On Forgiveness, part two

A lot has happened since I last posted. Joyous holidays, the battle with a depressive episode—- still lingering and touched mightily by recent family affairs, progress with workouts under direction of my personal trainer, and the severe illness and death January 31st of my beloved younger sister, Ellie. She was the first in our family of six brothers and sisters to pass. I miss her greatly.

I have been studying forgiveness and the power of forgiveness in one’s life for some time now. Indeed, I have an essay On Forgiveness on this website already devoted to the topic.   In that essay, I wrote that “forgiveness does not mean forgetting. And yet it is more than tolerating. I was startled to read that forgiveness is beyond letting go of negatives, such as anger; it is also the inclusion of positive gift-like qualities such as compassion, generosity, and even love.”

This posting is part two of my growth in understanding of this most powerful act of human reconciliation.

*   *    *    *    *    *    *

I’ve now made a little dent into the literature of forgiveness, and have learned two major facts: One, there is research to show that physical and mental health benefits come from forgiving and Two, that forgiving, learning forgiveness, is hard work. I’ll write about those benefits in this posting. The hard work of forgiveness will be addressed in future posts.

“NOT Forgiving — nursing a grudge—is so caustic”, reports Fred Luskin, PhD, a health psychologist at Stanford University and author of Forgive for Good: A Proven Prescription for Health and Happiness. “It raises your blood pressure, depletes immune function, makes you more depressed and causes enormous physical stress to the whole body.”  In this book, citing research and teaching by vivid example, Mr. Luskin shows that people who are forgiving tend to have not only less stress but also better relationships, fewer general health problems and lower incidences of the most serious illnesses like depression, heart disease, stroke and cancer.

So how does one forgive? Is it a process one can learn, something each of us might do, or a work for the saints among us only?

Forgiveness can be hard work. Robert Enright, PhD, the author of Eight Keys to Forgiveness, says: “….in its essence forgiveness is not something we do to just help ourselves. It is not something about you or done for you. It is something you extend toward another person, because you recognize, over time, that it is the best response to the situation.”  And then, Professor Enright continues:  “Working on forgiveness can help us increase our self-esteem and give us a sense of inner strength and safety. It can reverse the lies that we often tell ourselves when someone has hurt us deeply—lies like, I am defeated or I’m not worthy. Forgiveness can heal us and allow us to move on in life with meaning and purpose. Forgiveness matters and we will be its primary beneficiary.”

I’ll end this post with a brief outline of forgiveness’ process.

First, accept that something happened in opposition to your wishes and you can’t change it. What can you do to suffer less?  Then, look at your involvement with this person—simplify it.

Second, try to move past the hurt and go on. Perhaps the steps suggested below will help you progress.

  • Acknowledge that you have been hurt. Talk to a few close friends to explore your feelings and obtain a sense of perspective.
  • Make a commitment to forgiveness.
  • Start with small things. Start by trying to forgive modest slights by people who have done you harm in life.
  • Recognize your “grievance stories” and gradually deemphasize and replace them by thinking of your own positive goals.
  • Focus on facts rather than emotions. Attempt to understand what led the person to the hurtful behavior. Bless you.
  • Try not to take things personally. Many offenses were not deliberately targeted to hurt you personally, but were byproducts of other people’s own selfish goals.
  • Forgive those you love. The most important people to forgive are those close to us.

( Find these steps in Terrie Heinrich Rizzo’s posting The Healing Power of Forgiveness, 2006 )

Suicide: It’s not inevitable

Could we say ….
that even one death resulting from a suicide is acceptable in mental illness? Clearly, we wouldn’t want that one person to be OUR relative, neighbor, friend, right?  That one person can’t be anyone’s relative, neighbor or friend. So zero deaths by suicide should be our goal.

Are you a clinician dissatisfied with the suicide prevention approach used at your center? Or perhaps are you a survivor concerned that suicidal feeling will recur and you question who or what is going to truly help you??? Or maybe you’re someone whose relative attempted suicide last year and was found in time, and you’re hunting for a more proactive and effective suicide prevention program but unsure where to turn?

I have an approach that I’d like you to consider for your clients, or for yourself or for your loved ones: I recommend the Zero Suicide (www.zerosuicide.com) program.  Zero Suicide, an approach and program developed for the health care system, views suicide deaths as a preventable outcome and insists that the goal of zero suicides among persons receiving care is a goal that system can and should accept!

Zero Suicide, a project of the Suicide Prevention Resource Center (SPRC), grew from work done by the National Action Alliance on Suicide Prevention (NAASP). It is a specific set of tools and strategies. It is a concept, a practice, and a goal.

NAASP views suicide as preventable and the goal of zero suicides as a goal we should all aspire to accomplish. The word ALL is significant. This initiative requires the engagement of suicide attempt survivors, family members, policymakers, and researchers, and the clinic or hospital. The effort seen by the NAASP and Zero Suicide is a community endeavor—an effort including but beyond health care providers and clinicians.  Beyond heroic efforts of individual practitioners.

Where did this Zero Suicide program come from? The approach builds on work done in several health care organizations, including the Henry Ford Health System (HFHS) in Michigan.  The Henry Ford Health System had already applied a rigorous quality improvement process to problems such as inpatient falls and medication errors. They also realized that mental and behavioral health care could be similarly improved … an individual involved with the quality improvement group challenged the team:  “Why don’t we adopt zero suicide as our improvement goal?” As a result HFHS developed the Perfect Depression Care model, a comprehensive approach that included suicide prevention as an explicit goal. Both best and promising practices in quality improvement and evidence-based care are applied in their model and they have had wonderful, life-affirming results—-an 80% reduction in the suicide rate among health plan members.

NAASP’s Clinical Care and Intervention Task Force then identified essential elements of suicide prevention for health care systems having a defined population of individuals with mental illness. The Zero Suicide approach is created around these essential elements.

Here’s what I like about their approach:

Zero Suicide asks for a change in culture with firm leadership buy-in. The workforce – this includes both clinical and non-clinical staff – is to be trained using the Zero Suicide Toolkit.  The cultural milieu is to foster a caring, non-judgmental workforce.  Considerate and compassionate caring has sometimes been absent when the person being cared for has attempted or considered suicide (c.f. The Way Forward report).  Suicide risk among people receiving care is identified and assessed systematically. Every person has a suicide care management plan, or pathway to care, that is timely and adequate to meet their needs.  Finally, I’m very encouraged that this planning includes collaborative safety planning and restriction of lethal means.

It is also vital that treatment address the person’s suicidality. The patient’s own suicide planning needs to be discussed in detail and taken apart and turned into a scenario where the person is once again safe. Contact and support for the suicidal person, especially when in transition between emergency room and home or inpatient care and home, must be continuous. Many suicides occur after discharge from the hospital or emergency room (c.f. The Way Forward and Continuity of Care for Suicide Prevention reports).  Deaths that occur after discharge aren’t inevitable; they can be tackled by better transition and discharge planning with greater attention to detail.

Fellow advocates, we can do better.  Zero Suicide’s program can help.

Communities in Action to Prevent Suicide, part III

A core value, again taken from The Way Forward, that Ursula Whiteside highlighted during her keynote:

Preserve dignity and counter negative stereotypes, shame, and discrimination

“The negative perceptions of behavioral health issues and subsequent discrimination pose major barriers to help-seeking.” …. “Stigma, negative stereotypes, and discrimination (covert or subtle) are particularly damaging when we already suffer from depression, hopelessness, damaged self-image, trauma, self-doubt, and shame – thoughts and feelings common during a suicidal crisis. In contrast, when we are treated with dignity and compassion, it reaffirms our sense of worth and value.”

My second psychiatrist (and each of those who followed) treated me with the dignity and compassion I needed to progress. It made a HUGE difference. One appointment I’ll never forget is the day I thanked him for NOT telling me ‘my difficulties’ were that I was ‘too sensitive’ (as I had been told by my first psychiatrist) . My doctor got very still, sat up straight, looked me in the eye, and said, “Gail, it’s not that you are too sensitive. You have major depression. It is an illness for which we will pursue and persist in finding the right treatment combination for you.”

He treated me with full dignity by clearing up any chance that I would misunderstand ‘sensitivity’ for major depression. Or think that ‘my difficulties’ were only that, ‘difficulties,’ and that they were something I caused. I felt affirmed and clear about the real lesson I was learning.

I particularly like this core value because it is so active…….counter stigma.

You can see from the photographs that Dr. Whiteside – Ursula – is younger than I. Her experience and youth were very helpful as I gained insight on how to reach to a younger public than I am used to addressing. She does social media very well; I need to go there too. The mid-part of her keynote presented her vision developing www.NowMattersNow.org into an online public resource focusing on strategies for managing suicidal thoughts and intense emotions. Ursula introduced us to her colleagues: Team Now Matters Now. I smiled with pleasure as one of the team members mentioned was Marsha Linehan, PhD, clinical psychologist. Nothing more was said about team member Marsha … But it’s worth noting that Dr. Linehan is the creator of Dialectical Behavior Therapy, the psychotherapy that has helped so many people with borderline personality disorder. She is well known and admired for her work.

DrUrsulaWhiteside    DrMarshaLinehan

Ursula summarized what she and Team Now Matters Now had learned from suicidal people working through a crisis. Here are some of these points (underline emphasis is Ms. Whiteside’s):
Be fully present with me
• Help me hold my pain ( so I feel less alone in my pain)
• I feel helpless, broken and scared
• Discuss with me my diagnosis, as it is in the charts and go thru the DSM criteria with me
When including family and friends, tell me and let me decide who and how
Help me empower myself
• Gently examine my paranoid thoughts with me
• First I need empathy, a witness (rather than fixing)
Know that I am telling you about my suicide ideation/plans because I want to live, I want help and I want to work together

Communities in Action to Prevent Suicide, part II

Spring in Wisconsin has brought us needed and gently persistent rainfall. Nourishing rain on fertile ground; good food for our thoughts together.

Ursula’s keynote message, “…Zero Suicide and the Engagement of Those with Lived Experience” was a blend of her experiences working with others, and of new directions advocated in “The Way Forward: Pathways to Hope, Recovery, and Wellness with Insights from the Lived Experience, 2014”.

The Way Forward is the most readable, engaging, no-nonsense document that I have ever read. In fact, it is so good and there is so much to learn from it, that I read deeply through the report twice! It is a unique and creative look at suicide prevention. Prepared by the Suicide Attempt Survivors Task Force of the National Action Alliance for Suicide Prevention, the report’s recommendations are based on and prepared by people who have previously attempted to take their own life, and are now helping others in a crisis situation. Over the next days, I will highlight core values and recommendations from the report as presented in Ursula’s keynote. The first core value is:

Foster hope and help people find meaning and purpose in life

Pervasive hopelessness is a major risk factor for suicidal thinking and behavior. Studies have found that hope and optimism can help guard against suicide. From The Way Forward: “Hope is also linked to self-esteem and self-efficacy, as well as improved problem-solving. The pursuit of meaning can help a person cope with pain and suffering. Similarly, research on reasons for living has demonstrated that meaning and purpose are keys to recovery in many different groups of people who have lived through a suicidal crisis.”

I know this well. In my own suicidal crisis, I was saved by my husband who knew, somehow, that he had to teach me how to hope. (Please see Oh So Real: Pregnancy and Suicidal Depression) I had no hope for me or our unborn child, but I did have hope in our beautiful daughter who was about to turn 5 and start kindergarten in the fall…….when the baby was due. So Jim taught me to focus on specific events or achievements or activities of our daughter. One hope at a time, sometimes very small, got me through those difficult days and hope for her life certainly gave me a reason for living that had meaning and purpose. While the psychic pain of feeling suicidal is or can be overwhelming, meaning and purpose dull the pain…….take pain from the driver’s seat to the back seat.

It is possible to fuel a very small hope.

The Coming Days Emphasis ………… Suicide Prevention

Good day!   I officially launched my website and blog last Friday and Saturday at the NAMI (National Alliance on Mental Illness) Wisconsin Conference. So many friends and colleagues expressed interest and well wishes to me that I am more eager to write than ever.

I took yesterday off to spend an afternoon hiking the prairie and woodsy grounds of one of my favorite places, the International Crane Foundation (ICF) near Baraboo, WI. It was so serene and peaceful that I was able to see long and deep. Today I find my mind is free and my body is relaxed to think and write.

I will focus on prevention of suicide in my coming posts this spring. Particularly on advances in suicide prevention. Why? I believe suicide prevention should be a top priority for mental health organizations and concerned individuals, indefinitely. The US suicide rate is unchanged in 2 decades. Mortality from various medical causes has decreased (see charts below).
In hope of gathering current material on advances in suicide prevention, I am traveling to Stevens Point on Wednesday to attend another conference. The conference theme is “Communities in Action to Prevent Suicide” put on by Prevent Suicide, Wisconsin and sponsored by Mental Health America (MHA). There are two nationally known keynote speakers from the prevent suicide movement featured. I am eager to hear what they have to say and the advice they have to give.

I will couple the information from the Stevens Point conference with the conclusions and recommendations offered in the report The Way Forward: Pathways to hope, recovery, and wellness with insights from lived experience, National Action Alliance for Suicide Prevention: Suicide Attempt Survivors Task Force. (2014).  The report is available on my Resources On Suicide page. My hope is that you will feel better informed to look at suicide prevention practices in your area and seek input, if needed, and to update local policies and procedures to save more lives.


These graphs from a keynote presentation by Dr. Thomas Insel, Director of National Institute of Mental Health at the NAMI annual convention


On Forgiveness

One aspect of my illness that I’ve struggled with for many years is forgiveness – forgiving the people, events, and even the institutions where I have felt anger, humiliation and pain.

Why do I struggle and feel so strongly about this? A level playing field must be found among friends, family and providers to nurture communication, comfort and a new beginning. Imagine setting aside blame while acknowledging responsibility. Think of deeds being forgiven and the tangled web of the past losing its ability to shape our future.

Just what deeds am I thinking of forgiving? Sadly, they are all real, and the ability to forgive them will not come easily. People with mental illness many have experienced being abandoned when ill, or we may remember restraints and seclusion. We may have experienced involuntary commitment, deep humiliation, or poor care resulting in severe symptoms that led to years of mistrust toward caregivers. For many family members, deeds that need forgiving may include their relative’s antagonistic behavior, violent acts or threats of violence, sexual infidelities and indiscretions, verbal abuse, or unreasonable demands or careless spending sprees which left the family in debt.

I have a thoughtful book of essays that is helping me sort through many questions about forgiveness. What is forgiveness between us? Why forgive? And where to begin? Exploring Forgiveness, edited by Robert Enright and Joanna North, contains a forward by Archbishop Desmond Tutu of South Africa that states:

“Forgiveness is taking seriously the awfulness of what has happened when you are treated unfairly. It is opening the door for the other person to begin again. Without forgiveness, resentment builds in us, a resentment which turns into hostility and anger. Hatred eats away at our well being.”

What I am learning is that forgiveness is not pretending that things are other than they are. It is not cheap. Robert Enright and others write that forgiveness does not mean forgetting. And yet it is more than tolerating. I was startled to read that forgiveness is beyond letting go of negatives, such as anger; it is also the inclusion of positive gift-like qualities such as compassion, generosity, and even love. Joanna North insists that forgiveness is hard work, and that:

“Forgiveness is not something that we do for ourselves alone, but something that we give or offer to another. The forgiving response is outward-looking and other-directed; it is supposed to make a difference to the wrongdoer as well as to ourselves, and it makes a difference in how we interact with the wrongdoer and with others.”

Learning how to forgive includes understanding both the perspective of the injured party and that of the wrongdoer. When we begin to separate the wrongdoer from the wrong which has been committed; we also begin to see the person who has committed a particular wrong. Healing can then occur to the person injured and to the relations between the two parties.

It is my hope that in the year to come we can learn, as people with mental illnesses and as family members, to speak not only of understanding and empathizing with the other, but also to explore issues of forgiveness. “Without forgiveness there is no future,” Bishop Tutu declared.

Let us create a good future.

Resources on Suicide – and the way forward

I’ve written a resource page on Suicide – Look on the menu bar, click Suicide and then Resources on Suicide.  There are links there for anyone who may be at risk for suicide or is a survivor of a suicide attempt.  I hope they can be of help for you.

Especially I want to draw attention to the link for the report The Way Forward: Pathways to hope, recovery and wellness with insights from lived experience (2014 pdf), by the National Action Alliance for Suicide Prevention’s Suicide Attempt Survivors Task force.   The report is unique in its breath and scope, and unique in that its co-leads were one, a survivor of suicide attempts and mental health advocate, and the other, a psychologist with years of experience working with people in suicidal crisis.

“For far too many years suicide prevention has not engaged the perspectives of those who have lived through suicidal experiences. Because of social stigma and fear, as well as personal shame, a culture of silence prevailed. The Way Forward represents a seminal moment in this field’s history; it is an opportunity to benefit from the lived experience of suicide attempt survivors. Many of its recommendations are derived from evidence-based practices, and several are aspirational. All are grounded in the evidence of recovery and resiliency that is clear in the lives of our Task Force members.”
– from the report.