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Reflections on working with suicidal patients: Laura McDaniel, UNC Wakebrook FBC Clinical Supervisor

I work on a psychiatric crisis unit. A large proportion of the patients I work with are actively thinking about suicide. I work with people who come to us on their own because they are trying to listen to that small part of themselves that still wants to live, and I work with people who do NOT choose to come to us because we, as a society, have decided that we are willing to suspend people’s civil liberties in order to prevent them from dying by suicide. What we do on inpatient units to prevent suicide is fairly straight-forward: we restrict access to anything that would be effective in killing a human body, and we give people medications to try to help their brains out of a place where suicide is an option.

But here’s the thing. It’s not that simple. It’s so much bigger than just the tinkering with the brain as an organ. The urge to end one’s own life is so amorphous and complicated and octopus-like that it is nearly impossible to contain and define. For example, not everyone who thinks about suicide has a mental illness; and not everyone who has a mental illness experiences suicidal thinking. As such, my “helping” needs to be as multi-pronged as what I am trying to help.  So this is where we bring in the “evidence-based practices.” These are the interventions that I am taught to use to help people stay alive. But here’s the thing with those practices: the most powerful “evidence” is comprised of numbers; to have numbers, we need to make things measurable; and to be measurable, we need to make things descriptive and definable. Often by the time we get there, however, we forget that there is a person sitting in front of us who is in pain . . . we forget that one of the most powerful things we can offer to another human being is the willingness to bear witness to their pain.

An inpatient setting HAS to be sterile, sparse, minimal, and restrictive to be safe. They are not warm. But I don’t have to be that way. What I have found is that real, authentic, and honest human connection is the most effective “treatment” I can offer my patients. Elio Frattaroli, MD, explains it well in his 2001 book Healing the Soul in the Age of the Brain: Why Medication Isn’t Enough: “Healing the soul requires a growth-enhancing personal encounter with another human being in a psychotherapeutic process. It requires what philosopher Martin Buber called an I-Thou relationship—a “personal making present,” in which one person recognizes the unique individuality of another, and the other flourishes in being so recognized” (p.12).

I am not going to pretend with my patients that this medication, or that therapy, holds the key to them wanting to stay alive. I will validate how hard it is and I will be forth-right about my own struggles. Mental health provider’s resistance to being real and transparent with our patients (we fancily call this “self-disclosure”) is completely ineffective. That “self-disclosure” is thought of as “unprofessional” stops many new practitioners from doing it, but I fear it also stops patients from listening to us. It makes sense because, in our private lives, mutual self-disclosure is how we build relationships and trust. I had one patient tell me that she could see in my eyes when I switched from being authentic to saying things that I think I should be saying, rather than what I actually mean.  She would call me out when she thought I had switched modes and she was usually right.

WAIT is a helpful acronym to help you think about whether you should share something you are thinking with your patients. WAIT stands for “why am I talking.” Always question your motives before you speaking. Ask: Will this harm the patient? Don’t do it. Is it advancing some sort of agenda I have? Don’t do it. Will this result in a role reversal where the patient will feel like they need to take care of me? Don’t do it. Does this information burden the patient in any way? Don’t do it. Always be vigilant and self-aware.