How to Seek Help
Find a therapist through Psychology Today.
List of Warmlines (when you would like some support but you’re not in crisis)
Mental Health Apps
The Veterans Affairs Department offers a variety of mental health apps that are scientifically-guided and free to all. For example, they have apps focused on insomnia, irritability/anger, and self-care during the pandemic.
Racism irrefutably exists, and it undeniably influences mental health. Yet, some mental health professionals do not talk about racism in the same ways we discuss other aspects of clinical practice (e.g., cognitive-behavioral therapy’s effectiveness). There are a number of possible reasons for this, including: 1) viewing it as politically-charged and preferable to avoid, 2) discomfort due to feeling like it’s not your place to speak up, 3) not believing it directly affects you, and 4) not feeling knowledgeable enough.
I understand these perspectives and can empathize with them. However, I am alarmed by how racism hinders our ability: 1) to provide services equitably and effectively to our patients and 2) to advance our field with the inclusion of mental health professionals from diverse backgrounds. We are missing out on valuable contributions from people from currently underrepresented backgrounds in the field of psychology because of racism-related barriers. I think this section from the American Psychological Association’s Ethical Principles and Code of Conduct gets it right:
If you agree that fighting racism is a mental health and moral priority, it can feel overwhelming to know how to contribute to this goal. I’m not an expert in this – much more of a person who is trying to learn and who has changed my mind on issues over the years (teaching a Diversity in Clinical Psychology course was a major component of this). I want to share some of the resources and actions I’ve found helpful from listening to people who are experts. I list these resources in case they’re helpful to you, and I’d be grateful if you shared resources you found helpful with me (either through the comments or via e-mail). Please know that there are multiple ways to join the fight against racism.
1. Learn about current racial inequities and their historical context. There are a lot of websites and reading lists shared on social media. Here are just a few examples that I’ve found informative – including popular press articles, a PBS documentary, and podcast episodes: on healthcare (1, 2), on housing (1, 2, 3), on voting, on education (1, 2, 3, 4, 5, 6), and on criminal justice (1, 2).
2. Join and/or donate to organizations that work to fight racism in your community. There are some amazing local groups out there doing impressive on-the-ground work. Barack Obama posted this useful guide.
3. Vote and help elect officials with policy plans to fight racism. Put pressure on them to take action where racism occurs in your community. Ultimately, I believe (from listening and learning from many others) that systemic change is the only way to root out racism.
4. Provide culturally-responsive care for your therapy patients. Some books I’ve found helpful: Addressing Cultural Complexities in Practice, Connecting Across Cultures: The Helper’s Toolkit, Even the Rat was White (an exchange I had with the author had a huge influence on me), and The Unapologetic Guide to Black Mental Health. Some podcasts I’ve found helpful: Naming It and Tatter. You can volunteer to provide culturally competent therapy services to underserved communities through the Boris Lawrence Henson Foundation.
5. Talk about racism with the people in your lives. Speak up in your workplace, friend groups, and school when you hear or see racism. Push for change where you can. It’s not an all-or-nothing thing – I understand that people have individual circumstances that shape their decisions about when they speak up and when they don’t. We all have some places where we can help by being there, speaking up, and reaching out.
There’s so much pain and suffering that disproportionately affects Black people in our field and our communities right now. Let’s work together to make real change where we can.
News of the COVID-19 (coronavirus) pandemic can be stressful and social distancing might limit people’s typical coping skills and therapy access. I compiled this list of online mental health resources that I hope you’ll find useful. All are free except for the self-help books listed at the end. Distant Together is a website with mental health resources specifically geared toward coping during the pandemic. You can find a therapist who practices empirically-guided treatments here.
1. Guided Audio Relaxation Exercises (e.g., diaphragmatic breathing, guided imagery, mindfulness visualizations, progressive muscle relaxation)
2. Guided Audio & Other Self-Compassion Exercises (e.g., coping through self-soothing instead of self-criticism, allowing rather than avoiding emotions)
5. FearTools (an app with cognitive-behavioral therapy exercises for coping with anxiety)
6. WoeBot (an app with cognitive-behavioral therapy and other types of exercises for coping with mental health concerns)
Last week, USA Today published an article with this quote:
Suicide is the nation’s 10th leading cause of death, yet experts say training for mental health practitioners who treat suicidal patients — psychologists, social workers, marriage and family therapists, among others — is dangerously inadequate.
That article prompted this post. If you’re a therapist interested in learning more about working with clients who experience suicidal thoughts and behaviors, I hope that you’ll find this useful.
- Brief Cognitive-Behavioral Therapy for Suicide Prevention by Craig Bryan, Psy.D., ABPP & M. David Rudd, Ph.D., ABPP
- Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan, Ph.D.
- Dialectical Behavior Therapy Skills Training Manual, Second Edition by Marsha Linehan, Ph.D.
- Helping the Suicidal Person by Stacey Freedenthal, Ph.D., LCSW (also check out her website)
- The Interpersonal Theory of Suicide: Guidance for Working with Clients by Thomas Joiner, Ph.D., Kimberly Van Orden, Ph.D., Tracy Witte, Ph.D., & David Rudd, Ph.D.
- Managing Suicidal Risk, Second Edition: A Collaborative Approach by David Jobes, Ph.D., ABPP
- Chu et al. (2015). Routinized assessment of suicide risk in clinical practice: An empirically-informed update.
- Cole-King et al. (2013). Suicide mitigation: A compassionate approach to suicide prevention.
- Hom et al. (2019). Suicide attempt survivors’ experiences with mental health care services: A mixed methods study.
- Hom et al. (2020). Suicide attempt survivors’ recommendations for improving mental health treatment for attempt survivors.
- Klonsky et al. (2018). Ideation-to-action theories of suicide: a conceptual and empirical update.
- American Association of Suicidology
- International Society for the Study of Self-Injury
- Live Through This
- Patient Safety Plan Template
For National Eating Disorders Awareness Week, I tweeted that people could ask me anything about eating disorders. Thank you to everyone who submitted questions – they were very interesting and thoughtful! I aimed to be as concise as possible, while providing links for more in-depth information. If I didn’t fully answer a question, made an error, or was unclear, please e-mail me at email@example.com to let me know. Thanks for reading!
1) @KCapo45 asked:
Is bullying by everyone on social media making it harder for people to be honest in therapy about their true feelings about their body because they are being shouted down by groupthink for not loving their body and being afraid of gaining weight*?
*For extra context, listen to this interview I did with Ken about his recovery from anorexia nervosa. We talked about whether there were any possible negative effects of body positivity movements.
Because Ken specifically asked about people being honest about their feelings toward their bodies in therapy, and I couldn’t find any data on the topic, I’ll share my clinical observations as a therapist:
- It’s striking to me that many of the patients I see — across a broad range of sizes, mental health issues, and ages — struggle with body image issues.
- Many don’t hold back and will openly say that they feel bad about their bodies, even when changes are linked to having babies, medical conditions, or menopause.
- A subset have tried to follow body positivity social media accounts and question beauty norms, so that they can love their bodies more. Still, many have body dissatisfaction and then feel like failures for not 100% loving their bodies. This is the group that will say things like, “And I know I shouldn’t care…” or “And I know I shouldn’t feel this way…” or “I know this sounds superficial, but…” and who end up in an even deeper state of shame and self-criticism.
For these patients, I recommend aiming for body neutrality over body positivity. That means that they accept their body as it is (not reject it or love it, but accept it) and accept their feelings about their body (good, bad, and all else). If they want to make changes in their body and/or their feelings about their body, we can collaboratively discuss those longer-term goals. However, in the short-term, what I’d like is for them to be okay enough with their bodies that they engage in their lives, rather than avoiding valued activities (e.g., socializing, exercising, sex, going out) due to feeling self-conscious or waiting until a time when their body is different. Here are some suggestions for ways to feel more okay about your body.
I think I’m already missing my goal of being concise, but in short, I’ll link to some other approaches I use to work toward this point of acceptance: cognitive-behavioral therapy for body image, I Am Me by Virginia Satir, self-compassion exercises, and opposite action.
Below are some interesting articles on this topic that provide history, context, and more nuance than the headlines suggest.
2) @on_perspectives asked:
ED is extremely complex and certain treatments can backfire. Does the timing of treatment, in regard to what is going on in a patient’s life, play a role in recovery? When would immediate treatment of ED not be recommended because it would mean a lesser chance of success?
In the vast majority of cases, earlier treatment is associated with better treatment outcomes. The general rule is that a person with an eating disorder should get treatment as quickly as possible. If a person gets worse while in treatment, it’s extremely important to identify the factors that are responsible and adjust the treatment approach accordingly. With regard to what is going on in the patient’s life at the time of treatment, we appear to generally have more effective treatments for anorexia nervosa in youth than adulthood. I think this is due to younger patients being treated within the context of family-based care, though there are treatments aimed toward bringing in a support system for adults as well. Other factors that are likely to play a role in recovery: comorbid psychological problems (e.g., depression, PTSD, substance abuse), social support, access to empirically-supported interventions, readiness to change, other general life stressors (e.g., divorce, moving, bereavement, financial stability), functioning in other areas (e.g., academics, romantic relationships, at work), etc. On average, people who have good social connections and fewer additional stressors in their life tend to do better. This is why it’s important for therapists to look at the whole person and the environment they exist in when planning treatment.
I was trying to think about a time when you wouldn’t want someone to get immediate treatment for an eating disorder. It would be dependent on an individual’s particular circumstances, but some possibilities that came to mind would be if the person has some other more dangerous issue that needs to be immediately addressed and can’t be treated at the same time as the eating disorder (e.g., imminent threat of harm to others, imminent suicidal risk, drug dependence with a high level of associated, immediate dangerousness).
3) @mwebb22752561 asked:
Re: goal setting in therapy, should target weights be set by the client, collaboratively or prescriptively on the basis of a healthy weight determined by BMI or similar measurement tool?
Whenever possible, all therapy goals should be set collaboratively with clients. This guideline is the same for people with eating disorders, except that sometimes eating disorders (especially anorexia nervosa) can interfere with the person’s ability to set a healthy target weight. The eating disorder can influence the person such that setting a healthy body weight does not feel like a goal they can agree to. When I have treated people with eating disorders, I find the most effective approach is to work with a team that includes a physician that can speak to medical factors relevant for setting the target weight (e.g., lab results, weight/growth history, menstrual status, etc.). I have seen therapists set a prescriptive target weight (in collaboration with a physician) only when the individual with the eating disorder cannot (due to interference from their eating disorder) and is in a state of medical risk.
4) @lluaces said (and @BianchiKristin said she was curious about this too):
Disorders that don’t have to do with body image like ARFID a lot of people get curious about
Anorexia nervosa and bulimia nervosa are eating disorders with DSM-5 diagnostic criteria that specifically mention an excessive concern with body shape and weight that leads to distress and unhealthy behaviors. Binge eating disorder has also been found to be linked to body image issues. In contrast, avoidant/restrictive food intake disorder (ARFID) is characterized by a disturbance in eating, but specifically excludes people whose behavior is driven by a fear of weight gain or disturbance in body image. ARFID often presents as an avoidance, pickiness (e.g., with textures, types) or low/lack of interest in food associated with at least 1 of the following: 1) significant weight loss or failure to achieve expected weight gain in children, 2) nutritional deficiency, 3) dependence on nutritional supplements, 4) interference with social functioning. For a fuller description, please visit this link. ARFID is typically treated with cognitive-behavioral therapy, and I have included links on the model and its treatment below. The purpose of the therapy is to identify and modify the factors that maintain ARFID (e.g., sensory sensitivity, fear of aversive consequences, lack of interest in eating or food).
5) @ThisIsSpecious asked:
Is it possible to have an eating disorder and not realise it?
Yes, these are the most common scenarios I have observed:
- people with anorexia nervosa who are severely underweight or who have medical problems, but believe that they are overweight or in good health (this is a particularly painful part of the eating disorder that can make it hard to seek help)
- people who have binge eating disorder, but think that their problem is “weak willpower” or “no self-control” because they don’t know about the disorder or know about it, but blame themselves anyway
- people who are dieting, exercising, or fasting to an extent that it is causing significant problems for their health, distress, and/or functioning but who don’t attribute it to an eating disorder (e.g., they think they have an unrelated medical issue causing it)
In these types of scenarios, it often takes a friend, family member, or physician stepping in to suggest that they seek help.
Here are some useful tips for talking to a loved one about an eating disorder, and here is a post about how psychologists determine if someone has an eating disorder.
If you were to go and advise anyone who might have an ED how would you advise them to seek help? Particularly if there is a stigma around that person’s preconceived conditions? (i.e. being overweight etc)
I am most familiar with the U.S. health care system, but I recommend starting with telling your general practitioner/physician about your concerns and asking for a referral/recommendations for local eating disorders treatment. Alternatively, the Academy for Eating Disorders is an excellent organization that has an expert directory search to help you identify an eating disorder practitioner near you (the directory is international). Unfortunately, people, including health professionals, may have weight stigma or bias that interferes with their ability to recognize an eating disorder in an person who is overweight. If a physician or other health professional is dismissive of eating disorder concerns, please seek care from someone who specializes in eating disorders. Professionals with expertise in eating disorders should be aware that people of all different body sizes are affected by eating disorders.
6) @ahlandreth asked:
Would love to know more about body dysmorphia and the way trauma (injury, illness etc) can play into that
Body dysmorphia is currently classified with obsessive-compulsive and related disorders rather than with eating disorders, but there are definitely overlapping features. Body dysmorphic disorder is diagnosed when someone is overfocused on an aspect of their physical appearance (thinking about it at least 1 hour per day), such that it is causing them distress and impacting their functioning (e.g., in their relationships, in their ability to work). While eating disorders are often related to disturbances in perceptions of body shape and weight, body dysmorphia tends to focus on particular body parts or features (e.g., perceived inadequate muscularity, skin, nose). People with body dysmorphia range from relatively high levels of insight about their misperceptions of their body to relatively low levels and engage in repetitive behaviors related to their concerns (e.g., reassurance seeking, mirror checking, skin picking, extensive grooming routines). For more detailed information, this is an excellent resource.
I did not find much research on the role of trauma, illness, and injury in body dysmorphia, and I have not treated many people who have it. However, people with body dysmorphic disorder do report higher rates of abuse and neglect compared to people without the disorder (e.g., 1, 2, 3). Research suggests that body dysmorphic disorder is caused by both genetic and environmental factors. If someone has a genetic risk for body dysmorphia and then experiences a significant stressor (e.g., illness, injury, abuse), it may increase their risk for developing body dysmorphic disorder through a number of pathways. Their self-esteem, emotional coping, anxiety, negative mood, attitudes toward their body, social support, and other life factors may worsen under conditions of the stressor(s), leaving them more prone to developing the disorder. Importantly, there are treatments available for body dysmorphic disorder, including cognitive-behavioral therapy.
7) @Ivuoma asked:
Can you talk about racial disparities in these disorders and/or disorders that manifest mainly in certain groups?
Udo and Grilo (2018) examined prevalence rates of eating disorders in a nationally representative sample of U.S. adults (n = 36,306) and found:
*Lifetime anorexia nervosa rates were significantly higher among White participants as compared to non-Hispanic Black and Hispanic participants.
*Lifetime and 12-month rates of bulimia nervosa did not significantly differ by race/ethnicity.
*Lifetime binge eating disorder rates were significantly higher among non-Hispanic White participants than among non-Hispanic Black participants, with no significant differences between non-Hispanic White and Hispanic participants.
Due to small ns, the authors combined Asian, Native Hawaiian, Pacific Islander, and Native American participants into one group. Here is the table of lifetime rates:
Here is the table of past 12-month prevalence rates:
For more information, I recommend:
I’ve done some research examining acculturative stress, perceived discrimination, and body shape ideals and how they’re potentially related to differing prevalence rates:
We need a lot more research in this area! I’m glad to see that it is has picked up quite a bit in recent years.
8) @jonathanstea said:
Brief overview of evidence-based treatments might be helpful. In my clinical experience, our teams find these disorders particularly difficult to treat, especially when concurrent with addictive disorders—and especially when addictive sxs in remission/eating sxs increase.
I completely agree that eating disorders are challenging to treat and that we need to keep improving on existing treatments. I also agree that one of the difficult aspects of the treatment is that many people with eating disorders suffer from multiple mental health issues. I have observed what you are describing too – that some patients were using substances to cope with emotional pain and other stressors. When that strategy is no longer being used (i.e., when they are in remission), you can see an increase in eating disorder symptoms. I find it beneficial to treat the complexities of eating disorders within a team context to best conceptualize and individualize each person’s care with multidisciplinary expertise (e.g., physicians, psychiatrists, dietitians).
The major evidence-based treatments that we currently have include:
- Family-based treatment (AKA Maudsley) for children and adolescents with anorexia nervosa or bulimia nervosa. This treatment involves empowering caregivers (typically a parent) to warmly and firmly help their child to eat in a healthy, non-disordered way (e.g., meet their nutritional needs, prevent purging and excessive exercise). This is a great article written by a parent and child who received this treatment. More information on the scientific backing for it is available here and here.
- Cognitive-Behavioral Therapy is used in a transdiagnostic protocol for different eating disorder presentations. It targets maintenance factors for the disorder (e.g., negative mood intolerance, all-or-nothing thinking, body dissatisfaction, perfectionism, fasting/restriction). More information on the empirical evidence is available here and here.
- Interpersonal Psychotherapy for eating disorders helps the patient recover by identifying and targeting a particular interpersonal domain that is maintaining the disorder: 1) lack of intimacy and interpersonal deficits, 2) interpersonal role disputes, 3) role transitions, 4) complicated grief, or 5) life goals. There is a good review of available evidence here.
- Integrative Cognitive-Affective Therapy is a relatively newer therapy that appears to be as effective as cognitive-behavioral therapy for bulimia nervosa. It has also been tested in binge eating disorder, but those results are not yet published. It focuses on helping the patient to regulate their eating patterns and then identify an area for skill-building (e.g., assertiveness, healthy ways of relating to one’s self, coping with emotions).
- Dialectical Behavior Therapy has been used to treat both bulimia nervosa and binge eating disorder. It focuses on increasing skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. More research is needed on the effectiveness of the approach, but here is a useful article on its application.
9) @DrSamanthaMyhre asked:
A general discussion on the overlap of BDD and EDs and how to differentiate (I typically revert to clinical interview + BDD Y-BOCS and EDE-Q to help, but definitely interested in learning other strategies).
Using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Eating Disorder Examination-Questionnaire (EDE-Q) is an excellent way to approach this differential diagnosis. The only other approach I’ve used is the Structured Clinical Interview for DSM-5 (SCID). I think that the distinction is tricky, but body dysmorphic disorder (BDD) often focuses on a particular feature (e.g., skin, nose, ears), while eating disorders tend to focus on body shape and weight. That being said, you can definitely see overlap in checking behaviors, self-esteem issues, and appearance anxiety — especially with muscle dysmorphia (MD). The International OCD Foundation website makes this distinction, “While individuals with MD often follow very precise, time-consuming, and painstakingly picky diets, their eating habits are driven by an all-consuming concern with improving the mass and leanness of their muscles, as opposed to issues relating to their weight or body fat percentage, as seen in individuals with eating disorders.”
I liked the way that the website discussed differential diagnosis:
I also like their short version as a rule of thumb:
I could not find a large study with very clear statistics on rates of comorbidity between BDD and eating disorders, but one study found that approximately 1/3 of people with a BDD diagnosis had a lifetime eating disorder diagnosis and another study found that ~1/2 of people seeking treatment for an eating disorder screened positive for BDD. Therefore, it is certainly appropriate to diagnose both if you see symptoms that are not fully captured by one diagnosis. Our diagnostic system is far from perfect, and I think it makes sense to choose the diagnosis(es) that seems like the best description and guide for treatment for the patient. If you are gathering data from the measures that you mentioned, your clinical judgment and decision-making will be very well-informed.
For more information:
Male Eating Disorders (discusses muscle dysmorphia)
Thank you so much to everyone who sent questions! I hope that I provided the information you were looking for – but please reach out if you’d like to know more.
For more information, check out my Short Guide to Everything You Need to Know About Eating Disorders.
Suicide is a major public health problem in the United States. In 2018, we lost nearly 50,000 people to suicide. That means that 1 person, in a deeply pained state, ended their life every 11 minutes. Left behind are heartbroken family members, friends, and communities who desperately wish they could have helped. Suicide rates are the highest they have been in 50 years, which stands in stark contrast to the declining rates of other types of death (e.g., stroke, heart disease).
Popular press articles have speculated about explanations for climbing rates, including smartphone use, scarce research funding, a weakened social safety net, and income inequality. Many suicidologists agree that we do not yet really know why this is happening. One public response has been to launch campaigns against stigma that encourage help-seeking. These efforts involve people, including celebrities like Lady Gaga, Logic, and Demi Lovato, openly sharing their struggles with suicidality. Another response has been to increase research devoted to understanding suicidal behavior and its prevention. Despite significant funding constraints, the past several years have resulted in a greater scientific understanding of suicidal behavior, how to treat it in a therapeutic context, and how to reduce risk in moments of crisis. If stigma has decreased and scientific knowledge has increased, why are suicide prevention efforts not stopping more deaths?
Many current initiatives advocate for intervening after a person has become suicidal, including improving access to quality mental health care and suicide hotlines. These downstream components are absolutely necessary, but insufficient on their own, for reversing current trends. Suicide prevention must include directing additional, comprehensive resources toward the root causes that put people on a trajectory toward suicide in the first place. As Archbishop Desmond Tutu said, “There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.”
A society that is serious about stopping suicide must expand beyond a model where an individual is identified as mentally ill and then referred for services that they may or may not be able to access. Even if all financial-, stigma-, and discrimination-related obstacles were removed to accessing quality mental health care (as they should be), and all existing therapists conducted scientifically-guided practice (as they should do), the field could not adequately meet all of the mental health needs. There simply are not enough therapists, hospital beds, and crisis line staff in many pockets of the country to provide services to all who suffer at the time they need it. And with suicide prevention, time is of the essence.
A public health approach means acknowledging that personal and population health are inextricably linked and that individual-level suicidality occurs within the context of societal structures. It means pushing for health equity, maximizing population-level well-being, and preventing many more people from reaching the point where suicide is viewed as the only escape from their pain. To illustrate the importance of this approach, consider the lead poisoning crisis in Flint, Michigan. Childhood lead exposure is linked to several adverse adulthood outcomes, including worsened mental health. It is absolutely necessary that Flint residents receive safe drinking water immediately, along with services to help with the damage that’s been done. However, effective prevention initiatives must also identify what allowed the lead poisoning to occur and continue in the first place (e.g., racism, irresponsible politicians) and create safeguards (e.g., policy, structural changes) to stop them from happening again.
What would systemic suicide prevention initiatives look like? They would financially empower communities to nourish mental health from the beginning stages of life (e.g., paid parental leave, affordable housing, quality education and health care, fostering community connections). These policies would also allocate resources to people and organizations with the multidisciplinary expertise and experience needed to design, implement, and evaluate community-level policy changes that directly target factors that contribute to suicidality: isolation, illness, unemployment, incarceration, adverse childhood events, and homelessness.
With Flint, the need for a holistic, preventative approach is obvious. A system that stops lead from getting into water is the most powerful way to reduce a repeat of human suffering – more so than providing services after the damage has been done (though this is completely necessary as well). The same holistic approach must be applied to suicide prevention: help those currently struggling and devote resources to upstream prevention. If we want to reverse the trend of increasing rates, save lives, and mitigate suffering, we must treat suicide like a public health crisis.
Many, many thanks to my sister, Linda Gordon, for sharing her expertise in public health and anthropology with me. Our discussions about these topics inspired this post.
For World Suicide Prevention Day, I tweeted that people could ask me anything about suicide. Thanks to everyone who already sent me questions – they’re really good ones! If you want to submit a question, tweet it to me (@DrKathrynGordon) or e-mail it to me (firstname.lastname@example.org).
If you’re in crisis, please contact the National Suicide Prevention Lifeline or the Crisis Text Line. The responses below are my opinions and should not to be taken as professional advice. More suicide prevention information and resources are available here.
Added September 11, 2019
Anonymous asked: What criteria do mental health professionals use when deciding whether someone should be admitted to a hospital involuntarily for suicide risk?
Laws vary by location, and the criteria depend on the particular mental health professional, client, and situation. The typical criteria for involuntary hospitalization is that the person is at imminent or immediate risk for suicide. The field has a lot of work to do to get better at predicting when someone is at immediate risk for suicide (e.g., see Franklin, Ribeiro, et al., 2016). Some factors that therapists tend to view as indicative of immediate risk for suicide include (e.g., see Chu et al., 2015):
- a clear, resolved plan and/or preparations made for suicide, intent to act on the plan, and access to lethal means (or plans to acquire lethal means)
- multiple past suicide attempts (especially if recent)
- the therapist and patient cannot create an alternative plan for safety (e.g., staying with a friend, temporarily storing lethal means elsewhere, identifying ways of coping with emotional pain that don’t involve suicide)
The mental health professionals who I have interacted with over the years tend to be eager to find alternatives to involuntary hospitalization. They seek to respectfully and collaboratively create a safety plan with their clients. However, I know from listening to other people’s stories that it’s not always the case. For example, Rudy Caseres is a mental health advocate who has spoken and written about these issues, and I recommend checking out his website here.
Published September 10, 2019
@ToWit12 asked: Let’s go worst-case scenario, where I encounter someone already with a gun to their head or about to jump off a bridge. What is the right (or rather, least wrong) thing to say/do?
Most people in that kind of emergency situation are experiencing pain, loneliness, and hopelessness. Individual situations vary quite a bit, but this would be my default:
I’d ask them to put the gun away or step away from the bridge, so we can talk (to increase safety). I’d talk to them in as calm and warm of a tone as possible. I wouldn’t endanger myself in this process, say they’re bluffing, or ignore them. I’d call for help if I could (911). I’d tell them I care about them, and that I’m there to listen and not to judge them. If I had struggled in my life, I’d let them know that (to increase a sense of connection). I’d commit to helping them find resources for addressing their problems (to increase hope).
For more on this topic, I recommend listening to this Story Corps segment about a police officer (Kevin Briggs) who helped a man (Kevin Berthia) who was about to jump off of the Golden Gate Bridge. It’s also worth watching Kevin Berthia’s TEDx Talk, The Impact of Listening and listening to this NPR segment, Mental Health Cops Help Reweave Social Safety Net in San Antonio for their approaches in mental health crises.
Anonymous asked: I developed PTSD in the course of supporting a suicidal friend. Now other people’s suicidality is triggering to me, and I expect it to be that way for a while. I want to support friends who need it, but I want to support them at arm’s length. I’m in no position to be in the front lines of anyone’s mental health support team. This has been a problem: having gone to bat for one suicidal friend, I seem to be socially marked now as a person who will be supportive, even among people who are intellectually aware that it traumatized me. I’ve been somewhat beset by men, in particular, who demand that I provide womanly sympathetic listening without regard for my own mental health. Dealing with this gently while managing my PTSD symptoms is challenging.
World Suicide Prevention Day is coming up and I dread it. This is the kind of season in which I’m approached directly for mental health support that I’m not in a position to give.
I want to set very firm boundaries about how much mental health support I’m willing to do, preferably without hurting or antagonizing extremely sensitive people or getting into any arguments about whether I’m an ableist who’s contributing to stigma. How do I do that?
First of all, I’m very sorry that you had to go through such a painful experience. I hope that you have been able to find effective treatment for your PTSD.
Secondly, in my work as a therapist, I’ve heard a useful analogy used about helping others. When you’re on an airplane next to a child, they tell you that you need to put on your own oxygen mask in an emergency situation before assisting the child. If you don’t, you could suffocate while trying to put the mask on the child, and then neither of you will survive.
Right now, it sounds like putting on your own oxygen mask first means not being available to others in suicidal crises. I would say something like this, “I see that you’re in a lot of pain, and I really feel for you. I can’t be the one to support you right now. I’m struggling too, and to be well, I really need to focus on working through that first. If you can’t think of anyone else to talk to, you can always contact the National Suicide Prevention Lifeline. I hope you find the support that you need.”
My hope is that most people would respond to that in a positive, understanding way. However, if they perceive your response as ableist, stigmatizing, or anything else like that — it’s important to stick with your boundaries anyway (repeating what you said, if necessary). We can’t control what other people think of us, but we can do our best to live according to our values and strive to be okay with our own decisions. Your mental health matters, and good friends should support your decisions to take care of it.
Zach Clement asked: How can I support a friend who is considering suicide while keeping myself emotionally healthy, and how do I disengage with them when my relationship with them becomes unhealthy for me?
I recently was trying to give support to someone because I knew they were having a hard time, and they had said that they thought about killing themself. However, as time went on, they started attacking me and my relationships with others. I realized that my only reason for talking to them was that I knew I would feel guilty if I didn’t. Eventually, I told them that I wouldn’t talk to them anymore if they continued to attack the things that I valued, and they didn’t stop, so I told them I would just ignore them. I offered to help them find a therapist when I cut things off with them, but I still sometimes feel like I should have done something differently.
This is a really tough situation, and I don’t think these potentially complicating factors are included enough in public discussions of suicide. It sounds like you told the person how they were affecting you and gave them chances to apologize and change their behavior. Unfortunately, the person didn’t. A natural consequence of someone attacking you and your relationships with others is that you’re going to want to distance yourself from that person. And no amount of the other person’s pain gives them a right to be abusive toward you.
Honestly, I think I would have done the same thing that you did. I’d tell them that I couldn’t keep being around them if they treated me like that, but that I wanted to help them get connected with a therapist. The fact that you offered that was very kind and above and beyond what most people would do. I might give them some additional information like the National Suicide Prevention Lifeline. If I knew someone else close to them – and it fit with the situation – I would mention that the person brought up suicide before and that you’re concerned.
I’d probably feel a bit unsettled about the situation, because I’d worry if the person hurt themselves I’d feel responsible. From my perspective though, you can’t allow someone to treat you like that repeatedly because you feel guilty. It sends the message to the person that it’s okay for you to be treated that way or that it’s okay for you to suffer because they are. So, then I’d try to cultivate some acceptance about the limits of what I can do for the person. It sounds like you made a healthy and correct decision for yourself. I hope the person pursues professional help and that you feel at peace with the way you handled it.
Tyler Pritchard asked: Who are your top 3 influences in suicidology research and/or practice?
- Without a doubt, the most influential person in my scientific and clinical work is Thomas Joiner. He was my research mentor during undergraduate and graduate school. Thomas also directed my graduate program’s training clinic and played a huge role in my development as a therapist. His compassion, intellectual curiosity, and direct approach are all qualities I admire and strive to bring into my work.
- Marsha Linehan created a therapy for people who were traditionally excluded from clinical trials (e.g., high suicide risk, multiple mental health issues) with an empathic, skills-based approach. Her courage, irreverence, and dedication to helping people build lives worth living inspires me.
- It’s hard to pick the third person, so I’ll say my former grad school labmates as a group (e.g., Kim Van Orden, Tracy Witte, Jill Holm-Denoma, April Smith, Ted Bender, and Mike Anestis). They’re brilliant scientists and clinicians and also exceptionally kind people. Conversations with them over the years have helped me to understand suicidology at a much deeper level than I would without their friendship and collaboration.
There are a bunch of others that come to mind, but you didn’t ask for my top 300, so I’ll stop here. 🙂
Mike Heady asked: I’m not sure you have an answer for this but here it goes. I’m looking for data on how many people present or are admitted to hospitals for suicide risk when in fact the person is having intrusive self-harm OCD.
Unfortunately, I didn’t have any luck finding data on this either. This is a great question though, and I want to discuss the meaning of it for any interested readers out there.
Obsessive-compulsive disorder (OCD) often includes unwanted, distressing images or thoughts (referred to as intrusive thoughts). Sometimes, these thoughts are about contamination with germs, hurting others, or hurting oneself. You can see what this looks like in this video of an adolescent being treated for self-harm OCD symptoms.
Many people — even those without OCD — have experienced a self-harm image or thought come into their mind, even when they are not suicidal. For example, Hames et al. (2012) asked a college student sample (n = 431) if they ever had an urge to jump when in a high place. They found that it was fairly common, including among participants with no history of suicidal ideation (see the table below).
For some individuals with OCD, their thoughts about self-harm are alarming, distressing, and feel like no part of what they would actually want to act on. They are not typically at high risk for suicide, because they usually try to decrease their anxiety about intrusive thoughts by taking extra safety measures (e.g., not handling knives). They’ll say that the thoughts are disturbing because they really do not want to die.
For other individuals with OCD, they may be struggling with their symptoms and considering suicide, because they believe it would be an escape from their pain. This type of situation is more worrisome.
Clinically, I’d look at the context of their suicidal thoughts to make my best judgment about their risk and whether hospital admission is appropriate. The presence of any of the following would put them at higher risk for suicide: a lack of distress or even a sense of comfort when thinking about self-harm, a history of self-harm or other suicidal behavior, a suicide plan and lack of fear about carrying it out, access to lethal means (e.g., an unsafely stored firearm), sleep disturbance, agitation, social withdrawal, severe mood disturbance, or significant weight loss.
For more information, check out this blog post: When People with OCD Fear Harming Themselves.
Anonymous asked: Suicide is a concept I am ambiguous about. When I am distressed over something after a day, or when I feel I don’t belong in society or I will never be able to function normally like other people would, I feel or think that suicide is an escape route. Like, if all else fails and pain is too unbearable to take, I could choose it. That way, I would get rid of all the things that are troubling me.
Or sometimes, I think that I am not courageous enough to pull the last act for suicide. When I brought this up during one of our sessions with my therapist, she told me that suicide is not about being courageous it is about cowardice.
So, my question is,
1 Is suicide about courage or cowardice? Does it take courage to commit suicide or does it means cowardice? Well, of course if doesn’t have to be one of those, but saying it’s cowardice feels like it’s underestimating the pain underneath. What do you think how should we look at this?
2 What do you think about the existence of the idea of suicide lingering in your head as an escape route as a comforting idea? Is it healthy, if not what can I put in its place?
1. Suicide is not an act of cowardice. Though there are different pathways to suicide, most people get there because they see no other way to escape excruciating emotional pain. They often mistakenly believe that they are doing others a favor by not living any more. Even very brave people are vulnerable to, and die by, suicide when afflicted by this pain. It’s not a sign of weakness (more about this on an NPR segment, Deconstructing Myths about Suicide).
In terms of courage – that’s not the word that I tend to use, because of it’s kind of value-laden. I prefer to describe to the ability to die by suicide as others have: capacity, capability, or fearlessness (about the pain and injury involved in suicide). For someone to kill themselves, they have to override a very strong human survival instinct. That drive to live is protective and life-saving for many people. Tragically, people who die by suicide break through that.
So, I don’t think suicide is an act of cowardice or courage in the vast majority of cases. It is an outcome that occurs when people are intensely hurting and don’t see another way out. Suicides hurt those who are left behind, even if that is not what the person intended to do. In the eyes of the bereaved, I would be surprised if they see either cowardice or courage in the situation — just heartbreak.
2. I have spoken with people personally and professionally who think about suicide to decrease painful emotions. If you’re interested, there’s some research on it in this paper called Daydreaming about Death: Violent Daydreaming as a Form of Emotion Dysregulation in Suicidality.
First, I want to say that there’s nothing to be ashamed of and that you’re not alone in doing that. It’s valid to want to decrease your emotional pain. However, I do suggest that people find other strategies for feeling better. My concern is that fantasizing about death might increase suicide risk. It could potentially reduce the protective fear that surrounds suicide and strengthen the links between positive feelings and death.
In terms of what to put in its place, you could try to imagine feeling better and that your problem is solved. If that doesn’t feel authentic or practical for you, I recommend finding ways to remind yourself of your ability to cope from past situations, that you can take things one day at a time, and that you find other ways of dealing with distress. For example, there are some ways listed in this post here that include distraction and finding emotional uplifts (e.g., watching comedy, intense exercise, seeking social support, etc.). If it’s relaxation that you are looking for, this website has some nice audio recording options that are worth trying instead. I hope you find some of these other approaches helpful and comforting.
Coral More asked: Do you see another model than assess & refer to 911/hospital given what we know about trauma resulting from police encounters and hospitalizations/emergency rooms? I know it’s a very tricky one but I never see folks talking about it.
I’ve been on both sides of this, feeling the need to call emergency services but also voluntarily presenting to the emergency room and being absolutely traumatized by the dehumanization and cruelty there.
I personally have recommended calling 911/the hospital in certain (though very few) situations where other options were exhausted and there’s urgency. These include situations where: 1) the person already hurt themselves or 2) they’re at immediate risk of self-harm. This pathway can be lifesaving, appropriate, and beneficial (though experiences vary a lot, as you said above — people can also have horrible, terrifying experiences that are detrimental to their well-being).
There are many, many more situations where I have collaboratively worked with someone to find an alternative suicide prevention approach. My default is to collaboratively create a safety and coping plan. This includes reducing access to lethal means, identifying supportive people (I often try to call at least one friend or relative with the consent of the patient, and this tends to go well), and listing methods for reducing emotional pain (e.g., emotion regulation skills, crisis survival strategies for distress tolerance). In addition, I provide them with emergency numbers, and we identify when they would need to go to the hospital or call 911 (e.g., if their suicidal thoughts escalate to suicide planning or preparation).
Part of the discussion also includes ways to intensify treatment without using the hospitalization or emergency services route. For example, increasing the frequency of therapy sessions or attending a partial hospitalization program (where people go in for treatment during the day, but sleep at home).
This article is good for looking at suicide risk as a continuum with a variety of interventions that correspond with severity: Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update.
I like what Marsha Linehan says in this video about hospitalization (keeping a person alive through constant monitoring) versus taking a risk by not always hospitalizing at any threat of suicide, so they can have a chance at building a life worth living.
Note: Usually, when I write about any remotely politically-charged topic, I make sure my arguments are very clear in my mind and supported by 9000 citations first. This isn’t the case with this topic, which I’m still forming ideas about. I’m posting this because I’d love to hear feedback/counterpoints from cognitive-behavioral therapy (CBT) and social justice perspectives: email@example.com.
I was recently on Jesse Singal’s podcast, and he asked thoughtful questions about the applications of CBT to campus culture war issues. Apparently, a side effect of asking me good questions on a podcast is that follow-up blog posts occur (well, it’s happened twice so far, anyway).
Here are my current, still-forming thoughts about whether CBT should be applied to college students making claims about politically-related offenses and psychological harm. My points are based on a variety of different arguments I’ve heard and are not directed at particular people/texts, though I believe this is the original article applying CBT in this way.
1. CBT is excellent and improves the lives of a lot (but not all) people struggling with mental health issues. I’d love for all college students to read David Burns’ self-help CBT book, Feeling Good: The New Mood Therapy (which is referenced in the original article on this topic). I read it in college, found it eye-opening, and then proceeded to recommend it and loan it to countless people since — including undergraduate students who I taught when I was a professor. Seriously, ask anyone who knows me — I have probably recommended that book to them. Not all students find it helpful (which is consistent with research on any treatment modality), but some really do. However, it’s important to recognize that CBT is designed and scientifically-tested as a treatment for people who are having mental illness-related distorted cognitions and thinking errors. It does not focus on societal stressors related to healthcare access, income inequality, rights, or prejudice, and it doesn’t offer solutions to those issues either. My concern is that placing thoughts related to these issues in a CBT framework reinforces some individuals’ default position that people talking about experiencing prejudice or feeling upset about political issues are exaggerating. Within a therapeutic context, these complexities can be addressed with nuance. Outside of that context, I worry that it bolsters notions that people can and should just think their way out of these types of stressors. This NYT article is about an illustrative real life example of how this kind of disbelief or minimizing default can lead to negative consequences.
2. Relatedly, I’m wary of using CBT as a method for ‘correcting’ other people’s thoughts and feelings about offense or harm unless I’m the person’s therapist (and even then I’m cautious) for the following reasons:
Humility & Accuracy: If you think someone is overreacting to a politically-related incident, you can just plainly state that as your appraisal of the situation instead of using CBT language (e.g., calling it catastrophizing or emotional reasoning). When you say someone’s thinking is distorted, the assumption is that you know for sure that they’re overreacting and also that you know why they are (and that is mindreading). I don’t see the incremental value of using CBT terms in situations where you don’t know much of the context, unless it’s to tone down the fact that you’re making a judgment about the accuracy of a person’s thought by framing it as a concern about their mental health.
Effectiveness: In the self-help version of CBT, a person learns tools for investigating their own distortions and thoughts. In therapy, it’s a collaborative process, where the therapist hears the person’s point of view and guides them through the steps of evaluating their thoughts in a compassionate, contextualized process. By design, CBT helps people arrive at reframed thoughts that ring true for them. It can be hard to get to that place in therapy — it seems much harder to get to that place through some of the other methods I’ve observed (articles/posts referring to students’ behavior as evidence of their fragility). To be clear, I’m not saying that thought errors don’t happen in certain college campus situations — I’m just saying I don’t see how motivated the average college student would be to evaluate thinking errors when presented with them as a sign of their fragility.
Ignoring Real Problems Where They Exist: As I wrote about before, I think that disproportionate focus on students’ purported lack of resilience ignores the valid reasons for their actions. If students get painted with too broad of a brush and are characterized as simply being unable to tolerate opinion differences, then it distracts from points of legitimate concern about the spread of ideas that perpetuate social inequities. When therapists disagree with their clients’ approaches to situations, they motivate change by looking for and validating the truth in what the client is saying and collaboratively generating ideas about adaptively achieving their objectives.
Furthermore, there’s a long history of people from marginalized groups being misdiagnosed and poorly treated within mental health fields (e.g., 1, 2). Broadly applying cognitive distortion framework in a public way doesn’t allow for a culturally appropriate framework that therapists are trained to use in treatment. Without that context and training, people might minimize or deny others’ valid experiences–which could be harmful to their health.
In conclusion, there are helpful elements in cognitive-behavioral therapy that apply to particular types of problems — especially when depression- or anxiety-related thinking errors are present. I have reasons to doubt it would generalize beyond what it’s been tested on and designed for, but could be convinced otherwise with empirical data.
While research on the effectiveness of gratitude interventions appears mixed, there’s a shared wisdom that being thankful for what you have is good for you. Most of us have had experiences where something stressful happens (e.g., a minor car accident, an argument with a friend), and we gain perspective by stepping back and appreciating the positive aspects of our lives.
But I’ve also observed instances when gratitude gets in the way. I’ve had friends and therapy patients start to talk about something that bothers them and then they cut themselves off and say, “But I know other people have it worse, so I shouldn’t complain.” I get the impulse–I do it too. I think it serves the purpose of displaying self-awareness or maybe mitigates fears that you’ll be judged as having petty concerns or maybe you think telling yourself that will make the feelings go away. To be sure, there are times when people could use a more zoomed-out perspective and appreciation for their lives. However, I’ve observed this approach hindering progress and worsening well-being too.
The pattern is usually that a person experiences distress, they try talking themselves out of it being a big deal, and then they end up avoiding actions that would actually help them feel better and improve the situation (e.g., leaning on a friend for support, doing something healthy like exercising, gaining clarity about painful emotions, problem-solving, going to therapy). If you’ve tried to address a situation by telling yourself that you should be more grateful and the feelings persist, it’s time to try something else. It doesn’t mean that you’re an ungrateful person for recognizing that you’re bothered by something despite all the people who have worse lives (and by the way, many of the people I’ve heard say this have had objectively terrible things happen to them!). It just means that you’re human and affected by the events surrounding you. Acknowledging your experiences and directly addressing them is a healthy way to deal with them and not an act of self-indulgence.*
*I think it’s really hard to make any general statements when people can be all over the spectrum of gratitude and stress responses and vary from situation to situation, but thought I’d write this out for people who happen to fit into this kind of scenario.