Sunday, October 22, 2006

Suicide (Part I)

It’s a touchy subject for some. Some reading this have had someone close to them end their life by suicide. Even more know someone who has attempted suicide.

I’ve been fortunate and my connections to the topic of suicide are less personal; however, I have had the opportunity to do a bit of studying through my academic career on the topic. It is a fascinating topic to human behavior analysts.

And while it is fascinating to me to study the human reasoning for leading up to suicidal attempts, at the same time it is a scary topic to be dealing with as a mental health provider…

It is said that mental health providers have the highest rate among career professionals for committing suicide. I find that interesting.

[Story] One of the psychiatrist residents working on a mental health team with me this past semester in my internship had a close friend who also was a psychiatrist resident commit suicide during the time we were working together on the team. The resident on our team had to take a good amount of time off to grieve because of the loss. I mean this resident’s friend was a resident psychiatrist as well. There isn’t many better paying careers than being a psychiatrist, but this individual still reached the point of feeling like suicide was his/her best option. This sheds light on the fact that the act of taking one’s own life is not limited to any one race of people, or one career type, or one gender, or one socio-economic class. Anyone can be at risk of falling into this downward spiral of cognitive reasoning…

It is said that one of the most difficult situations to deal with as a mental health provider is the suicide of a client. This makes sense to me.

[Story] My most admired professor during my graduate degree program spoke to us in class one day about how he had a client who had met with him in a counseling session one day and was depressed. That evening the client ended up committing suicide. The client had mentioned my professor in a manner that was not so encouraging in the suicide note. My professor explained to our class how that was an incredibly difficult time for him following the death, and that he even had to take some time off from his private practice to cope. He mentioned that he had to turn to a fellow colleague during the trying time to help him to get through the situation.

Though I wish I did, I don’t have a statistic on what is the likelihood of a client committing suicide while under the care of a clinician. I imagine that the statistic is surprisingly high. I say this not because clinicians are not doing their job, but because sometimes suicidal clients are unpredictable. Many times a person will not give hints to their suicidal thoughts. They will choose to keep those thoughts to their selves. Yes, they might obviously be depressed, but is every depressed person suicidal? No.

At the same time, realizing the prevalence of depression among clients and the correlation between clients who commit suicide and their state of mood being depressed, I would be willing to say that my career in the mental health realm will put me in a situation where a client of mine will commit suicide. Unfortunate? Of course. But still likely? Yes.

[The Main Story] Over the past several months I have had my first experiences in the counseling setting. As an intern therapist, I would be providing intervention strategies with clients who were victims of domestic violence and/or sexual assault—individuals who are at HIGH risk for suffering from depression. With this being the case, the topic of assessing clients for suicidal ideation/thoughts and plans is crucial. This was the heavy thought on my mind the whole first week of training. I hadn’t even gotten close to having my first client, but I couldn’t stop thinking about how to properly assess for suicidal thoughts and plans and recalling what the procedure for when you have a suicidal client was. My fellow interns were concerned about remembering which forms to use with which clients and how to best word the questions on the intake form when interviewing clients, but I couldn’t stop focusing on the possibilities for interacting with the suicidal client. It was the last day of training and I remember still having questions in my head on EXACTLY what to do in the situation with a suicidal client, so I broke down and actually spoke up in the training (which is very rare of me, as I’m typically real quiet when first getting to know other adults and professionals). I was given some answers and I was feeling more comfortable. Then my first client came the following week…

Would you believe it that this client had issues with practically EVERYTHING else in the book, but NOT suicide. Phew, it was a sense of relief! I had (somehow) survived my first client (who to this day has been one of my most interesting clients—way to start off with QUITE a character), and made it through the “Have you had any thoughts of hurting yourself or suicidal thoughts in the past” question. Phew. I could breathe a sigh of relief.

Four and a half months worth of clients passed with the closest to a “suicidal client” being the ones who had had thoughts weeks before, but had no plan (which is a “safe” client for release in a clinical setting, though precautions should still be arranged). I hadn’t had to deal with the client yet that we would have to have “hauled off” to the psych. ER because of his/her suicidal thoughts at the present time with plans and means available. But maybe my “luck” was running out…

I had had a good record thus far—hadn’t had a client yet that I was unsure how to handle their response to the suicide questioning during the initial intake assessment. But then my time came. I look back on it now and think at least I DID get this experience BEFORE I left the internship and was out on my own…HA! It was just recently and…

This client admitted to having suicidal thoughts that morning. ^^Thoughts in my head at the time: Geez, why did it have to be just this morning that you were having the thoughts?! Why not like weeks ago or months ago like everyone else?! Okay, be cool. Lets assess for if the client has a plan and/or means^^

I had a struggle with getting out of the client whether a plan did or didn’t exist, but the answers I kept getting from the client was that the plan that had been planned to be used months ago was no longer an option, so currently a plan did not exist. ^^Great, so does that mean the client is plan-less and safe to go?!?! How come these real client sessions go NOTHING like the role-play scenarios we do in preparation for the “real thing??!!?” Okay, let’s keep assessing and just make sure…^^

We had somehow gotten off the topic of suicide and were talking about narrowly-connected topics. ^^Why had I waited to address the suicide question until the last minute in the session?!?! Because you hadn’t had any issues with it arise in the past with clients, so you figured this one would go down just like the rest, but boy, were you wrong. Now look—your 45 minute session is pushing an hour and 15 minutes. You’ve got to figure out whether this client has to be “hauled off” or is safe to leave!^^

At this point, after talked around and about with the suicide question for approximately thirty minutes I was feeling like this client was going to be “safe” to let leave after establishing some safety precautions with the client first. But then at the same time, who wants the thoughts of “what if” looming over their head ALONE as a young student?!?! So I did what any good student intern would have done…lied. HA! I basically led the client to believe the session was over, when I knew I had a “second part” about to occur.

[Note to self: Way to encourage the trusting relationship between the therapist and the client right off the bat in the first session. We’ll see how the trust aspect works out if the client even decides to come back to see you now! Crap! HA!]

I took the client back out to the waiting room telling them I was getting their discharge paperwork following the session put together and then we would go to the secretary and schedule our next appointment together. This was when I made a break for one of my supervisors’ offices (hey, it was a new client—they had no idea where the copy machine was located in the building. As far as they knew, I could have been heading in that direction to get their paperwork ready…HA!). In a matter of a couple of minutes I was asking the client to come back into the counseling room with me. At this point, my supervisor joined us in session and we went over our concerns with the client about their safety. Within 3 or 4 minutes my supervisor had established a sense of the client’s suicidal thoughts/ideation and then my supervisor left the room, giving me the “okay” to release the client.

Phew! I had made the right decision in the first place (but it never hurts to have the supervisor’s stamp-of-approval when you’ve only been in the business for a few months). HA!

So there it was—my first “suicidal client.” Well, I suppose I haven’t had the client yet that I HAVE had to have “hauled off,” but this was close enough for me for now. After getting the approval from the supervisor and then scheduling the client an appointment to see one of our staffed psychiatrists, I felt a lot more comfortable with releasing the client on their way. Let’s just hope the psychiatrist can get this client on some medication that will help with the desperate thoughts they had been experiencing.

[Part II of this series on suicide will be posted on Tuesday. Please return then for a controversial talk concerning the topic]

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