Menu
There is something fundamentally daunting about spending a good portion of our lives trying to talk people out of ending theirs. But that is exactly what some of us have chosen to do. Day after day, we invest not only time and energy in our work but part of ourselves as well. To be effective in what we do, we must guide, assist, and sometimes push troubled patients into experiencing the strong emotions, painful memories, and sources of conflict that have brought them to the brink of self-destruction. Anything less probably won’t be enough. So, necessarily, we do much of our work in an emotionally charged atmosphere.
If we wish to be successful in this business of saving lives, as well as remain optimistic about the work we do, we need to have our ideals – but we also need to be realistic, especially about ourselves. And so, to anyone who works with suicidal people, I would offer some basic advice:
The most effective therapist for a suicidal patient is someone who has a firm sense of self, a clearly articulated philosophy of life, and the courage to accompany the patient on what is bound to be a sometimes frightening journey. Never losing sight of the fact that our patient’s life may be at stake, we must accept this possibility and yet be willing to push ahead into the darkest corners of human experience, where the real work of healing takes place.
Losing a Patient
As I have explained, those of us who work with suicidal people must remember that we, too, need care and support. Whether as suicide interventionists, crisis workers, case managers, or therapists, we’re not much good to anyone unless we are in good spirits and getting enough rest. Nor are we of much use unless we’re still active in the field of human services.
I say “still active” for a reason. Losing a patient to suicide can be a career-ending experience. Not surprisingly, suicide threats and actual suicide attempts on the part of their patients are two of the most extreme sources of stress that therapists and counsellors encounter in their professional work. The death of a patient by suicide is even more traumatic. There is nothing like a completed suicide to devastate our self-esteem and threaten our ability to work successfully with other patients. Therefore, as far as it is possible, we must try to protect ourselves from the tragedy of losing someone to suicide.
We can do so by taking every reasonable step to be sure that a suicidal patient will be safe once he or she leaves our office and that what we understand to be our duties have been carried out to the best of our ability. We take care of ourselves by knowing what we did what any responsible and prudent person with similar training and experience would have done with a similar patient under similar circumstances.
To do our best, all of us can begin by educating ourselves about suicidal behaviour and its etiology, including the psychological and medical conditions that contribute to risk, and about the treatment options available to us and how to employ these therapeutic interventions to reduce risk factors and enhance protective factors. This means getting appropriate training and keeping up with developments in research and current best practices.
Suicide in clinical settings is rarely the result of malice or gross neglect on the part of clinicians. But it can be the consequence of core ignorance about suicidal behaviour, inadequate assessments of risk, and poor communications among clinical providers or between those providers and a patient’s family members, whose vital observations too often go unsought.
It can also be the product of arrogance. If we as clinicians allow ourselves to become so self-assured, so cocky, and so impressed with our own credentials that we cannot even imagine that one of our patients could die by suicide, more of them surely will. Difficult thought it may be, if we are to be wise, we must be willing to admit that we don’t know everything. We need to remain humble. Obviously, the loss of a patient to suicide is something we all seek to avoid. However, no matter how skilled we are in the treatment of suicidal persons, we may not be able to prevent the suicide of someone in our care.
We also need to understand that our beliefs matter. I have heard seasoned clinicians remark after a patient’s suicide, “Once they make their mind up, there’s nothing you can do.” Or, “You can’t predict this sort of thing, so you can’t prevent it, so why try?” Or, “There was no stopping her … I finally just gave up.” These after-the-fact expressions of futility mirror a suicidal patient’s own attitude of hopelessness. While therapists who voice such sentiments cannot reasonably be held accountable for a patient’s suicide, their attitude may well have contributed to the eventual outcome.
For that reason, anyone who harbours beliefs such as these – anyone who would argue that suicide is fated and cannot be deterred, anyone who is convinced that there’s little point in trying to save someone who is determined to die – has no business working with suicidal people. As professionals, we cannot risk placing a suicidal patient in the care of someone whose attitudes might endanger the person’s hope of recovery. Even though we cannot easily afford to lose a single healer who counsels suicidal people, neither can we afford to lose a single patient because the healer was pessimistic about the patient’s potential for survival.
The Perils of Denial
Apart from fatalism, one other sure way to increase risk for potentially suicidal people is to dismiss or minimise their talk of suicide and their nonfatal attempts. A poster once distributed by the American Foundation for Suicide Prevention issued a clear warning: “Today’s suicide attempter could be tomorrow’s suicide.” And yet I have conducted at least a dozen death reviews and psychological autopsies of people in whose medical record someone had written (sometimes more than once): “Appears to be manipulating.”
This is not to say that suicidal people don’t sometimes use the language of suicide in order to manipulate others. As we have seen, they do. For the chronically suicidal, threats of suicide, along with nonfatal attempts, have become a standard coping mechanism. Even someone who is not chronically suicidal may threaten suicide in an attempt to control a loved one or get out of a difficult situation. An angry teenager may threaten to kill himself in order to avoid being expelled from school. Prison inmates may talk of suicide in hopes of being sent to a psychiatric hospital, where the company is apt to be more interesting and they will have a little more freedom.
Of course, some people do more than just talk about suicide. They repeatedly attempt suicide, but in ways that seem destined to fail. This pattern has prompted some researchers to wonder how truly serious such people are about ending their lives. How do these people differ, psychologically, from those who succeed in killing themselves on the very first attempt? And what about people who seem to talk about suicide all the time and yet never actually make an attempt – or those who repeatedly inflict injuries on themselves, and yet the injuries in question have almost no chance of being fatal? Such behaviour demands attention, but are these people really in danger of dying?
There are no easy answers to such questions. What is required is a thorough assessment of each individual and the circumstances surrounding the crisis. One thing is clear, however. If a person uses the word suicide, even in a statement that appears intended primarily to influence the behaviour of others, the possibility of self-inflicted violence has at least been considered. No matter what the situation, an evaluation is always in order.
Substantial research exists to confirm that people who talk about suicide run a higher risk of attempting suicide, and those who attempt suicide are at a higher risk of eventually dying by suicide. In a five-year follow-up study of a group of individuals who had made an attempt on their life, researchers discovered that one-sixth of the group since died, either of what was unambiguously suicide or as the result of engaging in high-risk behaviour of some sort (Rosen 1976; see also Tuckman, Youngman, and Kreizman 1968). A previous suicide attempt is, in fact, the single most powerful predictor of an eventual death by suicide. Experts therefore advise us to take every suicide attempt seriously – and we should.
Nor should talk of suicide ever be taken lightly, even in the absence of openly suicidal behaviour. Lest we wind up with another death that could have been prevented, people who threaten suicide must always be carefully assessed by a competent professional, someone who can determine the appropriate course of action. Emerging standards of care require that healthcare professionals and counsellors be trained to assess suicide risk and, in particular, to evaluate the likelihood that a suicide threat will be carried out. If we are lucky, a cry for help will not go unheeded but will lead to intervention and treatment that will ultimately result in a healthier, happier person.
The Power of Hope
It is my firm conviction that preventing suicide is fundamentally about the restoration of hope in the hopeless. But if the hopelessness that breeds suicidal thoughts, feelings, and actions is contagious, so, too, is hope. Above all else, we who work with suicidal patients must understand that, even though the patient may wish to give up, we never can. Many of my former patients have told me, years after our work together was completed, that it was my faith in them and in their ultimate victory over despair that kept them going – that kept the spark of hope alive. And I doubt I am alone in this experience. Jerome Groopman’s wonderful book The Anatomy of Hope: How People Prevail in the Face of Illness offers eloquent testimony to the power of hope in medical settings. Caring treatment and unyielding hope are, indeed, the first and best antidotes to suicide.
Despite the emotional demands of the work, I am chronically optimistic about suicidal people. I believe that a suicide crisis is a terrible thing to waste. A suicide crisis screams out for change, for a re-evaluation of one’s life choices, one’s relationships, and one’s mental and physical habits. A suicide crisis opens fresh opportunities to explore the array of possibilities that life has to offer. In the final analysis, this is perhaps the greatest reward for those of us who work in suicide prevention. Given competent and compassionate care, not merely can suicidal people save themselves from self-destruction, but they can go on from their destination of despair to lead rich and productive lives.
As healers, we must always remember that suicide does not aim to solve extraordinary problems – only ordinary ones that have been magnified beyond their importance by searing psychic pain wrongly believed to be at once unbearable and inescapable. Framing the problem in this way allows our interventions, our gentle yet thought-provoking questions, promptings, and observations, to express what is at once ancient, empathic, tolerant, and kind – our shared humanity. And to the extent that our work reflects this understanding, it is that much more effective.
Suicide does not offer an answer; it poses a question, the answer to which may be a life full of purpose and passion and unencumbered by the fear of tomorrow. If we who counsel suicidal people are unswerving in our belief that suicide can be prevented and that recovery is possible, we can do more than save lives: We can turn them around.
And so, above all, I ask of you this one thing. Think deeply about this good work you have chosen to do. Think of yourself not only as a healer armed with knowledge and skills but as a merchant of hope.