By Kim Johancen-Walt
The initial interview with the self-harming and suicidal client
Deidre, age 24, had agreed to see me after confiding to a close friend that she was thinking about killing herself. During our first session, she discussed how self-mutilation and an eating disorder had allowed her brief moments of relief from isolation and self-hatred. Diedre had been self-harming for more than 10 years and, although her behaviors had helped her survive unbearable emotional pain, she had become increasingly hopeless, desperate and suicidal.
As a licensed professional counselor and therapist working with clients who are suicidal, self-harming or engaged in both behaviors simultaneously, I have learned the importance of the initial interview. So many of our clients, like Diedre, have been doing the best they can, yet still feel caught in a landslide with suicide rolling toward them. During this first critical meeting, counselors need to create an environment that will become a therapeutic foundation communicating hope and connectedness to a caring other and nurturing a commitment to treatment.
Counselors working with this population must assess lethality (throughout treatment) while also targeting the painful thoughts and feelings fueling the client’s potentially life-threatening behavior. Through my research, experience and constant search for more effective treatment, I have created a model that allows the counselor a vehicle to accomplish these tasks effectively from the very first interaction. It blends strategies with assessment tools to create a therapeutic space in which change can happen for even the most difficult of clients. Here, I offer an overview of the three stages that have guided treatment for my clients, helping them achieve success in their efforts to create lives worth living.
Stage 1: Creating safety
One of my clients recently likened counseling to a living, breathing diary, with the added benefit that a counselor can offer support and sound advice. We have to embody that kind of safe container for the vulnerable individuals we are treating. As my clients begin telling me their stories of self-harm and survival, I offer my belief that people do not engage in these behaviors without reason. Our clients are hurting themselves or wanting to kill themselves because they are desperate to end their emotional suffering. Through understanding and accepting their behavior, we can directly target feelings of shame and isolation that may be keeping our clients chained and silent. Regardless of their behaviors, it is important to remind our clients that they are doing the best they can and that their lives are worth saving.
Many therapists focus on behavior instead of asking questions about the painful feelings fueling that behavior. It is of utmost importance, of course, to find out if clients’ actions are putting their lives at risk, but if we are interested solely in the behavior, we will find ourselves only treating symptoms. In our efforts to help clients feel safe and understood, it is important to ask them why they are self-harming or suicidal. Many of my clients have had their self-esteem and sense of self-worth shredded through a variety of traumas. In these instances, the need to punish themselves for their perceived flaws may be fueling their self-harming and suicidal behavior.
Samantha, age 18, had become suicidal after experiencing sustained trauma while growing up with an emotionally and physically abusive mother. These experiences led Samantha down a road lined with isolation, rage and self-hatred. In a desperate attempt to end her emotional pain, she found herself with a knife in her hand and a desire to slit her own throat. Thankfully, Samantha did not kill herself, but she was obviously drowning in unbearable emotional pain. By focusing on what had fed this suicidal gesture, she was able to resolve many of her issues and was no longer suicidal. She left therapy soon after with her prevention strategy plan firmly in place.
As the story of my client’s unique and painful journey unfolds, I am diligent about checking in repeatedly during the interview to ensure that the client is feeling safe and accepted. Furthermore, I request that the client correct me if at any point I miss or misinterpret any part of the story. This type of questioning creates a collaborative environment in which the client feels like her/his input is an important part of the process. Matthew Selekman, a respected therapist and internationally published author, discusses how this approach can be richly therapeutic because it makes clients an active participant in their treatment and takes the therapist out of the “expert” role.
Stage 2: Assessing risk of suicide
After a sense of safety has been established and the counselor has communicated the critical role that the client plays in her/his own treatment, it is imperative to assess the client’s level of risk for life-threatening behavior. Jack Klott, a therapist with more than 40 years of experience working with this population, explains that clients who are talking about suicide are ambivalent. This ambivalence leads them to talk about the part of them that wants to live and the part of them that wants to die.
These discussions offer the counselor a wealth of information about what is keeping the client alive while also supplying details about the irrational belief systems that may be leading the client toward attempting suicide. Cognitive restructuring techniques can be extremely effective in these situations, allowing the counselor an opportunity to challenge the client’s irrational thoughts and beliefs.
Victoria, 19, was in my office describing an incident in which she had contemplated hanging herself. A survivor of child sexual abuse and incest, she discussed what led her to this moment of crisis, including the irrational belief that her life would be “better” if she were dead. Through flowing tears and rapid speech that conveyed her need to release the story and the pain attached to it, she recounted how she had tied the sheet around her neck but decided not to commit suicide at the final moment. When I asked her about this life-saving decision, she shared how thoughts of her nieces and nephews had kept her from completing her suicide attempt.
While discussing what was keeping Victoria alive, I was also able to challenge the belief that her life would be better if she killed herself. We talked about the skills Victoria had used to stand up to suicide since this incident. She explained that, at times, focusing on a future career as a doctor helped her stand up to suicidal urges; other times, it was the memory of that day with the bedsheet that reminded her of her strength to survive.
Throughout my career, I have compiled a list of the factors that most commonly heighten clients’ risk level for suicide. For example, although it is a myth that all clients who are self-harming or suicidal have been sexually abused, it is important to note that 12 out of the 14 suicidal high school students I worked with last year reported previous sexual trauma. Other common risk factors include overwhelming feelings of rage, isolation and hopelessness. Clients who have not resolved issues surrounding previous suicide attempts are also at risk of completion. Obviously, the more red flags our clients present to us in treatment, the more at risk they are for life-threatening behavior. According to Anne Marie Albano, director of the Columbia University Clinic for Anxiety and Related Disorders, adolescents who have an untreated anxiety disorder at age 13 are also more at risk for depression by age 15. Add to that a substance abuse disorder, and you have a client who is at a heightened risk for suicide.
Stage 3: Identify strengths and resiliencies
One of the purposes of the assessment interview is to gather information about the level of risk facing our clients. It can also be a valuable therapeutic experience that immediately targets feelings of hopelessness and isolation. By offering our clients a belief that they have the answers and solutions to their problems, we are encouraging them to focus on their ability to overcome and survive.
Tess, 21, had previous success standing up to the shame and isolation associated with an eating disorder. In therapy, we explored how she had “pulled this off” in the past by focusing on her long-term goals (graduating from college) and through her daily practice of mindfulness techniques. We also discussed ways Tess could transfer her previous successes to new crises as they arose.
By encouraging our clients to look at themselves through this solution-driven lens, we communicate faith in their ability to stand up to self-harm and suicide. It is critical that we begin this process at the beginning of treatment because so many of them are coming to our offices feeling isolated and hopeless and in some cases, have had several failed treatment attempts. Many of these clients are becoming increasingly suicidal.
Lisa, 18, came to therapy feeling gradually more suicidal. She had a history of significant substance abuse, bulimia and cutting, and she had walked up to the edge of a busy highway in Denver one hopeless night with thoughts of stepping out into traffic. Lisa was quickly spiraling downward and had become increasingly depressed and withdrawn. During our initial meeting, we talked about how in spite of incredible suffering, Lisa had successfully stood up to many of these behaviors. We talked about her inherent strength and her determination to find meaningful connection with others. Subsequent treatment included validating pain associated with previous trauma, tending seeds of change and identifying the skills and strengths Lisa had used to confront so many challenges in her 18 years of life.
By offering our clients a powerful experience during the initial interview, we can help them uncover the path to hope and recovery. Counselors can use the assessment model discussed in this article in many ways, because that is the dance of therapy. But if the counselor keeps the elements of this model in mind from the very first interview, then therapy can be a collaborative experience that allows us a deeper look into the client’s world. It can also become a protected space for clients to explore and find the ground beneath their feet as they continue their journey toward a life worth living.
Kim Johancen-Walt is an ACA-member licensed professional counselor and consultant living in Durango, Colo. In addition to maintaining a private practice, she is a counselor and assistant training director at Fort Lewis College, where she helps train therapists working with high-risk young adults. Contact her at email@example.com.
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