Talking About Suicide

Talking with Natalie De Stefano

 March 4, 2013

This is a story about someone who worked for years in suicide prevention, knew and preached the coping skills and still ended up trying to kill herself. Natalie De Stefano wrote to me last month, and her story leapt off the page.

Imagine having a migraine, or living on the brink of one, for 20 years. And finding no medications that help. And being told, “Hang on ’til after menopause.” Natalie tried. As she counseled suicidal veterans as a case manager, she wore sunglasses and kept her pills nearby. She loves her work, And then last year, the pain got worse. She began having migraines every day, with nausea and vomiting. After her attempt, she was in a coma for more than a week. She woke up angry.

And pretty bewildered. Her psychiatrist told her he couldn’t see her for three months. “So I sat at home wondering what the heck was I supposed to do. Nobody could relate to me.” In her work, she wrote, “we made sure veterans had follow-up appointments, phone calls, letters, cards, support group meeting appointments, and they were always welcome to call me or drop by anytime. I look at what is happening to me and think, ‘Huh, this is rather strange.'” Finally, her boss at the VA hospital stepped in to take over her care.

Here, Natalie talks about the special challenges of comforting veterans, the national pilot project of veterans’ support groups for attempt survivors and, of course, her most recent lesson in suicide prevention.

I’m a nurse at a VA hospital. I was in the Navy seven years, and so I wanted to be there and serve fellow veterans. Being a nurse is something I decided to do later in life, but I really enjoy it. I really enjoy having vets to talk to. I have a good rapport and understand where they’re coming from because I’ve been exposed to, well, I’ve had depression a lot of my life. I had a lot of the same problems. I know when you’re a vet and you work at the VA, they feel they can trust you more. And if you experienced some of the same things, they feel more open to talk to you about things. So I like that part. I’ve worked in the in-patient psych unit, in suicide prevention. I love all aspects of mental health nursing. Anything about helping people. I just really took the job seriously. If someone called and was suicidal, I just did whatever I could to get them resources to get some help.

I have one son, he lives in Belgium. I had him while I was in the military, to a Italian citizen. We eventually divorced. My son was parentally abducted from me when he was 7, and I haven’t seen him since. He’s 25 now. I only talked to him on phone and Facebook and stuff since he was, like, 13. So that was a lot of depression right there that I eventually overcame, but it’s still there. Both of my parents are gone, no brothers and sisters, just me in the world. So I go to work and really put my, you know, it’s like my family.

I have a dog. My dog is like the thing I love so much. He’s a Boston terrier, his name is Adler. He has so much energy. He gets up on my bed, kisses me, keeps me going. I have a roommate who’s also a nurse at the VA. We keep each other going. She’s a psych nurse also. That’s basically who I am.

There must be something about dogs. So many people I speak with have them.

Yes, I when went to a conference in San Francisco, we had a woman speak about how effective they are as therapy. Really, I always tell vets, if you’re able to take care of yourselves, a dog is so beneficial.

I’m thinking over what you said in your e-mail. One part that really stood out was when you said that you had worked in suicide prevention and knew exactly what to do.

Obviously, I know all the coping skills. We have a group at our VA. If you’re at high risk for suicide, you’ve had a high-risk attempt, we have a group on Tuesdays at 1:30 and Thursdays at 6 for people who survived, because they have no one else to talk to. They just give each other encouragement.  Part of my job was to call people, make sure they were OK. I called them every week: “Hi, this is Natalie, how are you doing today? What’s going on? Any suicidal thoughts? Have you eaten today? Have you taken your meds? Do you need to talk?” Plus, we sent out cards and letters. I tell people they can stop by the hospital any time it’s convenient, just come into my office and I’ll make time to talk. So I knew, I know what people need when it’s over and they’re just left there. And I know what they feel when they’re getting ready, when they’re on the edge. So I know both sides of the coin.

So, after it was over and they told me I could go home, nobody made any appointments for me. I was at a regular hospital. I had been in a coma eight days and was not expected to live. I had a living will, but they didn’t honor it. Anyway, nobody helped me. My psychiatrist didn’t contact me, and when I tried to make an appointment, I was in shock, and he couldn’t give me an appointment until the middle of March. So I was like, “What am I supposed to do now? I don’t have my medicine.” It was like, “This is terrible.” I kept trying to call and page him.

I have really bad insomnia. While I was in a coma, I lost a lot of my short-term memory. I have no ability to sleep now. I will stay awake 24 hours a day. I’m literally awake if I don’t have something to help me. I was awake for days. I finally talked to the chief of mental health at the VA and she said, “Just let us handle your care.” She got me to a new psychiatrist who didn’t know me as a VA employee. So she was very nice to me, and on a day she wasn’t even working, she met me and talked to me, worked out a treatment plan. She understood I couldn’t sleep and made it available for me to get meds to sleep. Because if I don’t sleep, it brings on migraines, which was the number one reason for my attempt. So that was really important. That was good.

Also, normally, our psychiatrists at the VA are so busy, they only see you 15 minutes to do a med check. Also psychotherapy. So she’s really going over and above. Tomorrow, I have an hour’s appointment. I can talk about all that’s going on, what’s changed, what’s gotten better. She’s really more like a therapist and a psychiatrist all in one. Normally you just go into the psychiatrist and it’s, “How’s your medicine working? OK, see you in three months.” My chief of mental health helped me so much. She helped facilitate because I’m still on leave. They’re really just like a family. And I know a lot of people have one bad experience and think all of the VA sucks, so this is just to let them know it doesn’t.

How recent was this for you?

Jan. 11

You’re OK talking about it?

Yeah. It’s all right.

With all of your experience in suicide prevention, how could you still do it?

My number one thing was pain. And pain, as I found in working in that suicide prevention position, pain is a big, big factor for people. You don’t understand until it’s your own personal thing. I had migraines for over 20-something years. And for the last six months before my attempt, the migraines were worse and worse. I missed so much work. I went to doctor after doctor. They tried me on different medications, which made me sick to my stomach, made me uncomfortable, fatigued. They never, ever took the pain away. I went to one, supposedly this person in the civilian world who was a headache specialist. I’m 50 years old, and I can’t go on vacation, can’t go out at night, can’t make plans because I don’t know if I’ll have a headache. It had been that way for a long time. So I see this specialist, or his nurse practicioner. She doesn’t have much of anything new to tell me. She tells me that in time, it will get under control. Well, my time was up. I was tired of having a headache, and I’m sure people were tired of hearing me say I had a headache. The pain was just so excruciating.

I had an outside therapist and kept telling her this pain was really starting to get to me. And I knew what the coping skills are. But to me, in my mind, it was best not to have the pain at all. I just didn’t want the pain anymore. I’ve heard all the arguments about that. You know, “Suicide is a permanent solution to a temporary problem.” Well, this temporary problem was going on for over 20 years. It was a problem every single day. It had become who I was, and if you knew me, that’s what you associated me with, having a headache. And it wasn’t just me. My mother had had these, and I just saw how she was. And I didn’t want to be some debilitated person. I just wanted to go out my way. That’s it. I really had no intention of ever being alive again. I thought I had planned it pretty good. But someone had another plan for me.

But yeah, I had been going to more frequent counseling. I journal, I crochet, I do tons of different stuff. I have my dog, I read, I do a bunch of stuff on the Internet. I do a lot of coping skills, you know. And I know the coping skills for pain and have told them to people. “Why not have a nice hot shower?” I’m in so much pain that only if I got a gun and shot my head, and you’re telling me to take a hot shower? I don’t think so. For a time I was on narcotic pain medicine, but that just took it away for that moment and then it was back again, a blinding insane pain.

How is it now? How are you?

On Friday, I went to my VA primary care doctor to get medication that you can take every day to cut down on the frequency and intensity of headaches, but nobody wanted to let me take it because suicidal thoughts are one side effect. Well, that’s one side effect of almost every medication. I was getting frustrated, crying, couldn’t take it anymore. So I’ve been taking it since Friday, not really time to build up, still having some headaches. But if I take the medicine immediately. And I know what all my migraine triggers are. Last night, the guy next door, teenagers, started playing their garage band outside, so that one I had no control over. I just had to deal with it. I’m hoping that will cut down on things for me. And I’ve got about six appointments. Before, all they wanted to do was MRI and CT. Now they’re doing vascular studies for circulation to my brain, some really in-depth tests to figure out what’s going on. This much was not done until it got serious.

How much longer are you on leave?

I don’t know, that’s up to the psychiatrist.

What have been the reactions?

Most people that I helped knew I was a veteran. Of course, I didn’t cross the therapeutic boundary and share my personal life. I think some knew I’d had headaches. I had the meds on my desk, had sunglasses on, things like that. The majority of them don’t know, but the ones I’ve seen have been OK with it. They treated me like another veteran. I think the employees have been a little more uncomfortable, not the ones I work with directly, but some others have been more uncomfortable with me than the veterans themselves.


I think because a lot of the veterans I worked with in suicide prevention, I also had worked with them in the residential substance abuse unit, so I guess they could empathize.

Like you empathized with them in the first place.

Exactly. You don’t have to really know what someone’s reason was. You just have to know it was something they couldn’t deal with anymore. You don’t have to know that much about it to know it was something extremely disturbing to them to do that. It really has to be your very last resort. And I’m not saying it was easy to do. It was something I had resigned myself to. I just got up and, I don’t really remember much about that day even. I just had read a whole lot and wanted to make sure that I didn’t throw up, drank milk between handfuls of pills. I remember lying down on the bed, but that’s not where they found me.

They took you to a non-VA hospital. Once you woke up, how were you treated?

While I was in ICU, they were very nice. I had a one-to-one sitter. At first, I didn’t realize that was going on. That’s the right protocol. The nurses were nice. I couldn’t eat anything or drink anything after they removed the tube from my throat. They gave me some ice chips. I was so thirsty. They got a little impatient with me then. But you know, nurses have a lot to do. I understand it.

How did you wake up?

I don’t know. I have absolutely no idea. I just remember, I guess it was one morning, and I opened my eyes, and when I opened them I thought, “Oh shit, this is not good.” I saw my roommate and my boyfriend and I was just like, “Oh my God.” The chief of mental health came and was saying, “I’ll take care of everything for you, Natalie. Don’t worry about missing work, just call us and let us know what’s going on.” Of course, lots of things were going through my head. I was angry, really angry.

How do you get over that?

Well, I think you just have to …  I think I’m still angry. I don’t think you can get over it that fast. I just try to push it to the back of my mind. I think the only time I think of it is when I get a headache: “I never would have had to deal with this if I had died.”

When had your migraines started?

They started in the military. The day I got out of boot camp, me and two other girls in the same command, we rented a car. We were in Florida and were going to a girl’s home in Alabama for an Auburn football game. We had three days’ leave. She was driving really fast in the country. I was sitting in the front seat: “Please slow down, you’re scaring me.” “Oh, I know the road like back of my hand.”

I just remember the car just rolling, and then I woke up and went through the windshield and woke up in a bush. I don’t know. I lost my shoes. All these trucks had pulled over, and all these people were praying over me. And the girl in the back broke her neck. So, the start of really bad headaches.

How will this recent experience change what you do in your work? Will it?

Well, yeah. I think the three of us, when we worked together in the office, we went to so many educational seminars. I read so much, just trying to get as much information about suicide as we possibly could. I think that we heard so many people say that, you know, suicide is preventable. And I think you can help some people to not do it. But I think in my mind, maybe I just thought that if you reached anybody in time, you can stop them. Now I know that you may be able to reach 99 percent, but pain is the one driving force that people can’t live with. And a lot of suicides I saw, or attempted suicides, were over relationship problems, “My wife left me, my girlfriend left me.” Even the completions were about relationship things. The people who ended up, most of the ones completing, though, were pain things. And at the end of my time in that job, the KASPER reports were coming out, and people were cracking down on not giving out pain medication, and more people were calling the hotline saying they would kill themselves because their doctor stopped the pain medication. People really have legitimate pain, and they all get lumped into the same category of drug-seeking, and you leave out people truly with pain issues, and that’s where these things can happen.

Now you work in a different section of the VA.

I have people who say they had a suicide attempt and were addicted to, say, crack, and so they left the inpatient unit of psych and came to my unit. They’re still dealing with what they did. So I think that’s more insight when talking to people, and understanding.

You mentioned not crossing the boundary of therapy and telling too much about yourself. But it seems it would be helpful if a person knew that the therapist really understood their situation. How do you balance that?

Some things you can do. But you have to be really selective about with whom, and what information, you share. If I was talking one-to-one with somebody who, say, lost a child or had a child taken away to foster care or such, and they’re angry and upset and having suicidal thoughts, “No one understands about not having my child,” I might share something about that. Because a lot of times when you’re in a really dark spot, you feel no one understands where you’re coming from. So, knowing that the person you’re talking to has experienced something in that area, that can develop good rapport. You don’t have to tell your whole life story, because you’re not there to be their friends. Because then they’re confused. You’re there to support, but you want them to know you’re a person and not immune. A lot of times people think, “You’re hospital employees, you have no problems,” but that’s not the case at all. You just have to draw that line.

Can you imagine sharing your recent experience?

I can. Yeah, I can.


It would depend on the person. Maybe if they were still in that angry state. It’s hard for people to actually get clean. So, doing the work of getting clean and just having a suicide attempt, that’s two things to work with. And if you’re angry you’re still alive and you’re trying to get clean, and you feel nobody else understands because “I don’t even want to be alive, but I’m trying go get off crack” or whatever, at times I think a powerful something like that can be helpful to somebody. I don’t think it would be something I would share every day.

I’m always surprised to hear about stigma among colleagues in the mental health profession. That they wouldn’t mention their past. These are just the kinds of issues you’ve trained for.

Sometimes at work, people just freak out, even though they work in that area. They don’t expect to see that from you if you’re working there. They’re at a loss. To me, I think I would be able to make that transition to, “This is someone who needs help,” but I guess some people can’t. It’s too scary for some people. It’s still suicide. And there are still people who don’t want to talk about it. We constantly did education on how to handle a suicidal phone caller. And there were people who were like, “I can’t talk to someone who is suicidal.” Licensed social workers of 20 years! People get nervous and anxious and feel like they might say the wrong thing and don’t know what to say. We do the training to explain it to them, but I think it just obviously takes a special person to work in that area.

And it’s stressful, I’m not gonna lie. There’s so much PTSD, and there’s so much self-medication, and there’s so much suicidal thoughts that even people in the retail store of the VA or other areas like MRI, CT, X-ray, they still have to have those communication skills. Therapeutic communication skills are a must at the VA. You can’t be the VA of the 1960s anymore, where people were yelling at you and ignoring you and pretending your problems were not there. This is where everyone’s trained on how to talk to you if you’re freaking out, having a flashback. If it’s happening in the lobby and a greeter is there, in the pharmacy, they should know to handle it.

Do they?

Yes, that’s part of the suicide prevention policy. I’ve been training all over the hospital. And when something happens, nine out of 10, it’s because somebody didn’t know how to verbally de-escalate the person who was upset. You know, people don’t have a lot of patience. PTSD, people with depression, they don’t want to get out of the house, much less go to the pharmacy and wait two hours. So they raise their voice. So the response is not to raise your voice even higher or to treat them like a child: “Listen here!” That’s not the correct response. The correct response is to lower your voice and ask, “How can I help you right now? Can you explain the situation to me, please, so I can try and help you better?”

I don’t think I’ve asked, where are you?

I’m in Louisville, Kentucky.

How would you change the system, based on your experience?

I still think there’s a lot of stigma as far as active-duty people. You can tell. When I do trainings in different places, it’s just not something … It’s still, “Suck it up and go on.” A lot of times, it’s mostly in the Army and Marine Corps. I think the Air Force and Navy are pushing to not hold it against you when you have suicidal thoughts and get help.

The speakers who would get up and talk, you could tell there was still somewhat of a stigma. And the survivors of the men _ I say boys _ who committed suicide were so angry because had written letters to commanding officers and nothing got done.
And you know, for me, the pain was my number one thing, but for them, it was what they’ve seen that was the number one thing. As much as my pain was an everyday source of stress to me, these young men, what they’ve seen is so completely horrific that it invades their thoughts every single day, and it gets to the point where they can’t deal with it.

We really have to be more aware of what’s going on around us. I would go do a training and ask, “OK, what are the signs that someone might be depressed?” And then, “When they get worse, what are some signs?” Some people might know, but if they’re in the military, the thoughts get kind of pushed aside in the immediate day-to-day things they have to do.

But now what they’re here, the spouses have to be more aware. I have a lady who does my hair, and her husband just got back. I told her if he needs anything to come see me. I’ve asked her, “How are things going?” “Well, he’s having problems adjusting.” “Is he angry?” “Yes.” “Is he violent?” “Not with me and the kids.” And last time, she said he had been drinking more than he usually did.

I think people don’t want to believe it’s something that could happen. And the soldiers don’t want to tell their wives these things. Or they’re self-medicating. They’ve got kids to take care of. The wives just really have to know. The families have to know. The friends have to know. And if you’re not mental health professionals and not involved with their care, you think, “Oh, he’s just going through a hard time, he’ll be all right.” That’s a 50-50 chance you’re taking.

I just talked to my stepmother for the first time last night since I got out of the hospital. She said she had asked my roommate, “Do you think she did that on purpose?” My roommate said, “Of course.” My stepmother told her she had had no idea I was having those kinds of thoughts, but she had heard me every day say what kind of pain I was in.

I’m not arguing here, but saying you’re in pain is not the same as saying, “I’m in so much pain, I’m going to end it.”

You know, to me, if somebody’s talking to me on the phone every day a lot, and they were talking to me about how much pain they were in, crying, how they had no life because they had nothing but pain, I would immediately be talking to their family. I would. Anything that is invading somebody’s thoughts every day to the point where it’s consuming their life definitely is something to be concerned about, and if they’re not talking about it, but maybe something has changed, they’re not talking about it at all, they’re isolating, you know, I would be bringing that to somebody’s attention. It’s not always going to be the textbook signs and symptoms.

When I go out to, you know, I’d go to the mall _ well, not the mall, because I hate the mall _ but I could tell, I could see people’s depression. If I saw someone was crying, sometimes I’d go up to someone I didn’t know and talk to them. I’d be at Costco or whatever and see someone having a hard time and just talk to them.

It’s a lot of work, and lot of times it’s easier for people to think, “She’ll be all right.” And once you bring up that thing and you ask somebody, “Are you having suicidal thoughts? Are you thinking about killing yourself?” you’re kind of in the driver’s seat. To talk to them. You know, that’s why we have the QPR training. It takes time to have those conversations. People, a lot of times, are just involved in their own thing.

You see so many people at these conventions, 900 or 1,000 people at these conventions, all trying to get information on how to help people. Think about that. Only 1,000, then all the people who are suffering, maybe be having suicidal thoughts. And these people are trying to increase awareness.

You know, if you Google “survivors of suicide,” that’s for the people who are like the wives, the husbands, the parents. They’re not for the people who have survived their own attempts.

You said you have a support group at the VA. I’m impressed.

Yeah, but I don’t go to that one. It would be crossing the boundary a bit. I want to go where I can feel free, open up about myself a bit without making people feel uncomfortable. We have people who have come to our support group since day one, almost three years. They all relate to each other, provide support. There’s not something like that in the community. There’s just not. And it’s a shame. And there’s a bit of an insurance thing about that. “You can’t get a bunch of suicidal people in the same room talking about suicide.” It’s like the, “Don’t mention suicide because they’ll kill themselves.” Or like, “Don’t talk about contraception because they’ll go have sex.” Myths.

I’m curious, does every VA hospital have a support group?

No it’s a pilot program that started at ours. Now Dr. Jobes is using his model, helping them with a grant to show that it helps. I really can’t speak to how that’s going, but I know our groups had something to do with that. And people didn’t initially want to go: “I’m not going to sit around with a bunch of people talking about killing ourselves!” But we urged people to go to four groups, and for the most part, people who came to the four groups were glad they did it. Some stayed for months. Some never left. It’s what they needed. And everyone’s free to come back.

Otherwise, you’re just left to deal with it on your own. Really, there’s nothing. You can journal. I journal a lot.