Dear Psychiatrists, Psychologists, Clinical Social Workers and therapists,
I am writing to you as a psychiatric survivor. Psychiatry is the only medical specialty to have its own survivor movement – not from the illnesses it hopes to treat, but from the practices of the profession itself.
For me personally, my individual experiences with mental health treatment have harmed me much more than they have helped me. As a survivor of bullying and sexual violence, my mental health treatment served largely to re-traumatize me instead of helping me heal.
When I was bullied during middle school and high school and struggled emotionally as a result, I was encouraged by my parents and my school administration to seek mental health treatment. There, I was diagnosed with half a dozen labels and medicated in high doses.
However, although my treatment team was in frequent contact with my school, not one clinician recommended addressing the root of my struggles: bullying. While I now understand that my anxious, depressed and lonely feelings were a natural response to being bullied, I was told that I was “sick” and “ill” for reacting this way.
This lack of trauma-informed care has followed me all through college and graduate school.
One of the most traumatic experiences I have ever had was being forcibly hospitalized the night of my college graduation.
Let me backtrack a bit to tell you how much my graduation would have meant to me. As I mentioned, I was bullied constantly in high school. I was told that I was ugly and weird by teachers and students alike almost every day. Although I was the valedictorian of my high school, I did not feel safe attending my graduation.
My college graduation was a symbol for me of how much had changed since then. I had a supportive group of friends with whom I was planning to sit. I felt included in all my classmates’ graduation activities, I had a loving boyfriend there to support me and most humbling of all, my professors had chosen to recognize me with an award for my community service and I was going to be a speaker. I remember thinking in the week leading up to my graduation, “Wow, this is what it must be like to be normal!”
The night before my graduation, I told a psychiatrist that I was feeling passively suicidal because of the stress of graduating college. I said that I did not at all have plans to actively attempt suicide, but I wouldn’t mind if I died soon.
I did not expect that this comment would land me in a psychiatric hospital. When I was told that I was about to be involuntarily hospitalized, I frantically tried to explain myself, saying that I did not have any active plans or possess the means to kill myself, and begging to just be able to attend my graduation. The psychiatrist did not listen. It was done. I had said something I could not undo.
As if missing my own graduation wasn’t punishment enough for saying a passively suicidal comment, I could never have imagined how traumatic and scary the process of involuntary hospitalization, even for just 72 hours, would be.
During my hospitalization, I was invasively strip searched, secluded and restrained, verbally abused by staff members and given medication without being informed of potential side effects and told that I had to take the medication if I wanted to leave the hospital.
When I told hospital staff members what had happened and how sad I was to be missing my own graduation, they responded by telling me that I should’ve kept my mouth shut. My bodily autonomy was completely stripped from me. It was all too familiar and triggering for me as a survivor of sexual assault.
My experience of being re-traumatized by forced treatment is not uncommon. The experience of forced treatment is very often traumatic, and very rarely, if ever, beneficial. Many individuals report their mental health worsening greatly after being subjected to these practices. A recent study found that 63 percent of patients have witnessed traumatic events in psychiatric settings. Thirty one percent have experienced physical assault, and 8 percent have experienced sexual assault (Frueh et al., 2005).
After my first hospitalization, I began experiencing nightmares and flashbacks, both to my sexual assault and to my hospitalization. I had never before experienced these symptoms, even after my assault. My suicidal thoughts became worse, but I did not seek help for fear of re-hospitalization and re-traumatization. Keeping my suicidal thoughts all bottled up eventually turned them from passive to active and led to a suicide attempt.
This is a story with a happy ending. I am alive today. But so many aren’t.
If you are reading this letter, you are taking a very important first step toward providing compassionate, humane, trauma-informed care: listening to mental health clients/consumers/survivors, learning about our experiences and putting yourself in our shoes.
A crucial part of trauma-informed care is approaching mental health treatment with an in-depth understanding of what types of hardships and forms of oppression individuals may have experienced that have led them to seek help. Trauma-informed care means not asking, “What is wrong with you?” but instead “What happened to you?”.
Another important part of trauma-informed care is understanding the ways that forced hospitalization can re-trigger or create trauma. Coercion and force underlie all forms of abuse and oppression and it is essential for mental health professionals to recognize that while they may have good intentions, the use of forced hospitalization or treatment does utilize these mechanisms of control.
I realize that many mental health professionals see forced treatment as a traumatic but necessary tool to use as a last resort to keep people from harming themselves. I of course understand this sentiment; indeed, the desire to preserve life is noble. My personal position is that all forms of forced treatment should be abolished, but in the meantime, while forced treatment does exist, I implore you to use forced treatment truly as a last resort – meaning only after every voluntary, non-coercive form of treatment has been tried.
The following are some alternatives that I recommend trying before resorting to forced hospitalization:
Make a suicide safety plan.
A suicide safety plan is a way that individuals can use their strengths and support systems to keep themselves safe. Suicide safety plans often include warning signs and triggers, internal coping strategies, people and social settings that provide distraction, helpful and supportive friends or family individuals can turn to, professionals to call in a crisis and methods of making their environment safe such as removing all weapons.
For me personally, the act of making a suicide safety plan has felt extremely empowering and reminded me of all the strengths and supports I do have–enough so to keep me motivated to stay alive. Suicide safety plans are often utilized by suicide hotlines and have proven very effective. Please click here for a sample suicide safety plan.
Refer the individual to a support group where they can speak openly about suicide.
Something that has helped me greatly with my suicidal thoughts is having a safe place to speak openly about them without fear of re-hospitalization or even any sort of diagnosis, labeling or judgment. There are many self-help support groups that allow members to speak openly about suicidal thoughts, including Alternatives to Suicide, Depressed Anonymous, Emotions Anonymous, The Icarus Project and local support groups for suicide attempt survivors.
I remember the first time I spoke openly about my suicidal thoughts after my hospitalization – it was in a Depression Anonymous meeting. I was shaking, terrified that someone in the meeting would call 9-1-1 or a mental health professional. Instead, I was met with understanding and love. Many members spoke to me at the end of the meeting to give me their phone number and tell me to reach out to them and they checked in with me the next day and afterwards.
The experience of attending self-help support groups has given me so much hope and support that even on my worst days, I know I have a safety net of people to turn to, and that keeps me from hurting myself.
If it will make you feel more comfortable, you could have the individual sign a suicide contract stating that they will not attempt suicide during the time in between your evaluation and their first support group meeting. I understand that some mental health professionals recommend against the use of no suicide contracts. However, I have found that promising myself I will just wait one more day, or just wait until my next support group, has been very effective.
Note: Many fellowships and support groups have online meetings, as well, for people who may live in areas without these kinds of resources.
Arrange for the individual to stay in a peer respite.
A peer respite is a center for people in crisis that is entirely staffed and operated by people with lived experience with mental health. Peer respites provide community-based, trauma-informed, and person-centered crisis support in a non-clinical, homelike environment. Mental health peer specialists are on staff 24/7 to counsel and support people going through crisis. Many psychiatric survivors have had very positive, helpful experiences at peer respites. Please click here to find out more information about peer respites in the U.S.
Ask the individual to provide evidence of means disposal.
One of my therapists once helped me feel safer being open with him by telling me that if he ever had reason to believe I had a plan or means to attempt suicide, he would first ask me to provide him with evidence that I have disposed of the means. He has asked clients to send videos of themselves flushing pills down the toilet and/or spoken with their family members to confirm that they no longer have the means to attempt suicide.
- Read through the book “Hello, Cruel World: 101 Alternatives to Suicide for Teens, Freaks and Other Outlaws” by Kate Bornstein with the individual and find an alternative that sounds better than suicide.
This book has saved my life many, many times. The alternatives to suicide range from exercising to exploring your spirituality to “killing off” the parts of yourself that you dislike (personality traits, etc.).
I will admit that some of the alternatives are controversial – self-harm is one and so is trying drugs. The author takes the stance that anything is better than suicide. You as a professional can pick which of these you would like to suggest to your clients/consumers.
Often, just reading the book has given me a laugh and helped me feel less alone in my suicidal thoughts or feelings of being an outcast. Please click here to access the book. There is also an iPhone app with the full version of the book.
Help the individual access culturally responsive and linguistically competent care.
Many times, people may be going through a crisis as a natural response to forms of structural oppression, including racism, religious prejudice, xenophobia, queerphobia, misogyny, ableism, poverty and other forms of bias that can lead to severe trauma, so often reflected in state, institutional and interpersonal violence. These forms of oppression are strongly correlated with suicide attempts and a person’s risk for suicide increases when they experience intersecting oppressions.
Very often, mental health systems fail to offer programs that are culturally sensitive to members of minorities and oppressed groups that adequately recognizes the trauma of the oppression they face every day. People of color, people of size, immigrants, refugees and LGBTQIA people are disproportionately subjected to forced treatment.
Additionally, many community-based programs intended to support survivors of violence only re-traumatize people by coercing them into making police reports, cooperating with law enforcement investigations or filing for restraining orders, which can force survivors to relive their experience.
Members of oppressed groups have the right to culturally competent care, including services provided by and for people from racial, ethnic, cultural, and LGBTQIA populations that are historically underserved. Culturally responsive care can also include traditional healing arts such as Ayurvedic and traditional Chinese medicine, Native sweat lodges and talking circles, shamanistic healing, and community garden programs for Hmong refugees. This can also include faith-based counseling or support for religious individuals.
For me personally, LGBTQIA affirming therapy as well as spiritual counseling from a Rabbi have been important parts of my healing and recovery.
Help the individual address or make a plan to address whatever external issues are causing them to feel suicidal.
The night before my graduation, I felt depressed and ashamed because some of my family members had told me that they wished I had pursued a more lucrative career. They were disappointed that I was graduating from an Ivy League only to attend social work school instead of becoming a medical doctor or entering a more prestigious profession.
One of my family members actually said exactly those words in front of the psychiatrist and the psychiatrist did nothing to stand up for me or address my feelings of guilt and shame over my career choice. In a lot of ways, my suicidal comment was my way of saying, “I need validation. I need to not feel like a failure right now.” I often wonder what would have happened if that night, the psychiatrist had validated and supported my choice to attend social work school or if we had even acknowledged the difficulty and scariness of sacrificing profit and prestige for one’s passion.
Regardless of your views on the chemical imbalance theory or nature vs. nurture, we can all agree that external factors can be a major cause of suicidality. Bullying, sexual violence, domestic abuse and childhood trauma all increase victims’ risk of suicide. One important way to prevent suicide is to address some of these underlying issues. If a child or teen is being bullied, you can prevent suicide by making a plan involving their family and/or school administrators to make school a safer place for them.
The last time I was triggered and started to experience some passive suicidal thoughts was as a result of a workplace bullying situation. Instead of hospitalizing me, my therapist validated my feelings and helped me make a plan to address the issue in a politely confrontational, constructive way. I immediately felt empowered and hopeful, and my suicidal thoughts quickly dissipated.
I strongly believe that if all of these alternatives were used before resorting to forced hospitalization, forced hospitalization would almost never occur. I was not offered these options as an alternative to either of my two hospitalizations. The times that I have been offered these alternatives, they have been extremely helpful.
Remember: if you do not try these alternatives first, you’re not using forced hospitalization as a last resort.
Thank you very much for listening to my story and considering my perspective. On behalf of the psychiatric survivor community, we thank you for your open-mindedness to these ideas and willingness to provide trauma-informed care.
Mental Health Peer Specialist
Frueh, B. C., Knapp, R. G., Cusack, K. J., Grubaugh, A. L., Sauvageot, J. L., Cousins, V. C.,…Hiers, T. G.
(2005). Special section on seclusion and restraint: Patients’ reports of traumatic or harmful
experiences within the psychiatric setting. Psychiatric Services, 56(9), 1123-1133.