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In the therapeutic world, the trend is now toward “manualised” treatments grounded in science. But there are any number of strategies that can be employed in doing therapy. Up to a point, these strategies can be taught and learned, and a well-trained therapist is familiar with a wide range of techniques on which he or she can draw. What cannot be so easily taught is the intuitive sense of which strategies to use with whom, and when. This intuitive understanding is perhaps the essence of the healer’s art, and it comes chiefly through experience.
The ideas and suggestions that follow have been culled from the literature, picked up in lectures, and taught to me by colleagues and patients. One of these patients was a woman named Mary.
Mary was in her early forties when I met her. For the past twenty years she had suffered from a major depressive disorder. She had twice overdosed and had nearly died on both occasions. Antidepressants had failed to provide sufficient relief. Hospitalisations only humiliated her. Mary was utterly pessimistic, all but bereft of hope. She was also intelligent – and clever to the point of nearly convincing me she ought to go ahead and die.
Working closely with a psychiatrist colleague, I treated Mary weekly for three years before she began to make a recovery. She and I often clashed over the merits of living, and on some days she begged me to give up on her and let her go. But I didn’t quit. And neither did Mary. She is now a grandmother of four and for over two decades has been doing fine.
What Mary, and others like her, taught me about the suicidal mind – about the dark interior landscape through which the sufferer must travel and about how one endures the bouts of utter despair born of psychological pain so intense that it is felt physically – were lessons from life I could have learned nowhere else.
As to the observations and strategies that follow, no single rationale or theory underlies them all, although I have tried to provide an explanation for each of the suggestions I make – some sense of why, in my experience, the approach is effective. Obviously, though, not every technique is appropriate for every patient. To some extent, it will be clear from the nature of the intervention whether it is likely to be helpful to a specific person. Beyond that, your own best judgement will have to be your guide.
But if no two patients are alike, neither are any two therapists. If you feel that a particular line of questioning or a specific maneuver, scheme, or ploy is not well suited to your personality and established style, then don’t use it. At least some of these approaches, however, should work for just about anybody.
1. Empowering the Patient
If you accept the premise that some suicidal patient are suicidal because they feel helpless, overwhelmed, and out of control, then anything a therapist can do to combat the feelings that feed a sense of powerlessness will be a plus. Here are several relatively simple things you can do to enhance the patient’s sense of command:
Patients are apt to feel especially powerless about the decision to try medication. Not all patients who are prescribed antidepressants or other psychotropic drugs are eager to take them. Some patients simply forget, some don’t like the side effects, some just don’t like drugs. Suicidal people present a special problem. If they take the medication they’ve been prescribed, this suggests to them that they’ve decided to live, and some patients are initially too ambivalent to make this decision.
It is thus important that you spend as much time as necessary to convince a patient that a recommended medical treatment plan will make a real difference. I will often say, “Believe me, these medications work. They’ll help you sleep. Your mood will start to improve in a couple of weeks or so. If things work right, you’ll get some energy back and begin to feel better. But they won’t stop you from killing yourself. Only you can make that decision. In the meantime, let me give you some information about depression so that you can learn a little about the illness and its treatment.” Providing patients with the acts about a proposed medication frequently proves very helpful. If it seems appropriate to do so, you can also refer patients to Web sites that you’ve reviewed where they can find answers to commonly asked questions concerning specific drugs.
Because involving patients in the decision to begin medication allows them to feel some measure of control, it tends to improve their rate of adherence. It doesn’t change the therapy agreement, but it indicates that you respect the patient’s intelligence and his or her right to participate in treatment decisions. It also serves to remind patients that, as always, they are the ones ultimately responsible for their own welfare.
2. Givens and Not-Givens
Certain factors that contribute to suicide risk are beyond our power to influence. A psychiatric disorder or other chronic illness, a prior suicide attempt, a family history of depression, gray, overcast skies – factors such as these are not under our control. What we can control is our attitude toward these givens and our ability to reflect on the meaning they hold for us.
One of the main goals of cognitive-behavioural therapy is to bring about fundamental shifts in a suicidal person’s way of thinking, including his or her perceptions of life’s givens. At the same time, such therapy helps a patient develop a sense of control over those areas of his or her life that are not given. Not-givens include relationships, jobs, hobbies and other personal interests, diet, exercise, and rest and relaxation. But they also include our emotions. It can easily seem that our feelings – especially painful ones such a jealousy, anger, hatred, a sense of abandonment or rejection, and the desire for revenge – simply happen to us. In truth, however, the way we think goes a long way toward determining how we feel.
A good exercise here is to have the patient make up two lists, of givens and not-givens. Such an exercise obliges a patient to evaluate what truly is immutable and can thus provide a useful focus for the patient’s thoughts and energy as he or she struggles to make changes. These changes may include giving up efforts to change the unchangeable. One of my patients, a woman who had been angry and disappointed with her mother for the past twenty-five years, ultimately decided that her mother belonged in the “givens” column because, as she put it, “She is never going to change, and I might as well stop trying to fix her.”
Perhaps the most important of the not-givens, however, is what we choose to believe is the nature and ultimate purpose of a human being. This is a tough and complex subject, but it has been my experience that suicidal people can benefit greatly from learning to reflect on philosophical issues as part of a reevaluation of their reasons for living or dying. Young people, especially, often have little experience with stopping and thinking a matter through. Therapy can show them how to do this. As the thoughtful therapist who questions just how smart it really is to kill yourself, you serve as a model for the adolescent, who learns to adopt a more critical perspective on his or her thoughts.
The overarching aim of therapy is nothing less than teaching someone to become more psychologically observant and analytical so that he or she can, one day, become his or her own therapist. As part of this process, the patient learns to think differently about the problems of living and, into the bargain, find ways to fix what is fixable and let go of the rest. In my view, there is no better preparation for the vicissitudes of life than a good working personal philosophy. Therapy can help a suicidal person find one.
3. Diet and Exercise
Among the general recommendations you can make to suicidal people are a few that can hardly fail to be helpful, for the simple reason that following these recommendations is virtually certain to enhance mood and promote a sense of well-being. These common sense suggestions include getting enough sound sleep, eating a balanced and nutritious diet, drinking plenty of water, and making time for relaxation and recreation.
What we eat and drink plays a large part in how our bodies and minds function and in how we feel. And, as we all know, a walk or a light workout produces positive changes in body chemistry. According to Physical Activity and Health: A Report from the Surgeon General (U.S. Department of Health and Human Services 1996), even three ten-minute periods of light exercise each day will significantly improve one’s physical health. Particularly in view of the lethargy and overall lack of motivation that accompany depression, however, suicidal people are rarely getting adequate exercise.
They also tend to be eating too little of what we know is good for us and/or too much of what we know is not. Early on in my work with someone who is suicidal I therefore make a point of asking a few questions about their eating habits and, if need be, referring them to a dietician. Although some physicians are attentive to diet, many are not. A dietician is a specialist and can be counted on to evaluate everything from sugar intake to coffee consumption.
In addition, I typically encourage patients to set up a regular schedule of light exercise. Bear in mind, though, that when someone has previously been sedentary, a program of exercise – be it a home stretching and movement program, a few laps around the track, a daily walk down a country road, or a yoga class – may need to be undertaken gradually. Especially in the case of an older patient or one who has had health problems, you should be sure the patient’s doctor knows and approves of any potentially vigorous efforts at physical training.
Even if getting some exercise appears to be small medicine for a big problem, it represents a change in daily routine and can constitute a powerful affirmation of life. It also increases opportunities for social contact and may serve to interrupt ruminations about suicide. Similarly, the fact that you are paying attention to your patient’s diet – to what they use to sustain life – conveys a message of caring and hope. You want this person to live.
4. HALT
Every action occurs twice, once when we first think of it and then again when we actually carry it out. To get from the thought to the action we must pass over a threshold. Like any other action, then, an act of suicide requires that a suicidal person cross the threshold between thought and deed.
Even people who are severely depressed do not live in constant and imminent danger of stepping across the threshold between the thought of suicide and the act itself. Many protective factors stand as barriers at that threshold. These factors intervene between the moment the thought of suicide first comes to mind and the final action of reaching for a knife or gun or fashioning a noose and throwing the rope over a rafter.
Among the factors that afford some protection against suicide is a sense of well-being, which is to some degree depending on states of mind and body over which we have considerable control. Elevated levels of agitation and anxiety, especially in combination with sleeplessness, can easily produce a frame of mind in which protective factors are weakened, making it more likely that a suicidal person will cross the threshold between thought and action. Anything we can do to enhance overall mood therefore helps reduce risk.
The acronym HALT was borrowed from the recovery program of Alcoholics Anonymous and the literature on relapse prevention. “HALT” stands for “hungry, angry, lonely, tired.” If any of these states of mind and body are allowed to develop in an alcoholic or addict, he or she is in greater danger of moving from the idea of taking a drink or drug to the action of doing so. When, instead, the person has eaten, is feeling reasonably relaxed and content, is in the company of friends, and is well rested, these positive conditions strengthen the buffer between thought and action, thereby reducing the risk of relapse.
Similarly, someone who is severely depressed is more likely to cross the threshold to suicide when he or she is hungry, angry, lonely or tired. And this is doubly true for a suicidal addict or alcoholic. Once someone suffering from both depression and alcoholism or addiction is over the threshold to that first drink or drug and becomes intoxicated, the risk of a suicide attempt skyrockets. As I said earlier, and will say again, there is no safety without sobriety – and there is absolutely no safety for a suicidal person who is hungry, angry, lonely, tired, and drunk.
So teach your suicidal patient these four things:
Of all the practical suggestions offered in this text, these are the easiest and most effective ways to head off a suicide attempt. In fact, Alcoholics Anonymous has probably prevented more suicides than any other organisation in the world.
Following this simple advice accomplishes three key things: It puts control over one’s state of mind directly into the hands of the sufferer, it reduces the risk of conflict with others, and it helps restore a state of mind that is fundamentally incompatible with the wish to die. If abiding by this advice seems unworkable to the suicidal person, a serious reassessment of risk is in order. You need to ask yourself:
If the answer to any of these questions is yes, and the patient is still contemplating suicide, then inpatient hospitalisation should be considered.
I once had the sad task of reviewing the suicide of a 42-year-old man. At the time of his death, he had not eaten for almost two days, and so he was hungry: he was angry because his wife had thrown him out of the house and had filed for divorce; he was lonely because he had been denied access to his children and had lost a close friend in recent weeks; and he was tired because he had been up most of the night in an emergency room undergoing a psychiatric evaluation after he threatened to kill himself. Now add to all this the fact that he was an alcoholic who had recently relapsed. It was no surprise to learn that when he shot himself in the early morning hours, following his discharge from the hospital, his blood alcohol level was twice the legal limit. We cannot know whether this man would still be alive if he had known about HALT. But it is at least possible that he would not have relapsed, which might in turn have prevented the final downward spiral to suicide.
5. One Day at a Time
Coaching suicidal people to live one day at a time – reminding them that they just need to make it through the current twenty-four hours – can help them make it through a bad day. But it can also give them a tool with which to counter one of the cognitive distortions that often attend depressed and suicidal people. To appreciate the value of this approach, you need to understand how suicidal people see the future.
Ask the question, “What are your plans for next week?” and many suicidal people won’t have an answer. Ask the question, “What will you be doing this time next year?” and you’re likely to get a blank stare.
People who are so seriously depressed as to e suicidal typically suffer from a narrow and foreshortened view of the future, one in which pessimism rules. If they are swift to draw negative conclusions from almost any circumstance, they do so simply because they are unable to imagine any other conclusions. This distorted perspective, this view of one’s self and one’s world as lacking in any real worth or promise, leads to a negation of the future tense. Suicidal people can’t think about the future or invest a dollar’s worth of hope therein when the present seems unbearable. They can’t imagine a better tomorrow when they can’t get out of bed today, not can they dream of happy endings when the sweet smell of flowers conjures up a funeral.
In the eyes of those who are suicidally depressed, other people seem to live in the lovely, lighthearted world of a musical, full of bursts of colour and song, while they are trapped in the black-and-white world of film noir. Worse yet, the picture jerks, stops, starts, and stops again, and the popcorn is stale. To someone stuck neck deep in the rut of a serious depression, staying alive for even a few more days may seem impossible. But staying alive one more day is doable.
Living one day at a time is a plan, and most likely a workable plan. You may not be able to get a suicidal patient to imagine the end of next week. But you can probably get them to imagine the rest of today. Then, tomorrow morning, they can focus on getting through the next one day. As the days go by, and therapy progresses, living through the entire next week will start to seem possible.
When a patient has plans for the future, this is powerful evidence that the person is beginning to heal. I knew one of my chronically depressed patients was finally getting better when she told me at the end of a session. “You know, come May, I may take a trip to see my sister.” Evidently, she was planning to be alive in the spring. As it was only January, this was wonderful news.
6. Driving a Wedge
To the suicidal sufferer, psychological pain takes the form of a relentless series of awful ideas, uncontrollable thoughts, and agonising feelings. Even though the pain, the psychache, may come in episodes, overall it seems endless and unbroken. A initial diagnosis – saying to a patient, “Look, here’s what’s causing all this pain” – drives a wedge into the seamlessness of suffering. It puts a border around the big problem and fixes it in one place, so that the patient can step back and look at it. Then, once the patient is able to identify the main problem, the two of you can start in one the smaller problems that are currently overwhelming the patient.
By driving wedges in the form of additional diagnostic and fact-finding questions, you can begin to parse psychological pain, to divide it into segments that the patient can examine one by one. Driving a wedge separates the sufferer from the source of pain. This process gradually leads to a better understanding of the pain, of where it is coming from, and of the faces it wears. Once a suicidal person gets some distance on present problems and life circumstances, he or she will begin to feel better.
Here are some handy wedges worth driving:
In addition to putting some distance between the person and the psychological pain in which he or she has been immersed, a good wedge-driving question causes the suicidal person to rethink conclusions already drawn, some of which will surely be wrong. Such questions open up gaps in the constricted circles of logic that have led the person to consider suicide.
You know you’re asking good clinical questions when your patient says things like “I’m getting confused” or “I hadn’t thought of it that way.” Or when your patient falls silent. Such responses are pure clinical gold. I sometimes tell patients I’ve just tripped up by driving a wedge, “You’re confused? That’s great! Now we’re getting somewhere!”
7. Bibliotherapy
Odd though it might seem, suicidal patients can sometimes profit from reading about suicide. Books are another way of driving a wedge, of giving a suffering patient a new perspective on his or her experience, which helps to separate the person from what feels like endless and all-encompassing pain. There are many informative and life-affirming books about suicide that you can recommend to patients. More are being written all the time, so the list provided here is hardly definitive.
Thomas Ellis and Cory Newman’s Choosing to Live: How to Defeat Suicide Through Cognitive Therapy is an evidence-based, self-help approach designed to teach suicidal people how to understand the sources of the thinking and feelings that lead someone to consider suicide. The book also features a step-by-step guide to recovery that can serve as a useful adjunct to therapy. My own book Suicide: The Forever Decision, is addressed directly to the suicidal sufferer and takes the form of an extended therapy session. It is available world-wide as an e-book, in several languages and at no cost.
Anyone interested in a sympathetic, highly readable personal account of what it feels like to be suicidally depressed should read William Styron’s Darkness Visible: A Memoir of Madness. I can also highly recommend Lincoln’s Melancholy: How Depression Challenged a President and Fueled His Greatness, by Joshua Wolf Shenk, which contains a fascinating discussion of Abraham Lincoln’s struggles with depression and suicidal thinking. Kay Redfield Jamison’s Night Falls Fast: Understanding Suicide offers what is perhaps the ideal blend of good writing, solid science, and in-depth information about suicide. Jamison, who suffers from bipolar disorder and once made a serious suicide attempt herself, is one of the most highly respected experts in the field, and her writing is superb.
Three first-rate books for young people and their families are Bev Cobain’s When Nothing Matters Anymore: A Survival Guide for Depressed Teens, David Fassler and Lynne Dumas’s “Help Me I’m Sad”: Recognising, Treating, and Preventing Childhood Depression, and Andrew Slaby and Lili Frank Garfinkel’s No One Saw My Pain: Why Teens Kill Themselves. Other books aimed at youth are coming on the market almost every month, and I encourage you to keep an eye open for them, read them, and, if they seem to you worthwhile, recommend them to parents and other family members, as well as to patients.
In addition to the many excellent books that can prove therapeutic to suicidal patients are a few that could be antitherapeutic, such as Derek Humphry’s Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Although Humphry’s best-selling book concerns the right of the terminally ill to choose the time and place of their death, the information it provides about the various methods for ending one’s life could be dangerous to suicidal individuals. Such literature is hardly good medicine for someone who is ambivalent about living. When you first begin working with a suicidal patient, you would be wise to determine whether he or she has been reading books about euthanasia or is involved in a suicide chat group on the Internet.
8. Blocked Exits
The term blocked exit refers to a situation in which someone believes that there is no means of escape from a set of circumstances that he or she perceives as intolerable. Faced with her infidelity to her husband and a massive burden of debt, Madame Bovary swallows arsenic. As she says on her deathbed, “There were no other possibilities.”
A man of high reputation who has been engaged in fraud is threatened with a humiliating public exposure. A woman who suffers from clinical depression and an addiction to heroin is arrested for prostitution, has her children removed from her care, and is detained against her will in a psychiatric facility. For someone who is mentally ill, the intolerable and inescapable situation may be the apparently self-imposed yet nonetheless exquisite torture of his or her own mind. In circumstances such as these, the sufferer feels trapped in the experience of severe and seemingly interminable psychological pain, pain that cannot be relieved by any means known to the sufferer save death.
Typically, the blocked exit is composed of a series of blocked exits. Imagine yourself in a movie theatre beginning to watch a film – but the movie isn’t the one you were expecting. It’s a horror film, and it’s terrifying beyond all belief. All you want to do is to get out of there, but on testing one exit you discover it’s locked. So is the second, and the third, and the fourth. Rushing to one remaining door, you find it padlocked. There’s no way out. You close your eyes, but you can still hear the screams of the victims on the screen. Panic strikes.
This is the way life often feels to suicidal people. They’ve searched for ways out of their growing fear, anger, and despair and theIr rising sense of panic. But they haven’t found any.
Sometimes, of course, our circumstances genuinely are inescapable. We have little choice but to accept them and deal with them as best we can – which generally does not include killing ourselves over them. But suicidal people are frequently unable to see a way through a difficult situation other than suicide. This inability to come up with alternatives is symptomatic of the impaired cognitive functioning characteristic of the depressed mind. As we know, depressed people who have a history of suicidal ideation perform poorly at problem solving (Williams, Barnhofer, Crane, and Beck 2005). Creative solutions are simply not available. New paths do not open up. Combine this inability to think outside the box with increasing levels of agitation and anxiety, and suicide becomes the awful but only escape.
The therapist’s job here is straightforward: You start looking for an exit. The Dalai Lama once described the job of the healer as that of leading lost strangers through the briar patch of life. The briar patch is dark and dangerous, and once you are tangled up inside it – once you have been born into this world – exits from troubles will not always be obvious. Especially for the young and inexperienced, and for others who have lost their sense of direction, the path through the briars seems to consist of nothing but blind alleys lined with flesh-tearing thorns.
But because we are therapists, because we have read all these books and have been trained to help others, we are issued a special pair of thick leather chaps. With these chaps on our legs, and armed with what we have learned about the various paths and ways through the mass of briars, we can guide others to safety. In other words, when you are working with suicidal patients whose exits are blocked, your job is to find ways over, around, and through the briar patch.
For a time, this will require that you lead and they follow. Given that your patient’s problem-solving capacities are impaired to the point that he or she cannot imagine an alternative to suicide, it will be up to you to take the flashlight and start looking for another way out, a secret opening, an escape into the light. Don’t worry about creating a dependent patient. Once such patients are safely on the other side of the present tangle of briars, they can learn to go forward on their own. Worry instead about keeping the person alive until a path through the briars has been found, and hope is reborn.
9. Not Approving Suicide
As I’ve mentioned, suicidal patients will sometimes try to persuade you that their situation truly is hopeless and that suicide is the only sensible solution. Years of psychological pain and suffering, repeated failures and losses, have left them with a deep and abiding sense of hopelessness that they are convinced will never pass. And so they are seeking professional approval for their suicide. Whether openly or obliquely, they are looking for someone in authority who will say to them. “I understand. So go ahead – it’s okay to kill yourself.”
If a suicidal person appears to be searching for someone in power to grant him or her permission to die, be sure you are not that someone. Never allow yourself to become an unwitting accomplice in a patient’s quest for approval. Be aware that professional approval is not always overt. It can be as simple as lowering your head and letting out a sigh at the end of a long tale of woe. Or it can be as unequivocal as handing your patient a month’s supply of a potentially lethal drug with the advice, “Now, George, you know if you take this all at one – especially with alcohol – it could kill you.”
To avoid becoming an accomplice in a patient’s suicide, make up your mind right from the start that nobody dies, everybody lives. As a healer, I make it very clear that, if I have anything to say about it, no one is going to die on my watch. So when I sense that a chronically suicidal patient is asking me to validate the conclusion that everything is indeed hopeless and, into the bargain, is requesting my permission to get it over with, I simply don’t give it. This means I make every effort never to agree with patients who would argue that their psychological pain is so intractable and untreatable that they have earned my permission to stop living.
I have had suicidal patients put it to me bluntly: “Why can’t I kill myself? Why won’t you let me?” I tell them just as bluntly: “Because I believe you can not only survive but thrive.” Another answer to someone who believes that suicide is the only option is: “I agree, something needs to die here. But it isn’t you!”
When a patient is seeking approval for his or her plans to die, you will know it. In one way or another, you will sense what he or she is after. You may feel it rubbing against the grain of your life-is-worth-living wood. It may feel like a rough spot in the flow of the interview, a bump in a smooth road. You may sense it physically, as an odd feeling in your stomach, a sudden shiver, or a jump in your heart rate. Or you may feel that you are being asked to officiate at a funeral when nobody you know has died.
Pay close attention to these fleeting feelings, these gifts of tension, anxiety, or foreboding. What you are sensing may well be the person’s fear – fear of the vast unknown that he or she is contemplating. Fear travels faster than thought, and ore often than not it is right on target.
However you recognise this anxiety, this feeling that something bad is about to happen, trust your recognition. It could make the difference in saving a life. The intervention can be as simple as saying:
But whatever else you say or do, if a patient is saying, in effect, “Please stop fighting for me to live,” don’t give into the request. Remember that once the therapist has been convinced that a patient can’t make it – that he or she is not worth the effort of rescue – the situation truly is hopeless. If every you feel yourself giving up on a suicidal patient, don’t delay. Turn to a supervisor or colleague and get some help.
10. Dealing with an ERA
Some suicidal people are not going to give up the means to suicide simply because you’ve convinced them to enter treatment. They may like you, they may take their medications and keep their appointments, but back at home in some safe place they have an ERA – an Early Retirement Account. An ERA is a suicide plan and the means to carry it out. In much the same way that an Individual Retirement Account ensures financial security in one’s old age, an ERA gives the suicidal person the security of control over the end of his or her life. And, just as you would not easily give up your rainy day savings account, your pension funds, or your family’s farm, neither will some suicidal people give up their capacity to control what they are convinced may be the only option for pain relief ultimately available to them.
Especially in the eyes of a seriously suicidal person, a well thought-out suicide plan can be a thing of beauty. The ERA may be something quite simple – a couple bottles of sleeping pills, a gun and a special bullet, some masking tape and a length of garden hose. It could be grandfather’s old straight razor. These days, the ERA could even be some of the suicide-friendly how-to information available on the Internet.
An ERA can also be fairly elaborate. A colleague once told me about a suicidal person who had a truly impressive ERA. In addition to having had his attorney prepare a will, which provided for the distribution of his assets, he had taken care of all the death details. He had signed and post a “no resuscitation” document over hi bed in case his overdose failed and had notified a mortician to arrive at his home within two hours of his anticipated demise. Instructions were left as to who could enter the home, who was to clean up afterward, and what was to be done about the phone, the power company, and the newspaper delivery.
Sometimes the ERA represents a lifetime of thinking and planning. But the ERA can also be a recent investment, such as the purchase of an expensive .44 Magnum. But whatever it may be, the ERA is very valuable, and a seriously suicidal person is not likely just to hand it over to you simply because you asked for it. Don’t expect it.
As I indicated in the chapters on intervention and assessment, when someone appears to be at imminent risk of death and yet refuses to give up the means to suicide, you may have little choice but to consider hospitalisation. But a patient who has an ERA is not necessarily in any immediate danger. The ERA is the secret backup plan – the emergency exit, to be used if and when the going gets too rough. The first step in dealing with an ERA is therefore to discover that it exists. This will probably require time and some gentle but persistent probing. Until a solid therapeutic alliance has been established and the patient has come to trust you, chances are he or she will choose to keep the ERA safely out of sight.
Even after you learn about the ERA, however, the patient is unlikely to let go of it without a struggle. Psychologically speaking, he or she is going to arm-wrestle you for it – not once, but possibly every single time you meet for a therapy session. In fact, sometimes the central preoccupation and overriding goal of a long psychotherapeutic struggle with a stubbornly suicidal patient is to persuade the person to give up, finally and forever, the Early Retirement Account.
When someone is reluctant to give up an ERA, your best option (and often your only option) is to be patient and to continue doing therapy. As treatment progresses, and hope is revived, the person will gradually come to see things differently – and one day he or she will decide that an Early Retirement Account just isn’t necessary.
11. The Columbo Technique
The popular television series Columbo featured a detective, Lieutenant Columbo, who was known for his dogged persistence in following up the details of case. Until he was satisfied that he understood what was going on, he never let up in his pursuit of information. The Columbo Technique says: Never let up until you know as much about your patient’s plans and reasons for suicide as he or she does.
While useful in many situations, the Columbo Technique is especially valuable when a patient has plans for suicide that he or she would prefer go undetected. As we have seen, people who have thought long and hard about killing themselves have often developed an elaborate suicide plan – perhaps even several such plans. They know where they will get the gun or the pills or the rope. They may have picked a time and place. They may have written several drafts of a suicide note. Yet when the therapist asks whether they have such a plan and, if so, what it consists of, the patient dismisses the question or gives only a brief, uninformative reply.
People who have been careful and methodical in the living of life are likely to be careful and methodical in carrying out and act of suicide. Especially from such people, you should never accept vague, evasive, or incomplete answers to your questions about plans for suicide. But rather than demanding a full account early on, which could put a burgeoning therapeutic alliance at risk, you would do better to come back to the same question again. And again. And again. Or put the same question in a slightly different way. For Example:
Therapist: You said you were going to use a gun … Is that your gun, or someone else’s?
Patient: What difference does it make?
Therapist: Oh, non, I suppose. I was just wondering. Maybe your friend wouldn’t give it to you if he knew what you were going to do with it.
Patient: He’s not a friend, he’s my brother, and he would, too. He knows me and respects me. If he know I was going to kill myself, he’d let me do it.
Therapist: Is your brother’s gun a .38 or a .22?
Patient (growing testy): Why are you so interested in my brother’s gun?
Therapist: Does it come with bullets? Hollow points, or just soft-nosed rounds?
Patient: I don’t know what kind. And, hey, this is my business.
But it isn’t his business, not now that he’s sitting in your office or you are sitting in his home on a professional visit. And, thanks to the Columbo Technique, you now know several things you wouldn’t have known if you’d allowed the patient to put you off. You know whose weapon it is and that it probably comes with bullets. You also know that your patient has a brother who respects him and so might be of help in saving a life.
I once had the occasion to review the completed suicide of a clinically depressed older man who was facing unwanted surgery. Reluctantly, he had acknowledged to a social worker that he was planning to use a pistol to kill himself. But then, when the social worker asked whether he would give up the pistol, he agreed quite readily. He went to a closet and handed over the gun. The next day he shot himself with another pistol. We will obviously never know whether intense curiosity and a few further questions – “Is this the pistol you planned to use?” and “Do you have any other firearms in the house?” – might have resulted in a confrontation that could have led to hospitalisation and lifesaving treatment.
This is not to blame the social worker, who acted very responsibly. The lesson to take is that seriously suicidal people, people who firmly believe that death is the only answer, are unlikely to be deterred from following through on their plans unless the healer takes a persistent, even dogged approach to the assessment of risk. Curiosity kills cats, not therapists, and intense curiosity may save a life.
12. Monkey Wrenching
Much like the wedge-driving questions outlined earlier, cognitive monkey wrenching is a way to invade and then disrupt a patient’s suicidal thoughts and plans. In this case, you do so by putting yourself right in the middle of them. Being intensely curious helps make this possible.
For at least some suicidal sufferers, suicidal ideation is more a friend than an enemy. It is the one place they can go where they still feel some sense of control – even relief. Allow a therapist into the middle of these calming reflections, this chapel of peaceful flirtation with death, and that place of respite will never be the same again. In short, cognitive monkey wrenching is a way to desanctify the church in which the image of death is worshiped.
To throw a monkey wrench into the works, you begin by gently prying into the patient’s private world with questions about the details of their experience with suicidal thoughts and feelings – how they envisage their suicide, what means they would choose, what place they would select, how they feel when they think about it, what fantasies they have about the reactions of others, and so on. Once you know as much about the shape, colour, smell, and texture of the patient’s thoughts as he or she does, it is usually quite easy to toss a wrench into the works. Here are a few wrenches that worked for me.
“Hmm. The next time you’re down by the river looking at the water and imagining what a relief it would be to slip quietly under the ripples, I wonder whether you’ll hear my voice right behind you, asking, “Are you sure this is such a good idea?”” The patient’s once-perfect fantasy of suicide has just had a monkey wrench tossed into it. Plan A, jumping into the river, is never going to be quite the same again.
“You know how you like to sit and stare into the candles just before you take out that little razor you keep in the drawer by your bed to make cuts on your wrists? Well, I hope my face doesn’t mysteriously start to appear in the flames.” The patient’s self-hypnotic induction into an episode of life-threatening behaviour, and the comfort she derived from the warm blood flowing over her arms, is no longer a private party. A gate crasher has ruined everything.
You know you’ve jammed things up if the patient gets upset with you. People who find relief in thinking about suicide don’t generally like you or anyone else mucking around in their reveries. These are, like garden paths and quiet pools, mental retreats that provide respite from otherwise seamless suffering of their lives. Not a few of my patients have become visibly angry right after they realised that my presence was going to intrude the next time they started thinking about killing themselves. But that’s okay. People get over anger. It’s death that’s not so easy to undo.
One teenage boy I worked with used to lie on his bed in the evening listening to songs about suicide and tickling his chest over his heart with a needle-sharp bayonet, all the time wondering how quickly his heart would stop beating if he sliced it in half. In our second session, we engaged in a long, detailed exploration of this behaviour, and I suggested that perhaps together we could find other ways for him to entertain himself. In the very next session he told me, “It doesn’t work anymore … the knife thing, I mean. I tried it once, and all I could think about was what we talked about last time.”
This depressed kind and his family needed and got family therapy. The parents eventually divorced, and their talented young son went on to college, majoring in art. When I asked him, at one point, whether he would copy down the lyrics from one of his favourite suicide songs before our next session, he said, “Got a pencil?” Then, without a pause, he dictated the lines to Helix’s “Deep Cuts the Knife” to me from memory. I still have the lyrics, and I even remember a line or two – which just goes to show that patients can do a bit of cognitive monkey wrenching, too.
13. Permission to Live
However it comes about psychologically, some suicidal people feel they are obligated to die. They may believe that certain standards exist and that, by the light of these standards,, they no longer have a right to go on living. Down through history, and in many different societies, the creed of “death before dishonour” has resulted innumerable civilian and military suicides. Even today, cultures exist in which women who have been raped are expected to kill themselves, and often do.
But if we now view the notion of obligatory suicide as a relic of the past, it is well to remember that one of the more common messages heard from suicidal people is that they don’t want to be a burden on others. Because they are financially and emotionally dependent on others, children and adolescents are especially vulnerable to such feelings, and so are the elderly. Under some circumstances, they may come to believe that their death would be a release for others – that suicide is the only responsible solution to someone else’s problems.
Of course, no one has the right to expect another person to kill himself or herself in order to solve a problem, be it social, psychological, or economic. However, whether consciously or unconsciously, people do sometimes wish for another’s death, and a sensitive soul can pick up on that wish. Then again, the suicidal person may have drawn the wrong conclusions from the evidence available. Either way, though, the patient’s conviction that his or her death would unburden someone else is very real.
Here are several ways to explore such a belief and convey to a suicidal patient that he or she is under no obligation to die:
You can also counter the belief with affirmations such as:
Here is one situation in which your authority as the healer and therapist is invaluable. It gives you the power to override the messages that suicidal patients have been hearing from others, or from themselves. For suicidal people of all ages, but especially the young and the old, granting permission to live can be life saving. The effect, when I’ve personally seen it take hold, is often like that of handing a reprieve to someone who is expecting to be hanged on the the morrow.
14. Permission to Say the Unsayable
It is always worth considering the possibility that the suicidal person in front of you has never been able to, or felt allowed to, expressed the full range of his or her emotions or to talk about certain aspects of his or her thoughts, particularly those that seem unspeakably ugly. Part of what we do in therapy is to name and normalise what the sufferer believes should be named and is abnormal. What is nameless produces fear. What is thought to be abnormal produces shame.
In order to reduce anxiety, fear, and shame, we sometimes need to give a patient permission, implicitly ad/or explicitly, to say what he or she has already thought and to voice what he or she has already felt – like wanting to kill your husband, for example. Or wishing your whole family would die in a fiery crash. Or being afraid that if you start crying you will never be able to stop. Or it may be that patients have done things they regard as so reprehensible or so disgusting that they live in fear of what others would think if they knew. But if dark secrets and “unacceptable” thoughts and feelings are ever to be examined in the light of common human understanding, they first need to be shared. And sharing them is usually only possible in an atmosphere of support and trust.
It helps if you’re not easily shocked, or even much surprised, by the full range of human behaviour, no matter how offensive or bizarre. If you do find yourself stunned, or appalled, by some unusual revelation, try not to overreact. Whatever your private feelings, you must guard against conveying a message that would essentially confirm the patient’s worst fears and thus add to, rather than reduce, the person’s already heavy load of shame and self-recrimination. If you do, your patient will almost invariably retreat from the session, quickly putting the cork back into the bottle in which unspeakable thoughts and feelings have been so carefully hidden. Rather, the goal is to bring secrets into the open and allow the patient to discover that, strange though it may seem, others have thought and felt and done equally “abnormal” things. The more experience you have as a therapist, the easier this will be to do.
15. Family Entanglements
Suicide almost always involves significant others. Sometimes the suicidal person is striking back at loved ones for abuse received or rejection perceived. Others are entangled in dysfunctional family systems and are clinging to intricate, long-standing pathological patterns from which death seems the only means of escape. There may be all sorts of dark struggles going on among the players, in which the patient is deeply enmeshed. Or there may be shameful family secrets, as well as firm prohibitions against anyone stepping outside of the family system for help. Given that suicide would solve, quite permanently, all the patient’s problems – enmeshment issues, conflicted communications with parents or parental figures, separation anxieties, fear of abandonment, and so on – the thought of exiting a sick family via suicide can be very tempting.
In working with suicidal children (and a person of any age who is still living in the home can be considered a child), ask yourself what would happen to the parents if this child grew up and left. If terrible consequences would ensue – the parents would probably divorce, the mother would sicken and die, the father would lose the only child who defends him against his wife – then you know, right off, that family therapy is indicated. The family’s chief task is to raise its offspring into healthy, autonomous adults, and the failure to do so is a signal that something is very wrong. Growing up shouldn’t be a form of disloyalty. It shouldn’t mean abandoning your mother to an abusive husband or condemning your father to intolerable loneliness or otherwise putting a family member in some sort of physical or emotional jeopardy.
This is not the place to detail the ins and outs of good family systems therapy. But if you are working with someone who is clearly struggling with family pathology, you must at least understand precisely how your patient’s wish to die fits into the family belief structure and what consequences his or her suicide would have for others. Dysfunctional family systems often include an identified patient – the person who has volunteered (usually unconsciously) or been asked (usually wordlessly) to assume the burden of illness. To deal only with the identified patient in such systems is to significantly limit your effectiveness and thus your ability to lower the risk of suicide.
If there really is no other option, you will have to work with the identified patient alone, and this is certainly possible, even if it is not ideal. But when your clinical judgement tells you that your patient’s suicidal impulses are grounded in broader family issues, your best option is to get everyone together, have them make a commitment to keep everyone in the family safe, and then set the ground rules for how the therapy will proceed. If you’ve already had experience with family therapy, you know what to do. If you’re not, bring in a trained family therapist or get some training for yourself.
16. Removing Parents
The vast majority of parents of suicidal children do love them. They may not understand the nature and the dangers of depression or other psychiatric disorders, but they love their children. Sadly, though, it is also true that some parents do not love their children. As difficult as it might be to believe, some parents openly wish their children were dead. Many more keep such wishes to themselves but express the desire indirectly, by reinforcing, whether consciously or unconsciously, self-destructive behaviour on the part of a child. They may even encourage a child’s suicide, if not in so many words then in deeds – for example, by giving a depressed, anxiety-ridden teenager facing school and relationship failures a hunting rifle for his birthday.
Kids are especially smart about relationships and can sense rejection across a crowded room. Sometimes the impressions they gather are wrong, but sometimes they’re right. When we are working with youth, we cannot afford to take chances by automatically siding with the parents’ version (or versions) of a family’s reality. Parents who hate their children can actually kill them – and suicide conveniently shifts the blame to the victim.
I remember once making observations such as these during a discussion of suicide on a television talk show in Los Angeles. The moderator challenged me: “Doctor, are you saying that some parents actually encourage their children to suicide?” I said yes.
Sitting next to me was a Catholic priest who worked with troubled and suicidal teens. The moderator turned to him and asked. “That can’t be true, can it, Father?”
“Oh, it’s true all right,” the priest replied. “We wish it weren’t true, but it happens all the time.”
Consider just the following possibilities. Could it be that the child in front of you:
Obviously, no child should have to die to solve a parent’s problems. This is another of those times when we need to be bold. We need to take off our blinders and let go of the comforting illusion that all parents deeply love and respect their offspring. Instead, we need to learn everything we can about the family’s history, dynamics, rituals, beliefs, and expectation.
Once you have determined that a child may be acting out the desires of parents who are terribly troubled, it is essential that you evaluate the entire family system and take whatever steps may be necessary to safeguard the child from harm. Removing sick and suicidogenic parents from a child’s life is not an operation to be undertaken by the inexperienced or unskilled. Still, performing a “parentectomy” can be a lifesaving intervention. Sometimes the only way to guarantee a child’s safety is to remove the parents from the child’s life – if not physically, then psychologically, through counselling and therapy.
To remove a parent or parents you will need the help of a child welfare agency and perhaps a clergyman, a physician, and/or a whole team of mental health professionals. There are authorities who can assist you and laws that will protect your actions on behalf of an at-risk child. Learn what these laws are and do not hesitate to turn to them when you need them.
17. Unlearning Shame
Particularly when you have encouraged patients to express their innermost thoughts and feelings, it is critical that you keep shame at arm’s length. This is especially important in the case of adolescents and adults who were raised in shame-based families. Feelings of worthlessness and an abiding sense of humiliation can often be traced to a parent or parents whose techniques of child management were founded on the notion that a properly shamed child is a properly behaved one. Some parents are able to instill feelings of shame in a child almost as if they were skilled hypnotists making posthypnotic suggestions. Their children are taught shame before they’ve even developed much by way of language skills, let alone any self-esteem or the ability to fight back.
A lingering sense of shame is often a driving force behind the impulse to suicide. A person who has internalised the message that he or she is a deeply undeserving human being will often plan a very proper suicide. The plan will be discreet and tidy, and all due attention will have been paid to matters of propriety – to the appearance of the corpse, to ensuring that personal affairs and household matters are in order, to the details of funeral arrangements, and so on. People who have grown u believing that they are fundamentally flawed human beings will tend to be at pains to avoid inconveniencing others by their death.
Even intelligence and successful adults can be trapped in a legacy of shame. I once worked with a physician raised by a cold and distant father who evidently suspected that his son was basically “a dirty and worthless little bastard.” One of his main messages was, “Don’t you ever dare to do anything that might bring shame to this family.” And so there was never really any question in this man’s mind that sooner or later he would have to kill himself. Undoing this curse by investigating the roots of the shame he experienced as a boy was the central part of the therapy. Helping patients such as this man understand and accept that, as the poet said, we come through our parents, not from them, can be life saving.
It makes good sense, then, that when you are working with patients who are terribly burdened by shame, you must be careful not to allow even a whisper of condemnation to escape your own lips or to behave in a way that might suggest disapproval. Our job is not to judge but to root out potentially lethal feelings of shame, lay them on a heavy table in a good light, and smash them into harmless pieces.
Be advised, however, that it usually does little good to make a frontal assault on the shaming parent, especially if the parent is still alive, lives in the same town, or is sitting out in the waiting room. Blood is thicker than water – at least at the beginning of therapy. It is your gentle questioning, your unstinting support, and your understanding of the process of separation and individuation that will, over time, lead to a change in self-perception and foster the development of enough self-esteem that your patient will finally be able to separate successfully from his or her parents.
18. Reframing
Sometimes a person who is suicidal doesn’t actually want to die. What the person really wants is more power over a problem or an unpleasant set of circumstances, and suicide seems like the obvious solution. In such situations, a technique known as reframing can prove very valuable.
The point of reframing is to translate the overt wish to die into the underlying wish for greater control. For example:
Reframing helps the patient to see that suicide is an escapist response to a situation that feels awful and uncontrollable. The goal is to convince the patient that, if the need for greater control is the real problem, then suicide truly is a false solution. Repeatedly prompting the patient to acknowledge the wish for more control can gradually reorient the person’s thinking and thus lead to better problem solving.
Because such patients don’t want to die so much as gain power over people and circumstances, they are somewhat less at risk than patients who are struggling with an overwhelming sense of utter hopelessness. But this is not to say that people don’t kill themselves in a misguided effort to influence others or get out of a mess they’re in. They do. And in a way motivations for suicide that involve an underlying desire for control are among our most challenging. To help such patients we need the usual working alliance, solid therapeutic boundaries, and many of the tools and techniques outlined in this book.
19. Times of Increased Risk
Over the sometimes long haul of therapy, it is likely that events – both planned and unplanned – will occur that increase the patient’s level of stress and hence his or her vulnerability to thoughts of suicide. These are often developing situations over which the patient feels he or she has increasingly less control, or none at all. Anticipate these windows of risk, bring them into the therapy, and be prepared to manage them aggressively. A partial list of such risks would include:
The wise therapist anticipates as many of the slings and arrows of outrageous fortune as possible and tries to prepare the patient to cope with them, as well as offering support and guidance during such events and in their immediate aftermath. This may entail scheduling extra sessions or calling an outside support. It is often valuable to begin by asking a patient to think about what could happen in the future that might provoke renewed suicidal feelings. Talking these possibilities through can make them seem more like known quantities and therefore less frightening. Likewise, discussing what the two of you will do if and when a dreaded event occurs can help to reduce anxiety and thus safeguard the patient against another suicidal crisis.
20. The Calm Before the Storm
As is well known, suicidal people often feel a wonderful sense of relief when finally they decide, once and for all, to kill themselves. They have been engaged in a life-and-death struggle before their own mental jury, and at long last the verdict is in. Even though the sentence is death, the case is now closed, and their tribulations are behind them. Beware the suddenly peaceful patient!
The decision to die lifts a great burden from the shoulders of the sufferer. After the decision has been made, a beatific, Buddha-like smile may appear on the suicidal person’s face. You may find yourself wondering. Why is this person suddenly so at peace? What has truly changed? Has the medication magically kicked in … or is this a decision to die? Indeed, to the therapist whose patient has been battling with the choice of living or dying, this smile – this sudden chipperness, this abrupt change in the weather, this overnight shift from misery to peace, this miraculous cure – should sound a five-alarm fire bell.
Having read the final entries in the medical records of a number of patients who killed themselves shortly after their last outpatient visit, I can assure you that observations such as “Seems much better today” or “Mood much improved, patient doing well” come to seem almost predictable. Consider the following:
A depressed suicidal young professional woman who was recently fired from a much-loved job throws a party for her closest friends the day after her discharge from a psychiatric hospital. That night she dies of a massive overdose. Where there is no real cause, why is there a celebration?
A middle-aged man seeks therapy for depression but denies his alcoholism. His marriage is failing, his job is in jeopardy, and his children won’t speak to him. He expects to be laid off from work at the end of the week, but on Thursday he tells his therapist that he’s come into some unexpected money and seems “almost jovial.” He shoots himself in the heat with a shotgun two days later. Unexpected expressions of joy are suspicious and must be explored.
A woman who for the past two decades has suffered from chronic pain and depression announces to her physician that she no longer needs her antidepressant medication and has stopped taking it. She appears in an upbeat mood. A devout Catholic, she tells her doctor, “There’s nothing to worry about now … I’ve seen the Virgin.” She returns home and shoots herself in the head with her husband’s .38-caliber pistol. Where the medicine is not working, there should be no cure.
The work of therapy is seldom easy for anyone, let alone suicidal people. Sometimes, after weeks or even months of long, difficult, and seemingly unproductive therapeutic efforts, and the failure of one medication after another, the patient will decide to give up the struggle without letting you know. But because the patient feels that courtesy is owed, he or she will keep one last appointment. Or make one last call to cancel. It is during this appointment or phone conversation that the patient’s mood may appear so much improved.
When you are working with someone who is suicidal, this is the time to hit the panic button, and hit it immediately. Ask the person:
The best place to ask these questions is in the office, but if you first detect this strange calm over the phone, ask over the phone. But wherever you are, and whatever else you do, you must restore the therapeutic alliance. You must persuade the patient to talk about what is going on and to reaffirm a commitment to safety and ongoing treatment.
21. Back to the Couch
This intervention was taught by me by a chronically suicidal patient I once treated. She invariably waited until the end of the therapy hour to let me know she was going to leave my office, go home, and kill herself. She had several roundabout ways of communicating this. One of my favourites was, “You’ve been awfully kind to me these past months. I’ll call and schedule another appointment sometimes next week.”
This was a lie. We had a standing appointment. She had no intention of calling me. Her smile and apparently much brightened mood was – excuse the pun – a dead giveaway. What was she really saying was, “Thanks for trying, but I’ve decided to go ahead and get it over with.”
On receiving this message, I would march her back to the couch, and we would start in all over again. My next patient might have to wait, but this one wasn’t leaving until she was feeling properly miserable again – miserable, but recommitted to therapy, at least for another week.
22. Rewriting the Script
In working with someone suicidal, one of your first tasks will be to discover just where he or she got the idea that suicide is an acceptable solution to life’s problems. The previously unexamined belief that, under certain circumstances, killing yourself is a reasonable option – or perhaps the only option – must be traced to its very source. Once the foundations of this belief have been laid bare, the belief can be challenged, chipped away at, assaulted, disassembled, and otherwise undermined.
The idea that “If things don’t work out, I can always kill myself” does not materialise out of thin air. It has been learned. Most often, it has been learned directly from another human being – a parent or other relative, or perhaps a friend. Then again the source could e a movie or book or someone the patient has heard about but never met. And, as we have seen, the idea that suicide is acceptable can even be embedded in culture. It was tradition that taught a samurai warrior what he was obliged to do should he ever be disgraced.
Some suicidal people, however, don’t merely believe that suicide is a viable option. They believe that their suicide is somehow inevitable – that they are destined to die by their own hand. Ernest Hemingway’s father, for example, scripted his son to suicide by shooting himself while Hemingway was still a youth. The themes of death and suicide haunted the writer all his days, and we can only hope that the legacy of Hemingway suicides ended with that of his granddaughter Margaux.
Locating the psychological source of the conviction that one’s suicide is essentially a foregone conclusion will probably include identifying a role model for suicide. But pinpointing the source is critical to undoing the influence of that belief. Unless this fatal setup is dismantled, healing may prove very difficult, even impossible. Here is one useful intervention:
The answer to these questions should tell you who set the stage for tragedy and who wrote the first draft of the suicide script. Then, not only must the script itself be called into question, but the right of its original author to cast the patient in the role of suicide victim must be challenged.
Too commonly, as in the case of Hemingway, the script’s author is a parent who died by suicide. A patient will often feel protective of this long-deceased parent and may at first react defensively to your attempts to probe the past. You may be told that you should allow the dead to rest in peace rather than dig them up and begin attacking them for the psychological legacy they bequeathed to those they left behind. But that’s exactly what you must do. Regardless of how the patient came by the script, the belief that he or she must one day die by suicide is just that: a belief. A belief is not a reality until you act on it. Nothing is destined. Death by suicide is never a requirement, no matter who wrote the script.
Fortunately, the strength with which our beliefs are held is not fixed. Early on in counselling, those scripted to die by suicide may be quite firmly convinced that they will someday die by their own hand. As therapy progresses, however, the belief that they might instead die of natural causes at the close of a long and relatively happy life begins to gain strength, and the believe in an early death by suicide weakens accordingly.
Even so, the conviction that suicide is both acceptable and inevitable can be remarkably tenacious. I have had a patient’s belief in life appear to increase dramatically only to hear the person later say, “Well, things are going all right now, but if she leaves me again, I’ll have to kill myself.” When this happens, it is clear that the core of the belief is still firm, which means that work remains to be done.
To help a suicidal patient revise a deeply rooted belief in the inevitability of his or her suicide you will need to help the patient rewrite his or her own life scripts, often from the very beginning. Such a process can be empowering, but it can also be frightening. Many patients have never seen themselves as the author of their own lives. Getting anyone – let alone a depressed and suicidal person – to assume this awesome responsibility, teaching them to take charge of their destiny, is seldom easy. You must work at it, and your patient must be willing to work with you. But once the process takes hold, the growth of a patient’s sense of personal control over his or her own life can be amazing. Once those scripted to suicide realise that death by their own hand is never foreordained – one they realise that, at the very worst, someone could murder them – then the heavy cloud of impending doom lifts, and the future is suddenly filled with possibilities.
23. Imaging After Death
This technique is one to be approached with some caution, and only when you are absolutely sure you have a firm therapeutic alliance with your patient. When I have used this intervention, I have done so because other methods of countering the patient’s desire to die were not working. Used carefully, it is a technique that can pay big dividends. It can help you to evaluate how clearly (or not) a suicidal person is thinking and to what extent anger, the desire for revenge, and/or sheer impulse are driving the wish to die.
The technique involves asking a series of questions that push patients beyond the act of suicide itself and require them to imagine what the future will look like without them in it. Such questions might include the following:
As a therapeutic strategy, posing such questions has a number of advantages:
If the suicidal person has difficulty coming up with answers to your questions, it may be that the person’s thinking is more severely impaired than you initially thought. Seriously depressed people tend to suffer from tunnel vision, which can lead them to believe that suicide is their best, or their only, option.
The tunnel vision that so often accompanies the journey to suicide is memorably illustrated in the Christmas classic It’s a Wonderful Life – required viewing each holiday season in America. In this story, George Bailey (Jimmy Stewart) is faced with the unacceptable and personally humiliating loss of an investor’s funds, for which he is wrongly blamed. Realising that his business will be forced into bankruptcy and that he will be sent to jail, he becomes frightened and angry. He goes to a bar, drinks too much, and eventually winds up on a bridge, where he resolves to jump to his death. In his agitated and intoxicated state, he believes that suicide will solve his problems. It will allow him to avoid public humiliation, and his wife and children will have the money from his life insurance. His thinking stops there: He can’t see any farther into the future.
But fate intervenes in the form of an angel named Clarence, who jumps into the river himself, thereby obligating George to save him. Clarence then shows George what would have happened if, instead, he had been the one to jump. He painfully learns that, had he perished, all the people he most cared about would have ended up in misery, and the greedy bank owner, Mr. Potter, would have succeeded in gaining control of the town, renaming it “Pottersville,” and reducing it to a slum.
This may be the stuff of Hollywood, but it is also the stuff of therapy. Caught in the press of the problems facing them, suicidal people focus on the immediate relief that death would provide, not on the consequences for others of that death. In their depressed condition, they have only a limited capacity to envisage future scenarios or to appreciate the part they play in other people’s lives.
In truth, survivors of suicide are often furious at the deceased loved one, whom they accuse of being “selfish” or “thoughtless.” In a way, these words are apt. But if in choosing to die their loved one acted selfishly and thoughtlessly, it was probably not so much out of a basic insensitivity to the needs of others. More likely, the person’s ability to think clearly and critically and to imagine alternative solutions to his or her problems was crippled by severe depression, possibly coupled with intoxication. He or she could not see far enough beyond the act of suicide itself to imagine with any accuracy what it would mean.
24. Revenge Suicide
Pushing a patient to spin a death-and-consequences scenario sometimes reveals that the desire to die is very much about inflicting psychological pain on others. Called a revenge suicide, such an act is motivated by a desire to strike back, to hurt others as the patient believes he or she has been hurt. Sometimes the perception of having been gravely injured by others is quite accurate. More often, though, there is relatively little reality to support it. As we know, impaired thinking, with its distortions and wrong conclusions, is a hallmark of serious depression.
If you learn that the desire to retaliate is a significant part of a sufferer’s motivation for suicide, you will need to work on reframing this desire. The desire for revenge may be rooted in a need for more control, a need for more love and attention from others, or a need to be heard and understood. By shifting the focus to underlying needs and wishes, reframing allows the suicidal person to view his or her situation in a new and more realistic light.
Ironically enough, however, far from being rooted in a desire for revenge, sometimes the wish to die is grounded in what the suicidal person sees as altruistic motives. Especially for a patient who feels that he or she is fundamentally a burden to others, suicide is intended to make life easier for the survivors, not harder. In reality, however, this conclusion is almost always inaccurate.
I once treated a suicidal patient who, before killing himself, was planning to sell his business and make arrangements with an attorney so that the money from the sale would be used to take care of his three children, ages four, seven, and nine. (His wife, he told me, could “Go such an egg.”) I knew that this man deeply loved his children, but I also knew that he was far from a multimillionaire. And so I challenged him to do the math to support his goodwill gesture – not later, at home, but right there in my office, right this minute. I handed him a pocket calculator. Would he be leaving his children with enough money to see them through a college education? Hardly. After we’d crunched the numbers, the truth shocked him. The money wouldn’t suffice to get them out of high school, let alone college. This hard fact brought him up short and enabled us to work toward a more effective solution to this problems.
Even though his future included an ugly divorce and a long road to recovery from alcoholism, this once suicidally depressed man eventually ended up not only building a successful business but winning full custody of his children. I’ve run into him several times since we worked together, once when he was coming out of a theater with two of his children, now teenagers. He introduced his kids to me and told them. “This man helped me a long time ago.” It is rewards like this that keep a therapist going.
Consider also a parent who says, “The kids would be better off without me.” One can challenge this distorted perception head on, simply by reminding the person that such a conclusion is not true and will never be true. Even the most flawed parent has value. When we are depressed, we are naturally prone to see only our shortcomings – but this is a problem with our vision, not our reality. Moreover, when parents kill themselves, not only do they leave a psychological curse as a legacy to their children, but they also duck out on their very real emotional, psychological, social, and financial responsibilities to help their children grow up, finish school, and make their way in the world.
Making such an argument may seem too harsh, too guilt inducing, and hence too risky an approach to take with someone who is already seriously depressed. But when nothing else is working, grounding a patient in future reality can be a powerful means of demonstrating that suicide is a false solution. I have not generally found that fear of the hereafter, or of God’s anger, or of the possibility that death is unending nothingness to be much of a deterrent to suicide. If anything, it is their responsibilities on this side of the grave that help keep people alive – a fact I am not about using if I need to get someone’s attention.
Sadly, though, sometimes a patient’s conclusion that his or her suicide would make things easier for others is all too correct. If you ask a patient to imagine what the future will look like after he or she is dead and discover that nobody in fact wants this person around, you have obviously learned something extremely important. But you will need to get to work right away at bringing about a fundamental change in the patient’s environment, both social and psychological, and in the patient’s self-perception. Your job will be to guide the person to the conviction that, no matter what, he or she is a worthwhile human being who deserves something better than death.
25. Socratic Dialogues
One of the most useful tools for a therapist who is grappling with the negative, distorted, and confused cognitions of a suicidal person is the Socratic dialogue: the method of teaching by posing a series of questions that lead the student to a new understanding. Rather than tell his students what to think, Socrates simply asked them questions until they uncovered some truth or other for themselves. Ask enough good questions and, sooner or later, the suicidal person will be drawn to a conclusion other than self-inflicted death.
Consider a situation in which a man is being left by a woman he doesn’t want to lose. Here is how such a dialogue might proceed:
Therapist: Why do you think she rejected you?
Patient: They always reject me. Didn’t I tell you that? I’m selfish and stupid.
Therapist: Have you always been selfish and stupid?
Patient: Yes.
Therapist: With everyone, or only with women?
Patient: Hmmm. Maybe more with women.
Therapist: Maybe more with women?
Patient: Well, once in a while I can be pretty generous.
Therapist: Like when?
Patient: I once gave an old fiancee an expensive diamond.
Therapist: What happened to her?
Patient: It didn’t work out. I found somebody else.
Therapist: What happened to the ring?
Patient: I let her keep it. I’m not stingy.
Therapist: Let me get this straight. You left her, she didn’t leave you? And you let her keep the ring?
Patient: Yes.
Therapist: And you didn’t become suicidal?
Patient: No, why should I? I was leaving her.
Therapist: Then women don’t always reject you. In fact, sometimes you reject women?
Patient: Say … are you trying to trip me up, or what?
Depending on the quality of the therapeutic relationship, the therapist might now say something like, “You old heartbreaker, you. You’ve left a few, haven’t you? And being a big-hearted guy, you let the last one keep the ring? Am I right?”
Socrates would wait for an answer, and so should you. Prompted by the therapist’s questions, the patient was able to discover a few small truths on his own. He learned that:
The purpose of such questioning is to reveal the distorted “facts” and the inconsistencies in reasoning based on these false facts that in turn lead to false conclusions. According to the categorical and rigid thinking of depressed persons, if you are always rejected because you are always selfish and stupid and can never make any relationship work with any woman, well, then, you are a hopeless case. And if you are a hopeless case, then you ought to do the decent thing and just shoot yourself. The truth, however, is not black or white, not something always or never. Our man has been hurt, but the wound is not fatal. He does not have to die. He may need to grow up a little – but die, no.
This approach owes its origins not only to the Greek philosopher but also to one of his students. Albert Ellis. Socratic questioning is one of the techniques outlined in Rational Emotive Behaviour Therapy (Ellis and MacLaren 2005). Here are three keys to getting good results with this method:
For example, the patient may say: “Maybe I don’t always get my facts straight, but I’m really not such a bad person.” Or, “People used to really like me before I met Christy … Maybe she changed me for the worse.” Or, “I guess I forget about them, but actually I have done a few good things with my life.”
To combat the logic that so relentlessly argues the case for death by suicide and to improve the patient’s chances for survival, you need all the positive self-statements you can extract from the person. Repeatedly returning to such statements over the course of therapy can give the patient strength in the same way that a well-considered compliment makes people genuinely feel good about themselves. More important, such self-affirmations will help the patient slowly restore a positive self-image – and people who value themselves choose life, not death.
Socrates might say to the patient. “So now we know you’re basically a decent, thoughtful, caring human being who only occasionally draws wrong conclusions from questionable facts. Tell me, then. Does it make sense to put such a person to death?”
26. False Price
Ending one’s own life can be a matter of honour or pride, a way to safeguard one’s reputation or avoid some personally humiliating event. History is strewn with lives self-sacrificed on the altar of honour. One can understand why, say, a military leader who makes a horrendous blunder that costs the lives of countless soldiers and civilians might choose to take his own life. But suicides are more often the result of ordinary, garden-variety false pride. Consider the alpha male who boasts, “I’m not the kind of man women leave! If anyone’s going to leave, it’s going to be me! Where’s my shotgun?” Here is a man for whom rejection at the hands of a woman delivers such a blow to masculine pride as to render continued existence impossible.
Injuries to pride and the threat of being shamed can thus play a large part in triggering an act of suicide. The greater our pride, the more vulnerable we are to insult. The utterly unacceptable circumstance might be falling seriously ill or suffering a disabling or disfiguring injury, being diagnosed with a psychiatric disorder, being rejected by a lover, being fired, losing a ton of money on the stock market, flunking out of college, or even being sent home from school. When a proud person is already depressed and susceptible to thoughts of suicide, events such as these can prove to be the last straw.
I once worked with a retired army major whose wife wanted to leave him. When things didn’t go his way in quarrels with his spouse, he had taken to sticking a .45 automatic in his mouth – an approach he’d learned in Vietnam while interrogating prisoners. A .45 in anybody’s mouth demands your attention. Pride was out problem: He was not the kind of man women leave. After several weeks of white-knuckle therapy with this arrogant, stern, prideful man, I remarked that, if his wife wanted to leave him, it seemed sort of silly to me that he should have to go down with the sinking ship. The major quickly corrected me: “Sailors go down with their ships, young man, not soldiers!” In an effort to defend myself, I reminded him that I had been a corporal in the same U.S. Army in which he had served. He snarled, “Ha! Just as I expected. Enlisted swine!”
Then he started to laugh. Here was the big-shot major in therapy to save his extremely important life, and his therapist was a mere enlisted-swine psychologist. The more he thought about it, the more he laughed. He laughed until tears came to his eyes. This was progress. He had discovered the capacity to see himself as absurd, and he had been separated a few paces from his pain.
On more than one occasion, I have also been called in to intervene on and attempt to treat men of high reputation caught in situations where, in the opinion of others, they were absolutely and without hesitation going to kill themselves. I count among them several policemen, two military officers, a handful of lawyers, doctors, businessmen, and college professors, and one member of the clergy who had slipped, however temporarily, from his pulpit and stumbled into sin. In itself, this might not had been so bad, but his arrest for public lewdness had made it into the local newspaper. In his eyes, all his exits were blocked, except for the one to heaven, which was always open.
There is, unfortunately, no one more dangerous to his own health and welfare than a proud, upstanding, high-profile man caught suddenly in the bright light of public exposure for a shameful, illegal, or morally corrupt act. If a pistol is within reach as the net closes around him, and no escape is offered, his life may soon be forfeit. Working with such a person is a tricky business, and there is no simple formula for doing it. Of all the suicide that might be prevented, this one is perhaps the most difficult to head off.
An inflated self-image, the fear of looking bad, the refusal to accept imperfection, a tendency to take offense at the slightest of provocations, an inability to tolerate rejection – such issues must be confronted in counselling. But this will require an extra measure of care and sensitivity. Above all, it is critical that such patients be left with some of their pride intact, enough to enable them to save face. You will need to build a therapeutic relationship in which the patient feels respected, and even then the work of therapy will require a delicate touch. The goal is not to puncture the balloon but to gradually let some air out of it – enough so that the patient’s self-image no longer seems worth dying to preserve.
27. Self-disclosure
When I mentioned to my patient the retired army major that I had been in the army, I was engaging in self-disclosure. The question of whether therapists should every divulge information about themselves to patients is controversial. Some say you should never do so; others say you should never not do so. The answer is probably somewhere in between.
If you are working with suicidal people, it is especially likely that at some point the issue of self-disclosure will come up. Suicidal people will often ask, “Have you ever thought about killing yourself?” How you choose to respond to this question is ultimately your call, but here re some guidelines to consider:
Greater candor reinforces a sense of connection between two human beings and fosters mutual trust. The downside to self-disclosure is that you risk undermining your placebo effect. The more a patient knows about you, the more human you become, which tends to tarnish your halo. Upon learning you too were once suicidal, your patient may be tempted to see you as emotionally frail or unstable or to wonder, “Jeez! Isn’t anyone sane anymore?” So before letting a patient in on some aspect of your life, always pause and think about the effect the information is likely to have. In the case of your own experience with suicidal thoughts, keep the emphasis on recovery – on the fact that, even though you’ve had some hard times, you made it through them and went on to enjoy life again.
28. Imagining the Worst
This technique consists of a series of questions that prompt a patient to set aside the notion of suicide for a moment and consider the worst possible consequences of the present crisis. The idea here is to extricate a suicidal person from the intolerable present, the one filled with what he or she perceives to be unbearable psychological pain. Obliging patient to imagine the worst that could happen if they absolutely had to continue living carries them past the present endpoint of suicide and helps to get at the very fears that may very well be driving the desire to die.
Patient: He’s leaving and I can’t stand it.
Therapist: What’s the worst that could happen if he left?
Patient: He can’t leave!
Therapist: I understand how you feel, but what’s the worst that could happen if he did leave?
Patient: I’d … I’d be lost.
Therapist: Then what’s the worst that could happen?
Patient: I … I … I don’t think I can live without him.
Therapist: But if he left, and you have to live without him, what’s the worst that could happen?
Patient: I’d be alone.
Therapist: Yes, you’d be alone. And you’d probably feel a little lost, like you did before you met him.
Patient: But I hate being alone. I mean, I really, like, hate it!
Therapist: But suppose you had to be alone. What’s the worst that could happen?
Patient: Well, if I had to be alone … well, I guess I’d have to be. For a while anyway.
The future is where fear lies, and patients sometimes need a gentle shove into the reality of that future. The suicidal mind may have been tiptoeing up to the edge of some vast, terrifying forever, taking a quick look, ad then backing quickly away. But each time the person backs away their present fear are unconsciously reinforced.
Like a kid watching a horror movie, suicidal people keep their faces covered with their hands and peek through their fingers. In such cases, our job is to get their hands down from their faces and ask them to have a square look at whatever it is they fear – that “something” lurking just around the corner. By gently asking, again and again, what the very worst would bring, you give form and substance to their fear – and a known fear is always more manageable than a vague one. In this way, moving them beyond present miseries and forward into the future can help to revive hope.
If you meet resistance to this line of questioning, you can simply say, “Look, we know suicide will get you out of this situation and put you far beyond any fear. And, for a fact, you won’t ever have to solve another problem, feel any more pain, or face any more uncertainties. But supposed you have no choice but to stay alive. What’s the worst that could happen then?”
29. Plan B
I use Plan B all the time, with all sorts of patients, not just suicidal one. The Plan B approach begins with Plan A. Whatever the patient has been doing – his or her life to date, including goals and expectations – is Plan A. And the point is that Plan A hasn’t been working very well.
In the case of suicidal patient, once I have a good sense of the person’s history and can sum up what has been going on that has culminated in the forever decision, I play back the patient’s own description of the fix that he or she is in. Then I agree that the situation is both intolerable and hopeless. This amounts to supporting the negative side of the patient’s ambivalence about life and his or her typically constricted view of the present problem.
I have uniformly found it counter therapeutic to disagree with patients about how sick or suicidal they think they are. When it comes to the patient’s own private experience of pain, my opinion couldn’t matter less. I have seen more than one patient attempt suicide after being told by a professional, “I understand that you’re very distressed, but I wouldn’t say that you’re seriously suicidal.” So I have the utmost respect for the sufferer’s view of how serious things are.
Basically, then, I concur with all the patient’s reasons for being suicidal. This affirmation of the hopelessness of the situation almost invariably produces a relieved sigh and a comment such as, “Thank God, someone finally understands.” Once the patient lets me know that my summation dovetails reasonably well with the patient’s own assessment of the problem (“Yeah, that’s how it is all right”), then I say, “Okay. That’s Plan A. What’s Plan B?”
“Plan B?”
“Yes. Now don’t tell me you’ve spent all these years working on Plan A without backup plan? You know, a Plan B – what you were going to do if Plan A didn’t work out.”
“Huh?”
Far too many people in this world do not have a Plan B. We just muddle through life with Plan A. Plan A can be that job you’ve angling for at the factory, or taking over the family business, or becoming a doctor, or marrying your high school sweetheart. Plan A is what you’ve always wanted – the way you think life should be. When Plan A is working out, you feel happy and rewarded, and life is fun living. Plan A is great.
Unfortunately, bad stuff happens. Call it chance, fate, or providence: The cause matters a lot less than the consequences. All it takes for Plan A to go up in smoke is for the factory to close, the family business to be forced into bankruptcy, the practice of medicine to become impossibly stressful, or your high school sweetheart to leave you for someone else. With Plan A in ashes, what’s a person to do?
What you do is grieve, take a deep breath, and maybe kneel down and utter a prayer or two. Then you take Plan B down off the shelf and start a new life. Most of the suicidal people I’ve met do not have a Plan B, however, let alone a Plan C or D.
Plan B can be anything. To get patients unfrozen from their decision to die while standing neck deep in Plan A, I tell them that they do not actually have to live out Plan B. But they at least owe it to themselves to imagine what Plan B might be like. It doesn’t have to be realistic, although as you and the patient work on creating it. Plan B often begins to look more and more viable. In fact, Plan B can turn out to be a whole lot more rewarding and more fun than Plan A ever was.
Yes, some folks will resist. “That’s impossible,” they’ll say. “There’s no way I could ever …” This is followed by any of 1,001 reasonable-sounding excuses for not changing one’s life. To which I say, “I understand that, and you can always keep plugging away at Plan A. But what’s the harm in dreaming?”
Spinning “impossible” scenarios for the future is something only human beings can do, and persuading suicidal people to do it can free them up in amazing ways. Like those spirited prisoners who are forced to live as inmates (Plan A) but who keep hope alive by actively scheming, dreaming, and working on a means to escape (Plan B), so too can suicidal people find hope by imagining a life other than the one they are prepared to die to be rid of. The effect here can be quite dramatic.
I have found the Plan B exercise to be especially powerful when I ask patients not merely to think about what another life might look like but to actually write out a description. I ask them for details – where they would live, what kind of house or apartment they would want to have, whether they would need additional schooling and where would they get it, what sort of hobbies they might take up, and so on. The more details the better: The clearer your view of the territory ahead, the easier it is to venture into it.
Because working up a Plan B requires energy and imagination, it may be more than a seriously depressed patient can handle. But once the person has had some treatment and begins to feel better, the Plan B approach can be very helpful. My experience has been that, once people have any sort of backup plan at all, the tension and the sense of impending doom that they were experiencing begin to evaporate very quickly.
30. Resurrecting Dreams
This approach goes hand in hand with helping folks develop a Plan B. It begins from the notion that all of us, when we were young, had dreams. We might have dreamed of becoming a forest ranger, a rocket scientist, a lawyer, a painter, a stand-up comic, or a songwriter. It doesn’t matter what the dream was – only that we once dreamed it.
They say that without our dreams, we die. Certainly, once you kill yourself, you forsake all your dreams – including the ones you never even attempted to turn into realities. By an act of self-destruction, you say, in effect, I gave up all my dreams. But wait a minute. Before you kill youself, could you tell us what those dreams were?
This questioning often leads to grief for noble deeds never done, mountains never climbed, rivers never crossed, words never spoken, and sons never sung. But that’s okay. Allowing ourselves to feel the sorrow of what could have been frees us to reach out for the joy of what still might be.
And so I try to prompt suicidal people to talk about the dreams they will leave on the shelf. I usually begin by asking something like, “Remember back when you were a kid? The way you dreamed about growing up? Do you remember what you wanted to be, or something you always wanted to do? Can you tell me what it was?”
This should be a gentle, but persistent, challenge. I often use the image of a dream stored away high on a shelf where nobody can find it but the dreamer. The dream, written on a slip of paper and rolled up and tied with a red ribbon, has been secreted away because others somehow convinced the dreamer that it was foolish, or immature, or impractical. Or perhaps the dreamer was led to believe that he or she had no right to dream dreams, no right to aspire to something different. But is this a valid conclusion? I encourage the patient to take the dream down from the shelf and have another look at it to see whether, just maybe, he or she ought to go ahead and try to breathe life into it.
If I encounter resistance – “It’s too late for me,” “I’m too old to start over” – I remind the patient that Colonel Sanders didn’t start frying his own chicken until he got his first Social Security check. I remind them that ten years from now we’re going to be ten years older, no matter what. So why not dust off one of those old dreams and give it a go?
But if they are ever to come true, our dreams must be concrete, clear, vivid, and specific. The dream needs to be laid out and written down, and the details filled in. Once this happens, the dream has become a Plan B. It has been given wheels and, powered by hope, it can roll forward into the future.
31. Being Someone’s Teddy Bear
To the question, “So, how’s it going?” June Carter Cash used to answer, “Still trying to matter.” When we feel that we matter, that we are of value to others, the risk of suicide is reduced. But suicidal people often feel that no one needs them.
To be needed by others is to be somebody’s teddy bear – the person who provides unconditional love and comfort to someone else. The teddy bear idea came to me from a favourite Shanahan New Yorker cartoon in which two police officers are trying to talk a suicidal teddy bear in from the ledge of a high-rise building. One of the officers is saying, “There’s an Officer Ripley in here who could use a hug.” And we know, instantly, that now the teddy bear cannot jump. Once he has been reminded that others need his love, his suicide becomes impossible.
The need to be needed should never be underestimated. Feeling that, far from being needed, one is in fact a burden on others may lead to the feeling that one is intolerably alone, and such unbearable psychological pain can lead, in turn, to the desire to be dead (Rudd et al. 2006; Williams, Duggan, Crane, and Fennell 2006; Shneidman 1998; Baumeister and Leary 1995). In his excellent book Why People Die by Suicide (Joiner 2005), Thomas Joiner persuasively argues that a thwarted need to belong and the feeling that one is a burden on others are two of the three necessary but insufficient conditions for suicide. Research suggests that women who are responsible for the welfare of others, particularly if the others are children, are at a lower risk for suicide. In fact, mothers and pregnant women are among those least likely to die by their own hand (Marzuk et al. 1997). You can’t, if you’re a reasonably thoughtful and caring person, just go off and kill yourself and leave those who are dependent on you to fend for themselves.
Therapy must address the suicidal person’s feeling that, if he or she were to die, no one would really notice or care. Gently but stubbornly, the patient’s belief that he or she is not needed must be challenged. In addition, if suicidal people can be persuaded to do something that requires getting out of themselves and into the life of someone else, so much the better. An act of charity or a gesture of goodwill toward others makes us feel that our lives have meaning. I have recommended to suicidal patients that they volunteer in a nursing home or send a card to someone who is ill or buy a homeless person something to eat. I have tried to show them that giving of themselves to others will make them feel good.
I remember working with a particularly angry woman who hated humankind but loved animals. After I wondered aloud whether the animals in the local shelter might need her attention, she volunteered her time for a while. Later on, she was hired by a veterinarian to work in his small animal clinic.
Sad to say, though, suicidal people are often so preoccupied with their own suffering, and their ability to reason clearly so impaired, that they find it difficult to imagine what they might mean to others. But the fact remains that their love and support are much in demand. Everywhere people are hug deprived – children, parents, friends, relatives, the elderly and neglected, the homeless. Even stray cats could stand to be petted (and I’m not fond of cats).
We all need to be someone’s teddy bear. Once I have established a trusting relationship with suicidal patients, especially those who believe they don’t matter to anyone, I often try to unwrap the arms they’ve been using to hug their own pain and get them wrapped around someone else. Because creatures who are hugged hug back.
32. Pets
A woman at a workshop once asked me whether caring for a pet might be a protective factor against suicide. I said I was sure it was, but I was curious why she had asked. She then told me the story of her mother’s death. Her mother, who was in her mid-seventies and had been widowed for three years, was desperately depressed but was receiving no treatment. Her sole companion was her cat. Following repeated entreaties that she leave the Midwest or her childhood and move out to California to live with her son and his family, she finally agreed.
“Good!” said her son. “Now, you know we want you to come, but we can’t have the cat. Alice has allergies. So you’ll have to leave the cat behind.”
After a pause on the line, the mother said, “I understand. Well, I have a couple of things I need to do now.” And she hung up.
Within two days of making this statement she took her much-loved cat to the veterinarian and had it put to sleep. On the drive back to her home she died in a high-speed crash into a utility pole. It was estimated that she was going over 90 miles per hour at the time. She did not have to move to California. Her death was officially called an accident, and the cause was never questioned. But how this accident could have happened remained a family puzzle.
Was this suicide? We will never know. But what we do know is that being responsible for other living things helps keep people alive. So does loving someone else, including a pet. Especially for those who otherwise live alone, the love of and for a pet can be an important protective factor – and, not surprisingly, there is a growing literature that supports pet therapy. If you think that a suicidal person might profit by having a pet and that he or she could be entrusted with an animal’s care, it is a possibility well worth suggesting.
33. Putting Problems in Perspective
Suicidal people are typically overwhelmed by what seems to them the sheer enormity of their problems. Whatever the situation facing them, it feels vast and insurmountable. From the outside looking in, we may not think that their problems, however real they may be, are worth dying over. But, as we know, our view of their suffering matters little in comparison to their own. The trick is, then, to persuade suicidal people to step back from their own misery for a moment so that they can gain some perspective.
Insensitive, knee-jerk comparisons – “You think you’ve got it bad? What about those poor kids living on the streets!” – only make the crisis worse, especially if the are delivered early on in counselling. But once the suicidal person has passed through the initial crisis, has had the benefit of some treatment, and has decided, at least for now, to live, the following strategy can prove helpful.
Ask the person to imagine putting al of his or her problems onto a great big table with all the other problems faced by all the other people around the world.
It takes a big table because the human race has a lot of problems.
Now tell the person that he or she can trade his or her own big problems for any other set of big problems that someone else on the planet is facing.
Let your patient think it over for a while.
What you will often find is that after considering the problems with which other people must contend, most of us – including suicidal people – would just as soon stick with our own problems. This shift in perspective often allows the suicidal sufferer to understand, in concrete terms, that his or her woes are probably not so enormous or so unique that they cannot somehow be mastered. After all, if other people have found ways to cope with their miseries, then perhaps we can do the same.
Taking a fresh perspective can help even seriously depressed patients begin to believe that their problems are manageable. It fosters hope, which in turn renews their commitment to therapy. The growing awareness that even big problems have solutions gives a suicidal person a powerful reason to continue learning how to find those solutions. Given a little faith that a path through suffering does exist, the person may eventually come to agree that our problems are rarely worth dying over.
34. Good People in Impossible Situations
As we have seen, people sometimes become suicidal because they find themselves in what seems to them an impossible situation. Sometimes these perceptions are distorted, but sometimes they are right. For almost any given personality, there are bound to be truly impossible situations, impossible relationships, impossible jobs, or impossible living conditions – circumstances that make life unlivable. In a word, someone can be a good person in a bad place. Except in prison camps and jails, however, people who are otherwise sane and sober seldom resort to suicide simply because they are caught in a bad situation. Rather, suicide comes to seem a desirable solution only after the person has developed psychiatric symptoms, usually of severe anxiety and/or clinical depression.
Over the years I have seen far too many basically sound, healthy people who were trapped in circumstances that were fundamentally at odds with their values. Among them was a compassionate and highly principled nurse who had the misfortune of working for a nursing home that was more interested in its bottom line than in the quality of care it provided its patients. As a cost-cutting measure, it had reduced its staff with the result that this good nurse was confronted daily with situations that compromised patient care. The necessity of working under such conditions violated her core beliefs and her sense of right and wrong. She could not sleep, she was losing weight, and she became depressed.
Another patient was an attorney and a devout Catholic who held himself to high moral standards. For ten years he had worked in a firm surrounded by colleagues whose ethics were questionable and for whom he had no respect. He was caught in a cesspool of corruption and could not see a way out. His way of adapting to what was for him a living hell was to become so depressed that he was unable to get out of bed and make it into the office.
Helping someone caught in a bad life situation requires first that you gain a thorough understanding of the person you are working with and a clear sense of how their personal values are being thwarted or threatened. The question that will need answering is, Does this person fit into the life he or she is living? If you look for the frustrated psychological needs first, the stress points will show themselves quickly.
Sometimes the problem lies with a lack of fit between a person’s talents and temperament and the demands of a specific job. Someone who is creative and free-spirited is not going to have much fun turning nuts on bolts for General Motors, any more than someone who is meticulous and highly controlled is likely to enjoy working with a roomful of kindergarteners. In such cases, simply suggesting, “Maybe you just weren’t cut out to be a salesman” (or a lawyer, nurse, electrician, farmer, theatrical agent, therapist, or whatever) can provide relief. Given that careers are more likely to be decided by random opportunity than by deliberate reflection and career counselling, severely depressed people often find it very enlightening to explore how they ended up doing what they are doing. It is also worth reminding folks that over a full life span most of us will have at least three distinct careers. Realising that other people do make changes can give sufferers a sense of freedom and the flexibility they need to reconsider their choices and move on.
Very often the problem lies specifically with clashes between a person’s fundamental beliefs and values and those of other people or of the organisation in which the person works. Many suicidal people have been struggling for years in situations and relationships that are deeply antithetical to their needs, their personalities, and their dreams and, as a result, have become seriously depressed. They feel hopeless, and they despair of change. The possibility that they are actually perfectly okay, even nice, people caught up in unhappy circumstances may not even have occurred to them. I once counselled a suicidal insurance salesman who hated himself for having to high-pressure old people into buying policies they didn’t need. “What’s a decent fellow like you doing in a job like this?” I asked. “I don’t know,” he replied, as if he’d never thought about it before. “What am I doing?”
Affirming that the patient is a worthy soul who is simply trapped in a bad situation gives the person permission to start thinking about a way out. Hitherto unimagined exits suddenly open up. Moreover, because some of the blame for the patient’s present suffering can now be shifted to external conditions, the patient is able to regain some sense of self-esteem.
I remember working with a senior corporate executive had been brought in by his wife because he was talking about suicide. His former boss – a benevolent man who had founded the company for which this man worked – had died, and now his four sons were running the company. The sons were not benevolent people. While my patient was overseas on a business trip, they had used the occasion of his absence to strip him of his job title, his influence, and his stock options, actions that all but forced him to resign.
His wife and friends were surprised when he refused to file an age discrimination suit against the company’s new chief executives or otherwise fight back. So I asked him why he wasn’t more interested in ripping their heads off. “When I was a boy,” he replied, “I always wanted to be a man of God – a priest, actually. I’m gentle and forgiving at heart. Revenge just isn’t in me.” So then I asked him what a nice guy like him was doing keeping company with a bunch of young cutthroats in the first place. He admitted that, until he returned from his trip, he hadn’t recognised just how malicious and greedy they were. But now that he did, he said, it was probably a good thing he was no longer with the company. The more he thought about it, the more he realised he would never want that job back. In the end, he concluded that perhaps they had done him a favour.
Some time later, I ran into this man at our local airport. He had taken a new job, which happened to be with one of his former firm’s competitors. This new firm was now doing very well, and it was eating deeply into his old company’s share of the market – a sweet revenge, if ever there was one.
I have also counselled people trapped in relationships so unloving and so filled with anger and mistrust that each new day was a dreaded event. Toxic relationships, because they are stressful, can make people sick in mind and body. When a relationship grows to be so stressful and so soul crushing that it triggers major depression and thoughts of suicide, it needs to be either fixed or ended. We are lucky that the laws governing marriage no longer oblige us to remain in a relationship that is endangering our health and destroying our spirit.
For a patient struggling with a relationship that has become impossible, a simple suggestion such as, “Maybe you and Shirley weren’t made for each other after all,” can again be remarkably freeing. It shifts the patient away from the notion of blame – from the idea that either the patient or his or her partner must be the one at fault in this mess – and from the sense of personal failure that so often accompanies a dying relationship. It also opens up the possibility that out there, somewhere, another, more suitable mate awaits.
People who have wound up in the wrong place often feel locked into the choices they once made and may be kicking themselves for having made the choices they did. I have thus found it very helpful to relieve patients of the weight of their own past decisions by saying, “You know, we all make the best choices we can. We use the best information we have at the time, and then we just do it. There’s no other way. But sometimes we don’t have enough reliable information, especially about ourselves, and maybe that’s what happened here. What do you think?”
Once sufferers come to understand that, like the rest of us who have to make choices, they will never have the perfect information and the perfect insights that would allow them to arrive at perfect decisions, they can stop feeling so guilty and beating themselves up for being so stupid. Making what later turn out to be mistakes is an inescapable fact of life. It’s why they put erasers on pencils.
35. Deep Breathing
Many suicidal people are labouring under both acute and chronic stress. As a result, not only their minds but also their bodies feel out of control. To help them gain some degree of mastery over feelings of discomfort and panic, I often teach them a simple breathing technique, one that amounts, quite literally, to a sigh of relief.
I begin by explaining that deep breathing generally produces relaxation. Then I instruct the patient as follows:
As I explain to patients, whenever they find themselves caught in a stressful situation or having thoughts of suicide, they can practice some deep breathing. If they remember to do this each time they start to feel anxious and overwhelmed or thinking about suicide, it should help them to recover a sense of balance. While inhaling and exhaling, they can say to themselves, “This too will pass.”
Not only does this relaxation technique give patients some on-the-spot control over what feels to them out of control, but it can also teach them to recognise the conditions that tend to provoke self-destructive thoughts – the events, the kinds of interactions, and the overall circumstances that often generate such thoughts. I often ask a patient to take a moment after the crisis has passed to jot down what was happening (thoughts, feelings, outside events) just before they felt the need to do some deep breathing to relax. The goal here is to capture the chain of events that triggered their sense of anxiety and distress. Just as people write down their dreams so that they can remember them and analyse them, recording one’s experience at a particular moment may lead to the discovery of specific negative thoughts or feelings that appear to be associated with the impulse to suicide. Such information is clearly very valuable when we are seeking to understand what is driving suicidal behaviour.
Severely stressed or anxiety-ridden patients may profit from more formal relaxation training, such as biofeedback. But deep breathing is remarkably effective. It is also a wonderfully portable relaxation method, one that can be practiced any time, any place.
36. Suicide Dreamers
“The thought of suicide is a powerful solace,” Friedrich Nietzsche once remarked; “by means of it one gets through many a bad night.” But some people carry a good thing too far. I have in mind my work with several patients for whom thoughts of death had become a central theme of life itself. Over the course of their therapy, they taught me how thinking about suicide can grow to be a comforting and familiar habit.
“Suicide dreamers” describe themselves as plagued by frequent and repetitive suicidal thoughts, and yet these thoughts are not typically associated with high-risk or overtly suicidal behaviour. In other words, although these patients think about suicide frequently, even obsessively, they rarely get beyond the thinking phase. These low-grade suicidal ideations do not merely occur in the days and weeks following the onset of an episode of acute depression but may in fact persist for months, years, and even decades. While such thoughts do not, at least in my observation, directly culminate in actual suicide attempts, they just as surely lay the foundation upon which an attempt could later be based.
It appears that this “suicide dreaming” is a kind of default mental activity or psychological reflex, often triggered by some unpleasant or stressful event. Odd though it might seem, these persistent suicidal ruminations serve to reduce anxiety for the sufferer, just as Nietzsche observed. Entering this fantasy realm of suicide produces a sense of calm and relaxation. As a form of mental escape, it is probably a conditioned response, one that lowers the autonomic nervous system’s overall level of arousal and may even have addictive qualities. In this self-induced hypnotic state, thinking of suicide functions as a kind of psychic tranquiliser that, taken in small doses in times of stress, conflict, or loss, can provide on-demand relief from the pain of existence. Patients thus self-trained are often very invested in their preferred method of escape from psychological suffering and will not be easily persuaded to give it up.
In the cases I have treated, dreaming of suicide had become a well-established cognitive habit, a routine mode of imagining death, characterised by deeply entrenched thoughts and repetitive melancholy themes. Sometimes patients had chosen a special setting, which served as a stimulus to their fantasies, and some had selected music to enhance the mood. Several had even developed elaborate funeral scenes, complete with music, flowers, and pallbearers. In one case, the aces of the survivors were clearly visible to the suicidal person as the casket was lowered away.
Strongly ingrained habits of thinking are stubbornly resistant to change and thus difficult to extinguish. Because suicide dreamers are typically anxious about their behaviour, I often begin by reassuring such patients that just because a person thinks a lot about suicide does not mean he or she has to act on those thoughts. I remind them that we human beings are free to imagine any damn thing we want to – it’s what we do that counts. This drives a wedge between thought and action, which reduces tension. I also point out that people who passively dream about suicide are not usually the impulsive sort. And so it is not very likely that as they are contentedly fantasising about suicide, they will suddenly jump up and kill themselves.
Beyond that, treatment for suicide dreamers can include any of the standard approaches to psychotherapy and, if appropriate, medication. In particular I try to teach such patients something about the underlying purpose of their repetitive cognitions and how they most likely came by them. I explain that humans learn through reinforcement, stimulus-response, and social conditioning, along with a bit of help from our neurochemistry. I also explain how we develop habits, including unpleasant cognitive ones. But if bad habits are learned, they can also be unlearned.
This is fundamental stuff, and I try to keep it simple and nonjudgemental. I stress that we learn to repeat, again and again, whatever makes us feel good or reduces anxiety. If we discover that lying down to listen to sad music and dream about suicide reduces tension and provides an escape from a world of distress, then this will likely become a habit. By acknowledging the powerful tonic their suicide dreaming provides them, I help such patients accept their obsessive thoughts as a way of coping, one often used by troubled persons who have been unable to come up with other solutions to the problems facing them. This approach normalises the process whereby such patients came by their familiar habits of thought.
Once patients have learned to identify cognitive cues to relaxation – the feelings and thoughts that make us anxious and prompt us to seek relief – I begin to offer alternative responses to these cues. The idea is to shift chronically suicidal patients away from the escapist solution offered by fantasies of self-destruction and encourage more proactive, problem-solving approaches to distress. This process involves explanation, psycho-education, gentle confrontation, paradoxical instruction, practice sessions in cognitive retraining, and redefining problems in ways that suggest new solutions.
Because suicide dreamers are often passive people with weak self-esteem, some form of assertiveness training can also be helpful. So can group therapy, especially for patients who tend to be isolated and are struggling to get their needs met within their limited social network. In addition, I have at times found it valuable to ask patients to express their dark thoughts on paper, by keeping a journal or writing poetry, or in drawings or music. Such expressive activities are useful because they transform subjective experience into something external to the self and thus separate the sufferer from his or her thoughts. But creative self-expression is also very freeing, and it often promotes greater self-understanding.
37. Paradoxical Suggestions
This is an intervention that can prove very helpful with patients who are obsessed with thoughts of suicide, such as the suicide dreamers just described. It is an approach that should be used with some caution, however, and, like many of the interventions described in this chapter, only after you’ve established a firm therapeutic alliance with your patient. For reasons that will be obvious, this is not a sensible strategy to pursue if a patient has ever acted upon suicidal thoughts or seems at all likely to do so. You will also need to be sure that a patient is not suffering from obsessive-compulsive disorder. If the patient’s recurrent thoughts of suicide do meet the diagnostic criteria for this disorder, medication may be in order.
Simply put, a paradoxical suggestion asks the patient to do even more of what he or she is already doing. The paradox here is that magnifying a symptom can actually serve to reduce it by increasing the patient’s control over it. To someone who is plagued with repetitive and intrusive suicidal thoughts, I might start by saying, “Just so I can get some idea how much time you actually spend thinking about suicide, I’d like you to take this index card and keep track of the total minutes, or hours, you spend doing so this week. You can think about suicide as much as you like.” This request immediately places the patient in the role of both collaborator and scientific observer, requiring him or her to isolate and measure what has been perceived as seamless and pervasive. If the patient reports spending an average of forty minutes each day thinking about suicide, I might then suggest, “Hmm … I wonder … As an experiment for the coming week, I’d like you to think about suicide for at least an hour each day. Nothing else for now – just suicide. And keep track of your time.”
Understandably, therapists are sometimes frightened by obsessive thoughts of suicide and so are tempted to tell a patient, “Stop that – you’re scaring me!” Others may worry that encouraging a patient to think about suicide might just prompt an attempt. But requiring patients to pay close attention to a symptom and even to deliberately exaggerate it actually shifts control to the patient. I often combine this intervention with bibliotherapy, by asking the patient to read one of the many excellent popular books about suicide, which again obliges the person to think consciously about the subject.
As I have said, comforting habits of thought that provide relief from emotional distress can be difficult to dislodge. In and of itself, the technique of paradoxical suggestion is unlikely to produce a cure. You will still need to work on fostering self-awareness and on helping suicide dreamers learn to substitute good habits for bad and otherwise find new solutions to old problems.
38. Working with Chronically Suicidal People
Karl Menninger used the term chronic suicide to refer to cases in which someone who finds the idea of suicide unacceptable, possibly even repugnant, nevertheless chooses to die a slow death by abusing drugs or alcohol or engaging in other life-threatening behaviour (Menninger 1938). I use the term somewhat differently. My chronically suicidal patients are those for whom being suicidal has essentially become a way of life. They have often made multiple attempt at suicide, obviously none of them successful, often because the methods employed were not very likely to be lethal.
I once received a letter from a woman who boasted that she had made over three thousand attempts on her life. She said she was willing to wager that I had “never met anyone so suicidal.” Given that I’ve met quite a few people who subsequently killed themselves, often on the very first attempt, her commend made me wonder whether her definition of suicidal was perhaps somewhat different from my own.
Indeed, the clinician may well be prompted to ask whether the behaviour of the chronically suicidal might not better be escribed as attention-seeking. The answer to this question is probably yes – but that does not mean such behaviour should be dismissed as merely manipulative or that it might not someday lead to death.
Although I am not an expert in the diagnosis and treatment of chronically suicidal patients, I know many who are, and over the years I have worked with several such patients myself. As they have sown me, being suicidal can confer certain rights and obligations, just like any other social role or public identity. People who constantly threaten suicide or engage in suicidal behaviour in an effort to control those around them eventually become known for their distinctive form of interpersonal communication.
Very often, those who become chronically suicidal grew up in seriously dysfunctional families in which their basic needs – including the need to have their emotions, especially negative ones such as anger or fear, acknowledged and validated – were constantly thwarted. And so they learned to resort to more extreme measures. As they discovered, the five simple words “I wan to kill myself” can be counted on to produce an immediate reaction. For instance:
Our common humanity insists that we seek to prevent death, including death by suicide. Just as we believe it is better to let one hundred guilty people go free than to execute an innocent person, we would prefer to overreact to one hundred suicidal people who will never actually kill themselves than to ignore the single one who will. If someone appears to be suicidal, we will therefore do everything humanly possible to keep that person from dying. As, of course, we should.
For the chronically suicidal, this means that a safe harbour an usually be found, provided the rescue signal they send is loud and clear and is accepted by the people on the receiving end. The chronically suicidal have had considerable experience with how people respond to suicidal threats and gestures, and they have learned very well how to make their wishes known and how to force calm from an emotional storm. They know the drill.
Working with someone who has learned to cope with all of life’s struggles by playing the trump card of suicidal threats is no easy matter. Treatment is especially challenging because chronically suicidal people are so often diagnosed with borderline personality disorder. The etiology of this disorder is complex, but i may be that some individuals are born with a hypersensitivity to sources of agitation and stress. Individuals diagnosed with BPD typically have a very weak sense of self-identity and are haunted by feelings of emptiness and low self-worth. In a desperate effort to avoid abandonment and to get their needs met, they tend to shift back and forth between a passive, approval-seeking stance and violent displays of emotion and other attention-getting behaviour, including various forms of self-harm. Their relationships with others are typically intense and highly turbulent. As patients, they can make enormous emotional demands on a therapist and may also be difficult to keep in treatment. Because a significant number of such patients eventually die by suicide, doing therapy with the chronically suicidal is much riskier than working with someone whose diagnostic profile is less complicated.
Through their behaviour over the years, perennially suicidal individuals have typically created negative expectations in others – expectations that they will, in fact, kill themselves. ow they are trapped. Part of our task, then, is to protect them from feeling obliged to live down to those expectations of an early death by suicide. At the same time, because chronically suicidal people can so easily seem manipulative, they can generate negative feelings in you, the healer. Your anger and impatience, whether openly expressed or hidden behind a forced smile, can prove very destructive, even lethal, for the suicidal person. As a son once said to his father, who had been talking about suicide for months in the wake of a divorce, “Dad, I’m real tired of listening to this. If you’re going to kill yourself, why don’t you just go ahead and get it over with?” Unbeknownst to the son, his father was holding a pistol to his head while they were talking. Following his exasperated challenge, the son heard not only the shot but also his father’s body hitting the floor.
As therapists, we must help these challenging patients change the way they behave – how they manage emotions and how they interact with others. Fortunately, thanks to the pioneering work of University of Washington psychologist Marsha Linehan, we now have evidence-based and effective interventions for use with the chronically suicidal. In the early 1990s, Linehan developed a treatment method now known as dialectical behaviour therapy. Founded on the cognitive-behavioural approach, DBT is a highly structured set of techniques in which the therapist works closely with the patient to address specific situations that come up in the patient’s life. The emphasis is on the reduction of mal-adaptive behaviour – first and foremost suicidal behaviour and other forms of self-injury – and on the acquisition of skills that enable patients to find more appropriate solutions to emotionally difficult events. In addition to individual therapy, patients attend skills-training sessions, which are usually conducted in group format (see Linehan et al. 1991; Linehan 1993a and 1993b). Professional training in this intervention is now available around the world. If you work with persistently suicidal persons, I strongly recommend that you complete such a training program.