Psychologist Martin Steendam was sitting in his office in Friesland, the Netherlands, when he had to make a difficult decision: should he treat the 16-year-old in crisis sitting in front of him? It sounds like a situation no mental health professional should have to deliberate nor that any person in need should be refused, but, due to complex billing systems, it’s an issue in the Netherlands and worldwide. In this case, Steendam can only bill, and thereby treat, patients 18 years of age and older. Furthermore, an inpatient facility with an adult population is not ideal for a 16-year-old, but, sending her home could have a tragic outcome. Technically, he was supposed to say no.
The teen in crisis, flanked by her frightened parents, was suicidal. She’d already gone to another clinic that she and her parents had been told was the only option for her in the Netherlands. The clinic refused to admit her. The family next went to GGZ Friesland. They were experiencing diminishing hope: what would they do if Steendam also said no? While deliberating, he thought on a recent #CrisisTalk article he’d read where retired police officer Nick Margiotta said crisis services need to have a no-refusal, no-wrong-door dropoff policy for patients in need. While the piece focused on the relationship between police and crisis service providers, Steendam interpreted the concept more broadly: there should be no wrong door for a person in crisis. Steendam turned to the teen and said, “I can start with you immediately.”
Hope, says Steendam, who is the project manager of No Suicide at GGZ Friesland, is already tenuous when a person is struggling with suicidal ideation, and whether they want the power or not, mental health professionals are in the position to foster hope or destroy it. The teen reached out for help, and the first clinic sent her away. Steendam said he could not do the same; if he did, it would diminish whatever hope she and her parents had remaining. At the same time, he realized he’d taken a risk. “Afterward, I had to think, ‘How do I organize the funds for treatment because, in our department, I can only treat people 18 years of age and older? I had to repair it.” Steendam went to his community funders and explained his actions, saying he felt it was what he had to do but that he also needed funding to continue treatment. He asked whether he “should stop or go on,” hoping it would make the funders examine the detrimental outcomes of halting treatment. They responded by saying, “You have to go on.”
In the Netherlands, there has been a 21% increase in suicides during the last decade, from 1,517 people who died of suicide in 1999 to 1,829 in 2018. That said, between 2017 and 2018, the number decreased by 88 people, dropping from 1,917 to 1,829. Steendam says while the overall decrease is positive, “there are 1,829 families who face an empty chair or bed, deafening silence, and overwhelming grief.” Also, the numbers went up slightly among women, going from 7.1 to 7.5 per 100,000, and the number of adults ages 20 to 39 who died of suicide increased from 400 to 464. “We have to dig into why there are these increases.”
In Frisian, the local language, the expression for a person who dies of suicide is jinsels tekoart dwaen, which roughly translates to cutting yourself short. “It means that during a person’s worst moment, he or she is making decisions from a place of loneliness and deep despair. We do not want people to struggle alone with these thoughts; to do so implies that we agree with their perspective that they are not good enough. People experiencing suicidal ideation are ambivalent; We have to explore why they are desperate but also what gives them hope.”
Steendam says mental health professionals have to navigate system boundaries, and they have to decide when to bow to the rules and when to challenge them. The compass, says Steendam, is doing what’s in the best interest of the patient and not to lose sight of it because of system obstacles. “It’s like driving a motorcycle—you have to look where you want to go, looking past the obstacles along the way otherwise you’ll wipe out. It’s a good reminder not to lose sight of where you want to end up.”