Passive Suicidality & the Jovial Client

Shane, a 32-year-old freelance graphic designer, enters your office on crutches with one foot in a boot. As he lowers himself down onto your couch, he says, “I’m here because I got into a fight with my girlfriend.” Your face must betray some emotion, because he laughs and follows your gaze to his boot. “The injury’s unrelated—I’m just a klutz. I tripped.” When you ask a follow up question about the fight, Shane sighs. “Liza was criticizing me for breaking her favorite mug. It’s like the second mug I’ve broken in a month since I moved out of my stepdad’s basement—he’s such an asshole—and in with her. Anyway, I said to her, ‘Well, maybe I should just kill myself so you won’t have to deal with me,’ and she totally freaked out! She wouldn’t stop crying till I promised her I didn’t mean it.”

Shane stares into the half-distance, then murmurs. “We made up, but the thing is, a part of me did mean it. I think about dying a lot, like not exactly killing myself, just not being here anymore.” Without missing a beat, he leans forward, his face growing animated, and he points at a framed picture on your wall. “That’s such a cool print! Is that woodcut?”

Assessing Collaboratively

By John Sommers-Flanagan

Shane’s multiple disclosures to open our session are intellectually fascinating, and emotionally disquieting. Initial therapeutic challenges include where to focus and how to manage my emotions. Part of me wants to explore what’s under Shane’s sudden interest in my office art. Another part of me wants to launch into formal suicide assessment. But my opening response is purposely much more boring.

“Yes! It is a very cool print, and it is woodcut.”

“Woodcut art has that cool texture,” Shane says. “Is that a hawk?”

“It could well be,” I say.

Job one is to connect with Shane. He asked about the art. He didn’t ask for my insightful clinical interpretations. Although his “thoughts of dying” and “not being here anymore” sound like less threatening passive suicidality (wishing to not exist), instead of active suicidality (thinking, planning, and perhaps intending to end his life), he also didn’t ask for my professional suicide assessment. We begin psychotherapy with clients, not on clients.

Shane and I chat for a few more moments about art. We have time. It may not seem like it to newer clinicians but talking about suicidality can wait. After our art chat loses energy, I go back to the charcuterie board of issues that preceded his woodcut comment.

“Shane, I appreciate that you noticed my art. Thanks for that. You also shared lots of stuff about yourself, including a fight with Liza, breaking two mugs, you being a klutz, you moving out of your asshole stepdad’s basement, your thoughts about suicide, Liza’s reactions to your thoughts about suicide, and that you think about dying a lot.”

I use an early summary for three reasons. I want Shane to know I’m a competent listener. I want him to hear my summary of his words. And I want Shane to choose where we go next. As Carl Rogers wrote in 1961, “It is the client who knows what hurts, what directions to go, what problems are crucial. . . .”

My first summary is all about content—the actual subject matter he’s raised. Exploring Shane’s emotions before we have an interpersonal connection is an excellent recipe for getting Shane to run away and never return to psychotherapy.

I don’t know where Shane will take this session. Most likely, we’ll explore painful or disturbing situations. He might say, “Like I said, I don’t want to kill myself, but I think about death a lot. Is that weird?” or “I feel terrible about breaking Liza’s mug. It’s like a metaphor of me always breaking good things in my life.” As Shane talks about these issues, I’ll begin with mostly surface reflections.

In many ways, our first 50 minutes is a dance with two partners who don’t know each other well. I know the suicide assessment dance well, but if I impose it on Shane, I might step on his toes, and we could lose the beat. I still want Shane to lead—at first. I’ll take my turns at leading along the way. Collaboration is central to all psychotherapy, but especially when suicidality emerges.

When Shane says, “God, let me tell you about my asshole stepfather.” I say, “Yes, I’d like to hear about that.” Then I listen, using both reflection (“You felt invisible around him”) and affirmation (“It’s hard to imagine how hard it would be to live with a stepfather like that.”) Eventually, I offer a small bite of psychoeducation, along with a potential interpretive connection. “Having an asshole stepdad and all the hard things that go with that can naturally trigger thoughts about death.”

Shane pauses and seems to take that in.

“Yeah, partly. But I think it’s more the idea that I’m going to fuck up any chance I’ll ever have at a healthy long-term relationship.”

“So, let’s talk about that idea—of fucking up your relationship hopes.” Although I don’t typically use profanity much, my intentionally using Shane’s language to describe his experience may help him feel more heard, and consequently, he might be more likely to elaborate.

Intermittently, I channel renowned therapists whose contributions guide contemporary suicide assessment and intervention. As the great suicidologist Edwin Shneidman (and great singer-songwriter Joni Mitchell) recommended, my first assessment focus lingers on the mantra, “Where does it hurt?”

To get clearer on where it hurts, I ask a David Jobes question. Jobes is a psychologist who developed the collaborative assessment and management of suicide (CAMS) model. His “one thing” question is beautiful, because it so elegantly illuminates underlying factors that push clients to have suicidal thoughts: “If we could somehow magically change just one thing in your life that would eliminate your suicidal risk all together, what would that be?”

Shane looks down at his hands, then back at me. “That’s easy. Trusting I won’t break the good things in my life. Knowing I won’t mess up with Liza like I’ve messed up with everyone else.”

“So it’s about self-trust,” I say. “Knowing you can take care of what matters to you.”

Shane’s response has helped he and I identify what’s pushing him toward suicide. Now that we know the suicide driver, we can work on it together.

Working with suicidality is always challenging. Shane’s immediate disclosure of passive suicidal thoughts would trigger me, along with most mental health professionals. My emotional reactions and behavioral impulses are idiosyncratic to me, my professional training, and my personal lived experiences. For me, the biggest challenge involves restraining an unhelpful impulse to tell Shane everything I know about suicide. Another therapist’s biggest challenges may be different, equally worth recognizing, and probably equally worth inhibiting—at least initially.

Most psychotherapists may feel a common urge, one that’s been ingrained by our professional suicide assessment training. We want to grab a suicide assessment instrument like the Columbia Suicide Severity Rating Scale (C-SSRS), which is often used to identify and categorize suicide risk.

Initially, with Shane, I resist that impulse, for two main reasons: I don’t want anything to interfere with the alliance I’m in the process of developing with him, and research evidence supporting the utility and validity of suicide screeners is minimal. I’m not against suicide screeners. I’m just saying, don’t immediately leap into it. First, make sure your client knows you’re deeply interested in hearing the stories of their life.

In psychotherapy, it’s often useful to begin with the end in mind. So, even during our initial sessions, I keep the end (my goal) in mind with Shane.

I want a therapeutic alliance with him. I want him to experience me as a credible, competent professional who can listen well and handle his issues, including suicidality. My hope is that together Shane and I will grow our insights into the interpersonal and intrapsychic factors contributing to his suicidal thoughts and discuss his helpful and less helpful coping strategies.

So, after our initial chat about my office art, our discussion of his stepfather, and our deeper exploration into his desire to trust himself and take care of the things that matter to him, I ask him if I could “do an assessment of his mood” (n.b., I’ve never had a client decline this request). Then, while using a scaling technique, I normalize suicidal thoughts, “It’s not unusual when people are feeling down or distressed, to also have thoughts of suicide.” I ask directly, “What brings on the thoughts about death and suicide?” and “What’s happening when you’re free from thoughts about death and suicide?”

Regardless of my assessment approach, I realize that suicide assessment procedures have minimal scientific support. Often, clients won’t elaborate on their suicidal ideation because of fears of hospitalization. Consequently, I will tell Shane that I view suicidal thoughts as a sign of distress, and not a need for hospitalization. In the process, I will be therapeutic, collaborative, and use strategies that make it easier for Shane to openly talk with me about his suicidal thoughts. Asking permission, focusing on mood, normalizing suicidal thoughts, and asking easy questions about situations that trigger suicidal ideation as well as positive, life-affirming situations set the stage for deeper questions. By the time I get to questions about previous suicide attempts, substance use, and firearms, those questions will feel like a natural part of our conversation. Eventually, I’ll ask permission to create a safety plan.

“Shane, I want you to be safe and I want you to feel safe. So, if it’s okay with you, I’d like to walk through with you what some very smart and famous psychologists call a safety plan. Would that be okay?”

Because I’ve approached this issue gently, collaboratively, and with respect, Shane is highly likely to consent to collaboratively create either a Stanley and Brown safety plan, or a Craig Bryan crisis response plan.

I may even channel my inner Marsha Linehan voice to say something like, “Therapy never works on dead people. Will you commit to staying alive and working with me, even if it means we go through hell together?”

All assessments, including suicide assessments, should be therapeutic. My first session with Shane will shape our collaborative work together into the future—it will just happen to include a suicide assessment. Together, Shane and I will focus on how he can build a life that feels more meaningful, more worthwhile, and more socially connected.

Taking a Direct Approach

By Stacey Freedenthal

My antennae perk up whenever a client alludes to wanting to die. And if they quickly add “like not exactly killing myself,” it’s highly possible that’s exactly what they’re thinking of. In Shane’s case, we already know that he appeased his girlfriend by telling her a fib: “I promised her I didn’t mean it.” He might be hiding something from me, too.

Research shows that roughly half of people with suicidal thoughts deny them when asked directly if they’re thinking of suicide. Even if Shane’s telling the truth, the passive suicidal ideation he reports is as big of a risk factor for suicidal behavior as explicit suicidal thoughts. Thoughts of dying and “not being here anymore” indicate deep distress that needs attention.

My immediate agenda with Shane is to try to create safety and trust. So, I simply answer his question and ask one of my own.

“Yes, it’s a woodcut. Thank you,” I say. “Could you tell me more about your thoughts of not wanting to be here anymore, or would you rather talk about other things first?”

He looks at me, then back at the woodcut. “Where’d you get it? It’s hard to find real woodcuts these days.”

“From an estate sale. But when I suggested talking about other things”—I smile—“I meant about you.”

He smiles, too, looks down into his lap, and wrings his hands together. “Yeah, sure, I guess that’s why I’m here, isn’t it?”

I nod but say nothing, hoping he’ll fill the empty space with information that can help me understand him. Which he proceeds to do. “You know how I said I tripped?” he says, his boot-less leg bouncing as he talks.

I nod.

“I just can’t get anything right. I’m a real loser.” His eyes dart around the office as he talks, but they never land on mine. “Not just the klutziness. I’d still be living in the basement if not for my girlfriend.”

It’s tempting to refute someone when they say they can’t get anything right and they’re a loser. To tell them, “No, you’re not a loser,” or to urge them to reframe the thought or to ask them about the times they have gotten things right. To try to help them feel better about themselves, starting now. But I don’t want to try to pull Shane out of the darkness in which he finds himself, or to turn on an artificial light. Not yet. Instead, I want to try to join him where he is.

“Those kinds of feelings are so painful,” I say.

“I just think,” he says, looking away, “people would be better off without me.”

My antennae spike again. Many people with suicidal thoughts feel like they’re a burden on others. He said earlier he doesn’t exactly think of killing himself, and he evaded the topic, but I need to ask the question. To avoid it would convey suicidal thoughts are unspeakable, which is the last thing I want to do as a therapist.

“A lot of people who say others would be better off without them have suicidal thoughts,” I say. “It makes me wonder, do you think of killing yourself?”

For the first time all session, he looks into my eyes and his gaze locks on mine. He nods.

Here, it’s important to say what I do not do next. I don’t immediately launch into 15 yes/no questions about suicide risk, such as “Do you have a plan? Do you have the means? Do you have the intent to carry out your plan? Have you ever attempted suicide?”

The answers to those questions are important, but for now, I want to hear his story in his own words. Drawing on the narrative-based assessment used in psychiatrist Konrad Michel’s Assisted Suicide Short Intervention Program (ASSIP), I ask Shane, “Can you tell me the story of what’s led you to think of suicide?” It might seem like that question would take a long time to answer, but Shane tells me in just a few minutes about how, since adolescence, he’s felt inadequate, a feeling that only worsened when he had to move back into his mother and stepfather’s house at the age of 25. He discloses he has ADHD and constantly feels like he’s “five days behind.” Ah, I think, that likely explains his distractibility.

I want to explore his experiences with ADHD as we work together, because disorganization, unmet goals, and other common consequences of ADHD can contribute to feelings of inadequacy. Research has found that people with ADHD are at least two times more likely than others to make a suicide attempt, fatal or nonfatal.

In the course of telling his story, Shane happens to mention that he first had suicidal thoughts when he was 25 years old, but he’s never acted on them. “I don’t really intend to off myself,” he says. “It’s just something I think about when I’m really down on myself. I don’t even know how I’d do it if I wanted to.”

He’s already ticked off some of the yes/no risk assessment questions without my asking. It probably feels much more therapeutic for him to tell me in his own words, rather than to be interrogated.

With that said, I do ask some risk assessment questions, to fill in the gaps. I ask if he has a firearm (“no, never”), how often he has suicidal thoughts (“like, maybe once a week”) and for how long (“maybe a minute, probably less.”)

“You’ve had suicidal thoughts off and on for a while,” I say. “What’s stopped you from acting on them?”

He tells me he likes mountain climbing. He loves his girlfriend. He wants to become a father. And he knows his bad moods pass like the weather.

We talk about his goals for therapy, particularly his wish to not beat himself up so much. I don’t ask him to promise not to act on his suicidal thoughts. Those kinds of promises, called safety contracts, are no longer recommended for practice, because they’re not effective, they center the clinician’s fears of liability, and they encourage secrecy after suicidal behavior. Instead, it’s advised to collaboratively create a safety plan with the client, which helps the client identify coping skills, social supports, and professional resources they can turn to.

I tell Shane about safety planning and show him the Stanley-Brown safety plan form I use. He says, “But I don’t really feel suicidal right now.” I share a quote attributed to Theodore Roosevelt: “The best time to fix a leaky roof is when it’s not raining.” He chuckles and reaches for the clipboard with the blank safety plan that I’d set on the table between us.

As the clock nears the hour mark, I check in with Shane. “What’s it been like to talk about these suicidal thoughts?”

He takes a deep breath and sighs. “Actually, not bad. You didn’t freak out, and it feels kinda good to not be alone with it.”

In the sessions to come with Shane, I’ll check in again about his suicidal thoughts, update the safety plan as needed, and use evidence-based techniques specifically for treating people at risk for suicide. I’ll deepen my assessment using the Collaborative Assessment and Management of Suicidality, which homes in on feelings of psychological pain, hopelessness, agitation, stress, and self-hate, as well as the client’s reasons for living and dying. I’ll draw from cognitive behavior therapy to help Shane challenge or reframe his negative self-talk, and I’ll teach emotion regulation strategies from dialectical behavior therapy.

My goals are to help Shane not only survive suicidal thoughts but also feel better about himself and life. For now, we’ve taken important first steps together, walking side by side in the darkness into a small ray of light.