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.
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.