In my last post, I talked about common fears clinicians face when conducting a suicide risk assessment. This week, I’m going to talk about our client’s fears and how we can help ease them.
Please note, aspects of this post are somewhat oversimplified. This post does not cover every nuance of every suicidal clinical presentation. The clinical needs, how suicide is experienced, and how it functions are different, for example, between acute egodystonic suicide and chronic egosyntonic suicide and engagement in non-suicidal self-directed violence. As such, different therapy skills, techniques and interventions are required. This post focuses more on the former to keep it as streamlined and clear as possible, though there is some overlap.
Egosyntonic: congruent with sense of self, feels tolerable/acceptable; in the case of suicide can feel comforting and reassuring and something you don’t want to let go of
Egodystonic: incongruent with sense of self, feels intolerable/unacceptable; in the case of suicide can feel agitating and something you want to get rid of though may not know how
Common Client Fears during a Suicide Risk Assessment
When we start to ask about suicide, it is common for our clients to fear that we will:
- Not understand
- Shame and blame
- Minimize or exaggerate their risk
- Get overwhelmed
- Lock them up
And these fears are not unfounded.
Girl, Interrupted
Remember this scene from Girl, Interrupted? It captures it all.
Let me begin by noting this provider should not be treating her. He is a family friend (thats called a duel relationship), he says he doesn’t practice anymore, and she did not consent to treatment with him.
In terms of how it models common client fears….
- He makes no effort to understand her. He doesn’t ask any questions other than if she is actively stoned, uses drugs in general, and what she feels in the moment. Instead, he tells her what she needs. And he makes assumptions about her recent alcohol use without asking her anything about it.
- He directly shames and blames her by saying “you are hurting everyone around you”.
- He has already made the decision (with her parents) to hospitalize her. So it seems feasible he is exaggerating her risk. We don’t know for sure though, because there was no assessment!
- Overwhelming the clinician wasn’t shown here because, again, there was no assessment, there was no therapeutic engagement, and all the decisions were made prior to the provider seeing the client.
- She ended up locked up, for quite a long time, with no informed consent or agency in her care.
It’s just a movie though, so it’s not real, right?
Yes, this is a movie. And this is not so far off from how women in general, women of color, and black men have been treated throughout history when it comes to undue, unfair, and unjust psychiatric hospitalizations. Much of that treatment stemmed from colonialist views, patriarchal influences, enforcement of power, eugenics, and outright racism. (Want to learn more? Check out Decolonizing Therapy by Dr. Jennifer Mullan).
It also stemmed from a lack of knowledge and understanding of suicide.
Study of Suicide (aka Suicidology)
For a long time, suicide was thought of as black and white. You either were suicidal or you weren’t. If you presented as somewhere in between, you were viewed as being gamey, manipulative, and just wanting attention. (This of course does not apply to the approach of all clinicians throughout time, and is reflective of cultural norms.)
And, as influenced by biological models of mental health and psychopharmacology, suicide was thought of as a symptom of another diagnosis, typically depression. The thinking for treatment was to use psychiatric hospitalizations for stabilization and safety while treating the depression through medications and talk therapy. The assumption was that thoughts of suicidal would in turn abate.
This procedure has proven ineffective time and time again. Namely, because of overuse of hospitalizations which were experienced as shaming/blaming, punitive, and even dehumanizing (again, think of Girl, Interrupted). It is also ineffective because suicide is never actually dealt with.
And this sort of stuff still happens.
In other words, our clients have good reason to fear being shamed/blamed, being misunderstood and thought of as attention seeking, and fearing hospitalization.
So, what do we do instead?
Normalization
Contemplating and desiring death at some point in your lifetime is normal. There is nothing inherently bad or wrong with thinking about suicide and desiring to escape from pain. It is not something to be ashamed of. Suicide is an understandable solution to seemingly unbearable suffering.
Working with Ambivalence
Despite previous assertions of suicide being black and white, it is an inherently ambivalent experience. Otherwise the client wouldn’t be sitting in front of you! We must engage with and assess the ambivalence. What are the clients’ reasons for dying and their reasons for living? What are their risk factors and their protective factors? How does suicidal ideations and related behaviors function for them? What is their self-assessment of their safety?
Recognizing the Continuum
Going hand-in-hand with ambivalence, is recognizing that suicidal ideations and related behaviors exist on a continuum. On one end of the spectrum are passive thoughts of death and dying, aka a passive death wish. Someone can have these thoughts while having absolute certainty that they will not take any actions towards death and will continue to take actions to preserve life.
On the other end of the continuum is someone who has a plan, access, and intent. Though again, if they are in your office telling you this, there is still ambivalence, some willingness to live, reason for clinical hope!
And then there is everything in between. Ideation without access, access without a plan, high desire for death with strong protective factors towards life. Everyone’s suicidal story is unique to them and must be assessed and treated accordingly.
Collaboration and Transparency
Demystifying the suicide risk assessment process can do wonders to reduce fear. Share your clinical decision-making process for seeking hospitalization. Acknowledge the ethics driving you to help this person stay alive AND acknowledge your desire to support the client’s preferences for care. And make the client part of the process; this is their story and their healing journey.
For me, this looks something like this:
“Let me tell you how I think about this stuff. I have a very high threshold for seeking hospitalization. I worked on an inpatient psych unit so I know when a hospitalization is warranted and can make all the difference and when it’s not helpful or may even be harmful.
If you or I have concerns that you are imminently at risk of suicide, like you are going to leave my office and kill yourself (or engage in severe self-harm), and none of our ideas for helping you stay safe seem like they are going to work, then we talk about hospitalization. We make the decision together.
How does that sound?”
Wrapping up…
This was one of my longer posts; thanks for sticking with it. There is a lot of ground to cover and a lot of nuances to acknowledge, and I barely scratched the surface.
For Clinicians: I hope this post gave you some new insights for conducting suicide risk assessments particularly how to demystify the process and help put your clients at ease, as much as is possible, when talking about such a difficult topic.
For Those Seeking Healing: As always, I hope this material helps you feel seen and understood and gives you hope that healing is possible. Per my usual caveat: these posts, and any recommended resources, do not equate to therapy. Please call 9-8-8 or go to your local emergency room if you are in crisis.
EXCELLENT. I am so thrilled to have found your poignant perspectives on this work to better understand what suicide is, and what suicide is not. I greatly appreciate your distinctions regarding acute and chronic suicidality; your dedication to the recognition of suicide as its own etiology ver a symptom of depression, etc. I look so forward to seeing more of your work. As a bereaved mother who lost her precious son to acute suicidality,and asa clinician and educator myself disillusioned with western culture mental health practices, I am invigorated by your work. Thank you.
Tommy’s mom