While Wilhelm Wundt, who opened the Institute for Experimental Psychology in Germany in the late 1800’s, is credited by some as giving birth to the field of psychology—mankind’s search for answers to solving depression and emotional maladies can be traced to the beginning of man. From shamanic healers to oracles, man has sought solutions to a variety of life’s issues. Today, psychology has produced a number of psychological ‘experts’ trained in assessing, diagnosing and treating whatever ails you. Some have specializations in medicine and neuroscience while others practice psychoanalysis, social work or counseling psychology. Whatever the practitioner’s field, therapists are human and can miss essential information, especially new therapists. If you are seeking therapy, you may want to advocate for yourself by disclosing the following (if the issues pertain to you and/or your family). For any therapists in training (and seasoned vets), this information might help in crafting your initial assessment.
The first and most serious issue is suicide. Did you know 1.5 MILLION lives are lost each year from suicide (according to the Centers for Disease Control and Prevention (CDC))? It is the second leading cause of death among 10-24 year olds and the fifth leading cause of death for ages 45-59. While more males die of suicide, females have a three times higher rate of suicide attempts. The effects of suicide are complex as it causes a deep ripple of confounding grief and guilt among those that surround the victim. The combined medical and work loss costs associated with suicide total $44 billion in the United States each year (per the American Foundation for Suicide Prevention)?
Research shows that most suicides and suicide attempts occur when a person experiences profound sadness and hopelessness brought on from abandonment and/or a series of losses. Additional studies reveal that many people do not actually want to end their life, yet they cannot see any way out of the intensity of pain and emptiness they are experiencing in the moment. Exhaustion and intense pain eclipses hope, meaning and purpose. In “Man’s Search for Meaning,” Dr. Victor Frankl called it the existential vacuum and observed a phenomenon of “give-up-itis” among people in extreme conditions like prisoners-of-war and concentration camps:
In the concentration camps…[they] refused to get up and go to work and instead stayed in the hut, on the straw wet with urine and feces. And then something typical occurred: they took out a cigarette from deep down in a pocket where they had hidden it and started smoking. At that moment we knew that for the next forty-eight hours or so we would watch them dying. Meaning orientation had subsided, and consequently the seeking of immediate pleasure took over. (p 163-164)
Frankl goes on to suggest that many people in less extreme conditions have lost meaning, even if they have money and comforts. Losing a loved one like a child or a job or not feeling a sense of purpose fuels the hopelessness that feeds suicidality. He compares it with laughter. A cause is needed to prompt laughter. Similarly, meaning is needed to promote happiness and purpose in life. Of course meaning and purpose can’t be cultivated if someone is someone commits suicide. The key is in identifying the risk factors before such an act occurs.
One of the challenges for therapists (seasoned and new) is that clients are immediately informed upon intake that therapists are mandated reporters and that disclosing any thoughts of suicide will result in the therapist having to report it. This sets up an almost punitive type of situation that can prevent the client from fully revealing their feelings while also inhibiting the therapist from probing. Thus, any discussion of suicide runs the risk of being perceived as taboo. The use of euphemisms or dancing around the subject only heightens this perception and increases the client’s sense of isolation and shame.
One of the things the therapist can do is to comfortably discuss suicide up front when doing the intake and de-stigmatize the issue when the paperwork is being signed. Explore what the client’s exposure to suicide has been (in life or through books and television). Literature on the topic can be given out with emergency contacts. In addition, a pre-screening of depression, suicidality, and meaning can be incorporated into the initial assessment. Speaking freely and making the topic safe is critical.
If you are reading this and thinking about suicide or know someone that is talking about suicide, please seek help. Call 911 in an emergency. You can also call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). Sometimes when a person has internally made the decision to take their life, they begin giving things away. Don’t be afraid to find out if the person has a plan. If so, the chances for an attempt are significantly increased, so get help right away.
Another issue that new therapists often miss centers around addiction and alcoholism. One of the main reasons for this is that the clients are presenting with other issues such as job loss, relationship problems, money problems, and legal troubles—all of which might actually be stemming from the addiction.
Even with experienced therapists, the underlying alcohol or addiction issue may not surface until the third or fourth session (if it even comes up). Not only does denial play a part, it is overlaid by common misperceptions people have about addiction and alcoholism. Addiction and alcoholism does not discriminate and has no economic, racial, age, cultural, or sexual identity preference. It cannot be easily stereo-typed, yet clients and their families may perceive that only a certain demographic could suffer from a gambling addiction, drug addiction, sex addiction, alcoholism, and other addictions, and therefore rule-out the possibility it’s happening to them.
Again, what therapists can do is provide pre-screening questions in a de-stigmatized and normalizing manner. Information about various addictions and alcoholism can also be shared with resources for additional information. Tests like the Michigan Alcoholism Screening Test (MAST), which has been shown to have good reliability and accuracy, can also be administered and used to explore other substances as well. Gambling assessments and information can be found through the National Council on Problem Gambling (NCPG). In addition, there are numerous 12-step anonymous groups for a variety of addictions that provide additional information and daily support for the addict and alcoholic along with family support.
Both suicide and addictions have high co-morbidity with depression and studies show that rates of depression for Americans have risen dramatically in the past 50 years—in spite of the number of resources. This is all the more reason for therapists to do a more thorough intake. Successful identification increases when the therapist is comfortable and can normalize the topics while providing safety and receptivity to clients. Being able to join someone in their deepest despair and shame not only shatters the isolation, it helps establish a connection with the life-saving human spirit that can transform tragedy into meaning. As Frankl shares, “Even the helpless victim of a hopeless situation, facing a fate he cannot change, may rise above himself, may grow beyond himself, and by so doing change himself.”