A prevent agenda
There are approximately 4,500 suicides in the UK each year – that’s 13 people every day.1 In 2015, suicide was the second leading cause of death among 15–29 year olds globally;2 in the UK, men aged 45 and under are more likely to take their own life than die from any other cause.3 The current UK policy on suicide focuses on reduction and prevention,4 aiming to identify high-risk groups and then reduce access to the means of suicide within these groups.5 In October 2018, the UK Government appointed its first ever Suicide Prevention Minister, who was tasked with reducing the suicide rate by 10 per cent by 2020.1
There is no doubt that suicide prevention is high on the agenda for all those in organisations and charities working with people in psychological distress.6 Many will have policies and procedures in place to identify and reduce the risk of suicide and self-harm. However, this potentially poses a conundrum for person-centred practitioners, who work from a fundamental perspective of client autonomy. The person-centred approach is a phenomenological approach, centred around the client’s individual view of their world.7 Within this, the individual’s basic tendency is to grow, either through maintenance or enhancement; this is known as the actualising tendency.7 Taking this into account, some researchers8 argue that it might be ‘anti person centred’ to defer to an external authority, such as a government or an organisation’s policy, when, as a practitioner, you have agreed to join your client in discussing their unique and subjective position.
As some researchers9 have highlighted, the Mental Capacity Act10 states that individuals have the right to make choices about their own life, as long as they are deemed to have the capacity to do so. Any decision to break confidentiality should be made on the basis of this Act.10 Overall, it seems to me to be a confusing position for person-centred practitioners. I therefore decided that, as part of my master’s degree in counselling, I would carry out research to consider the person-centred perspective on suicide.11 My focus was on whether the act of suicide has the potential to be considered an expression of the actualising tendency. This article sets out some of my key findings and reflections.
When I outlined my research proposal to my tutors, a few eyebrows were raised. Some appeared to be out of interest, some out of scepticism and others in mild horror. How on earth could you equate someone taking their own life with an expression of them fulfilling their potential? There was a feeling from some that, by even considering such a notion, I was perhaps being disrespectful not only of those who had died but also of those they had left behind. The wish to keep a client safe will always be at the forefront of my mind. However, I did, and still do, believe that this chosen behaviour should be viewed in the same way as any other behaviour would be, taking into account that there is no philosophical or empirical evidence to support the idea that the chosen act of suicide is principally any different to any other chosen act.12
My tutors’ next concern – and rightly so – was how I would research this. I believed that suicide notes provided me with a way of entering an individual’s frame of reference at the time they had chosen to end their life and, following ethical approval, I began my research. I decided to focus my analysis on a collection of suicide notes collated in two books by Schneidman and Farberow,13 and Etkind.14 My aim was to try to understand the different reasons that individuals had chosen to end their life. I grouped the reasons together to provide clarity. The four groups (or narratives) that I identified were ‘Can’t live with…’, ‘Can’t live without….’, ‘The other’ and ‘No other’.
There were various aspects of life that the note writers said they couldn’t live with; these included: not being ‘good enough’; not being able to live with a feeling of guilt, shame or regret; and not being able to live with physical or emotional pain. One note writer stated, ‘I have never been much good, I have only hurt everyone’;13 another wrote, ‘I’ve thought this over a million times and this seems to be the only way I can settle all the trouble I have caused you and others’.13
In terms of things an individual couldn’t live without, the most common aspect was a relationship or a specific love. This seemed to include not only romantic relationships, but also relationships with children. This is highlighted by one individual who wrote, ‘Mary, I love Betty and I can’t stand being without her’, with another stating, ‘Dearest Mary – I just can’t go on without Tom, John and you.’13
The other two groups of narrative I identified as reasons why a person took their own life were those I termed ‘The other’ and ‘No other’. In terms of ‘The other’, some people stated that it would be best for others financially if they were no longer here; similarly, some said it would be best for others emotionally. Others simply made it clear that they were taking their life as they believed that was what the other wanted or that it was the other’s fault. One individual wrote, ‘I knew that if I went to a doctor I would lose my job I think this is best for all concerned.’13 Another stated, ‘I know you will find someone better for you and the boys’.13
Within the grouping of ‘No other’, there was one consistent message from those taking their own life, namely that the course of action being taken was the only way out. Two examples of this are, ‘I’ve thought this over a million times and this seems to be the only way I can settle all the trouble I have caused you and others’, and ‘I’m sorry honey, but please believe me this is the only way out for me’.13
Suicide and the actualising tendency
Armed with my data analysis, I proceeded to try to understand each note in relation to the actualising tendency, being explicit about the fundamental tenets that make up this tendency. This included analysing: (i) whether the action was self-directed or autonomous;15 (ii) whether it could be seen as constructive, if viewed from within that person’s world and (iii) whether the individual was acting within 'perverse or unusual conditions' (Rogers15 stated an individual can only cause themselves pain or act in a way that could be deemed self-destructive, if the circumstances in which they find themselves are considered to be 'perverse or unusual').
I concluded that there were some notes that indicated that the act of suicide could potentially be an expression of the actualising tendency. An example is shown below.
You have been the best wife a man could want and I still love you after fifteen years. Don’t think to badly of me for taking this way out but I can’t take much more pain and sickness also I may get to much pain or so weak that I can’t go this easy way.
With all my love forever –
Assessing this against the tenets of the actualising tendency, I concluded that the writer, Bill, did not appear to have been influenced by anyone else to come to the decision; his choice was self-directed. In relation to the constructive nature of his action, Bill would no longer be in pain and, from his point of view (his perceptual field), it seems he believed it better for him to die before he experienced any further pain, which would render him unable to end his own life. In addition, I concluded that, for Bill, living with intolerable pain could be deemed a 'perverse' circumstance.
What does this mean as a practitioner?
If you are working in an organisation, you are likely to be required to complete some form of risk assessment in relation to suicide. However, increasingly, research seems to conclude that these risk assessments are ineffective predictors of behaviour.16 When we consider this alongside a prevent agenda and the fundamental person-centred value of respect for a client’s autonomy, it presents a complex picture for practitioners’ ethical practice. It seems clear that there can be many difficult choices that a practitioner has to make when dealing with risk, and the consequences of those are multiple. How do you strike the ‘right’ balance in terms of ethics, legality, your chosen way of working, the wishes of the client and your own personal position?
Use of supervision
Reeves9 outlines the importance of supervision when working with risk, and my research seems to underline this further. Utilising supervision may be particularly relevant when working with a suicidal client and Reeves9 highlights the potential outcomes from doing so. Supervision enables the client work to be explored in depth and allows the counsellor to receive feedback.9 One crucial aspect of the client work to explore might be the ‘judgment’ of whether the client’s behaviour is ‘constructive’ or ‘destructive’. My research highlighted that behaviour that can appear on the surface as destructive can actually be viewed as constructive, when seen from within a client’s frame of reference. Given the fundamental phenomenological basis of person-centred therapy, the client’s position surely has to be the starting point for any work. In addition, the supervisory relationship can enable an exploration of ethical and legal factors involved in working with risk, and the creation of space for personal and professional development.9
The counsellor's personal position
Reeves and Mintz17 noted the potential impact the counsellor’s beliefs on suicide could have when working with suicidal clients. Those who did not believe in suicide as a valid choice felt more clarity around when to break confidentiality with clients, whereas those therapists who felt that suicide was an individual choice struggled with this decision, feeling they were betraying their client.17 BACP’s Ethical Framework18 is clear that confidentiality can be broken if permitted by the client or by law; what is not clear is how to establish if the current risk that the client is demonstrating is ‘enough’ in order to break confidentiality. Principles of autonomy and non-maleficence within BACP's Ethical Framework18 may be particularly relevant here. The first highlights the client’s right to self-govern and the latter the counsellor’s commitment to avoiding harm to the client. Again, it may be reasonable to state that, regardless of the counsellor’s views – on suicide, in this case – they should endeavour to understand the client’s position from within their perceptual field as much as possible, before making a decision to break confidentiality.
The counsellor's feeling of competence
Reeves and Mintz17 highlighted counsellors’ feelings of incompetence when dealing with risk, and the potential impact this may have on the client work, noting the various responses of counsellors to working with suicidal clients. In their research, counsellors reported feeling a lack of perspective and competence in their ability to handle any issues relating to the client’s suicidal thoughts appropriately, referring to both ethics and the safety of the client. Feelings of anxiety, panic, impotence and fear were also highlighted.17 It seems reasonable to suggest that, if the counsellor’s response to their client is based on their own personal fears or anxieties, it will not be based on the client’s internal world. It is, therefore, unlikely to fulfil the core conditions as set out by Rogers, as they include the client experiencing empathic understanding for their perceptual field, unconditional positive regard and congruence.19
Potential consequences of risk assessments
Reeves20 acknowledges the desire as a practitioner to want clients to be safe, but also acknowledges research from Large et al,16 which highlights how inaccurate tools aimed at predicting risk can be. In addition, Procter21 highlights that one of the aims of therapy from the personcentred approach is to reduce ‘power over’ a client. It seems reasonable to conclude that directing the dialogue between client and counsellor through a risk assessment questionnaire is likely to give the counsellor power. Reeves20 highlights counsellors’ ‘…willingness to abandon discourse when it comes to suicide in favour of risk questionnaires…’, but the points made here and throughout this article perhaps reinforce the importance of dialogue between counsellor and client. They also underline the importance of supervision as a means to explore not only the client work, including the ethical and legal considerations, but also – crucially – the position of the counsellor in relation to suicide, in order to enable a thorough understanding of the direction of the work and any potential influences placed upon it.
Through completing this study, I was surprised at how little research and commentary there was about working with suicide from a person-centred perspective. Rightly or wrongly, I was left with a sense that discussing a client’s suicidal feelings is not viewed as a person-centred counsellor’s job, or that, as counsellors, we might judge those who feel suicidal. However, it feels to me that it is of vital importance to have a dialogue about suicide and to provide a space for practitioners to discuss their personal views, given the current rates of suicide, and presumably, therefore, the frequency with which counsellors are dealing with the risk.
As a person-centred practitioner, I work according to the fundamental principles of actualisation and trust in the individual, and the process of stepping into another’s world, without judgment, while being genuine and empathic. I hope to hold on to this at moments when I may be considering if I am enough for a client and perhaps considering reaching for a risk assessment. Of course, the wish to keep a client safe will always be at the forefront of my mind. However, I also recognise that I do not want any of my clients to feel judged or isolated and, having spent hours immersed in notes written by those who were about to take their own life, I felt that those feelings were apparent. On that basis, this research has only made me more determined to discuss all of my clients’ feelings, regardless of how difficult they may be for me, as the counsellor in the room.
Extracts from Clues to Suicide, by E Schneidman and N Farberow, 1957, republished with permission of the publisher, McGraw-Hill Education. Permission conveyed through Copyright Clearance Center, Inc.
Amanda McGarry is a person-centred counsellor, recently qualified from the University of Chester. She volunteers at the Liverpool Bereavement Centre and acts as a mentor for The Girls’ Network charity. Amanda runs her own private practice and is a consultant with Lead the Way Consulting, which works with organisations using a person-centred approach.
1 Department for Health. First ever cross government suicide plan. [Online.] Department for Health; 2019. www.gov.uk/government/news/first-ever-cross-government-suicide-prevention-plan-published (accessed 31 January 2019).
2 Samaritans. Suicide statistics report 2017. [Online.] Samaritans; 2017. www.samaritans.org/sites/default/ files/kcfinder/files/suicide_statistics_report_2017_ Final%282%29.pdf (accessed 15 February 2018).
3 Campaign against living miserably. Suicide. [Online.] Campaign against living miserably; 2017. www. thecalmzone.net/help/get-help/suicide (accessed 15 February 2018).
4 Reeves A. Counselling suicidal clients. London: Sage; 2010.
5 Department for Heath. Preventing suicide in England. [Online.] Department for Health; 2012. www.gov.uk/ government/uploads/system/uploads/attachment_ data/file/430720/Preventing-Suicide-.pdf (accessed 10 March 2018).
6 Moerman M. Working with suicidal clients: the person-centred counsellor’s experience and understanding of risk assessment. Counselling and Psychotherapy Research 2012; 12(3): 214–223.
7 Rogers C. A theory of therapy, personality and interpersonal relationships, as developed in the client centred framework. In Koch S (ed). Psychology: a study of a science. Volume 3: formulations of the person and the social context. New York: McGraw-Hill; 1959 (pp184–256).
8 Rogers A, Murphy D. Person-centred therapy and the regulation of counsellors and psychotherapists in the UK. In Joseph S (ed). The handbook of person-centred therapy and mental health: therapy, research and practice. Monmouth: PCCS Books; 2017 (pp376–387).
9 Reeves A. Working with risk in counselling and psychotherapy. London: Sage; 2015.
10 Mental Capacity Act (2005). [Online.] London: The Stationery Office; 2005. https://www.legislation.gov. uk/ukpga/2005/9/contents (accessed 20 June 2018).
11 McGarry A. Exploring suicide potential and the actualising tendency: a qualitative study of suicide notes. Unpublished dissertation; 2018.
12 Szasz T. The case against suicide prevention. American Psychologist 1986; 41(7): 806–812.
13 Schneidman E, Farberow N. Clues to suicide. New York: McGraw Hill; 1957.
14 Etkind M. …Or not to be: a collection of suicide notes. New York: Riverhead Books; 1997.
15 Rogers C. The actualizing tendency in relation to ‘motives’ and to consciousness. In: Jones MR (ed). Nebraska symposium of motivation. Nebraska: University of Nebraska Press; 1963 (pp1–24).
16 Large M, Kaneson M, Myles N et al. Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time. PLoS ONE 2016; 11(6): 1–17.
17 Reeves A, Mintz R. Counsellors’ experience of working with suicidal clients: an exploratory study. Counselling and Psychotherapy Research 2001; 1(3): 172–176.
18 British Association for Counselling and Psychotherapy. Ethical framework for good practice in counselling and psychotherapy. Lutterworth: British Association for Counselling and Psychotherapy; 2018.
19 Rogers C. The necessary and sufficient conditions for therapeutic change. Journal of Consulting Psychology 1957; 21(2): 95–103.
20 Reeves A. Where do we go from zero? Therapy Today 2018; 29(7): 30–33.
21 Proctor G. Clinical psychology and the person-centred approach. In Joseph S (ed). The handbook of person-centred therapy and mental health: therapy, research and practice. Monmouth: PCCS Books; 2017 (pp333–354).