The COVID-19 pandemic has skyrocketed the demand for mental health services in many locations, city and rural areas alike (Richtel, 2022). Experiences such as loss of loved ones, disappearance of jobs, derailing of social activities, isolation, depression, alienation, etc., have contributed to an increase in people thinking of the unthinkable: ending their lives. Mental health professionals have been faced with a surge in demands for services by people struggling with despair, depression, overwhelm, and grief, which require more than ever before, the use of suicide assessment protocols. In this context, it becomes crucial to examine how these are performed, and their effects. Are these protocols conducted in the best possible way to ensure the wellbeing of clients?
Considerations of suicide have existed since far back in mankind’s evolution and have been handled differently historically. In many medieval European countries, it was a religious issue that leaders portrayed as a sin, while in the 19th and 20th century, it became considered a crime handled by the justice system. In modern times, it is considered a sign of mental illness and handled by health professionals. With the medicalization of suicidal intervention came a protocol developed to assess the severity of ideations along with the necessity of documenting certain information. While the original intent is to protect clients from desperate acts, it has in some settings also evolved as a method to protect therapists from liability, requiring documentation of answers to a list of questions. Examining all categories of suicide assessment required by our Code of Ethics (AAMFT, 2015) can look the same on paper, regardless of how it is performed. Too often, clients’ experience of the process (how it is done) leads to further alienation, feeling different, disconnected, further convinced of being “weird,” and unfit to live. This unfortunate effect also arises because clients often consider the act of suicide as a solution while professionals view it as a problem (Szasz, 1999). Ideally, the process of assessing for suicidal intent should not inadvertently contribute to further articulating plans, or increase clients’ sense of being disconnected from people and incompetent.
The question becomes: Are there ways to respect the requirements of our profession, and, simultaneously, empower clients to move away from suicidal ideations? The answer is: Absolutely.
The client’s emotional state is automatically lifted by an experience of agency, self-confidence, and trust in their abilities to manage their emotional experience.
Take for example, Laura, a college student who has been struggling on and off with issues of depression, and the impulse to swallow the entire contents of bottles of Advil, especially after drinking at parties. She is scared of herself, as ultimately, she wants to live and wishes to realize her dream of working as a veterinarian. She has already been hospitalized twice, and has periods of feeling stable and others of feeling the depression swell in her mind. She has been through the standard suicide assessment protocol many times: Do you have thoughts of hurting yourself? “Yes.” Do you have a plan? “Yes, I think swallowing pills would be a nice way to end the pain”. Do you have access to pills? “My friends always have a bottle of Advil somewhere; it’s easy to find.” This line of questioning raises the stakes for therapists and clients, and exposes the high risk level of the situation, leaving Laura feeling scared of herself and out of control.
However, an alternative is possible. This is the process which was actually followed with Laura: How often does the depression make you think of hurting yourself? “Um…at least 30 times per day.” What is the depression getting you to think about more specifically? “To find someone’s pills and swallow them.” How long has the depression been doing that? “It’s been doing that every winter between January and April, on most days for the last four years.” Let’s add this up to get an idea of what you’ve been dealing with. This means four months for four years, multiplied by about 30 times per day, which amounts to 14,400 times. How many times has the depression actually gotten you to swallow some pills? “None!” Does that mean that the part of you that is determined to live has a 100% success rate at controlling the depression and controlled it about 14,400 times?! (Laura smiles: “I never thought about it this way!”) What is it like to notice this; what does it mean about your abilities to manage the depression?
The client’s emotional state is automatically lifted by an experience of agency, self-confidence, and trust in their abilities to manage their emotional experience.
This process is shifting the primary focus from assessment to assisting the client in feeling capable, while still collecting important information. The therapeutic conversation becomes about acknowledging the complex and contradictory nature of experience (Beaudoin, 2010). A person can be dreadfully depressed at home alone and enthusiastically outgoing in other settings. A child can be incapacitated by shyness at school, and a popular player on the soccer team. Human beings are significantly influenced by their environment, and develop many ways of being. One can be depressed like their father, confident like their mother, calm like an uncle, compassionate like a grandmother, and perseverant like a sister. All of these ways of being and their respective streams of thoughts co-exist in this same person and are available at any moment in time. Western psychology influenced by individualistic notions can sometimes simplify and reduce a person to a single description (e.g., a “suicidal client”), when people tend to be much more than that (Gergen, 2011). A person may experience a stream of suicidal thoughts, which co-exists with yearning to live, a love for someone, or a dream to change the world. Why would this not be equally important, if not more, to assess? And can those streams of thoughts be bolstered to then reduce the dominance of the suicidal ideations? Clients struggling with thoughts of self-harm can redefine themselves, not as people wanting to end their lives, but rather as people in pain who are disconnected from, or under-connected with, their sense of agency, what they value in life, their passions, dreams, sense of worthiness, and relationships. Such an understanding allows mental health providers to modify their focus from solely assessing risk, to one where they empower clients to regain dignity and allegiance to their purpose in life.
This shift in intervention is in line with the emergence of an extraordinary amount of research in neuro-affective sciences, which can have powerful effects in therapeutic conversations (Beaudoin & Duvall, 2017). We now have consistent data on how intense emotions can often over-ride the thinking process in the brain (Siegel, 2007). A client’s anger, for example, affects the blood flow in the brain, reduces one’s ability to connect, and impairs critical judgment. Despair can skew people’s memories in ways to mainly recall moments of intense sadness, temporarily making happier memories less accessible. These fascinating findings make the practice of externalizing problems (White & Epston, 1990; White, 2007) completely supported by empirical work. For example, rather than saying, “You are discouraged, that’s why you are thinking this way,” a therapist can acknowledge that, “The discouragement is getting you to think X.” By doing so, we are acknowledging linguistically that a person is more than this feeling or stream of thought. Several fMRI studies have shown that such labeling practices can have the physiological effects of dampening the activation of some key brain structures such as the amygdala, paving the way for enhanced regulation (Lieberman et al., 2007). Externalizing practices open the door to new conversational possibilities and greater therapeutic effectiveness with clients in the grip of powerful emotional states.
Here then, are some ways of modifying common questions:
Traditional questions intending to assess risk and lethality
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Alternative questions intending to assist clients in regaining agency
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These questions allow mental health professionals to cover the same categories required by the laws and ethics governing our profession while also having a therapeutic effect and actually helping people seeking our assistance.
To efficiently succeed in this process, the suicidal assessment steps in the protocol then become modified as follow:
Traditional Suicide Assessment Protocol
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Empowering Suicide Intervention Protocol
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In sum, transforming the suicide assessment protocol into an empowering process recognizes the complexity and multifaceted aspects of experience. No one tolerates suffering passively; people are wired to survive and minimize pain. Why would therapists ignore people’s own internal “break mechanism” and self-regulation systems when it is possible to build on these? There are so many ways, supported by brain research, to bolster people’s own self-regulation mechanisms, and this process can be applied to a variety of settings, whether we work with individuals, families, groups or even classrooms (Beaudoin, 2014). Many situations benefit from excavating clients’ abilities to overcome hardship. Working collaboratively with people to bolster their own internal resources renders our work much more effective and sustainable. This is especially the case if we follow-up with conversations that systematically boost people’s sense of preferred identities, connection to their values, and sense of being capable of contributing in meaningful ways to their communities.
Marie-Nathalie Beaudoin, PhD, is an AAMFT Professional member and a clinical psychologist working with adult clients, young people or families and helps them address struggles through respectful, creative, and collaborative conversations. She is the director and founder of Skills for Kids, Parents, and Schools (SKIPS) which offers a variety of services to children, educators, counselors, and parents of the San Francisco Bay Area. These services include on site counseling for schools, preventative community wide interventions, psycho-educational programs, and a wide variety of classroom projects. Beaudoin offers professional consultations to therapists around the world through Skype. She also provides supervisions and trainings in narrative therapy, neurobiology, and mindfulness to a wide range of people in the helping professions including psychology, MFT, and social work interns. After serving as the training director of another narrative therapy externship program for 18 years, she teaches as a visiting scholar in various international programs.
REFERENCES
AAMFT. (2015). Code of ethics. Alexandria, VA: Author. https://aamft.org/Legal_Ethics/Code_of_Ethics.aspx
Beaudoin, M. N. (2010). The SKiLL-ionaire in every child: Boosting children’s socio-emotional skills using the latest in brain research. San Francisco: Goshawk Publications.
Beaudoin, M. N. (2014). Boosting ALL children’s social and emotional brain power: Life transforming activities. Thousand Oaks, CA: Corwin Press Publications.
Beaudoin, M. N. & Duvall, J. (2017). Collaborative therapy and neurobiology: Evolving practices in action. New York, NY: Routledge, Taylor & Francis.
Beaudoin, M-N., & Maki, K. (2020). Mindfulness in a busy world: Lowering barriers for adults and youth to cultivate focus, emotional peace, and gratefulness. Lanham, Maryland: Rowman and Littlefield.
Gergen, K. (2011). Relational being: Beyond self and community. London, UK: Oxford Press.
Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S. M., Pfeifer, J. H., & Way, B. M. (2007). Putting feelings into words: Affect labeling disrupts amygdala activity in response to affective stimuli. Psychological Science, 18(5), 421-428. https://doi.org/10.1111/j.1467-9280.2007.01916.x
Richtel, M. (2022, April 23). It’s life or death: The mental health crisis among US teens. New York Times. https://www.nytimes.com/2022/04/23/health/mental-health-crisis-teens.html
Siegel, D. (2007). Mindfulness training and neural integration: Differentiation of distinct streams of awareness and the cultivation of well-being. Social Cognitive and Affective Neuroscience, 2(4,1), 259-263. https://doi.org/10.1093/scan/nsm034
Szasz, T. (1999). Suicide as a moral issue. The Freeman, 49, 41-42 (July). The Foundation for Economic Education.
White, Michael (2007). Maps of narrative practice. New York: W.W. Norton & Company, Inc.
White, M. & Epston, D. (1990). Narrative means to therapeutic purposes. New York: W. W. Norton & Company.
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