoughts to be able to talk about them without feeling ‘triggered’.

I can only speak for myself. For me there is a distinction between having suicidal thoughts and being ‘suicidal’ or ‘suicidally depressed’, as I have referred to it in the past. The thing about ‘suicidal thoughts’ is that the longer you have them the more rational they seem. For me suicidal thoughts are more of a hypothetical notion; it’s not something I am going to carry out. It’s an icy calm IF. IF things don’t get better, IF that was to happen, IF there isn’t another way out, IF the pain becomes unbearable, IF.

I know exactly how I would kill myself. I know exactly how I would spend the jackpot from a lottery win. I know exactly what I would get done if I had free access to plastic surgery. It’s all hypothetical.

It’s hypothetical. Until it’s not. Until I am suicidally depressed. Until I am in pain. Until the self-loathing I carry around with me every day takes over. Until I truly believe that the people in my life would be better off without me. Until I can’t see any way out aside from that way. And that place is not icy calm. It’s a messy, clinging on to something, anything to get through hour after hour, painful, emotional swamp. I feel emotionally swamped. I can’t think in a straight line. I can’t sleep. I can’t eat. The anxiety eats at my stomach. The panic attacks feel like I am dying of a heart attack. The after effects of which last for days. And nothing, nothing stops the pain. That’s how suicidal feels like for me. I know, however, that it is not what it looks like to other people. People see what they want to see. Even people who are trained to see more. I am brilliant at hiding it. I know how to put on my mask and polish up my armour. It is exhausting.

There are cracks in my armour, sometimes the mask slips. My fellow walking wounded can see though them, but for the most part the people I see every day wouldn’t know. I can make people feel so good about themselves. I can make people cry with laughter. Then, the second I am alone, the pain floods over me and I can barely breathe. I keep coming back to pain. It’s about pain. Not control, nor attention seeking, nor escape; in that moment it is about wanting that pain in my heart to stop. To. Stop.

It’s a horrendous place to live to be honest. It’s a half life. I had to choose to live better. To live for me. To get help – medications, counselling, CBT, exercise, diet. It’s a conscious choice. And what helped me make that choice was being asked ‘RU OK?’

.

Post Script 2:

So, turns out it’s not a verbal gastro bug. It’s verbal C.Diff. The words just keep coming out.

I think I need to make it clear that I am talking about a period of over 10 years. I need to make it clear that I am talking about the past. I might write ‘I know’, but I suppose really it is ‘I knew’. Deciding to share this is a decision that has been easy, but it is a decision that I have made because these words have been in my head and they needed to come out. There are more things I could say, about specific attempts, specific feelings. However, I don’t want to share them. I think that’s OK.

I need to make it clear that I support ‘RUOK’ & WHO suicide prevention strategies. I need to make it clear that if you judge me negatively based on what I have written or if it changes your opinion of me, then that’s your thing, not mine. I’m not asking for agreement or understanding, but I do ask for kindness.

I was asked recently what the best thing in my life is right now. Aside from Nursing, the answer is the people in it. I know that my people love me, and accept ‘me’, and that’s enough.

Black Dog Institute Healthy Living Study is a program to help those experiencing suicidal thoughts manage them: http://www.blackdoginstitute.org.au/public/research/participateinourresearch/index.cfm

Black Dog Institute Healthy Living Study is a program to help those experiencing suicidal thoughts manage them: http://www.blackdoginstitute.org.au/public/research/participateinourresearch/index.cfm

End.

Short URL:  meta4RN.com/guest02

Many thanks to Stevie Jacobs for sharing this gutsy piece of writing. Your sensitive, constructive feedback is welcomed in the comments section below.

It’s also important to acknowledge that talking and thinking about suicide can be distressing. People in Australia can access support via:

Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

MindHealthConnect www.mindhealthconnect.org.au

phone_hotline-40Outside of Australia and not sure where to get support? Google usually displays a red telephone icon and your country’s suicide support phone number when searching for a suicide-related topic.

This guest blog post has a companion piece, which I have imaginatively called “A Blog About A Blog About Suicide” – the link is here: meta4RN.com/mindframe

Paul McNamara, 23rd September 2014

A Mental Health Nurse in the General Hospital

MHCBelow is a copy of the blog post I was invited to submit at My Health Career. The website is targeted at high school and university students considering or pursuing a career in health, guidance officers, career development professionals, and others working in or with the health care sector.

To see the post where it was first published online, and/or to have a look around at the My Health Career website, please visit www.myhealthcareer.com.au/nursing/mental-health-nurse-paul-mcnamara

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A Mental Health Nurse in the General Hospital

Paul trying not to look too much like a goob.

Paul trying not to look too much like a goob.

Paul McNamara has extensive experience providing clinical and educative mental health support in general hospital and community clinical settings. He holds hospital-based, undergraduate and post-graduate qualifications, is Credentialed by the Australian College of Mental Health Nurses (ACMHN), and has been a Fellow of the ACMHN since 2007. Paul is a very active participant in health care social media, and is enthusiastic about nurses embracing “digital citizenship”. More info via his website meta4RN.com

There is an odd little sub-speciality of mental health services called “consultation liaison psychiatry”. This waffly, jargon-ridden mouthful of syllables is usually abbreviated to “CL”. What is CL? Easy – just think of it as “general hospital mental health”.

I’m a mental health nurse on a CL team. The only ward in the hospital I don’t visit is the mental health unit (the mental health unit already has heaps of mental health nurses – they don’t need me there). It’s the rest of the hospital I serve: the surgical wards, the medical wards and the maternity unit.

General hospital patients are more at risk of experiencing mental health problems than the general public – being sick is stressful. It works the other way around too: people who experience long-term mental health difficulties are more at risk of becoming physically unwell – being under lasting emotional stress can take a toll on the body.

Nurses, doctors, social workers and other allied health practitioners will phone CL when they have concerns about the mental health of a patient. Sometimes all that is required is a bit of information and clarification about medication or follow-up services available in the community – we do that over the phone. More often, we are asked to meet with the patient and determine what, if any, mental health matters can be sorted-out while they are in hospital.

The most common mental health problems experienced in the community are anxiety and depression – it’s the same in the general hospital – a lot of the people I meet with are experiencing either or both of these conditions. There are other mental health problems like eating disorders and deliberate self harm that sometimes require input from both the medical/surgical team and the mental health team concurrently. Helping-out with planning and providing support and care of these patients is a pretty big part of my job.

Sometimes it’s not the person in the pyjamas (the patient) who needs our support – sometimes it’s the communication, the systems and the clinical staff who benefit most from CL input. This can be in the form of structured education sessions or, more typically, in the form of supporting discussion, reflection and problem-solving on how best to meet the needs of the patient within the limited resources available in the hospital. In this aspect of the job, a CL nurse will try to help the clinicians involved step-back from the busyness and pressures of the hospital ward and take “a balcony view” of what is happening. By taking ourselves out of the chaos of a busy shift and calmly looking back at things with a bit of distance, sometimes we can see how we can “do business” in hospitals a little more constructively.

We also spend a lot of time “undiagnosing” (this is a “neologism” – a made-up word – I heard recently via Sydney psychiatrist Dr Anne Wand). The people we “undiagnose” the most are those who are experiencing grief. There can be a lot of grief in general hospitals, but we try to be careful not to confuse the emotions of grief (sadness, anger, temporary despair etc) with a psychiatric disorder. Grief emotions are often really uncomfortable but they are part of what makes us who we are. We don’t want to “psychiatricise” or “psychologise” the human condition. Grief is not something to be simply fixed; grief is a part of life – a difficult part of life – that is usually successfully navigated without psychiatric input. Support from loved ones and/or social workers and/or specific counselling services can help.

So, that’s an overview of what it is to be a mental health nurse in a general hospital. It’s a varied role where we spend nearly as much time with the general hospital nurses, midwives, allied health staff and doctors as we do with the hospital patients. The role involves direct clinical care, collaborating with colleagues and providing education. For more information on the speciality please visit my website or the consultation liaison nurses special interest group section of the Australian College of Mental Health Nurses website.

END

Print Version (PDF): CLnurse

Thanks to Amanda Griffiths of My Health Career for inviting me to submit this overview of consultation liaison nursing.

As always, your comments are welcome.

Paul McNamara, 2nd May 2014

 

Nursing’s Peculiar Privilege

Dear Reader: please don’t read this blog post if you are offended by strong swear words or find talk of suicide a trigger for unsettling/risky thoughts. Kind Regards, Paul.

Who is Going Behind the Curtains?

Working over Christmas and New Year made me especially cognisant of one of the peculiar privileges that we nurses have: we spend a lot of one-to-one time with the person who is medically/surgically recovering after a suicide attempt. My current role is Consultation Liaison Mental Health Nurse – a role that provides mental health assessment, support and education in a general hospital (more info about the role here). When the person is admitted to the general hospital after a non-fatal suicide attempt we are asked to be involved in planning and providing their care.

There are few things more privileged and more important than spending time with the person who is alive after deciding not to be. I do worry that this role is sometimes delegated to the least qualified (and lowest paid) member of frontline clinical care: the Assistant In Nursing (AIN) when there is “nursing special” in place (i.e.: when there are concerns that the person may abscond and/or harm themselves again).

Naturally, being an AIN does not mean you are incapable of sensitive, compassionate, safe care. I just think that “going behind the curtains” to assist in holding and containing the often very strong emotions of the person who has survived suicide is incredibly important. I don’t feel comfortable that someone without mental health qualifications or clinical supervision is tasked with sitting at the bedside for hours at a time. It may not be good for the either the person/patient or the AIN.

Suicide rates per year. Chart courtesy of www.mindframe-media.info

Suicide rates per year. Chart courtesy of http://www.mindframe-media.info

Parallel Processes

In clinical supervision we often explore the parallel processes and how they apply to our clinical work. When working in perinatal mental health I aimed for the therapeutic relationship to be a template for the parent-child relationship: kind and nurturing, responsive and interactive, empowering, educative and enjoyable. The idea being that, at some level, the qualities/values that inform the therapeutic relationship can then have a knock-on effect for the relationship the parent has with their baby. Not many perinatal mental health clinicians have an abrupt, cold, clinical style of interacting with their clients: they tend to be warm, gentle communicators.

When nursing the person who has survived suicide we need to think about parallel processes again. Julie Sharrock (a rock star of consultation liaison nursing) first introduced me to the phrase “holding and containing” as a part of the therapeutic relationship. Traditionally the notion of holding and containing has been attributed as a function of the inpatient setting/building: a place to keep people safe. Julie introduced it to me as a way to keep people safe, by reframing it as a concept for interpersonal therapy. That is, we nurses can assist and model the act of holding and containing difficult emotions.

For the person who has unexpectedly found themselves alive and in hospital after intending to end life, we may need to hold and contain the person physically for a short time, but (to my way of thinking) it is even more important to support the person to hold and contain their thoughts and feelings.

Thoughts are slippery, and prone to be dropped.

Feelings are brittle, and prone to cracking.

Holding and containing such difficult-to-secure, fragile things is fraught: the clinician needs their thoughts and emotions held and contained too. Its a parallel process: as I’ve discussed previously we need to nurture the nurturers.

Suicide rates per age group (2010). Chart courtesy of www.mindframe-media.info

Suicide rates per age group (2010). Chart courtesy of http://www.mindframe-media.info

Profound Moments

Some of the most profound moments of my working life have occurred while supporting the person who has survived suicide.

The incredibly dark humour: “I’m such a fucking loser I can’t even kill myself properly!” said the very nice man. He was not laughing out loud, but smiling at the grim absurdity of his situation. He was alive, but physically worse-off than when he decided to die: now fractured, urinating through a tube, receiving fluids and antibiotics via an IV line. More wounds. More pain. Yet, despite the extra physical insults, he was pleased that he had survived.

The worry: “Is my brain OK? I feel really agitated and confused.” asked the lady who had been in intensive care for a few days. Her brain was OK in the long-term, the distress she was experiencing was mostly short-term stuff:  delirium is really common amongst ICU patients. Hypoxic patients aren’t so lucky: they sometimes never recover the former function of their brain.

“You are the biggest fucking cunt that has ever existed in the whole world!”, said the man after being told he was unable to leave hospital. I was filling-in paperwork that would mean he was an involuntary patient as per the Mental Health Act. I didn’t think I was being particularly nasty. The mental health act is handy because there are times when I need to say, “It seems to me that you don’t have the capacity to keep yourself safe at the moment. So,  I’ll take some of the responsibility of keeping you safe for now. Naturally, we will hand the job back to you when you come good.” Using that framework, filling-in the paperwork for the mental health act is sometimes the most nurturing thing I can do. That’s why i was genuinely surprised, not offended, when he said, “You are the biggest fucking cunt that has ever existed in the whole world!” I asked, “Really? Worse than Hitler?” He laughed and said, “Yeah, Definitely.” I laughed too. Take that Hitler.

The person who had two high perceived lethality, but fortunately non-fatal, attempts to take his life in the fortnight before we met reworded Shakespeare’s famous opening line to Hamlet. Instead of saying, “To be, or not to be, that is the question”, he said, “After what I have experienced in hospital, I now think that it is better to have a difficult life rather than no life at all.” I was so pleased to hear him think that way, and at the same time felt so sad for those people who do not have the opportunity to reconsider: those people that bypass the hospital wards and go straight to the morgue.

These are profound moments in the lives of people.

Nurses, myself included, have the peculiar privilege of being with the people who are experiencing the most important days of their life: the first few days of life that they planned not to have.

Let’s not take that peculiar privilege of nursing lightly.

In Closing

Talking and thinking about suicide can be distressing. Australians can access support via:

 Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

MindHealthConnect www.mindhealthconnect.org.au

phone_hotline-40Outside of Australia and not sure where to get support? Google usually displays a red telephone icon and your country’s suicide support phone number when searching for a suicide-related topic.

As always, comments and feedback on the blog post is welcome. Suicide can be a sensitive topic to comment on, and this blog is the public arena; so, before wording your comment, please check-out this: Mindframe guide

Paul McNamara, 19th January 2014