Being A Psychotherapist: Things School and Books Can’t Really Prepare You For Part Two: Suicidal Clients

Another thing school and books can’t really prepare you for are suicidal clients. Sure they cover the subject of suicide in graduate school, but the training of dealing with suicidal patients is usually very brief. There are many great books on working with suicidal clients and I have read a few, but I don’t think anything can really prepare you for sitting face to face with and working with a suicidal patient.

From my experiences, there are many types of suicidal clients and they all have to be taken seriously.

There’s the client who doesn’t really want to commit suicide, but they like to self-injure and that self-injurious behavior may lead to an accidental suicide. These are often the most common types of clients, often called “cutters” and they tend to be the most frustrating since a lot of them have cluster b type personality disorders such as borderline personality disorder.

When I worked in a high school I had a whole group full of students who self-injured and ended up involuntarily hospitalizing at least one every month because while they said they weren’t suicidal, they were definitely at times flirting with death.

This picture was taken of one of my former students who likes to cut. The next day she had twice as many cuts on her arm and I was forced to involuntarily hospitalize her.
This picture was taken of one of my former students who likes to cut. The next day she had twice as many cuts on her arm and I was forced to involuntarily hospitalize her.

There’s also the suicidal client who is extremely depressed or emotionally unstable and talks about death and suicide a lot. They typically don’t self-injure and have never tried to commit suicide and don’t think they ever would, but they talk about it so often and their emotional pain is so deep that when they leave your office you often wonder if this will be the last time you ever see them.

These type of clients can also be very stressful to deal with. Often when I have had clients like this I found myself worrying about them when I wasn’t even at work, when I was on vacation,  when they didn’t show up for an appointment and sometimes I even dreamt about them.

One patient in particular was diagnosed with a terminal disease and she didn’t want to die a slow death. She didn’t think she would kill herself, but all she talked about was death and dying and her depression was so deep that it was hard to not be concerned about her when she missed an appointment. Eventually I had to hospitalize her after one particularly draining and emotional session when she couldn’t promise me she wasn’t going to go home and try to kill herself. Everything inside of me was screaming she would. She was angry that I hospitalized her against her will, but told me in later sessions that she had every intent of going home and killing herself that day and thanked me.

Another type of suicidal client is the one who never talks about suicide. Some are impulsive, but many just keep their thoughts and feelings buried deep inside.  They may never even tell anyone that they are in pain. They just attempt or commit suicide without any real warning signs. These clients take not only you by surprise, but everyone else in their lives too.

I once worked with a student for two years dealing with the grief of a parent and then one day he gave me a card thanking me for helping him. It was our last session, he was doing great. Less than a week later I got a call from his family telling me he had attempted suicide and was in critical condition at a local hospital. I was stunned. I rushed to the hospital and nearly broke down in tears as I looked down at his lifeless body. I kept replaying our last sessions together, our last interactions, his last words to me, trying to figure out what did I miss. Thank goodness he came out of his comatose state after a few days and I was grateful that he not only lived, but that I had the opportunity to process his suicide attempt with him. I didn’t miss anything. He had suddenly decided he didn’t want to live any more and wanted to be with his deceased parent.

A couple of years before that I had been part of a crisis team that was sent to two different schools after two students had killed themselves apparently out of the blue. One was a popular jock that killed himself and stunned the whole community because no one, not even his closes friends knew that he was in so much emotional and psychological pain. His friends, family and even school staff members were blaming themselves for not seeing signs that weren’t even there.

The other student apparently killed himself on impulse in the midst of an angry dispute with his girlfriend. He told her he was going to hang himself. She didn’t believe him, but that’s exactly what he did. He had no history of being suicidal and no one saw it coming.

In my nearly 8 year career as a psychotherapist I’ve dealt with hundreds of suicidal clients. My main job right now is interacting with inmates who have been flagged as suicidal. Luckily I have not had one client commit suicide although I have had a few who have made serious suicide attempts landing them in the emergency room.

Studies suggest that:

  • 1 in 4 interns/trainees will have a patient who attempts suicide at some point during their training and 1 in 9 will experience a completed patient’s suicide.
  • 25% of psychologists and 50% of psychiatrists will experience a patient’s suicide.
  • 1 in 6 psychiatric patients who die by suicide die in active treatment with a healthcare provider.
  • Approximately 50% of those who die by suicide in America will have seen a mental health provider at some time in their life.
  • Work with suicidal patients is considered the most stressful of all clinical endeavors. One third of psychotherapists who experienced a patient’s suicide subsequently suffer from severe emotional distress. Several factors may contribute to such severe distress including failure to hospitalize a suicidal patient who then died; a treatment decision that the therapist may feel contributed to the suicide; negative reactions from the therapist’s institution; and the fear of a lawsuit by the patient’s relatives.
  • 25 % of family members of suicidal patients take legal actions against the patient’s mental health treatment team.

As a coincidence, just as I was finishing this post I was informed that an inmate just purposely swallowed 18 Ativan pills in an attempted suicide and is being rushed to the hospital.

2 thoughts on “Being A Psychotherapist: Things School and Books Can’t Really Prepare You For Part Two: Suicidal Clients

  1. I am so glad you posted this. My son age 15, who has bi-polar disorder, and has been cutting. This is a new thing that has started in the last few months. He has been in therapy for 3 years and had been hospitalized 3 times in the last two years.
    I somehow feel that the cutting started as attention seeking behavior, but as a mom and not a therapist, I am never certain how to react to the marks and burns on his skin. My initial reaction is blank and cold. Although on the inside of me I am hurting for him.
    He makes sure I see his cuts and it is always after, I have told him he couldn’t do something, or that he need to stop doing something, and a big melt down has ensued. He then cuts then comes and showes me and tells me that it is my fault. All cuts this far have been superfical and not braking the skin. The burns concern me a little more. they look much more painful and real.He has never showed me a burn after an altercation. I usually happen on the burns.
    I know that he is 15 and will manipulate me any way he can to get his way. I guess that is why the blank face when I see this. Even if it is hard I feel I have to stand my ground.
    How should I react the next time I see this?This hasn’t happened in a few weeks, so could he have given up and moved on? How will I know when this is for real enough that he will take it too far?

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