Chronic Attempts at Solution: Working with People Who Have Made Repeated Suicide Attempts
All therapists have had the experience of that sinking feeling in the pit of the stomach when certain names appear in their appointment books. (Duncan, Hubble, & Miller, 1997, p. ix) We would gladly trade all we know for all we do not know about patients with suicidal lifestyles. (Chiles & Strosahl, 2005, p. 133) Success can occur with impossible cases when therapy is accommodated to the client’s frame of reference and the client’s theory of change is honored. (Duncan, Hubble, & Miller, 1997, p. x, emphasis in original) There are cracks, cracks in everything. That’s how the light gets in. (Cohen, 1992)
Ashley was seventeen when I first met her, and had already survived four suicide attempts by overdose, the first when she was only twelve. (If you prefer to read a partial transcript of our first meeting before knowing more of her story, skip the rest of this paragraph.) She also had a history of nonsuicidal self-mutilation, both cutting herself with a knife and burning herself with lit cigarettes. Ashley had been sexually abused by an older cousin when she was between ages
eleven and thirteen, and although she disclosed the abuse to her aunt and mother at the time, they did not believe her. The abuse ended when she told her cousin that she would kill herself if he bothered her again. Ashley had also sustained a serious head injury in a motor vehicle accident at age nine, with frontal lobe damage. Sequelae of this event included irritability, chronic fatigue, visual-spatial learning problems, and difficulties with concentration, short-term memory, and decision making. The last two issues negatively affected her school performance despite her superior intelligence and strong verbal skills. At the time of our first session, she lived with her mother, a successful executive who relied on Ashley to collect her from local bars when the mother was incapacitated by drink, and to see that her mother got to bed safely. Ashley routinely checked each night to ensure that her mother was lying on her stomach so that she would not aspirate her own vomit. Ashley had limited contact with her father, a career military officer. Her older brother lived nearby but rarely visited. A beautifully dressed and groomed young woman with considerable presence, Ashley was very dramatic in voice and gesture. In previous treatment relationships she had been diagnosed, despite her youth, with borderline personality disorder.