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I will never forget the first suicidal person I encountered. I was a young graduate student in psychology working in a state mental hospital when a logger was admitted. He had a nasty chest wound where he had attempted to run a hunting knife through his ribs and into his heart. I listened to his long story of woe. He had lost his job, his wife had left him, and he had started drinking again. His pick-up had been repossessed and, on a spree in a bar, he had gotten into a fistfight in which two of his teeth were knocked out. Drunk and despairing, he stumbled out into the snow, unsheathed the knife he carried on his hip, and tried to kill himself. As his tale drew to a close, I remember thinking, “My God! This man needs professional help!”
But, of course, I was the professional, no matter how green I might be. My chief therapeutic success with my first seriously suicidal patient was to avoid bolting from the room in panic. Perhaps like you, I had received no training in suicide risk assessment and was essentially clueless about what to say or do.
Now, forty years later, I rarely panic. In fact, over the past many years I have worked almost exclusively with suicidal people. Colleagues often refer patients to me, and, because of my reputation in the community, suicidal people themselves seek me out, as do their family members and friends. I’m glad they do, and I am grateful for what they have taught me and for the opportunity to share some of that knowledge with you.
I confess that, as a graduate student, I was something of a maverick. Try as I might, I could not find a theoretical approach or “school of therapy” in which to place my total faith. An incorrigible eclectic, I admired everything from the behavioural methods of B.F. Skinner to Carl Jung’s theories about symbolism to the pragmatism of Albert Ellis to the caring approach of Carl Rogers.
But then I went to graduate school well before some of the more compelling studies on the efficacy of specific psychotherapies had been published. Given the weight of evidence that has since accumulated for the effectiveness of cognitive-behavioural therapy in the treatment of depressive disorder and, in particular, suicidal thoughts and behaviour (Brown et al. 2005), I now view this approach as the one most likely to achieve positive psychotherapeutic outcomes, and I believe it should be our first line of defense. However, the issue at stake – life or death – pushes one to embrace existential and dynamic therapies as well. And, late at night, when no one is around, I sometimes read sociobiology and evolutionary psychology, as it seems that much of the explanation of human behaviour lies in our genes and in the environments in which we evolved.
That said, I have generally been more interested in doing things that worked than in understanding why they worked. And so I was always disappointed that my professors couldn’t give me more guidance about exactly what one should say or do in the counseling session. At times, this led me to wonder whether they really knew what to say or do, especially with suicidal patients.
My goal here, then, is to provide you with specific things to say and do. What I wish to pass along are tools that have worked for me, in hopes that some of them will work for you. Where these ideas and techniques for intervention are supported by research, I have provided references to some of the more important studies.
The Language of Suicide
When people talk about suicide, the language they use varies. It differs according to age, sex, and level of education, as well as with cultural and ethnic background. In mainstream America, a culture sill largely dominated by white males, a speaker can choose from any number of slang terms to describe suicide: “I feel like offing myself,” or “I think I’ll take a dirt bath,” or “I’m going to eat my gun.” In contrast, a young Native American might speak of planning to “take the spirit trail.” An eight-year-old may not know the word suicide, but even a child will understand what it means to say, “I want to get in front of a truck.” For many teenage girls in our culture, taking an overdose and then just drifting off is such a common suicidal fantasy that it has come to be known as the “Sleeping Beauty Plan.” Anyone who wishes to be an effective counselor of suicidal people will need to be familiar with this vocabulary. Be aware that people use euphemisms when they are frightened or embarrassed by a subject. Despite a shift in public attitudes, many people are uncomfortable talking openly about suicide, and so they turn to slang to express their suicidal intent or desire.
Broadly speaking, the risk of suicide increases with age. Those working with older people must therefore be especially sensitive to suicidal language – and, especially, to its absence under conditions in which any seriously depressed person might consider suicide a reasonable alternative to his or her present circumstances. Elderly people are often reluctant to talk about suicidal thoughts and feelings, which means that the counselor must be more direct and inquiring.
Indeed, it is frank talk about suicidal thoughts and feelings – as symptoms of an illness – that makes lifesaving interventions and treatment possible. If professional healers and community gatekeepers hope to play a role in the prevention of self-directed violence, we must learn to talk about suicide. In what follows, I have tried to suggest ways we can establish a therapeutic environment in which both sufferer and healer are at ease. When both parties in the therapeutic relationship can talk openly about a subject as difficult, and as frightening, as suicide, a foundation of hope is laid, and the prospects for genuine psychological healing are enhanced.
I have often thought that working with suicidal people is the equivalent of emergency room trauma surgery. The person in front of you is dying – if not literally, then dying of depression, of despair, of acute and utter hopelessness. Doing therapy with suicidal people is not for the weak of heart, but it can be the most rewarding work imaginable. Learn to speak the language of suicide, and you will begin to save the lives of those who suffer a pain so exquisite that only death seems a remedy.
The Suicide Journey
Suicide is a process, not a fixed event. Simply put, this means that when you first come into contact with someone who is contemplating suicide, you could be meeting that person at either end of what I call the suicide journey.
The suicide journey begins with the idea that killing oneself will end suffering – that death will solve the problems and pain of living. The journey ends, sometimes, with a completed act of suicide. Except for highly impulsive persons (and suicidal people can be impulsive), the majority of suicidal persons are on roughly the same journey. The back roads, the stretches of highway, and the detours may vary, but all those who ultimately kill themselves must begin with the thought of suicide, however fleeting, then move on to active contemplation of the idea, and eventually formulate what they believe will be a fatal plan.
As suicidal people move closer and closer to the tragic conclusion of their journey, they usually send signals to others that they are nearing the end. These signals will vary from silent behavioural clues, to verbal threats, direct and indirect, to suicidal gestures, to nonfatal suicide attempts. One way or another, though, before taking the final action, a suicidal person generally communicates his or her intention to die to others.
The journey to suicide can be a short, swift one, but it is more likely to be long and laboured. Where you meet someone along this tortured road has important implications for the journey’s outcome. If, for example, you happen to be the first person to become aware of the passive suicidal thoughts of a never-before-suicidal young person who is currently facing problems that seem overwhelming, you chances of success should be fairly good. If instead you encounter a main in his late fifties whose career has failed and who is under indictment for tax evasion, who has a severe drinking problem, and who has twice been divorced and has just learned that his third wife is leaving him, you may be meeting someone whose journey toward suicide is nearly at its end.
The way we respond to each of these travelers is critical to helping them survive. How best to greet these travelers – what questions to ask and what actions to take to keep them safe – is the stuff of the first part of this book. In it, I deal with intervention and the assessment of risk, and with risk management.
The second part of the book is directed at therapists, counselors, clinicians, and others who work with suicidal people. As such, this section looks at the many ways we can use our human capacities and individual talents, our training, and the healing relationships that we have established to help weary travelers not only pass over a stretch of bad road but learn to enjoy the journey of life as far as its natural end. Often cast in the form of strategies and techniques, these are the tools from which you may pick and choose in your work with suicidal patients.
Finally, I share some thoughts about how we as healers can continue to be effective in the lifesaving work we do. I have also appended a page on which you can list the phone numbers of local mental health agencies and mental health providers, including those who specialise in the treatment of suicidal individuals, as well as any other resources that can provide you with a personal support network. Once you have identified the resources available in your community and have made the choices you prefer, you may find it useful to carry the relevant phone numbers with you at all times.
This book is not a comprehensive treatise on the treatment of suicidal persons. It doesn’t even come close. But for many who have never studied suicide it will be a beginning. My aim is to translate research into practice and to make what is known about assisting suicidal people accessible to everyone who works with them: crisis volunteers, counselors, pastors, social workers, fire and police chaplains, case managers, youth workers, therapists, physicians, nurses, alcohol and drug counselors, and anyone else in the field of human services.
I call what follows a therapy of hope. I have always believed that it is better by far to be optimistic and miss the mark by overshooting it than to be pessimistic and miss the mark by never trying. As individual practitioners, our job is not to save all of the approximately thirty thousand Americans who will die by suicide this year, much less the estimated one million people around the world who will die by their own hand. Rather, our job is to do our best to save the life of the person in our care. If each of us helps just one soul survive a suicide crisis and recover from depression and despair, we will have done our work well.
If nothing so memorialises our human capacity for misery as suicide, then nothing so rewards our human capacity for compassion as preventing it.