Angry and at high risk of suicide: how to help

Written: July 17, 2019

Anger combined with suicidal intent can create a fragile and unpredictable situation where the client is very much at risk. Despite this, medical and mental health clinicians sometimes react negatively to a patient who is having suicidal thoughts and expressing intense anger.

I run a Suicide Crisis Centre in Gloucestershire and witness extreme anger on occasions from clients who are at the point of suicide.

People who are experiencing extreme emotional pain and intense anguish may use swear words. I wonder why we would be surprised that a person who is so distressed that they want to end their life might swear. It’s not uncommon to hear expletives within a sentence “This is a _________ nightmare and I can’t ___________ handle it”

I have noticed how clinicians sometimes respond at that point by saying “Don’t swear at me.” I find this totally puzzling. They’re not. Swearing at a person would be “You are a _______ ” This is specifically directed at the healthcare professional and would be classed as verbal abuse. What the patient is actually doing is swearing in a “descriptive” way. The swear words are being used to describe his or her situation, not the clinician.

NHS departments have adopted “zero tolerance” policies to ensure that patients treat staff with dignity and respect. In many of the policies, swearing is described as an act of aggression and so this is perhaps why some staff members are interpreting “descriptive” swearing as being specifically directed at them.

I have heard a member of the mental health crisis team tell a suicidal patient that if they don’t stop swearing they will end the conversation. The patient was swearing about their situation, not about or at the staff member. I remember thinking “What’s more important – the patient’s life and survival or the staff member’s feelings about hearing swear words?”

This kind of swearing is not intended to challenge or offend the clinician. It is an expression of profound distress and rage, and often emphasises the loss of control that the patient is experiencing at that point.

This fury and loss of control should be of great concern to any clinician who is focusing on trying to ensure that the patient does not harm themself. An intense angry outburst can greatly increase the risk of an imminent suicide attempt.

Our focus should be on supporting the patient to reduce their level of anger. By responding with a command “Don’t swear at me”, or “Don’t swear”, you risk inflaming the situation. In a high-risk situation, what matters is that the person survives.

If you are concerned about the impact upon other patients or other people present, then take the angry person to another room (in the context of expressing a wish to sit down with them and hear them and help, rather than of removing them simply because they are being “disruptive”).

We have been providing services at our Suicide Crisis Centre for over three years. During that time, no client has ever sworn directly at me or my colleagues. Indeed, if they swear in a “descriptive” way within a sentence, they usually quickly apologise. However, I have witnessed clients who swear profusely when they are at high risk of suicide. At that point it’s clear that their behaviour is very different from usual. That raises immediate concerns. They are less able to control what they are saying and therefore less able to control subsequent actions. When this happens, I know that the individual may be close to ending their life. At that moment, nothing is more important that helping them survive. That should be our entire focus.

On every occasion that this has happened, we have found that giving the client time and space to ventilate their anger has enabled them to return to a calmer state. We try to really understand what has caused their rage. We validate their emotion. In every case I have been able to understand why the person has experienced such intense rage.

It is far better for us as professionals to let a person express their anger at that point rather than asking or expecting them to suppress it. If they are not able to express it outwardly they may turn it inwards and act violently towards themselves.

Those of us who work with people in crisis or encounter them in the course of our work should surely be prepared for the fact that they may behave in a different way from usual and that they may be in a highly-charged emotional state. Our response to them may make the difference between them engaging with us or disengaging completely. If their anger is criticised or deemed inappropriate, they may at that point walk out of the A&E department or out of the meeting with their clinician or put down the phone to the crisis line they were calling. They may be doing so at a time when their life is at particular risk. Our focus must be on them at that time. We should do all we can to help to ensure that the person continues to engage with us and survives. We need to react in a supportive way to their anger.

By Joy Hibbins: previously published in HuffPost UK

For information about the Suicide Crisis Centre: www.suicidecrisis.co.uk

Sources of support: UK nationwide: The Samaritans can be contacted on 116 123. In Gloucestershire, the Suicide Crisis Centre provides face to face support: http://www.suicidecrisis.co.uk  

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