The other day at my placement was particularly difficult for me. One of my clients, let’s call her S, came in after having cut herself a few days earlier and as I questioned her, I learned that she had some suicidal ideation. In layman’s terms, this means that she expressed some wishes or fantasies about wanting to be dead.
S is a young female who is involved in a committed two year relationship and has suffered various traumas in her childhood. She has the borderline personality disorder which manifests itself in her as anger, impulsivity and frequent mood swings, as well as her having a chronic feeling of emptiness, self-mutilating behavior and suicidal attempts.
Puzzle Pastel Pattern by Patrick Hoesly
From what I have learned about people who have borderline personality, I know that one of the behaviors that I can expect is that she may alternate between idealizing and devaluing other people. However, I have not really seen any of this to date. S has only demonstrated positive regard towards me and been a very sweet and committed client who has been coming to see me on a regular basis since September.
The struggles that S experiences around anger management and impulsivity tend to lead to some difficulties in her interactions with others. For example, when she feels disrespected, she often resorts to getting into a physical fight so as “to save face.” Alternatively, she may curse out the other person for less severe slights.
My approach has been to basically validate her feelings and then to show her more productive ways of engaging with others so as to achieve her goals. I’m also working on explaining the whole connection between our perception of events and how they affect our feelings and ultimately our behaviors.
In any case, prior to this week’s appointment, S had not shared with me her prior history of self-mutilation or suicidal attempts. I only knew this information from her medical record. However, once she came in and shared her experience of having cut her arm after being angry, this allowed me to then explore not only what may have triggered this particular self-mutilation act but her history in this regard.
One of the next steps in a situation where a client has just committed an act of self-mutilation, is to find out whether the client has any suicidal ideation or intent. Sometimes a client may wish to end his/her life and sometimes not. If the client expresses a wish or fantasy to no longer be alive, I would then need to ask some additional questions to help gauge whether that person is at risk for committing suicide and if so, I would need to arrange for him/her to be hospitalized to ensure my client’s safety.
While I had studied about these steps and discussed the “what if” scenario with my supervisor, it is one thing to read about what to do and it is quite another thing to have to apply the right steps and to feel totally responsible for the welfare of another person.
Digital Apple by Patrick Hoesly
The reality of being responsible for S’ potential life made me feel anxious because it was a bit scary. That said, I went through the requisite steps and saw that while she had some suicidal ideation, she did not express an intent to end her life. Therefore, once she had “contracted for safety,” I was able to let her leave my office as opposed to my arranging for her to get hospitalized.
For those who are unfamiliar with the expression “contracting for safety,” S had essentially promised me that she would either call (or come to) our office or the ER/911 (after hours) should she have the urge to end her life to get help so as to ensure her safety.
As soon as my session with S ended, I quickly sought my supervisor and she asked me to bring S in to speak with the head of the department. The part that felt good in all of this is that the head of the department proceeded to walk S through the same questions that I had asked her and drew the same conclusion as I.
Furthermore, S had conveyed her degree of comfort with my being her therapist at that meeting. All this made me feel that I had handled this event well despite it being my first time, my worries about S and the overall anxiety about having such the huge responsibility of her safety on my shoulders.
pHow did you feel about handling your first client who engaged in self-harm and had suicidal ideation? And how do your feelings change as you get more experienced? The sense of responsibility is not going to change… there is still a risk; someone’s life is still in your hand’s if you make the wrong call…
Please share your thoughts and comments. I really appreciate them 🙂
Photo Credits: Patrick Hoesly
Puzzle Pastel Pattern
Digital Apple
Sounds like you handled this all extremely well. It’s a sign of trust that she shared this information with you.
By the time I was working as a therapist I already had a lot of experience with clients who hurt themselves, having worked with many in the community residence programs where I worked with people who had serious mental health problems (before my MSW). So I don’t recall being scared when I first encountered this in my psychotherapy work, although I do recall being scared the first time I encountered someone who was seriously suicidal in my psychotherapy work (an older man who was thinking about shooting himself with the gun he had at home, after having lost his wife in the prior 6 months). The sense of responsibility is scary…which is why I always try to share the burden with a colleague/supervisor.
While it’s absolutely correct that you need to assess someone’s lethality after a self-harm episode, most often the crisis has passed after the self-injury. There is an extensive research literature now on self-injury/parasuicide..the acts often release endogenous opioids and often are very successful at changing mood, which is one reason people do it. Many of my clients used it to regulate emotion and it works for this purpose. The problem is that the behavior brings some risk (because methods can produces unintended results) and often many negative consequences too (not the least of which is hostility from service providers).
People who have lived through significant, repeated childhood trauma often have significant problems regulating affect and end up diagnosed as having bipolar II and/or as borderline personality disorder. What they really need is help learning to regulate affect in other ways (Linehan’s Dialectical Behavior Therapy is one way to do this) and then they need specialized trauma treatment to allow them to emotionally process what happened to them (the latter requires special training..I’m not talking about traditional talk therapy).
It’s often interesting to explore with clients what the good and not-so-good things about self-harm are. Just asking this question helps build trust, because very few professionals understand that there some good things about the behavior (from the client’s point of view). I had one client identify that people would see she is tough and not hurt her.
That’s interesting that you already had experience working with lots of people who had hurt themselves prior to working as an MSW therapist.
Having a protocol of sharing the burden with a colleague or supervisor sounds like a good idea. Interestingly, my supervisor sought immediate administration involvement. This may have been for the very same reason.
That’s good to know that in most cases the crisis has passed after the self-harm episode act has been completed.
Coincidentally, we just started to discuss the DBT modality as the method of treatment for people with borderline personality in my CBT class this week. Unfortunately, we only have one more class left so we are not going to be able to cover this technique in depth.
However, it is my intent to take the DBT mini-course elective next semester and that should enable me to get a more in-depth picture of how I may apply this approach with S.
Re the good parts of self-harm, I had done some exploration but I agree that it is a good idea to do some more. For now, I understand how the cutting is effective at dissipating all of S’ anger and that she feels a tremendous sense of relief once she has completed the act.
Thanks so much for all your invaluable input and guidance!
I agree with NJSmyth that you handled the lethality assessment very well. I didn’t have any experience with suicidal ideation or self injury prior to my MSW training. I remember feeling scared of the responsibility; I was afraid of making the wrong decision. After close to 30 years, I still feel a little momentary anxiety when having to determine suicide risk.
Usually I find that clients who engage in self injury are not trying to kill themselves but trying to regulate their emotions. I’m glad you are going to take the DBT mini-course. Even before you start the class, you can read up on mindfulness skill training, because mindfully accepting the present moment without judgement is a significant part of DBT affect tolerance skills.
It’s so nice to hear that feeling scared of the responsibility at the beginning is “normal” 🙂
That’s so interesting to learn that mindfulness is part of the DBT affect tolerance skills…Nancy (Smyth) had suggested a few weeks ago that I learn some mindfulness to assist in focus/attention during my sessions.
Thanks so much, Andrea, for having visited and shared some of your experiences and feedback,
Dorlee
Wow, what a week you’ve had. I think the above comments have said a lot of what I would have, but I can add that DBT has a lot of very effective strategies for patients to use between sessions. I highly recommend Thomas Marra’s book Dialectical Behavior Therapy in Private Practice. It is a great resource, and has a CD with several worksheets and slideshows that patients have really responded to. Much of DBT has begun to be used beyond just BPD because of its broad efficacy. I use it often with my online therapy patients to complement the Skype sessions, and have found it useful with helping people with ETOH and other substance dependence as well.
I agree with Nancy that her sharing this was a sign of her trusting you. It may also have been a test: Can you contain me? Will you take my life seriously? From a psychodynamic perspective, once you have assessed for safety and offered some skills-building for alternative to self-injury, it is important to wonder about the communicative quality of the self-injury, as well as its metaphoric quality. Does the place of self-injury on the body have significance? Is it marking the place of a trauma? Is there something written or drawn? Are there wishes being expressed by the injury? These should not be overlooked after safety has been established, because patients will often continue to communicate until you get the message.
As for my first experience with suicidality and risk assessment, I’d like to say I remember it, but the truth is I have done it so many times in private practice and in other settings that I can’t. This may speak to the tendency as clinicians for us to become alert and attuned in a certain way during a crisis. Too often we don’t have time (or make time) to debrief and reassemble for ourselves what happened. I am glad you followed through on that part with your supervisor, and hope that you were able to connect with loved ones and friends afterwards to continue that. Congratulations on another “first” completed.
Thanks for the DBT book recommendation 🙂 It sounds like a great resource to learn from and use in one’s clinical work.
I’m also most appreciative of the additional questions and areas you have suggested that I explore regarding my client’s self-injury. I will make sure to look into these with S.
Hmm…so self-mutilation acts and suicide risk assessment are something that one should expect to face many times as a clinician. That’s pretty rough.
Actually, I only did a partial debriefing with my supervisor but I will have a full debriefing after she reviews my process recording of this session with S.
Looking back, writing this post and putting together the process recording was also a bit of debriefing for me.
Thanks so much, Mike, for all your encouragement and guidance,
Dorlee
Another excellent post, Dorlee! I think you handled the situation extremely well in ensuring your client would remain safe and in assessing safety issues. In addition, it is clear that you have a positive connection with your client and that she trusts you, in which enabled her to open up and share her intimate thoughts about unsafe gestures and suicidal thoughts. Great work, Dorlee!
Are you experienced in DBT? Dialectical Behavior Therapy is quite effective in treating Borderline Personality Disorders.
Thanks so much, Laurel 🙂
Not yet…but I will be learning about DBT very soon. And it is my intention to start reading up on it so that if it is not too difficult, perhaps there are pieces that I will be able to start applying sooner rather than later.
With much appreciation for all your support and encouragement!
Wow, Dorlee. Your post reminds me how important and challenging being a therapist is. I am grateful that so many wonderful people are passionate about doing this good work. From my ‘layman’ background, I have learned that Borderline Personalities are some of the most challenging to work with…I hope S comes to find some peace for her/his self. And I am wondering how you detach yourself from these complex and intense situations with clients? How do you let them go?
It is hard, Terry, but I am finding that by sharing some of what I have gone through with my supervisor, other students, and supportive friends like you, I am able to regain my inner equilibrium and focus again on figuring out and/or learning what would be the next steps to work on with each client.
Thanks so much for being there for me as I go through this challenging training phase 🙂
I am going into my first internship next fall, and it has been a real privilege to read your posts on your experience. Your clients are fortunate to have you and the supports you bring with you.
I am also someone who has done suicide assessments as part of previous social service work. From that, as well as training and listening to people who have self injury as part of their past, I’d like to offer a slight language shift. A less charged phrase than “self mutilation” is “self injury.” Sometimes that involves cutting (as you mentioned), but it can also be a wide range of other behaviors, which might not leave permanent marks. Referring to SI as “mutilation” can convey to the client a weight of judgment or stigma which [from your blog] I don’t think you hold. The more neutral “self injury” can allow a client to open up about what they are doing, with fewer fears that they will be misunderstood. Very often, they do have the awareness that their actions are a precise, measured strategy for coping with pain, or gaining some control in a situation where they feel powerless. Using neutral language also enables them to trust that you will differentiate between their self injury behavior, and a suicide attempt (as you clearly were able to in this case).
Apart from the DBT, you may find this site useful. It is a few years old, but solid and clear: http://www.palace.net/~llama/psych/injury.html If you work with a harm reduction approach, that site also has some tips for reducing the lasting effects of SI, preventing infections, and substituting other means of achieving the clients’ emotional needs in the moment. Best of luck as you continue your work!
Thanks so much for all the helpful advice and guidance, T!
While I did not use the term self-mutilation with S for different reasons, I am glad that you shared with me the possible negative connotations that it could have raised. This way, I will make sure not to use it with other patients plus I will cease to use it on my blog so as not to convey the wrong impression.
As I’m thinking about it, an additional benefit to using the word self-injury is that it would encourage clients to share other acts that they may be engaging in on the spectrum of self-harm that could get lost with the rather limiting self-mutilation word.
I will definitely check out the site you mentioned on providing harm reduction tips.
Thanks so much for visiting and being willing to share all this great information.
I’m so glad that you have been finding this blog helpful and I wish you the best of luck on your internship next year!
Dear Dorlee,
You give such valuable information for others who are in the process of becoming social workers. I hope you’re reaching these people with your blog!
Great job!
Lauren
Dear Lauren,
I’m trying…Thanks so much for your very enthusiastic endorsement!
You are most kind,
Dorlee