A few weeks ago I received a call from an intelligent, depressed and suicidal professor from a prestigious Eastern university who, after two attempts to find a therapist able to sit quietly and listen to her, found my free e-book (Suicide: the Forever Decision) on the web, and rang me up. As she put it, “You seemed like someone who could listen to the reasons I want to kill myself without butting in.”
Without butting in? And here I thought all therapists were trained not to butt in.
“Are you accepting new patients?” she asked.
“Sorry,” I said, “I closed my practice some years ago. But I’m happy to hear you out and help you find someone if I can.”
So we talked; or rather she talked, and I tried not to butt in.
Selecting a psychotherapist is challenging, let alone finding one able to listen carefully to why people want to end their lives. In addition to the language barrier inherent in the subject of suicide, prospective patients must consider location, availability, qualifications, affordability, insurance coverage, cultural differences, and what sort of therapy is offered. Psychoanalysis? Cognitive behaviorist therapy? Family systems? Or some spook therapy that oozed out of the bottom of a whisky tumbler and remains unencumbered by any scientific support.
On the public service side of things, the Substance Abuse and Mental Health Services Administration just published a survey report that found, “57 percent of all known U.S. mental health treatment facilities offer suicide prevention services.” I interpret this to mean that 43 percent don’t. You can Google the SAMHSA full report for details, but if over 40 percent of the agencies that are supposed to employ the “go to” folks when you are suicidal say they are not in that business (of helping to combat our greatest public mental health threat), I beg to be enlightened about how they justify their funding.
Accounting for possible distortions in her interpretation of events, I was not surprised to learn that the lady I was listening to had seen both a psychiatrist and a psychologist. One visit each. With someone clearly in need, a one-visit length of stay is referred to in our business as a “drop out” – someone who needed care but didn’t get it.
In this case, the psychiatrist interrupted her narrative to recommend medications. It seems the word suicide stimulated his reach for the prescription pad. This woman is a crack scientist and well versed in the pros and cons of antidepressant medications. She said thank you and left before completing her story.
By her report, the psychologist became so visibly anxious during her suicide narrative that he changed the subject, not once, but twice. Hardly bereft of interpersonal insight, our lady Ph.D. deduced that the poor therapist was far too frightened to be helpful. Since he could not engage in a full-on existential discussion of suicidal ideation, its merits, threats, strengths, challenges, likely causes, and possible remedies, she politely closed the interview and did not reschedule. Had he be able to hear her out fully he would have learned what I did by simply keeping quiet: that she was suffering from a chronic circadian rhythm disorder triggered the year before by a traumatic event and had not had a full night’s sleep since the trauma.
Suicide talk makes therapists jumpy. Losing a patient to suicide is their number one fear. Patients talking about suicide create a special terror deep in the hearts of therapists, and if there is anything more icky to talk about during a therapeutic hour than that a patient wishes to explore the option of ending his or her own life, I don’t know what it is.
In a recent issue of the journal Crisis, Rothes and colleagues titled their paper “Facing a Patient Who Seeks Help After a Suicide Attempt.” The authors explored the reactions of therapists to patients who were suicidal but who had not yet made an attempt, as well as those who had made an attempt. The most significant “difficulties” reported by clinicians to the authors were “emotional and relational” not technical, family, or logistical in nature
What interested me most in this report was this: “A very important and informative finding from our study is that although only 19% of health professionals reported specific training in suicide, 89% felt competent to assess suicide risk and 50% thought they had adequate suicide training.” In other words, 1 in 5 clinicians reported any training at all, yet 9 in10 felt they were competent to assess and treat suicidal patients.
Unless I am much mistaken, when the majority of clinicians report they have had no specific training in the problem they are about to treat (a suicidal patient), but feel perfectly competent to treat them anyway, back when I taught Psych 101 we called such false beliefs delusions – or, an idiosyncratic belief or impression that is firmly maintained despite being contradicted by the facts or reality. As such, a delusion is a symptom of a mental disorder.
Now, I am not accusing the majority of clinicians of having a mental disorder when it comes to believing they are competent to assess, treat, and manage suicidal patients without training, but I am saying that any wrong beliefs about one’s abilities to care for suicidal patients creates three unacceptable outcomes, none of which are good for anyone.
First, suicidal patients deserve competent care by trained professionals. Millions need it, few get it. Our lady Ph.D. was just one. A suicide crisis is the mental equivalent of a heart attack and anything less that fully-informed care is unacceptable. Or the public should know why.
Second, any therapist providing care to suicidal patients without training is likely engaged in unethical practice, since the first requirement of all healers is to do no harm by attempting to fix a problem you don’t understand. How our graduate schools can continue to pass untrained professionals off on our communities in the face of a preventable public health problem that takes 2,700 lives a day around the world is beyond me.
Third, multiple studies have shown that the quality of the relationship and communication skills with a suicidal patient are essential to preventing further suicidal behavior. Thus, ignorant, fear-stricken therapists who lack self-awareness about their skills and competencies are not only no good to suicidal patients, they may actually make them worse.
Don’t think for a minute that our lady-in-search-of-a-therapist felt better after striking out her first two times at bat; in fact, she was scouring the web for reasons not to kill herself when she found my book.
The challenge for suicidal people and their loved ones is to find someone who won’t make them feel worse. I’ve little data to support this, but having interviewed lots of suicidal patients whose early ventures into psychotherapy were a bust, I’ll wager I am right.
Go ahead, imagine you are suicidal. Now go to your Yellow Pages and find a therapist who advertises, “Suicidal people welcome!”
HelpPro (http://www.helppro.com/) recently partnered with the National Suicide Prevention Lifeline and others to launch a search tool for those seeking suicide-prevention therapists. Prior to this, finding a suicide-savvy therapist has been next to impossible.
Even today, millions of untrained practitioners around the globe continue to treat suicidal patients they don’t even know are suicidal, or if they do know they are suicidal, remain stubbornly ignorant about what actually works to prevent suicide. This is cough drops for throat cancer, and it is no wonder that according to the National Violent Death Reporting System, somewhere between 31 percent and 39 percent of suicidal patients die while in active care with a health professional. In some reports I’ve seen, the number is much higher.
Ha! And just when you thought it was safe to call a therapist.
Twenty-odd years ago the leadership of the American Association of Suicidology asked me to serve as the chair of the Ethics Committee. An unelected position without staff support, pay, or even other committee members, I took on the job because my predecessor, Dr. Jerome Motto, assured me that the only ethics committee in the world with less to do was the Wall Street Ethics Committee for the Protection of the Public, the last meeting of which was held in the early 1960s after its last member expired in situ at a small dusty conference table in an abandoned office building somewhere in Manhattan.
As a life-long consumer advocate, it is my view that suicidal people and their loved ones would benefit greatly if all the healthcare professionals to whom they turn in their times of trouble asked themselves this single ethical question: “Since I have had no training in suicide risk assessment, treatment or management, is it still OK for me to take money from suicidal patients?”
I await their answer.
Dr. Paul
PS: Through my contacts with experts in the treatment of suicidal folks, I was able to find a fully qualified practitioner for the lady whose storied inspired this post.
onsuicide 
Response to your last question: “GET trained.”
My own approach (after I ‘read ’em their rights’) is, “I have 16 pages of questions that I’m going to need to fill out at some point, but for right now, I have just one question, “What do I need to know to help you?”
Then I LISTEN . . .
I like your approach, too.
Phenomenal post. My experience with those with suicidal ideation or prior suicide attempts is fraught with the same issue you describe above. Those calling me are from the military or mil/veteran families and the usual resources have failed them; again as you describe above. I’m neither a psychologist nor psychiatrist, yet find myself often in the position of being a trusted listener. Trust and listening are rare, it seems.
My key goal is to guide a suicidal person to the best helpline/resource possible as quickly as possible since I am not a clinician, which is no small task. I have found many times that a peer support line, trained to manage potential suicides is the best option. Yet, the matter of follow-up, continued therapy visits, or post-vention is another dark abyss, and it’s hard not to become discouraged anew when that secondary call arrives.
Thank you for this posting; faith and fear cannot coexist, so we do the best we can because we care – something no one can pay or train anyone to do.
HUA Linda! (Heard, Understood, Acknowledged)
Thanks for your feedback and observations. We – a few of us – believe it is raw fear that drives the way too many clinicians respond to suicidal folks, and we have submitted some research for publication to try to illuminate this problem.
Oh so true!! The military is losing soldiers daily to suicide, yet I have never found a therapist to help me with my suicidal thoughts and actions. All the VA does is lock you up on a ward and degrade you until you say “I don’t want to kill myself”. Then they let you go and treat you like any other depress vet. All they do is shut you up. I want to talk about it and find out more about why I have these thoughts and how I can help myself.
Well said, Paul! The consequences of managed care and regulatory bodies are making patient first engagement almost impossible and any sign of risk requires a flurry of referrals to cya, none of which actually serve the person’s soul searching needs. It’s disheartening.
I have retired effective yesterday and will be starting a different type of practice – transformational coaching and consultation. The couching looks at a persons potential and what wants to happen next – as you accurately identified with the woman – she wanted to be heard and she wants to live. Thank heavens you steered her in the right direction. The consultation will continue to focus on diverting mental illness from the justice system. It will be nice to be able to do these things as they need to be done.
Please make note of my email address so I will continue to receive your posts. As ways, you are doing what is important and needed !
Best to you! Connie cpmilligan@live.com
Sent from my iPhone
Another great one Paul.
It occurred to me that as I was reading this blog that health care providers, including those that do some kind of talk therapy, have another thing to fear…that of realizing at some level that they are incapbable of doing their job. In these cases, the suicidal person sitting across from them represents a threat to the very basis for their professional existence. So perhaps, breaking out in a sweat, changing the topic, and/or not just listening is not only a reaction to the suicidal patient and the enormity of not knowing what to do to prevent the patient’s death, but also an unconscious reaction to the self-admission that they are inadequate.
Hopefully, Dr. Paul, your insight will help others in that pit of despair to reach out for the professional and faith based help that is available today. And, hopefully, my experience will help others also.
Therefore, it sadden me to see assisted suicide taking the headlines in our news here in Oregon recently. It also saddens me that some of our medical doctors have moved away from the “Original Hippocratic Oath” which states in part; “…I (the doctor) will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone…I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion”’ (From Wikipedia, the free encyclopedia).
There is, however, an alternative to suicide that I have experienced and it is called Faith. Some twenty two and a half years ago I tried to take my own life because I thought I had no hope in dealing with my emotional pain. The bullet should have killed me, but by a miracle it didn’t. There were painful years in my recovery but I knew that my Lord would carry me through because of what I had learned from the faith in Him that He instilled in me; that He always has a greater good involved, and it is not always about me.
Does that mean God will always cure us from a terminal illness? No. Because His greater good may involve, displaying through us, His love to others who need that strength demonstrated by what we are experiencing (see the Lauren Hill story, “Player with brain tumor fulfills hoop dream”; beautifully reported in the 11/4/14 Grants Pass Daily Courier’s Sports Section).
The apostle Paul said in Philippians 1:21; “For to me, to live is Christ (Who suffered for us), and to die is gain” (wonderfully restored, in Heaven with God, and in His timing).
Faith in Jesus continues to give me hope and I know He will for all others too, who want Him in their lives.
Sincerely,
Stewart Whittemore
I don’t know if Paul will respond to your note Stewart or, if he does, what he will say. I will though. And my answer is that I’m pleased that you and others have found an answer to your troubles in a particular faith. I’m even pleased that your answer comes through that faith and that you shared that fact with us. However, there are many people who find answers elsewhere, in other faiths not all of which are religious, and I’m not pleased that you stand in judgement of them either explicity or by implication.
I agree with Crumudgeon, Stewart. Bringing religiosity (and specifically “Jesus”) into the discussion often closes the door to getting help for many. It did with my 20 year old son despite an upbringing steeped in Lutheran ideology (and confirmation). That said, asking about a Faith background is very appropriate, but too many persist in stating Christianity is the ‘only’ way out of the depths of depression, clearly not true. That said, I do appreciate your post and your Faith. Your testimony could very well be the story that saves many a life when offered in the right way to a receptive ear.
I made the mistake of telling my therapist I had plans and she freaked out. Maybe she overreacted, maybe I’m making things seem better than they really are. But the things I had to do to prove I was safe made me feel worse and now I feel like it’s not possible for me to trust anyone. It was hard enough to admit it out loud without the details… and now I’m so alone. Well, lonely… Not even sure why I’m posting this. Or if it matters at all. /rant
“Rant” – You did not make a mistake. And it matters. Your welfare and peace of mind matter. Your life matters.
Therapists should want – and need to know – if you are thinking about suicide. Her “freaking out” is not your problem, but it seems to have led to more isolation and distrust, neither of which is good. Can you ask to meet with the therapist again to sort out what happened or, if that seems impossible, can I encourage you to call your local crisis line and ask for a referral to someone who has some experience with suicidal folks. I’ve no idea of your circumstances, but if you are seeing someone in an agency, ask to meet with a supervisor.
This blog is not a crisis line, but I encourage you not to quit counseling because of one therapist’s reaction to the truth. Others who read this space need to learn about your experience and since you did not ask me not to respond in private, and your note is confidential, I decided to respond here so people could see what this experience is like.
Remember, you can always call the National Suicide Prevention Lifeline at 1-800-273-TALK. There are great folks waiting to help you work through this.
Take care,
Dr. Paul
Paul, You wrote “I beg to be enlightened about how they justify their funding.” Exactly! Congress needs help writing laws distributing funds to multiple organizations (through SAMHSA or not) all claiming to do the same thing (redundancy) non of which are doing it (fraud). I appreciate the HelpPro link.
On being asked, “How are you?” June Carter Cash once remarked, “Still trying to matter.” Same here. Paul