Suicide Solution: Why Some People Pay the Ultimate Price

When I was 12 years old I had my first brush with suicide. A family member had attempted it once previously and was successful on her next try. While any survivor of suicide will inevitably feel the sickening absence of their loved one, I experienced an additional loss, that being the opportunity to discuss, process, and make sense of what had happened in my young mind. The event became the elephant in the room throughout my family, the dirty little happening that, while it was never explicitly stated, was not to be discussed. As a result I was simply left with the impression that my family member had committed suicide because she was crazy. No further explanation was provided or offered. I did not receive any counseling or education regarding mental illness and was, therefore, left to draw my own conclusions with an adolescent brain that was ill-equipped to do so.

There are many myths regarding suicide that are perpetuated by people that view life from the perspective of not understanding the intense and unique emotional suffering of the desperate individuals that go through with this most destructive of acts. Following the tragic death of Robin Williams in 2014, Henry Rollins famously condemned him in the press, stating that he had lost respect for Williams and that he could not understand how someone that had so much going for him could have even a single bad day. As a mental health professional I can confidently state that, while I am by no means offering any sort of formal diagnosis of Robin Williams (and that it would be grossly irresponsible and unprofessional for me to do so), the actor’s behavior off-set and stage hinted at symptoms of ADHD and mania (which is almost always accompanied by minor or severe depression). He was also reportedly dealing with the diagnosis of a grave physical illness.

The truth is that none of us will ever truly understand the depths of this entertainer’s pain. It is impossible to fully put yourself in someone else’s shoes and, in my experience, the people that actually take their own lives are the least likely to let on that they are suffering. I learned this the hard way when my life fell apart at the age of 23. I had been an active addict for several years and had stopped using abruptly, only to find that all of the psychological symptoms I had been unknowingly medicating began to manifest themselves in my sober life. From the outside my life appeared to be perfect. I had a decent car, good grades, a nice wardrobe, a loving family, and a pretty girlfriend. People were shocked when I entered 12 step recovery as they had trouble seeing me as a suffering addict in need of help. For the first four years of my sobriety I rarely shared with people outside my immediate circle of friends and I stayed in the same codependent relationship in which I had wrought so much emotional destruction. My mental anguish was so severe that I would have gladly given all my worldly possessions if only someone could immediately alleviate my fear, depression, and anxiety.

Only then was I able to revisit my family member’s suicide from a completely different perspective. To this day I wholeheartedly believe that I have been as humanly close to that path myself without crossing the line. I actually felt a kinship and closeness with my loved one knowing the magnitude of pain she suffered, albeit under different external circumstances. Emotions are the universal language that is experienced by all people regardless of race, culture, sexual orientation, culture, or socioeconomic status. We all understand joy and we all understand pain. We all feel loss and happiness. I no more blame someone suffering from unbearable emotional suffering for committing suicide than I would condemn a man on fire for jumping into a lake. The difference is that emotional pain is a soul-eroding illness that becomes increasingly and progressively worse as time goes by.

So what can we do for such people to provide them with the necessary life-saving interventions? The truth is that I do not have all the answers. I know that removing the stigma from getting help for mental illness will go a long way toward accomplishing this goal. On a personal level I have a habit of connecting with people in most places I go, establishing at least a minimal bond with them as a matter of course. My experiences in recovery and as a social worker make it damn near impossible for me to do so and I have ended up having many people confide to me that they are suffering in some way. Being present and engaging with those around you, even in the most seemingly insignificant of ways, can have a profound impact. Ask someone how their day is and then listen. I find that people want to be known, understood, and acknowledged and that most people have at least some psychological scars that still impact their daily lives years after the fact. I don’t advocate trying to be anyone’s therapist, but I do believe in the power of being caring and understanding. You never know how much the slightest gesture will affect someone when they are going through a tough time. Until next time.



Hospice Series (Part Two): Hospice Services in the Nursing Home

Hospice services can be delivered in several different settings including hospital inpatient, home services, assisted-living facilities, and nursing homes. This entry in the Hospice Series will deal specifically with the ins and outs of arranging services for loved ones in long term care facilities.

More than half of my patients currently reside in nursing homes. A significant percentage of my home patients will end up in such facilities once their loved ones can no longer handle the “heavy lifting” of their care by themselves at home. Hospice can be extremely beneficial for patients in long term care for several reasons including the following:

  1. Once a patient is living in a nursing home, their Medicare benefits are no longer paying their room and board as Medicare will only do so for a fixed amount of time and only for patients that are receiving restorative or rehabilitative therapies. The great majority of hospice patients do not qualify for such treatments as they are unable to participate and make the significant gains required by Medicare for continued reimbursement. At this point room and board are either being covered by private pay, long term care insurance, or Medicaid (or some combination of these). This means that Medicare will cover hospice costs at 100% with no additional charge to patients or families.
  2. Hospice patients in nursing homes typically receive more person-to-person contact than other residents. Hospice nurses will usually make 2 one-hour visits per week as will hospice aides. Patients will also have a social worker and chaplain making regular visits as well as potential massage therapy and volunteer time. This is likely the reason why patients coming onto hospice service may become a little more social toward their own family members as they are forced into interpersonal interaction with more people. Hospice is participatory for patients and families and keeps them more engaged with one another.
  3. In any nursing home, whether it be the nicest five star facility or a notoriously undesirable one, the patients that receive the best care and the most attention from staff are typically the ones that have the most visitors. While this may seem not to make sense on the surface, facility staff are kept on their toes as there is more potential for hospice personnel to notice dereliction of duty by such staff. Simply put, hospice provides several extra sets of eyes for families and tends to communicate anything of concern directly to a patient’s family. Nursing home staff know this and act accordingly.
  4. Nursing homes are unfamiliar places and a patient’s adjustment to them can range from disruption of normal lifestyle to extreme paranoia and emotional discomfort. Hospice staff offer a modicum of consistency that can provide comfort for patients as they tend to look forward to seeing the same faces on a regular basis. Patients also feel more important and loved by the extra attention.

The bottom line is that, should you find yourself in the position that your loved one’s physician feels that hospice is the desired medical intervention, you can take some comfort in the aforementioned facts. Once these are adequately and tactfully explained to families, they come to see hospice in the nursing facility as what I call both a “win-win situation” and a “no-brainer”. Until next time.



Getting Comfortable with Discomfort

One of the most important lessons I’ve learned as a social worker is that, in order to excel, you must absolutely get comfortable being present in situations that make your skin crawl. You will encounter people, places, things, and circumstances that will test the limits of your ability to maintain a modicum of objectivity, but how do you become comfortable with discomfort? From my experience, three things will help you learn how to do this:

  1. Time on the job. Repeated exposure over a long period of time will familiarize you with the unpleasant particulars you will face. I always say that, while nothing surprises me, some things do shock me.
  2. Having a strong sense of yourself and your values. This will help you notice whether your discomfort is more about you than your client’s presenting issues.
  3. An understanding that the process of learning this skill will never be over. You can refine this skill, but you will never perfect it.

For instance, my very first client at my first “big boy job” was a 15 year-old boy with significant anger issues to whom I would be making home visits. When I pulled up to his family’s trailer, he was sitting on the front steps smoking cigarettes with his family. By family I mean his mother, 12 year-old sister, and 10 year-old brother, all of whom were smoking. His home was infested with fleas from the seven dogs that crowded the living room, only a few of which were his family’s pets. The others were strays that had simply wandered in and were being tolerated by the family.

He had lit fire to a neighbor’s car because he was unhappy with the relationship between the man and his mother. While my own values and the way I conducted  myself in my personal life were completely at odds with much of what I was experiencing, I quickly learned this kid was a person with very real and alarming concerns that deserved a shot at help as much as anyone. I had to put my judgment on the shelf and realize it wasn’t about the life to which I was accustomed. The fact that I included this story from so early in my career, about 13 years ago, shows how deeply it affected me and how, so many years later, I am still conflicted about the way I handled the situation.

I could fill a book with stories of clients/patients that led me to places that challenged my ability to stay present while feeling extremely uncomfortable. Some of these situations involved people I was tasked to help in which I found very little about them to like or admire. However, I have made it a lifelong goal to practice Carl Rogers’ idea of “Unconditional Positive Regard” which states we must treat people as human beings regardless of things they have done. It is not always easy and it would be dishonest of me to say that I always succeed, but it is a work in progress. Remember, the things that make you the most uncomfortable are also your greatest potential learning opportunities. Do not shy away from them.

Most importantly, it is crucial to have a support person, whether it be your own therapist or a colleague with whom you can process such events. This will help you more clearly see what it is in you that causes your discomfort. Your continued effectiveness as a social worker depends upon your dedication to ongoing personal growth. If you do not have a support person, please seek out someone with whom you feel comfortable. It will make all the difference!



The Illusion of Balance

I often hear people talk about achieving “balance” in their lives as some sort of Holy Grail, like a permanent solution to the inevitable ebbs and flows they are experiencing in different areas. It’s become a bit of a cliché in society, so much so that we have the stereotypes of the workaholic, the parent that has given up their career (or at least put it on hold) to stay at home with the children, and the people pleaser that never turns down an obligation at the detriment of his/her personal well being, among many others. If we could just get everything firing on all cylinders in all areas of our lives, we would be perfectly in balance and, as a result, happier and more well-adjusted. Most people with whom I interact at least partly believe this is possible.

I’m here to tell you that it’s a bullshit myth or, as Morgan Freeman so eloquently stated in “The Shawshank Redemption”, a “shitty pipe dream”.

We all have multiple areas in our lives that require our attention. These include career, family, friendships, social obligations, volunteer work, hobbies, and many others. The myth is that we can create a life where we are getting a healthy dose of each of these things without our participation in some of them taking away from our time in the rest. Someday, we think, the stars will align, the magical percentages among these slices of life will add up perfectly, and we will have arrived. Everyone around us will marvel at how well we are managing all aspects of our lives and, in the process, becoming optimal human beings.

That all sounds very nice, but the fact remains that such balance would be mostly impossible even barring unforeseen external events, let alone with the potential for everything to be derailed by one of life’s whimsical and arbitrary interruptions. The plain truth is that, on the whole, we get out of something roughly what we put into it. The more energy I put into my marriage, the better my relationship with my wife is apt to be. Spending excess time in the pursuit of career development will likely enhance my professional standing. Paying more attention to my close friends will strengthen those bonds. It is exceptionally rare, however, that any one person has the time, resources, or energy to manipulate all of these conditions to his/her favor at the same time.

Thus balance does not really mean a fair relative satisfaction amongst the different spheres of our lives–it merely means that everything is temporarily going our way. This inevitably happens for short periods, and is usually due to factors other than our own direct personal influence. Sometimes things just click and we feel we are coasting through our days without any speed bumps. Other times it seems that, although we are desperately trying to keep everything together, we just can’t get anything to work out in our favor. That’s life. Balance, like stability and permanence, is an illusion, a mythical state for which we all strive, yet remains maddeningly elusive. I think the trick is to enjoy the times when everything is going well, to know when one area requires more attention than others, and to be mindful and present in our lives no matter what is happening. In the end even the difficult periods are worth it because they enrich our understanding and experience.

Until next time, stop trying to micromanage everything and relax into the rhythm of the universe. It’s much more beneficial to go with the flow than to fight upstream.



Hospice Series (Part One)

People fear death. Even when they or a loved one are beyond any hope of a cure and their illness is causing them so much suffering that the mere act of living has become an arduous chore, death remains the white elephant in the room. Perhaps it’s because the dying process reminds us of the potentially terrifying reality that we are mortal, or maybe we feel we don’t have the right to make any choice that may hasten the end of life, but I have seen grown men and women rendered incoherent, awkward, and even interpersonally dysfunctional when they are forced too close to the fire. This is part of what makes my job as a hospice social worker difficult as I feel I am usually a leg down when meeting with the family of a potential patient.

One of the most rewarding parts of my job, and my career in general, is having the opportunity to provide education and information to those that are in desperate need. I liken hospice to 12 step recovery in one sense: almost every adult is familiar with the concept of helping someone die peacefully (in the case of hospice) or of seeking a means to quit alcohol (in the case of Alcoholics Anonymous), but the same people have absolutely no idea what actually takes place in either case. Hospice is something they may philosophically support when it applies to other people, but It remains, for the most part, an issue with which they hope they will never have to deal personally. It is precisely for this reason that I would like to reach the largest population possible in order to, as I put it, take some scary out of the word “hospice”.

Families typically assume that it is virtuous and courageous to fight disease unceasingly, no matter what the cost. Call it denial or call it hope (most call it denial, I call it both), but the concept of embracing death seems to be diametrically opposed to our very nature as human beings. This is why many cancer patients, when faced with the grim reality of their prognosis, still choose to participate in grueling, painful, and ineffectual procedures in the hope that they will be one of the lucky few that come out the other side. The persistence of this illusion is exacerbated by the fact that many oncologists become heavily emotionally invested in an individual’s care to the point that they perceive hospice and palliative care as a personal failure. By the time such patients come on service with us they are often days or weeks from death and cannot, therefore, benefit from the full array of services hospice can offer. 

Medicare currently covers nearly all hospice costs, making the service absolutely free to most of the people that qualify. Nevertheless, there remains a vicious cycle wherein people wait until the very end to accept hospice care, pass away within a short time, and friends and family (as well as people in the community) see this and perpetuate the assumption that hospice is only for those that are literally days from death. This thinking is why I have actually been called to hospitals where a patient is being terminally weaned from a ventilator with full expectation that they will pass and I am only there on the off chance that they survive. Never mind that my agency could have been involved for the past six months, educating the family on signs and symptoms of decline and helping them be ready emotionally to say goodbye. While we offer thirteen months of follow up bereavement services to families following death, this does absolutely zero good when we only have three days to connect with them and build rapport. At that point every bereavement contact becomes a mere reminder that they have lost their family member and thus does more harm than good.

This is the first of a multipart series of the realities of hospice care. I feel distinctly qualified to write on this subject for several reasons. To begin, hospice is my first love and the path I have chosen after performing social work in various settings. Secondly, as I am an LCSW I am able to perform much needed clinical work with families experiencing complex grief and other systemic issues. Lastly, I have worked on both the clinical and marketing sides of hospice and can, as a result, provide a complete look at the bigger picture (macro) as well as the individual level of care (micro). I hope to provide useful information for anyone that has a client, patient, friend, or family member that may benefit from hospice and palliative care. More to come…



The Importance of the LCSW Outside of the Therapy Office

My post-graduate social work career began in 2002 at the community mental health center as a crisis intervention specialist that provided follow-up therapy for those I had assessed in the field. As with most similar gigs, the pay was low and the atmosphere chaotic, but it was not without its benefits. I had plenty of seasoned therapists with whom I could staff cases and I received free supervision for my LCSW, a perk that would, in and of itself, have made the job worth it. I view the four years I spent at that particular agency (two in the crisis intervention position and another two as a Child and Adolescent Outpatient Therapist) as a kind of social work boot camp, a wholesale education in clinical work, community resources, networking, and the incorporation of theory into practice. I could not have asked for a better foundation upon which to build my career. It is somewhat ironic that I did not receive my LCSW until shortly after leaving the agency in 2006 to go into Hospital Social Work, a field where a clinical license is not mandatory.

I found a portion of my new job in the hospital to be dull in comparison to my clinical work. Social workers in the hospital setting are primarily responsible for “tasky” things such as arranging safe discharges for patients and making sure that patients are discharged before they cost the hospital any money. While being a therapist consisted of building rapport and relationships within a somewhat stable structure, working with patients and families in the hospital involved forming rapid alliances in order to present an acceptable outcome following a relatively short stay. The rest of the job did provide opportunities to deliver more clinical services in that many families had difficult dynamics that were being strained by the stressful event of having a sick loved one. For example, I found myself working with several families that were struggling with the heartbreaking decision to put their family member on hospice. These situations required a skilled practitioner and my clinical training was very applicable. This was what ultimately led me to choose a career in Hospice Social Work.

I find that working in hospice is the perfect combination of clinical skills and medical social work knowledge. I have the luxury of building relationships with some patients and families while addressing complex grief issues and seemingly irreconcilable family differences. I am a unique piece of the puzzle, as important to the agency as the nurses, aides, and supervisors. I bring insight regarding patients with mental illnesses and emotional difficulties and get to work with such people that would not otherwise reach out to or have ready access to a counselor. I also have the freedom to choose how often and for how long I see each patient. In addition, I often find myself entering intense crisis-like situations where families are making split-second decisions about hospice and require clear, concise education as to how we can help their loved one. Lastly, the job demands a seasoned veteran as hospice social workers are very autonomous and have to be extremely organized in order to balance patient acuity, rapid response, triaging on the fly, and completion of documentation. These are all skills that I first developed in a clinical mental health setting and that are transferrable to all areas of social work.

While many medical social workers do not hold clinical licenses, I feel better-equipped to handle certain complicated circumstances than my peers that have not had prior clinical experience. The wonderful thing about medical social work, and primarily hospice social work, is that the job can be as clinical as you want it to be. I have developed the ability to perform patient and family counseling while maintaining the boundaries that I learned to set with my therapy clients. I would not be half as good at my job without my mental health background.

In short, the skills accrued in a clinical setting while earning your LCSW will be transferrable to any future social work setting in which you find yourself. In fact, they can only serve to make you better in all your interactions with people in both your personal and professional life. Until next time.