The Compassion Pain Scale

I never did do much with the kitten pain scale, because the pain meds’ effects were so striking there was no need for hour by hour monitoring.  But I’ve found another good marker.

When I first started at crisis chat I really really loved it, and would frequently stay hours past my scheduled shift.  I often left feeling energized*.  At some point that changed.  I put it down to a loss of novelty, or maybe nostalgia making me remember it as more fun than it was.  I kept going because it wasn’t about me having fun, it was about me helping people, but I was more conservative about the latest time I would start a new chat.

Then I got those really awesome pain meds in January, and suddenly I was staying late again.  But at some point it disappeared again.

One of the nice things about the meds is that they have a long lasting effecting.  They push the pain-tension cycle back, so I’m in less pain for days or even weeks after they wear off.  One of the bad things about one of them is that I hate being touched the next day.  That’s suboptimum on its own, but it scares me to think of what else it’s doing that I’m not noticing, so I try to go as long as possible without taking it.  I’m also very good at pushing away conscious knowledge of pain, even though it still effects me.  So I ended up going really way too long without taking the topical pain medication.

Finally I took it again, and what do you know, I stayed more than two hours past the end of my next chat shift.

It doesn’t surprise me that I’m better at chatting when I’m in less pain, but I am surprised by the way I’m better.  Ending chats is a tricky business.  You don’t want people to feel shoved out the door, but a good chunk of our target audience is having anxious ruminations.  The last two times I’ve been much better about recognizing when we’ve reached the end of the productive portion of the chat and wrapping it up.  A few people even seemed to take the nudge out as permission to relax.

*although not always.  Most days I had to call a child abuse report in were bad days

**Shift end times are a little fuzzy because of course you can’t leave in the middle of a chat.  If it’s 5 minutes before your shift ends, of course you don’t take a new chat unless you’re prepared to stay late.  But if it’s 30-45 minutes?  You’ll probably be done only a little after your stated end, but you never know which call is going to be a two hour active rescue.

How effective is volunteering at a suicide hotline?

Months ago my local EA group had a meeting around the concept of Effective Volunteering.  EA is not opposed to volunteering anymore than it it’s opposed to working directly for a cause, but it is more skeptical than the general population that this is the most effective way to help the world.  This doesn’t mean volunteering is bad, it can have all sorts of benefits outside of helping the world- building community, buffing one’s resume, and generally feeling good.  But if you want to justify volunteering on its helping-the-world merits, you have to compare it to the standard option of “work more, donate money.”

[I’m ignoring the argument that most people aren’t paid hourly because “learn skills to boost wages, donate excess” is an equally valid plan]

Based on the local discussion plus this post by Ben Kuhn, I propose that volunteering is most effective when some critical mass of the following are met:

  1. The product produced by volunteers is not the same as that produced by minimum wage workers (e.g. food kitchen volunteers are generally more cheerful than McDonalds workers)
  2. The volunteer has some comparative advantage in the task (e.g. pro bono work by lawyers)
  3. The activity does not take away from paid work (e.g.I have more hours in the week total than hours in the week I am capable of programming).

The problem is that 2 and 3 are often in conflict.  People’s comparative advantage tends to be used at work, either because that’s what led them to the work or they developed the talent there.  So it either has to be someone not capable of working regularly, or the person has to have two different comparative advantages.  I happen to think I fall into this category, because I’m very good at both programming and crisis chat counseling and they use entirely different parts of my brain.  And actually crisis chat makes a good play for having trait 1 as well: it’s heavy emotional work, and there are a lot more people capable of doing it 4 hours a week than 40.

Which got me thinking: how effective is crisis chat?  I’m fully prepared for the answer to be “not very”, it really seems like it’s on the less efficient side of things, but let’s run the numbers.

First step: how much does running a suicide hotline cost?  The first posting I found that listed a salary said $16.00/hour, and that’s for bilingual workers in an area with a cost of living 60% higher than the national average.  Let’s say $20/hour to include taxes, phones and computers, vacation time, etc.  GiveWell considers anything under $5,000 per life saved to be extremely cost effective, so to be competitive a hotline worker would have to save one life every 250 hours worked.  Statistics on chat line effectiveness are hard to come by because they’re anonymous by design, but I worked ~170 hours last year and I know for a fact I was 1/2 of a team that saved one life, and find it plausible that I saved more.  I work on the text line, which for various reasons is less likely to attract people who are imminently suicidal, so I suspect the phone line workers are more effective.  By this measure, suicide hotlines are competitive with GiveWell’s top charities.

The complication is that the hotline doesn’t do this alone.  I gave myself half a life because I called in a rescue for a phone worker who contacted me via chat, but that success depended on emergency workers finding the person and a mental hospital to take him in.  Malaria nets don’t work alone either (they can’t solve famine or war), but this seems more like evaluating the cost of the nets without the cost of employees to distribute them.  On the other hand, some percentage of chats may talk people out of suicide without requiring an active rescue.  If I help a person form a plan to keep themselves safe until the urge passes, that’s incredibly effective.

The other way to look at it is what would people pay for the service.  My gut feeling is that the service I provide is more valuable than anything the visitors could buy with $20*.  The most comparable services, therapy and psychiatric visits, start at $60/hour.  Crisis lines are not a substitute for psychiatry or counseling, but a marginal hour of chatting may be a reasonable substitute for an hour of either, given how much of their sessions is empathetic listening.    Even if hotline workers are not as effective at listening because they are lower status, that’s still substantial savings.  Plus we get a good chunk of people are uncomfortable talking to a real professional because they are so high status, but feel okay talking to us.  On the other hand, I’m pretty sure most of the bottom billion would take the $20, or even $2, over an hour talking with me.  Competitive within the sphere of 1st world interventions is not the same as competitive.

Still, that’s a much higher effectiveness rate than I was anticipating.  And it manages to hit all three of my criteria above (for people who are good at listening but don’t do it professionally), which is a pretty neat trick.  Unfortunately it does not work for Kuhn’s use case at all, since he was looking for things EAers could do as a group on an ad hoc basis.  I suspect this is not a coincidence.

*Testing this directly would be hard, since there’s nothing to stop someone who wants two hours of chatting to say they want five, but will accept two + $60.

Things I Say a Lot in Crisis Chat: You Are Worthy of Help Too

I talk to a lot of people in crisis chat who feel bad taking up my time, or are reluctant to seek treatment from a professional, or would pay for help but are reluctant to accept free help, because there are so many people out there with more serious problems.  How serious their problem is varies: sometimes it really is a mild problem, sometimes it is years of horrendous abuse that is still technically not the worst thing a human being has ever experienced in the history of time.

The most useful response I’ve found is: “We treat people with sprained ankles even though there are other people with broken bones.  Be honest about your situation and trust the doctor/therapist/charity to prioritize their resources appropriately.”  Nothing works all the time, but I can’t think of a time it didn’t at least help.

Cutting

Cutting/self-harm comes up in crisis chat even more than borderline personality disorder, in part because cutting is common among both BPD patients, depressed teenagers, and depressed/anxious young adults. I have a lot of thoughts on cutting.

First, it is obvious to me that the shame around cutting is a million times worse for cutters than the actual cutting. I talk to so many kids terrified to reach out for help because people have or will judge them, shame them, or commit them for cutting. Even if they hide it perfectly, they know, and they know their support network doesn’t know, and they will never rid themselves of the fear that the support would be withdrawn if they knew.

Luckily my program gets that, and we’re at least allowed to be chill about cutting.  It doesn’t trigger an active rescue call, we’re explicitly supposed to reassure them it’s not shameful and we’re not judging, and we’re even allowed to praise it not as an alternative to suicide*, but as a coping mechanism that removes the necessity of it.

We are not, however, allowed to suggest it as an alternative to other popular coping mechanisms for the same problems, even to visitors already doing both. This confuses me.  Mental illness often leads to self medication through substance abuse**, eating disorders, social isolation, or simple inability to function in the world.  Done safely  (sterile instruments, proper care afterwords, incisions in safe areas- all of which can be taught) , cutting leads to… cuts.  Maybe some scarring if it’s really bad.  Cutters often report greater feelings of cope after cutting, and are able to invest that cope in other therapist approved things, like eating or seeking out a support network.

Not to mention the things you need to do to prevent people from self harming are incredibly intrusive (because everyone has finger nails), at a time when people most need to feel like their autonomy is respected.  Thin is a documentary about an eating disorder clinic, but a lot of the patients had self-harmed in the past (full disclosure: it’s been two years since I watched this and details might be fuzzy).   I’m sure the clinic had the best of intentions, but the section on the methods they used to prevent cutting left me screaming “do you not realize anorexia is about control?  I understand the feeding tube can’t wait till they get better, but is preventing cutting really worth triggering them like that?”.

In my perfect world, bystanders would treating cutting the same way participants do: as an external representation of an inner ugliness.  And then they would work on resolving that ugliness, rather than pushing away the evidence of it.  In a less perfect but still better than this world, cutting would qualify for the same harm reduction plans that drug addiction does, with health facilities providing sterile blades, bandages, and instruction of safe places to cut.  And then people would notice it is way, way less harmful than heroin or methadone*** and it would lose the stigma and now we’re back to my perfect world

*We’re allowed to praise a lot of things as alternatives to imminent suicide, up to and including later suicide.  It’s not often that “Why not see a doctor first and kill yourself if that doesn’t work out?”  is the right thing to say, but it’s not never either.

**Nothing like a depressant to chase the blues away

***Which is in fact significantly more dangerous than heroin, but less fun.

PS: If a patient or loved one of yours is cutting and you don’t know what to say, I have found “For a lot of people cutting is about releasing stored emotions.  Is it like that for you?”  to be a productive question.

Borderline Personality Week: when your desire to kill yourself is an annoyance to others

Jesus Christ I hate the wordpress post management system.  It published my first BPD entry three days early and then ate drafts of two planned posts.  Let’s see what I can recreate.

There are a lot of insights I get from working at the crisis chat center I would like to talk about, but talking about them requires examples, and using the chats as examples would be a huge violation of privacy, both morally and legally.  Lots of health care workers get around this by writing semi-fictionalized or composite characters, but I don’t feel skilled enough to pull that off.  Luckily, Kiera Van Gelder  wrote a book,The Buddha and the Borderline, about her recovery from learning to cope with Borderline Personality Disorder, and there is absolutely no privacy violation in using her as an example.

The first issue I want to discuss is how health care professionals treat BPDers’ threats of suicide.  Van Gelder was committed for short term stays due to suicidality several times- first as a young adult, and then three times in six months around age 30.   BPD can lead to suicide, at about the same rate depression, bipolar disorder, and schizophrenia do (with the exactly number being hard to determine because co-occurrence and misdiagnosis between BPD and the first two of those disorders is so common).  But BPDers are (perceived as) more likely to enjoy their stays.  That is probably because (crudely) depressed people want to kill themselves because they think everything is hopeless, bipolar people because they simultaneously think think everything is hopeless and have the energy to act on that belief, and schizophrenics think the CIA has told the demons where to find them.  Whereas BPDers are often thinking things like “no one cares about me.” and “I’m all alone.”  A hospital stay with kind staff checking to make sure you haven’t killed yourself salves this directly, and as such can be pleasant.  I can’t even judge them for this because even though I don’t think I’d have fun in a mental hospital, I got my IV nutrition + immune support at a concierge medicine place and it was awesome. *

But after two stays in a few months, the hospital was not so nice.  On the second visit, they told her that if she kept this up insurance would force her into the state hospital, which she would “not find so pleasant”.  When she came back a third time anyway they suggest maybe she needs to just learn to live with being suicidal and when she insists she is.  not.  safe.  they put her in a “rapid recovery unit”, which is basically a holding tank for the hospital to prove they did their due diligence vis a vis keeping her from killing herself while expending as few resources as possible.  It is not warm, it is not comforting, no one is demonstrating they care about her.

Perhaps the fear is that BPDers are faking suicidality, or worse, pushing themselves to become genuinely suicidal, to get attention.  I can’t prove that’s not happening.  And if anyone is going to do it, it’s probably borderlines.  But as I said above, the death-by-suicide rate for borderline personality disorder is only slightly lower than that for depression and bipolar disorder.   That doesn’t mean they have the same chance of following through on a given threat (it’s quite possible BPDers threaten more often), but it seems like the safer plan might be to give them more attention without requiring them to resort to suicide, rather than calling their bluff.

Perhaps it is that the act of denying a BPD sufferer admission to the hospital makes suicide more likely, in a way it doesn’t for other mental illnesses.  You might think that that would make admission a better idea, but a consistent thread in the medical treatment of BPDers is trying to make them get less out of treatment.  I’ll talk about that tomorrow.

[ An important note if you’re dealing with a person with BPD: even if they are making the suicide threat “for attention”, ignoring them doesn’t mean it will go away.  Suicide also looks like a viable means of getting attention and/or coping with not getting attention.  This does not obligate you to indulge their every whim when they mention the word suicide, you are in your rights to cut them off, but if you think the threat is credible, alert their support network or emergency services ]

*Have you ever had a nurse be happy to peel an orange for you?  I have.  Having insurance cover treatment at conceirge locations is like getting bumped to first class when you bought a coach ticket.

Optimal hammering time

Last month I watched Home, a documentary about a charity offering homes to poor people (maybe just poor single mothers?) at a significant discount.  It focuses specifically on one woman who applied for help and the case worker assigned to her.   Watching it, I was struck by how much the case worker defined her goal as getting this woman this house, rather than helping her, or giving the house to the person to whom it would do the most good.   I thought it was a case of cargo cult, another friend described it as a cultural fixation on helping the poor by making them middle class rather than making being poor bearable.  Either way, it seemed to me like an example of misapplied charity.

Last week I started training to volunteer for a crisis hotline.  One of the things they drill into us is that most callers have a lot of problems we can’t solve.  We have very few tools:  occasionally we make referrals if they have certain  specific issues (e.g.  we’ll offer LGBTQ kids the number for the Trevor Project, or suggest they call 211 to get referrals to programs that could help their material problems), but mostly we listen.  That is what we do.  We are to apply that one tool as best we can.  If it helps, great.  If not, we end the conversation anyway.  There’s a weird tension between “Anything is a crisis if it feels like one to you.  We’re here to listen to anyone, any time, for any reason.”  and “Some people are just black holes, cut them off after 45 minutes.  But they can call back tomorrow.”

The only way I can justify this is by thinking “We have one tool.  It’s impossible to know if this tool is what this person needs.  Even when it is, there are diminishing returns to using the tool.  After 45 minutes, the marginal returns to further use are 0.  Therefore, treating everyone as receptive at minute 0 and no one as receptive at minute 45 is the optimal use of our time.”

I still think the case worker in the movie was pushing her tool too hard, and not listening when the person she was nominally trying to help brought up very reasonable concerns.  But I’m a lot more sympathetic to the myopia now.