If your client or patient reports that suicidality occurs immediately on waking, it can be helpful to do an analysis of those initial moments in which the urge occurs.
First – was that the very first thought that went through the person’s mind? Like; Wham! – I’m awake, now I want to kill myself. Usually it doesn’t happen that way. Sometimes the client wakes and gets a physical sensation – perhaps pain due to illness or injury. Is there some physically draining health condition that just wears this person down? So much so that becoming conscious of it immediately prompts the desire to escape. Can this be problem-solved or can the physical pain be mitigated in some way? How long is it since they had a pain review?
Although early morning low mood is a symptom of depression, don’t assume that’s all there is to it. On waking is the person predicting an unwanted event. In my experience this often consists of social circumstances in which the person feels trapped; The abusive partner, financial problems, childcare issues, work stress. Can the therapist and client make a plan to change this thing or if not, add in some other factors to make it more bearable? Is there something the client says they cannot face that is likely to happen in that particular day? There is nothing worse than predicting an unpleasant event and then having to actually deal with it. The golden rule – help the person both deal with the problem when they get to it, and also cherish the moments in which it is not happening.
Sometimes it is not a feared event, but anticipation of non-events. The client can see nothing that has meaning for them in the day to come. Even if they can identify such a thing, they can’t work out how to get it. The hardest part here for the therapist is that it always (always) takes time to build those positives, and it is hard to get ones feet on the path when the destination feels impossibly far away. This problem sometimes presents as a kind of regret-paralysis, wishing to turn back the clock and make different decisions. When this happens it is energy-sapping, and so the client has no reserves to put into creating the new future. Mindfulness can really help here. Sometimes the patient can see a better future but feels blocked from it, “I want to leave my partner but it would cause too much heartache”. But hey, ALL not-dying options trump the others, right? Even the world-rocking ones.
For some the fear is in the past – manifesting as traumatic memories. If this is a symptom of PTSD then the client should be encouraged to seek proper prolonged exposure therapy. This can be a daunting prospect so is it possible for them to speak to someone who has had the same treatment and recovered?
Finally some clients deal with relentless pressure on a daily basis without being suicidal, and then exhaustion just crashes through their resilience. This is the equivalent of running 20 miles of a marathon and then crumbling under the weight of one’s backpack with 6 miles still to go. Suicide masquerades as a comfy resting place. Is there something that has overtaxed the client’s resources on this particular day? Can the therapist help them to get some respite without quitting the race? Has a protective factor been lost? Can it be replaced?
From my experience clients really appreciate the feeling that whatever problem they face, they and the therapist or care worker are in it together – getting their two detective heads on the issue and working on solving it. To really feel this co-bearing effect the therapist needs to add in non-routine contacts, an extra call, a card, a text. Genuine human connection with the client, honouring their problem. Just to say, “I’m thinking of you, I’m sending good vibes, I think we can work this out together, stay in this, we can do it.” in this way the therapist is lending their own energy and resources to the client to effect problem-solving until the suicidal crisis passes. “Let’s break this thing down into what we can do today to move closer to a better future, and what we can do after that, one step at a time.” Suicidality is transient. It WILL pass.
When working with upon-waking suicidality I have always suggested the client make an environmental change immediately to remind them we’re now problem-solving; Turn their bed 90 degrees, or put their head at the foot end, pull the mattress onto the floor if necessary. Wake up in a different physical space to begin the journey to a different mental space. Mostly clients’ predictions and fears have a lot of validity, but that does not mean they are unsolvable. It’s a journey, and one that is better shared.