I remember it as if it was yesterday. Nearly 30 years ago, I greeted…let’s call her Becky for confidentiality sake…I greeted Becky for the first time in the therapy clinic waiting room. She presented with disheveled brown hair, no make up, and a deer-in-the-head-light stare. I wondered if she were using drugs or drinking excessively. For now, that was ok because she appeared sober. I’d go ahead and see her. Her boyfriend was with her. He appeared to be caring and concerned.
Becky came into the therapy office alone. Therapy was for her and her alone, she insisted. She was super defended. This was her last attempt at getting help, she said. There was a long list of therapists and failed outcomes in her past. Her silent challenge to me was ‘fix me! fix me now!’
I attempted to engage her. But she wasn’t having any of it! She did not trust anyone. Becky was clear. She had relationship problems. Her family relationships were disrupted. Even the boyfriend, who brought her to therapy and was still in the waiting room, was a source of discontent for her. He was married to but separated from…someone else. I clarified her goals. She only had one…to fix her family relationships.
Then she went on to list her numerous failed attempts at killing herself. My antennas went up. Then she said that she didn’t think her life mattered and that no one would miss her if she died. She got my attention! I asked about her support system. Becky was not connected to anyone, she insisted. Remember she didn’t trust anyone.
Becky, was the first client to disclose to me a suicidal history and a passive desire to die. I hid my anxiety behind a calm, cool professional facade. I wondered if her failed suicide attempts were an indication that she was just very bad at it or if she, on some level, didn’t want to die.
I tried even harder to connect with her. Again, she wasn’t having it. I decided, I needed reinforcement. Maybe, her boyfriend could serve as her supporter and maybe I could get some more insight into what made this client tick. I knew it wasn’t the ideal situation, but it was what I had to work with. Surprisingly, Becky agreed to have her boyfriend join us. He did.
He disclosed multiple interpersonal, traumatic events in Becky’s life. It became clear that Becky did not have a sense of belonging to any group or relationship.
Fifty minutes go quickly, especially when you have a challenging client. I asked if Becky was currently suicidal and could she keep herself safe until the next appointment. She said, something vague and suspicious like, “I don’t know.” I pressed. Becky explained that she would not lie about this. So that was her best answer. Red flag! My anxiety peaked. I offered her the option of going to a higher level of care, framing this as a time out, rest, or vacation from her life. She was adamant that she did not want to go to an inpatient mental health facility.
I offered to extend the session and asked them to wait. They agreed. I rescheduled my next client. Then I went to consult with one of the clinical faculty. He joined us for the remainder of the session.
He introduced himself, attempted to connect, and did a suicide assessment. Long story short, Becky and her boyfriend convinced this clinical supervisor that she was not currently suicidal. She did not meet the criteria for involuntary hospitalization. I invited the couple to come back in together next week. She had future plans…she was going to visit her family next week. They scheduled an appointment for the week after she returned, two weeks from then.
At the time of the next appointment, Becky was a no show. I waited the requisite time before calling to remind her of her appointment. No answer. A voicemail was left. Then I called and I got her boyfriend. He said that Becky had died in a car accident in her home town. My heart plummeted to bottom of my stomach! How could that be?
When I picked up my jaw, which had also dropped, I invited the boyfriend in for a session to support him. He declined to schedule an appointment.
I contacted my supervisor and gave him the update. We dissected our interactions with the client. Was it just a untimely death? Was it a planned and executed car crash? Was this just a horrible tragic traffic accident? Or was it an intentional, suicide-by-car? Argh! We would never know and only suspect the unthinkable.
Then we rationalized, “It was only one session. The client said all the right things. There was no way to predict. There was nothing more that we could have done for Becky.”
Yet, I left that supervision session with more questions than answers. Did I do enough? What signs did I miss? What could I have done differently? Can we stop someone who is intent on dying by taking their own life?
What I have learned in the intervening years, is that hindsight is 20/20. It is much easier to be a Monday morning quarter back. Therapists are not mind-readers. Suicide assessment and intervention are not exact sciences. If someone sets out to deceive you, and they are good and you trusting, you can be fooled. Even if we exceed the standard of care, clients can and will kill themselves if determined to do so. We and, perhaps, others, like the grieving family, may be hard on on if there is a successful suicide. As a therapist, we have to use all of our skills, experiences, and instincts to make sound clinical judgments and provide effective treatment for clients whose intent is to harm themselves. Ultimately, clients have the right to self-determination. They get to chose life or an ambiguous death.
About the Author:
Dr. Michelle J. Richards, Ph.D. is a therapist, supervisor, practice development coach. She offers Live webinars on ethics and standard of practice on various topics and provides other professional educational products and services. To learn more call 972-906-5607 or go to https://www.JoyfulLifeInstitute.com/clinicians.
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Vignettes and anecdotes are works of fiction. The names, characters, incidents, locations, and interactions herein are fictitious. Any similarity to or any identification with any person (living or dead), history of any person, historical figures, event, location, product, or entity are entirely coincidental and unintentional. The descriptions of people and their interactions are composites of many people she has met in her life.
(c) 2017 Michelle J. Richards