Sitting with suicidality, with Kerry Horrell, PhD

There is a particular kind of quiet that happens when someone is deciding whether to say the thing out loud. They are reading your face while they decide. And most of us, early on, were not nearly as good at controlling our faces as we thought.

In this episode, Dr. Gabriel Lowe sits down with Kerry Horrell, PhD, a staff psychologist at The Menninger Clinic at Baylor College of Medicine in Houston, where she specializes in trauma and personality disorders, and a co-host of Menninger’s Mind Dive podcast. She also sees clients in private practice. She and Gabe go back further than the credentials suggest: same doctoral cohort, same pre-practicum small group, watching each other’s tapes during the first therapy either of them had ever done. Ten-odd years later, they are talking about the subject that frightened them both most back then.

The script we were handed

They both remember the training as concrete and rigid, and neither thinks that was wrong, exactly. If this comes up, here is what you do, in this order, do not deviate. For first-time therapists seeing college students, that is a defensible way to teach it. What it also transmitted was a mood — that this was the most serious thing that could possibly happen in a room.

Kerry’s first placement outside the university clinic was community mental health in downtown Los Angeles: substance use, houselessness, the whole stack of psychosocial stressors that manufacture hopelessness. She describes shaking in her boots. Some of that was fear for her patients. Some of it was fear for herself — what a bad outcome would mean for her, for her supervisor, for whether she was any good at this at all.

And the fear took up so much room that going near the subject became almost unthinkable. Which is the problem, because patients can feel it.

I really want to know about this part of your mind. I really want to get into it, and I’m not afraid of it.

That is what she says to patients now, out loud, deliberately. Most of the people she sees on inpatient and residential units are carrying some level of suicidality, and the exposure has done what exposure does. Her anxiety came down. What replaced it is not casualness — she is emphatic that none of it got less serious — but room. Room for someone to bring this part of their life in without the sense that saying the word summons men in white coats.

Both lists

Kerry works from Thomas Joiner’s interpersonal theory of suicide, which puts two things at the center: perceived burdensomeness and thwarted belonging. The word she keeps returning to is lonely. Whether or not the belief holds up to reality — usually it does not — the felt experience is: I am alone, I am a problem for the people who love me, and this is not going to get better.

That framing also dismantles one of the more durable myths on the subject. Joiner’s line is that suicide is not selfish, and Kerry hears the case for it constantly, from patients who say some version of I know they’ll be sad, I know it will hurt for a while, and their lives will be better without me. That is not indifference toward other people. It is a distorted, blinkered, agonized concern for them.

The other structure she leans on is CAMS — the Collaborative Assessment and Management of Suicidality. Part of it maps the drivers: psychological pain, hopelessness, self-hate, agitation, the stressors stacked up in a person’s life. But the part she loves is that it insists on assessing two things alongside each other. The wish to live and the wish to die. Why would you want to stay alive. Why would you want to be dead. Both, in the same conversation, on the same page.

She says she has rarely, if ever, had a patient who could not put something on both lists.

That matters clinically, because the ambivalence is not a technicality — it is where the person actually lives, and holding it is exhausting. Some of what looks like urgency is a wish to stop being torn. It also matters relationally, because of a split Kerry names later on: when a patient takes up only the wish to die, the people around them almost reflexively take up only the keeping-them-alive side, and now it is a tug-of-war with one person on each end. Nobody in that arrangement gets to be ambivalent out loud. Her aim is the reverse — to help someone locate both halves inside themselves, which turns out to be the more agentic position, not the less.

The ask is time, not a promise

Kerry does not use suicide contracts, and says so plainly. What she asks for instead is smaller and harder: while we are working together, don’t act on it, and give this enough time to find out whether it is really the only thing on the table.

She is candid about why she frames it that way. She cannot stop anyone from dying by suicide, and pretending otherwise mostly teaches people to stop talking. Leaving the option there — the fail-safe, the lever — is, for a lot of patients, exactly what lowers the urgency enough to do any work at all. One patient’s review of the approach: you’re the weirdest therapist I’ve ever met. She took it as a compliment. Mostly.

Underneath the request for time sits a neurobiological argument. Severe psychological pain is metabolically expensive; the limbic system runs hot and draws down the regions you would most want online for long-range decisions. People in acute crisis are not in a good state to think, and time is the one intervention that reliably reintroduces nuance.

And underneath that, humility. The field is bad at predicting who recovers. Kerry has worked with people who by every visible measure looked unreachable and who got better, and she has lost patients she did not see coming. So she will not hand anyone a certificate saying they gave it a fair go and there is no hope left — not because she knows they will improve, but because she genuinely does not know that they won’t.

Where it stays hard

None of this resolves cleanly, and the episode does not pretend otherwise.

There is the autonomy question, which Kerry finds genuinely unsettled. She is grateful for the hard legal lines — glad that when a patient is not safe at their level of care she does not have options, because empathy means getting into the mess, and getting into the mess can cost you your bearings. She is also unwilling to wave off the philosophical version. Her young adult patients, the ones who went through high school during COVID, bring it directly: my parents decided that I would exist, so why is this the one decision that isn’t mine? Answering none of that matters, you have to stay alive is not a real answer, and she doesn’t give it.

They are honest, too, about what intervention actually looks like from the inside. In Texas, someone committed out of a residential program may be handcuffed by constables and driven away in a police car. Kerry describes the aftermath — frightening for some patients, genuinely traumatic for others — and is clear that the hesitation people feel about disclosing is often not irrational at all.

Then there is chronic suicidality, which she names as the place she feels the pull hardest. When someone has been carrying this for years, through the residential stays and the medication trials, give it more time can land like a cruelty. This is where she leans on consultation — not for the paperwork, but because the empathy required to go down there with someone is the kind you can fall into. Her image for it is a dark hole you lower yourself into on purpose, and colleagues as the thing that keeps you from going all the way down.

It is also where the wish for a protocol gets loudest. And the demand for one correct answer, they notice, almost never comes from the suicidal person. It comes from everyone around them — family, friends, clinicians — because suicide makes anxious people want a procedure to follow. The person actually in it is usually helped by the opposite: by their situation being treated as specific, and by nobody pretending a formula exists that would erase it.

What people stay for

The question under all of it is old: why does anyone choose to stay alive in the face of suffering? Kerry’s touchstones are the classics — Frankl, Tuesdays with Morrie — and the answer people arrive at is almost always some version of connection.

Which is precisely what shame goes after first. Shame’s instruction is to hide, don’t say it, don’t let anyone in — and every hour spent following that instruction warps the thinking further, because almost nobody thinks well alone.

So the move that looks small is not small. Telling one person is a step out of the cave.

They’re not in there with you, but they’re holding your hand.

Not a solution. A pinprick of light, which is what makes the next thing imaginable.

If any of this is sitting close to home, you don’t have to sort it out by yourself. You can call or text 988, the Suicide & Crisis Lifeline, any time. And for the slower, ongoing work, our clinicians see people through depression, trauma, and the psychodynamic work underneath both — a free consultation is a low-stakes place to start. There are more conversations like this one across Where Did Your Mind Just Go?

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Where Did Your Mind Just Go? is a production of Coastal Therapy Group. This episode was edited by Serena Rio.