Reminder from the bridge: Suicidal individuals are full of ambivalence

Sign on NYS BridgesToday Mike Hogan, Ph.D., the Commissioner of the New York State Office of Mental Health honored RNN-TV and the NYS Bridge authority for their work in suicide prevention. The bridge authority put up signs and installed lifeline phones with direct link to the National Suicide Prevention Lifeline.

For clinicians assessing and managing suicide risk, the fact that phones installed on a bridge have been used by individuals who went on to live is testimony to just how much ambivalence remains, even in people who have gone very far toward resolved plans and preparatory behavior.

Understanding that ambivalence is key to clinical work with suicidal individuals. When I train clinicians about assessment and response to suicide risk, I often get questions about whether it is useful or even right to assess suicide risk. I'm also asked, "What about people who have good reasons for killing themselves or who rationally decide they want to end their lives?" My answer goes something like this:

Thankfully, for health care professionals there is no practical dilemma here. If you find out about a person's suicidal thinking, then there is some degree of ambivalence. Everyone knows that psychotherapy or primary care are about health...that is life. We're not about suicide and death. So if someone is coming to us, at least some small part of them is aligned in that direction. And it's our job to understand that ambivalence and work toward health and life until such time as the ambivalence is resolved in one direction or the other.

That line of thinking can apply to any person, really--not just healthcare professionals. Except in some rare circumstance that you'd have to work hard to construct, the fact that someone is still alive and letting someone know by words or action about suicidality reflects ambivalence.

The fact that people read signs and use phones on bridges also discourages a fatalistic stance on the part of clinicians. We can't simplify the matter by saying "If someone really wants to kill themselves they will, so what's the point of screening or assessing?" That question misses the point. We assess because people don't want to kill themselves. Some just don't see options for life and, under the wrong circumstances (like under the influence of substances or after a particularly deep emotional wound), they overcome their ambivalence just long enough to do the unthinkable. We need to have deep compassion for the amount of pain that must be, and nurture the life-embracing side of the ambivalence until the person can see options again.