Saturday, October 24, 2009

chronic suicide ideation

As most of you know, I work in a program for adults with mental illness who want to reenter the workforce. One of the main criteria for program admission is current stability. In other words, you have to be emotionally ready to work and have enough control over your symptoms to function in a work environment. We'll support you, we'll advocate for you, we'll work with your employer, we'll help you, etc, but we aren't a placement agency, we help people find jobs in main stream employment. Of course, because no one is perfect and mental illness can be unpredictable, not all over our clients are able to find employment, and they don't all remain stable. Right now, I'm working with a client who is very not stable, and it's a little bit outside my comfort zone.

Said client is chronically suicidal. Suicide ideation is part of her daily life. However, since entering our program she has attempted suicide on three different occasions. She was not stable enough to maintain employment. So, it came time to discharge her and refer her to more appropriate services. So I did... refer her that is. She and her doctor decided that a hospital day program was a good option for her, it offers DBT and CBT skills training and would provide her with tools and a lot more support then our program can. So the client and I agreed that I would discharge her as soon as she started the program...

The program kept bumping her date of admission back, and so, two and a half months later, here we are. We meet for counselling, but I feel like we're getting no where. Every session is potentially our second last session (we'll do a last one for closing once she starts) and because her suicide ideation is so prevalent it's almost all we talk about. We have safety planned so many times that both of us could probably recite the whole thing backwards, forwards and upside down. The crisis lines have heard from her day in and day out for months. The mobile team won't see her right now because it's a "long standing issue". I was out of ideas.

So, when I saw her for the second time this week, an extra session, just to get her through till her day program starts Monday (we hope, we hope, we hope) I took a totally different approach. Rather then doing the whole ASIST thing where you explore reasons for death, reasons for life, align yourself with the side that wants to live, safety plan and contract (which I don't do anyway), I thought, we'll, this isn't changing anything, screw this. So, we talked about death. We talked about who finds her body, we talked about how long it stays in her apartment, we talked about who feeds her gerbil, we talked about her funeral, her ashes, the affect on different people in her life, and you know what, our session went a whole lot better. I wasn't frustrated (something my student noticed in our last session) and I left more room for silence and thinking. She wasn't forced to answer the same questions (with the same answer "I don't know") as usual. It certainly wasn't the answer, and it certainly didn't fix her suicide ideation, but it seemed to be a better approach.

In April I'm going to a two day workshop about working with chronic suicide ideation and it's connection to trauma. I'm super excited. I felt very unequipped in this situation, and while I did make all sorts of appropriate community referrals, the person she felt comfortable talking to was me. So I did research, I consulted coworkers and my supervisor and I kept in mind that not only do I not know everything, but I don't have to know everything.


liz said...

nice post, i think its very important to remember we don't have to know everything

Anonymous said...

I experienced chronic suicidal ideation for over 8 years, getting worse over time.

I tried many therapies and close to 15 medications, and finally, I came to accept, that those thoughts are part of me, and that they are just my brain's way of cueing me in that I feel strongly about something.

instead of saying "oh f**k", like most people would, my mind says, I need to just end it all via whatever means pop into my head atm.

Once I realized I wasnt wrong, or fataly flawed, just different, I was able to take the thought and ask, what is really going on?"

and then make an effort to change that item. If i thought "kill myself" every time I had to, say, parallel park, I stopped parellel parking, and found a different parking spot, even if i had to walk.

Not the same as avoidance, more of picking battles. And when the thoughts do occur... as long as I address whats behind them, they do pass...

that's me, non-scientific, and whatnot.

mel said...

Thanks for this post! I am working with someone who experiences chronic suicidal ideation and borderline personality disorder. Likewise, I feel like we have the same conversations over. So I appreciate a fresh perspective!
And thanks also to anon for your insights into the experience - that is truly valuable.

Reas Kroicowl said...

Yup, I appreciate Anon's perspective as well. But, SD, I think coming at it from the practical side is a good thing too. I think it's helpful for people to think about the immediate impact of suicide should they decide to make an attempt. Sometimes it's enough to prevent it. Sometimes.