Depression
by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way
I don’t think of myself as an expert in suicide assessment by any stretch of the imagination. However, I have come to cultivate some ideas about how to stay connected to clients who are in throes of suicidality. It has taken some time to achieve any inner calm around suicidal clients, because working with suicidal ideation and or intent is some of the scariest work that we do.
Staying open to clients who feel intense isolation because of their wish to die requires a steady openness to our own darkness. This openness often defies much of what feels clinically instinctual.
The primary means by which I find myself able to connect with a suicidal client is to reserve judgment about how they are feeling. We often feel so pressured to properly assess for suicide that we are placed in a heightened state of judgment, often removing us from the empathy that calming suicidality requires. When we are jerked into a suicide assessment by noticing at-risk client behaviors, we often abandon our clients in search for an answer: are they safe or are they not?
If we can slow the urgency and anxiety that accompanies assessment, we can engage our clients with curiosity. The fact is that inside all of us is a place that deeply understands suicidality. Perhaps we have not really considered suicide, but we still know it in some way. Almost every person can answer the question about how they would kill themselves. It is just something that we have almost universally given thought to. It is an upsetting thought, but a compelling one. The fact that we can end our own lives is one that is psychologically gripping, if not fascinating.
We also all have something that we live in horrible fear of (loss of a loved one, a job loss, illness) and have wondered what would happen if that thing happened. We have considered that we might kill ourselves if our fear came true. For the most part, we know that we wouldn’t take that route, but the idea is certainly not completely foreign to us. There is some comfort in the possibility. It is a terrifying comfort, yet it stands there as a hypothetical, though improbable, option.
Our minds also play weird tricks on us. This is particularly true around issues of suicide and death. Sometimes if I walk past a knife and see my cat, I wonder what would happen if I stabbed my cat. I love my cats more than I can even say. I would never stab them. However, this curiosity and wonder moves through me. It has no power, no resonance. It just passes through. For people who are struggling with intense depressive states and suicidality, the fantasies don’t just pass through. Instead, they get stuck on the thought and it can become almost metastatic in its ability to become an obsession.
If we are to open up to our own knowing of the ways our minds work, the suicidal client becomes more knowable, accessible, and far less scary. If we can open up to the parts of ourselves that know the suicidal client, we better accompany them on their journey. Further, we can perform an assessment that keeps us from othering our clients in a way that makes them feel more alone than they already do.
We know our suicidal clients. We know them if we let ourselves into the depths of our own psyches.
Part of my strategy in working with suicidal clients is to surrender to the need to bravely and unwaveringly discuss what is going on in the client’s mind. There is a lot of debate about whether or not doing this gives more power or gravity to the suicidal wishes. From what I have witnessed, quite the opposite is true. The more a client is able to give voice to what is in their internal world, the more benign those thoughts and feelings can become. In a vacuum, the thoughts feel fatal. In the light of day, their power is lessened.
Our work when assessing suicide is incredibly nuanced and demanding. We need to delineate between suicidal thoughts, ideation, and intent. We need to determine the difference between self harming behaviors and suicidal behaviors. We also need to try to access parts of people's minds that are often siphoned off with a lock and key. It is only with an unabashed look inside of ourselves for the connective tissue to sooth the isolation of our clients that we can properly perform this complex assessment work. Further, with a strong willingness to hear what clients feel is unutterable, we can start to ease the unrelenting impact of obsessive power of suicidal tendencies.
We don’t often talk about the bravery that suicide assessment takes. It is gut wrenching and soul stirring work. Done well, we are drawn into conversations about the deep wish that many feel for the relief that death would supposedly bring. Placed squarely on the side of life and safety, we walk on a tight rope. We bear witness to the strong seductive current of the wish to die as we move toward inviting our clients back to shore, alongside our welcoming sands.
Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She provides more of her clinical perspective and tips for developing clinicians in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.