I have one more part to the series on reactive detachment but wanted to pause to discuss this topic. We frequently work with individuals who have had fleeting suicidal thoughts for years. It’s become part of their life. This is the case for most of the members who participated in a recent group I facilitated. The group began as a discussion about secondary gains. The topic of suicidal thoughts came up. We dove in.
Generally, the discussion of suicide on the ward is skirted. It is limited to two closed questions: “Are you suicidal?” if yes then “Are you able to stay safe?” Staff feels uneasy about exploring it any further because they worry that it might upset the patient. It’s ironic that we fear that talking about suicide will upset someone who has been admitted to an inpatient unit for thinking about or attempting suicide. It is crucial, however, that any discussion of suicide in a group setting be well contained so members feel safe. Frequent check-ins and follow up individual work must be part of the process.
In this case, the discussion of chronic suicidal thoughts and secondary gains proved to be an excellent fit. As we explored it, an amazing paradox arose. At times, the thoughts of suicide were soothing and provided a sense of power. These folks found relief in the option to end their life. The idea of death created an energy in their life. This option offered the individuals a sense of “control” when their lives felt unmanageable. Much like addiction to drugs, chronic suicidal thoughts provided an escape from overwhelming stressors. And like other addictions, continuing use of suicidal thinking prevents individuals from enduring the process of developing other coping skills. As you know, building new coping skills is a scary process. Commitment to the process requires one also commit to abstinence. In the case of chronic suicidal thinking, it is not abstinence from a behavior but rather abstinence from a thought process.
By the time these folks are admitted to our unit, they have “overdosed” on their suicidal thoughts. They invested time and energy into engaging their drug. They cultivated and nourished their suicidal thinking until it became all they could see. When they are assessed in the ER, patients express that they feel “out of control” or “scared.” Some acted on the thoughts and then called friends or 911 when the reality of their action hit them. The soothing quality was gone. The drug had lost its pleasure.
I asked members of the group to imagine how they would feel if they were immortal and taking their life no longer was an option. They expressed feelings of fear, anxiety, and even anger. We explored these feelings as they related to control, power and self-soothing. All members of the group shared past moments when they had and internal sense of strength and we investigated the factors involved.
Seeing chronic suicidal thinking as an addiction resonates with patients. It may benefit clients to offer this approach to understanding the problem. Consider the first of the twelve steps “We admitted that we were powerless over [suicidal thoughts] and our lives have become unmanageable.” People with chronic suicidal thoughts are powerless over whether the thought enters their mind. If they invest energy in fighting it or judging it then they actually end up feeding it. I often suggest that these folks view these intrusive thoughts as signals that they need to pause, evaluate what is going on, and choose a coping strategy that will meet their needs and the needs of the situation.
I’m interested in your thoughts about this approach. If you have found other strategies to help those with chronic suicidal thoughts I would greatly appreciate it. Work on an inpatient unit is a start, but for these folks the real work is done on the outside.
Jill Presnell is a Counselor in Northeastern Pennsylvania as well as an advocate for the provision of recovery oriented mental health services.