Won’t Ask, Won’t Tell

Last month I went to a suicide prevention seminar designed for therapists. In the first training video, a man who had jumped off the Golden Gate Bridge talked about his experience. For hours he was out in the wind trying to decide what to do. He told himself that if someone, anyone, asked him if he was OK, he wouldn’t jump. Eventually someone did stop to talk. But only to ask him to take her picture. He took this as his final sign.

The moment he cleared the railing he regretted his choice.

For chunks of the training I was dissociating. Words stopped penetrating. I felt floaty, detached. Dissociation is a natural process that kicks in when we’re overwhelmed. My body was shutting itself off from more input while my mind dealt with what was already on my plate. The same thing, dissociation, had happened to me only two times before — on the two occasions when I learned that a Kaiser client of mine had killed himself.

You might think it would be disturbing to dissociate in the middle of a training. But I knew what was happening. I knew I was safe, just overwhelmed by memories. Dissociation was a marker that I was in the right place addressing these issues. It proved that the suicides at Kaiser still bothered me years later, as one would expect, even hope. It motivated me to learn proven strategies to protect my current and future clients. I never again want to get news like that about someone under my care. Not if I can help it.

One of the stated goals of the training was to foster a willingness in therapists to conduct thorough suicide assessments. The need to foster willingness presumes that there are times when therapists are unwilling to ask about suicidal thoughts. Maybe the reason therapists avoid asking these difficult questions is that we don’t know what to do if our client says, “Yes, I am thinking of suicide. Yes, I do have a plan. Yes, tonight.”

To foster willingness, the seminar demonstrated that people with suicidal thoughts often respond to very basic interventions. Anyone can intervene just by opening up the conversation and focusing on safety planning. Consider the man on the bridge…. If a stranger had said, “How’s it going? Are you OK?” he would have said, “No. Actually I’m not OK.” And if the stranger had said, “Then let’s get off this damn bridge and talk for a little bit,” he would have gone with the stranger and talked. Someone who self-presents to a therapist, not a stranger, is even more likely to talk things through, to allow the therapist to make friends with the part of the client that wants to live, and to work collaboratively toward the client’s survival.

This training message worked for me. The very next day I started asking my clients at the health center where I now work, “When you get really down, how bad does it get? Do you think of suicide? Do you have a plan? Have you been having any of those thoughts recently?” I thank my clients for their honesty. I let them know that if suicidal thoughts emerge I want to know about them. There’s no need for anyone to sit alone with such loneliness.

I got into some very bad habits in my years at Kaiser. Perhaps the worst is that I learned not to ask too deeply about suicidal thoughts. I didn’t have time to manage a yes. To rationalize my avoidance I relied, as I’m sure my colleagues did and still do, on the questionnaire clients filled out every clinic visit. The questionnaire asks: “Over the last 2 weeks, how often have you been bothered by…thoughts you would be better off dead or of hurting yourself?” When clients responded with anything other than a “not at all,” I pursued. If they circled “not at all,” I left it alone. But, of course, there are many reasons why someone might not put in writing that they have suicidal thoughts. And only two reasons a therapist who cares about people would avoid repeating the question in person. The first was addressed by the training: not knowing what to do with a yes.

The second reason is not having enough time to manage a yes, even if you know what to do with one. At Kaiser, when I had only an hour to conduct an assessment of mental illness and develop a plan for follow-up, I was not going to open up a can as wormy as the one containing suicidal thoughts. Not if I could avoid it by rationalizing.

I’m just now undoing the far-reaching effects of working for seven years under such extreme time scarcity. Today there’s no can too wormy to explore. Because I have time to build relationship with my clients, at the clinic and in private practice, I can ask the hard, important questions. The training was all I needed to be reassured that I can handle a yes, that any of us can as long as we have time.

Barbara Ragan, who killed herself on July 5, 2015, by jumping from a Kaiser parking structure, had been for months telling her providers that she she needed help, that she was depressed and at risk of suicide. No one had the time to listen or to develop a plan for her safety. There are thousands of Kaiser patients every day who keep private their suicidal thoughts, hoping, like the man on the bridge, that their providers will ask, “How are you really doing?”

Kaiser therapists have announced their intent to launch a statewide open-ended strike. Soon they will leave their jobs and refuse to return until they are guaranteed adequate one-on-one time with their clients.Their message is the message of this post. If we have the time to listen, the man on the bridge will talk. He’ll even let us help him choose life.

But we have to have the time.

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5 thoughts on “Won’t Ask, Won’t Tell

  1. Thank you for posting this. I consider Kaiser’s attitude a reflection of our cultural attitude of not asking itself or telling itself what the unspoken agenda behind this almost universal dereliction of duty that is now considered a kind of ‘evidence based” therapy from Kaiser’s ‘behavioral health system.”

    A system that doesn’t recognize the complexity of the human mind; does not respect it’s patients and does not display any recognition of its responsibility for the lives of the people it seduces into joining the Kaiser ‘system of care. Kaiser spends more on advertising than it does on treating it’s psychiatric patients. What good is it to have ‘facilities’ everywhere if there is nothing in them?

  2. Then there are clients like me, who would never tell a therapist, unless I had years and years of experience with her (like my current therapist, 15 years and counting), that I am suicidal, have a plan, have the means, and have a time. The one time I answered those questions asked by a different professional, I ended up in the hospital for a 48 hour observation. That did not change anything except my willingness to admit to my chronic suicidality. I will certainly carry out my plan, at the appointed time. No 48 hour admission will change that, but it has changed my “honesty is [not always] the best policy” policy. On the other hand, most “regular people” who are suicidal are indeed happy to engage with a sympathetic other, and this is often life-saving. Throwing a drowning person a life-buoy is a wonderful thing to do. I’m glad you now have the gift of time to do it.

  3. Pingback: Thinking of you, Barbara Ragan | All Things Chronic

  4. Andy, I have followed your blog for quite a while. Thank you for your effort. I had bad experience with kaiser psychiatry too. A few years ago I had depression due to jobless and infertility, and turned to a psychiatrist in kaiser fremont, who is very unprofessional. I told her how my life fall apart, which seems nothing to her. One time she even scold me treating her as a therapist and said things like ‘say this to your therapist, not me’ and ‘why don’t you go to kaiser hospital at xxx (somewhere other than fremont) to see a MD who can give you drugs’. She saw me every FOUR months when I was not stable with the medication, and she prescibed very small dosage to protect her liability. I don’t like the way she treated me and finally gave up the medication. I am kind of traumatized and afraid of seeing a doctor after that, And often when I was depressed, I recalled her anger, her rudeness. Fortunately my therapist at kaiser is a very nice person. She sees me every 3 or 4 weeks. She is not very helpful to get me out of my situation but at least when I was down I had someone to talk to. Another problem is that almost every provider in kaiser mental health I saw, were trying to put me into group therapy, even I told them I was not comfortable with that. I guess that is because kaiser’s system, where hospitals and insurance company are together, reduces their cost and makes the most profit this way.
    Thank you for speaking out, for us.

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