This is a Trick (or treat) question: The answer is either, neither, or both pumpkins. One could be minimizing, the other might be overreacting. The right answer is that more information is needed.

This is a Trick (or treat) question: The answer is either, neither, or both pumpkins. One could be minimizing, the other might be overreacting. The right answer is that more information is needed.

Are you ever concerned that someone you know, or care about, is depressed?  Maybe you’re even worried about yourself.  What are the signs that people who judge those things — like therapists or doctors — look for?

Most importantly, what should you look for, and what can you do about it, anyway?

Here’s a quick tour of the symptoms of depression:

  1. Lack of motivation is more than daydreaming or putting off housework once in a while.  Lack of motivation due to mood disturbance is all-encompassing and includes not wanting to do things you usually like to do or not finding pleasure in doing them.
  2. Sleep disturbance isn’t just the once-in-awhile variety of insomnia nor is it the weekend catch-up sleep most of us seem to need.  While we all worry and sometimes we can’t sleep because of it that’s no reason to believe you’re depressed.  By the same token, you may oversleeping because you need rest.  Sleep disturbance due to depression is not refreshing, not productive and happens more times than not during a distressful period.
  3. Poor concentration describes difficulty keeping your mind on a task, especially when the task is something that needs attention paid.  This includes work, reading, watching television, a hobby, or talking with someone.
  4. Poor appetite or overeating is remarkable if the behavior is outside the norm.  No doubt that, from time to time, we’ve all indulged (too much) in a favorite food; teenage boys are notorious for being bottomless pits.  Reasons for not wanting to eat range from having a stomach bug to not liking what’s for dinner to being fussy.  If an eating disorder is present, though, that’s cause for concern because of its link to depression.
  5. Feeling down, depressed or hopeless has no up-side; always pay attention.  Feelings such as these are not transient, in-the-moment feelings; hopelessness is in no way comparable to disappointment.
  6. Never ignore thoughts or verbalization that it would be better to be dead.  Talk to a counselor, doctor, or clergy as soon as possible.  Don’t second-guess yourself If a plan is in place, and the means to act on suicidal impulses are handy — get to the emergency room right away!  Perspective gets lost when people force a permanent solution onto what may be a temporary problem.  Getting the right help can literally be a lifesaver.

If you’re concerned about suicide, ask.  It’s a misconception that asking “plants a seed”.

Depression is a signal that something’s not right.  Is it brain chemistry?  Relationship or work problems?  Something personal?  The biopsychosocial model says that all spheres of who we are — the biological, psychological, and social —  all “communicate” with each other.

Like all things that get out of whack, whackiness comes in degrees.  Problem-solving the degree gives you information about what to do.

What to know

  1. Is there significant distress or impairment?
  2. For how long?
  3. How often?
  4. Who notices?  And what’s noticed?
  5. Could it be something else, like substance abuse, medication, or a medical disorder?

Sometimes the only intervention needed is someone to listen; an interested and uninvolved second party can give the much- needed perspective someone needs to get out of a funk.  If you feel like you’re in over your head, you probably are.  In fact, even professionals call on other professionals when they feel stymied.

There’s no shame in helping someone identify resources that don’t include you.

The pumpkin illustrates there’s not just one face to depression. It’s complex and sometimes not easily spotted.  The best we can do is to be non-judgmental, kind, and available to listen to someone who’s having a hard time, depressed or not.

In case of a mental health emergency, call 911 or go to the nearest hospital emergency room.  

US Suicide Hotline 1-800-784-2433

Kathe Skinner is a psychotherapist in private practice who works primarily with couples, individually and together.  She supports several mental health initiatives, including Project Semicolon, whose message is that your story is not yet over — and encourages obtaining a semicolon tattoo.  She lives in Colorado with husband David and their two hooligan cats.  Find out more about Kathe @ www.coupleswhotalk.com or www.beingheardnow.com.

© 2015 Being Heard, LLC

Cartoon © Donna Barstow, used with permission


suicide wordly

(This blog was first published by Disability.gov.)

 In the mega-wattage aimed at Robin Williams’ suicide everyone had something to say.  But when all was said, everything went back to the way it’s always been when mental health’s the issue.

The disabled or chronically ill population often inhabits a landscape where mental health is a place of shifting sands; they know that psychological symptoms are only part of the territory.  And though they might not know it, anyone else who’s ever seriously considered, or attempted, suicide has been there, too.

Reason 1:  Suicide is a perfect storm. A confluence of factors accounts for an attempted or successful suicide.  The biopsychosocial effect describes three separate but linked factors that make for the perfect behavioral storm.

The first, biology, talks about the genetically present markers that provide the tinder that can predict a life-ending event.  Certain mental health disorders result from biological events and can’t be caused by events in our lives, schizophrenia for example.  In fact, most of the diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), are a result of nature, not nurture.  (That doesn’t mean that nurture or experience can’t affect nature.  For example, brain structure can actually be changed by the cumulative effects of stress).

A solid neural whack is enough to upset the brain’s apple cart and to actually affect the apple cart itself (i.e., traumatic brain injury, chemotherapy).

The psychological factors refer to how thoughts and feelings are processed into behaviors.  How we think and what we think about ourselves and our world are significantly influenced by nurture and experience.  Amazingly, significant amounts of emotional stress will actually change the structure of the brain – the hard wiring.

The good news is that when brain structure has been determined this way it can also be reversed.  Buddha had it right when he said that we make the world with our thoughts.

Adult caregivers, or older children in our own families, are the early source of how we position ourselves psychologically.  Peer groups, even one person within that group, are also influential: bullying comes to mind.

Social factors refer to what’s happening around and to us.  For example, when terrorists blew up the World Trade Centers people around the world experienced significant psychological reactions that were clinically diagnosable.  These are the situational diagnoses without a biological cause, although an existing mental health problem may be triggered by events.

For instance, a major depressive disorder can be brought on by grief, whether or not a history of depression exists.   Trauma can be brought on by exposure, or over-exposure, to a horrifying event.  That’s what happens when people are flooded with 24/7 video of disaster images, or a job involves continual exposure to disaster or tragedy.

Reason 2:  Suicide is a game of dominoes.  A precipitant can be found in any third of the biopsychosocial formulation, igniting reactions in the other two spheres.  Reactions are ramped up as one sphere feeds the others in endless loops.  Without intervention in at least one area, a body’s systems can break down.

For example, I’ve worked with diabetic clients who pay poor attention to insulin levels, diet, and exercise.  This is especially true of teens.  Reasons might include not wanting to be different, interference with having fun, being marked as “not normal”, or that testing is an interference.  So while anxiety is part of diabetes’ medical description, that emotion may be worsened by psychological factors like negative thinking, and social factors like being shunned at school.

Reason 3:  Suicide is personal.  Duh.  Suicide is the ultimate personal decision and action.  Even if you think you’ve made up your mind about whether it’s ever right for a person to take such action, there’s always a “but what about this?” scenario.   The rule that works is stated “It Depends”.

Consider these factors:

· Quality of life

· Loneliness

· Unrelenting physical pain

· Chronic emotional pain

· Persistent emotional and/or mental pain despite treatment

· Terminal illness

· Loss of dignity in living

· Fearfulness about the future

Which of these situations justify taking your own life?   Do you think that one area of the biopsychosocial model predominates in a decision to commit suicide?  Does seeking to die always signify depression?

In 1975 the Karen Ann Quinlan case went to the U.S. Supreme Court before the right to die with dignity for those in a vegetative state was established.  It might be said that Karen Ann’s parents fought for the right to “commit suicide for her”.

The 1981 film starring Richard Dreyfus, Whose Life Is It Anyway?, addresses a quadriplegic’s right to die by refusing nourishment – a passive suicide.  The film presents the moral, legal, ethical arguments that are often arrayed against individual choice.  Not much has changed: decades later over 90% of states don’t allow for physician-assisted suicide, what is euphemistically called death with dignity.  

Our society lags behind other industrialized nations regarding physician-assisted suicide.  Here the rule is that the illness must be terminal with physician intervention occurring only when death is judged to be imminent.  Rather than being enlightened, our nation’s religious, legal, and medical institutions are queasy at best about death, and hands-off at worst.

The result is that lots of suffering happens well before a physician provides assistance.

Reason 4:  To suicide or not to suicide, that is the question.   Without human resilience the rate of suicide would skyrocket.  That this is true is demonstrated by people who don’t commit suicide even though they share circumstances with others who do and even though their mood is likewise affected.

In the case of minors and adults with diminished intellectual capacity, it ought to be our business.  But all American institutions consider all suicides their business, acting in many ways to prevent it.

Death of any kind seems to be owned by the living, whether it’s scary or exciting or mourned or praised.  The morals of the civilized world seek to prevent death at any other hand than its own.  It’s a great irony that once a life is saved little energy may be expended in assuring the quality of that saved life.  Society sends double messages:  suicide is prevented but it all too often doesn’t accept the burden of providing for care or being respectful and inclusive to those who’ve been saved from a fate-worse-than . . .

Reason 4:  Suicide can be just a matter of time.  Robin Williams’ death illustrates that suicide can be the result of many factors, not just depression.  He was loved around the world with an enormous talent and humanity that made a difference in many lives.

It wasn’t enough.

Robin Williams carried the burdens of Bipolar Disorder, so his death ought not to have surprised anyone who knows about the illness.  It wasn’t just the depressive side that Williams’ displayed, although that’s what most news reports covered.  I suspect it’s because most everyone is familiar with depression as causal in suicide.   A rare opportunity to educate around the world about Bipolar Disorder, which includes periods of depression and mania, was missed.

While most everyone knows that depression can lead to suicide, poorly understood may be the role of mania, which is more than mile-a-minute speech and behavior and includes impulsivity, especially relevant here:  Williams’ final impulsive act was to hang himself with his belt, not a well-thought out suicide.

Reason 5:  Stress can result in suicide.    Any problem in an individual’s system – chronic or acute illness, situational or inherent mental illness, social or environmental factors, the ways in which we think – can provide the potential for distress.   Lots of straws have to drop into place before the camel’s back is broken.

Even so, suicide isn’t a slam-dunk.

But know this:  chronic illness or disability increase the odds of being negatively affected physically, mentally and socially by distress.  An already-stressed system is already part of the way there.

And while some of us are more exquisitely tuned to stress than others, it’s familiar territory for everyone.   Even so, from prisoners of war, to marathon runners, to cancer survivors, many of us display a resilience we didn’t know we had.

Robin Williams was carrying financial problems, mental illness, and a fairly new diagnosis of Parkinson’s disease into an upcoming year of hefty professional commitments.  Despite the affection of the world, Williams ended his life alone.


For the abundantly stressed, chronically ill, or ultimately alone, like he was, suicide may be the most understood act of all.


This blog was first published by Disability.gov.  

Kathe Skinner has been diagnosed with multiple sclerosis for over 35 years, which has compounded genetically predisposed depression.  She knows first-hand what suicidality feels like.  Ironically, she finds her work as a Marriage & Family Therapist anything but depressing.   She is in private practice in Colorado where she lives with her husband, David, and their 2 hooligan cats. Read more about Kathe at www.beingheardnow.com or ilikebeingsickanddisabled.com.

Kathe welcomes your comments and can be reached at 719.598.6232.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net
©  2014, Being Heard LLC



I keep a book in my office and if I had a coffee table, it would be on it.

It’s red, with a coffee spill down the front that’s dried into a Rorschach-kind of thing.  Nifty for it to be in a therapist’s office.

Inside, dozens of clients have written their “should’s”.

It’s not instructive to describe what they said; more than likely, their self-flagellations are the same as  yours.  What catches the new subscribers is how similar their self-flagellations are.  Put another way, there’s nothing special in their dysfunctional thinking.

Back when I was exploring how should’s get perpetuated, I was stunned and amazed to find myself described in the exact words I’d always used in describing my neuroses (notice I used the plural).  Admittedly, there was disappointment in seeing myself laid out like some common Rorschach wench.   I suspect that others, too, hold their depression, anxiety, mania, whatever, as a sort of badge of differentiation from others.

For others, as it was for me, depression is powerful; it was the coin of my realm and the way I bought into the realm I inhabited growing up.  Depression can get attention, especially when nothing else seems to.  That can be true in a  marriage where one partner exists with an invisible disability.   And just like for the kid who acts out, it’s attention of some kind, even if it bears a high price.

Being a therapist, consequently, has been double-edged: one edge cuts through the dysfunctional thinking, the should’s, the irrespective unfairnesses; while the other is sad to see those defenses so cut down.  What I do in my office forces me to be embarrassed at my own mental laziness.  Being depressed is hard; so is being anxious or manic.

But hey, it’s hard even when you’re not.

Kathe Skinner is a Marriage & Family Therapist and Relationship Coach in Colorado Springs, Colorado.  She comes by depression naturally as well as artificially and has recently added anxiety, for which she can thank multiple sclerosis.  Petey and Lucy, the two hooligan cats Kathe and David share their lives with, are too annoying to let depression settle too quietly in their home.  Kathe and David get out of the house by teaching partners the communication skills their relationships need.