Menu
The research is in. Suicide prevention is a therapy of hope. Regardless of how one goes about measuring it in a clinical setting, a sense of hopelessness has repeatedly been shown not only to be a core characteristic of depressed people but also to be strongly associated with other psychiatric disorder that can give rise to suicidal thoughts, feelings, and actions.
As the seminal work of Aaron Beck and his colleagues demonstrated, intense feelings of hopelessness are an important signal of a long-term risk for suicide – perhaps the most important. In one study, Beck and his colleagues carried out a detailed psychological assessment of 207 patients who had been hospitalised for suicidal ideation but had no recent history of actual suicide attempts (Beck, Steer, Kovacs, and Garrison 1985). A follow-up conducted five to ten years later revealed that fourteen of these patients eventually died by suicide. As was apparent from a review of the initial data, most of these patients had originally scored 10 or more on the Beck Hopelessness Scale, making it the more reliable indication of an ongoing risk for suicide, followed by high scores for pessimism on the Beck Depression Inventory.
Research has also shown that the intensity of suicidal intent is more highly correlated with hopelessness than with the diagnosis of depression. In a study of 384 patients who had been hospitalised following a suicide attempt, feelings of hopelessness accounted for 76 percent of the association between depression and suicidal intent (Beck, Kovacs, and Weissman 1975; see also Beck et al. 1990). Hopelessness is also a strong predictor of suicidal intent among drug addicts and alcoholics who are suffering from depression (Beck, Steer, and McElroy 1982).
The belief that all is hopeless appears to derive from the impaired cognitive functioning and disordered neurochemistry of the depressed mind. In comparison to mentally healthy individuals, depressed people, and especially suicidal ones, think more slowly and are more constricted in their thinking, are more easily distracted, and have more trouble solving problems (Williams, Barnhofer, Crane, and Beck 2005). People who are struggling with depression cannot project themselves into a rosy future. They are quick to draw negative conclusions and, to make matters worse, suffer from the tendency to recall only failures and other unpleasant experiences, while ignoring positive events, including personal triumphs.
Cognitive-Behavioural Therapy
No one knows for certain precisely how therapy ought to be done with suicidal people. But research on the relative value of specific therapeutic approaches has been under way for some time. As a result, we now have a much clearer understanding of how we should proceed.
As I mentioned at the outset, evidence strongly supports the use of cognitive-behavioural therapy with suicidal people (see, for instance, Brown et al. 2005). Cognitive-behavioural therapy focuses on a patient’s attitudes and beliefs and, especially, on how the patient interprets his or her experiences. Although healing is fundamentally a gentle process, cognitive-behavioural therapy is confrontational in nature, and the healer’s role is often quite directive. The sufferer’s beliefs are viewed as hypotheses, not as realities or “givens.” Just because someone has concluded that a situation is hopeless, for example, doesn’t necessarily mean it is hopeless. It only means that the person thinks it’s hopeless.
In a nutshell, the goal of the cognitive-behavioural approach is to change the way a patient perceives and understands life’s problems, including their basic nature and causes, as well as the biological factors and learned patterns of response that may be contributing to a sense of hopelessness and despair. As research on problem solving has repeatedly shown, when we are frustrated by some familiar problem, we don’t reach for new solutions – we reach for a bigger hammer. Unless we learn to see old problems differently, with more clarity and in less polarised terms, no new solutions can be found.
We must help suicidal people understand that the way the world seems to them is a creation of their own thinking. If the logic they use to interpret the world is flawed, their perceptions will be distorted, and they will be led to false conclusions, which can in turn prompt actions that are unnecessary, hurtful, and possibly even self-destructive. If we fail to address the cognitive distortions and skewed logic that most suicidal people fall prey to as they trudge endlessly back and forth in a deepening rut of depression and hopelessness, we can leave them with no conclusions but the one they started with: Suicide spells relief.
In general, then, my approach to working with suicidal people is to challenge, directly, a patient’s thinking. Especially with acutely suicidal people, I am purposely not passive. A lack of assertiveness could tempt the patient to conclude that we are not about urgent business.
But make no mistake: We are about urgent business. We don’t have all day to wonder about how things might turn out. We don’t have a month to mull things over. What we are engaged in is not something cosmetic or elective. It is serious, lifesaving work. So, both physically and psychologically, I lean forward into the relationship and actively ask questions. If the process needs a leader early on, I am not at all reluctant to tackle the job.
But however directive I may be in the beginning, the work of therapy is always carried out within the context of a caring alliance between patient and healer. The protective wall built by relationships with others is the strongest safety barrier between a suicidal person and the hopelessness that could kill. Specific interventions, techniques, and strategies are the nuts and bolts of therapy, but in the absence of a genuine sense of connection – and understanding between therapist and patient that, no matter what, we’re in this together – they can be all but useless.
The Therapeutic Relationship: Some Basics
A solid working relationship is not the end but the beginning of therapy. Constructing a therapeutic alliance is essential to the success of both the counsellor and the patient. Much of what makes this alliance possible is already built into the therapeutic setting and into the predetermined roles that each of us brings to the relationship.
When you see a suicidal person in your role as healer, it is assumed you will do so in a private place, such as a quiet office where you will not be interrupted. In all likelihood, the two of you will also share a reasonably clear cultural understanding of what therapy is – that yours is a helping relationship, that it is something special, and that what goes on in it is confidential. If all goes well, your relationship will also be of limited duration: It will have a beginning, middle, and an end. If you want to make this relationship work, here are some basic points to keep in mind at the outset:
Finally, never finish a first session without learning something positive about your patient – a personal victory or accomplishment, or any life-affirming action, dream, or desire. You need this as much as the patient does. Suicidal patients often spend most of their initial few sessions trying to convince you what truly burdensome, loathsome creatures they are and why they should therefore be permitted to die. Neither you nor your patient can afford to be persuaded of this. No one’s life is without value. She collects dolls. He once ran a marathon. She took care of her grandmother in her last days. Almost anything will do.
I remember one of the psychiatry residents at Spokane Mental Health presenting a case he was treating to our weekly case-study group. The woman he was working with had been chronically suicidal for more than twenty years and had already been treated, unsuccessfully, by a host of therapists, some of them highly experienced. His patient was very intelligent, and she was bringing him books to read about how he should approach doing therapy with someone such as herself. He was obviously frustrated and even embarrassed by his lack of progress with this woman, who was still threatening to kill herself.
At the end of his presentation, he asked the group in exasperation, “So, what do you think?”
No one spoke. Finally, I asked, “Is there anything about this lady that you like?”
He thought a long moment before responding. “No,” he sighed. “Not a single thing!”
I ask therapists this question for the simple reason that if you can find nothing to like or appreciate or value about a suicidal patient with whom you are working, both you and your patient are in trouble.
Bear in mind that it is the healthy, life-affirming part of the patient that joins with you in creating a therapeutic alliance. The part that wants to die cannot, and will not, do this. Each time you make a genuine human connection with a patient, you strengthen the bond between the two of you, and the risk of suicide is directly reduced. It appears that people who have close, mutually respectful, and emotionally solid and safe relationships with other people are less likely to kill themselves (Joiner 2005). Help the sufferer find, build, and sustain such relationships. The process can begin with you.
Respect for Boundaries
Many suicidal patients have been physically, sexually, and/or psychologically abused at some stage in their life. In the even that both physical and sexual abuse has occurred, the risk of suicide rises dramatically (Petronis, Samuels, Moscicki, and Anthony 1990). Abuse of any sort presupposes a fundamental lack of respect for someone’s rights as an individual. It is an assault on the person’s integrity and spirit. A patient who has been abused may be suffering from residual symptoms of post-traumatic stress disorder. Clearly, then, anyone who occupies the role of a healer must be supremely sensitive to personal boundaries and do nothing that might so much as hint at a possible violation of these boundaries.
Healing can take place only within a framework of mutual respect. So, if you’re working to build a therapeutic alliance, don’t break the rules that permit such an alliance to succeed. Here are some guidelines that should help safeguard that framework of respect:
Keeping the boundaries of the therapeutic framework clear and fair will ensure the best possible working situation for both you and your patient. Of course, there may be times when you feel that bending the rules a little would be helpful. But such exceptions should be made only with due consideration, preferably after consultation with a more experienced colleague or, if you are in training, under supervision. Your patient’s safety is yours to protect, and you can do this only if your standards of practice are ethical and respectful of your patient’s integrity – and your own.
Keeping a Sense of Balance
Even with all we have learned about suicide and about the effectiveness of specific therapies, understanding and treating suicidal patients remains as much an art as a science. What we do isn’t physics, and it bears not the least resemblance to the symmetry of math or the predictable syntax of chemistry. Given our limitations, not the least of which is the subjective element in what we do, we are sometimes forced to make treatment decisions in a frustrating haze of uncertainty. At best, what we do is guided by evidence-based practices, by our experience, and by a certain amount of educated guesswork. At worst, we have to rely on uneducated guesswork.
In view of our imperfect knowledge, and because we are only human, no matter how hard we try we are going to make our share of mistakes. You may let a therapy session slip out of control. You may say something impossibly insensitive or ignorant. You may forget to ask a critical question (which will probably come to you twenty minutes after the session has ended). And, most assuredly, you will at some point assume something that is not so.
But that’s okay. As long as the goal of saving a life is uppermost in your mind, don’t worry. Suicidal patients are typically desperate for some shred of hope. Rather than grading your performance for adequacy, they are much more likely to study your face for sincerity, for some sign that you believe their lives are not as hopeless as they have come to believe them to be. If you make a mistake and quickly own it, your patient is likely to forgive you much more readily than you may be willing to forgive yourself.
So abandon the myth of perfect practice. Remember that you aren’t a god but a fallible human being. For this reason, never let a suicidal patient cast you in the role of saviour. Allowing yourself to become the one and only person in the world who can rescue the suicidal person from self-destruction places both of you are risk. Being idealised is one step away from being worshipped – and being worshiped is one step away from falling from grace.
It helps to be clear in your own mind about who has the final responsibility. Presumably you have already resolved that no suicidal patient is going to die with your permission and that you intend to do all you possibly can to prevent this person from taking his or her own life. But suicidal patients will sometimes try to convince you that their life is entirely in your hands. This is simply not true. When all is said and done, each of us is responsible for what we decide. If, in the end, a patient chooses suicide, that is his choice or her choice, not yours.
Be sure you understand that, then, even though you do your very best, someone you are working with could die by suicide. It happens, even to the most skilled and experienced clinicians. Emergency room physicians do not save everybody they see, and neither do counsellors. Consider that if we ever succeeded in getting all the suicidal people who live in our communities into treatment, the total number of deaths among patients receiving inpatient or outpatient care would probably go up, simply because there would be a larger number of suicidal people in treatment overall. And this would be a good thing. At least then every suicidal person would have the opportunity to benefit from potentially lifesaving interventions. Even if getting everyone into treatment meant that, in the shorter term, we had more patients dying on us, we might see our base rates for suicide start to fall.
The Placebo Effect
There is an element of faith in all healing. Because you are a healer, the mere fact of your qualifications, along with your presence and your attention to the patient’s problems, can have a beneficial impact on symptoms. If a suffering patient believes that he or she is going to feel better after having talked to you, he or she probably will. I call this placebo effect.
As a healer, you are a merchant of hope, and so the sufferer will already have some degree of faith in you before he or she ever enters your office. And because you are a trained professional, your patient will tend to assume that you are honest, trustworthy, courageous, and loyal – as well as smart. After all, you’ve presumably read a lot of books about the human condition (including this one). Smart therapists allow the suffering patient to believe that he or she is in good hands. This belief is critical to the rekindling of hope.
It stands to reason, then, that you don’t want to do anything that might undermine the benefits to be had from your status as a healer. There are many things you can do to foul up your placebo effect: Doze off, fiddle with paperwork or otherwise seem uninterested in what the patient is saying, be overly abrupt or impatient, take phone calls during a session, or ask questions that suggest you haven’t been paying attention. Don’t do these things.
In addition, because you’re the professional, your personal appearance matters. You should always look neat and dress appropriately, according to the standards set by your place of work and the culture more generally. Your office also speaks volumes about you, so make sure it doesn’t convey the wrong message. Check it out. Do you have silly or potentially offensive posters on display? If you have plants, do they look healthy and well cared for? Is there anything on the walls or desk that might add to the patient’s sense of failure or disillusionment? Does the place exude warmth, or does it send off a bureaucratic, we-don’t-care-much-about-people chill? If you don’t know how your office decor comes across, ask a few people whom you can trust to give you an honest opinion.
Of course, patients are more likely to have confidence in you if you appear to believe in what your’re doing. Among other things, when you are working with a patient, especially an actively suicidal one, it is critically important that you not seem ambivalent or uncertain about the nature, purpose, and power of therapy and of appropriate medications. Hundreds of lives are saved each day by both words and medicines and, above all, by wonderfully sustaining combinations of the two. So be bold. Sow hope where none grows.
Therapy does work! Certain schools of thought and practice may be temporarily in the ascendant; others may fall from favour. But a fundamental faith in healing and healers is essential for suicidal patients. Without a belief in the possibility of a cure, hope dies. A therapist who is clearly confident about the benefits of therapy enables the patient to find hope for the future – to believe that, no matter how deep the present despair, someday life is going to feel worth living for.
The faith our patients have in us is a precious commodity. It gives them the willingness to believe what we say and do what we suggest. Yes, you will make your share of mistakes, but at least try to avoid making the obvious ones. Don’t hand a patient reasons to question that faith.
Naming the Demon
People go to professional healers to get answers. The first and most important question to which they need an answer is, “What’s wrong with me?” The anxiety born of uncertainty multiplies the pain a person is experiencing. A clear diagnosis – however grave the ailment – can reduce this anxiety. Therapists and counsellors have the power to name the demon, and naming the demon is the first step toward healing.
Naming the demon reassures the sufferer that, if nothing else, someone knows what is wrong. It also inspires hope – because if someone knows what’s wrong, it can probably be put right again. In addition, putting a name to the problem assures the patient that you paid attention to what he or she had to say. Bear in mind that talking with you may be the first open and straightforward communication the patient has had with anyone in a long time. The knowledge that we have been heard and understood dramatically reduces feelings of confusion and despair.
The diagnosis is, or course, critical to the treatment you will recommend to the patient. So, before arriving at a final diagnosis, you should always carry out a thorough and careful assessment. But while it is important not to jump to any conclusions, it is also important to offer some sort of tentative description of the problem at the end of an initial session. By the end of the first hour, after you have taken the patient’s history, you will usually have a pretty good idea about how to name the problem. You don’t have to be certain, but you can say, “Given what you’ve told me, I wonder whether what is going on is …”
In making your diagnosis, you need to give some thought to the way it is phrased. If your patient feels uncomfortable with the terminology you use, he or she might resist the diagnosis, at which point you may have difficult getting the patient to accept treatment. I once saw a seriously depressed police officer who was having suicidal thoughts. He had all the classic symptoms that accompany a major depressive episode, but I suspected he might reject the word depression as a description of his feelings. So I asked him to tell me, in his own words, what he thought was wrong. “Well,” he began, “I think I have broken give-a-shitter.”
The language of diagnosis can take many forms. For some patients, a formal, medical-sounding statement works best (“You have what the Diagnostic and Statistical Manual of the American Psychiatric Association terms a major depressive disorder”). In other cases, something less sophisticated might be more effective (“You know what, kid? Your’re suck in Blues City”). A favourite of mine – useful for, say, clinically depressed young men who are thinking of killing themselves because a relationship has just ended – is: “What you’re going through here is what we call open heart surgery without benefit of anesthetic.” If I get a laugh (however grim), I know I have just accomplished the most important thing a diagnosis does: separates the sufferer from the source of the pain.
Monitoring the Treatment Plan
As I have argued elsewhere, one of the difficulties with treating suicidal patients is that suicidal thoughts and feelings, and likewise suicide planning and attempts, are a symptom, not a diagnosis. Because suicidality is only one symptom among many, such as impaired sleep, weight loss, or irritability, when it comes to monitoring a patient’s response to treatment it is all too easy to regard suicidality as on a par with other symptoms. This is a dangerous temptation – given that suicide is the most probable cause of premature death in someone who is already suicidal. Rather, suicidal ideation should be constantly tracked and evaluated as the key indicator of a patient’s therapeutic progress (or lack thereof).
It is not uncommon for therapists who have had a patient die by suicide while in treatment to admit that they were not aware that their patient was suicidal at the time. The sad truth is that we can all too easily be lulled into believing that patients are no longer at risk when in fact they are. It could be that the therapist never asked the S question in the first place, and so the subject of suicide was never explored. Or it could be that after a period of improvement the patient has once again become suicidal but has given no clear indication of the downturn.
I am convinced that during relapses into depression and in some cases substance abuse, our patients – especially those who happen to like us – often do not wish to burden us with the fact that our medicine and our psychotherapeutic interventions apparently aren’t working. They may also feel a sense of failure, and so they are embarrassed to admit the they’re feeling worse, not better. This leaves it to us to make sure that nothing escapes our attention.
This may seem obvious, but even though it is the patient who is ultimately responsible for his or her life, the therapist must assume ultimate responsibility for control over the therapy. This means taking charge, asking questions, digging for facts, and scouring the emotional landscape for glimmerings of hope or other evidence of change. It means listening well and long, closely observing actions and reactions, and never assuming you know something you actually do not know. It also means following up on any action or remark – no matter how subtle – that even hints that things are not going well.
Remember that therapy is a fluid process, one in which the various twists and turns cannot always be anticipated. This being the case, it simply makes good sense to take stock of a patient’s progress from time to time. Not only does this sort of routine checking give depth and nuance to your working alliance, but it also allows you to revisit the treatment plan, if need be. As things change – for better or worse – so should the course of treatment.
Repeated reassessments of risk, symptoms, and clinical status over the course of treatment are in fact one of the hallmarks of competent counselling. All you need to do is ask, “So how are we doing? Have you had any thoughts about suicide this past week?” Asking this question now and then, after the initial suicide crisis has passed, lets the patient know you haven’t forgotten the reason for his or her original visit. It also gives you a little added insurance against missing a clue that the patient’s condition has worsened. So never sit and wonder whether a once suicidal person is again suicidal. Ask and you will know. If you query a patient so frequently about possible suicidal feelings that he or she finally complains, “Would you stop being so worried about me?” you can always apologise and say, “I’m just double checking – because I care about you.”
When you reassess a patient for current suicide risk, always try to record in his or her chart something the person recently said (“Nope, I haven’t thought about suicide in weeks,” for example). Also make note of any changes in positive or negative symptoms and in the patient’s life situation, particularly its sources of stress. Such chart entries are a matter of due diligence, as well as a sensible precaution. But they also remind you to stay on target – to make sure the primary issue you are addressing in treatment remains clearly in sight.
Healers Matter
Despite the unquestionable value of such miracles as antipsychotic, anti-anxiety, and antidepressant medications, it is still often necessary for people who have talked themselves into suicide to be talked out of it again. Helping people doesn’t get any tougher than working with folks who want to die. If we, who seek to heal, are to do this work well, we need to know something not only about our patients but about ourselves.
It is my strongly held belief that, whatever the underlying illness or precipitating event, the treatment of suicidal people is fundamentally the treatment of hopelessness, a hopelessness born of unremitting and unendurable psychological pain. Hopelessness is a psychological state in which the sufferer believes that nothing positive will ever happen again. This overwhelming affective and cognitive state is contagious – to other people who are vulnerable to suicidal thinking, certainly, but also to healers.
If you have ever worked with someone who is seriously suicidal, you may already understand what I mean. When someone has just spent an hour presenting a seemingly airtight case as to why life is no longer worth living, and in the end you find yourself beginning to agree, then you know that therapists are not immune to the contagion of hopelessness. Rule number one in working with suicidal people? The therapist must survive the process. If, after working with someone suicidal, you notice yourself feeling oddly impotent or ineffective, consider the possibility that you’ve been persuaded to become an unconscious co-conspirator in your client’s suicide. If the patient is helpless and then convinces you that you are helpless, then you will both be hopeless.
You need to inoculate yourself against this contagion. Because as soon as you become as pessimistic about your patient’s prospects as he or she is – or come to believe, as your patient does, that life is not worth living – you are likely to be part of the problem, not the solution.
Doing therapy with someone produces strong feelings; it’s supposed to. If we wish to do our work well, especially over the long haul of a professional career, we need to take good care of our own emotional health, and this means learning to manage the feelings we have toward our patients. Up to a point, this is something we can do on our own, but there will be times when we need to turn to others for advice and support. In my experience, anyone who works with suicidal people would do well to keep in mind the following:
Finally, it is my conviction that humour is empowering. I am not referring to jokes made at the patient’s expense but to humour anchored in the compassion that is fundamental to the work we do. Humour gives us a sudden, sure distance from the source of our pain. It allows us to think the unthinkable and to chuckle at an old line from W.C. Fields: “Life’s a funny old business, and you’re lucky to get out alive.”
I am in fact convinced that humour shared between two people is absolutely incompatible with serious thoughts of suicide. I once interviewed an alcoholic logger who had been hospitalised after driving his truck off a cliff in a drunken suicidal rage. I asked him how it was possible that he was still alive. “Well, I was so drunk,” he told me, “I picked the wrong cliff. It was only two fee high.” Then he laughed. “If I’d have been sober, I’d have found a much higher cliff. And now you want me to quit drinking!”
We both laughed. And both of us felt a lot better.
There is no darker subject than self-destruction. But, as someone once said, wit is the only thing between us and the dark.