Jeff Levy, LCSW
Mental Health, Relationships, Trauma, Identity
Jeff Levy, LCSW
(originally posted on Branching Out: The Live Oak Blog, April 2015)
One of the premises underlying the work we do is our desire to help. Implicit in the idea of helping is improving concrete life conditions or increasing the experience of happiness or peace in someone’s internal landscape. Helping means feeling better. If that is one of the most basic premises underlying the work we do, how do we respond when someone expresses a desire not to live?
Of course there are variables we consider: the age of the person, their life experiences, their health, and their supports. Often then, our questions become more specific about thoughts of suicide, fantasies about suicide, plans for suicide, access to drugs, weapons or other materials, and the lethality of one’s plans. Sometimes we think about creating a safety plan or contracting for safety. And if suicide feels imminent, we may go so far as to make a 911 emergency call.
There are few things that raise anxiety as quickly as someone sharing with us the desire to end their own life. And paradoxically, I’ve found that those of us who share with another our desire to die are often the most ambivalent about dying. If we are 100% intent on dying, we won’t share it with a friend, family member or therapist.
I’m not saying those of us who say we want to die shouldn’t be taken seriously. I’m just inviting us to consider that when a desire to die is shared with another person, there is some degree of ambivalence. A small door remains open to life and the challenge is to somehow find the door and gently inch it open.
Death Versus Relief
David was a 62-year-old single man who had been in therapy off and on for the majority of his adult life. He had been in several long-term relationships, but none that lasted for more than several years. He began seeing me after his most recent relationship ended and because he was having another of what he called “a period of hopelessness.”
After several sessions with David, I learned that he felt mildly depressed for most of his life, and that there were periods of more significant sadness that punctuated his longer stretches of mild depression. “I feel like I’ve tried everything,” he said to me in our fifth session. “No medication seems to help and I don’t think I can spend the rest of my life feeling this way. I just want to die.”
Whenever I hear anyone share a desire to die, even after 30 years of doing this work, I can feel my back tense as I sit up in my chair. I had a sense that David had shared this with other therapists at other times in his life, and I wanted to be able to say something that might offer an opportunity to see his life, and his sadness, through a different lens. I also knew that by telling me he wanted to die, he also wanted to live.
He looked down, into his lap, waiting for me to say something. Safety planning or assessing for suicidality didn’t feel like appropriate immediate next steps, so I decided to explore David’s statement a bit more. “When you say you just want to die, I don’t know if that means you want to stop living—to not exist—or are you saying you want relief from these feelings?”
I watched David shift in his seat and slowly look at me. There was what felt like an interminable silence before he responded. “I want relief. I don’t want to keep feeling so incredibly hopeless.”
We spent the rest of that session exploring in more depth the pain that felt insurmountable and all the strategies he’d tried in the past that didn’t offer him the relief he sought. And in subsequent sessions, we clarified further that in sharing he wanted to die, he was also asking me to help him find ways to live.
While I haven’t kept data, I’d estimate that when I ask people if they want to die or want relief, 90% or more say they want relief. And if the expressed desire is relief, that means there’s a way to tip the scale toward life. With David, it meant clarifying his desire to live while respecting his history of pain. While he continues to experience long stretches of mild depression and sometimes more acute sadness, our work focuses on an acceptance of the sadness while also looking for ways to experience hope, connection, and even joy.
Reasons to Live
Last week I was facilitating a monthly consultation meeting with the staff from a counseling agency in Chicago. June, the therapist who was sharing a case is a skilled and intuitive clinician. Her practice is solidly trauma informed. She spoke of Rachel, a young woman with a history of childhood sexual abuse and multiple suicide attempts. Even in her first session, Rachel expressed a desire to die.
I’m confident that it was June’s ability to hear Rachel’s statement and fully absorb it that immediately fostered a connection. She didn’t panic. She didn’t immediately ask intrusive questions to gather information about a suicide plan. She listened carefully and, I’m sure, saw Rachel’s desire to die as a way to protect the part of her that held hope for her future and her desire to live.
Because of Rachel’s extensive history of abuse and lack of validation from her family, holding out for support felt more dangerous than thoughts of suicide. She also had a host of behaviors that I would label as survival strategies but others might label destructive and self-harming. Rather than stripping the only ways Rachel had learned to manage her pain, June instead chose to focus on reasons to live.
She did develop a safety plan with Rachel and included in this was an agreement that to continue to work together, Rachel needed to agree to live. She didn’t need to agree to live forever and she didn’t need to agree to disengage from any of her other survival strategies—she simply agreed to live for the time being. This powerful component of the safety plan provided an opportunity to focus on life and included in this focus was an agreement that together they would create a “Reasons to Live” charter. This became a dynamic component of Rachel’s safety plan and as they uncovered new reasons to live in their work together, the list became longer and longer.
June’s work with Rachel continues. I anticipate there will be existential crises that trigger thoughts of suicide and fantasies about death. I also anticipate, however, that the work Rachel is doing in therapy is gradually but consistently tipping the scale of her ambivalence toward accepting her pain and opting for life.
You Can Always Die
Ed was a middle-aged man who told me he “always” knew he was gay, but his family’s religiosity was a significant force in his growing up. He knew that being gay was not acceptable and was perhaps even punishable from a religious perspective. So he married whom he described as his best friend from high school, and together they had three children.
When Ed first came to me, he was in crisis. His feelings for men had been growing over the years. “I feel trapped and hopeless,” he whispered in a session after a few weeks of therapy. “My life will never change. I can’t keep going like this.” I attempted to validate his frustration and the extent to which he has felt hopeless in the past, while at the same time trying to invite the possibility that his past sense of hopelessness might not necessarily carry into the future.
We spent a number of sessions exploring even small changes he might be able to make in his life to help him feel more authentic and hopeful. After several weeks of discussions like this, he started one session by telling me he didn’t feel like things would change. “I’m done,” he said with resignation. Based on our past conversations and his circumstances, I knew enough to ask more explicitly what being done meant. And, as expected, he told me that he wanted to take his own life.
I followed with the questions many of us ask our clients in situations such as this. He denied having a plan and also denied having thought through in any specific way how or when he might end his life. “I just want it to be over,” he shared. We talked about the possibility of a safety plan and he was open to developing one, but was also quick to tell me that having a safety plan didn’t help him feel safer. “Does it make you feel safer?” he asked me with a mix of irritation and humor.
As I thought about his question, I had to acknowledge that developing a safety plan with my clients often does help me feel more safe and less anxious, though I also hope that having a plan in place acts as a support when we most need that kind of structure. In Ed’s case, however, the safety plan didn’t help him feel supported or less depressed. I decided to try a different tactic. “Well,” I offered, “you can always take your life. That is an option you have and you can exercise that option at any time. So if we know it remains an option, can we talk about how your life might change so that you don’t need to exercise that option?”
While I wouldn’t approach every client’s desire to die as I did with Ed, he later shared that knowing that I wasn’t trying to immediately strip him of the option to take his life made him feel more in control and, paradoxically, less hopeless. By not moving automatically into a more anxious mode of suicide assessment and prevention planning which, in Ed’s case would exacerbate his feeling trapped, we could more readily explore how to tolerate difficult emotions while building other more tangible supports into his life.
Holding the Tension of Life and Death
So much of our work requires an ability to hold seemingly incongruous and difficult feelings and desires. Perhaps one of the most difficult tensions to hold is one that involves life and death. At the very foundation of our work, and perhaps the primary reason we chose a helping profession, is our desire to improve and foster change in the lives of our clients. When someone shares an explicit desire to die, most of us feel an immediate rise in anxiety and a pressure/impulse to quickly intervene.
One thing that has helped me in the past, and continues to help me, is to remember that when someone tells me they want to die, the very act of explicitly stating this desire, means there is also a part of them that wants to live. If we are intent on dying, we are much less likely to share. I try to remember that whenever someone sits across from me and talks about dying. Some part of them wants to live—and it’s that part of them I invite to say more.
Of course suicide is a much more complicated issue than can be addressed in one blog post. And there are innumerable circumstances when the approaches I’ve shared wouldn’t be appropriate. Some of us talk about taking our lives and have made attempts previously. Or some of us vaguely allude to death and unless we skillfully and gently ask questions, we may not get at the unstated desire to die.
I’ve shared here just a few experiences I’ve had that I hope will alleviate some of the panic that comes with statements about suicide. Instead, I hope it allows us to hold the tension of life and death, tipping the scale of ambivalence toward life.
All AIDS Anger Apologizing Asking Questions In Sessions Authenticity Beginnings And Endings Being The Expert Boundaries Boundary Crossing Boundary Violations Breaks From Therapy Collaboration Between Therapists Coming Out Compassion Fatigue Contact Between Sessions Continuity Between Sessions Courage Crying Death Depression Disclosure Disclosure And Technology Dogs Email Emotional Support Animals Emotions Empathy Ending Psychotherapy Endings Expectations Experiments Failure Finances Forgiveness Framing Therapy Fraudulence Gifts Goals Grief Happiness Healing Rituals HIV Holding Back Homework Honesty Hope Human Animal Bond Identity Imposter Injuries Interpersonal Neurobiology Intersectionality Long Term Therapy Loss Loving Yourself Memory Metaphors In Psychotherapy Microaggressions Money Multiple Identities Neurophysiology New Information New Normal Normal Not Knowing Pain Physical Contact Positive Emotions Present Moment Priorities Privacy Questions Rage Real Relationships Resentment Resolution Rites Of Passage Rituals Rupture And Repair Sadness Safe Spaces Safety Safety Plan Safety Versus Comfort Secrecy Session Structure Short Term Therapy Silence Stigma And Mental Health Suicide Survival Strategies Themes In Psychotherapy Therapist Client Relationships Touch Trauma Trigger Warnings Values Vicarious Resilience Vicarious Trauma