One of the most treacherous terrains mental health clinicians navigate comes when a client struggles with severe depression, yet disavows any suggestions of suicide ideation.
“Depression, yes. Would I take my life … never!” the client protests.
And then one day, “out of the blue,” the client completes the ultimate act of self harm.
Everyone, including the therapist, is flabbergasted. Shocked. How could this have happened?
As trained professionals, we go back, pore over clinical notes, check the checklists, reread the literature on empathic attunement, and cognitive and other interventions — looking for red flags, triggers. The care was solid. We covered our bases and then some. And yet …
The clinicians feel devastated, guilt-ridden, sad, angry with ourselves. Compassion for ourselves lacking — for a fleeing moment identifying, perhaps, with the grim mental state of the suicidal patient.
So what happened? Why did this young teen kill himself? Why did this older woman with loving adult children choose to take her life?
There are perhaps several aspects of a presenting scenario that may remain unattended by even the most seasoned clinicians. In the mire of hidden nuances, comments made in passing often allude to more complex trauma states and vital disavowed affect/emotional states. Yet these comments often are missed or misinterpreted by well-meaning therapists.
Using meta communication
Some of the most difficult work in which we engage as clinicians requires lending our attuned ears to that which is unspoken in the room, deciphering language that is often expressed in code, or “meta communication” (a term often utilized in our profession).
A therapist dealing with an at-risk client would be well advised to pause at quips or passing comments, including ones in which positive observations are made. For in the world of a potentially suicidal patient, the sharing of positive experiences also equals vulnerability, and vulnerability brings the potential of pain. Sometimes these nuggets of communication hold vital yet conflicting information. The patient seeks to promote a hopeful stance while concealing unbearable fragile states that lay closer to the surface than realized.
By following repetitive themes, and being aware of limited affect states — i.e., only anger, only sadness, or even no affect — a therapist may pause at each juncture, exploring piece by piece, frame by frame, the potential negative interpretations of the client’s words and any self-deprecating shadings. Conversely, inflated self reports may represent dissociated aspects of unexpressed loss and pain. (Many patients with expressed or unexpressed suicidal ideation communicate with defensive grandiosity, or chronic defensive self-deprecating descriptions. These are intended to conceal crippling and self-loathing aspects of the self.)
Unbearable feelings of self loathing may be projected onto another person. Comments such as, “He is such a loser, I would never do (this or that),” are potential red flags not to be overlooked, for these are likely the very feelings of self loathing experienced unconsciously by the one who is suicidal.
By illuminating and exploring such states, via sustained, steady and cautious empathic inquiry, a therapist may gain access to the client’s fragile and painful emotional world.
Beware of hope
Another hidden hazard: A “positive” therapeutic experience, counterintuitively, might send a suicidal client reeling in shame or fear upon leaving the session. A vulnerable self has been revealed, even in the smallest way. The consequences could prove dangerous for the most at-risk clients.
In order to preserve the connection with the therapist (counselor, close friend or pastor), a suicidal patient may profess to be “feeling better,” saying that “things are looking up” as a way to seek approval or no longer burden their confidant with more negativity. This is a critical red flag. The expression of “feeling better” requires immediate attention and exploration. Often these are the times when suicidal patients complete the “act” of taking their lives.
Deep depression often prevents destructive actions because of lethargy and immobilization. “Feeling better” sometimes speaks to the client’s newly found capacity for movement — and therefore the possibility of taking action such as suicide.
Therapists also are encouraged to remind clients that the sharing of their positive experiences may later be viewed by them through a lens of dangerous vulnerability. Fear and self-criticism for having exposed themselves (often described as “backlash”). This caution and the clients’ subsequent understanding will help the therapist create an ongoing space for the clients to share a wider range of experiences, including the most intimate moments.
Inside the ‘relational home’
Carl Rogers’ work reminds us of the importance of “holding a space where our clients may receive unconditional positive regard” — the sacred place we call our therapy room.
Suicidality is often completed as a result of complex core beliefs that a person’s life is inherently worthless. The belief that along with an unbearable existence comes a destined or somehow deserved consequence. These self-annihilating states and organizing principles (R.D. Stolorow) often manifest as a result of core childhood neglect and trauma, coupled with the absence of a “relational home,” a place where deep meaning is found in a person’s unique life story.
Traumatic past experiences such as emotional neglect are slowly and steadily related and addressed under its roof. The potential for a wider emotional world exists, bringing forth the promise of a more meaningful and flexible life. Self-criticism becomes reduced. Strength and courage are affirmed with measured awareness of a patient’s capacity to permit expression of vulnerable relational needs. Such deep longings buried; such deep needs and such deep terror of rejection lie within this territory.
Unless vulnerable affects that produce thoughts such as, “I am worthless. I am not worth knowing,” are interpreted and integrated with empathic attunement, clients run the risk of suicide ideation — and in certain cases the completed act. Trauma and shame states are more closely intertwined than imagined, and may lead to destructive behaviors.
As a collaborate relational home between patient and therapist develops, and a range of vulnerable feelings and emerging safety is revealed, understood and transformed within the therapeutic dyad, the risk of suicidality has a greater chance of being reduced and eliminated.