Kyle: It all hit me at once. The vet bills were through the roof in those last days. Trying to treat the cancer, keep my pup alive, but I lost her anyway. [pause] Then the basement flooding and the contractor telling me I had to repair the foundation of the house. I felt so desperate. I went back to the casino last week… ended up losing everything that I worked for in the last eight months. I don't know what to do. I feel like such a loser.
Therapist: This all sounds really overwhelming, Kyle.
Kyle: Yeah. [pause] I don't know how I'm going to pay my mortgage or anything else for that matter. I feel so hopeless. Why am I so stupid?
Therapist: It sounds like you wanted to do whatever you could to keep your dog alive, and at the same time, were stressed and overwhelmed with the burden of a bunch of new financial responsibilities coming at you all at once. We've talked before about some of the emotional triggers and life stressors that make you more vulnerable to urges to gamble. Does it seem like that's what happened in this case?
Therapist: You know, Kyle, based on some of the things we've talked about in previous sessions and what you've shared with me today, it sounds like you're losing hope once again. Last time you felt hopeless for a long stretch, you had thoughts of wanting to end your life. It makes me wonder, are you currently thinking about killing yourself?
Kyle: [pause] Um … yeah, I am.
Therapist: Okay. Thank you for letting me know. I want to get a sense of how intense these thoughts are for you right now. I know you've said before that rating your thoughts feels a little weird, but answering this question is useful in helping me gauge where you're at right now. Let me know if this makes sense for you. If you were to rate your intention to kill yourself on a scale of 1 to 10, 1 being "I have no intention of killing myself" and 10 being "I am going to kill myself," how intense are the thoughts?
Kyle: Um … like a 9?
Therapist: 9. It sounds like you're in a lot of pain. Tell me more about what being at a 9 means for you. For example, what makes you at a 9 right now, rather than an 8?
Kyle: I just … I just don't see the point. What does it even matter if I'm here or not? No one would even notice.
Therapist: I would notice. [pause]. I can hear how alone you're feeling, though. And Kyle, if you think back to the past week, how often have you had this thought, that you want to kill yourself?
Kyle: Every day.
Therapist: It sounds like that thought is really front of mind right now. And when you think about it, do you have a plan for how you would kill yourself?
Kyle: Probably … probably pills. I have lots of pain killers left over from my surgery last year.
Therapist: Mmm-hmm, you would take pills. If I remember correctly, the suicide attempt last year was an overdose, is that right?
Kyle: Yeah, it was …
Therapist: I'm hearing that the desperation and hopelessness and just feeling bad has gotten unbearable once again. [pause] And if I ask you to think back to how you were feeling and what you were thinking last year before you took all those pills, was your intent to kill yourself?
Kyle: Well … yeah. I think so? I don't know. I just couldn't handle dealing with life and how absolutely crappy I felt ALL THE TIME.
Therapist: I hear that. You were overwhelmed and wanted a way out. Do you have thoughts about when you would take the pills if you were to follow through with this plan?
Kyle: Um … I don't know. It's not like I have a date in my calendar or anything. I just know that when I've been drinking lately, it feels … more possible, you know?
Therapist: Mmm hmm. How often are you drinking? How many days in the past month, would you say?
Kyle: At least a beer every day. But some days, it's a lot more than that.
Therapist: [gentle] Yeah, we've talked about that too, eh? How alcohol—at least in the moment—can be effective in dulling the pain. What worries me, Kyle—and I know we've talked about this—is that drinking can also increase the risk that you might do something to hurt yourself. [pause] Lately when you're drinking, it could be one beer up to … What would be the most you'd drink in one day?
Kyle: I don't even know … maybe six beers, plus a few glasses of Jameson or something … I sometimes lose track.
Therapist: [empathic] It sounds like you're in a lot of pain right now, Kyle. What I'm hearing is that you just want to make that pain go away. To make it disappear. It's common for people with similar experiences to yours―a long battle with depression, overwhelming stress, major financial loss, the painful emotions that come with relapse―all of this happening at once―to consider suicide. Based on everything you've told me, I'm really worried about you. I want to help you stay safe right now.
Kyle: Okay …
Therapist: Do you remember when we talked about confidentiality and those times in therapy when I have to break confidentiality?
Kyle: Kind of …
Therapist: This is one of those times. Depending on what we decide to do together, in order to keep you safe right now, I have to let others know that I'm worried about you. I'm worried about the risk of you hurting yourself or following through with your plan to kill yourself.
Kyle: Okay … um, well, what does that mean?
Therapist: I'm going to suggest―and I've done this with other clients―that we go to the emergency room together, right now. It's very important that you're not alone right now. If you've been to the ER before, you probably know somewhat what to expect. You'll first see a triage nurse and tell her why you came. I'll be there if you want some support describing things. And then we play the waiting game. We'll have to wait for a while until you see a psychiatrist who will ask you similar questions to the ones I've asked you today. I know it can be uncomfortable talking about this stuff with a stranger, but it's important that you be honest with them, as honest as you've been with me. The doctor will decide if they think the best plan is to keep you at the hospital, and for how long, or something else. I can stay with you throughout this process, but I'm wondering if there's someone else who you might want there with you?
Kyle: I don't have anyone.
Therapist: Okay. I'll be there with you. Does that sound like a plan? We can take a taxi together and leave now.
Kyle: Umm … I'd rather not. I hate the hospital.
Therapist: [empathic] I know. It's not an easy place to be. But I'm suggesting we go there right now because I'm worried about you. It's the one place I know of that you'll be safe. And you don't have to go alone. I'll be there with you.