Suicide Prevention: Relationship Is The Greatest Tool We Have
For National Suicide Prevention Month last September, I wrote a blog on lessons learned from working with survivors of suicide loss. For this year, I thought deeply about what can we, as EMDR therapists, can do to prevent suicide in our sphere of influence.
The tagline for The American Foundation for Suicide Prevention (AFSP) is, “Talk Saves Lives.” How simple. Sounds easy enough, right? Uttering the words, “I don’t think I can go on living…It’s too painful to live through…I want to end my own life,” are the most crucial words to share, yet a myriad of factors gets in the way of doing so. Shame, stigma, misunderstanding -- and most important for us to pay attention to -- the idea of being a bigger burden than they already feel like they are.
What I settled on for this blog is a desire to help us, as therapists, approach the topic of suicide as something we can talk about and be in relationship with. Suicidality, like trauma, is on a continuum, from utter hopelessness and abject despair to an attachment cry that is expressing a primal need to be seen, heard, and understood.
Here is where I invite you into thoughtful discussion.
I’ve talked with many colleagues about the challenge of working with suicidal clients over the years. A common response is to go into risk management mode and get busy with making plans for safety, skipping over the crucial next question, “Tell me more.” While we may be understandably anxious about our clients’ safety, it is also important to slow ourselves down long enough to do our due diligence and assess the actual level of risk.
A past-present collision
When we ask to know more, what can sometimes surface are old wounds that have yet to be healed. “I’m so overwhelmed,” or “I’m such a burden,” are feeling states that are likely familiar to the client. As EMDR therapists, we understand that our reactions to present-day situations are informed by past experiences that are unresolved, sometimes resulting in very powerful and painful states. This is particularly likely when the client’s situation in the present, e.g., partner suddenly leaving them, is touching into their parent suddenly leaving them as a kid. The challenge then, is to invite our clients to be curious about a past-present collision that might be the wellspring of their despair, helping both therapist and client alike begin to make more sense of their experience. Once we can arrive at a mutual understanding of why the client is feeling the way they are, they can then have some separation that allows them to begin to reflect on the intensity of their feeling state.
Validating and normalizing the client’s pain
If I jump straight into creating a safety plan with that client and having them identify who they are going to contact to share the plan with for that extra layer of accountability, I miss the opportunity to validate and normalize the pain. We can create a space where the sorrow and suffering are now shared and the client is no longer alone in the experience.
I was working with a client who had lost her husband to suicide, and on one particular day, she came into the office, more distressed than normal at some health related news she had received. As we began to talk through her thoughts and feelings about the information she was given, what became apparent was a part of her that was happy at the idea of potentially having a terminal illness. The shame that she experienced in that moment, as she and I made her thoughts explicit between the two of us, was the same shame she felt believing that her husband's suicide was ultimately her fault. She continued to share that she had been having more active suicidal thoughts herself, but that would then activate her deep state of shame over "thinking such bad thoughts." As I validated and explicitly stated that all of what she was sharing with me made sense, considering the pain and grief she was experiencing, it allowed her to have more curiosity about her own thoughts and feelings. Ultimately she was able to reflect how hard this all was to do alone, and a brief moment of self compassion came in for her current circumstance.
Human beings are a mammalian pack animal at their core. We are meant to be with others, living in community and connected to one another. In the wild, it is the weak and isolated animals that are the easiest prey. The same can be said for humans. The wounds of isolation, abandonment, defectiveness, powerlessness and abject fear are healed when shared with others and hope is provided. Ken Baldwin, a man who survived making a suicide attempt by jumping off the Golden Gate Bridge stated “I instantly realized that everything in my life that I thought was unfixable was totally fixable-except for having just jumped.”
Inviting our clients to be active participants
When working with clients who have struggled with chronic suicidality, it is always an interesting conversation when I ask them what has allowed them to choose life for so long.
Being genuinely thoughtful about the idea that if you are sitting in my office telling me you are suicidal, means you have, perhaps unconsciously, CHOSEN life. As Relational EMDR℠ therapists, we always invite clients to be an active participant in their therapy as well as in their own lives, and it is no different when we create an avenue for their safety. “Let’s tell the person you’re closest to how much pain you’re in, so you have the support and the care you need right now.” Loneliness is always a contributing factor of suicidality and often, encouraging a connection to others is enough to move a client towards healing and a willingness to live.
Creating a safe place
We have named that one end of the spectrum of suicidality is that we may have to intervene on someone’s behalf to keep them safe, when they cannot see the need on their own. On the other end of that spectrum is the client who can find a shift in their desperation through the creation of a safe place, to express how much pain they’re in, and then having someone validate it.
Someone who actively wants to end their own life and somebody who doesn’t want to live anymore are two different things. One is coming from this place of, “It hurts so bad, I’m so lonely, I’m so sad, I can’t imagine continuing to live feeling like this” vs. the person who feels, “I know longer have a will to live and want to end my life.” These are two different states of consciousness and require different interventions.
Our ability to hold a safe space for these painful states AND inhibit the impulse to do something immediately is no easy task. It requires a certain steadiness that allows us to be open and present to their pain. But what gets created in that space is the opportunity for the suffering to be shared and not carried alone. Within that same space is the fertile ground for someone to then move towards life, instead of death.
With the client who lost her husband and now facing her own mortality, I assessed for the lethality of her suicidal ideation by inviting her to lean into her feelings more and to find the words to share them with me. It was interesting to note that even in the space of a session, the thoughts had almost completely subsided. It was in the naming of her reaction to the possible terminal illness diagnosis that had sparked a more active thought of ending her life to be with her husband again. But when she was able to express her feelings out loud in the safety of our space, the feelings passed. That safety not only allowed her to process her feelings with me, but later began to explore feelings of anger towards her husband for the first time.
Inviting curiosity
As clinicians, it is important to invite curiosity. We need to be willing to sit with the unknown for as long as it takes, which for us, as clinicians, is something we don’t like. And, as we simultaneously sit in the discomfort of the unknown, the challenge for us is to be curious, and ask all the questions we need to better understand our clients and the complexity of their pain.
This is some of the tension that we need to be able to sit with. Our instinct is to act; isn’t actively helping people why we got into this field to begin with?! Here is the interesting fact that we need to sit and wrestle with as we contemplate what necessary action looks like. We know that the most at-risk an individual is to end there life is at the one-week and one-month mark post-psychiatric hospitalization AND those that have been psychiatrically hospitalized are 30% more likely than the national average to end their lives even years later (JAMA Psychiatry, July 2017, 74(7), 694-702).
When the risk is real
If someone says to me, “I don’t want to live, and here’s my plan,” of course, that requires us to go into action. As clinicians, we know it’s imperative to get a plan in place to keep our clients safe, because that’s our clinical imperative, not an option. We can validate that a person feels that way. But the action of taking one’s life is suicide is not an option on our watch.
A need to bring truth to the conversation
If we as clinicians set the tone for the conversation, it doesn’t have to become a crisis with this sense of anxiety and urgency. We need to ask questions and make it an open dialogue with our clients, in the same way we manage all other aspects of the therapeutic process. With my previously mentioned client, we had processed through several self-destructive adaptations that were the result of her deep sense of defectiveness. Gaining a deeper understanding of her desire to end her life was no different.
Every September, I take stock of my own internal system and my own need for support. Consultation groups start up again this time of year at The Center. For me, it is a new season of learning, camaraderie and support. I am grateful for the clients who teach me what it is like to choose life every day. I am reminded that living through grief, my own as well as my clients, doesn’t have to be the end of the road, but instead, can be a new beginning. May we all be brave enough to ask the right questions, be brave enough to be curious and nonjudgmental, and brave enough to sit in the discomfort until we understand what is true, so that our clients can borrow that bravery long enough to choose life.