Unexpectedly, suicide has dominated my practice and thinking for almost 30 years. When I first qualified as a social worker, I hadn’t anticipated that one of my earliest experiences would be the suicide of a young, male client. He had talked about suicide with all those involved in his care; his death, however, was still poignant and cause for deep reflection.
Likewise, when I first began my training as a counsellor, I hadn’t expected that one of my first practice experiences would be the death through suicide of one of my clients. It was unexpected, a few hours after a session where she had seemed so bright. It was also personally and professionally devastating in equal measure. Here I am, 30-odd years later, still writing about it, with the same degree of incredulity that, as a profession, we talk so comparatively little about suicide, even though all of us will no doubt encounter its shadow in our work.
In two, short paragraphs, I have already introduced two deaths, trauma, reflection, personal and professional impact and – essentially what this article is about – our relationship to suicide as therapists. The dominant culture of healthcare settings sometimes unceremoniously shoves us further away from the essence of who we are as therapists, perhaps leading us to collude with a risk industry that is dominant but, in my view, deeply flawed.
I offer here my own practice experiences, built over 30-plus years, learnings from clients, peers, colleagues and organisations, research evidence and a healthy dose of personal opinion, which I invite you to agree or disagree with, as a means of thinking about your own work. My intention is to explore how we work with suicide risk in our healthcare settings, and the challenges we might encounter along the way.
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It is important to outline a key caveat here: as we know, there are some occasions when an individual’s distress is such that they might be deemed to have temporarily lost capacity to make informed decisions about themselves and their lives. There is scope in law to
help provide a safe space for people at those points. My commentary here is about how we work with people around their suicidal thinking, where they retain the capacity to make decisions for themselves.
Risk as a binary concept
Let’s begin, however, by talking about risk, which has become an increasingly pervasive discourse over recent years. In my opinion, risk is also persuasively offered as a binary concept, so we are invited to view our client’s experiences accordingly. In binary terms, a client is either ‘at risk’ or not. The tools, tick-boxes, questionnaires and other paraphernalia that are designed to identify risk are predicated on the vast array of risk-based research that essentially links risk of suicide to key ‘risk factors’: gender, age, occupation, relationship status, DSM-5 criteria, history and so on.
That’s not to say that such information isn’t important, but it identifies the presence of risk factors; it doesn’t help determine nuance of risk. As we know, risk factors per se are a poor determination of whether someone is likely to kill themselves.1 The overwhelming majority of people who tick the ‘risk factor’ boxes do not end their lives through suicide. The information is not redundant and, in the context of other information, it might be useful. But it doesn’t tell us what we are told it will tell us – and yet we still dutifully tick the boxes, in the belief we are doing something useful, even when some of the big players in mental health, such as the Royal College of Psychiatrists2 and the National Institute for Health and Care Excellence (NICE),3 advise some caution.
I don’t know about you, but my own personal relationship with risk is more nuanced: there are degrees of risk. Sometimes, risk can provide an opportunity for true insight and, where desired, change. One thing is certain: there’s nowt binary about it.
Malik makes it perfectly clear from the outset that he doesn’t ‘talk feelings’. I say that’s OK; we can talk however he prefers. Once we get that out of the way, he opens up about his lifetime’s experience of abuse and trauma. He’s only 20, but has led several lives already, it seems. I’m walking alongside him but am treading carefully, as the ground beneath sometimes feels eggshell thin.
And that brings us on to the persistent driver in practice that risk is bad and should be managed, mitigated or avoided, if possible. We’re sent on risk assessment workshops, where we are told that we should identify risk and put strategies in place to manage it. We are sometimes told that we should be careful about working with people at risk at all, and certainly not online. In short, we hear that risk gets in the way of therapeutic work.
I would argue the opposite – that risk is often an essential aspect of our work. My assertion is that risk ought to be explored and embraced as part of a dynamic experience that offers – if engaged with – meaningful insight into a client’s experience.4 Otherwise, it is a bit like offering counselling only to people who are not unhappy.
My assertion is based on the assumption that risk is a fundamental aspect of living and, rather than being mitigated away, it might be better repositioned in the mental health – and therapeutic – discourse as a valid part of our work. Therapists can collaboratively create a space with and for our clients that might provide fertile ground for understanding and change. The idea that risk is bad has gained momentum over the past few decades, perhaps partly fuelled by the emerging dominance of a medicalised view of human distress and experience that links risk – and suicidal thinking – with a concept of ‘mental illness’. In my opinion, this discourse has profoundly shaped the lack of engagement with risk in mental health settings, and has created fertile ground for anxious organisations and individuals alike.
Many people have argued against an unquestioning link between suicide and ‘mental illness’ – most famously Thomas Szasz, the psychiatrist. Szasz wrote: ‘Suicide is a fundamental human right. This does not mean that it is desirable. It only means that society does not have the moral right to interfere, by force, with a person’s decision to commit this act. The result is a far-reaching infantilization and dehumanization of the suicidal person.’5 Szasz outlines the subjective and human dynamics here. He also perhaps suggests that our own perspectives on suicide can shape our thinking about our work.4
He looks so sad, angry and lost. He tells me this past week has been really terrible and that stuff in his head could implode. Whatever happens could be awful. I’m still treading carefully but have this knot in my stomach. I think he’s telling me that he has had thoughts of killing himself. How do you say that to someone who seems too shaky and uncertain?
The evidence base that informs risk assessment around suicide is dominated by a ‘risk factor’ focus. Countless studies have tried to determine the likelihood of an individual acting on suicide based on broad risk factors, often using demographic and diagnostic information. If a risk assessment tool could be developed to accurately predict the likelihood of suicide, then that would be a popular choice for the many risk-averse organisations that work hard to create policies and procedures to mitigate suicide.6
Whether we should always work to prevent suicide is a question rarely – if ever – considered by the risk narrative. But the working presumption is that we should always try to predict and prevent, although I have many practice experiences that might profoundly challenge the humanity of that position, akin to Szasz’s observations.
The pervading culture is, I believe, over-reliant on the dominant prediction-prevention approach. Science is assumed to provide an objective, accurate-enough system to identify those at high risk of suicide, so that we can put in place mechanisms to manage the risk or refer on (to whom?). How else could policy have asked for a ‘zero target’ for suicide in mental health settings, without strong, scientific predictability?7
By simply embracing this way of thinking, I would argue – controversially, I suspect – that therapy might have entered into a Faustian pact with this positivist-scientific view of human experience, including of suicidal ideation. It might find itself having to give away much of what it uniquely has to offer to become a place where people might be asked about suicide, but in a functional rather than relational way. The relationship then becomes a treatment, a session becomes a dose of that treatment, and the entire process is manualised to measure efficacy. In terms of suicide risk, efficacy is often viewed as the prevention of suicide, rather than the exploration of risk.
While I’m anxious, I know that keeping this thought to myself – when I have otherwise been so honest with him – is kind of disloyal or dishonest. So, I ask him if that is what it means – the talk of ‘imploding’. Has he had thoughts of killing himself? He pauses and looks at me – then looks away. Oh no. In some ways it felt counterintuitive to ask so directly, and in other ways exactly the right thing to do. But I have done it now.
The worst-case outcome is that people experiencing suicidal thoughts are passed from pillar to post. Or, they are asked countless times about suicide, but often through the use of tick boxes and with an invitation to offer only a binary answer – yes or no – to determine the presence of risk to inform a management plan. Or they quickly learn to keep their thoughts of suicide to themselves, thus compounding a sense of shame that they are feeling suicidal at all.
Organisations and practitioners alike are becoming more risk averse, fearful of ‘getting it wrong’ and finding themselves in the position of holding the parcel when the music stops.8 I can still recall my own trauma following the death of my client through suicide: that sickening feeling at the bottom of my soul on hearing the news that she had taken her own life and that I, in all likelihood, had been the last person she had spoken to. So, I do not diminish the fear of suicide lightly or quickly. I do acknowledge that I am, to an extent, exaggerating to make a point.
The reality is that many therapists do wonderful work with people wrestling at the very edge of their existence. They provide an important, relational space when it is needed the most, often at risk to themselves, when working in organisational settings that might expect a different response to risk. It is this reality that I am arguing we build on and, in the face of undoubted pressures to work in a particular way with people at risk of suicide, we retain what is uniquely ours.
I am not advocating that we disregard the expectations of organisations when working with risk, nor that we position ourselves in a place where we believe research evidence has little or nothing to offer us. We do not operate in a vacuum and good practice is, in part, determined by our capacity to work sensitively and respectfully in the context in which therapy is accessed and delivered. We owe this authenticity of practice to our clients, who often attend therapy with expectations and an understanding of what we are there to do.
However, there is much more we can do within the scope of our work, without stepping outside of policy or contractual expectations of practice, and thus putting the very presence of therapy in an organisation on the line. It has been my experience that all professionals within a mental health context have something important and unique to offer. I also believe that best practice is delivered when professionals have a clear sense of their own contribution and how it complements the contributions of others.
He bows his head and starts to cry. He hasn’t cried yet, but now he does. I wait and sit quietly, respecting his space and hoping he can sense my presence. He looks up and says, ‘yes’. He really didn’t think anyone would care. People have asked before and just ticked a piece of paper, then said no more. I say I would like to hear more, if he wants to tell me. He does, and we talk.
As therapists, we offer something profoundly relational – regardless of our therapeutic model. The relationship does not simply provide a context for an intervention, as a social worker might assess to provide services or a psychiatrist might assess to offer a diagnosis. Rather, the relationship is what we do. Our intervention is to be alongside our clients through a process of insight, understanding and, possibly, change – and that includes being alongside our clients in their suicidal space. That is what is unique about our role in healthcare settings.
Our task, I would argue, is not simply to ask about suicide in order to determine a mitigation plan, or to assess for the presence of risk factors. Rather, our task is to open the door labelled ‘risk’ and walk through, as we explore with our clients their experience of engaging with their feelings of suicide, what it means and what sense the client is able to make of it.9 Our task is to go there, to be brave and to really hear what others are often unable to tolerate.10
He doesn’t want to die, but he doesn’t know how to live. He doesn’t know what to do with all this stuff he feels is stuck inside him. He is surprised that I wanted to know more about this – that I am interested. That he is interesting. He’s never, ever said it out loud before and it feels weird to do so now. But he is glad he did, as I am.
I have been told by many clients over the years that my willingness to ask directly about suicide, without hesitation, embarrassment, awkwardness or an attempt to ‘dress it up’, has been one of the most important things I have been able to offer. To explore suicidal thoughts in a way that is not functional, has directly contributed to our shared sense of relational depth. Asking about suicide has not put the thought into their mind, nor created a fracture in our work. At worst, it has left risk unchanged; at best, it has opened a space for the client to say out loud their thoughts and, in doing so, to make sense of them and to draw out different meanings.
We work in particular settings, often with particular expectations of what we should do in relation to risk. As professionals, we should do those things. However, we shouldn’t just do those things; we can do more. We can ask about suicide directly, clearly, openly, honestly, respectfully – and we can go further. We can explore what it means for the client, what it says to them and about them. Instead of walking around the pool edge taking the temperature of the water, we might be able to dive in and ensure our clients can explore the currents and depths, to achieve an understanding that can only be reached when in visceral contact with another, but to do that safely, knowing we can both get out of the water.
We agree that talking about him wanting to kill himself doesn’t make the rest any better. But, he says, if we can talk about that, we can talk about anything. I know that Malik is young, male, traumatised and believes he can’t ‘talk feelings’ – although he can, as I point out – and so the red flags of risk are flying. But we find a way of holding the risk together, making it a part of our working relationship and ensuring it can always be talked about.
1 Large M, Kaneson M, Myles N, Myles H, Gunaratne P, Ryan C. Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time. [Online.] PLOS ONE 2016; 11(6): e0156322 (accessed April 2022).
2 Royal College of Psychiatrists. Self-harm and suicide in adults: final report of the patient safety group. [Online.] London: Royal College of Psychiatrists; 2020. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr229-self-harm-and-suicide.pdf?sfvrsn=b6fdf395_10 (accessed April 2022).
3 National Institute for Health and Care Excellence. Self-harm – longer term management. [Online.] London: National Institute for Health and Care Excellence; 2011. https://www.nice.org.uk/donotdo/do-not-use-risk-assessment-tools-and-scales-to-predict-future-suicide-or-repetition-of-selfharm (accessed April 2022).
4 Reeves A. Counselling suicidal clients. London: Sage; 2010.
5 Szasz T. The ethics of suicide. The Antioch Review 1971; 31(1): 7–17.
6 Reeves A. In a search for meaning: challenging the accepted know-how of working with suicide risk. British Journal of Guidance and Counselling 2017; 45(5): 606–609.
7 Nick Clegg calls for new ambition for zero suicides across the NHS. [Online.] London: Deputy Prime Minister’s Office; 2015. https://www.gov.uk/government/news/nick-clegg-calls-for-zero-suicides-across-the-nhs (accessed April 2022).
8 Reeves A. Working with risk in counselling and psychotherapy. London: Sage; 2015.
9 Good practice in action EL002: exploring suicide risk with clients. Lutterworth: BACP; 2022.
10 Good practice in action 120: working with risk within the counselling professions. Lutterworth: BACP; 2021.