Words Make Worlds: Language and the Culture of Mental Health in the Workplace

Republished with Permission from Insurance Thought Leadership
By Sally Spencer-Thomas and Donna Hardaker

Part II: The Words about Suicide

[Part I of this series focused on why language matters in mental health advocacy and suicide prevention in the workplace. This article explores wording related to suicide that we want to see change and why. Part III will look at wording related to mental health.]

"suicidal" -- "suicide attempter" -- "he chose to die by suicide"

Photo from pexels.com

Language evolves as understanding evolves. We seek to draw attention to word and phrase choice about suicide and mental health as a means of articulating current understanding and intentionally pushing further evolution.

We are often asked: What is the best way to talk about suicide?

"Died by suicide"

Much of the language related to suicide death comes from a stigmatizing history. The term "committed suicide" originated when suicide was thought of as a sin or a crime, instead of as a fatal outcome of a set of thoughts, often a result of a mental health condition. It is still the most common way for people to describe a death by suicide in the general public, the media and even in the mental health sector. We can ask ourselves: does someone die by committing a car accident? By committing cancer?

Terms commonly used to describe whether a person has died or not: "successful" suicide or "unsuccessful" attempt. The use of the word successful is highly insensitive to the tragedy of a death by suicide. Similarly, we hear the term "completed suicide" to refer to a death by suicide. In North American culture we place a positive value on success and on completion, as with goals, projects, education, etc., so there is an inference that there is a good inside of the suicide death when we refer to it as successful or complete.

When talking about suicide in general, the suggested practice is to test language by substituting the word "cancer" for the word "suicide." If it sounds odd, chances are the phrase has come from a stigmatizing origin. For example, we wouldn't say "the cancer was successful," we would say "a person died from cancer." Thus "dies by suicide" is the best option we have to describe suicide death.

This also informs us as we are speaking that suicide is a cause of death, which encourages us to look at it with the same lens we look at cancer, car accidents, and other causes of death. We can seek to apply a public health advocacy approach, rather than a blame the victim approach which is a result of the use of archaic language.

"A person who is thinking of dying suicide"

When we label people, and group them according to an identifier, we are seeking to simplify who they are. It is a short-cut language strategy that also short-cuts understanding and connection. In suicide, it is often seen the label: "a suicidal person", "he is suicidal". Using our swap "suicide" for "cancer" rule: Are you cancerous or are you a person who has cancer? We prefer: "a person who experiences suicidal thoughts". "a person who is thinking of dying by suicide".

The fallacies of choice and manipulation

For most who die by suicide, we believe their choice would have been to live if they could have found a way out of the mindset of dying. Unbearable psychological pain may be accompanied by very strong internal commands to die. This experience is not the usual type of rational choice in the way we commonly think about choice. People often say "a person chose to die by suicide". Inside this thinking, there is a sense of an absolving anyone other than the person who died of any responsibility, which we understand. It is very difficult to grasp that a person has died by suicide, and we often seek solace in using language that infers that the person acted completely freely. We wish to undo this type of phrasing that infers that true "choice" is part of the picture. We prefer that people do not use the word "choice" when talking about a death by suicide.

Also in the language of suicide, we find phrases that infer that a person who has made a suicide attempt is manipulative, and is just "seeking attention." The phrase "suicide gesture" has an inference that intent is not genuine. We prefer: "an action with suicide intent."

"Precipitating Events"

When a person dies by suicide and we wish to talk about what lead up to their death, we often talk about "triggering events." The word "trigger" is problematic because of its strong connection to firearm use. Also, by calling something a triggering event, the phrase denies an opportunity for people to have mastery over the impact of the event. It is preferable to use a more objective term to describe prior events and challenges. We prefer: "precipitating events."

Clarity around "survivor"

The term "suicide survivor" is confusing. Depending on how it is used, this phrase may mean a suicide loss survivor (a loved one left behind when a person dies by suicide). At other times, it means suicide attempt survivor (the person who has made an action with suicide intent, and survived the action). Thus, the preferred terminology for people who are left behind: "a person who is bereaved by suicide," or "a person who is surviving a suicide loss". People who attempt suicide, but do not die can be referred to as: "a person who attempted suicide and survived" to help with clarity. In addition, the field of suicide prevention also seeks the expertise of people who have lived through a suicide crisis and did not have an attempt, and sometimes these folks are included under the umbrella of "people with lived experience of suicide."

In conclusion, "messaging matters" in suicide prevention and suicide grief support. For more best practices, review "The Framework for Successful Messaging by the National Action Alliance for Suicide Prevention: http://suicidepreventionmessaging.actionallianceforsuicideprevention.org/.

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SALLY SPENCER-THOMAS: As a clinical psychologist, mental health advocate, faculty member, and survivor of her brother's suicide, Dr. Sally Spencer-Thomas sees the issues of suicide prevention from many perspectives. Currently, she holds leadership positions for the Carson J Spencer Foundation, the National Action Alliance for Suicide Prevention, and the American Association for Suicidology.

DONNA HARDAKER: Donna is an internationally recognized industry expert in the emerging field of workplace mental health. She is an award-winning curriculum developer, advocate, public speaker, writer, and advisor, who has leveraged her personal experience of mental health challenges and their impact on her employment history into a significant body of work. She is the Director of Wellness Works, a workplace mental health training program for Mental Health America of California that has been evaluated as highly effective in stigma reduction with lasting behavior and culture change. Donna is from Toronto, Canada, but now lives in Sacramento, where she greatly enjoys the California sunshine.

Trigger Warning: Means Restriction, Suicide, and Gun Safety

By Thomas Wallingford and Jess Stohlmann-Rainey

In the United States, more than 60% of people who die from guns die by suicide (Center for Disease Control).

In Colorado, more than three-quarters of all firearm deaths during 2005-2012 were suicides. Of those suicide deaths by firearm, most are among males (84%) and the white, non-Hispanic racial/ethnic group (88%) (Colorado Department of Public Health & Environment).

For youth under the age of 20 years killed by firearms in Colorado, almost 50% were suicides and 41% were homicides (Colorado Department of Public Health & Environment).

Proponents of gun safety have developed a list called the 10 Commandments of Gun Safety, which include guidelines like, "always point the muzzle in a safe direction" and "don't mix alcohol or drugs with shooting." Because of the connection between firearms and suicide, prevention advocates have worked with gun safety proponents to suggest an 11th commandment, "Consider off-site storage if a family member may be suicidal."

There are obvious benefits to adding this commandment, but putting it into actual practice can present some challenges. For gun owners in distress, finding a way to store firearms with someone else requires a difficult conversation about their mental health for which they may not be prepared. For support people, asking a loved one who is struggling to give up their weapons can be intimidating.

Thomas Wallingford lives with schizoaffective disorder, which causes him to experience intermittent suicidal intensity. Thomas and Jess Stohlmann-Rainey have been close friends since college and use each other for peer support as people who live with mental health conditions. In order to demonstrate how this commandment can be put into practice, we would like to share our personal accounts of means restrictions.

Jess:

Jess and Thomas

I remember the first time I asked someone about their suicidal thoughts with pretty vivid intensity. I worked on a sexual assault advocacy hotline, and was on the phone with a client who was really struggling. My palms got so sweaty I was afraid I would drop the phone. Because most of my jobs have required that I talk about and ask people about suicidal intensity pretty regularly, I have gotten a lot more comfortable with asking the question. Asking Thomas to let me hold onto his firearms while he was in crisis was an easy decision the first time, but caused me the same level of anxiety. I called another friend to practice what I was going to say. Fortunately, because Thomas and I talk about our mental health all the time, any weirdness that might have happened in a new mental health discussion was out of the way. I remember saying "I have to ask you this because I love you and because I would never forgive myself if I didn't...would it be okay if I hold onto your guns for a little while?" 

When Thomas agreed, we ended up making jokes about the whole situation because it seems so surreal. It is entirely possible that I am more uncomfortable with guns than anyone else in the world. Thomas gave me this duffel bag full of firearms, and we cracked some jokes about how weirdly I was holding the bag (it was pretty weird). I continued being extraordinarily awkward riding in the elevator up to my apartment, feeling certain that everyone in there knew I was holding a bag of guns and was freaking out. They didn't, and I got them safely into a secure area in my home without scaring anyone but myself.

The entire time I had firearms in my home, I was acutely aware of their presence. As much as I wanted them out of my home, I was nervous that Thomas would ask me to return them before it seemed like it was safe. I believe really strongly that people living with mental health conditions should have the same rights as people who don't, so if Thomas was adamant about me returning his firearms, I would have a really difficult time refusing. I decided that I would ask him to make another safety plan if that happened.

Thomas ended up leaving his firearms with me for several months, until his mental health was significantly improved. When he wanted his firearms returned, he spent a lot of time explaining why he felt well enough to have them again. Returning them was relieving both because I didn't have them in my home anymore, and because Thomas was in such a better place with his mental health. He explained his safety plans and his current mental state, and made me feel confident that his suicidal intensity had dissipated.

After the first experience, the whole process has become much simpler. Thomas has since asked me to hold onto his guns, and I have asked him. The conversation is short and can even happen over a text message - "hey, can you hold onto my guns while I do a treatment program?" or "it sounds like you are thinking about suicide again, can I hold onto your guns?" I am still incredibly awkward about guns in general, but asking about means restriction feels pretty easy now.  

Thomas:

Thomas with one of his guns

Handing guns off to your support person is somewhat distressing. You're constantly second guessing yourself, wondering "Am I really at this point? Shouldn't I be well enough to keep them?" For some gun owners, particularly those concerned with home security, I'm sure it would be an added challenge, weighing the possible dangers from outside with the possible dangers from within. After the initial shock wears off, and you're considering your decision from a more distant vantage point, it's apparent that what you've done is the most rational decision regarding your safety.

Realizing when you've hit the point where you need to reach out to your support system is very tricky. There's no black and white to it, no hard line; it's a huge gradient.

How I know to reach out to my friends is when I'm ruminating on suicide more often than not. Specifically, it's when my ruminations on suicide go from conceptual thoughts to considering it as an option. To ensure I take the preventative step of giving my guns to my support people, I don't wait until I consider it as my only option; once it becomes any option it's time for me to take my guns elsewhere. It's better to be too early than too late.

Asking someone to take your guns is a multi-step process that begins before any suicidal thoughts occur. Talk to a friend, or a few friends, that can offer safety and support and tell them about your personal concerns regarding suicidal thoughts or behaviors. Ask them if they are okay with you relying on them if you begin feeling suicidal.

Actually asking someone to take your guns is difficult. It's the same feeling as having someone come over to take your guns. You ask yourself, "Am I really at this point?" you might stigmatize yourself, asking if you're really that "crazy," and you may even feel childish, like you can't take care of yourself. The fact that an individual struggles with suicidal thoughts from time to time says nothing about how capable they are as a person. Suicidal thoughts are an unfortunate part of a chronic mental health condition for me, but prevention is a necessary step in managing it.

Just like giving them up, there's no hard and fast rule about when to ask for them back. For me, it's when I've had no intrusive thoughts or ruminations about suicide for over a week, maybe two. Having one good day isn't enough to know that I'm safe, but having several in a row lets me know that there is a pattern to my thinking and that the pattern has improved. But just as with knowing when to give up your guns, knowing when you can safely take them back is very personal. The best advice I can give is to ask for them back when you've seen a trend. If you're a gun owner who has them in the house for personal protection, know that sometimes having them out of the house is just as important.

You might worry that your support person won't think you're out of the woods yet, even if you think you are. If you and your support person disagree, just know that they're looking out for you. If you've been isolating, they may not have seen your progress. Simply avoid isolating and allow them to see that your suicidal thinking has run its course for the time being.

For the most part, being honest about how you're feeling and what you've been experiencing is the most important piece of asking for your guns. A pivotal piece comes before talking to anyone else. Asking "Am I okay?" is the most important part of the process.

 Means restriction can feel complex and overwhelming, but maintaining open and honest communication and focusing on safety makes the process easier. Going through it has made our relationship stronger and closer. We know that we have someone to rely on who understand us no matter what.

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Thomas Wallingford is a Denver-area writer and poet. He is a graduate of the University of Northern Colorado and has been a featured speaker and writer on topics ranging from social justice and mental health to fiction and poetry. Thomas is passionate about understanding the world and the people in it, dedicating his work and free time to science and psychology. Thomas integrates his lived experience with mental health challenges to his work as an author and advocate. His creative work illuminates parts of life from which most people look away, challenging readers to explore the least understood parts of the world and their human experience.

Jess Stohlmann-Rainey, MA, is the Senior Program Director at the Carson J Spencer Foundation. She has spent her career in violence prevention, currently leading innovative programming that elevates the conversation to make suicide prevention a health and safety priority. Jess has presented and trained nationally and internationally about suicide and violence prevention, diversity, and leadership, and is a contributing author to Postvention in Action, a currently unreleased suicide prevention anthology. As a suicide attempt survivor, survivor of loss, and person living with a mental health condition, Jess integrates her lived experience into her work in advocacy, research, training, and program development.

Rage Rage Against the Dying of the Light

By Heidi Kathryn

I was 10 when the first fleeting thoughts of suicide flashed like white lights through my mind. I knew at a young age that my brain worked differently than others. Freshman year of high school was the beginning of a series of traumatic events that impacted my ability to regulate my emotions and sustain healthy relationships. I found myself in an extremely unhealthy relationship with a much older man that resulted in a terminated pregnancy and my first suicide attempt. I was hospitalized for a week, then was forced to move out of the city and into my father's house in a rural Colorado town.

Life in the small town wasn't much better. I went to class, made some friends, played sports, and endured three years of physical abuse from my father. The dog and I got the worst of it. Home was never safe for me. I lived in a constant state of fear and apprehension, wondering if he'd be in a bad mood when he came home. It wasn't until years later that I could put a term to that feeling. That feeling was anxiety, and I would learn to live with it, always.

Things never really seemed to get better. I went through the motions, survived high school and got the hell out of that tiny town. College would only exacerbate the anxiety and depression. I turned to self-harm, starvation, and drug use to feel in control or nothing at all. Suicide was always on my mind. I would go weeks on benders, without sleeping or eating. I would frequently show up to class agitated, sometimes even in tears. My professors would send me home and tell me to sleep. I got to the point where I didn't even care to cover my scars, new or old. I woke up wanting to die, and if I was able to sleep, I would dream of dying. My social scene was a series of abusive, drug-addled, violent relationships; I gravitated towards men who would hurt me. I circled the drain until graduation and then moved on again.

Photo by Aleksandar Radovanovic

As I've learned the hard way, multiple times now, changing my address never actually solved any problems. My anger and self-hatred festered the longer it went untreated. I became fearful of myself. I became fearful of others. Generalized anxiety turned into anorexia which turned into full-blown obsessive-compulsive disorder. I was so scared of bugs that I couldn't sleep through the night. My perseveration around germs was out of control such that touching a doorknob with my bare hands would send me into panic. Crying at my desk became a common occurrence. I struggled to find a therapist who could really help. Or even one who could understand. And in October 2014, I attempted suicide again. This time, it almost worked.

My colleagues and I agreed that treatment was the best option for me. The people I work with and our connections outside our organization worked tirelessly to get me into a program. These are friends and colleagues who know this field, and it still took a week. When we finally found a place for me, I had convinced myself that I didn't need anything intensive. I had planned on doing a program that was three days a week. After my intake, the provider suggested that I would need something more intensive, with more structure, to get me through this crisis. I remember my friend telling me "if you broke your arm and you needed surgery, you'd have the surgery. This is no different."

I entered the partial hospitalization program, which was followed by their intensive 12 week Intensive Outpatient Program that is rooted in Dialectical Behavior Therapy. The first day of partial hospitalization was the hardest. I remember sitting across from my psychiatrist while he did my intake. We talked about symptoms, sadness, numbness, and anger. We talked about physical and emotional abuse. I admired his socks, and he read me off the criteria for my current diagnosis.

"Tell me if any of these things sound like you," he said. "Extreme reactions--including panic, depression, rage, or frantic actions--to abandonment, whether real or perceived...A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)...Distorted and unstable self-image or sense of self, which can result in sudden changed in feelings, opinions, values, or plans and goals for the future (such as school or career choice)..."

My stomach turned as he read off the diagnostic criteria.

Photo by Max Greenwood

"Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating...Recurring suicidal behaviors...Highly changeable moods, feelings of emptiness or boredom...Inappropriate, intense anger or problems controlling anger?"

The rage he kept referring to seared through me. I knew exactly what he was referencing. I planted my foot on the ground and slammed myself into the wall behind me so hard that my head bounced off the concrete.

"I'm not fucking borderline! That's not what's wrong with me! You're wrong!" I cried to him. Everything in me had wished that I would have just died.

Borderline Personality Disorder is a highly lethal, highly stigmatized mental health condition. The most recent data I've read say that 10% of people diagnosed with BPD die by suicide. The Diagnostic and Statistical Manual (DSM) lists BPD under the umbrella of personality disorders. It is the result of years of trauma. And it makes clinicians' skin crawl. From what I've noticed, the general public doesn't really seem to know much about it. But the things I've heard from mental health professionals about people, specifically women, with BPD are scathing and hateful. We are a clinician's worst nightmare. We are not the "right" kind of mentally ill.

This frustrating reality is what has prompted me to share my story with the world. I am a suicide preventionist who lives with chronic suicidal intensity and a diagnosis of Borderline Personality Disorder. I am deserving of hope and help. I am difficult, but that doesn't warrant being brushed off. Thank goodness my workplace and career choices have allowed my the opportunity to really learn how to advocate for my own mental health treatment. I am angry for anyone else with a history like mine, who have been brushed off as manipulative or difficult, who have been told their chances of success and recovery are nil, that they'd never be able to hold down a job, or that they'll never make good parents and should take their birth control and medication and shut the hell up. I hurt for folks who are so sick that leaving the house is more miserable than staying home inside their head, trapped in their thoughts, and folks who show up to an emergency room or clinic scared that they'll hurt themselves, and get dismissed because of a condition the world gave to them.

Heidi's dogs, Ivan & Violet

It is an injustice that the very people we are supposed to turn to for help are consistently blaming us for our condition and either flat out refusing to help us with our treatment, or giving us little attention when we show up for our appointments. It is an injustice that mental health professionals can victim-blame their clients. It is an injustice that anyone can list "trauma-informed" on their resume or website while still insisting that people with BPD are untreatable.

I have spent the last two years of my life reading, searching, and educating myself on my mental health condition. I see a therapist every week, take my meds every day, and visit the psychiatrist every two months. Instead of self-harm, I use tattoos to cope. When I feel an identity crisis coming on, I change the color of my hair. I use a combination of traditional and non-traditional methods to help me stay alive, like comedy and the company of my dogs. I have stayed relatively quiet about my experience with this diagnosis.

Not anymore. I will not remain silent while others are suffering. I will be loud enough so that others with similar experiences and diagnoses don't have to feel ashamed. The thing about activism is that it's so invigorating that is has given me a reason to keep living when my brain is telling me not to.

This is my suicide prevention.

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Heidi Kathryn is the Community Outreach Coordinator for the Carson J Spencer Foundation. Her passion for violence prevention has moved her into the field of upstream, innovative suicide prevention work. She provides outreach and support to the community as well as delivering mental health and violence prevention programming in workplaces, schools, and local public agencies. She is currently pursuing her MPH from Capella Unversity and looks forward to continuing her career in violence prevention and community engagement and collaboration.