> I've known people personally in my life who have talked about, attempted and even committed suicide, but have very little understanding on how somebody comes to end their life.
Could I give you a book recommendation? Edwin Shneidman pretty much founded the field of suicidology, and his book Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior may be exactly the discussion you're looking for.
I am very sorry that you were treated like this. This must feel so horrible.
>All in all it's lead me to believe that therapists in general just don't understand suicide and aren't properly trained to engage with suicidal patients. I'm very sorry that you were a casualty of this messed up system.
I would say too many therapists are poorly trained to work with suicidality and fail to understand how they might help. However, I think you do both therapists and clients in need of treatment a disservice by generalizing to say "all therapists just don't understand".
There are people who were trained to help with suicidality and who do target the suffering at the root of it. (If you want to read how they approach this, look no further than the subreddits for therapists and see.) The book usually recommended is https://www.amazon.com/Suicide-Psychache-Clinical-Approach-Self-Destructive/dp/0876681518 .
Unfortunately, I do not know how to find the therapists who disproof your generalization. You might want to filter out people who use very directive modalities only, but beyond that, I think you need some luck.
>I could use a co-therapist on my shoulder...
Hey there! I'm willing to take a crack at this.
A lot of folks have talked about referring out, and, yeah, I hear you are way beyond your competence and confidence here, so referring out makes good sense. But I also hear you asking, "How do I treat this client? Quite aside from passing this client on to someone who knows how to do this, how does one treat a suicidal patient?" So that's what I am going to talk to you about. I work with suicidal clients, and I have a lot of opinions about how best to do this. I'm not sure I can fit most of them into a Reddit comment, but maybe I can give you the pointers you need.
First and foremost, you are clearly doing something very right, if the client is insisting on working with you. I know this is nerve-wracking, because you feel like you're being asked to carry a live grenade, and have no idea how to disarm it. That terror makes you feel even worse about your competency in this case, making you feel ignorant and helpless, and feels like a set-up to fail; don't let that blind you to the success you are already having. This kid, who won't talk to other adult is willing to talk to you, at all. Congratulations: you're doing better than anybody else who has worked with this kid, and you're getting further.
Now, what u/Bonegirl06 said about not meeting them where they are is exactly correct. I want to talk about how to do that.
I am a Rogerian – that is I do Client-Centered Therapy – and work with clients with suicidal ideation. I'm of the opinion it is a particularly appropriate and robust approach to suicidality. So I am seeing your case from that perspective, and I am recommending that approach to you.
So everything you are trying to do to get the client to stop being suicidal – "went over reasons to go on with life, reactivating their emergency plan, talking goals for us right now" – stop. All of this is counterindicated, and is likely to make the sucidiality worse.
Of course, the thought that this person might commit suicide while one is responsible for them is terrifying. It tends to fluster therapists who don't know what else to do, and cause them to urgently try to do very directive interventions. The problem is that's counterindicated, and can make the problem worse.
The model of suicidality I use is that of Edwin Shneidman, the founder of the field of suicidology. He wrote a book I recommend to you, Suicide as Psycheache: A Clinical Approach to Self-Destructive Behavior. He proposes the concept of "psycheache" (pronounced "psych ache") for emotional pain, and his research found that the necessary preconditions of suicidal behavior are intolerable severe psycheache + hopelessness (despair of things ever getting better) + helplessness (the feeling that one can't do anything to make things better).
This model is powerful, because it gives us three targets of intervention: the psycheache, the hopelessness, and the helplessness.
It also reveals what not to do: if the inclination to kill oneself is a function of feeling that one doesn't have agency in one's life, things that further reduce one's sense of agency will increase the inclination to attempt suicide. It means that the more the client feels controlled by others the worse their SI will get.
And that in turn means that directive psychotherapeutic approaches become dangerous with acutely suicidal patients. I'm not saying there's no role for directive approaches with acutely suicidal clients, just that it's playing with fire and one needs a very strong sense of wherein the risks are and how to mitigate them to do so safely.
(Continued, length limit)
So, I'm going to give this enterprise a bit of a hard time.
I think one of the huge problems for the field – that results in clinicians handling suicide poorly – is an over emphasis on suicide risk assessment to the nigh-complete obviation of suicidality treatment.
This pattern is anxiogenic for clinicians. They learn how to determine risk and not what to do about it when they find it, and that's just a school for terror. Worse, this pattern conditions clinicians to think that "what you do" about suicidality is merely to measure it, which I think explains the way many sensitive, compassionate clinicians abruptly change interpersonal mode when a client expresses SI, to a cool, calculating approach. Which is deeply unhelpful.
And the relentless equation of training-about-SI with suicide risk assessment gives clinicians the implication there isn't any sort of treatment for suicidality to be trained in, which leaves clinicians in a really horrifying spot: you're responsible for suicidality in your patients, you can measure it so you know when the problem is getting bad, but you have no idea what to do about it but call 911.
This is why I strongly feel nobody should get any training at all in suicide risk assessment until they have some basic suicidology under their belt. Because learning risk assessment when you have no grasp on the condition leads to clinicians getting panicky and over-reacting. But that's a fantasy because of the very problem I'm decrying: lots of trainings are nothing more than risk assessment, while trainings in treatment are rare.
I'm wondering how many people here have never heard the term "suicidology" before. It's a real thing.
If I were teaching a class in the treatment of suicidality, my core text would be Suicide as Psychache: A Clinical Approach to Self-destructive Behavior by Edwin S. Shneidman. Schneidman has been called "the Father of Suicidology", and it's based on his deep research into suicide, particularly the phenomenology of it, meaning what is experienced by suicidal people as they move towards (and away from!) attempting, and what to do – and what not to do – about it. I think many clinicians would find this book revelatory, and profoundly helpful.