I recently asked my daughter how a friend of hers was doing and the reply was, "He's still not comfortable around knives, but other than that he's okay." I asked if he was suicidal and she replied, "no just images." I really want to call her friend and talk to him about strategies for dealing with suicidal ideation and suicidality, but he would not welcome the call.
I've dealt with both in my life and with all the various suicides in the news and the diaries about suicides here on dkos, I thought I'd share some strategies. Maybe my daughter can share the link with her friend and maybe it will help someone here.
I was sexually, emotionally, and physically abused as a child. I spent many of my teen years debating living vs. dying. I'm a pretty competitive person and for several of those years the only reason I chose to continue living was the feeling that my abusers would win if I died. Another fear was a botched attempt which I knew would make life after the attempt even more unbearable.
I got married & had a son my junior year in high school, and had a daughter five years later. When my daughter became the age I was when the sexual abuse started, my depression clicked over into active PTSD. I became actively suicidal again and finally got some therapy. I found an excellent therapist. What I write here comes from personal experience. I am not a therapist.
In my experience, there are three general levels of suicidality: suicidal ideation (w/o affect), suicidal, and suicidal with a plan. These each affect people differently, but there are strategies for coping with each. Each of them causes its own type of pain for the person experiencing it and for those around them.
Suicidal ideation without affect is when certain things (knives, pill bottles, etc.) bring the idea of killing oneself to mind even though there is no feeling of wanting to die. This can feel like a bolt out of the clear blue sky, even on a great day, and leave one wondering, "where the hell did that come from?" To my knowledge, this generally only happens to those who have previously been in one of the two other states for some period of time. It is as though a pathway was worn in the brain and a random stimulus sends you down the path.
What I am calling suicidal (w/o a plan) is someone who is in deep emotional or physical pain and sees ending life as a valid way to end the pain or to solve the problems that seem overwhelming. Those with chronic physical illnesses can be susceptible to it, as can PTSD and clinically depressed persons.
A person who is suicidal and has a plan (like Ryan in joshalot's diary ) has decided that the solution is to end it, has researched how to do it meeting whatever criteria is important (I've talked to folks who didn't want family to have to clean up blood), and is waiting for some triggering event to implement the plan.
These levels are not entirely discrete. When I first entered therapy I was starting to plan but not there yet. I left my children with my then husband because he would not accept his wife getting therapy and because I could no longer promise myself that my children would not walk in on my corpse one morning; when I no longer trusted myself to choose to live.
What worked for me: On a day when I was choosing to live, I worked with my therapist on the "Plan for Living." You see, depressed people who aren't feeling suicidal at a given moment tend to prefer not to think about it. We spend a lot more energy figuring out how to end it than we do figuring out how not to let the pain win. So my therapist encouraged me to think as hard about how to help myself continue to choose to live as I did in figuring out ways to die. I made a deal with myself. The first deal got me through my therapy and then was practically forgotten during some very good years. Then I came down with a chronic illness and eventually the depression came back. This time it only reached level two at worst and was mostly at level one, so a different deal was required. My deal is not the solution for everyone. I offer it as a template for consideration.
So, in the worst state, when I spent time actively wanting to die and thinking about how, there were a couple of rules. Rule One: I promise I will talk to someone before I act. Now this may seem like a small thing, but isolation is a huge contributor to suicidality. Part of the plan involved having a list of phone numbers with me. There were four categories. My therapist (and his "service"), friends who knew what I was going through and were willing to be on the list, friends who didn't know but would chat positively, and Suicide Prevention Hotlines. My first call would be to my therapist, if it went to his service or he was in session, then I called someone from the second group until he could call me back (call-waiting is a good thing). If no one in the second group was available, then either someone in the third or fourth groups depending on how I felt.
I should make clear, it was not my friends' job to convince me to live. It was their job to talk to me until my therapist could take the call. Rule 2: in the conversation, I promise to see if I can find the reasons I have previously chosen to live. My friends might tell "remember when" stories about fun we'd had or "I'm looking forward" to stories about future plans we had together. They might talk about my kids, or chocolate, or any random thing they knew I found positive. All I asked was that they not talk about their own problems during those phone calls. I'd call back the next day, I'd listen all they wanted, but in that phone call, keep it positive until my therapist called.
Rule 3: If I cannot promise to follow Rule 1 I will check myself in to a mental health facility. If I actually pick up a knife and apply it to my wrist I will stop and get myself to a mental health facility. I actually did this once. It was shortly after I was put on Prozac and the only time I violated Rule 1. They took me off Prozac and things were better.
Now this all probably seems like common sense, if you aren't or have never been suicidal, and like pollyanna bullshit if you are. To the first group I can say only, until you've walked a mile in my shoes you don't know the pain. To the second I say, yeah, that's what I told my therapist too, but it worked. Here's my theory: I believe in the power of the sub-conscious mind to support survival. Working with a therapist to Plan for Living can draw the sub-conscious mind into the process of survival. When you start sinking down that slippery slope and you are sure there is only one way out, your sub-conscious can whisper, "wait, you promised to talk to someone before you act." If you don't spend any energy planning to live, your sub-conscious mind might not think it is a priority.
When, after years of living depression-free and suicide-free, I suddenly had suicidal ideation hitting me out of the blue, I went back to a therapist. One of the things I learned is that there are triggers. For me, pain and fatigue are triggers for my suicidality. I did not sleep well growing up; when you don't know if your father is going to come in and rape you that night, falling asleep isn't the easiest thing to do and you tend to wake up any time the floor creaks. Pain + fatigue = horrific childhood I wanted to leave by dying. That path seems to be in my brain -- well rutted, perhaps even paved. So when I got Chronic Lyme disease and Fibromyalgia (fatigue + pain) suddenly I was beset with suicidal images even though my life was otherwise terrific. I was not depressed, I was not having another PTSD episode, I was simply having those triggers pulled over and over. A new plan was needed. First a slight revision to the old plan: Rule A: If I move from ideation to desire I will go back into full time therapy. Rule B: if I begin to plan, Rule 1 applies. Then a strategy to deal with the old triggers and paths.
Have you read about Neuroplasticity? Very cool research being done there. The brain makes new paths all the time. So first, create a new trigger: every time I thought longingly of a knife or pill bottle or driving into an embankment I sang a song about counting my blessings. I actually made up a little ditty about "I love my daughter, I love my son, I love my husband ..." sometimes I sang that, other times feel-good numbers from musicals. This didn't replace the first triggers, but kept me from going further down the path. It got to where I could go from image to laughter in 60 secs.
It still gets old. Even though there have been many years free of any of this, I still feel like I have been fighting to live since I was a child. So my next step, on which I am still hard at work, is remembering my triggers and trying to manage them. I am trying to replace my reaction to pain and fatigue. First by being careful not to become over-fatigued. If I need medical help to sleep, then I will get it because that way I will not be as susceptible. Second by not being a hero about pain. The chronic lyme and fibromyalgia are 95% gone. But if I need a percocet I will take one. That way I will be less susceptible. Third, and this one I haven't figured out yet: find something to replace "I'm tired and in pain and the only way out is death" thought that I get if I do get too tired and in too much pain (I got bronchitis a month ago, hard to control the fatigue and pain then). I'm thinking it will be an affirmation of some kind: "I'm tired and in pain, but thankfully my life is full" or maybe "I'm tired and in pain, but tomorrow I won't be" or maybe "I'm tired and in pain, but I can't wait to see what my kids will do" or maybe "I'm tired and in pain, but I want to watch my granddaughter grow up" or maybe "I'm tired and in pain, but I need to fight for civil rights" or maybe ... you get the drift. I need to get my sub-conscious in on this because sometimes (often, always?) that is where the battle is won.
To all those who have stood by me in good times and in bad: Thank you. To those who are currently suffering from depression and despair: I'm very sorry and there are things good therapists and good anti-depressants can do for you. But please, give at least as much thought to how to live as how to die. Make a Plan for Life.