“Suicide by Cop”—Mental Illness and Law Enforcement Response

by

JC Schildbach, LMHC

Georgia Tech engineering student and Pride Alliance president Scout Schultz phoned 911 at 11:17 p.m. Eastern last Saturday night to report a dangerous, armed individual—Scout Shultz. All indications are that the call was a suicide attempt, which the police, lamentably, completed.

In the world of crisis intervention and suicide prevention, we routinely assess for plan, means, and intent. In other words, we ask if someone expressing suicidal ideation has a plan to harm themself; if so, we ask if they have the means to carry out the plan; and we also seek to determine how determined the suicidal person is to actually go through with the plan.

For instance, if an adult male says he is suicidal and has a plan to shoot himself, but he has no access to a gun, there is a plan but no means. If that same person has a plan to shoot himself, and access to a gun, but says he is not going to do it because he would never do that to his family or has religious reasons for avoiding suicide, then he has a plan and means, but the intent is absent or lacking. If that same person has a plan to shoot himself as soon as he finishes his drink, access to a gun, and no reasons he identifies for not shooting himself, then plan, means and intent have all come together in a rather urgent fashion.

In the case of Schultz, the plan, means, and intent might be characterized in the following way.

Plan: suicide by cop; means: a call to 911 to anonymously report self (in the third person) as an armed danger to the community; intent: plenty enough to make the call and brandish a weapon at the police.

Scout and the cops

Crisis intervention or crisis escalation?

Schultz apparently knew enough to indicate the possible presence of a gun, rather than just reporting the knife (which turned out to be a “multipurpose tool”—something that is generally less fatal than a gun, or even, say, a hunting knife or kitchen knife). The threat of a firearm is likely to put officers in a different frame of mind prior to even arriving on scene, even if protocols are still essentially the same.

Even so, it is puzzling that an officer, with a second officer nearby who was also aiming a gun at the allegedly dangerous individual, would choose to stop said multipurpose-tool-wielding individual with a bullet to the chest. Granted, even with the best training available, professionals can panic in novel situations, or situations where they feel threatened. And, generally speaking, the sense of feeling threatened is the main criteria for police officers to be excused for fatally shooting anybody, regardless of what that anybody may be armed with, or why they may be engaging in some form of threatening behavior.

For those not familiar with the dynamic, I suppose there could be questions about how being shot by the police is a form of suicide. But for people in crisis intervention and suicide prevention, and, I suspect, for a majority of law enforcement officers out there, it’s far more common than one might imagine. Deliberately provoking an armed person into killing you is, arguably, less difficult than taking the steps yourself. For instance, if you don’t have access to a gun, shooting yourself is rather difficult. Getting shot by someone else is, perhaps, more within reach.

Beyond that, any method of suicide where you have to push yourself into that final, fatal act forces you to overcome eons of ingrained animal behavior that drives you to keep yourself alive. With the right threats, a suicidal person can turn that same instinct in someone else into a means for suicide completion.

When it comes to crisis intervention, and 911 dispatch, suicide by cop is also a bit of a conundrum. If a person calls to report suicidal ideation and refuses to ‘contract for safety’ (essentially, agree to do something other than killing him/herself), the person can report any of a number of intended means of suicide, including “suicide by cop”, knowing that the standard protocol in any report of intent to complete suicide is to send police out for a ‘welfare check’. Whether or not the person reports “suicide by cop” as the intended means, he/she is likely to know that the right provocation can lead to the use of deadly force. The police will get almost always get dispatched one way or another, because of the threat of suicide, and the directives to get suicidal people to an Emergency Room for a mental health assessment.

Schultz found a way to bypass some of the usual protocols by going straight to 911 and exaggerating the threat. No crisis counselors engaging in a clinical assessment. Deliberately misleading information provided to 911 dispatchers, which was, in turn, relayed to police.

But the entire situation begs plenty of questions about how Schultz’s plan, assuming Schultz was fully intending to die, could have been brought to fruition with what was essentially a minor manipulation of information.

Why was a shot to the chest the means the officer chose as self-preservation and to subdue the threat? If a gun needed to be the tool of choice, why wasn’t a debilitating, but non-fatal shot attempted instead? Why did the officers not use a taser or pepper spray to disable Schultz?

But, perhaps most of all, we need to ask if there are there police officers who aren’t trained to recognize and address attempts at suicide by cop? Police officers, so divorced from knowledge of mental health issues and basic human behavior that all threats are considered deadly? Police officers who are not trained to reasonably assess the threat level any given individual represents and to respond with non-lethal force in every instance possible?

Granted, when they are sent out on a call, law enforcement officers never know what they are walking into, or how any particular situation may unfold, and only have whatever information has been provided dispatchers, and then been filtered down to them. Such an information chain most certainly adds to the stress of police officers’ jobs, and the potential for error.

This post isn’t intended as an anti-police rant. In crisis intervention, mental health professionals have to work closely with the police in coordinating appropriate responses to potentially dangerous situations—which are most often about clients putting themselves at risk more than anyone else. That said, Police are the ones who put themselves in harm’s way as first responders, to ensure that nurses, doctors, social workers, and counselors can then step in to engage in assessments and treatment.

But we need to make sure that police aren’t bringing guns to a multipurpose-tool fight as part of a routine and accepted response, especially when that fight is against people struggling with mental illness—lest the need for mental health assessment and treatment is removed by a fatal, law-enforcement-administered gunshot.

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A Searchlight Soul

by

JC Schildbach, LMHC

Chester Bennington completed suicide by hanging on Chris Cornell’s birthday, just over a month after Chris Cornell completed suicide by hanging on the 37th anniversary of Ian Curtis’ suicide by hanging.

For those unfamiliar, Bennington was best known as the lead singer of Linkin Park; Chris Cornell was best known as the lead singer of Soundgarden; and Ian Curtis was best known as lead singer of Joy Division.

Now, Linkin Park’s music makes me want to grind my teeth, spit, and curse—and not in a good way. And I never got into Joy Division beyond owning a ‘greatest hits’ collection for a few years as an undergrad. I am, however, a big fan of Soundgarden, as well as another of Cornell’s bands, Audioslave—not such a big fan that I ever made it to a concert. But, living in Seattle, I would see members of the band at other bands’ shows around town in the way back of the early 90s.

cornell dark

How would I know?  Cornell from ‘Fell on Black Days.’

I have no idea if Cornell’s suicide was related to Curtis’ beyond coincidence. But Bennington’s was directly connected to Cornell’s. They were friends, and, from what I understand, Bennington took Cornell’s death particularly hard. Both Cornell and Bennington had struggled with addiction and mental health issues during their lives.

But the takeaway shouldn’t only be that a life marbled with addiction and mental health issues leads to suicide. That makes it too easy for people to distance themselves from suicide, its causes, and our potential susceptibility to its draw.

In the wake of a loved one’s death, thoughts of suicide can arise or increase, and suicide attempts climb.

In the wake of a loved one’s death from suicide, those thoughts and those attempts climb significantly higher.

There are those who have criticized Curtis’, Cornell’s, and Bennington’s suicides by pointing out that they had achieved success, or had spouses, friends, children…all of which should have somehow prevented them from committing suicide, much less having thoughts of such.

That’s a natural impulse—to want to point out why we never would have killed ourselves in similar circumstances. But it’s also false comfort.

Just try to imagine finding yourself in a space where money, success, and a loving family can be discounted as not providing enough impetus to go on living. Imagine finding yourself in a space where you actually feel the people who care about you most will be better off without you. Imagine being so deep into that thought process that you can’t find your way out—that it seems completely logical—that suicide actually seems like the only rational decision.

I could get into explanations of survivor guilt, or what grief can do to people, or the impact of knowing that a friend reached the conclusion that suicide was an appropriate response to the world around them–a world that you were part of.

But I’d rather you think on how declaring yourself immune to something, insisting you are completely separate from some problem, is the first step to blocking your understanding of that problem…or worse, blocking your compassion toward others affected by that problem. You can feel for the families and friends of those who complete suicide without feeling the need to condemn the dead. That condemnation does nothing to help the grieving, or anybody else, least of all you.

 

 

 

Yes, Breitbart, 33,000 People ARE Killed with Guns Each Year

by

J.C. Schildbach, LMHC

There is absolutely nothing controversial about Hillary Clinton’s claim that, in the United States, “We have 33,000 people a year who die from guns”–except maybe to those who don’t understand how words and numbers work.

Yet, AWR Hawkins, breitbart.com’s “Second Amendment Columnist,” posted a “Fact-Check” column, titled “No, 33,000 Not Killed with Guns Each Year” following the third presidential debate, claiming that Clinton deliberately inflated the CDC numbers of firearm deaths by adding in suicides. This is not the first time Hawkins has posted similar complaints.

What Hawkins fails to do is explain how suicides by firearm somehow fall outside of the “33,000 people a year who die from guns.” Certainly, Hawkins must understand that somebody who uses a gun to kill him/herself is dead, and did use a gun in order to die—making that person someone who ‘died from a gun.’

Using Hawkins’ preferred language of people “killed with guns each year” still doesn’t change anything. A person who commits suicide with a firearm still was, in fact, killed with a gun.

suicide-gun-mouth

Hawkins also strikes out by putting the phrase “gun violence” in quotation marks, saying that the use of that phrase (which Clinton did not use in the quote he complains about) somehow plays into Clinton’s strategy of fooling the public. But, again, killing oneself with a firearm does qualify as “gun violence”–first of all, because it involves an act of violence; and secondly, because it involves a gun. Or you can reverse that so the gun is first and the violence is second—still doesn’t change anything.

I don’t want to get into speculation about things that Clinton didn’t say, but perhaps if she had used the phrase “gun crimes” or had referred to murders using guns, then Hawkins would have a better argument. But Clinton didn’t. So Hawkins doesn’t.

And, in case you’re wondering, the 33,000 figure is dead-on. Here’s a chart, showing the CDC numbers of gun deaths for the years 2010 to 2014 (2014 being the most recent year statistics are available) clearly showing that gun deaths have reached well above 33,000 per year for 2012, 2013, and 2014, and averaged 32,964 per year for the five-year period.

avg-gun-deaths-2010-to-2014

A handy chart of CDC statistics on gun deaths, lifted from Everytown for Gun Safety at  https://everytownresearch.org/gun-violence-by-the-numbers/

Now, I get that gun-loving Americans, including the Breitbart crowd, don’t like to believe anything negative about guns. They also don’t like to believe that they may, at some point, end up so distraught, or so deep in the throes of mental illness, that they might use their guns on themselves, and/or their family members or other loved ones—or perhaps even neighbors or random strangers.

By pushing the suicide statistics aside, or pretending they ‘don’t count’, Hawkins ignores a harsh reality here: that people who own guns tend to kill themselves with those guns far more than they kill an intruder in their home, or otherwise defend themselves from the big, bad, scary world out there. People who own guns kill themselves with those guns more often than criminals use guns to kill innocent citizens; and more frequently than ‘gang violence’ leads to gun deaths.

There is also considerable overlap in the “murder/suicide” category—where gun owners kill their significant others, family members, co-workers, or random strangers, prior to turning their guns on themselves. And because guns are such a quick and effective killing tool, the decision to use them in an act of violence on loved ones or oneself is often impulsive—a few too many bad days in a row, a bad argument following a few too many beers, or even a partner deciding they want out of a relationship, and the gun comes out as the ultimate way to put a stop to whatever is so aggravating.

As for mental illness, Hawkins’ argument becomes even less convincing in the face of all the clamoring about how we don’t have a gun problem in the U.S., but we have a mental health problem. Of course, people who make such an argument are usually talking about the mental health issues of mass shooters. Yet, if we (properly) view suicide as a mental health issue, then the numbers of firearm suicides become that much more disturbing. Gun owners kill themselves at a rate roughly twice as high as the rate of gun murders. That’s a vast mental health issue that’s not being addressed, and that is being exacerbated by guns.

Yes, I know that many of the people who want to argue in favor of guns like to point out that people who commit suicide will find the means to do so, even if you take their guns away–an argument which is demonstrably false in terms of overall lethality. There are many ways to map out the evidence showing this falsehood, including the high rate of suicide by firearm–roughly 50% of all suicides in the U.S. are completed using guns. Another way to conceptualize the difference in suicide methods is to compare suicide completion rates using firearms relative to suicide completion rates using other methods. For instance, plenty more people survive suicide attempts by overdosing on pills than survive suicide attempts using guns.

Those who are willing to brush off the connection between firearms and suicide also sometimes argue that suicide is a matter of personal freedom—of being allowed to end one’s life when one chooses. I will say that I’m not completely opposed to people being able to end their own lives on terms they choose. However, I’ve learned enough to know that people are least equipped to make that decision quickly, impulsively, or while in a deep depression (among many other factors). Very few people attempt suicide while they are thinking in the clearest of terms, or making a rational decision based on a comprehensive review of the facts.

Depression and many other forms of mental illness are notorious for their association with cognitive distortions, aka, “thinking errors”—misinterpreting the world around one, the impact one’s actions have on others, and the view other people have of one (again, among many other factors). As I’ve pointed out before, the idea that a gun keeps one safe is, itself, a cognitive distortion. The suicide-by-firearm statistics make that clear.

There is also, perhaps, a great irony here, in that Hawkins believes he is advocating for gun ownership, when the “mental health” approach to suicide prevention involves removing the means for suicide. That is, safety planning for suicide prevention involves taking away those means most likely to be used in a suicide attempt, while the person at risk for suicide gets treatment.

So, how do we address the mental health problems associated with guns and suicide? Take the guns away, at least until the person moves beyond risk for suicide. Of course, mental health treatment is not predictive. Risk factors can be weighed, and support systems assessed, but given the ease with which a person can use a gun to end her/his own life, a dip back into depression, a few more bad days, a drift away from regular engagement with one’s (positive) coping skills, and the risk can escalate once again.

Hawkins thinks he is supporting gun rights by poo-pooing the statistics on firearm deaths in the United States. But what he is actually doing is pointing out that suicide is twice as big a problem, where guns are concerned, as murder is. His solution is to pretend the people who commit suicide with guns aren’t really people who “die from guns.”

At base, he is arguing that people who commit suicide with guns aren’t really people…or perhaps aren’t really people who deserve the support to go on living.

 

Escaping the Groundhog Trap

by

J.C. Schildbach, LMHC

I’m not a big fan of Groundhog Day—the holiday or the movie.

As a kid, the holiday just confused me. Why a groundhog? Can’t you just see if you cast a shadow yourself? Or if a bush, a stone, a dog…anything casts a shadow? I wondered at the particular properties of groundhogs, and why their shadows might be somehow different than those of any other thing on the planet. I suppose I never quite felt like anybody adequately explained the magical properties of particular varieties of burrowing rodents for me to really get behind the holiday or its alleged meaning.

The lack of a real explanation is one of the things that keeps me from enjoying the movie, Groundhog Day as well. What caused this to happen? And why is the resolution what it is? What would make any magical powers of time control so interested in getting Bill Murray’s character, Phil, together with Andie MacDowell’s character, Rita? Perhaps a resident of Punxsutawney is one of the aliens from Edge of Tomorrow who accidentally infected Phil with the time control powers. But that can’t be it, because then Phil would’ve had to die every day, and he only died on some of those days.

Beyond that, the movie just follows the theme of so many movies from the 1980s about how great small-town America is, and how some cynical guy from the big city needs to learn to appreciate that. As for Murray’s arc in the movie, it’s rather similar to Scrooged.

The audience is also expected to root for Phil to ‘get the girl,’ even after he uses his powers of time repetition to manipulate one of the local women into sleeping with him, and then trying to manipulate Rita into falling for him by pretending to like everything she likes—information he gathers from her in conversations she will never remember.

Ultimately, Phil has to get through one day being kind and helpful, rather than acting like his usual, egocentric self (but, again, why is this the resolution—and would it really matter whether Rita decided she liked him or not?). But that last, single day of generous Phil doesn’t feel much different from the videogame-style resets that go on through the rest of the movie, or in Edge of Tomorrow, and hardly seems like a long-term change to his character as much as it feels like him resigning himself to being a decent human being for one day if he ever wants to get out of Punxsutawney. How is his decency not just more manipulation—another possible route out of the repetition he is trapped in?

Many people have labeled Phil’s situation in Groundhog Day an “existential dilemma” or otherwise termed the movie as existentialist. Properly speaking, though, if Phil’s was an existential problem, he wouldn’t have a long period of being able to make whatever decisions he wanted with no thought, responsibility, or consequences at all, only to be pushed into making the “right” decisions–as judged by whatever power kept him perpetually trapped in Punxsutawney on a particular day–until he did what was deemed correct by that power and the “spell” was broken. He would be responsible for whatever he did, and nothing would compel him to do anything.

groundhog drive

The most important lesson of all–Don’t drive angry.

Still, it’s something of a tribute to Groundhog Day, the movie, that it has become synonymous in our culture with repetitive behavior or situations. And it is perhaps the fantasy that we could relive a particular day until we did it right, managing to impress everyone around us, and connect with our one true love in the process (as well as the opportunity to indulge in a great deal of irresponsible behavior along the way), that has led it to this level of popular recognition. Or perhaps it’s the underlying idea that we are trapped by our own behaviors in repetitive cycles, and that we can change ourselves in order to achieve a better life—along with the wishful notion that we need to be good people if we really want to get what we want.

After all, the idea of breaking out of repetitive cycles and habits, or perhaps of creating better habits and repetitive cycles, along with being better people…good people…our best selves, is what underlies much religion, philosophy, and, yes, therapy.

We all struggle through our own behavioral patterns, habits, and the potential sameness of our days, the rut of weeks, months, seasons, and years. But no bizarre fluke of time is going to trap us in a loop and push us to do things differently and become better people, or pursue what we want. That’s on us.

Whatever I might think of him, Phil found out that it wasn’t a groundhog, or the celebration that surrounded a groundhog’s shadow, that was at the core of his problem. Rather it was his own shadows, the darkness he threw out into the world.

So maybe Groundhog Day is the perfect time to look around at our own shadows and what they say about our forecasts—how much more winter we may have in store—and then think about what, if anything, we want to do to change that.

Happy Groundhog Day.

 

It’s World Suicide Prevention Day: Do You Know Where Your Mental Health Is?

by

JC Schildbach, LMHC

Just before I sat down to write this, around 8 p.m. my time, I lit some candles and placed them in the windows of my home–as was requested by the organizers of World Suicide Prevention Day–a small gesture that maybe nobody will notice–but a sign of solidarity nonetheless.

One might ask, ‘Solidarity with whom?’

With those who have died by suicide?

With those who have lived through a suicide attempt?

With those who have been impacted by the suicide of an important person in their lives?

How about just plain everybody?

None of us are immune to suicide, or the impacts of suicide.

A great many of us like to believe we’re immune.

But our mental health is not made up of absolutes.  It is not a simple either/or option: mentally healthy or mentally ill.

Suicidality itself exists on a scale of ‘definitely not going to happen today’ to ‘working on it right now.’

And perhaps the more we think we’re immune to issues with our mental health, the more we fail to recognize when we might be tilting toward trouble.

2015_wspd_banner_english

Take a big enough hit to your self image–loss of your job, loss of a spouse or signficant other; maybe add on a string of other bad occurrences–financial troubles, illness, the death of a loved one; mix in a few too many drinks and easy access to means, and who knows what might happen?

More than half of the 40,000+ deaths by suicide in the United States each year involve a gun.  How many of those do you suppose were the result of, say, long-term depression, versus a fairly quick unravelling of the deceased’s sense of self, and a lack of knowledge about how to identify and utilize available support systems?  How many of those were a booze-fueled ‘screw it’ to a really bad month, or week, or day?

Of course, when one believes one is immune to such problems, when those problems arise, one will be that much less likely to seek out help.

I don’t want to give the wrong impression.  Many people who die by suicide have been struggling with mental illness for the bulk of their lives.  Many of them have made multiple attempts before they finally die by suicide.

But there are also plenty who die by suicide because they are overwhelmed by circumstances, and have no real idea what to do.  They have never given thought to what to do, or who to turn to.  They do not want others to think of them negatively–perhaps the same way they have thought of others in similar circumstances.

So we need to recognize that we’re all travelling on the same continuum, that we’re all forever in flux, rather than believing we are in two separate camps that will forever remain apart: the mentally healthy and the mentally ill.  Otherwise, we potentially block ourselves off from the need for compassion.  It’s much easier to look away when we can say, “Not me.”

candle

So maybe those candles will go unnoticed, or maybe not.

And at least they’re flickering away against the darkness of “Not me.”

Suicide at the Oscars, part two: ‘The Phone Call’

by

JC Schildbach, LMHC

It was a great year for crisis lines at the Oscars—or, rather, for films involving crisis lines. Not only did the documentary, Crisis Line: Veterans Press 1 take home a statue, but so did the short, live-action film The Phone Call. And, while Crisis Line: Veterans Press 1 tried (perhaps a little too enthusiastically) to convey a sense of the actual drama that can occur at a crisis line, The Phone Call comes across as a disturbingly simplistic endorsement of suicide-on-demand and irresponsible behavior by crisis line workers, all while portraying a dangerously inaccurate view of the function of crisis lines.

I will begin with the same bit of disclosure I placed at the beginning of my piece on Crisis Line: Veterans Press 1: Having spent more than five years working full-time for a crisis line, and continuing to work in a position sideways from, and occasionally overlapping with, such work, I can’t help but come to these films with something of a bias. And I will also offer up a spoiler alert for The Phone Call: if you haven’t seen it, and you don’t want to know exactly what happens, stop reading now.

The Phone Call seems to have generated most of its praise based on the acting of Sally Hawkins (as Heather) and Jim Broadbent (as Stanley/John)—which is undoubtedly solid, even given the ludicrous material. But most reactions seem to ignore any other critical angle—like the crass manipulations taking place in order to make The Phone Call happen at all.

To begin with, the call center where the story takes place seems to be lost in time. Despite the opening shot of the movie panning by a sign that reads “City WiFi Zone,” the crisis center apparently has no computers and no Internet hookup.

Now, I don’t know the current state of crisis line call centers in the UK, or really the state of any such call centers aside from the ones I’ve worked in, visited, or seen in documentaries—all in the United States. But I will say that if a call center in this day and age equips workers only with a pad of paper, a pen, a phone, and a lamp—they are verging on worker abuse. Absent the most dire of funding situations, failing to provide crisis line workers with computers and Internet access is simply unacceptable, given the relatively low cost of such amenities—and the necessity of such items in making it possible for workers to track down lifesaving information—or even to assist callers who are simply trying to access other services.

At one point in the movie, we see Sally Hawkins’ character, Heather, get up from her desk—thankfully she sat at the front of the room near the bookshelves—to try and look up the “mystery caller” in the notebooks where past call records are kept—handwritten on paper.

Add to that the script manipulation of having absolutely minimal staffing. Despite there being numerous desks in the call center, when Heather arrives, there is only one other worker there–Daniel.  At the only time Heather even considers enlisting Daniel’s help with Stanley/John, Daniel is talking with another caller, back turned to Heather, and flipping through a phone book, or some other reference material. She immediately (and completely irresponsibly) determines she can’t get Daniel’s attention—as if muting her phone and calling across the room would have been too much trouble to stop somebody from dying.

'Would you look at that?  Daniel's busy.  Guess you really are going to die today, Stanley.'

‘Would you look at that? Daniel’s busy. Guess you really are going to die today, Stanley.’

Stanley/John is also supposed to be a sympathetic character, the main reason being that his wife, Joan, died two years ago after a long struggle with cancer. As Heather questions Stanley/John about other family members he may have, we also find out that he and Joan tried to start a family, but had only one stillborn child, 25 years ago, and then were unable to have any children after that. Certainly, it’s a sad tale. Certainly, we can understand Stanley/John’s despair.

But just imagine being in the same situation as Heather—or really any crisis line worker—being treated the way Stanley/John is treating her. Stanley/John has decided he is going to die, and has decided that whatever random worker answers the phone is going to have to listen as it happens.

John/Stanley sobs, makes vague statements indicating he has taken actions to kill himself, and refuses to provide information under threat that he will hang up to prevent anyone from tracing the call and sending an ambulance. The audience has to accept that either the call center does not utilize caller id—further putting workers in a terrible situation—or that John/Stanley blocked his information, in order for the whole ‘hanging up’ thing to really work as a threat.

Stanley/John eventually reveals that he’s taken “Antidepressants” that he got “from the doctor.” But killing oneself with pills tends to be a lot trickier than most people realize—at least to do it in the calm, and apparently quick way that Stanley/John manages, all while allowing for a conversation and a quick death before the ambulance crew can arrive and try to revive him—and without his body doing its damnedest to try and expel the deadly pills he’s ingested. Then again, perhaps Heather waited a good long while before calling for the ambulance, as she was looking through notebook after notebook to find the right person named John who lived around the corner from the Boston.

The big moment of connection for Heather, where she (mostly) accepts Stanley/John’s decision to die, is when Stanley/John asks in a pressured tone, “Can you just stay there and talk to me? Are you allowed to do that? Can’t you just stay there and talk to me and hold my hand? Isn’t that alright?”

Heather’s answer: “Of course, I can. I’m not going anywhere.”

There are an infinite number of much better answers Heather could have given at that time. For instance: “No, that’s not allowed, Stanley/John. I’m not here to make you feel better about killing yourself. And, to be honest, if I was really doing my job, my co-worker, Daniel, here would know everything that was going on, and probably already have an ambulance heading your way.”

Instead, in the course of the short conversation, Heather passes up numerous chances to make more than just a conversational connection with Stanley/John. For instance, Heather and Stanley/John discuss jazz, including Stanley/John telling Heather he could teach her how to play tenor saxophone properly. Yet, rather than latch onto that, and suggest that Stanley/John maybe teach music, or otherwise get back into music, Heather doesn’t push on that point of Stanley/John’s ambivalence at all.

In fact, beyond asking about immediate family, Heather does nothing to find out if Stanley/John was involved in anything else in his entire life beyond his relationship with Joan. Work? Friends? Family? Hobbies? Pets?

Heather also does nothing to explore what Stanley/John has done to deal with his grief over the loss of his wife. All we know is that he got antidepressant pills from his doctor. Apparently, Heather takes this as evidence that Stanley/John really has made a valiant effort to deal with the kinds of normal struggles anybody feels at the loss of a long-time companion. ‘Oh? You got a prescription? Wow—that was very brave of you. I’m sorry you still ended up feeling something.’

And perhaps the most obvious thing Heather leaves out is asking how Stanley/John’s wife, Joan, might react to Stanley/John’s decision to kill himself. Or maybe we are meant to accept that Joan is the kind of person who would want her husband to die—that she’s something of a monster, and Stanley/John is really stressed out because he’s two years late on following through with their suicide pact.

Throughout the conversation, Heather lets Stanley/John bully her into not talking about the things she should be talking about, all with the threat that he’ll hang up, and the assertion of his ‘needs’—how he just can’t go on without Joan, but really needs someone to ‘hold his hand’ at the end.

We are supposed to find it comforting that once Stanley/John insists that it is, in fact, too late for a rescue, he compliments Heather, saying, “you’ve been wonderful. You’ve been a wonderful friend to me.”

But Heather is not Stanley/John’s friend, and isn’t supposed to be acting in that capacity. And really, if Heather was either doing her job right, or actually acting in a capacity as Stanley/John’s friend, she would have done more to try and help him.

And then we get the most maudlin endorsement of suicide ever committed to film—we see the ambulance arriving outside Stanley/John’s home. The camera switches to an interior shot of the home’s front door. We see someone arrive, and…it’s Joan! We never actually see Stanley/John, only hear him talking to Joan for a while.  She talks about how she’s “been looking for” him, and they both agree that they’ve missed each other. So, we get this reunited-in-death sap that makes this suicide seem cute, since it helped an old couple get back together.

'What, John?  You've gone and killed yourself?  You go to hell for that, don't you know?'

‘What, John? You’ve gone and killed yourself? You go to hell for that, don’t you know?’

It’s no surprise that director and co-writer Max Kirby comes out of the world of commercials and music videos. The Phone Call is practically a commercial for suicide, with all the depth of the average music video. It’s a concept piece that tries to press emotional buttons, while keeping the audience from engaging in too much thought.

As we watch The Phone Call, we are not meant to think about the value in going on with life, and finding meaning after loss. We don’t even get a serious look at suicide, depression, or mental illness, because we are given only the most surface reasons for Stanley/John to kill himself. We are supposed to take this all as somehow romantic—the sad, old man who just can’t go on without his wife. Isn’t it sweet that he’s killing himself?

And perhaps even more aggravating is the summation of the movie from its official website: “Heather works in a helpline call centre. When she receives a phone call from a mystery man, she has no idea that the encounter will change her life forever.”

I’m not sure exactly what we are supposed to take away from this tagline—that the big change in her life is that she is now carrying the burden of having sat through this man’s death, while being derelict about trying to help him? The big scene we are supposed to take as evidence of change is one in which we see Heather following through on part of the conversation she had with Stanley/John—to go back and visit a jazz club she used to frequent. We see her getting cozy with call center co-worker, Daniel, a potential relationship that was hinted at early in the movie. ‘Gee whiz, isn’t it nice that all it took was the suicide of an old man to make me get out and live a little? Isn’t this rosé delightful?’

To clarify, my reaction to the movie is not meant as some discussion about the right to die, but about the way crisis lines operate, and the absolutely awful way this is portrayed in the movie. It is simply not the job of crisis line workers—paid or volunteer—to just “hold a caller’s hand” while that caller dies by his/her own hand.

It is a hazard of working at a crisis line that one may end up on the phone with somebody as that person dies. But this is much different than such an occasion being the purpose of that work. A police officer has the potential hazard of being shot on the job—but it is not the police officer’s work to be shot on the job. A teacher may be subject to the hazard of being verbally abused or even hit by an angry child—but it is not the teacher’s job to be verbally abused or hit.

And what kind of horrible people would you be attracting to work at the crisis line if you told them that part of their job was just to listen as people die? What would be considered an appropriate level of intervention if just letting people die was considered an acceptable or even desired outcome?

Heather, like any crisis line worker, when confronted by questions of listening versus intervening, should make it clear that, as much as crisis line workers are there to offer support, they are required to intervene in order to prevent callers from completing suicide. And with experience and training, one will gain a better idea of just when that intervention needs to take place.

In the case of The Phone Call, there was an admission that a suicide attempt was already underway; and for all intents and purposes, Heather did nothing. We are supposed to see that as somehow touching, and even life-affirming.

Don’t just feel about that. Think about that.

 

And now for the obligatory ending: If you or someone you know is having thoughts of suicide, call the national (U.S.) suicide prevention hotline 1-800-273-TALK.

 

Suicide at the Oscars, part one: ‘Crisis Hotline: Veterans Press 1’

by

J.C. Schildbach, LMHC

The topic of suicide came up in at least three acceptance speeches at the latest edition of the Academy Awards on February 22, 2015. (Okay, yeah, I’m late to the party again). And perhaps even more astonishingly, two of those acceptance speeches were actually related to films about suicide prevention hotlines. First up is the documentary, Crisis Hotline: Veterans Press 1. (A post about the short film, The Phone Call will follow soon).

Having spent more than five years working full time for a crisis line, and continuing to work in a position sideways from, and occasionally overlapping with, such work, I can’t help but come to these films with something of a bias.

As a matter of fact, I first saw a portion of Crisis Hotline: Veterans Press 1 on a Sunday morning after coming home from an overnight shift at a call center where the crisis line calls represent only one of many mental health functions with which the staff is tasked. Having spent the bulk of my work week on understaffed shifts, I was perhaps a bit resentful at flipping on the TV to see a scene what Bob Hosk, one of the Veterans Crisis Line supervisors who features prominently in the documentary, described as “five hours here at the hotline” utilizing “about four personnel to help one guy.”

Now, don’t get me wrong. I think it’s great that the resources were available and the effort was made, with (spoiler alert) a positive outcome for an active duty service member in Hawaii.

In the time since I first saw that segment of the documentary, I’ve become more familiar with the workings of the military in addressing the epidemic of suicide among veterans and service members, and will say it is truly impressive to see the complete change that has taken place over roughly the last two decades—from an approach to suicide and mental health issues that could be described as ‘don’t ask don’t tell’ to one of increasing and highly-promoted access to counseling services, to working with suicide prevention specialists and investing in the crisis line depicted in the documentary, among many other avenues.

But, back on that summer morning, knowing that in similar situations (an unknown caller making a vaguely suicidal statement, then hanging up) rather than having a specific staff member on shift to call a special “law enforcement” phone number at cell phone company to get information on the caller’s location by pinging cell phone towers, and then being able to devote ‘five hours and four personnel’ to find the caller, whichever one of us took the call would typically end up trying to call back, and, failing any respone from that, doing a quick Internet search on the phone number (like they show in the documentary) and then making a call to 911 dispatch in whatever location the phone number (probably) originated, to report that somebody had called and threatened suicide—‘no, we don’t have a name; we don’t have an address; we don’t know how they might do it or if they tried anything yet; we don’t know if there are weapons involved; no, we don’t know much of anything about anything—we’re following our protocol, sorry to bother you.’ Then on to the next call—which could range from a hospital social worker inquiring about a client’s mental health history, to a client with chronic mental illness telling us about his dinner, to someone struggling to get help for a family member with a mental illness, to…

In the case of Crisis Hotline: Veterans Press 1, my sense is that the caller from Hawaii was truly coming from a place of desperation, and, perhaps, wasn’t aware of other options available to him, or just what sort of response might kick in as the result of the call he made. He may have thought that by hanging up, he could just drop the whole matter. He may have scared himself simply by voicing the thoughts he was having about ending his life, and so tried to walk away from that.

But beyond my initial reaction to the portion of the film I saw back on that sunny Sunday morning, and my somewhat-tempered-by-time-and-new-information response now, I have mixed reactions to the film.

I’ll say that, overall, I think it’s an excellent depiction of some of the most challenging types of work that happen at crisis lines, and at the Veteran’s Crisis Line Center in particular, which the film notes “is the only call center in the U.S. serving veterans in crisis.” (A more accurate description would be that it is the only call center in the U.S. specifically established to serve veterans, and specifically engaging the particular protocols of that call center in order to assist veterans. Any crisis line in the U.S. will take calls from veterans, and do what they can to help. Call centers affiliated with Lifeline routinely take calls from veterans and their families, in part because the callers don’t always ‘press 1’ when prompted to get transferred specifically to the Veterans Crisis Line Center. And, while Lifeline workers typically will explain to such callers that they have not reached the veteran’s line, they always offer to help.)

Semantics aside, not all calls to a crisis line are life and death—or even crises. Each time the phone rings, it’s not a given that the caller is a someone on the verge of taking her/his life, or a family member of such a person. But you wouldn’t know that from watching this film. You only get the slightest whiff of the lighter calls, when, early on, the camera moves through the call center, the sound of constantly ringing phones and poignant snippets of dialog, reaching the microphones at just the right time: “really proud of you…Where were you stationed?..So twice you tried to hang yourself before?…Do you want me to send someone there for you?…Did you get injured while you were out on active duty?…diagnosed with PTSD?…If there’s anything we can do for you…”

Okay, so those don’t come across as all that light. That particular scene is one of many subtle manipulations used by the filmmakers—layering audio to create a particular impression of an “always on” call center. For the sake of drama, the filmmakers leave out audio involving callers who are just seeking information or non-emergency services. They leave out the repeat callers who are really just touching base and giving a brief synopsis of their day. They leave out those calls having any of a number of angles that aren’t even remotely related to suicide.

The filmmakers also choose to escalate the drama in a completely unnecessary way. For instance, the music, most often quiet, involves drawn-out, high-pitched tones that add to the tension viewers are meant to feel—as if trying to talk a stranger out of suicide isn’t drama enough.

I love this woman: Maureen--Crisis Line Responder, Extraordinaire

I love this woman: Maureen–Crisis Line Responder, Extraordinaire

On top of that, the final segment of the film takes place on Christmas Eve. The scene opens with outside shots of the call center at night, American flag flying, trees wrapped in colorful, twinkling lights, as a soft jazz version of “Have Yourself a Merry Little Christmas” plays–the song adding a sting of dark humor with it’s ‘all our troubles will be miles away’ and ‘let your heart be light’ emotions. The timing of the scene was undoubtedly selected because of the heightened emotions many viewers are likely to have around the idea of a “Christmas miracle” or notions of family togetherness at the holidays. But it also serves to reinforce the popular, but ill-informed, notion that ‘the holidays’—Christmas in particular—are a time of heightened depression and increased suicide, an impression reinforced by a shot of the notepad where the crisis responder has written a quote from a suicidal veteran: “Holidays are depressing.”

There are other things that could be taken as manipulation, but which I think were not only clinically sound decisions, but also place the focus where the documentarians wanted it: on the people working at the crisis line. Not hearing the callers, for instance–while likely done just as much for clinical reasons, as for legal and artistic reasons–provides for greater control over how the information will be presented to the audience, and also removes any impressions viewers might have of the callers based on their voices, or the tones they are using.  While I obviously don’t know the specifics of how any of the callers in the documentary spoke or sounded, anybody who has spent time working on a crisis line knows that many of the callers can come across in a way that, shall we say, challenges empathy. Responders need to be aware of the potential biases they bring to calls, and need to develop skills for de-escalating and connecting with difficult callers. At any rate, difficult or not, hearing the callers’ voices would create a completely different film.

Still, one of the most valuable aspects of the film is in giving voice to the crisis line responders, not only in their moments of calm where they appear to be completely in control, but when they are giving voice to frustrations as well. During one call, Robert, a veteran himself, complains that the response time from police is “ridiculous.” In a separate interview segment, Robert expresses the anger that crisis line responders can feel toward callers: “How dare you take your own life?” But part of the reason Robert’s rawness comes across in a potentially endearing fashion is that the filmmakers also let him speak about his struggles with questions of his own abilities, whether or not he has made the right decisions, or whether he made them in time—questions born of situations where the interventions failed.

There are other responders in the film with whom I had a harder time connecting—feeling a sense of kinship, or understanding their particular reactions, or the ways they tried to connect with callers. I don’t want to dwell too much on my snotty, hypercritical reactions, though—or even mention them in any specificity. For one thing, I know only a very limited amount about what was happening in those particular situations. And I don’t know how those people move about in daily life, or in their routine work at the crisis line.

But why I will most back away from potentially harsh or nitpicky-sounding criticism of any of the responders is because I can’t imagine having to work a crisis call with the knowledge that cameras are on me, and that whatever I do could end up on HBO.

That said, there is one responder in particular, Maureen, who comes across as the undoubted ‘star’ of the film. Little is explained about Maureen or her background, except, perhaps, that she reveals that she has sons, as she is complimenting a caller on her handling of a difficult situation.

Beyond that, Maureen demonstrates the perfectly complicated balance of compassion and detachment that is rare in crisis line workers. She is able to connect to the callers, but does not get visibly drawn into the drama, despite mentioning calls that ‘stay with you.’ Early on, we hear her say, “It’s ultimately the veteran’s decision if they are going to live or die…and as a responder, you have to have a really good grasp of that.” Truer words have never been spoken.

Maureen is able to deliver lines of perfect connection to callers–lines that may seem odd to those unfamiliar with such situations. After asking a caller about how his friend (who died in combat) would react to news of the veteran’s suicidal intent, she listens for a bit, then says, “He’d kick your ass? So he’s a good friend.” Maureen is able to drably ‘contract for safety’ with callers, getting them to promise that they at least won’t kill themselves while they are on the line with her, and then works to expand on that promise.

Maureen is the responder featured in the final scene of the movie—the one that takes place on Christmas Eve. Against this backdrop of heightened emotion, she is tasked with drawing a soldier with a gun out of the desert, and back to his parents, despite much of his life unraveling. She is further challenged by limitations on her involvement—having to direct the veteran’s mother on how to bring him home, and then sitting silently, listening, and hoping it all works out.

In the end, Crisis Line: Veterans Press 1 leaves much to contemplate—whether from a clinical or technical perspective—or any of the other myriad perspectives that could be brought to the film. It is incredibly effective in that it is able to provoke a range of emotions, and could, potentially, be used as a tool for training crisis line workers and volunteers, service members and their families, or really anyone who wants a better understanding of how crisis lines work, how the mental health system can be accessed, or how the military is responding to concerns of suicide among its ranks.

It remains to be seen if the film will help draw more workers and volunteers to crisis services, or perhaps scare more of them off. And this is where I have the most difficulty with the film. How much is too much when trying to convey the intenstity of real-life situations? What level of manipulation and film-making technique serves to create understanding, and what level serves to drive only emotional response?

Granted, the vast majority of people who see Crisis Line: Veterans Press 1 will never work in a crisis line call center. But, there’s always a chance they might need one.

So (obligatory ending)…

If you are concerned that somebody you know may be struggling with thoughts of suicide, call (or get them to call) the National Suicide Prevention Lifeline at 1-800-273-8255—Veterans Press 1.

Bipolar Illusion: Tom Sullivan, Rand Paul, and the Economics of Disability

by JC Schildbach, LMHC

Back on Wednesday, January 28, in a discussion of Social Security disability benefits on his Fox News Radio show, Tom Sullivan, who also serves as an anchor for Fox Business Network, said some incredibly stupid things about Bipolar Disorder. Sullivan, or whoever is responsible for the content of his web page, then proudly promoted Sullivan’s ignorance by posting what I can only hope is the worst part of that day’s show in a brief written piece, and a 5-minute audio clip, which you can see here: Tom Sullivan argues that Bipolar Disorder is a myth.

Among his statements, Sullivan called Bipolar Disorder “the latest fad,” adding, “We all have good days and we all have bad; and I don’t consider that an illness; and I don’t consider it a disability.”

Sullivan said plenty of other amazingly idiotic things, like suggesting people are talked into thinking they have Bipolar Disorder, and that it is a “made up” condition, as well as vilifying the entire “mental health business” and “big pharma.” (Wait–I thought Fox “News” liked big pharma.)

Broadcasting live from the Fox studios in the depths of hell, it's the Tom Sullivan Show.  Today's topic: Yes, you should hate and fear your neighbors.

Broadcasting live from the Fox studios in the depths of hell, it’s the Tom Sullivan Show. Today’s topic: Yes, you should hate and fear your neighbors.

On top of that, Sullivan asked a question that anyone with the most rudimentary knowledge of psychology, or the skill to do an Internet search, could answer: “What were these people called 25 years ago before they came up with this Bipolar diagnosis?”  (He didn’t mean that as a question that had an actual answer, but in the sense that he believes Bipolar Disorder was dreamed up by psychologists and drug companies 25 years ago).

I could let Jimi Hendrix answer Sullivan’s question in a song from 48 years ago, but I’ll let the good people at Healthline take this one.  Read their answer here: Bipolar Disorder just may have been recognized more than 25 years ago.

In case you didn’t bother to check the Healthline article, it basically notes that the first modern diagnosis of the illness that was eventually deemed “Bipolar Disorder” was first established in the mid-1800s, but that the basic condition was recognized in one form or other going as far back as the time of Aristotle and even before.  And prior to the Bipolar Disorder moniker, it was common to call the condition Manic Depression or Manic Depressive Illness, among other, similar things.

Sullivan’s staggering ignorance of mental health issues (and classic rock) aside, the truly insidious question that he asked in all of this was, “So what are you going to do when the money runs out?” By “the money,” Sullivan meant the Social Security disability fund, which he claimed will be bankrupt by 2016.

Beyond the more obvious stigmatizing of people with mental health issues, Bipolar Disorder in particular, Sullivan’s big question, and his chosen targets, may just be another entry into the vast library of right-wing fear-mongering about Social Security, and why it needs to be privatized. I’m sure it is. But it’s also part of a discussion that’s (once again) rumbling up about “entitlements” and poor people defrauding the government.

In fact, it appears Sullivan’s ill-informed rant about Bipolar Disorder may have been inspired by earlier comments from Rand Paul. As “support” for the items on Sullivan’s show that day, Sullivan’s website features a clip of Rand Paul, Republican Senator from Kentucky/compassionate ophthalmologist, speaking to a crowd in New Hampshire about how at least half the people on disability payments are collecting those payments fraudulently. You can see the clip (from CNN of all places) on Sullivan’s website here: Rand Paul is a medical expert who knows you’re not hurt, you crybaby!

Paul tells the (New Hampshire) crowd that, “everybody in this room knows someone who’s gaming the system.” Now, I’m not the kind of person to show up at a Rand Paul event, but I have to wonder about the people who do, if they all know somebody who is “gaming” the disability system. Then again, maybe Paul is just jaded, since his home state of Kentucky ranks third among the states in terms of the percentage of total population collecting disability payments. (I got that information from looking at the actual source of some of the Social Security Administration stats that were posted in an incomplete image on the same page of Sullivan’s website with the Rand Paul video) One might also ask what those stats, and Paul’s claims of fraud, could possibly say about doctors in Kentucky, who are signing off on all those disability claims.

Among those actually deserving of disability payments, Paul counts only paraplegics, quadriplegics, and the “horrifically disabled,” noting that “half the people on disability” are no worse off than anyone else, only “anxious, or their back hurts.” Paul’s standard for not deserving any kind of disability payments: “if you look like me and you hop out of your truck.” So, I guess a whole lot of white males with trucks are headed toward losing their disability payments, unless they’re careful to avoid getting caught hopping out of said trucks.

One would think that Paul’s background in medicine, as well as his position as an elected official might lead him to realize it’s his job to productively address problems with the way government systems work—particularly if those systems are tied to an area of his expertise. Likewise, Sullivan’s background in economics, along with his national platforms on both radio and television, should mean that a discussion of how to fix the Social Security disability system’s funding problem might be in Sullivan’s wheelhouse.

But rather than seeking out ways to tackle, say, the potential of those receiving Social Security disability payments to find work through job training programs; or promoting ways of obtaining additional funding, like removing the income cap on Social Security taxes, we get more condemnation of the poor–calling them lazy thieves.

Instead of having an informed discussion about the needs of those on disability, and why somebody who doesn’t “look disabled” might actually be struggling with things that many of us take for granted, we get accusations that people coping with mental illness are faking it and claiming to have conditions that don’t even exist.

Hell, Sullivan and Paul could even look into ways to make the disability system more functional by addressing the ways disability payments are established and rewarded.

But, no—we get wealthy white guys complaining that people with disabilities are a bunch of cheats, stealing from their neighbors. We get those with tremendous privilege trying to pit the poor and middle class against those with disabilities—’Hey! Let’s all pile on people who’ve been injured! Let’s knock down those who suffer from mental illness!! Get ‘em!!’

There are plenty of other things absent from these discussions of the Social Security disability system, like that those receiving the payments have to periodically have their status as “disabled” validated by doctors or mental health professionals, or that many of them end up assigned to a “payee” who controls the way their money can be spent, or that they have limits on things like what portion of their disability check can be used for housing. They are often confined to extremely limited options for government-approved housing, where their homes are subject to inspections, including being warned with ‘corrective actions’ if they aren’t keeping things clean enough.

Perhaps Mr. Sullivan and Mr. Paul think that those taking in, say, $1100 a month for being diagnosed with Bipolar Disorder (which is roughly the average monthly payout) are scamming us all, and stealing our tax dollars because they’re lazy. But the amount of money one can earn is hardly worth the effort that goes into obtaining it in the first place, or keeping it over time.  It might be a fun and entertaining exercise to have either Paul or Sullivan attempt to live on that amount of money for a month, and under the same restrictions.

Yet when one is so completely ignorant or out of touch as to think that Bipolar Disorder is make believe, or that we are surrounded by people stealing from the government through the Social Security disability system, then one has given up any credibility in the discussion of how to address the problems of vulnerable populations in our society–or even the discussion of how to address the possibility of fraud in the Social Security disability system.

Demonizing fellow citizens by claiming they have phony injuries or fabricated mental illness is a great way to stir up righteous anger among the poorly-informed. It may even achieve the goals of getting votes, or making disability requirements even harder to meet, or of having Social Security privatized or partially privatized.

So, don’t be surprised if you start hearing more and more about scammers bankrupting the Social Security disability system, or even more about mental illnesses being phony. Even if Sullivan did attract the ‘wrong’ kind of attention with his obnoxious comments, all he needs to do is get the poison in the stream. Then, Rand Paul and his ilk can still seem educated and rational and folksy enough that they appear sensible by comparison.

Sylvia Frumkin’s Place

by JC Schildbach, LMHC

I’d venture a guess that many who enter the mental health field, as with any potentially dramatic profession all the way from police to executives, do so with visions informed by Hollywood. One of the main Hollywood portrayals of the mental health worker is is that of the therapist/psychiatrist as a well-compensated genius, ensconced in a plush office, treating the worried well or other “eccentric” or “neurotic” types, while constantly being admired by clients for one’s observational skill and ability to call forth ‘breakthrough’ moments. The other end of the spectrum is the heroic social worker who, through sheer tenacity, overcomes all the problems an impoverished neighborhood can throw at her, overcoming multi-generational patterns, and very recent traumas, to really, really make a difference in the lives of an entire community.

Many in the field are drawn to books by Yalom, or Rogers, or perhaps even some acolytes of Oprah, who tell us that just by listening and accepting our clients, or by throwing the right bit of tough-love advice a client’s way, true transformation will take place, and clients will make huge leaps forward, forever changing their lives for the better.

Susan Sheehan’s “Is There No Place on Earth for Me?” is perhaps the perfect antidote to the pie-in-the-sky visions of one’s brilliance and dedication making all the clinical difference in the world. It balances out the ideas about the wondrous gift of therapy with the reality of chronic and severe mental illness, and its resistance to ‘ah-ha moments’ and dramatic progress. It pushes past that “we don’t need no medications” mantra, which can, in fairness, apply to a lot of mental health issues.

“Is There No Place on Earth for Me?” was first published as a four part series in The New Yorker in 1981, then published as a book in 1982. For it, Sheehan won the Pulitzer Prize for General Non-Fiction in 1983. A new edition of the book was released roughly a year ago, including a new afterword by Sheehan. On reading about the re-issue in the online version of the New York Times in January of 2014, and having never read it before, I put it on my ‘to read’ list, and eventually checked out an old edition from the library.

Frumkin cover

The book, written from the perspective of a journalist, and not of a therapist trying to convince the readers of the efficacy of particular approaches to treatment, is involved in ways that few case studies can be. Sheehan spent over two years with Sylvia Frumkin (not her real name), a woman diagnosed with schizophrenia. Sheehan had a great deal of access not only to the information on Frumkin’s treatment and behavior during the period when Sheehan shadowed Frumkin, but also to family members and others, getting a great deal of background on Frumkin’s life prior to her diagnosis, and the progress and setbacks that took place before Sheehan had ever met her.

Having had numerous contacts with clients diagnosed with schizophrenia, or suffering from other forms of psychosis, most often from a distance, it took me a while to get through the book. That is, the kinds of delusions, rants, and flights from treatment that plague Frumkin and those trying to help her, and which Sheehan documents in detail, were familiar to me—of course, with Frumkin’s behaviors being particular to her own case. Still, it was like trying to read about many of the most frustrating aspects of work during one’s down time.

For the uninitiated, I imagine the book is much more compelling, rather than overly familiar, and thus, somewhat draining. In discussing “Is There No Place on Earth for Me?” with colleagues, I’ve most often likened it to Kafka’s “The Trial”—a book that is deliberately tedious in its depiction of a bureaucracy more intent on sustaining itself than serving any clear purpose—although, that comparison probably has much more to do with what I bring to the reading of Sheehan’s book than to what she has documented in such depth of detail. Also, I don’t think the mental health system—either now or at the time—is deliberately set up to be frustrating…it just frequently is, particularly for those most in need of help.

In addition to capturing the daily details of the behavior of a (this) client with schizophrenia, Sheehan also does a masterful job of explaining, simply and concisely, some fairly complicated legal, medical, and treatment-related concepts. For instance, Sheehan outlines the concept of “least restrictive” forms of treatment, both the bane and the beauty of our mental health system, which has been around since well before the current lack of options made it so completely mandatory.  In doing so, she answers that most familiar of questions about why we can’t “just lock up” people suffering from chronic forms of mental illness who can become rather taxing to a variety of public and private resources.

The most fascinating elements of Frumkin’s story to me, though, were the ‘side treatments’—pointless, and sometimes dangerous, programs that Sylvia was subjected to. Without going into a great deal of detail, the treatments ranged from moving in with a relative and his family who believed that all Frumkin needed was a good dose of Jesus and discipline to overcome her laziness and wicked ways, to a doctor who felt that manipulating the insulin levels of patients to extreme degrees could cure them of schizophrenia.

Ultimately, what works for Frumkin (or worked back around 1980) is what still works for clients today: a small number of medications that prove effective in treating schizophrenia, as well as (to greatly simplify things) a structured environment and supportive professionals. Unfortunately, said medications can lose their effectiveness over time, or the side effects can become increasingly detrimental to the clients. It is also quite common for clients to simply quit taking their medications, feeling them unnecessary or viewing them as the root cause of various forms of discomfort or other troubles in their lives. In addition, the structured environments can only be maintained for as long as clients are compliant with treatment, and as long as the treatment remains effective, and as long as funding and various programs allow. On top of that, anything from the restructuring of institutions, to changes in law and other policy, to the career changes of providers, to differences of opinion between providers and family members, can lead to new doctors and other providers making changes, sometimes rather arbitrarily, to a client’s medication regimen or support systems. In Frumkin’s case, alterations to her treatment and medications were made numerous times, in the most haphazard of fashions, often by doctors and other providers who seemed ignorant of her case history, or of how the medications work.

One might also note that this book was written back before the U.S., under President Ronald Reagan, decided that people with chronic mental illness enjoy the freedom that homelessness brings. So, Frumkin’s movements within the system are relatively easy in terms of her various forays into decompensation leading to fairly quick, and relatively long-term inpatient placements, with step-downs to semi-independent housing, and other supports that are much rarer today (and for most of the last three decades).

Ideally, Sheehan’s book would be taught in graduate schools, or maybe at earlier levels, by instructors who are familiar with the clinical aspects of schizophrenia; the current and historical treatments for it; and the current and historical state of affairs with regard to mental health facilities, available inpatient beds for clients with mental health issues, and legal and systemic complications to accessing those beds or other program options.

To be clear, it is necessary, as therapists, or in other capacities in the mental health field, to come equipped with a belief that we can make a difference. Without a bit of the dreamer in us, we would never head down this path to begin with.

But it is also necessary for providers at all levels to understand just what they are up against, particularly given that almost all providers in the mental health field will end up doing at least a round or two in the public mental health system–from practicums/internships to early jobs to entire careers–where the most challenging of clients often end up by default—frequently after being abandoned by families and other support systems, including insurance companies.

Frumkin’s family, as dysfunctional as they are, and as frequently detrimental to her treatment as they can be, at least hang in there to the extent that they can—which I imagine was at least somewhat less difficult when hospital beds and supported living options weren’t at such a premium as they are today. In the end, though, this isn’t a story of a family hanging together and triumphing over a terrible disease. It’s the story of a debilitating mental illness, and the toll it takes on the client, as well as those around her, and the wildly inconsistent efforts by a variety of people and systems to help her cope.

Welcome to Sylvia’s Place.

Dropping Keys, Dropping Letters

by Jonathan C. Schildbach, LMHC, waning ASOTP, reforming soul-eater

An eighth-season episode of The X-Files was built around a “soul-eater”—a person who could draw the disease out from others into his own body, eventually vomiting it out. The concept of the soul eater is based in various forms of folklore involving a range of ideas about curses and cures, and the ability of some to take away those things that most harm or most sustain a person. Unfortunately for this particular soul eater, the demands of those who knew of his powers began to overwhelm his ability to process and expel the disease. He existed in a perpetual state of deformity and misery.

I like the soul eater as a metaphor for the work done by many people in “the healing professions.” In this field, many of us work at building a skill set that allows us to help extract the mental and spiritual toxins in others. Ideally, those receiving help will find a way to vomit out the toxins themselves. Yet, such toxins are in no short supply, and many who are most in need of help thrive on a constant diet of disease coupled with a willingness to let others take on the burdens of that disease. It becomes far too easy for helpers to end up like the suffocating soul eater, awash in the illness of others.

In the professional parlance, we call all that business of being overwhelmed by the problems of others “secondary trauma.” There’s a tendency to assume that, as trained professionals, we are able to recognize and address our own forms of distress. But, like many people in positions of suffering, particularly those who are considered high-functioning, it is entirely too easy to soldier on without addressing our own needs. We know how to address all this, and yet we often don’t, or we often address it in an unhealthy fashion, assuming it will pass in time. We take on more than we can handle, and think nothing of it. Whatever doesn’t kill me makes me more convinced I’m strong enough to take it.

Hey--eat any good diseases lately?

Hey–eat any good diseases lately?  The X-Files’ soul eater.

I bring this all up by way of saying that I’m in the midst of a career shift—not out of the helping professions, but into some different channels in the same field.

In particular, last night I dropped off the keys to the office where I’ve been serving as an ASOTP for the last year-and-a-half, at least temporarily distancing myself from a particular portion of the field that I have been involved with for over seven-and-a-half years—the treatment of sex offenders.

The change was forced by way of making a shift in my full-time employment in crisis services. As I write this, I am deliberately allowing myself only some small bit of awareness of the insanity of my professional life over the past several years. Yes, I have been working full time in crisis services, while also working anywhere from zero to ten hours per week with sex offenders. Such arrangements are not unusual in the helping professions—where we are pushed to learn our craft in rigorous, unpaid positions, while also attending school and working a paid job just to stay afloat. The habits of overextension established while in graduate school can extend out into professional life, and feel totally normal, even as we are pushed toward deformity and misery.

Currently in a break from a years-long pattern of toxic soul-eating, and ready engagement with secondary trauma, I realize I’ve become numb to plenty of very bizarre things. Running plethysmography assessments, I can sit through audio scenarios of sexually violent behaviors, paying them as little attention as if they were overplayed Top 40 hits from yesteryear piped over a grocery store or dentist office sound system. I’ve become entirely too comfortable asking people about their masturbation habits, and pressing them when I think they’re lying (only in the course of assessments, of course—well, mostly). Fortunately, I haven’t become so numb that I’ve lost all awareness of the twists and turns of my mind, although I frequently find myself stumbling in otherwise polite conversations when frighteningly dark and vulgar jokes spring to mind—an entirely appropriate coping mechanism in certain circumstances and with particular people—but definitely nothing you want to spring on friends of friends who don’t even have the most limited of contexts for understanding where such thoughts could come from.

And all of that was on top of 40-plus hours per week of run-of-the-mill crisis intervention, suicide prevention, utilization management…

So, if I want to mix in some metaphors, I can say I’m now a ronin—a samurai without a master—an ASOTP without a CSOTP—which, really just makes me a guy with an expensive piece of paper that says I’m an ASOTP until next September, but which conveys no real ability to treat any offenders unless and until I take on another master/CSOTP. Weighing the massive number of hours I still have to accrue across assessment, face-to-face treatment, and supervision, in order to get the full credential myself, I think this may be it for my involvement in offender-land.

I’ve dropped off the keys; and, with no further action, the letters, too, will drop—as will the level of…expulsion required of me on a regular basis. Sure, I’ll still do what I can to draw out various forms of mental/spiritual disease when that is required of m—but hopefully now in more manageable, fun-sized portions.