Should we be talking so plainly about suicidal ideation? What are the benefits of assessing our thought patterns over a period of time? Join us as we discuss the Columbia-Suicide Severity Scale screening tool. We tackle this sensitive topic after Jackie was surprised by a suicide assessment at a physician’s office. Rare trigger warning this week for a tough subject, as we explore talking openly about suicidal ideation.
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About The Not Crazy Podcast Hosts
Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, Mental Illness is an Asshole and other Observations, available from Amazon; signed copies are also available directly from Gabe Howard. To learn more, please visit his website, gabehoward.com.
Jackie Zimmerman has been in the patient advocacy game for over a decade and has established herself as an authority on chronic illness, patient-centric healthcare, and patient community building. She lives with multiple sclerosis, ulcerative colitis, and depression.
Computer Generated Transcript for “Suicide Questionnaires” Episode
Editor’s Note: Please be mindful that this transcript has been computer-generated and therefore may contain inaccuracies and grammar errors. Thank you.
Jackie: This episode discusses the Columbia-Suicide Severity Rating Scale. Listener discretion is advised.
Announcer: You’re listening to Not Crazy, a Psych Central podcast. And here are your hosts, Jackie Zimmerman and Gabe Howard.
Gabe: Pay attention Not Crazy fans, right now Not Crazy listeners get 25% off a Calm premium subscription at Calm.com/NotCrazy. That’s C A L M dot com slash Not Crazy. Forty million people have downloaded Calm. Find out why at Calm.com/NotCrazy.
Gabe: Welcome to the Not Crazy podcast. I would like to introduce my co-host, Jackie, who still has not seen the new Star Wars, just unacceptable. This is why you live with depression. You realize this, right?
Jackie: Wow. That snarky A-hole is my co-host, Gabe Howard, whose absolute lifetime favorite Star Wars character. Jar Jar Binks.
Gabe: Oh, that that is not true. That is a lie.
Jackie: Maybe that’s why you experience being bipolar. Because you can’t handle the guilt you feel about you having your favorite.
Gabe: I this is gonna be the last episode of Not Crazy because that’s so mean, you just can’t tell people.
Jackie: The truth?
Gabe: No. My favorite Star Wars character is probably like a toss up depending on my mood between Princess Leia, because a beautiful bad ass, and Darth Vader because, you know, I’m adopted. So he could be my real dad.
Jackie: I still maintain that before we started recording, everybody, he told me it was Jar Jar Binks and now he’s lying for the masses. Speaking of the masses, I was recently given my very first suicide severity rating test, and that was a bit of a doozy that I did not see coming. We don’t normally do this, but I feel like this episode might be a massive trigger. So here’s your trigger warning about suicide and suicidality. We are going to be talking about it in depth because of the in-depth questions on the screener.
Gabe: To put a little context here, a suicide severity rating scale test and one of the most popular ones is the Columbia-Suicide Severity Rating Scale. It’s essentially a questionnaire that medical personnel ask people to determine if you are suicidal, passively suicidal, actively suicidal.
Jackie: This screener was specifically was developed by Columbia University, the University of Pennsylvania, and the University of Pittsburgh in 2007.. But since then, in 2011, the CDC took it on using the protocols, definitions for suicidal behavior. And then in 2012, the FDA declared this protocol to be the standard for measuring suicidal ideation. So this is something that’s out there. And I guess I’m still surprised I didn’t know about it or didn’t see it coming.
Gabe: Is this literally the first time you’ve ever been given one?
Jackie: Literally the first time and a little bit of background, so I recently started a clinical trial for a multiple sclerosis drug. So on my first appointment they gave me this screening and I was assuming it was gonna be your average sort of like, have you ever been suicidal in the last two weeks? And you’re like, yes or no? And then you move on. End of quiz. But it wasn’t, and it was oof . Some of the questions I just did not see those coming. It was very I mean, it does its job. It’s supposed to find out on the scale how severe you are in terms of being suicidal and or how much you’ve planned around suicide. So I immediately sent Gabe a text and was like, do you know about this? Have you ever had it? We need to talk about it on the podcast.
Gabe: You were like, hey, they want to talk about suicide and the questions, I didn’t expect them. And the first question is, do you wish to be dead? And I don’t mean to make light of suicide. I’m sincerely not trying to do that. But one of the things that is fascinating about what you just said is you didn’t expect the suicide screener to ask if you wanted to die. And this is sort of where we are as a country. We always talk about suicide in like, hey, how you feelin? And the person’s like, pretty good. Excellent. They’re not suicidal. We’ve done the screener. And when the questions are really direct, they feel like like they feel heavy on your chest, like, oh, why are you asking me direct questions about life and death? I don’t like this. And I understand that, they’re heavy.
Jackie: Well, on my own behalf. They did not tell me actually the name of this scale. They were like, we’re gonna do a C-SSRS test. And like, I don’t know what the fuck that means, but hit me with the test, right. And then she did. And the first question, as you said, is do you wish to be dead? That is also not phrasing you generally get from medical professionals. And I think that is really the root of what kind of threw me on this one is the verbiage throughout the screener almost feels conversational. It doesn’t feel medical, which is, again, I think the point. This sort of conversational colloquial test is the standard now.
Gabe: As somebody who’s been in the mental health advocacy game for almost a decade now, it is interesting to see how it’s changed. People like me have been banging the drum that we need to talk about suicide, using real words directly. We can’t change speech patterns. We can’t come up with, you know, the words that make people feel comfortable, right. Because nobody feels comfortable if they’re dead. This screener does do a really good job. So full disclosure, we found the screener. This is the nice thing about having an extraordinarily popular podcast. People tend to give you shit when you ask for it. So we contacted a psychiatrist. We got all of their opinions on the subject. We got opinions of some of their colleagues, both good and bad. But the first topic is wish to be dead. But they actually have the specific question. And one of the suggested ways to ask the question, I really love it. It says. Have you ever wished you could go to sleep and never wake up?
Jackie: That’s what I’m saying, the verbiage here. Again, if you’re not expecting it also, I just want to like sidebar for one second. First of all, this protocol is meant to be given by trained professionals, which we are not. We are not giving each other the screener. We are merely discussing the questions on it.
Gabe: And just to be very, very, very, very, very clear, do not e-mail us and ask us for the screener so you can give it to your friends. It doesn’t work that way. If you feel that you have a friend that this needs to be given to, please go to an emergency room, call 9-1-1, make an appointment with their general practitioner. If you suspect they might need this screener, please act. Just don’t act by emailing a podcast, act by getting them medical attention.
Jackie: So the way that this protocol works is it asks you yes or no questions. And it talks about in your lifetime and then also within the past month. So, for instance, on the first one, it would say, have you wished you were dead in your lifetime? And I said uncomfortably, Yes. And then it said, have you wished you were dead in the last month? And I said, no. And that’s the thing, too, is they repeat the question completely for lifetime and last month. So it’s not like, OK. But in the last month, it’s they repeat it word for word. So you hear these questions at least twice during the screening.
Gabe: Jackie, while you were sitting there because you’re there for a physical health issue. So you weren’t planning on dealing with your mental health at all because again, for reasons that we can never explain. Most people separate physical and mental health out entirely. So I kind of want to give like a round of applause to this clinical trial and this medical staff that they understand that your mental health and your physical health go hand in hand. You kind of bought into this idea. You were there for physical health. Right. So the minute mental health questions came up, it was like an extra whump because it was unexpected.
Jackie: It was a whump, indeed, Gabe. I felt shame. I felt so much shame to have to say, yeah, I wanted to kill myself. And later on, this is how I plan to do it. I did not expect to feel that. But then as I realized the questions were going to be quite detailed, I almost had like an internal pep talk where I was like, nope, own this. Don’t be ashamed of this. It’s not who you are right now and you can’t learn from it, they can’t learn from it, if you’re not honest. So I had to like pep talk myself to get through some of these because the shame storm was brewing, but it didn’t need to.
Gabe: Let’s talk about the shame storm for a moment. Jackie’s shame storm, because you have been suicidal in the past. So the lifetime question you answered, yes. But in the last month you answered all no’s you have not been suicidal in the last month. You have not been suicidal in years.
Gabe: And yet the shame storms still came a comin’, even though you were essentially answering, for lack of a better word, correctly. Are you suicidal today? No. Do you want to go to sleep and never wake up today? No. In the last month, have you wanted to kill yourself? No. Like these are the right again making air quotes. These are the right answers. And yet you still reflected back to all those years ago when you answered yes and felt shame. Didn’t you feel any pride at how far you’ve come?
Jackie: No. And I think part of that is because of the nature of the questions. And don’t get me wrong, I think that this protocol is smart. It is the only one that really measures the severity of your suicidal ideations. However, for me personally, being in a good spot. Going back and reliving it in detail was kind of shameful because dying by suicide is shameful. Just ask anybody. Right. I don’t agree with that statement, but I think that’s the go to an end. The person giving me the screener, I was like, she doesn’t know me. She’s going to judge me. Just all these like negative self-talk moments came up and I just really wasn’t expecting it.
Gabe: I don’t think that anybody ever expects to talk about suicidality. It’s not a subject that most of us gravitate toward. Right. You know, we started this podcast out by teasing each other about Star Wars. That’s the kind of stuff that people want to talk about, pop culture. Small talk is designed around the weather and the local sports team. This is a weighty subject. But as we’ve learned, not talking about these weighty subjects is one of the things that’s given these weighty subjects space to really do a lot of damage. People who are feeling suicidal, they don’t have the words, they don’t have the words to walk up to somebody and say, hey, I want to kill myself. I want to go to sleep and never wake up. I have a plan. They don’t understand any of this terminology. And perhaps even more dangerous, even if somebody in that position does have the words, most people don’t understand how to respond to it. We tend to make jokes. I want to go to sleep and never wake up. Oh, don’t we all. Wake me up when September ends. Ha ha ha. Well, everybody feels this way in the winter. The winter blues. We just dismiss that person entirely. This obviously cuts through that.
Jackie: We’ll be right back after these words from our sponsors.
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Jackie: And we’re back talking about the Columbia-Suicide Severity Rating Scale, which freaked me right the f out when I received it at the doctor.
Gabe: Did you feel supported in this process? Because you’ve described feeling shame. You’ve described being caught off guard. You’ve described being scared. And then you described wanting to do a podcast on it. But never anywhere have you described feeling supported.
Jackie: The person giving me the screener, honestly, it’s not her job to be supportive or to be comforting during this process. I mean, she indicated even a little discomfort with the questions. At some point, because I guarantee you most people she’s asked this to said no to everything. She was just like, boom, boom, boom, this is super easy. And then she got to me and it was not easy. Because the first question said, have you ever wish you were dead or wished you could go to sleep and not wake up? So, yeah, right. I’ve wished I was dead. But the next question says, have you actually had thoughts of killing yourself? Which I thought was fascinating because you would think it would be. Well, yes, duh right. But it’s not right. They’re not the same question. They’re different. And the nuances of the question, I think, is what makes this interesting, also triggering, terrifying all of the like negative feelings that can come out of it or hopefully if you’re not me and you’re just sort of like owning your past and your story, just willing to say, yes, this is what happened.
Gabe: I want to give a little push back on something that you said, you said that it wasn’t the person’s job to make you feel comfortable, it was the person’s job just to ask the questions and fill out the charting. The pushback that I want to give is this is kind of untrue, right? It is the medical person’s job to make the patient feel comfortable. And I think this is one of the things that gives suicide space to hide. Right. So the person giving the test is uncomfortable. The person answering it is uncomfortable. So it sort of feels like that rhythm of, hey, how are you today? I’m fine. I’m fine, too. In the meantime, both of the people saying that are actually in extreme distress, but they both assume that the other person is fine. This shows you that we’re not doing a good job of training our medical personnel, especially since I would almost guarantee that that person probably thinks that mental health isn’t the primary part of their job because you were there for a physical issue. And again, I know I sound like a broken record, but this is why we have to stop treating them separately. The psychiatrists that I talked to that administer this test, they’re a lot more comfortable and they’ve talked about practicing poker faces and they talked about the advantage of silence where they would say, have you actually had thoughts of killing yourself? And then they would just sit and the person would mumble and make a joke.
Gabe: And just on and on and on. And they would just sit politely with that poker face and look at them and wait for that person. That’s like an excellent training point, right. Because when you’re uncomfortable and when people are making jokes, your knee jerk reaction is to like joke back. But then that diminishes the question. Obviously, I want to educate all the patients because I don’t think we have a lot of doctors listening to the show. Take this seriously. It’s a great way to gauge whether or not you’re doing better. The majority of us are in long term mental health care. We’re seeing therapists and doctors talking to our general practitioners. We’ve been dealing with mental illness and mental health issues for a long, long time. So having this in our charts and being able to look back five years from now and be like, oh, my God, I’m doing so much better. Like, that’s awesome. Right. But it’s also an early warning system.
Jackie: I actually totally agree because every time I go back now, they ask me the same questions and I’m in a good spot, right? So I say no to everything. But I wish that I had this when I was actually severely suicidal because it would have been nice to see where I was. And maybe then I could have said, like, look how far I’ve come. Right. So, question 5 Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? And that’s where I was like, oh shit. I’ve never really told anybody my plan to kill myself. Right? It’s one thing to say I’ve had suicidal thoughts. I really thought about it. But it’s another thing to say this is exactly the plan that I had and I told her and that felt wildly uncomfortable. She gave me a look of like, oh, wow, this is intense, right? Like when people give you a suicide screener, say, hey, how you feelin? And you’re like, I’m cool. All right. How’s your blood pressure? It doesn’t get into tell me how you planned to kill yourself. That feels like a therapy question.
Gabe: I believe that 100 percent of conversations about mental illness, mental health, our emotions, our feelings, have value 100 percent. And people say things like, well, even the asshole trolls on the Internet? Yes, it has value. It shows you what not to do. It shows you how not to behave. It shows you how not to be supportive. There is something to glean from every interaction. And we, Jackie, hate it when people tell you the right way to talk about mental health. We hate it when people tell us the right way to discuss mental illness, emotions, mental health crisis, grief, anxiety, because not everybody has the same words as Gabe Howard and Jackie Zimmerman. And we don’t have the same words as everybody else. When I was a kid, I described anxiety as a tummy ache, and I was shocked to learn years later that a research study confirmed that kids who have chronic stomach aches more often than not are having issues with anxiety. But my family did the same thing that other families did. Oh, it’s just butterflies. Oh, you’re just nervous. Oh, don’t be a baby. And of course, it was the 80s, so I got don’t act like a girl. Don’t be a sissy. And none of this addressed the anxiety that I was having and my family, they go all the way back to all of this. And like, man, imagine if we would have gotten Gabe help for his anxiety when he was twelve instead of 25. Like what horrors could he have avoided? It’s all water under the bridge now. But, I’ve always said that I want the next Gabe to have better resources and openly discussing these things is going to get you better resources. I don’t know that this was available back in 2003 when I was in the hospital.
Jackie: It wasn’t. It came out in 2007.
Gabe: Yeah. So Gabe in 2003 was kind of asked some basic and some blunt questions. Now, ultimately, it did get me admitted to the psychiatric hospital. But I read over this thing and I read the history of this thing and it’s an excellent step. And I talked to the psychiatrists, and even some of the psychiatrist that were like, you know, it needs work, they still see it as a vast improvement
Gabe: Over doing nothing. They still see it as a vast improvement over the well, every psychiatrist just kind of figures out how they ask and uses their gut. This has a scoring method. This has a list of questions that you really don’t skip over. Right. You ask them all. You score it. It doesn’t rely as much on an individual’s provider’s gut instinct. And I think that’s incredible.
Jackie: Yes, there is no subjectiveness it’s still is on the patient to give honest answers, but at no point in here does the facilitator of the protocol give an opportunity to say, oh, I think they’re actually feeling this way. I don’t know if maybe some of the other screeners do that, but this feels like actual data that they are collecting. It’s not subjective and it’s measurable based on the scoring over time as well, like you said, which makes it a great tool, right? It is a great tool. It’s just when you’re not expecting it. It is a slap to the face where you’re like, oh, we’re talking about this now. We are like really talking about this now.
Gabe: I understand it’s scary. I understand it’s a slap to the face, but there’s lots of things in our life. That’s a slap to the face. There just are. Having somebody that you respect and somebody that you trust to tell you that your favorite Star Wars character is Jar Jar Binks is a slap to the face. But then it gave me the opportunity to explain to everybody that Jackie is an idiot and that Jar Jar Binks is awful and that allows us to work it out and move forward. The bottom line is, if we’re not discussing Jar Jar Binks, Jar Jar Binks would have had a much larger role in episodes 2 and 3. But by openly discussing how much we hated that character, he was diminished. And that’s what we want for suicide. We want suicide to be diminished and impact less people.
Jackie: It’s not funny, I’m laughing, but it’s not funny. It’s kind of funny. But yes, I agree. I think that the better tools we have, the more we make this something that people can talk about now. You know, it’s not supposed to be hidden. And I think that there’s a lot of motion among advocates and among patients worldwide to make this something that we talk about now, only because it helps with prevention, but also because it gives us something to learn from. And this protocol is a great way to do it from a medical provider standpoint. I just think that you should give your patients a little bit of warning what they’re getting. But if you are that patient, use it as a learning tool, like Gabe said earlier. It is a great tool. It’ll be kept in your file. You’ll be able to refer to it later. If you get this protocol don’t want the shame storm build like it did for me. Look at it as a learning experience and be proud that you’re still here to be answering these questions, even if they’re difficult.
Gabe: And Jackie, don’t be so hard on yourself. Yeah. It’s a big topic. You had a shame storm. You owned it. You admitted it. And you called a buddy.
Jackie: I agree there is no easy way to talk about how you planned to kill yourself. There just isn’t. But you can own those experiences by talking about them and by reaching out to people like Gabe said.
Gabe: I like it. Now, I want to be very, very, very clear, if you are worried about yourself, tell somebody call 9-1-1, go to an emergency room, and tell your general practitioner. Tell a trusted friend or family member. If you are worried about a friend or family member, encourage them to seek help. We don’t want to sit at home and doctor each other. That’s not how any of this works. So please, please, we’re really serious about that. Jackie is in roller derby and she will check your ass.
Gabe: All right, everybody here is what we need you to do: where ever you downloaded this podcast, leave us as many stars, bullets, hearts or whatever they’re using this week as possible. But use your words. Tell people why you love this podcast. We would take it as a personal favor if you share us on social media. Want to hear something on the show? Email [email protected] and tell us what you want to hear, know about, what you like, what you dislike, and whether or not Jackie should die her hair blue again. Gabe has personally missed it. Remember after the credits there are always outtakes because it turns out that Jackie and I screw up a lot. We will see everybody next week.
Jackie: Have a great week.
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