The Aeschi Working Group

MEETING THE SUICIDAL PERSON

The therapeutic approach to the suicidal patient

Therapeutic Empathy With the Patient’s Death Wishes
(excerpt from a forthcoming book on suicide by Israel Orbach)

Beginning therapists especially often mention the sense of responsibility for the life of another individual as the most frightening element of working with the suicidal patient. We clearly can and must do everything in our power to help the patient, but at the end of the day, suicide is an act of free will carried out by an individual in extreme distress. This choice is made under the constraints of overwhelming psychic pain, but the choice is nevertheless that of the patient. Although the decision to continue to live or die is influenced by what takes place in therapy, the decision is essentially the patient’s alone.

Relevant to this issue is the work of Thomas Szasz. In his book The myth of mental illness (New York: Delta Books, 1961), Szasz claims that suicide is an act of free will and he even hints that this decision should not necessarily be interfered with. This approach arouses opposition because of the apparent indifference Szasz shows to the life of the suicidal individual. Moreover, the human urge to help a person in distress is almost instinctive and Szasz, therefore, appears to confront us with an option that is fundamentally unacceptable.

However, I will permit myself to interpret Szasz’s words a little differently. Suicide is indeed an act of free will within the specific constraints governing this choice. This choice is not founded on a moral imperative, but is the product of intense and unbearable suffering. It is this suffering that confers the right to choose death. As therapists, we have to treat this choice with the full and proper respect it deserves, but the conclusion that should be drawn is not that we must adopt an indifferent approach to suicidal longings, but that these longings deserve our utmost empathy. We must employ empathy toward the intense suffering of the other person, suffering with which we have no way and no right to argue, and it is from this empathic stance that we have to approach the patient’s desires, longings, and decisions. This principle of therapeutic empathy toward the patient’s death wishes seems on the surface to contradict the very concept of therapy with suicidal individuals. Nevertheless, I hold that maintaining therapeutic empathy toward the suicidal longings of suicidal patients is, in fact, the best way and perhaps the only way to help such individuals extricate themselves from the suicidal option. Suicide is commonly perceived to be the result of an accumulation of psychic pain and distress and that the most effective way to help is to find immediate solutions to ease the distress. To prevent the act of self-annihilation, it is often recommended that immediate attempts be made to locate and solve the problems in the patient’s life or that various means, such as medication, be used to reinforce the forces pulling toward life. Also, it is often suggested that a contract be struck with the patient, whereby s/he undertakes not to commit suicide while therapy is ongoing.

I have no real argument with these tactics and it is clear that every appropriate and available means should be used to postpone or revoke the suicidal plan. However, these tactics cannot replace the overall therapeutic strategy whose essence is empathy toward the desire to die. In line with the above interpretation of Szasz’s philosophy and from the understanding that the suicidal crisis is essentially a crisis of intense pain and loneliness, I believe that the therapist should endeavor to place him or herself in the suicidal patient’s shoes and try to understand the distress from within the inner world of that suffering individual. I am referring here to more than the normal empathy required of the therapist. What is needed is empathy that is akin to a process of regulated and controlled identification. In my work, I ask the patient to "show” me how s/he got to the point of the end of the road and how it became to be that suicide remained the only option, and why there is in fact no other available path. I myself endeavor to "see” and feel how the paths of the patient’s life and psyche had led to the "justified” feeling that there is no way out. I try to "bring myself” to the same point as the suffering individual and try to persuade myself of the "justification” of this feeling of deadlock. This means that we should allow ourselves, as therapists, to view the pain and choice of death with deep respect. Even when tactical bargaining is employed by the therapist to postpone or revoke the terrible experience, it should be from this same standpoint of empathy toward the patient’s death wishes.

The first step forward afforded by this approach is the conjoining with the patient in his/her loneliness. The patient who is tormented by terrible psychic agony is also alone is this agony, a loneliness that stems both from social and existential isolation. The fear that is provoked by suicide threats and the swift attempts made to dismiss the option of suicide may at times only serve to exacerbate this terrible loneliness. The empathic stance that I recommend here can help ease this loneliness, merely by giving the patient the sense that there is another person who can understand the intolerable pain and all that is implied by it.

I do not sign my patients on contracts that they refrain from attempting suicide. Primarily, I do not believe that such a signature carries any weight in the face of intolerable pain. Instead, I try to give the patient license to truly and extensively examine the option of suicide as one of a number of alternatives and I try as far as possible to put alternative options forward for examination. This license is expressed in the relentless joint search for the patient’s difficult experiences and for the understanding of how these have developed into a craving for death. This search should be conducted without fear and alarm and without attempts to pressurize the patient toward quick solutions. In practice, I ask the patients to share with me their life events, their pain, their fantasies about death, their feelings that there is no way out. I ask to help me "see” how suicide became an option. I try to understand how and why matters evolved along this path, what the background was to the final breakdown, at what point the patient decided on suicide, and what at that precise moment. I try to understand what it is that is so terrible and so intolerable, what has been irreparably destroyed for the patient, and why s/he is unable to wait any longer. I respond to the patient with empathic reflection guided by an optimistic belief and by the wish to understand. When I deem it appropriate, I ask about other options that could help solve this or any other particular source of distress, but not because I wish to dissuade the patient from his or her suicidal convictions. This empathic exploration does not necessarily reduce the patient’s distress, but, as previously stated, it can lead to an immediate easing in the feeling of loneliness.

The actual reconstruction of the suicidal patient’s difficult experience and its examination from an empathic stance in and of themselves produce a respite in the inner struggle between life and death. This process itself often raises new hopes and prompts the examination of new possibilities, not that a partial respite has been procured in the patient’s battle to resolve immediately the complexities of his or her inner state. I believe that the empathy and respect toward the patient’s suffering paradoxically bring hope and the willingness to try.

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