There are few things a therapist fears more than the client who walks through our door, barely clinging to hope, who has attempted suicide in the past or who has suicidal urges now. While we’re grateful for their pursuit of help, there is always a risk that their present suffering will leave a lasting impression on our psyche, no matter how much self-care we plan for ourselves. For many of us working with these clients, our desire to help and our need to be a source of hope is impacted by the reality confronting us: how to treat somebody who believes their only solution is death?
You may not be working with someone who is actively suicidal at this moment, but chances are you will at some point in your career. It is never easy. The gravity and weight of this profession when we are faced with a patient who is at a very real risk of death by suicide are unlike any other in the burdens we assume on behalf of our clients. The experience of losing a patient to suicide is similarly unparalleled. Support, education and resources are available to clinician survivors thanks to the American Association of Suicidology (see Suicide Loss Survivors – American Association of Suicidology).
September 10th is World Suicide Prevention Day
Awareness holidays like World Suicide Prevention Day—celebrated on the 10th of September each year—are helpful in that they allow us a platform to talk about serious issues like taking one’s own life, but they don’t always leave us feeling prepared for the next suicidal client who walks through the door.
In the awareness community, there are some unhelpful mantras that contribute to the challenges we face as clinicians who treat individuals at the highest risk of suicide. One such phrase is “every suicide death is preventable.” The unfortunate truth is that when someone intends to kill themselves and has a means, a plan, and the determination to carry it out, there is nothing that you as their clinician, family member, or friend can do to prevent it. Even 24-hour vigils may fail. Rather than changing the outcome in this heartbreaking situation, the idea that their death could have been prevented sets us up to compound the pain and guilt of the bereaved.
In light of this, we do well to remember our actual purpose in the battle against suicide. “As therapists, we are not in the business of suicide prevention, we’re in the business of building a life experienced as worth living,” reminds everyone at THIRA Health. Our job is not to save someone from killing themselves—our job is to treat the problems that are contributing to the person wanting to die, strip away the delusion, and get enough distance between the desire for suicide and the means to carry it out. In this vein, the mantra to cling to is “life can be worth living”.
What Do We Say To Suicidal People?
At times, we can get lost in the clash of wills and in the scramble to present a worthy reason for someone not to act on their darker impulses. We may fear that certain arguments are taboo, or will lead to equally harmful experiences of shame. However, if it works in the moment, you can use it! We want to help suicidal individuals delay their urges, deter them from acting on their thoughts, help them cling to hope, and affirm or help build their desire to live.
When we become myopically focused on preventing death, we lose access to life, which is the real antidote to suicide. This concept of a “life worth living” is one that is central to Dialectical Behavior Therapy (DBT), and specifically our work here at THIRA Health.
The Reasons For Living Inventory
Dr. Marsha Linehan, the developer of DBT, has expanded the concept of a “life worth living” into a Reasons For Living Inventory, which contains 48 statements that therapists can use or suicidal persons can turn to during dark moments in their lives.
In this inventory, Dr. Linehan refers to six subscales and identifies some thoughts in each category that may help suicidal individuals resist and avoid suicidal thoughts, impulses, and behaviors. Throughout the course of therapy, these thoughts and beliefs need to be strengthened and brought to the surface and then can be used as affirmations in moments of internal conflict.
Here are some notable examples from each category:
- Survival and Coping Beliefs
• I still have many things left to do.
• No matter how badly I feel now, I know it will not last forever.
• I believe killing myself would not really accomplish or solve anything. - Responsibility to Family
• I would not want my family to feel guilty afterwards or believe I did not love them.
• I would not want my family to think I was selfish or cowardly. - Child-Related Concerns
• The effect on my children will be devastating.
• It is not fair to leave my kids for others to raise. - Fear of Suicide
•I am afraid of the actual “act” of killing myself (the pain, blood, violence).
• I am afraid my method would fail and I might disable myself instead.
• I am afraid of death or the unknown. - Fear of Social Disapproval
• Others may think I was weak and selfish.
• I am concerned about what legacy I will leave and what others think of me. - Moral Objections
• I believe only God can decide life and death.
• I am afraid of going to hell.
When you have clients that struggle with severe depression to the point where their suicidal ideation is interfering with their ability to function, you may be unsure where to turn. Here at THIRA Health, we provide holistic care for individuals that are living with depression, using self-injury to cope, or who are actively experiencing suicidal urges. Connect with us today to learn more about our program and why we use DBT to help our patients create their life worth living.
