As I write this, thoughts of suicide are very far away. In fact, my mood is a little bit elevated. I am having trouble sleeping, despite the quetiapine, and I am waking frequently at nothing – only to be pulled back into sleep by the antipsychotic, over and over, countless times. I have no doubt that without the quetiapine, I would be wide-eyed awake all night long. Noises are too noisy again, tastes are intensified. I don’t feel very elated, but I am full of brilliant, life-changing ideas (note to self: apply the 48 hour rule!), I don’t feel remotely grumpy despite my reduced sleep, and can feel that I am overly talkative. Overall, I’d say I’m fairly joyful about being alive and probably even over-optimistic about the future.
Yet only two weeks ago I wanted to die. I had the old familiar feeling of being in so much pain that I did not see how I could stand it for even one more hour, let alone one more day. I looked at the situation with what felt like clinical detachment, and concluded – as so many times before – that suicide was the only logical option. I thought obsessively about the Government’s consideration of provision for assisted suicide for those with terminal illnesses, and felt bitter that this option was not open to me; that despite 25 years of going in and out of acute depression, I would be forced to end my life in what would most likely be a violent, painful way which would be distressing to my family and any staff involved.
And this is the reason that my psychologist has asked me to draw up a suicide prevention plan. This is a novelty to me; I have spent so much of my life putting together suicide plans, and here I am putting together a plan to beat all my planning. Suicide plans have to be narrow and specific, because there’s no point in having the opportunity and not knowing exactly what you’re going to do. They also have to be sneaky and secretive, because for some ridiculous reason if family or friends got hold of your plan, they would try and prevent you from implementing it. A written suicide prevention plan is everything that its darker sibling is not. Instead of a secret in my head, it will be a written document to be shared with my partner, key friends, my psychologist and my psychiatrist. Rather than being linear steps towards a single course of action, it will contain a broad selection of possible actions which I know from past experience can be helpful in taking the edge off in times of desperation. I set myself a challenge of identifying 25 things that might help. The first 16 or so came easily, but beyond that I’ve had to think more laterally. I did not allow myself to include any self-harming behaviours.
The crucial point about this list is that it’s personal to me. Mind’s recent inquiry into crisis care suggests that many mental health professionals are aware that distress tolerance or distraction techniques can be used to stave off suicidal behaviours, but fail to recognise that “common sense” distraction techniques such as making a cup of tea, having a bath or going for a walk only work in certain contexts. Going for a walk is not something which will improve your situation if you live in a scary area. My area is safe enough, but double-deckers go right past my house; if I’m preoccupied with walking out in front of one, a walk’s not really all that good an idea. There’s no point telling me to make a hot drink, because I don’t drink them (OK, hot chocolate a few times a year, but I never have milk in the house, so that’s a no go; tea and coffee are just vile). People who think about drowning themselves don’t need telling that they should go and have bath. My friend Female PTSD was recently visited by her Crisis Team, who seemed to have a preoccupation with their idea of what constituted appropriate distraction techniques (starting with making a cup of tea – how much tea do professionals think service users can drink in the course of a suicidal day?) and were unwilling to listen to my friend’s own, carefully thought out, 10 step suicide prevention plan. My psychologist wanted me to put the number for the Samaritans in my phone, but I find speaking on the phone so difficult at the best of times that there is no way I could ring someone up in a crisis. I far prefer to email, text or tweet.
In working on my plan I have gone for a breadth of possible interventions. I haven’t put them in particularly order; although I would generally consider that there’s a hierarchy of “self help” or “natural” ideas, followed by trying pharmacological solutions, followed by calling in the professionals. My aim was just to come up with as many suggestions as possible in the hope that I can at least do one of them, and to give myself a fair shot of managing things at home before I decide I must go to A&E or call the Emergency Duty Team. Some of them will be inappropriate at certain times. When I was thinking a lot about cutting my legs a few months ago, I needed to stay away from the vegetable knives, so cooking probably wouldn’t have been a great move. So here it is – my list of 25 things to choose to do before I choose to die.
1) Have a bath. Yes, it does sound simplistic, especially if suggested by someone who doesn’t really know you. But sometimes hiding myself away from everyone else – preferably in very hot water and a few drops of some kind of soothing essential (lavender, for example) – works wonders. Can be combined with:
2) An escapist book. If I can concentrate, a good book can be an effective technique for lifting me out of myself. In order for it to work, I need to read something that is no way like my real life and with strong characters with whom I can fully identify. I generally pick science fiction or fantasy, but make sure it’s nothing too dark.
3) Sing something. Anything. Pop, jazz, classical. Sing along with the radio or my iPod. Choose the harmony to engage more of my higher brain than the easier melody. Get out some sheet music I’ve never touched and do some sight reading.
4) Relaxation exercises. Lie on the floor and work my way up my body from my toes to the crown of my head. Use a CD or an app if it’s hard to focus.
5) Breathing exercises. Try lying with my hands on my belly, feeling the breath come in and helping it out with my abdominal muscles, making a long, soft “haaaaaaaaaa” noise. Try imagining that the top of my head can open like the blowhole of whale (a little bit gross, I know, but I love it) and I can breathe in and out through there. Use my little finger and thumb to block first one nostril, then the other, for alternate nostril breathing.
6) Self-massage. Feet and legs are easiest, but neck and shoulders can be really helpful.
7) Pay for a massage. I don’t really have the cash to do this, but if I can find it from somewhere, I know that someone else touching me in a therapeutic way is really helpful.
8) Pure distraction via casual gaming. Must be absorbing, but not too challenging, and not get the adrenalin flowing in any way.
9) Tapestry. I have a kit I’ve been working on in a desultory fashion for a couple of years. Sometimes it’s a good distraction, although the details of the pattern are more absorbing than the straight runs and patches of solid colour.
10) Cooking – slowly and methodically. A mindful approach: if I am stirring the sauce, just stir the sauce. If I am chopping veggies, just chop veggies.
11) Go for a walk. Either a fast, hard pace if feeling very agitated (the movement helps me burn off the stress and anxiety) or a slow, mindful one if the problem is more one depressed mood. If even slightly depressed, I usually need to avoid places which make me feel more alone, for example avoiding places I go with my kids if they are not with me. It helps to pick a less familiar route, and to try and set a task of seeing at least 10 beautiful things along the way. Beauty can be an interaction between people, a cat, a flower, a leaf – whatever my eye finds that might challenge my belief that the world is a terrible place.
12) Yoga. Preferably involving positions that I find a bit tricky, that require me to focus entirely on what I am doing. Use a DVD if I feel at a loss as to where to start.
13) Do some more strenuous exercise. Run, climb on the exercise bike, put on a kickboxing DVD, an aerobics DVD, a dancercise DVD. Don’t try to do anything that feels like a chore, but pick an activity that appeals to me at that moment, even if the level of appeal is just a glimmer. Set a timer and tell myself that it only has to be for ten minutes if I don’t want to do more.
14) Dancing. You know, that formless kind of “dance like no-one’s watching” thing. Luckily, in my upstairs flat which is not overlooked by anything, I can be fairly confident that no-one is. Sometimes I like to do this with the lights off anyway.
15) Sort something. Sort through our giant jar of beads, put books in alphabetical order or Mr Persuasion’s travel magazines in date order.
16) Do some colouring in. My daughter has some great colouring in books of geometric patterns which I know she’d be happy to share.
17) Contact someone I know. If I’m at home with my partner, it’s preferable that I talk to him. It’s helpful for him to know how I’m feeling, in case these techniques aren’t enough, and he needs to get me some help. If he’s at work and in a meeting, I have a list of people I can text, email or tweet.
18) Contact someone I don’t know: email SANE or the Samaritans (less likely I’ll be able to do this, but it’s a back-up option in case I can’t get hold of anyone I know).
19) Consider taking extra meds. I have a small amount of diazepam which was prescribed to get me through crises. I have resisted taking it so far, but it’s an interim step to try if self-help methods aren’t doing it, and before I move to call Duty.
20) Sleep. I have always found this a good thing to try in a crisis. If it’s possible to get off to sleep, it can sometimes be the brain equivalent effect of the tried and trusted, “try turning it off, and then turning it again” IT solution. I’m willing to take extra quetiapine to help me sleep if needed.
21) Watch TV/a film. This doesn’t always work, because I can’t always focus. But sometimes watching something familiar (a film I’ve watched before, or a series I’ve been enjoying regularly before getting to crisis point) buys me a little window of feeling safe, especially if I can watch with my partner and/or children.
22) Cleaning, the kind that doesn’t require thought but allows for repetitive action. Cleaning the bathroom – too fiddly, several different products, forget it. I’m not a big fan of housework in general, so it has to be just the right kind. Cleaning the kitchen floor by hand, down on my knees, is therapeutic. When I was a kid, we had a silver tea-set that had been left to my parents by some relative. Every so often my mum would allow me to polish the silverware, which I found very satisfying.
23) Listen to music on headphones. I find lots of relaxation music a bit twee, but I have managed to find some to my tastes which I use for yoga or relaxation.
24) Mindful acceptance of what I’m feeling. Sometimes it keeps me going for a few minutes if I name what I am feeling and accept that’s there. I remind myself that a feeling is a feeling, and it can’t hurt me and kind of let it wash over me. It seems to take the edge off.
25) Hold, use or wear something belongs to me or was given to me by someone who cares about me. This emphatically does not involve trying to feel that I should not kill myself because people care about me. I find people often offer the idea that “someone loves you” as a reason to hold off from suicide. I know they mean well, but all I feel when I hear/read that is yet more guilt. No, it’s not enough to stop me that I have a partner, children, friends, parents who would be devastated to lose me. Yes, I know that’s terrible. So now I feel like a monster, thanks! This is about trying to get feel even a tiny spark of comfort from the fact that someone cared about me enough to give me this thing. So maybe I light the scented candle my friend Rach sent me in the post. Or I wear the necklace my former boss gave me after I had an awful day at work. I seem to prefer objects that did not come from family members, probably from a depressed belief that they only love me because they are obligated, whereas friends and colleagues must genuinely like me.
So that’s it. 25 ideas is as far as my ingenuity will stretch. I’d genuinely like to hear other people’s techniques for getting through the worst on a minute by minute basis. This is a toolkit for survival, and I don’t believe you can have too many tools.