Suicidal Debates with Clients in Psychotherapy

• Separating Depression from Sadness
• Five Depressing Truths
• Disagreeing with the Depressed
• Preventing Depressive Takeovers
• The Arrow and Shield

When I started working as a therapist, the prospect of a client dying from suicide terrified me. I worried I would miss the warning signs, and that my negligence would have deadly consequences. There was a dangerous side of therapy, and I worried that eventually, there would be no avoiding it.

I still remain cautious, but I’m no longer terrified. I’m cautious because tragic events in my own practice have confirmed that the dangers in therapy are quite real. Yet I’m no longer terrified because I’ve learned how to think about suicide and depression more carefully. I’ve learned there are deaths that I won’t have the ability to prevent, but there’s still much I can do to help. I still believe that in most cases, therapy can interrupt clients as they shuffle down the path of despair, and it can turn them back towards the community of the living.  

Separating Depression from Sadness

My early concern around suicide came from the difficulty of thinking clearly about depression. The word “depressed” means different things across different contexts. It’s like the word “drugs.” Am I using drugs each time I go through a Starbucks drive-thru? Caffeine is a drug, so by one definition, I’m a daily drug user. A real bad boy. Leather jacket. Fingerless gloves. However, there’s an obvious difference between hot bean water and heroine, even though the word “drugs” can be used to accurately describe them both. When I think of paraphernalia, 20-oz cups and green stirring sticks don’t usually come to mind.

I think the word “depression” is also overly broad in a similar way. Before I was a therapist, I would use the word “depressing” to describe a sad mood, events in the news, or microwaving hotdogs for dinner. I no longer use the word depression in this way. Instead, I try to limit myself to when I’m describing a major depressive disorder. The reason I work to limit my use of the word is because depression, in its clinical form, increases the risk of suicide dramatically, and so I think it’s important to avoid the blurring of language. In matters of life and death, clarity is vital. Forcing myself into this distinction also helped me learn about five significant differences between depression and sadness in my therapy. My clients taught me their five depressing truths about depression.

Five Depressing Truths

When I first met clients who had traveled to the outer frontier of depressed states, I noticed that while despair could be their primary mood state, this wasn’t always the case. For some, it was an absence of feeling that they experienced. The client didn’t always tell me “I’m extremely sad,” but instead they sometimes they said, “I feel nothing — and I don’t know where I went.” Depression could present with a numbness, or more precisely, my clients were experiencing the first of their five truths; self-missingness. Their inner selves had left them behind, and what remained was an empty waiting room. This was one of the first differences that I noticed between depression and sadness.  

I also noticed that depression could create sleeping problems, difficulty with focusing, low energy, and a guilt that bent towards exaggeration. This guilt condemned my clients to wrongdoings they hadn’t committed. They felt guilty about being depressed, and when they had moments of reprieve, they felt guilty about that, too. My client’s minds would become kangaroo courts, and they would find themselves guilty on every trumped-up charge they could conjure. But in its most exaggerated form, this guilt could convince my clients they were harming others by committing the crime of simply being alive. More on this a little later. But this guilt, along with the collection of other symptoms, taught me another distinction between depression and sadness. While sadness is the description of a single mood state, depression includes a constellation of interconnected symptoms. In other words — and here is the second truth for my depressed clients — sadness is singular, but depression is plural.  

The absence of identifiable causes was a third truth, or dynamic, that my clients taught me. While stressors could certainly inaugurate depressive episodes, depressive episodes didn’t need external events to bring them about. Depression simply didn’t care about how well my clients were doing. Depression would invite itself into their life without notice, track mud into their house, and climb into their bed with its shoes on. In fact, many of my clients would tell me that they were on vacation when they first noticed that something wasn’t right. From their wicker chair, they watched the sun flicker on the water, listened to the waves — and felt absolutely devastated. It was the very contrast of the internal and external landscapes that brought them to realize that something was significantly wrong. These clients showed me this third truth about depression: it can darken the internal world, without identifiable darkness in the external one.

A fourth difference between sadness and depression that I learned from my clients was that sadness is an expression of the authentic personality, but depression is a departure from it. When depression eventually loosened its grip, my clients often expressed how unrecognizable their former self appeared to them. Depression seemed to operate like a spell. It would capture their emotional state and pull them into a shadowed place, and when this spell would loosen its hold, a return to their authentic personality would occur.

The final difference my clients taught me, and I think it’s the most important, is that depression can be quite dangerous, but sadness is not necessarily so. Far from being dangerous, I think sadness is a vital feeling. Sadness is how my clients felt when something important had been lost. Whether they lost a relationship, a home, or a career — sadness was the pain of absence. And as much as it hurt for my clients to feel it, this pain of absence was deeply important. It was important because when saddened, what mattered most to my clients was revealed. The pain of absence taught them what needed to be present in their lives. It was in the same moments they learned which losses they couldn’t bear, that they also learned what must be restored. To return wholeness to their lives, sadness told my clients which way to walk.   

But depression didn’t work this way. When my depressed clients looked inward, their inner state offered them no wisdom, but only suffering’s dead eyes stared back. This amount of suffering was unsafe. It was unsafe because this type of pain is simultaneously extreme and pointless. Clients can endure extreme psychological pain if they have a good reason, but depression provides no such reason. It seems that depression is a pain without purpose.

So, these five differences between depression and sadness left me with a more limited definition of depression: it’s a state of despair or self-missingness that requires no identifiable cause. It includes a plurality of symptoms, it’s a departure from the authentic personality, and it’s also dangerous. It’s not about microwaving hotdogs or the news. Or it’s barely about microwaving hotdogs and the news. But as I started to understand depression in this way, two things happened. The first is it made it possible to reconsider how I thought about suicide. The second was that my work with my clients significantly changed.  

Disagreeing with the Depressed

It’s hard for me to overstate how difficult it is for me when my clients try to convince me that they cannot be helped. While they might concede that people shouldn’t wish to die, they often tell me there is one exception, and it’s them. They tell me that the details of their pain are unique, and that they’re a rare and untreatable case. Their suffering stands apart from the rest, and in this way, it’s superior. Sometimes depression can cleverly recruit a pinch of narcissistic grandiosity to increase a client’s despair. Bon appetite!

This creates a challenge because my training taught me to honor, and not to disagree with, the feelings of my clients. In my education, disagreement was to therapy what deodorant was to teenagers. They simply don’t go together. But when my depressed clients try to convince me that they can’t be helped, I’ve found careful disagreement to be important. While it’s true that disagreement can elicit defensiveness and early termination with clients, disagreement has been a a useful skill in the presence of a client’s hopelessness. I think this skill of careful disagreement can be especially useful when it’s implemented in two steps. When I don’t mess it up, these disagreements can sound like this:

Client: I’m going to give therapy my best, but honestly, nothing has ever worked. It’s hard to imagine that after trying therapy for 10 years, this will be different somehow.

Therapist: 10 years. I can’t even imagine that.

Client: Yeah, it’s pretty hard to get that across to people. I’m just one of those rare cases where you can’t make any real improvement. I mean, those cases exist, right? I just happen to be one of those cases.  

Before getting into the heart of the disagreement, I want to mention how helpful the phrase “I can’t even imagine that,” can be. When I was learning to become a therapist, I worried that unless I shared similar experiences with my clients, they would view me with suspicion. I was concerned they would think of me as someone who “doesn’t get it,” and I’d be exposed as the imposter I was convinced I was. I didn’t handle these insecurities well. Instead, I exaggerated the breadth of my own life experiences. The good ol’ therapeutic skill of misleading clients. A classic. I would find ways to connect my client’s experiences with my own, even when there weren’t real comparisons to be made. I hoped that this would reassure my clients that I was qualified to help them, but mostly, it allowed me to hide my imposter syndrome behind my flexible autobiography. In therapy, this was my hiding spot.

I eventually learned that it was better to handle my insecurities by acknowledging when I couldn’t relate. Not lying, I call it. A cutting-edge intervention, I know. But it wasn’t realistic to expect myself to contain the totality of human experience within my past, and when my clients thought our histories were more similar than they were, I was taking too many steps away from sincerus. For me, this style for building rapport was too far from “whole, pure, and clean.” Not only was stretching the truth of my personal history unethical, but I also risked that my clients could be left with the sense that their pain was unexceptional. “I’ve been there before,” didn’t necessarily carry a reassuring ring to it.

But once I accepted that my clients would experience many problems I would never experience, it became easier for me to tame my imposter syndrome. The truth is that personal experience isn’t a prerequisite for clinical competence. Instead, I think it’s better to share with my clients when the depths of their difficulties are hard for me to imagine experiencing. In the case of depression, most clients already know that most people haven’t felt the depth of depression’s deep waters, but when they hear that I know this too, something paradoxical happens — they know they’ve been heard.

Okay, enough about my poor character. I want to move back into the transcript. Here’s how the beginning of how cautious disagreement can occur:  

Therapist: Hm. That hit me a little different than I expected. Let me get some feedback from you, is that alright?

Client: Yeah, go for it.

Therapist: Well, I’m feeling two different things. The first is that I’m hurting for you. You’ve been through so much. But the other is when I hear you talk, I also feel this sense of protectiveness within myself. It’s like an urge to protect you, against you. I’m not sure you’re very fair with yourself. What do you make of that?

Client: Look, I don’t think I need your protection. I’m just saying I don’t think things will get better.

Therapist: Right, after trying therapy for 10 years, improvement sounds unrealistic.

Client: Bingo.  

Two things are going on here. The first is that I’m expressing disagreement by sharing my own feelings about their hopelessness. This is Step 1. There’s nothing to be gained by debating with my clients about whether they’re truly beyond help. This can leave them feeling less understood. But when I express how I feel about their hopelessness, this allows me to disagree without being disagreeable. For me, there’s usually a feeling of protectiveness that emerges, but sometimes there’s a feeling of sadness inside me, too.

There’s another part that I try to keep in mind when disagreeing with clients in their depressed state, and I think it’s the most important: I express my own hope about their situation. This is Step 2, and sometimes it sounds something like this:

Therapist: I gotcha. You know, if I’m honest, I wouldn’t ask you to feel hopeful at this point. My fear is it might feel too risky — like a setup for another letdown, and things have already been hard enough.

Client: Yeah, I’ve been through that. Having hope, and then things not working out. Done that several times.

Therapist: With all you’ve been through, not reaching for hope makes sense to me. I guess I’d like to share that in the meantime, I’ll be hopeful for the two of us. Maybe if you start seeing small improvement later, then you can join me, but for now I don’t want you to have hope. I can carry that part for us both.

My hope is that showing my clients that I understand why they’ve rejected hope can be an unexpected act of kindness. This might seem like a strange way to be supportive, but for many clients, I think hope can feel too vulnerable. Allowing themselves to become excited about the possibility of feeling better can seem risky, and so I encourage them to continue protecting themselves. But I also tell them that in the meantime, I’ll be hoping for the two of us. This lets them know that while I disagree with them about their prognosis, I won’t debate the matter — in our disagreement, I’m still on their side.    

Preventing Depressive Takeovers

That is how I practice expressing disagreement with my clients in their depressed states, but I think managing my private disagreements is just as important. Here is what I mean. I think disagreeing with my clients about the hopelessness of their improvement within myself is a precondition for honest therapy. How could I work with a client if we both agree that they’re beyond help? But in some cases, this private disagreement is a fluid process. There might be sessions when I find myself more optimistic about the client’s progress, and other sessions, less so.  

I think it’s important that when I find myself feeling less optimistic, that I treat this feeling with extreme caution. Hopelessness operates the way that yawning does – when one person yawns, others in the room will involuntarily follow. Hopelessness can also move across the room, and when spending hours in the presence of client hopelessness, it can spread across the therapeutic relationship and into myself. If I’m not careful, I can become worn down, and then I can become pessimistic about the client’s prognosis. When I join in the client’s hopelessness, I haven’t influenced the depression, but instead the depression has influenced me. The therapy itself has undergone a depressive takeover.

A depressive takeover is a phenomenon where a client’s distress spreads to the therapist over the course of therapy. The problem with these takeovers is that if I allow them to occur, my clients can sense that I share their pessimistic outlook, and this can reinforce their preexisting despair. Fortunately, I think there’s something that can be done to prevent this from occurring.

To prevent depressive takeovers, it has helped me to notice the connection between my being emotionally absorbent and the contagiousness of hopelessness. In my view, the more I’m sensitive to experiencing the feelings of others more generally, the more susceptible I am to the contagion of hopelessness. This means that there are rare moments in therapy when, for the sake of my clients, I attempt to become less emotionally porous. I try to shut my inner doors, and to absorb less of their experience.

To do this, I inwardly recite a phrase when I notice that I’ve started to feel pessimistic about their prognosis. I tell myself: that’s your mental health, not my mental health. Reciting this mantra in the privacy of my mind allows me to distance myself from my client’s experience. Creating this internal limit creates a pushing-away feeling, and it helps me close my emotional doors. It’s an empathy reduction exercise. When I create this distance from my clients, it helps me stand apart from the pull of hopelessness, prevent a depressive takeover, and remain hopeful for the two of us.   

The Arrow and Shield

Frank was 75 years old, and he’d never seen a therapist before, but he started saying things that made his adult children nervous and so they convinced him to speak with me. When he walked into my office, he got straight to the point. He told me he was ready to die, and shortly afterwards, he told me his name. Frank spoke with energy, “I’ve lived a full life. I’ve had children, grandchildren, and a lovely wife who died 10 years ago. The truth is that I’ve had everything I’ve ever wanted.” He continued, “I don’t want to get much older than this. I don’t want to become less recognizable to myself. I don’t want my kids to have to deal with that either.”

I was perplexed. It seemed like Frank’s desire to die was coming from a place of focused reflection. He wasn’t tearful, nor was he numb — he was grateful. I wasn’t sure if he was making a rational calculation about ending his life, or if he was under the influence of a depression that was undetectable to me. I took a breath and responded, “Frank. I’ll be honest with you. I’m not sure what to make of what you’re telling me, and I’m not completely sure how I should proceed. I’ve never been 75 years old, and I imagine it’s quite difficult, but I’m not sure if your wish to die is related to an underlying depression or not. If I take your word for it, I run the risk of overlooking this possibility, and that worries me. I hope this doesn’t sound too dismissive.”   

Frank nodded and I continued, “You mentioned you don’t want to put your kids in the position of helping you age. Can you teach me about that?”

“That’s big for me. I’m no use to anyone anymore. My kids are raising their kids, and they shouldn’t have to care for me, too. I can’t really give to them anymore; I can only take. I’m burdening the people I love the most.”

The word burden flashed in my mind. I felt a hunch and I wanted to test it. “Frank, this simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering that if you were depressed, if you might hide it from your family. Maybe you’d worry that, in addition to your age, this would burden them, too. I’m only saying this because if you’re trying to protect your family by keeping things private, I’d hope you’d relax your protective nature with me. But tell me what I missed.”

We sat in silence as Frank looked out the window behind me. He clamped his palms together, cleared his throat, and we restarted the conversation.

Over the course of my therapy, I think it’s been useful to pay attention to the word “burden.” I’ve come to believe that this word, and the emotional experience to which it points, is the first part of suicide’s moral calculus. When my clients begin to think their existence is hurting others, being alive can start to feel like an ethical dilemma. “Should I stay alive if it harms those I love?” they might wonder.

This guilty feeling can become more dangerous when it’s coupled with a strong desire to protect their loved ones. I think this is the second part of suicide’s moral math. While suicide might look selfish from the outside, from the inside, clients often perceive suicide as the way to protect their loved ones from themselves.

With many of my clients who have survived their suicide attempts, they often express that while they were afraid of dying, it was their protective instinct that pushed them beyond this fear. From their vantage point, suicide was the right thing to do. They believed they were hurting their loved ones, and it was their responsibility to protect them. From within their suicidal mindset, many of my clients considered themselves both the arrow and the shield. It was the pulse of a self-sacrificing ethic that motivated them.    

***

As I look back at the therapist I was “back then,” and the clinician I have become, I realize that once I better understood depression and the moral dimension of suicide, this gave me something to work with in therapy. I learned that when my clients expressed the five depressing truths or when they believed they were a burden, there were things I could do to help. I could start by gently disagreeing with their hopelessness, disagreeing within myself to prevent depressive takeovers, and disagreeing with my clients when they’re convinced their loved ones should be protected from themselves. I am no longer terrified when the specter of suicide enters the therapeutic relationship.

Editor’s Note: In the next installment of this five-part series, the author will address strategies to address despair in therapy.    

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