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.

Inside The Thoughts of a Cutter: A Poem

The other day one of my students who used to cut herself, but hasn’t cut in several months, shared a poem with me she wrote that I thought would be beneficial to share.

I think it gives a quick glimpse into the mind of those who self-injure.

Although she and most of everyone else who was a part of her group I treated for self-injurious behavior have stopped cutting, many of them still fight with the urge to do it when they are faced with certain stressors.

With her permission, I share this poem that has no title.

Depressed and suicidal

Need to escape the misery

Not caring to continue this life

Blood loss has me weary

Scars show my painful past

As the stained blade opens up

Areas of my skin torn and scarred

To be a reminder of a dark past

Mind torn between love and hate

Will I ever be free?

Everyday is a struggle

To be free from this depression

Lost in darkness and misery

Puddles of dried blood stains

From every deep cut that is made

Full of depression and misery

Not worth saving this life of hate.

One Mother’s Experience with Bipolar Disorder and the Importance of Support Groups for Caregivers

The other day I was fortunate to have the opportunity to speak with a former client’s mother about her experiences dealing with her now 19 year old daughter, who was diagnosed with bipolar disorder at the age of 8.

This girl from what I knew of her was extremely unstable, as could be expected from a teenager suffering from bipolar disorder.

Unlike other people suffering from bipolar disorder, teenage girls tend to be even more fickle when you factor in the normal hormones of teenagers as well as social pressures that make even some non-bipolar teens act and feel erratic.

This girl was prone to bouts of depression, mania, impulsivity and explosive anger.

At home her mom had done everything she was supposed to do to support her child including psychotherapy, family therapy and medication, but her daughter was still a hand-full.

When she was in her manic states she tended to have anger directed towards her mother and would at times try to get physical with her and had to be hospitalized several times for suicidal/homicidal ideations.

Her mother tried all she could to pacify her daughter, including painting her room the pretty purple she wanted, only to come home one day and find nearlyevery inch of that wall covered in permanent marker with words directed towards her mother such as “bitch”, “whore” and “I hope you die”.

On top of that she was extremely needy, wanting to be up under her mom 24/7 to the point that she got angry whenever her mom left her and would tear up the house or refuse to go to school.

When she was depressed she would self-mutilate and attempt to kill herself. Her mother would be afraid to leave her alone.

“My biggest fear, even today, is that I will come home and find her dead”, the mother told me.

The biggest thing this mother did that made the most difference was getting educating herself on her daughter’s illness and counseling for herself and joining a support group.

Support groups are invaluable resources that often aren’t utilized enough by those living with or taking care of people with mental illnesses or substance issues.

Through counseling and the support group she learned that she was not alone, that many other parents were on the same roller coaster ride she was on.

She also learned how to change the way she had been dealing with her daughter.

If what you are doing isn’t getting you the results you desire, you have to try something different.

She started accepting that her daughter was going to have good days and bad days, and sometimes within the same day. She also had to understand her role and limitations as the mother of a child with bipolar disorder.

She had to accept that some days she might feel like giving up, or not care when her daughter threatens to hang herself, and that doesn’t make her a bad mother, but it is a sign that she needs to take a break, regroup and seek support herself.

At the end of our reunion I was happy to see that a mother, who just a couple of years ago who was so flustered, angry and exhausted, had turned into a woman not only surviving, but thriving with a daughter suffering from bipolar disorder.

Her and her daughter are doing better, but they are still taking it one day at a time.

Saving the Lives of Butterflies: Part 2

It’s been a few months since I first introduced The Butterfly Project to the high school kids I work with (if you haven’t already, you can check out my post entitled “Saving the Lives of Butterflies”). Well I’m happy to report that over the past two weeks I’ve had a number of them come up to me and show me the butterflies that they drew on themselves in efforts to refrain from cutting themselves! I was so happy to see one or two of them do this, but was overwhelmed to see nearly all of the ones who have issues with self-injury trying this technique and so far it appears to be helping! Some of them even name their butterflies and they have been encouraging each other. It’s a small step, but I am so thrilled by it’s success so far that I just had to share some of the pictures!

With summer coming up, I am really worried about all of the teens I work with at the high school, especially the ones who self-injure, but I am really hoping that everything I’ve taught them over the summer, including cognitive behavioral interventions, emotional self regulation strategies and now the Butterfly Project, will help them make it through whatever they encounter and that they will emerge stronger and more confident. I will also be worried about the ones who use drugs, the ones who make irrational decisions, the ones with anger issues and the ones with severe depression and anxiety. Pretty much, I’ll be worried about all of them, but I have to hope and trust that I’ve helped them all enough or at least did my part in preparing them to better handle life.

Saving the Lives of Butterflies

Self-Injury

The Butterfly Project

Self-injury, also known as self-mutilation and cutting is defined as the intentional, direct injuring of body tissue mostly done without suicidal intentions wikipedia.

Self-injury is unfortunately a very common issue among teenagers. According to research, it mostly effects women from ages 13 to 30.

In a typical year at the high school I work at, I usually only see about one case of self-injury a year. Not to say that there’s only one person at the school that cuts themselves, chances are, the rest are just hiding it better. This year however, I’ve had so many instances of self-injury that I actually have a group comprised mostly of “cutters”, as they refer to themselves. Coinciding with research, three out of the four people in the group are female. Most of them cut on their arms and one cuts on her arms and thighs. All of them cut out of anger, frustration and depression. They express to me that it helps them feel alive and/or that it helps them take out their frustrations on themselves. For all of them, it has become a form of addiction.

During my last meeting with this group, one of the newest members told me about The Butterfly Project. The Butterfly Project basically is a way to try and help those who self-injure and those who know someone who self-injures. It has seven rules.

1. When you feel like you want to cut, take a marker, pen or sharpies and draw a butterfly on your arm or hand.
2. Name the buttery after a loved one, or someone that really wants you to get better.
3. You must let the butterfly fade naturally. NO scrubbing it off.
4. If you cut before the butterfly is gone, you’ve killed it. If you don’t cut, it lives.
5. If you have more than one butterfly, cutting kills all of them.
6. Another person may draw them on you. These butterflies are extra special. Take good care of them.
7. Even if you don’t cut, feel free to draw a butterfly anyway, to show your support. If you do this, name it after someone you know that cuts or is suffering right now, and tell them. It could help.

I thought that this was a very creative and safe alternative to self-injury so my entire group is trying this and maybe it will help others out there who self-injure so definitely pass this on.

The above picture is an actually picture I took of a previous client of mine who self-injures. She actually did much more damage to her arms a few days after I took this picture and required psychiatric hospitalization.