I recount the grey walls. The freakishly clean air. The anxiety. I sat in my hospital room in the mental health unit, waiting for my inpatient psychiatrist to see me. I had no idea what we would be speaking about; only that I would be walking with him to another room to talk. He came into my room and escorted me out to a place terrifyingly labelled the ‘interrogation room’. I tensed up and prepared for an hour of pretending to listen to ramblings about adding more activities to my life, the benefits of exercise, and the importance of compliance to my treatment.
And then he slid me a booklet of papers with a graph on the back. “I want you to listen very carefully because for your recovery, it is imperative that you understand this,” he told me. “Recovery from mental health issues is not about healthcare professionals giving a patient a series of treatments while the patient sits passively and receives it. It takes an equal contribution between both parties – the professional and the patient – to facilitate recovery. That being said, this here (and he gestured to the page) is a theory that I teach all my patients coming through the mental health ward.”
Photo by Anh Nguyen
Now, I am not going to attempt to explain the theory using the graph, as it is not intuitive unless I were to draw it out in real time as my psychiatrist had done. However, there are some main points that I’d like to outline. One thing to note is that there are, theoretically speaking, three levels of distress: mild, medium, and severe.
1. Everyone’s baseline level of distress/dysfunction is different.
Sally might be a very easygoing, chill girl who experiences a mild level of distress in her day-to-day life. She takes blips in the road in stride. She just stepped in some gum on her way to work.
That’s fine, I’ll just scrape it off at home later. I can handle this.
Joe might be a rather high-stress boy who still experiences a mild level of distress, but hovers much closer to the medium level of distress than Sally. He just stepped in some gum on his way to work.
Oh my gosh, everyone’s going to see it on my shoe and laugh at me. I don’t know if I can take that. I have to get rid of it NOW.
The way that Sally and Joe go through life on a day-to-day basis are different, but neither is necessarily wrong. Just because someone seems more stressed and easily distressed does not mean that they will be sent over the edge. Likewise, just because someone tends to have a more easygoing nature who rarely seems stressed does not mean that they won’t be sent over the edge. It is important to see this.
2. There are generally two common ways that people develop suicidality.
a) Marlin has a rather mild level of baseline distress. When bad events occur in his life, he copes well, and his level of distress rarely peaks beyond the medium distress level before returning to baseline. One day, he was abruptly removed from his job due to the downsizing of his company. This event was significant enough that it caused an acute, large peak in his distress level – so much so that his level of distress peaked to the severe distress level.
I can’t take this anymore. How will I support my family financially without my job? I will never be able to find another job. The economy is horrible and I can’t do anything about it. There aren’t enough jobs and I can’t get another one now that I lost this one. I’m a failure. Get me out of here. Make it STOP.
As his distress level increased, it surpassed what my psychiatrist called the “breaking point” – the distress level required for Marlin to experience clinical issues in his mental health, whichever form this may take.
b) Edna just entered her second year of university. She had an amazing educational career thus far – graduated with a 98% average from high school, was accepted to a prestigious program, and had sustained a high GPA in first year. She has always been rather stressed out, having a rather high baseline distress level. Over her second year, she continued to do well in her academics, but sacrificed a great deal of life balance in order to accommodate her perfectionistic study habits. Her level of distress rose steadily and stably throughout the year. When exam time arrived, she suddenly shut down.
I can’t do this anymore. Why can everyone else balance their lives so well but not me? I’ve done nothing but study all year…I’ll never have any free time. I have 5 exams to study for and I am going to fail all of them and flunk out of university and be left scrambling. I don’t even have a true friend to confide in about my stress. No hobbies, no friends. It’s too late to change. No one likes me. I’m all alone. I want out. Stop. Everything, time, everything just STOP.
Clearly, Edna also reached her breaking point, albeit in a different way than Marlin.
It is important to note before we move on that not everyone will experience the same distress peak from the same scenarios. There are many, many people who will never reach this distress level despite having similar situations – and this does not mean that anyone is above or below anyone else. There are incredibly complicated factors contributing to mental illness symptoms and suicidality. It is never only a result of one’s environment or life circumstances. In fact, in many cases it may not have anything to do with one’s objective life circumstances.
3. Once a person reaches their breaking point, the main two thoughts that lead to impulsive, risky behaviours common in the symptomatology of many mental disorders are:
a) Hopelessness. This is defined as the thought that when the going gets rough, nothing will change. “It will always be rough.”
b) Helplessness. This is defined as the thought that one cannot do anything to change their circumstances. “I can’t do anything to get myself out of this rut”.
In Marlin’s case, the hopelessness would be his thought,
I will never be able to find another job.
The helplessness would be his thoughts,
The economy is horrible and I can’t do anything about it. There aren’t enough jobs and I can’t get another one now that I lost this one.
These irrational thoughts suggest to Marlin that for the rest of his life, he will be jobless, and he cannot do anything about it because external influences (i.e., the recession) make him powerless.
Conversely, in Edna’s case, the hopelessness would be her thought,
I’ve done nothing but study all year…I’ll never have any free time.
The helplessness would be her thoughts,
It’s too late to change. No one likes me. I’m all alone.
Combined, these thoughts suggest to Edna that she will always be working and without a social life she desires, and that because of an external influence (i.e., her thought that no one finds her likeable), she has no agency to change.
Both Marlin and Edna feel stuck. They believe nothing will change, and they can’t do anything about it even if they tried. Thus, these thoughts of hopelessness and helplessness is what finally leads to the impulsive, risky behaviours. Many prevalent mental disorders have distinctive behaviours. For example, depression is associated with suicidal tendencies, and/or self-harm. Obsessive Compulsive Disorder (OCD) is associated with compulsive actions done to calm an obsessive thought. Substance use and excessive alcohol consumption are common behaviours exhibited by those suffering from severe social anxiety.
Fundamentally, my psychiatrist believes that all of these behaviours (and others) can be traced back to thoughts related to hopelessness and helplessness, which can then be traced back to a ‘trigger’, whether this be acute or building over time, which can then traced back to one’s ability to cope with events causing distress seen in the distress level “peaks”, which fluctuates from one’s baseline level of distress.
Now, that may be a bit confusing to take in, so I may attempt a little sketch of the graph that my psychiatrist showed me in the future. However, understanding these basic principles behind why people are sent “over the edge” is important to understand the intervention points…which will be explained in a subsequent post.
*If you are experiencing suicidal thoughts or feel worried that you may do something to harm yourself, tell someone immediately. Go somewhere safe where you can be with a trusted person or ask a friend or family member to stay with you. If you are unable to connect with someone, call 1-800-273-8255 (National Suicide Prevention Lifeline) if you reside in the U.S., and 1-866-797-0000 (Telehealth Ontario) if you reside in Ontario, Canada.
Always remember to love (ARTL),