On the Knife’s Edge

Sure, you can transfer the call to me,” I tell the lead clerk. “But let me get this straight, we don’t know his name, or where he lives, and he has a knife on his lap which he’s going to use to kill himself?”

“Yes, I couldn’t get much from him.”

“Ok, let me talk to him.”

I brace myself for the challenges of managing this call. A lot of information will be unavailable without any visual cues. Developing a therapeutic relationship will be challenging since our only link will be through voice. The words we choose and tone of voice we use are all we’ll have to communicate with each other.

My ability to empathically engage with him in a meaningful way may make a difference in his life. This presents the most serious challenge—one more difficult and personal. Cynicism has been slowly creeping into my attitude over the previous several months and I cannot figure out why it is happening. Is it the stress of working in community mental health, a character flaw, or the beginning of unrecognized burnout? I am mindful that I cannot be simultaneously cynical and empathic.

“Hi, I’m Mark, one of the therapists here. Who am I talking to?”

A brief pause. In a steady, deliberate voice he responds, “I’m not telling you my name.”

Strike one.

“That’s fine. How should I address you?”

He declares, with more rapid speech and an edge of agitation, “It doesn’t matter. Nothing matters. Call me whatever the **** you want.”

Strike two. Time to jump in.

“I’ve been told you have a knife and are thinking about killing yourself with it. Is that right?”

“Yeah, that’s right. Though it ain’t really worth getting dirty on a piece of **** like me.” The agitation is notable, but I also hear sadness.

Over the next 45 minutes, he shares a sad story of job loss, relapse into drugs, legal entanglements, and estrangement from spouse and children. His experiences of anger, guilt, shame, and fear resulting from missed opportunities and personal vices have led him to this decision point. His profanity throughout was prolific. I find the frequent use of expletives during initial contact may signify a patient’s inner turmoil or defensiveness. Given his situation, I suspect the former.

“I’m just a piece of ****!” he yells into the receiver. Desperation, clearly in his voice now, seems to block out everything except his utter hopelessness.

My desperation mounts as well. I have no identifying information to send someone for a safety check. There is no indication he is willing to put his knife away. His agitation is increasing. Everything points in the wrong direction for this man.

Yet, I experience an odd connection with him—we both feel quite desperate, isolated, and helpless.

During this panicked moment, a detail springs forward in my mind. He has described himself as refuse no less than six times. By employing such a graphic metaphor about himself, he seems to have no connection with his inner strengths and inherent potential, and so he feels hopeless. He feels cut off from possible solutions—suicide seems inevitable. He needs a glimmer of hope to turn this around: a compassionate perspective of himself. I decide to gently challenge him. Given his emotional state, this could go awry. Yet, with few options and increasing urgency, I try something new and a little out of the ordinary.

Deep breath. Here goes.

“Sir, are you literally telling me you are a piece of excrement that fell from a cow’s anus?” My tone is direct and firm.

Silence.

Oh, no…strike three.

The clock continues to tick.

“No,” came the meek, soft-spoken response. I imagine his head hanging down and shoulders slumped.

“Then what are you?” My tone is quiet and inquisitive.

“A guy…who’s messed everything up.” He sounds dispirited and somber.

“You may be right, but a guy who’s messed things up can also fix ‘em.”

The conversation proceeds much more productively from this point. A few minutes later I hear the familiar scraping sound of a knife being sheathed and the “pop” of a snap to secure it in place.

Now comes my moment of silence. He really did have a knife on his lap! Despite knowing the facts of the situation, in this moment it fully hit me that he was balancing on the knife’s edge.

I’ve reflected on this moment many times. What prompted me to say such a ridiculous thing? Desperation? Instinct? Both likely played a role. During our interview, I had asked all of the textbook questions and followed the suicide assessment protocol. Yet, the algorithm simply wasn’t working. I did not need to measure his degree of suicidality: that had been obvious from the beginning. I had needed to help him escape his deadly mental trap. In that moment, I had learned that the art of healing requires innovation and compassion, not simply standardized application of protocols. In this case, thinking outside the box was more than a good idea, it was the only idea that worked.

I also felt the fog of cynicism slowly begin to lift. Perhaps my cynicism had stemmed from the daily pressures of patient care, the collective weight of patients’ burdens, and my limited ability to help them. Yet, I had clearly helped this man. That proved to be a turning point for me and I began to experience a personal sense of healing.

The call concluded after developing safety plans and obtaining a verbal commitment from him to seek help. That was all I could do.

I never learned his name.