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Overcoming Communication Challenges in Treating Suicidal Patients

December 18, 2019
By Douglas A. Landy, MD
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(Part 3 of an occasional series)

In my work, I see patients already identified as suicidal either by word or deed. My job is to assess the degree of risk and decide whether inpatient care is needed (higher risk), intensive outpatient treatment is sufficient (lower risk), or routine outpatient care is appropriate (when the identification of suicidal risk has been erroneous). This stratification is not at all straightforward, and part of it depends on the interaction with the patient—listening with the third ear, so to speak. In meshing my own experiences with suicide with those who I treat, I’ve arrived at a number of conclusions which happily are supported in the literature.

The initial goal is to form an alliance with the patient. This can be complicated because people who are severely depressed, feeling hopeless and isolated, may believe they are failing to communicate their distress, or that nobody understands their distress, or both. I apologize for the coming digression, but it’s important to understand more about this first.

There are various models of communication with various numbers of elements, but the basic model is that of a sender and a receiver within a given context.  Within that context (1), the sender (2) encodes (3) the message (4) which is transmitted using words and behaviors through a channel (5) to be decoded (6) by the receiver (7) who gives feedback (8) in the form of a reaction.

Part 1 of the seriesSuicide: A Survivor's Perspective

With so many crucial elements, it’s easy to see how things can go awry, but let’s focus on just a few of these. We’ll use a patient with depression as our model.  A person with depression or another mental health syndrome could misinterpret communicative signaling. As a result, a statement such as “I think you’re great,” may seem to them, “Eh. You’re OK, I guess.” As a result, the patient may say “I’m going to kill myself,” and hear the reaction of others as “We all have hard days. Suck it up.” This is hardly going to facilitate communication. Assessing someone with communicative deficits on the basis of depression, personality disorders, substance abuse, brain disease (e.g., traumatic brain injury), or other problems certainly presents a challenge!

Furthermore, language itself can be inadequate for conveying emotions or complicated thoughts. As the cynical and misanthropic Aldous Huxley said, “…in spite of language, in spite of intelligence and intuition and sympathy, one can never really communicate anything to anybody.”

While there may be some truth to that, there is also the responsibility to do what we can. For that reason, especially for one with communication impairments, lending words is a powerful tool—not only to understand others but to help them feel less isolated and hopeless. With someone who comes into the Emergency Room I might say something like:

“Let me see if I can put this into words for you. Please tell me where I’m wrong. It seems to me you’re trying to say that despite all your efforts to tell people that you feel awful, they just can’t hear it. It’s like you’re in the middle of a hurricane, trying to shout how awful you feel, and nobody hears you, and you feel alone and unloved and afraid it will never change and you’re waiting for the hurricane to kill you, and you want to be dead, for it all to just stop. Does that sound like what you’re trying to say?”

Putting it this way gives the patient power and responsibility and I’m lending them words using imagery. Most patients respond to this approach with a cautious step towards collaboration.  They aren’t interested in fMRI findings or Cochrane studies; they are an N of 1 and their study tells them matters are hopeless and they should be dead. It’s not our job to tell them otherwise; it’s our job to help them tell themselves otherwise.

Part 2 of the series: Suicide Attempt Survivor Shares Lessons Learned

Please note that I said “you want to be dead,” not that the person wishes to die. Most of the suicidal patients I’ve worked with want to be dead, as death is a refuge from the vicissitudes of life; but the process of dying is what has them scared. They are already suffering. They don’t want any more, but if death will make the pain stop, the pain of dying might be worth it. This is another important point to explore.

When I overdosed, my plan was to lie down and just slip into death while I slept. Not dramatic, just practical. Others might take more certain steps, but this is not the place to discuss suicide methods. The point is that some people prefer certainty of death and some prefer avoidance of pain. Which one the patient tried, or intended to use, is important as well. The choice of a less violent method is not the same thing as the certainty of death. Unfortunately, I could not find any studies on this point, but my own experience suggests that people who choose certainty over pain avoidance may need more intensive treatment and have a higher risk of another attempt. Until such research is done, however, that is merely speculation on my part.

To recap: Communication is impaired in the suicidal patient. Our attempt to help the person communicate can lead to a decrement in their isolation.

My next blog post will talk more about the process of identifying how to help a patient move past a suicide attempt and restart their lives.

Douglas A. Landy, MD, graduated Hahnemann University School of Medicine (now part of Drexel University) in 1983. He is a board-certified psychiatrist, and practices primarily in an inpatient setting with additional work in the Emergency Room and nursing home consultations. He has had experience in sleep medicine and  forensic psychiatry, and has an interest in traumatic brain injury. He lives in Rochester, New York.

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