“No-suicide decisions”

The problem with having an option to kill oneself is that it is effective in reducing anxiety without solving the basic problem. The suicide option is a plan of action, and like all action plans, functions to reduce the anxiety that arises from having a problem with no easy solution. A reduction in anxiety also reduces the motivation to find another and better solution. Making a “no-suicide decision” will sharply increase the anxiety-level. The increase in anxiety motivates us to find a new solution to life’s problems

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Recently a battered wife whose alcoholic husband regularly threatened her life told me she could stay in the marriage because “if it got too bad, I can always kill myself”. The thought of having a “way out” through suicide reduced her anxiety at the thought of being “trapped” and made it possible for her to continue living in that situation. The effect of making a no-suicide decision is fairly obvious: 1) her anxiety level is going to rise sharply since she no longer has “a way out”; 2) the rise in anxiety level should trigger other solutions that do not involve suicide.

Imagine yourself for a moment in her position. You can find the situation barely tolerable by reminding yourself that if the situation “gets too bad” that you can always kill yourself. Your counselor tells you that if you make the no-suicide decision, you may have another 30 years in that situation.

The counselor then asks “Can you imagine enduring your situation another thirty years or so?”

You reply “Absolutely not!”.

This vignette illustrates the power of the no-suicide decision to provoke a new decision to change things.

The no-suicide decision has been described in other articles by myself and others, and is quite simple to describe technically, if somewhat more difficult to put into practice. A person who indicates their willingness to make such a decision is asked simply to read the following words from a piece of paper or from a blackboard: “I may feel like killing myself AND I will not.” The person making the decision should be told not to change the wording. Note that the statement deliberately separates feelings from behaviors. It is important because patients frequently feel they are unable to control their emotions and thus would be making a “false promise”.

The therapist then points out that only the client can tell whether or not the statement is true. The client may be asked to read the statement without meaning it, in order to clarify the difference between commitment and insincerity. The person can be invited to “Say it again and mean it”, but more often the patient will spontaneously carry out this action. I always ask the patient if they felt “solid” with the decision or if they were not sure if they meant it. If they indicate uncertainty, I suggest they spend some time thinking about it and discuss it with family, and at a later time with me. It is not useful to bring pressure to bear on the patient, since inducing some kind of insincere compliance is counterproductive.

It is important to emphasize that this decision is NOT a contract of some kind. It is not an agreement between client and counselor. It is not a “promise”. Contracts and promises can be broken. The no-suicide decision is not between the client and anyone. It is not dependent upon anything. Sometime their heightened anxiety causes them to look for “loopholes”. I suggest they add the following: “If I find a loophole in my decision, I will not take it”.

I am intrigued by the fact that making such a decision is so difficult without the presence of another person. Why can’t I tell what I mean when I’m simply thinking to myself, or even talking aloud while driving alone? I do know that the moment such thoughts are expressed to another person actively listening whose opinion I respect, I can tell whether I am being truthful or just playing with thoughts.

Bear in mind that the no-suicide decision is not for the benefit or reassurance of the therapist. It is to allow the patient to force him/herself into a position in which s/he will be under pressure to make changes rather than continue temporizing. Patients sometimes want to engage in pseudo-philosophical discussions rather than actually make a commitment. These tend to be the same patients that talk and talk in therapy without actually doing anything. “Talking about” for them is instead of taking action, rather than preparatory for action. I have been known to suggest suspending therapy for a period of time to “give them time to think things over”.

I strongly believe that patients in therapy with open suicidal options will do very little except talk. If therapy is a place in which people wish to change, an open suicidal option precludes that possibility. In early stages of therapy clients are often involved in philosophical exploration, rumination, self-examination. They are not ready to change; they are in what Prochaska calls “pre-contemplation”. I want to be clear that no-suicide decisions are necessary only in the stage of therapy in which change is the goal.

A more serious technical difficulty is in the timing of suggesting a no-suicide decision. Very early in the therapy, when the relationship of therapist and client is still new and tenuous, it is easier for the client to terminate rather than face the anxiety and discomfort of change. By suggesting the no-suicide decision too soon, the therapist may be asking the patient to give up a tactic that for some time has provided the only “way out” of a difficult or impossible life. Why should the patient believe the therapist is competent and has something to offer that is better?

Clients would not come to therapy if they were simply and purely suicidal. They would be dead. They are in therapy because, whether or not they know it, they are significantly ambivalent. They want to have a life but fear it. They fear they won’t be competent to solve their important problems. They fear that a solution to their problems may require a radical rethinking of their values and beliefs. They may not be ready; they may not be able; they may lack the courage.

A caveat: Therapists who have open suicidal options themselves will be generally ineffective in getting no-suicide decisions from patients.