Common Therapist Mistakes Part 8: Missing the Dialectic Nature of Suicidal Intent or Gestures
This topic isn’t conducive to using cute cartoons as with the other posts in this series so I used my sister’s art work. I explained to her my dealings with people who have severe ambivalence and this is how she depicted it.
One of the biggest dilemmas that therapists face is around the issue of suicidal ideation or actions. It is extremely important to access ambivalence when someone is having suicidal ideation or making gestures or attempts. However, this is probably the trickiest time as well, because every ideation or gesture must be taken seriously. When a patient expresses suicidal ideation, I generally explore the sources of hopelessness as well as the reasons the person hasn’t acted on the thoughts. I also create, with my patient, a very detailed safety plan.
However, we often get concerned with questions about whether the ideation or act is a true desire to die or some desperate attempt to get some form of attention. A dialectic is when two opposing things can exist at the same time. Thus it is possible that a person would want to die when they equally wish for some type of attention, or what I would like to think of as connection. I also believe that most gestures, regardless of how serious or severe, have a communication embedded within them, such as an expression of fear, anger, or feeling misunderstood. Many therapists hesitate to explore this because they don’t want their patient to think that they are being accused of “just” wanting attention or being manipulative. Therefore, addressing this must be done with skill and intentionality.
It’s not necessary to determine whether a person is genuinely suicidal or looking for secondary gain, as long as both possibilities are carefully explored. If you explore both, you don’t have to feel responsible for trying to decide which it is. Sometimes the patient doesn’t even know which it is. Additionally, even when people truly want to die, there is usually some form of communication or wish embedded in the impulse.
For example, Sarah was being treated for an eating disorder, depression, and anxiety. She had expressed suicidal ideation and had two suicide attempts in the past. She had developed a safety plan with her therapist and was in individual, group, and family therapy. She tended to be agreeable with suggestions, and, although fairly quiet, she participated in groups. She was usually smiling and seemed to hold in most of her negative feelings. But every once in a while, she would say something surprisingly sarcastic and pessimistic.
One day, Sarah’s therapist received a call that Sarah was in the hospital after a suicide attempt. She was held for 2 days and released back into our care. Behind the closed doors of our treatment team, some staff members voiced their opinion that the suicide was a cry for attention, thus manipulative. Other members were concerned that she truly wanted to die because she had made several attempts and this one could have been lethal.
I consulted with Sarah on her first day back. I asked her about the day that she had hurt herself. She replied that she had been alone and just started feeling hopeless. I talked with her about her safety plan and about the steps that she had taken on the safety plan before the attempt. She had done several things, including telling her parents. Without trying to determine whether Sarah had a wish to die or a wish to communicate, I simply said, “Sarah, sometimes when people are feeling bad enough to do something like what you did, there is something that they want to communicate and just can’t for some reason. Is there anything that you feel like someone just isn’t getting on your team or at home?” She immediately, without the slightest pause, said her mom just didn’t understand mental health problems. I reassured her that we would increase our attempts at helping her mother understand.
I believe that had I neglected to explore the hidden communication in her suicidal act, we wouldn’t have known exactly where to focus our attention in ongoing sessions. This can be conceptualized as another dialectic such as, I want to die and I want to be understood. These two conditions do not seem capable of existing at the same time, yet they do. It isn’t necessary to determine which is true; assume that both are.
My book A Clinician’s Guide to Pathological Ambivalence: How to Be on Your Client’s Side Without Taking a Side can teach you how to avoid this and other common therapeutic mistakes by developing skills to work directly on resolving ambivalence and rewriting old narratives. I would love to hear from you. Please scroll down to the bottom of this page (past the banner of recent posts) to leave a comment.