Back From the Brink Some people who stutter have at some point felt so depressed that they’ve considered extreme measures. How have they become so lost? And how have they found their way back? Features
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Features  |   May 01, 2014
Back From the Brink
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Speech, Voice & Prosodic Disorders / Fluency Disorders / Features
Features   |   May 01, 2014
Back From the Brink
The ASHA Leader, May 2014, Vol. 19, 44-50. doi:10.1044/leader.FTR2.19052014.44
The ASHA Leader, May 2014, Vol. 19, 44-50. doi:10.1044/leader.FTR2.19052014.44
Communication and emotion are caught up in such a delicate dance, and some of it isn’t pretty.
The ability to be heard by others, to listen to what the world has to offer each day, to share readily and easily one’s memories, experiences, opinions and dreams—all contribute to a sense of social completeness and belonging, to feelings of contentment.
The reverse is also true. Emotional responses to communication disorders—how we react to the continual threat of being isolated from friends, family, colleagues and peers—can run a complex gamut, sometimes over the course of a single day. Sometimes we accept, other times we might get frustrated, angry or really depressed.
Originating in a well-received ASHA convention session, Katherine Preston’s powerful piece profiles two people who stutter who confronted the darkness at the extreme end of this cascading emotional spectrum. With the help of speech-language pathologists, Scott Palasik and Tim returned to the light.
While there are no data to indicate a higher rate of suicide among people who stutter, we know anecdotally that thoughts of suicide do occur among people with communication disorders, including stuttering. Why? Sometimes it seems just too much.
As I have previously shared, I—a life-long stutterer—once became so depressed because of my disorder, so lost, so cut off from purpose and future, that I traveled the dark road taken by Palasik and Tim. Others have also confided to me about their or their friends’ experiences at the brink. Such extreme reactions are not limited to people who stutter, of course. In this issue, we also take a look at depression among those struggling with aphasia, dementia and traumatic brain injury.
There are many ways for SLPs to help. Raw emotional responses to communication disorders cannot help spilling over in treatment, on display for clinicians on the frontlines of helping, intervention and prevention. In this issue, Joseph Donaher and Lisa Scott offer detailed advice for communication sciences and disorders clinicians dealing with clients who are wrestling with mental health issues in general, some of whom may be contemplating suicide. As the authors make clear, such instances are rare but they do happen. The clients they discuss are not just people who stutter, but also people affected by other types of communication disorders. Any client seen by a communication professional could face the types of difficulties described in this piece.
A two-hour session at the 2014 ASHA Convention will focus on this specific topic. “Clients at Risk For Suicide: Our Experiences and Responsibilities,” led by Joseph Donaher, Robert Fifer, Barbara Froman, Judith Kuster, Scott Palasik and Rachel Wynn, will look at depression, anxiety and isolation in people with a variety of communicative disorders; the possibility that they will contemplate suicide; and risk of suicide completion.
We hope that this issue will help sensitize readers to this possibility and offer some guidance about providing these clients with the help that they need.
—Gary Dunham, editor-in-chief, The ASHA Leader
As a kid, Tim found it hard to swallow a single pill. His mother had to crush them up to get him to take them. And yet here he was, at the age of 26, throwing back handfuls. Almost 20 Zoloft, followed by a fistful of Celexa. Then he started on the second bottle of vodka. Always the perfectionist, he was determined to do it right.
He’d been researching for months. The Celexa had been prescribed by his psychiatrist to help with depression and he’d ordered the Zoloft illegally from Canada. Planning had given him a release when things got really bad. It had been that way since he was 16, since he’d first stood on a bridge and thought about jumping. Since he’d first imagined an escape from stuttering.
It was hours before dawn, the bars were long closed. No one was walking past the street corner he’d chosen and no one knew he was there. His mind became lucid—too late, he realized the enormity of what he had set in motion. He thought about his mother, he thought about the life that he was leaving behind. It stopped, he went numb. Then nothing.
Listening to the unspoken
Roughly 1 million people kill themselves every year worldwide. According to the World Health Organization, global suicide rates have increased by 60 percent over the past 45 years and someone in the United States takes his or her own life approximately every 14 minutes. It is estimated that more people die by suicide than by car accidents.
We do not know how many in those statistics are people who stutter, but we know that they are among those numbers (see “Be Prepared to Help At-Risk Clients”). We know that stuttering can breed its own fatalities. And yet, we do not talk about it. Just as stuttering itself has long remained taboo, the convergence of stuttering and suicide remains largely unreported and shrouded in guilt.
We are not alone in that silence. As David Satcher, the U.S. surgeon general, puts it, “As a society we do not like to talk about suicide.” Perhaps we want to maintain the illusion that suicide is rare, that it is a rash act done only by the cowardly, the selfish and the permanently unstable. Perhaps the survivors want to look ahead and leave their experiences unearthed in the past. Whatever our reasons, the result is an epidemic that remains misunderstood.
We need to debunk those myths and open up the conversation. In truth, it is hard to take your own life. It takes a sort of overwhelming desperation that most of us are lucky not to have known. And yet, no one is exempt from pain and suffering. All of us have known darkness at some point in our lives. So what combined state of mind drives someone to believe that life is too painful to go on living, and what saves people from the brink?
Psychologist Thomas Joiner, author of “Why People Die By Suicide” and “Myths About Suicide,” believes that people kill themselves when they have both the desire to die and the ability to die. His danger zone emerges when three tightly defined, overlapping conditions create a “pathway to suicide.”
Isolation
Joiner calls the first condition “thwarted belongingness.” He argues that the desire to die begins with loneliness, an unfulfilled desire for inclusion and connection.
As someone who stutters, I once knew the state of isolation well. Not in the sense that I was often on my own, but rather that I struggled alone with my inner demons and felt stifled by my difference. For much of my life, I believed that my voice cut me off from the “normal” world. I believed that other people only heard the words that I would allow myself to say, the mangled approximation of the unspoken words piling up in my head.
I’ve heard stories of others who were bullied mercilessly because of their speech (see “Bullying Be Gone”). I talked to some of these people about their experiences of feeling excluded, misunderstood, unloved and ashamed by their inability to control their own bodies. They spoke to me about being imprisoned and silenced by their stutter.
One of them is Scott Palasik, today a speech-language pathologist, artist and counselor. As a teenager he never imagined that life for himself. He remembers worrying that people were judging him because of his voice. On the rare occasion that he spoke up in class, he felt hot and small, as if the room was on top of him pushing down.
“I thought that my stutter was in control of everything, that it dictated my path and made me quiet and shy,” he says. “I thought that it told people that I was dumb in some way.” The summer after his senior year of high school, tired of struggling, he decided to stop speaking. “I didn’t talk for about six months.” He believed that if he didn’t talk, then he wouldn’t be judged, and possibly he wouldn’t judge himself. And yet, that silence created an acute sense of loneliness. As Palasik stopped talking, people gradually stopped talking to him. His rage toward his stutter turned toward himself, making him blind to all the people who did care for him.
“It snowballed into this idea that if I was alone anyway, then what did it matter if I was dead or alive?” He started to think that he would be better off dead. “And coming to that conclusion wasn’t scary,” he says. “That’s what is so scary about people who are suicidal: These thoughts do not scare you. It feels right, it feels natural.”
Liability
Returning to Thomas Joiner’s conditions that create a pathway to suicide: the second is “perceived burdensomeness.” He argues that when people see themselves as effective, they maintain the will to live. But when they feel like a liability, when they feel as if they are letting others down, that will to live can be sorely tested. It is this condition that debunks the myth that suicide is a selfish act. In reality, it often comes closer to mistaken, or misguided, heroism.
Suicide wasn’t a selfish thing for Tim. If it was, he would have killed himself years ago. Rather, he felt like he was a burden on those around him, he felt like he was letting them down. He was completing his final adult case management placement for his social work degree, but he kept dropping cases because he was so afraid of talking on the phone. He prided himself on his ability to battle through, to take care of those around him. But he believed that he was failing: at school, at his job, at speech-language treatment. He wanted to be perfect and he couldn’t meet that impossible ideal.
Many of the people who talked to me about feeling suicidal remembered their lowest moments being those times when they felt hopeless about their future, when they couldn’t get work, when they felt like their stutter was trapping them into a smaller and smaller life, when they felt helpless to change their situation. They spoke about worrying that they were letting down their families. They spoke about the perils of feeling useless, of feeling depressed, of turning to drugs or alcohol when they could no longer square off against that monster called stuttering.
Nothing left to fear
Joiner calls his final condition for suicide “fearlessness” or “the ability to die.” Killing yourself is not cowardly or weak or impulsive. Neither is it laudable. But it takes a certain kind of courage to numb yourself to violence. Our impulse to survive is hardwired into us. It explains why so many people save themselves at the brink.
Palasik had started to drive home at night with his eyes closed. He would listen to the sounds of the road and imagine “hitting a car, a tree, a house, going off the road and into a bottomless ravine.” Eyes closed, he would feel the car veer off the road, he would feel the rocks crunch under the wheels, thinking that this was what he wanted. And then some instinct would save him, something screaming at him that he wasn’t done, that he still had a voice. He’d open his eyes and swerve back, just missing mailboxes and trees. Sometimes he’d be inches from oncoming cars.
Our survival instinct is often strong enough to save us, and yet the ability to die can develop over time. A lifetime of numbing ourselves to painful physical experiences can make us strong in ways that can galvanize or break us. For some, the strength that comes from the daily battle of speaking can be transformed into something deadly.
Salvation in belonging
Suicide is not an unfathomably psychotic state. Rather is made up of circles that we have all stepped into, or skimmed close by. The gaps between us are not so wide.
So what saves people from an attempt to kill themselves? And, perhaps more important, what helps them recover from the desire to kill themselves?
The answer seems to lie in the life­saving power of belonging. Palasik believes that he owes his life to the people who reached out to him along the way. The first person to notice the change was his friend Gina. “She noticed I wasn’t talking, smiling or engaging,” he says. “She got mad at me and said, ‘Bub! You gotta talk.’ I just shook my head. She called a speech pathologist right there in front of me. I had nothing to lose, I was certain I would be dead within the year.”
He went to the SLP and was surprised to find that the sessions weren’t filled with anything except another person sitting there, waiting for him to talk. “That was the greatest gift she gave me, just waiting without any judgment or agenda,” Palasik recalls. He went back every week for a year and a half. For years, he still thought about death as an option, but the feeling of being drawn toward living began within six months of starting treatment.
In spite of their experiences, or perhaps because of them, Palasik and Tim are both men who cling to life. They are the type of people you want to be around, the ones with the infectious laughs, the kind eyes and the compassionate minds. They are the ones who help others feel less alone by telling their stories. They prove that there is hope, that the unrelenting grayness will end, that the indefatigable human spirit is strong enough to climb out of almost any dark place.
Tim woke up in a hospital bed, looking up at nurses and doctors. They told him that somebody had found him and called an ambulance just in time. He was so weak that a friend had to carry him home. Six months later he went to his first ELSA (European League of Stuttering Associations) youth group meeting. Whereas some people might have found it hard to walk into that cacophony of stuttering, he loved it. He felt at home, as if he could tell them anything.
Looking back, Tim feels as if the darkest parts of him died when he took that overdose; it changed something in him. Today suicide is no longer an option. He looks after himself to deal with any lingering traces of depression, he meditates, he has learned to let go. Spending time with other stutterers has made him think that he might like himself less if he was fluent, because they have taught him that acceptance and vulnerability can give him the freedom he always craved. Beyond his mother and his family, he feels that he has people to live for. As he puts it, “It is only the beginning of the journey. I have so much more to do, and so much more to say.”

Suicide Risk Heightened Among Those With Aphasia, Dementia, TBI

The risk of suicide is significantly increased, relative to the general population, among some people with acquired brain injuries, particularly aphasia, primary progressive aphasia and semantic dementia, and traumatic brain injury.

It is not uncommon for people with stroke-associated lesions in the left anterior cortex to experience depression, including thoughts of suicide, as post-stroke major depression is significantly associated with left anterior lesions, especially during the two years after the stroke. Diagnosing post-stroke depression can be challenging— especially in the context of language impairment—and it often goes unrecognized and untreated. A National Aphasia Association survey indicated that more than 90 percent of people with aphasia feel isolated and lonely and have a diminished sense of belonging. Although suicide incidence is relatively low among those with aphasia—about 1 in 2,000 cases (see sources)—the possibility that a person with aphasia will contemplate or attempt suicide merits serious consideration.

It is also not uncommon to see depression and suicidal behavior among people with primary progressive aphasia or semantic dementia—a degenerative disorder that selectively affects semantic knowledge until the later stages of the disease. One study estimated that approximately 20 percent of patients with semantic dementia contemplate suicide and approximately 10 percent of these patients will attempt suicide.

People who survive a traumatic brain injury may also be at increased risk of suicide. Researchers Grahame Simpson and Robyn Tate found high levels of suicide attempts (18 percent) and clinically significant suicide ideation (21 to 22 percent) among people with severe TBI in research reported in 2007 in Brain Injury. Even among those who sustain only a mild TBI, the risk of suicide increases approximately 3 to 4 percent relative to the general population. Veterans with a history of TBI are 1.5 percent more likely to die of suicide than those without a history of TBI.

Thus, SLPs who treat patients with aphasia, dementia or TBI should recognize that these patients are at special risk of committing suicide, particularly if they have depression and preserved insight.

For some patients, that risk may be exacerbated by the risk of suicide associated with normal aging. Among the elderly, factors associated with attempted suicide include being unmarried, living alone, low education level, history of psychiatric treatment, and previous suicide attempt.

SLPs and audiologists who understand the factors that increase risk associated with these conditions and learn to recognize symptoms of possible suicidal behavior may be able to make better clinical decisions regarding suicide risk evaluation in these vulnerable groups. Given that we often spend more time than most other health care professionals communicating with patients, SLPs and audiologists have a responsibility to be aware that some of patients may be “on the brink” and to provide them with the counseling and referrals that they and their loved ones may desperately need.

—Margaret Rogers, ASHA Chief Staff Officer for Science and Research

Resources

References
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May 2014
Volume 19, Issue 5