What's after therapist/psychiatrist but before psych ward and 911

October 31, 2019 6:31 PM

(CW Sui Ideation, Depression) What are my options between "showing up to weekly therapy" and "calling 911"/"checking in to a psych ward" and/or "completely losing my shit and having this decision made non-consensually for me"?

I am not a danger to myself or anyone else. I am concerned, however, about my curves/velocity/acceleration around moods and behaviors.

Background
I have been doing talk therapy for 7+ years. I have been on a couple classes of anti-depressants which have not worked past a few months. I have tried rTMS and it is not clear that it has helped or hurt. I am on stimulants for ADHD. I am pursuing tests around some auto-immune disorders. I have been in an extended period of unemployment, and the constant, sustained rejection has been poisonous to my mental health.

Recently
I seem functional and social, sometimes I am. I mask a lot. Over the past year I have cultivated good, steady behaviors and habits, taking my meds regularly and on-time, cooking decent meals, quitting smoking. I've made friends in a new city and have many social engagements. I get the shit I need to done. I think I should feel good about that, but I don't.

What I do feel, is that I want to bawl my eyes out, smash things, punch holes in walls, and think a lot about suicide scenarios. I don't want to die. I want to live. And I don't want to live in this much pain. I am now at the point where a Counselor, Psychiatrist, and ARN are not keeping me out of the darkest depths. I would check myself in to a psychiatric hospital but as a trans person this seems terrifying—because I know what's happened to my friends when they did that. 911 is not an option; that is a suicide plan, not a path to treatment.

I have expressed to my therapist and psychiatrist the suicidal rumination. Therps response was empathetic with no advice. Psychiatrist doubled stimulant dose. Neither has been an effective approach, hence, why I'm looking beyond them.

What are my options between showing up to weekly therapy and 911 and/or completely losing my shit and having this decision made for me?
Difficultly level: no fancy rehab, I'm on cheap exchange health insurance because I'm unemployed.

posted by anonymous to Human Relations (10 answers total)

Sorry you're feeling so bad. I recommend DBT*. There are special counselors trained in DBT. DBT has a whole lot of skills you can learn and some are very specifically for suicidal ideations. There are many skills, so if one doesn't work for you, another might. You can even start on an internet group and/or learn about the skills yourself online -- since most new service providers can't get you in instantly. Memail me if you wish.

*Dialectical Behavioral Treatment/Therapy
posted by intrepid_simpleton at 7:04 PM on October 31, 2019 [4 favorites]

Knowing where you live would be helpful for this, but Partial Hospitalization Programs or Intensive Out-Patient Programs might fit the bill?
posted by superlibby at 7:05 PM on October 31, 2019 [11 favorites]

Would it be helpful to attend a support group as a supplement to the weekly therapy sessions? There might be options in your area.

Is changing therapists feasible?

I have experienced major shifts in mood around medication changes; have you recently begun or ceased one of the antidepressants? Has the new stimulant dosage messed up your sleep at all?

What you are going through really sucks; I am rooting for you and hope that you have a breakthrough soon.
posted by Schielisque at 7:21 PM on October 31, 2019

Here is a description of the partial hospitalization (up to six hours a day) and the intensive outpatient (3hours a day) program at our local hospital. The full day program includes a mix of individual sessions with a therapist, support groups, learning coping skills and some less demanding arts and crafts or something similar. You also get assigned a psychiatrist to make sure your meds are working for you. There was also someone doing life skills and transition planning to help figure out what came next. (The one we had was OK sticking with the existing mix if it was working.) A family member did this - the full day program was basically a safe place to be every day as well as providing a variety of short term therapy to get things back to functional. The shorter program was focused on the therapeutic part of the process. All of this was covered by insurance (with prior approval). For us, this was a transition after a hospitalization but I would imagine insurance would find it far cheaper than an in-patient care. For our local system, your therapist could the intake desk and make a referral to get things started.
posted by metahawk at 7:25 PM on October 31, 2019 [3 favorites]

Yes, partial hospitalization or intensive outpatient (IOP) are the programs at the level you want. Is there someone who can help you argue with your insurance company if they balk at covering it? As metahawk said, it's definitely cheaper for them than inpatient care.

Hugs to you. Memail me if you want help looking up programs in your area.
posted by lazuli at 8:23 PM on October 31, 2019 [2 favorites]

I'm sorry you're going through this. It requires real strength to stay functional, maintain your relationships, and manage all that wretched real life shit, especially while you're in such a painful place mentally, so it's totally rational for you to feel exhausted and frustrated when things have been so difficult for so long. Others have offered good info about ongoing intensive support, so I'll just add crisis hotlines as a potential option for especially dark moments.

It sounds like you're in the US--the Suicide Prevention Lifeline has a bunch of options, but The Trevor Project is focused on younger LGBTQ folks; I'm less familiar with Trans Lifeline but I know it's out there. Crisis Text Line is what it sounds like, and a number of the phone-based hotlines also have text/chat options. They're out there to listen and support you, and help you keep yourself safe in moments of crisis.

I'm rooting for you. Take care, and I hope you find something through this ask that's helpful to you.
posted by jameaterblues at 9:57 PM on October 31, 2019 [1 favorite]

Along the lines of what witchen is saying: If having a plan for care in advance sounds helpful, you can also fill out an Advance Care Directive, which is super legal-y but would give you the legal power in advance to say what kind of treatment you want/don't want, who you want informed, etc. if you are psychiatrically hospitalized. (I think that some people would find this process comforting and others would find it triggering, so ignore me if that sounds triggering.)
posted by lazuli at 5:46 AM on November 1, 2019

Call your doctor. A fresh course of anti-depressants may provide some relief. Call your therapist; they may have an emergency appt.

There is help. Call a hotline, find local resources. Even brief respites are valuable.

In addition to the above, there is a lot of evidence that exercise and being outdoors provide some help. If you can, spend some time outdoors in sunshine, walk or otherwise exercise. Vitamin D supplements may help. This is self-care that may provide a bit of relief, not a replacement for medical care. My dog is a terrific help when I'm really depressed, and he's not super-cuddly, just a good companion. Visit a shelter, borrow a dog to walk, offer to visit a friend's cat.

It's hard. I'm sorry you're having such a difficult time. I know you want to live, but the suicidal ideation means you are at risk. Be as good to yourself as you can be. I wish you the best.
posted by theora55 at 10:00 AM on November 1, 2019

Intensive Outpatient or Day Treatment programs. Maybe DBT to help you cope, emotions, and build a life that feels meaningful.

Distressing feelings are a regular part of life. Feeling like they're taking over your life is not. I'd recommend therapies like DBT that don't fix the feelings or promise to take them away, but help you live with them and build some enjoyable stuff into your life too.
posted by unstrungharp at 11:24 AM on November 1, 2019 [1 favorite]

Crisis planning: I told my psych+therapist I needed to set criteria for evaluating safety. This is different from the safety plan - it's more like if I start doing A, I will get an emergency appt; if B, I will go to the ER, etc. I did find that it made a significant difference admitting voluntarily to a hospital where my psych had privileges and therefore could act as my advocate.
You may want to look into the psychiatric advance directive - likely not legally binding, but more useful for psych care by far. Here is SAMHSA's. Carry a summary card in your wallet.

I guess ultimately it's: why do you need to mask? What do you fear happens if you don't? The people who showed up for me when I gave up on holding it together are why I stayed.
posted by ahundredjarsofsky at 1:03 AM on November 3, 2019 [1 favorite]