You are listening to a client describe very specific plans to attempt suicide by overdosing. She has 94 pills of a potentially lethal medication at home. She knows the number because she has counted, again and again, in a sort of ritual to prepare herself for the act.
A familiar unease settles in you. You ask her if what she is describing are merely thoughts, or plans. That is, does she really intend to actually attempt suicide very soon?
“Yes, yes,” she says quietly, sobbing. “I just don’t want to live anymore.”
You invite her to tell you more about her situation, her pain, her plans. She tells you she will take the pills tonight and that nothing will deter her. You probe for ambivalence, hope, desire to live. There is none. She says she is beyond hope or help. She is insistent on killing herself that evening in a motel room out of town, so that she will not be interrupted.
Eventually you tell her that you believe she needs to be in a hospital to ensure her safety.
“I would die before going to a hospital,” she says. She then tells you that if you do anything to make her go to a hospital, then if she does survive, she will quit therapy and hate you forever, because you will have shattered her trust.
The Role of Psychotherapists
A very difficult tension exists in the role of psychotherapists. On the one hand, we want to provide a safe space for people to reveal their deepest thoughts without judgment. Our goal is for clients to be understood, safe, and, above all, helped.
On the other hand, if a person’s statements indicate that he or she will act soon on suicidal or violent thoughts, then we may need to move beyond supportive, nonjudgmental listening. We may need to take action – whether the client wants us to or not.
Some clients will recognize that they need to be in a safe environment. These clients will go willingly, perhaps even gratefully, for an evaluation to see if they need inpatient hospitalization to protect them.
But when severely suicidal clients resist our efforts to keep them safe, we risk moving from ally to adversary. We now are in the position of using the information that they shared with us to thwart their plans to do violence to themselves or others.
Danger of Overreacting
It is extremely difficult to have someone involuntarily hospitalized, and appropriately so. Commitment to a psychiatric hospital is a drastic move. It takes away a person’s freedom, potentially harming the person’s livelihood, social relationships, and emotional state.
Commitment to a psychiatric hospital also can strain or even rupture the therapeutic relationship with a client. The client may become angry about needing to go to a hospital for an evaluation or admission. And the client may find it unsafe to ever confide again in you or, perhaps, any other mental health professional.
For these reasons, psychotherapists must avoid overreacting. Clients need to have a safe space in which they can talk about their suicidal thoughts without the therapist “freaking out” or moving to hospitalize when it is not actually justified.
Desire to die is not enough to constitute imminent risk of suicide, the criterion in many states for involuntary hospitalization. Persistent suicidal thoughts are not enough to constitute imminent risk. Even having a plan to die by suicide is not enough.
To justify involuntary commitment, the therapist must believe that a client will act very soon on the suicidal thoughts. (Psychosis or other features that make a person unable to control whether he or she acts on suicidal thoughts may also call for involuntary hospitalization.)
I have had clients describe to me in very specific detail how they would attempt suicide. And they expressed strong desires to die. But they did not strongly intend to act on their suicidal thoughts any time soon. For them, it was necessary over many sessions to be able to talk through their suicidal wishes, to not feel so alone, and to develop skills to stay safe and feel better. Premature or outright unnecessary hospitalization would have been devastating.
Even so, there are times when a therapist finds it necessary to seek involuntary hospitalization for a client. In the example I began with, the suicidal client had a clear plan to die by suicide that night, intent to carry out the plan, and the lethal means to do so. For the therapist to not take action would be irresponsible, even malpractice.
(I should note that some states allow for terminally ill people to die by suicide without interference if they use medication prescribed for that purpose. But that is material for a future post.)
Earlier I wrote that we move from ally to adversary in our efforts to keep a client safe against his or her wishes. The reality is that, in trying to keep an imminently dangerous client safe, we are the ally of the client’s healthy self, the part that wants to live.
When we believe that the client truly intends to act on suicidal thoughts very soon, the adversarial relationship exists only with the client’s unhealthy self, the part that wants to die.
When suicide is imminent, the client’s healthy self has become muted, cut off even from the client. The client may feel especially betrayed by our efforts to step in and keep them safe. That is okay. If someone truly has every intention to die by suicide within hours or days, our most important task is to help them stay safe.
If all goes well, sometime later, they may even agree.
UPDATED: May 29, 2014
© Copyright 2013 Stacey Freedenthal, PhD, LCSW, All rights Reserved. Written For: Speaking of Suicide
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