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July-August 2018

I tried to kill myself. I survived. When Canada’s health care system failed me, I tried again, and again

What needs to change in our country's suicide crisis intervention system

Sarah Mann

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For more than half my life, someone has been trying to kill me.

That someone is me.

The first time I considered ending my life, I was eight or nine years old, living in a rented house with my father and brother in Owen Sound, Ont. My mother had moved out years earlier, after my father tried to stab her; he had started directing his misogyny at me instead. We had just watched The Towering Inferno, an early-1970s drama about a fire in a skyscraper. My brother described how he would climb balconies and elevator shafts to safety, and I thought: I’d just jump.

I knew I shouldn’t say it out loud, that the thought was somehow shameful, but it seemed clear to me that there are better and worse ways to die. I couldn’t see a good answer to the question, “Why not?”

Karen Letofsky, board president at the Canadian Association for Suicide Prevention (CASP), was not surprised to hear this. “There is a lot of social ambiguity around suicide,” she says. Much of what we think we know about suicide is based on social mythology, which creates barriers to the honest conversations Letofsky says people who attempt suicide need to have.

Yvonne Bergmans also emphasizes the importance of talking about suicidal thoughts. Bergmans is a CASP board member and suicide intervention consultant at the University of Toronto’s Arthur Sommer Rotenberg Chair in Suicide and Depression Studies Program at St. Michael’s Hospital in Toronto. She says suicide attempts and suicidal ideations speak to a “great, deep pain: that hurt where there’s a story being written about ‘I can’t survive this’ or ‘I need to end this.’”

In our discussions about suicide, both women say our country’s mental health system is under-resourced and prioritizes crisis over long-term support. Its uneven structure leaves it poorly equipped to help survivors do what we most need to: articulate and understand the stories behind our suicide attempts. And those stories matter—hearing them helps demythologize suicide, so we can understand and address it as a social problem.

I grew up in poverty, in an abusive home. I learned early in life that my physical safety and bodily autonomy were not guaranteed, that I had little control over what happened to me, and that being killed was a real possibility. My earliest suicidal thoughts aren’t about giving up. They’re about regaining control: If I can’t choose not to die, I’ll settle for choosing how to die.

***

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Suicidal ideation was a secret I kept throughout my childhood. Even if there had been someone for me to share my feelings with, I didn’t have language to do so. Bergmans says this is a common problem. About 80 percent of her clients experience alexithymia, or an inability to identify and describe their emotions.

“A lot of folks can only talk about how they need ‘it’ to go away, without any language to understand what ‘it’ might be,” she explains: “The emotional literacy to be able to say, ‘I’m so angry,’ or ‘I’m so frustrated,’ or ‘I’m so lonely,’ or ‘I’m so hurt’ just doesn’t exist.”

Unable to communicate our feelings with words, people who attempt suicide learn to communicate with behaviour instead. I was 16 the first time I acted on suicidal thoughts. While I didn’t attempt suicide that day, I made a detailed plan: I was going to slit my wrists and then hang myself from the railing above the stairs in my foster home. My hanging body would block my foster parents’ path to the garage—they would have no choice but to acknowledge my pain. The idea scared me; that it seemed inevitable scared me more.

I confessed my plan in an online chatroom for people with depression, and someone called the cops. That was the first of many arrests under Ontario’s Mental Health Act—often referred to as “being formed” because there is a form the arresting officer or doctor fills out to require you to submit to psychiatric assessment.

The hospital discharged me back to my foster home the following morning.

The next year, I began struggling to determine what was real. My mind battered me with thoughts about scooping out my eyes, splitting open my abdomen and removing my uterus, cutting off my hands because they were being operated by someone else. I now have a word for what was happening to me—dissociation—but I didn’t then. I overdosed and wound up in the hospital again. Once again, I was discharged with limited follow-up. In these and other suicide attempts throughout my teens and 20s, I was telling a story, whether anyone wanted to hear it or not: I’ve got good reasons to feel this angry, and I demand to be heard.

Bergmans says it’s common to feel isolated after a suicide attempt: “Even when people are in crisis, their experience with the mental health system is often, ‘let’s find a diagnosis, try to medicate, and send them on their way.’ And what gets missed is the trauma of the experience that somebody has in attempting suicide.” The problem is both interpersonal and systemic. In a crisis, a person with suicidal thoughts can present themselves at the emergency room or call a suicide hotline and get immediate care. But, argues Letofsky, “once the crisis has passed, there really aren’t many resources. That compounds the problem.”

One area where we see the mental health system’s “crisis-driven service orientation” is in the programming that attempts to respond to youth suicides and attempts, such as the suicide crisis in Canada’s Northern Indigenous communities. “Most of the resources are front-ended and applied at the time of crisis,” Letofsky says, “and then you never hear again about that story or its longer-term impact.”

Indigenous people in Canada live with the trauma of ongoing genocide, a history that includes over-representation in the foster care system, in prisons, in poverty, and among suicide deaths. While Indigenous people are over-burdened with trauma that demands to be heard, the mental health system serving them is even more under-resourced than in the rest of Canada.

Makwa is an Indigenous social worker and mother of two from Sault Ste. Marie, Ont. Intergenerational trauma has shaped the experience of suicide for her and her daughter, Nimkii. (Both names and their location have been changed to protect their identities.)

Makwa’s mother, an Indian day school survivor, struggled throughout her life with self-harm, suicide attempts, and a substance use disorder, and Makwa and her siblings were apprehended by Children’s Aid when she was a baby. The first time Makwa attempted suicide, she was nine years old. She overdosed on acetaminophen in her foster home, thinking that if she died, she could leave the home.

By the time she was 11, Makwa was regularly self-harming. Each episode led to another crisis call: police, paramedics, hospitals, new foster homes, group homes when the foster homes would no longer take her. Sometimes, the hospital or jail Makwa was held in couldn’t discharge her because she had nowhere to go. Her sense that the system was tired of dealing with her crises left her “feeling even more worthless.” Eventually, a guard from one of Makwa’s detention facilities agreed to foster her.

Makwa developed a substance use disorder in her late teens, and when she aged out of foster care at 17, she was pregnant with Nimkii. Nimkii’s father, also a child welfare system survivor, used substances and abused Makwa. They lost custody of Nimkii and their infant son after Makwa, reeling from an episode of domestic violence, slit her wrists.

To be able to parent Nimkii and her brother, Makwa needed to change. She left her abusive partner, overcame her substance use disorder, went back to school, sought mental health treatment, and regained custody of her children. But as Nimkii entered her teenage years, Makwa saw familiar behaviour in her daughter: Nimkii began to self-harm, attempted suicide, and assaulted others.

For years, Nimkii’s only consistent support was Makwa. Makwa believed Nimkii needed residential treatment, and she knew being a child in the foster care system would open doors to treatment that she couldn’t afford. Makwa reluctantly agreed to a temporary care order with Children’s Aid, in hopes of getting Nimkii into the Roberts/Smart Youth Mental Health Centre in Ottawa. Nimkii eventually got into treatment, but at an enormous cost. She was placed into foster care. Like Makwa, she bounced between group homes, hospitals, and jails. She began using substances. Her behaviours worsened, and her criminal charges began to pile up. She ran away and was sexually assaulted. In the end, it took a year and a half to get Nimkii into treatment, and Makwa had to sign her parental rights away to do it.

Jane, a Barrie, Ont., high school teacher whose name and location have been changed to protect her job, also feels stuck in a repetitive cycle of crisis care. “When I was in crisis,” she explains, “I was able to talk one-on-one with a nurse, and they gave me phone numbers and set up initial appointments, but after that, I was on my own,” she says. Jane feels that, once the crisis is over, nobody cares whether she seeks treatment.

Both Makwa and Jane have had their parenting abilities questioned because of their mental illnesses. When Nimkii was released from residential treatment and returned to Makwa’s home, Children’s Aid remained involved. Their file was finally closed in November 2017, but it was reopened in January when Nimkii had an episode that required Makwa to call police. Most recently, Children’s Aid cited Nimkii’s mental illness as a reason to deny Makwa kinship care of another family member.

For Jane, the call from Children’s Aid came after her husband discussed suicide with a psychiatrist. In Barrie, the mental health system is so under-resourced that most patients can receive only a one-time assessment from a psychiatrist. Unfamiliar with Jane’s family, the psychiatrist concluded that two parents with the potential to self-harm constituted a risk to their children and reported them to Children’s Aid. She never considered that Jane and her family could find a way to cope with the risk of suicide.

Bergmans’s research found that even when follow-up support is offered to survivors, the conversation focuses on changing behaviour, not understanding emotions. One of Bergmans’s clients described behavioural therapies as “putting a doily on top of a pile of shit; there’s a pretty doily there now, but it still stinks.” Jane agrees: “As long as you’re making a valiant effort to fix your behaviour, people are more comfortable with that than with ‘this is who I am, this is how I am, this is how I think.’”

***

Sarah at an Athabasca University award ceremony in Toronto in 2013. Photo courtesy of photographer Janyce Mann.

Today, there are efforts to change that mode of thinking. Bergmans started trying to change the system in 1999, when her first therapy group for suicide attempt survivors in Toronto began, using an established intervention model that remains popular for treating suicidal individuals. But Bergmans’s eight group participants weren’t finding the therapy useful. So Bergmans adapted the group, working with survivors to build on academic research and on Bergmans’s experience working with children and youth. Together, they developed a program that “targeted the key areas for suicidality—safety, emotions, problem-solving, and interpersonal relationships.”

Bergmans’s intervention model lays out the core concepts participants use to understand the stories behind their attempts. The program includes 20 weeks of group therapy, during which participants also receive one-on-one support to process their learning and emotions. The challenge for participants is not to simply change their behaviour, as suggested in typical therapy models, but to understand it. Bergmans’s technique is in use at hospitals and community mental health centres in southern Ontario, including St. Michael’s Hospital, where 433 people have participated in the therapy. In fact, 121 of them have returned to complete it a second time.

Despite the success of Bergmans’s model, the Canadian mental health system is ill-prepared for widespread adoption of such resource-heavy methods. At St. Mike’s, Bergmans’s group participants all have one-on-one support. Other groups employ paid part-time staff, or they add the group to the workload of existing staff. It’s also a program in which service providers must become comfortable with risk—participants must feel safe discussing their suicidal thoughts and mental health challenges. In the risk-averse bureaucracy of the system, that’s not something health care workers are trained to do.

***

By 2013, I had scraped my way through a three-year Bachelor of Arts program at Toronto’s York University and made it into a graduate program in St. Catharines, Ont., but I had stopped coping. I still lived in poverty. I was raped two years prior, exacerbating my depression, anxiety, and gory, vivid nightmares—symptoms that would eventually be diagnosed as Post-Traumatic Stress Disorder. I was using opioids to cope with constant anger, sadness, and existential terror. There was nowhere, nothing that felt safe. A doctor at the walk-in clinic gave me a couple months’ supply of Cymbalta and sent me home. I took them all and texted goodbye to a friend.

This time, the hospital kept me. I spent 10 days in the Niagara Health system’s new mental health unit. They offered me group therapy, but the idea of explaining why I was so fucked up to strangers, doctors, and social workers sounded like torture. I played Uno with my friend when he came to visit, staring blankly across the room, dazed by the drugs I had poisoned myself with, while he dealt and nudged me to take my turns. I was discharged abruptly when a male patient grabbed me and tried to kiss me. Sometimes the story is just this: This story sucks.

But when I was discharged, I had a plan for follow-up. I would see a case manager at the Niagara branch of the Canadian Mental Health Association (CMHA), and I had an intake appointment at Quest, a community health centre in St. Catharines that specializes in providing health care to poor people, people with mental illnesses, and drug users.

My substance use disorder, which had been developing over years of increased use of OxyContin, heroin, and cocaine, worsened and eventually imploded. I often found the mental health system hostile, invasive, or outright harmful. Over the next three years, I was hospitalized nine more times, sometimes because I voluntarily presented at the ER in crisis, and others because I was apprehended under the Mental Health Act. But there were safe havens: a short-term crisis shelter at the CMHA, daily visits to a pharmacy for addiction medication, weekly visits from my case manager, monthly visits to the doctor. When I had suicidal thoughts, I brought them to people I trusted, who were knowledgeable about my mental illnesses, honest about what they thought would help, and consistent in these behaviours. I was learning to write another story: Slamming my head against this wall is exhausting. You slam it for me for a while.

None of my health care providers was consulted about that metaphor. And it’s hard, I imagine, for anyone who has never considered suicide to conceptualize such violence as therapeutic. It is absurd to crawl through a maze of bureaucracy and stigma, looking for someone to help me bash my drug-addled, self-destructive brains out. Why not just stop slamming my head into the wall? Finally, I was learning how to answer, “Why not?”

***

One way or another stories demand to be told to completion. At worst, these stories end in death. The key to reducing the number of suicide deaths is listening to the stories with alternate endings.

Although I still think about suicide most days, my last suicide attempt was in 2014. It took three years to find a combination of medications and therapy to keep me sane. By the fall of 2016, my mental health was stable enough that I was able to stop using drugs. Last year, when I returned to writing, art, activism, and community organizing, I realized I felt more like myself. Next year, I’m considering returning to graduate school.

Working with the Mental Health Commission of Canada, CASP has developed toolkits to support suicide attempt survivors. What’s important, Letofsky says, is being honest about the situation. Often, family and friends of suicide attempt survivors are afraid of saying the wrong thing. Letofsky advises support persons to begin by asking the survivor to tell their story: “What do I need to know? What do you need from me to help you stay safe?”

Jane’s Children’s Aid worker agreed that she and her husband pose no harm to their children and closed their file. The experience was stressful for Jane and for her eight-year-old daughter, who was recently diagnosed with an anxiety disorder. The ordeal had a chilling effect on Jane’s willingness to seek treatment. “All this experience has done for me,” she says, “is create and solidify more distrust in the system.”

Makwa works to help other Indigenous people navigate the mental health system and practises her Anishinaabe culture at home. Nimkii is stable and has returned to her mother’s home. She receives treatment at a community health centre for Indigenous women and sees a psychiatrist. They spend hours making jewelry together. While Makwa is afraid of what will happen when her daughter has to face the hospitals, community, and police on her own, she is also aware, from her own recovery, that her culture and traditions provide comfort and guidance. Decolonization is a healing practice.

In Bergmans’s therapy groups, suicide attempt survivors do the hard work of understanding their own stories. They make safety plans not for “what if” their suicidal ideations return, but “even if” they do. How will they manage their turmoil as safely as possible? How will they cope with suicidal thoughts that might never go away?

Suicide is scary, and a magic formula for answering those questions would be very reassuring. But there isn’t one. The best I can offer is this: This story has barely begun.


IF YOU NEED HELP, HERE ARE SOME RESOURCES ACROSS THE COUNTRY TO CONSIDER:

CANADA SUICIDE PREVENTION SERVICE:
By phone: 1.833.456.4566
By text: 45645
Online: crisisservicescanada.ca

KIDS HELP PHONE: 1.800.668.6868

FOR RESOURCES IN YOUR PROVINCE OR TERRITORY: yourlifecounts.org
READ MORE ABOUT SUICIDE PREVENTION: suicideprevention.ca

Sarah Mann is an academic, activist, and artist living in Sudbury, Ont. She writes and teaches about poverty, sex work, harm reduction, mental health, and feminism. Her writing can be found in Briarpatch, rabble.ca, the Hamilton Spectator, and more. Sarah is working on a community arts project to build solidarity among poor people, and with a group of Anishinaabe families on a storytelling project related to their experiences with the children’s aid system. She blogs at autocannibalism.wordpress.com.

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