No textbooks were involved in this reflection. These pastoral observations come from lived experience and the blessings of a fulfilling apprenticeship in the learned art of psychiatric assessments. The reader is welcome to take from my musing; what works, what doesn’t, and discard the rest.
“Are you thinking of harming yourself or someone else?” This seems like such a simple question. If it is so simple, try asking it of someone else.
“How dare you?” “It’s none of your business.” “Don’t you know who I am?” Strap in for the expected whiplash reaction. Because an anticipated response has the potential to damage or harm a relationships. It can be far easier to avoid the issue. Don’t talk about the elephant in the room, and, maybe, it will go away. Other than lawyers, who wants confrontation, anyways?
If you don’t know; ask.
Your curiosity didn’t come out of nowhere. You wonder about a person’s safety for a reason. It might be the way they look, suspicious behavior, or sudden changes in life status. In my experience, faith suggest that these moments of questions are intersections between God and consciousness; or, God moments, using common language. Could it be that God wants you to know? Could it be that God has already been priming the pump? Could it be that God chose you to be the one who prevents a tragedy?
When asked respectfully and compassionately, most people who have experienced homicidal or suicidal thoughts will honestly respond. Why? Because they’ve come to believe that you care. Most desire to be rid of such hideous, unrelenting thoughts. Telling someone else can ease the burden. Don’t we all want to be made whole?
Keep a box of tissues close at hand.
It is as if thoughts of homicide or suicide are signs of weakness. When connected to one’s mental health, thoughts of self-harm or harming others arise from more complicated processes. In my experience conducting psychiatric assessments some of those sources may be childhood sexual abuse, trauma, a manipulative religious experience, alcohol or substance abuse, sudden onset of situational stress, disease and neurological chemical imbalances, and, drawing an unlucky hand, simple genetics.
Abused children grow up to be messed up adults. Those adults are at risk of sharing the pain with others, the consequences infecting successive generations, thus perpetuating the original sin. Prisons, psychiatric hospitals, and therapist chairs are overflowing with adult survivors of childhood sexual abuse. Responsible adults are good and faithful stewards of the community’s children, blood relative, or not. Responsible people look after one another. Thank you, Lord, for highly trained, committed professionals who are able to intervene and break the cycle of child abuse, and provide effective treatment methods that lead to healing.
Trauma is a can of whoop-ass, when unleashed. Trauma gets burned into the neuronal pathways of the brain. Traumatic memories don’t seem to fade, like other, less significant memories, like the color of the most recent car that pulled into the neighbor’s driveway.
Traumatic memories tend to bloom and grow over time, if left untreated. Traumatic impacted imagination tends to fill in missing details, causing memory to become more vivid or realistic, some memories based in reality, others, not so much. Those protein encrusted electrical pathways from brain cell to brain cell remain active day and night, often abruptly interrupting sleep with nightmares, or interfering pleasant experience with intrusive, disturbing thoughts. Trauma is a specialty in mental health unto itself, requiring far smarter and more experience people than me to walk with people in a journey toward wellness.
Yep, bad religious experiences can make people crazy enough to take a life, their own or someone else. Bad theology can lead to guilt, depression, a pervasive sense of failure. Charismatic, manipulative religious leaders can take advantage of people’s weakness or lack of self-esteem. Inflexible doctrine, fundamentalist polity, judgment, fear, and manipulation are tools of religious extremists, at either end of the theological spectrum. This can contribute to an erosion of mental health. When in doubt, erring on the side of grace and love always works for me. Or, perhaps, a graceful approach allows God to work through me.
Drugs and alcohol, really, both two sides of the same coin, can make people homicidal or suicidal. What first is a means to feel better, when misused over a period of time, can lead some people to frantic, unrelenting obsessions for more, and more, and more. The research community is far better equipped to find safer, more effective means of symptomatic relief or diseases altering qualities, than I am. Self-medication is a bad strategy for living a healthy, fulfilling life, especially in this day and age with access to a wide array of effective, therapeutic treatments.
Sudden stress can make people snap. I’ve seen it happen far too often. Lose a job; jump in front of a train. A sudden death of a child; take a high dive off a bridge. Devastating diagnosis; go find your revolver. Caught in a crime; find a piece of rope. Intervention of a loved one, pastor, or professional clinician is essential to heading off deadly behavior in these, or similar, unfortunate circumstances.
Brain chemistry can become unsettled, leading to pervasive thoughts of wanting to hurt self or others. General medical conditions, such as urinary tract infections, thyroid disease, poly pharmacy (taking too many medications that lead to unintended side effects), malnutrition, and others … can all lead one to the crazy train bound for destruction.
Chronic mental diseases, such as untreated (or undertreated) bipolar disorder and schizophrenia will often include delusional mortal thoughts. A thorough physical exam by a professional clinician is absolutely required of everyone who finds themselves thinking about harming themselves or others.
Get thee to your primary care physician – immediately! – if thinking of hurting yourself or others. Speak candidly with your doctor. Suppress fear or guilt and lay it all out there for their evaluation. They can’t be your best doctor if they don’t have all the information.
Whole libraries have been written about each of these contributing factors for malignant ideation. If interested, dig deeper. Explore. Read. Take a class. Work on a degree. Just as important: be kind, tolerant, understanding. Listen. Be curious. Build trust. Have compassion for those hurt or broken, either by their own bad choices or just the circumstances of nature. Ask to be a channel of God’s love to a world full of hurt and harm.
Be the balm of Gilead that heals the wounded soul.
…
Laps at the pool the other day flew by as if a flash. My thoughts were filled with gratitude, with a focus on my learning to swim.
Dad had operated a learn to swim program for the American Red Cross at the new Jamestown High School pool in the early 1960’s. He and my older brother, Steve, even had a program to teach individuals with Down Syndrome how to swim, one of the first of a kind in the nation, or so I was told.
I was taught to hold my breath, put my face in the water, and blow bubbles. Once accomplished, I was shown how to dog paddle. Before I knew it, I was navigating around the shallow end of the pool. Later, I began to mimic the strokes of more advanced swimmers, learning rhythmic breathing, the crawl stroke, the back and side strokes.
The water gave me a freedom to maneuver, to go where I wanted to, to explore, and meet other people. Learning to dive to the bottom instilled a sense of freedom in three dimensions. My sister, Cindy, was a member of the synchronized swim team. She moved with beauty, grace, and efficiency through the water. Steve on the diving board gave me the confidence to enter the water head first. If he could do it, so could I. Learning to swim built self-confidence.
Swimming is a gift that I don’t take for granted. It can save a life. It is good for the soul. Fifteen laps ticked by; before I knew it, I was under a hot shower afterwards feeling the warmth of God’s love and the gratitude for a wonderful family.
—
The not-so-obvious follow on question to a positive response addresses lethality. “What are your plans?”
A lethal homicidal or suicidal individual most often will have thought through elaborate plans and set in place necessary means to complete their deed. Multiple prior attempts increases the risk. Less lethal is the person who may have had thoughts, but who haven’t thoroughly thought through their plan.
For a psychiatric assessment office such as myself, experience and collaboration with other clinical professionals will conduct a risk assessment. Risk cannot be truly eliminated, but it can be appropriately managed. It is the art of balancing risk and reward. Only those who are assessed to be actively lethal and have a plan to carry it out are appropriate for involuntary commitment to a secure psychiatric hospital. Even then, the confinement is for a short period of time, with periodic re-assessment such that an individual’s civil rights are not violated.
The goal is immediate treatment, stabilization, and release with immediate, intensive out-patient follow-up care. Medication balances the playing field; counseling provides insight, education, support, and healing.
“What brings you to the hospital this evening?” I asked the ten year old girl sitting on the gurney before me.
“The police brought me here,” she replied. Her mother and siblings were waiting in tears in the emergency room waiting room just down the hallway.
“Can you tell me why the police brought you here?”
“I pushed my friend in front of a school bus,” she replied.
“What made you do that?”
“She is a bully and she is trying to steal my boyfriend,” I seem to recall her answer.
Thereupon the table was set to uncover all the key motives and factors that led up to this near tragic encounter. She was amazingly candid with me. I was truly curious about her experience. I got the sense that she was measured, calculated, and logical in her thinking. At that moment, she intended to kill.
“Do you plan to try to kill her again?” I asked.
“Yep. At the very next chance I get.”
That sealed the deal. I finished the interview, thanked her for being honest and truthful with me, and departed to set into motion an intervention that I hoped and prayed would reduce her lethality, stabilize her mental health, and start her on the long journey of healing and recovery.
Psychiatric assessments are team work. We are cautious, never punitive, always acting in the best interests of the patient and family. A sad reality, in that day and age, New York State was resource poor in the treatment of adolescent psychiatric patients. The demand far exceeded the supply. I ran my report past the E.R. doctor and got his signature. I consulted with the on call psychiatrist. She agreed.
I updated her mother that we were admitting her daughter to involuntary in-patient psychiatric care. This took time. A lot of tears flowed. Guilt and regret. One can only imagine. Her emotional support took time and greatly drained me. “Sit tight,” I finally got around to saying, “and I’ll get back to you when I find your daughter a place.”
But where is there an open bed?
The University of Rochester, only 45 minutes away, was at capacity. The next nearest hospital was in Hornell, a good hour and a half. Nothing. I called the children’s unit in Buffalo. No dice. The Mohawk Valley. Nope. I was striking out left and right. I finally found an open bed in the lower Hudson River valley, over four hours away. I had no choice. “I’ll take it.”
I arranged for the doctor to doctor transfer, the nurse to nurse coordination, and for the local ambulance crew to make the transport. Paperwork was faxed back and forth. No medic likes a long transport of an involuntary psychiatric patient, let alone a child. “Oh, the poor mother,” I thought to myself. The long distance separation would make the follow on necessary family therapy a real challenge. Hopefully, stabilization would be quick and discharge to a local out-patient setting could ease the family stress.
And so it went. I wished her well and smiled as I closed the door on the ambulance. There was nothing more than I could do at that point than to deliver her over to the grace of God.
In that time and place, homicide didn’t happen. Neither did I hear anything later. And that, beloved, is a blessing.
