What The Heart Can't Erase

The mind replays what the heart can't erase.

- HealthyPlace.com

Thinking today of all of the suicide loss survivors who have lost their loved ones to firearms. For many, the sounds of explosions or fireworks bring back unwanted memories, some of which can cause a PTSD activation that can make holidays like the 4th of July very traumatic.

For anyone who suffers from PTSD related to gun violence, here are some tips for coping this holiday weekend, provided by psychiatrist John Lipkin, M.D., from peacehealth.com.

Ask your neighbors to let you know if they plan to set off fireworks. Anticipating the noise can help you avoid being caught off guard. (If you’re uncomfortable talking with your neighbors about it, have a trusted friend or loved one check with them instead.) You might let others know you struggle with anxiety or PTSD and that fireworks can make it difficult for you. You can encourage them to celebrate the holiday as they wish, but just tell them it would help you to know when they expect to set off their fireworks. They might even decide to forego the fireworks out of kindness.

Prepare a self-care tool kit. Consider positive things you can use for healthy distraction and comfort. Look through photographs that give you joy. Listen to favorite soothing music. Enjoy the fragrance of fresh pine, lavender, cinnamon or peppermint. Spend time playing with or grooming your dog or other pet.

Cover your ears. Wear inexpensive foam ear protection. When fireworks start with greater intensity or frequency, try other acoustic earmuffs or noise-canceling earphones. Listen to calming music, an engaging audiobook or nature sounds to cope with the noise. Run a fan or other source of white noise to help mask and muffle the outside sounds. Retraining can help you remove negative associations to loud sounds and help you begin to experience them as more neutral.

Darken your room. If flashes of light bother you when you’re trying to sleep, shut the blinds, use a room-darkening curtain and/or wear an eye mask or bandana over your eyes.

Allow yourself to accept the reactions that you have. Don’t be self-critical, embarrassed or ashamed. Millions of people have startle and upset reactions. Remind yourself you are ok; these noises are temporary, and you are safe.

Plan a getaway. While it may not always be possible or necessary, consider going outside of the city or neighborhood. Enjoying nature miles away from civilization can be restorative. Watching a firework display, for example, on a distant beach with friends or family, might turn out to be an enjoyable experience. 

Practice self-regulation and grounding techniques to help make your body and mind feel safe and more secure. For example, position yourself to keep your back against something hard like a wall or a chair, sit so you feel the solid support of the floor beneath your feet if you are starting to feel fearful and unsafe. Think about what makes you feel grounded and supported in other ways. Wear long sleeves and trousers. A favorite hat may also help you feel more protected.

Practice S-L-O-W deep breathing. Emphasize breathing from the belly (diaphragm).  Emphasize the duration of exhalation, breathing out nearly twice as long as breathing in. Breathe in to a slow count of three to four and exhale to a slow count of six to eight. Notice how the air entering your nose and mouth is cool and how it’s warm going out. Imagine blowing out candles on a cake as you do this.

Notice your surroundings, look around and even if you feel unsafe, remind yourself that you are safe and not in harm’s way in your current surroundings. Describe to yourself what you see around you that can keep you grounded in your present reality.

Practice a 5-4-3-2-1 sensory exercise to feel centered, grounded and calm. Identify

• five things you can see
• four things you can hear
• three things you can feel
• two things you can smell
• one good thing you are grateful for or can say about yourself.

Practice mindfully eating a piece of fruit, noticing how it looks, the texture of its skin, the fragrance of its aroma, the temperature, flavor, and how it feels as you taste it. See how long you can enjoy each bite until you swallow it. Notice how it feels when you swallow each bite and before you take another.

Use an app for assistance. The National Center for Telehealth and Technology and the Veteran’s Administration National Center for PTSD has helped develop two effective, free apps for smartphones to help people cope with symptoms of anxiety, panic and PTSD. One app is called Virtual Hope Box (on Google and on Apple) and the other is PTSD Coach.

Finally, if you do find your PTSD activated and your symptoms linger, seek help. Professional trauma-focused therapy can help you to help cope with, reduce and sometimes eliminate these anxiety responses.

Whatever you do this holiday weekend, I wish you the best. As always, my fellow suicide loss survivors are very close to my heart, and so are those who struggle with PTSD. May you be surrounded by comfort and support this weekend, and always.

The World Needs To Be Ready

Lorna Breen, MD, Emergency Room Medical Director

New York Presbyterian Allen Hospital

This traumatic episode in history, on a massive scale, will be studied for years to come. We know that after trauma comes the post-traumatic episodes and the world needs to be ready to help those who will need to be mentally supported once the worst is behind us.

― Aysha Taryam

Those of us with an understanding of Post Traumatic Stress Disorder (PTSD) who've been following the news (especially that coming out of Italy and New York) are likely less surprised that Lorna Breen,  a successful ER doctor in New York, died by suicide a few days ago. We are no less heartbroken, but less surprised because we could see this brewing. For those serving on the front lines of the COVID-19 pandemic, there is a perfect combination of the circumstances that lead to PTSD. 

Last month when I first read about what was happening in Italian hospitals, I shuddered. The overcrowding, the lack of beds, supplies, and medical personnel. And the number of people dying from this virus, despite heroic attempts to keep them alive. Doctors were often put in the agonizing position of having to determine who would receive lifesaving measures, and who would not. 

Most doctors go into their field in order to save lives. The Hippocratic Oath, the most basic tenet for medical doctors, states first: do no harm. But here, they were having to decide who they would let (likely) die in order to provide services to someone else. Having to make that type of decision flies in the face of 'do no harm.' This ethical bind alone will shake even the most stoic of medical personnel.

Looking at the causitive factors of PTSD, we can not deny that a pandemic the nature and scale of COVID-19 is going to have a lasting effect on hundreds of thousands of people - if not more. Some have called this pandemic 'the invisible war', Without going into the politics of who said it or why - it seems to be an apt term. Now consider that research on PTSD has shown that it is caused by certain circumstantial elements. One of the most common is a person's sense of helplessness when experiencing/witnessing a life-threatening or fatal event.

Children get PTSD from traumatic events (especially long term neglect or abuse) because inherently, they are without recourse when it comes to stopping the situation. Those who are physically, sexually, or emotionally abused/assualted are also often victims of PTSD. And for military troops in combat, PTSD runs rampant. In all of the above cases, we can see that a common thread is feeling as though there is a terrifying lack control over a traumatic situation.

Another factor in the likelihood of developing PTSD has to do with a perceived sense of responsibility. Loss that results in survivors guilt has a profound impact on the person suffering. This type of guilt and shame is a significant driving force in the development of PTSD.

For front line personnel in the areas hardest hit by this pandemic, in order to work, their psychological emotions are often in freeze mode. Physiologically they are inundated with a constant stream of stress hormones, specifically adrenaline and cortisol. And while both adrenaline and cortisol serve a purpose, long term exposure can be perilous to physical and mental health. When this happens, the deck for a healthy trauma response is stacked against a person.

If you are thinking that medical personnel should be trained to mentally/emotionally handle this type of trauma and loss, thinking along those lines is both dismissive and dangerously mistaken. Even prior to this pandemic, in the United States doctors die by suicide over twice as often as those in the general population. In the case of the armed forces, military medics represent a significant portion of those who die by suicide. More concerning are studies that have shown that among first responders,  those who indicated being regularly pushed to work past exhaustion and burnout are significantly more likely to die by suicide than their counterparts.

In the communities hardest hit by this virus, the medical personnel who are managing the sickest of those diagnosed with COVID-19 feel helpless when it comes to managing a novel coronavirus with no significantly effective treatment yet available. While many are having to confront the most brutal aspects of this virus, over and over again - they also feel the strain of an expectation that they should be able to comfort and heal patients. Combined, we have the perfect stew for developing a PTSD that leads to suicidality.

How do we help the health care professionals who are in this situation? The first thing to do is to acknowledge that there is very real possibility they are dealing with PTSD and recognize that suicidal ideation can be one of the symptoms of PTSD.

Recognize the increased risk factors, and go from there. Learn the warning signs of suicidal ideation, and learn what to do if you are concerned someone is suicidal.

Treat doctors, nurses, and hospital staff with kindness and caring, always. These are very frustrating times for all of us. Our entire world is dealing with the stress, inconvenience, and pain around this pandemic. If you have feelings of frustration around social distancing, shelter in place mandates, or other pandemic control practices - medical personnel are not the people to take these frustrations out on. Do what you can to support your neighbors and friends who are working in the medical/hospital/emergency services field. Reach out, text, or make a phone call. Ask if you can have a meal delivered to them at home or at work. Communities that are sending lunches and dinners to entire emergency rooms and/or intensive care units, are doing a good job of letting the staff know that they are seen and appreciated. Equally, when people are coming together to make noise to celebrate their medical personnel (virtually at a certain time of day, or in person during shift changes, etc.) there is a profound benefit. When a person feels as if they are seen, appreciated, and cared for, they feel less alone and helpless.

We are confronted with enough loss of life when it comes to COVID-19. Let's not let suicide lend to additional casualties. The world needs to be ready to support the first responders in this invisible war. So, do this today. Tell someone on the front lines that you care, and that you appreciate everything they do. Sometimes one measure of kindness can be the difference between despair and the ability to go on another day.

Day 26 - A Million Little Things

Today marks the premier of ABC's new television series, A Million Little Things. I wanted to talk a little about the television show, especially given its premise, which has to do with how a suicide impacts the survivors left behind.

A few disclaimers:

Beyond the previews (you can see one yourself, below), I have not seen the pilot in its entirety.

I am not a professional television critic.

And finally, the name of the character on the show who dies by suicide, is John. John was my boyfriend's name and that makes part of the introductory dialogue in the preview difficult for me to hear. ("You aren't going to believe this. John killed himself.") My difficulty in that innocuous part of the show may be influencing this blog post. Just an FYI.

Ok, having said all that, here is what I want to offer:

If you choose to watch this show and you are a survivor of suicide loss or a survivor of a suicide attempt, it may bring up difficult thoughts and emotions. Give yourself permission to turn off the tv, change the channel, or watch it another day.

Some survivors may feel that they are fine and ready to watch this type of subject matter (or they may be curious about how the topic is handled). However, remember that negative memories and/or feelings can be unexpected. It can help to give yourself permission ahead of time to remove yourself from situations that you find overwhelming. You do not have to push yourself f to watch certain scenes or any of the show, at all.

Arrange to watch it with a friend or loved one if you can. Having someone with you may help you to feel supported while watching. It can also help to to have someone to talk to during or after the show. Be sure that you and the person you are watching with agree to accept the decision if either of you needs to turn off the tv or change the channel.

Sometimes, we are distressed by memories that are brought up during an event, but the impact doesn't hit us until hours or even days later. Be prepared over the next few days for unexpected stress, anxiety, sadness or more acute grief to come up. Again, have a plan for if this happens. Perhaps there is a friend or a counselor you can call.

Whether it is a television show like this or any other event that brings up painful memories, be gentle with yourself. Allow yourself to avoid the situation if necessary. Always ensure that you have others to talk to when these things occur. Talking about the feelings you experience when you are overwhelmed can be very helpful in taking the power out of those feelings. However, pay attention to emotional 'flooding' when talking about your memories. Avoid discussing detailed memories, which can serve to re-traumatize. If you find that your voice is rising or you are beginning to speak very fast, or if you feel heightened anxiety while talking, try to slow yourself down. Take some deep breaths. Remind yourself that you can talk about your feelings a little later, or just in small increments.

Next, let's talk about responsible media representations and presentations of suicicde related material. Whether you have been directly impacted by suicide or not, it is very helpful to know the following guidelines. If the show seems to be pushing the boundaries in these areas, please consider being an advocate for suicide prevention and contact ABC to let them know that you would like them to handle the topic differently moving forward. Please note - again, I have not seen the show, so I am hopeful that all of the guidelines are already in place.

First, it is critically important that the Suicide Prevention Lifeline number (1-800-273-8255) is made available at either the beginning of the show or the end of the show (or preferably, both.) This is particularly important because this subject matter does have the capacity to exacerbate some people's thoughts of suicide. Being reminded that there is a lifeline available is very helpful and could even save lives.

Third, it is important that she show not get into the gory details of the suicide. It is always best if the act itself is not portrayed on the show, and that there is no overly descriptive language. There shouldn't be lengthy discussions of portrayls of the method used either. (They could potentially be construed as a 'how-to' lesson.)

Finally, it is important when reporting on suicide, that the focus include the pain of those left behind. (I am very hopeful that this will be the case on this show, given it's is supposed to be about those who are left behind.)

Having said all of that, I want to note that at this juncture (not having seen the show), I am really pleased that this subject matter is being addressed during prime time television. Offering opportunities for people to learn more about suicide and giving them a better understanding of the experience of not just those who are suicidal;, but also those left behind, is critical to fighting stigma.

And for my fellow survivors of suicide loss, whether you choose to watch the show or not, know that my heart is with us all and I have high hopes that shows like this will help others to be more kind and understanding about our grief and about suicide in general.