This is a very early story I wrote, probably in 2005. As promised, it’s posted “as is,” so if you want to improve upon your own writing, take note of the poor syntax, awkward sentences and changes in tense.
When I first started my private practice, I did a lot of internet advertising to get clients, and I offered significantly reduced fees. I figured it was better to be sitting in an office making a little money than no money at all. Because of my affordability, I received a lot of phone calls from college students and young professionals, people who couldn’t afford experienced (i.e., expensive) therapists. Monday mornings were always my busiest time to book appointments, because depression seems to peak at the beginning of the work or school week. I also got a lot of young people who made poor choices over the weekend, usually involving drinking, drugs, infidelity, bizarre sexual encounters, etc., and have decided “okay, this is it. I really need help.” I was particularly busy around midterms and finals, when students are totally stressed over exams and their futures.
“Patty” called around 10 AM on a Monday, right before Christmas break, citing my online ad for “AFFORDABLE COUNSELING!” We spoke on the phone for about 20 minutes before scheduling an appointment for later that day. A brief phone call is common practice for me, because I like to find out a little bit about what they are coming in for, to see if I’m qualified to take on such a case, and to allow the potential client to ask questions about my practice, such as fees, availability, qualifications, therapy approach, etc. People seem to appreciate the time you spend with them, helping them to feel comfortable before booking an appointment.
Patty told me that she had been feeling depressed and anxious lately, due to relationship problems with her boyfriend, poor grades, and constant fighting with her parents, who were furious at having spent well over $100,000 for a local college, just to see her go on academic probation. Patty came in that day wearing a big, bulky coat, oversized for both her frame and the time of year, holding in one shaky hand a tattered backpack with patches of left-winged political slogans, and a cup of what looked like jet-black coffee in the other. Caked eye-liner was all over both of her eyes. My office is generally scorching hot because of some weird pipe problems in the building, so I offered to relieve her of the coat right away, but she refused. She just sat down, crossed her legs, and waited for me to speak.
Dr. Dobrenski: So why don’t you tell me more about what brings you in?
Patty: Other than what I’ve told you over the phone, there’s not much else. It’s just really hard right now.
I didn’t learn a whole lot over a brief phone call, so obviously there’s a lot I don’t know about this woman. One approach would be to ask her to tell me more about what has been going on in her life, but when a client seems particularly distressed, it’s generally a good idea to find out how long this has been going on, and how she has coped with this so far.
Dr. Dobrenski: Yes, you sounded very upset on the phone. How long have you been feeling this way?
Patty: Probably about a month or so. My boyfriend and I aren’t working out very well, and my parents have been on my case since midterms. I didn’t do very well, and I’m at risk for failing out with only 3 semesters until graduation.
Dr. Dobrenski: Are there any times of the day or week that you feel better, any times at all when you feel more like yourself? Happier?
Patty: Not really, although I tend to feel very depressed in the morning and anxious at night. (She becomes a little teary) I just don’t know what to do. I feel like giving up. It feels hopeless.
If you ever want to become a clinician (or if you are currently one and are seeking a refresher course in crisis intervention), you need to immediately pair the terms “giving up” and “hopeless,” with the word “suicide.” In fact, the concept of hopelessness is most strongly correlated with suicide attempts. In other words, while there is no way to perfectly predict what someone is going to do at any given moment, unless they are holding a Deringer right at their temple, if they mention either of those phrases your eyebrows should either literally or figuratively go up, leading you to inquire about the possibility of suicide.
I immediately drew up my list of questions for these types of situations:
• Do you ever think about hurting yourself?
• Do you have an idea of how you might go about doing it (in clinical terms, they call this “assessing the plan”).
• Do you intend to follow through with this plan when you leave here, or before I see you again?
• Can you make an agreement with me that you will stay safe for (insert arbitrary time frame here)?
Patty made things easy for me. After question one, she said “I already have. I want to die.” At that point, she stood and removed her no-longer suspicious coat to reveal two red wrists that were ever-so-gently dripping blood on the carpet. There wasn’t a lot of blood to speak of, and she hadn’t lost any color in her face, but I think she reckoned she would get a strong reaction from me, given the dramatics involved in the act.
During my internship year, I spent most of my time working with suicidal and para-suicidal women. These women were often very depressed, and would harm themselves in very horrific ways. Razor blade cuts on their arms and legs, cigarette and lighter burns, banging their heads on tables and walls, and digging their own fingernails into their skin until they bled were part of these women’s daily routine. While the overall goal was to help these women improve their mood and their overall happiness, because of the potential severity of their actions, they needed to have their behaviors controlled as soon as possible. From a humanistic perspective, it was scary and psychologically painful to watch these women struggle. From an educational aspect, it allowed me to learn immediately not to panic when I see these types of actions in my practice. Empathy is beyond important, but it is also critical to show the patient that you are calm, prepared and ready to help. She doesn’t need to shock you to get the message across that she needs you.
With these experiences in mind, I ran through my next set of questions:
• What is the nature of the injury (e.g., where on the body, the depth and length of the wound, etc.)
• When did the act occur, and was anyone present or soon-to-be-present after the act?
• Why is this person volunteering this information at this point in time?
Patty’s cuts were pretty superficial. Upon closer inspection, she had made one slash on each palm, not wrist, about one inch in length, probably with a razor blade or steak knife. I would have been surprised if they even needed stitching. Because she was still bleeding, she probably couldn’t have done this long ago, or if she did, she must have just re-cut herself to get some more blood flowing, because she certainly didn’t seem to be at risk for significant blood loss.
Dr. Dobrenski: When did you do that?
Patty: Right before I came up here.
Dr. Dobrenski: Where?
Patty: Outside your building.
So now I know that this woman isn’t really trying to kill herself. She makes two superficial cuts on her hands immediately before her appointment, fully knowing that she was coming to see me right after the act. A lot of times, a panicky mother will bring her teenager to the E.R. for shutting himself into his room and taking 3 aspirin. It becomes my job to explain to her that her son is likely in a lot of psychological pain and is giving a “cry for help.”
Dr. Dobrenski: Patty, go into the bathroom and run cold water over your hands. There’s some Bactine, towels, and bandages in there. Bring those out and let’s decide if we’ve got enough in the makeshift first-aid kit, or if we need to take you to the doctor’s office next door for a closer examination.
She came out about 10 minutes later, and her hands and wrists looked much better. It didn’t seem like a trip to the doctor or hospital was necessary.
Dr. Dobrenski: Why did you decide to do that right before you came up for your appointment?
Patty: I don’t know. Maybe I thought that you would take me seriously this way?
Dr. Dobrenski: I see. Did I say anything on the phone to make you think that I wouldn’t take you seriously?
Patty: No no, not at all. Maybe it’s a classic cry for attention (smiles).
Dr. Dobrenski: It seems like it, but it’s also pretty obvious that you’ve got a lot going on right now, that you really could use some help.
Patty: I really do.
Dr. Dobrenski: I’ll try to help you as best as I can. I know I don’t look it, but I have a lot of good experience working with people, especially people in your age bracket, who are feeling pretty down about their lives. I can’t make any guarantees, but I’ve had good success with those people, so if we work really hard together, I don’t see why we can’t have good results with you as well. I really need to hear from you, though, that you won’t do that again, and if the urge to do that comes on again, you’ll either call me or your medical doctor, or you’ll get yourself to the hospital.
Patty’s situation brings up a common dilemma for many therapists: whether or not to introduce a “safety contract.” Some therapists insist on having their client sign a form, essentially promising not to engage in any self-harming behaviors. Other practitioners see this as treating the client like a child, and refuse to insist on having a worthless piece of paper with a signature on it. There are benefits and liabilities to the suicide contract. While a safety contract is by no means a legal document, some clients have reported that when they are feeling their lowest, when they have urges to hurt themselves, seeing the contract and thinking “my word is bond” has helped them not to act on suicidal impulses. This approach tends to work best with clients whom therapists have been working with for a long time. In graduate school, I had a client sign a contract, and I also signed the form, stating that I would do my best to help her find appropriate help if her urges became too strong (e.g., have her come in for a session, get her to the hospital, arrange an appointment with a psychiatrist). Other patients, however, have said that the contract does, indeed, make them feel like a small child, sometimes even leading to feeling resentful toward their therapist. Resentment on top of everything else they are experiencing is a disaster waiting to happen. I generally approach suicide prevention somewhere in between the suicide contract and “laissez-faire” approach. With Patty, I asked for her word that she wouldn’t take any action on suicidal impulses, fully knowing that because I am not with her 24 hours a day, she could easily retract that word if the urges to self-harm were too strong. Most clients seem to appreciate the implicit message: I know you can and will do whatever you decide, but if you tell me that you won’t hurt yourself, I do expect you to follow-through on your word.
Although Patty wasn’t acutely suicidal, at the end of the session she was still very fragile. We agreed that she would come in again tomorrow, and that we would work together two times per week (instead of the traditional singular session each week), until she was feeling much more stable. We also arranged for her to see a psychiatrist for advice on whether or not an anti-depressant medication would be of benefit to her. After a few weeks, Patty seemed more upbeat:
Patty: I feel a little bit better, more hopeful.
Dr. Dobrenski: That’s fantastic! In fact, “hopefulness” is one of the first signs that a client will have a good therapy outcome.
Patty: That’s good to hear. It’s amazing how much you’ve helped me in such a short period of time. You really are incredible.
Dr. Dobrenski: Thank you very much for saying that, but all I’ve done is what a therapist is supposed to do. You’ve done much more of the work than you might first think. You had to make a decision to come here for your first visit, make a promise to a virtual stranger not to hurt yourself, and open yourself up to psychotherapy and a medication evaluation to see what these services could provide for you. That’s asking a lot for someone who has so much on their plate.
Patty: True, but you just seem to have your act so…together. You clearly know how to handle problems.
Dr. Dobrenski: Well, I’ve been trained to help people handle their problems, but you should know that therapists aren’t superheroes. We have our own stuff to deal with on an everyday basis, just like everyone else. And we often don’t have all the answers.
Patty: Oh please. You must have a perfect life, great relationships, a rewarding job…
Right around that moment, the office line rang. While the ringer on the phone was always on, just in case the call was from the concierge in the lobby, informing me that the next client was here for their appointment, the answering machine volume was always off. Well, almost always off. I checked the caller I.D. on the handset to see it was my friend Mark, so of course I let the call go to the machine. Big mistake.
Mark: Dude, fucking pick up! I know you’re there, pick up…asshole! Pick up the goddamn phone! YOU’RE the one with the genius advice to be more assertive at work and demand a raise. Well I did, and I got demoted. When I see your giant, stupid face…
As soon as I heard his first word, I dove across the office to frantically press the mute button, just in time for Patty to not find out what my fate was when Mark did, in fact, see me. I immediately had a bizarrely ironic fantasy where I threw myself out the window, breaking my leg and being hospitalized just long enough for Patty to find a more competent practitioner and forget about my existence. Being on the 21st floor prevented my wish from coming true, however, so I was forced to sit back down, mortified as I prepared to resume hearing all the wonderful things Patty had to say about me. Good therapists own up to their gaffes, whether it be befriending a man as menacing as Mark, yawning in session, or having his or thoughts drift away from the topic at hand. At that moment, though, all I wanted was this session to be over.
Dr. Dobrenski: I’m sorry, where were we?
Patty: Wow, you’re friend seems really pissed.
Dr. Dobrenski: Oh, him? That’s nothing. Pay no mind.
Patty (laughing): This must be pretty embarrassing for you.
Dr. Dobrenski: To be honest, it’s more than embarrassing. I want to crawl in a hole.
Patty: I guess you proved your point, though. You do have your own set of problems, and it sounds like you don’t always give the best advice in the world.
Dr. Dobrenski: I guess that’s true.
Patty: That message was so great! Suicide is probably the LAST thing on my mind, at least today. Thank you!
Dr. Dobrenski: Anything to help. Just please let me choke and die right now.
Patty: You know, you should write a book or something. Like funny things like this that happen in therapy.
Dr. Dobrenski: Really, you think so?