Lowell arrived as scheduled at 1600 hours, or four o’clock. It happened rarely but today Jenn had to leave early for a dentist appointment. This meant I was sitting at the reception desk waiting for Lowell. At a couple of minutes to four a tall man, probably in his late twenties approached the clinic door. He was wearing a hunter-green quilted jacket and a University of Western Ontario ball cap. “Lowell?” I asked as he came through the door. He looked alarmed at being addressed by name without having identified himself first. I caught myself and added “I’m Hattie Crawford. I’m the nurse you are here to meet up with. Our receptionist left early so I was just sitting here waiting for you”.
“Oh” he looked relieved. “I wondered how you could already know who I was”.
“C’mon in,” I signaled to the interview room. After he shucked off his jacket and neatly lined his snow-covered boots in the rack, we walked together and sat in chairs set across from each other. I don’t necessarily like to sit behind a desk but I do find it easier when I have a bunch of forms to complete, as is always the case for initial appointments. Nevertheless, today using my knees as a tabletop would have to do. The necessary patter about confidentiality and insurance forms fell easily from my lips. Lowell followed easily and had no questions. He had accessed his employee assistance program once before so he was familiar with the process and he understood there was no information leak to his principal or the Board.
When the formalities were resolved, I started “so Lowell, you called the office at the end of last week. You spoke to Rudy and he set you up with me. He gave me a little bit of information but I’d rather hear from you about what is going on for you. What happened last week?”
Lowell had been sitting forward while we were working out the details of our contact. With my question, he exhaled, puffing breath through frowning lips and leaned back into the chair. He removed his cap and ran his fingers through his curls. Then he clasped his hands together, interlacing his fingers, and brought them to his chin. Like a prayer, I thought to myself. “It’s kinda complicated” was his initial salvo.
“It always is”. I countered. And I meant it. “Folks don’t often come into my world who aren’t tangled up in life”.
“Yeah, I guess” he surrendered, making solid eye contact for the first time, sort of measuring me. “I’ll cut to it. I called last week because I scared myself. I was longing to die. I don’t feel joy in my life…forget that, I barely even have any interest in my life”.
I held his gaze. My silence was his signal to keep talking. “I am not suicidal.” He added quickly, apparently appreciating the triggers and consequences.
“For sure?” I asked raising my eyebrows to accentuate the question.
“For sure. Hattie, it is Hattie, right?” I nodded. “Hattie, my life is complicated.” I gave him the keep-going nod again. “Here’s the deal. I work at Brookdale elementary school. I transferred to Carter two years ago after a relationship I was in collapsed. I teach Grade four. I am a good teacher. I like the kids. Rather, I should say I like being a teacher. I have to be careful about saying I like kids because I’m gay.” He looked at me square, assessing my response. I bobbed the keep-going nod again, accompanied by a shoulder shrug, signaling acceptance. Lowell relaxed, leaning forward. He placed his face in his hands. His voice was muffled but his words were clear “I am attracted to men, not boys. But people don’t get that. They think if I’m gay I must be a pedophile. I’ve kept my secret for two years knowing I could be ruined.” He pulled his damp face away from his hands and continued. “About six weeks ago, a new teacher started at our school who knew me when I worked in Guelph. Actually, she knew both me and my partner. She is cool but I am worried that she might say something, you know, innocently.”
“And you think if people find out about your orientation they will judge you?” I knew this was a real concern. Jody had wrestled with the same reality when she and I made the commitment to move in together and it was certainly intensified when we moved to a small town where your business was a little more transparent. But Jody is a woman, and the stigma is not as obvious.
“You know, really, I can live with people judging me. I frankly don’t give a rat’s ass…sorry. I don’t care much about what people think of me. But I don’t want them to see me as dangerous, or a threat… I am not dangerous; I am not a threat!”
“Well, that is complicated”. I sat back in my chair too, a signal that I was considering all this and taking it seriously. “Is it enough to drive you to suicide?” Lowell paused long enough to draw me forward toward him again and repeat my question in a gentle, prod. “Is it enough to drive you to suicide?”
“No.” He finally responded. “No, I don’t think this is enough to make me kill myself. But I would not be sad if for some reason I were to die”.
I led the conversation as inconspicuously as possible through an assessment of the personal factors associated with suicide: family history, previous attempts, high-risk behaviours, formulating a plan. Then asked about social and protective factors such as supportive family, network of friends, home and income security. All of these he dodged or negated. Because I knew he had described himself to Rudy as leaning toward alcoholism I asked the question about disinhibitors last.
“When you talked to Rudy, the guy on the phone who set this up, I think you told him you were leaning toward alcoholism.” He looked away briefly then continued to make direct, unwavering eye contact. I pressed on. “Alcohol is a red flag in our business, especially when people have a wish to die.” He did not respond. “It’s a problem for us because alcohol can disinhibit you. That means that even if you don’t want to actively kill yourself, you might do it impulsively when you are intoxicated.” Again I paused for a response and did not get one. “Alcohol can also be used to avoid or cover up our feelings. It becomes a way to escape from our realities. In some cases this is addiction, alcoholism, as you say, but in other cases it is just a way to cope. How worried should I be about you and your use of alcohol?” I find that sometimes giving people a choice in how they attribute their substance use yields a more accurate response. More importantly, it gives them an option of not denying their use.
“I drink everyday”. Lowell said softly, finally looking away, down at his still clasped hands. “I’ll be honest, when I called the crisis line I had finished a bottle of wine. But I haven’t had a drink since then. I said that to the guy on the phone because deep in my heart I know I am drinking too much but I don’t really think that is the main problem. I think we are closer to the truth in your second point. I drink to relieve the worry. I drink to relieve the pain of being alone. I drink to relieve the pain, no the agony, of being different…and having that difference used against me.”
This was a lot for me to take in. I struggled with disclosing my own situation. New evidence indicates that self-disclosure can be helpful. Under the right conditions, sharing personal experiences with a client can promote empathy and engagement. Under the wrong conditions, it might not. At this point I had to take into account that this was about Lowell, not about me. Rather than shift focus in this initial meeting, I pulled back. Instead, I relied on Carl Roger’s old standard: “Tell me more about your worry and your pain and how you deal with it”. Carl Rogers was a therapeutic giant and although he is long departed, his wisdom still warms my soul and guides my practice.
“Do you have a month to sit here while I tell you the whole story?” The crease of Lowell’s face faintly resembled a smile.
“In fact I do.” I delivered a definite smile in my response, which shifted his presentation to sight shock. “Just not all together in one appointment” I added. Lowell’s shock dissipated into relief.
Having confirmed Rudy’s first conclusion that suicide risk was present but not imminent, Lowell and I spent the rest of our first meeting negotiating a schedule of therapy in which he could tell me his story, describe his worries and pain and explore how to deal differently with his reality. Given the risk I sensed from his alcohol use, we developed a crisis plan in the event he felt he couldn’t wait until our next appointment that included among other strategies a guarantee that myself or someone at the crisis service would see him the next day.
As he rose to leave I offered “Lowell, I know you feel overwhelmed right now. I absolutely get that. I don’t know what I would do in your situation either. But I am glad you came here. I am glad that you chose to look at other options for yourself. You seem a nice guy and I’ll bet you are a fantastic teacher. We will come out the other side of this…it may take some wailing and gnashing of teeth but I have a feeling you can handle it”.
“I hope you are right Hattie.” Lowell paused, standing in front of his chair, his hands loose at his sides. His lips pulled thoughtfully to one side, with a nod he added “I think you are right”.
With that he reversed his entry donning cap, boots and jacket and raised his hand in mock wave as he departed. Lowell was correct, his situation was undeniably complicated.