I can still remember with a mixture of amusement, irritation and incredulity when a senior policymaker in the mental health setting in which I was working questioned the validity and relevance of my research: how counsellors and psychotherapists work with suicidal clients and whether a time-limited, cost-effective training session could be developed to improve confidence and capacity in working with such a challenging client group.
Indeed, it was with genuine bemusement that she looked at me and said that therapists simply wouldn’t find themselves in a position of working with suicidal clients because they would, in every eventuality, refer them on to more ‘specialist’ (and perhaps competent?) professionals. I tactfully explained that the majority of therapists probably do work with suicidal potential with their clients much of the time and, make no mistake, we do an excellent job at it too. It clearly wasn’t a tack that was intended to make friends with senior policymakers and I soon shuffled on to pastures new.
But in this anecdote lie a number of important truths for therapists in a range of settings, including private practice: suicide potential is evident in a lot of the work we do and, given how little (relatively speaking) we find ourselves in a position of breaking a client’s confidentiality, we seem to be able to work proactively with risk very effectively. That isn’t to say there aren’t problems, however, and this is at the heart of my research. To name these problems more specifically:
- suicide has enormous emotional and philosophical resonance for most of us in some form or another, and there is a great likelihood that this will find its way into the therapeutic relationship
- there is no legal requirement to disclose concerns of suicide risk, yet the overwhelming majority of us working in private practice will probably contract to limit confidentiality if we consider risk of suicide an immediate possibility
- the concept of capacity sits centrally to much of our thinking around suicide, yet therapists generally receive very little training in this area, and indeed, they receive very little training at all in working with suicide potential1
- there is an increasing tension between the risk factor approach to evaluating suicide potential (who is more likely to kill themselves) and the discourse-based approach, with the former generally structured around risk assessment tools and the latter around a human exchange (the former usually comes out on top because of its so-called ‘scientific rigour’)
- therapists are notoriously bad at articulating what they do. That is not to say they are bad at what they do in response to suicide risk, but rather that they struggle to clearly describe it. In many instances, it seems to be shared wisdom that evaluating suicide potential simply transfigures out of the ether, emerging from some ethereal and instinctive dynamic that only we are privy to. This, quite simply, isn’t true.
So, my research continued to reflect in more depth on the process of therapy with suicidal clients. The final stage was to develop an evidence-based, one-day training workshop for therapists (and other mental health professionals) to explore in detail their work with suicide risk and how they could bring together all that we know through research and evidence, but make it relevant to a relational process. In summary, how could we move beyond the two-dimensional and uncertain efficacy of risk assessment tools and instead build confidence in a discourse-based approach to working with suicide potential? Could we learn to talk about suicide and do what Shneidman2 said was the most important thing we should do with suicidal people: ‘…our best route to understanding suicide is not through the study of the structure of the brain, nor the study of social statistics, nor the study of mental diseases, but directly through the study of human emotions described… in the words of the suicidal person.’ Shneidman goes on to say: ‘The most important question to a potentially suicidal person is not an inquiry about family history or laboratory tests of blood or spinal fluid, but “Where do you hurt?” and “How can I help you?”’
The answer to my question was yes, and I have been travelling around the UK and Europe for the last few years doing just that. The purpose of this article is to flag some of the key areas explored in the training and to respond to the problems outlined above.
Personal perspectives: the hidden dynamic
I have left many people speechless when they ask me about my research, usually at parties, it has to be said. I say, 'Working with suicide.' They say, ‘Oh, how fascinating, you must tell me more. I just need to get a drink and I’ll come straight back’, and I never see them again. I am left standing alone contemplating what it was I said. The fact is that suicide is not a ‘neutral’ subject; it will provoke a range of feelings and responses in us that will be shaped and informed by many factors. These will include: faith and spirituality; family experiences of crisis and suicide; our own experiences of suicidal feelings; professional experiences; books, music, films, and news stories; others’ perspectives, and so on. It is not a fixed entity either, but rather one that is shifting and changing as we brush alongside crises and new experiences. Suicide is often a felt, rather than simply a thought response, and our actions and reactions are often rooted at a very emotionally visceral level.
Then there is another dynamic. I have read so often, and been told the same, that it is possible for therapists to ‘leave at the door’ their own thoughts, feelings, judgments, prejudices, and so on, when seeing a client. That somehow, and perhaps magically, as we sit in our therapist chairs, we become some sort of blank slate – without a personal history as it were – devoid of any prior shaping and influence. I’ve always thought this was bunkum. I suspect we take everything about ourselves and our history into the room with us. Instead, the challenge is to know of our history and to find ways of working with it so that it does not unknowingly become enacted as part of the therapeutic process.
If we bring these two ideas together – that we cannot leave our thoughts, feelings and experiences at the door, and that we will all have some perspective on suicide, such as whether suicide is something we can make sense of, or something that we might ‘disapprove’ of – we can see the potential for our own views becoming unwittingly predominant in the therapeutic process. There is an emerging body of research3 discussing the concept of unacknowledged countertransferential responses to suicide potential that is important here. In not getting hooked on the particular terminology used to describe the process, it can be helpful as practitioners to reflect on how views on suicide might inform our responses. Examples of unacknowledged countertransferential responses in working with suicide risk can include:
- underestimating levels of distress or intent
- an active avoidance of an exploration
- being too quick to be reassured about lack of risk or claims of improvement
- assuming exploration will be experienced by the client as clumsy or insensitive (we project our own fears)
- minimising the importance of our relationship
- premature ending of therapy
- focusing on a perceived ‘manipulation’
- feeling overwhelmed or hopeless
- feelings of incompetence, fear, anger, anxiety and impotence.
Even though I have written about and researched therapy with suicidal clients for many years, I am not immune to these processes. I can recall many instances in work with clients where these dynamics have been present. My point here is that they are understandable and can be present at different times during our work. In being open to their presence, we position ourselves in a place where we can work more effectively to mitigate their negative impact.
The importance of context
When the door is closed and we are engaged in the intricate relational process of therapeutic work, it is easy to forget there is a whole world beyond the therapy room. In becoming immersed in the client’s world and perspective, the wider factors that shape both the client’s and our own living and functioning become less apparent. Yet the reality is that therapy never takes place in a vacuum, but rather in a complex system of interrelated and mutually dependent processes. The professional challenge is often about how we respond to and manage that fact while keeping the client’s process in focus.
The same is true for working with suicide potential. The contracts we make with clients at the outset of therapy are informed by a number of factors, such as: our training experience; our modality; ethical expectations; what is understood to constitute good practice; the particular client group with whom we work; and how we construct the ‘organisation’ of our private practice. If we take this latter consideration, we can see quickly how that one factor alone can be so instrumental in how we work. As private practitioners we are not simply meeting clients in our own paid-for space and being paid, in turn, for the delivery of our service. We are responsible for the tone and structure of our work, which will, in turn, shape the culture of the services we deliver. This is true also for how we work independently with suicidal clients.
One of the findings of my research and contact with therapists working in organisational settings over the years is that often we find ourselves having to practise in ways not consistent with our own personal views. For example, if we believe that an individual ultimately retains the right to end their life, we might struggle with a policy expectation that we should refer on any clients with suicidal thoughts. We may believe the client has the right to kill themselves but are directed to act in a more preventative role. The reverse can also be true. What is interesting in my own research is that counsellors were often more inclined to deal with this dissonance by disregarding organisational policy rather than challenging it, where appropriate. It would be foolhardy to imagine that working privately might make us immune to such dynamics. Rather, there is an ethical imperative for us to take time, care and consideration in reflecting on the nature of the confidentiality we offer our clients around suicide risk, how that will be implemented, and why we have taken the position we have. We might decide to offer an inclusive level of confidentiality around suicide potential (ie never disclosing concern without client consent), but we would need to carefully reflect on the ethical and legal consequences of doing so, and particularly when our clients might lack the capacity to make informed decisions, perhaps through age, ill health or distress.
That leaves us with challenging choices: we have an ethical duty to our clients to ensure that we will do what we say we will do (and that we are competent to do so). If we contract so that confidentiality is limited in the event of high suicide risk, we have a duty to act on that transparently, honestly and, wherever possible, in collaboration with our client, even if that means going against a client’s expressed wishes as a last resort. In such events, we need to be clear about the rationale for our actions and not locate that rationale in some magical thinking.
The bigger picture
While there is no UK statutory requirement to disclose concerns regarding suicide risk (although assisting suicide currently remains unlawful at the time of writing), the majority of therapists have to manage a careful balance between the rights of the client (autonomy, confidentiality, right to refuse ‘treatment’) set against the responsibilities inherent in the role of being a therapist (a contract that limits confidentiality where risk is immediately evident). The ethical position of organisations such as BACP is to respect the autonomy of the client while working to safeguard their wellbeing. It is a difficult tightrope to negotiate and the safety nets are not always as apparent as we would like them to be. The fear of ‘getting it wrong’ with respect to suicide is one shared not only by therapists, but by psychologists, psychiatrists and other mental health workers. The spectre of a completed suicide of a client known to us can sit heavily on our shoulders and, for those who share with me the experience of the death of a client through suicide, the trauma and distress can be palpable.
Mental health legislation is typically not the frontline statutory instrument that counsellors and psychotherapists would reach for in the event of difficulty or confusion. Whether or not a client should be ‘sectioned’ under the Mental Health Act (1983, amended 2007) is not a duty placed on therapists and, having worked as a social worker under the terms of mental health legislation, I have found that it does not provide simplicity and clarity as one might hope. The concept of capacity is, however, a more pertinent concept for therapists (as defined by the Mental Capacity Act 2005 (in England and Wales), Adults with Incapacity (Scotland) Act 2008 and, under discussion in Northern Ireland, The Mental Capacity (Health, Welfare & Finance) Bill.
Adults have the right to make decisions about their life and treatment if they have the capacity to do so, including making ‘unwise’ decisions that might be detrimental to their health and wellbeing. The capacity to make informed decisions about treatment (which would include counselling and psychotherapy) is determined if the individual:
- understands what the medical treatment is, its purpose and nature, and why it is being proposed
- understands the benefits, risks and alternatives
- understands the consequences of not receiving the proposed treatment
- can retain the information and is able to weigh up the pros and cons in order to arrive at a decision
- can communicate the decision.
However, if a clear and appropriate contract is in place with clients, therapists are not likely to attract criticism if they go against a client’s known wishes regarding confidentiality in response to serious and immediate concerns about a client’s wellbeing due to suicide risk. Such ‘best interest’ actions are, as the term implies, decisions made by a professional to act in the best interests of the client in a situation where their immediate safety might be compromised. However, it is very helpful for therapists to make themselves aware of the concepts surrounding and informing capacity (and Gillick competency with children and young people), as reflecting on the client’s capacity to consent to therapy and their management of their own confidentiality can be important aspects to capture in record keeping. There is some excellent professional guidance available for thinking about capacity.4
Suicide discourse: the hardest words
If we return to Shneidman’s assertion that the most important question for a suicidal person is: ‘Where do you hurt and how can I help you?’, we go to what I believe is the heart and soul of effective work with suicidal clients. The application of science in the development of ‘objective’ measures and risk assessment tools to evaluate risk potential is ultimately a misnomer: the understanding of another’s feelings and potential behaviour is always a subjective process. This was highlighted during the delivery of a suicide workshop to a mental health team some years ago. They asked me to use my case study material to help them work through the risk assessment tool they were required to complete with each client. This involved me being the ‘client’ and answering their questions as they worked through the form. Even though each member of the team heard the same information at the same time, at the end of the process each one had reached a different conclusion. However worthy the research was that informed the development of this risk assessment tool, it was still ultimately subject to good old human interpretation, and vagaries inherent in that process.
At best, such tools can offer a structure within which a discourse can be initiated, or some flagging of risk potential. At worst, they can leave practitioners thinking they have successfully ticked their ‘risk assessment duty’. That is, if a client scores highly on risk (no matter how low risk they might actually be) the imperative seems to be to prioritise their allocation; or a high-risk client scores low on risk but may be imminently in danger, yet may not be prioritised as it is hard to disregard the numbers. We assume the science must have it right. However, as Shneidman so eloquently asserts, the real understanding and insight lies in the discourse.
This is not without problems, however. My own research clearly indicated that clients will often refer to their suicidal thinking in metaphor or by implication, and that therapists can be reluctant to pick up on the metaphor and name suicide more explicitly.5 The upshot is that suicide potential can often be something that remains unexplored or unasked about and, believe me, none of us are immune to that dynamic, no matter how much we think we would always get it right. The therapists in my study were all experienced and worked from a full range of theoretical orientations, so this is not a modality issue.
Therapists need to be carefully supported to find their own confidence and grounding to be able and willing to go to the most difficult of places with their clients and have the emotional, as well as professional capacity to name suicide, and then explore it. Saying to a client something like, ‘I wonder if you have ever had thoughts about harming yourself to cope with your problems, or of wanting to end your life’ will not put the thought into a client’s mind where it did not exist before but will, instead, open a door of opportunity for both therapist and client to explore and begin to understand the self-annihilatory pull. As Shea6 notes: ‘…when a [therapist] begins to understand his or her own attitudes, biases, and responses to suicide, he or she can become more psychologically and emotionally available to a suicidal client.’ Shea goes on to state: ‘Clients seem to be able to sense when a [therapist] is comfortable with the topic of suicide. At that point, and with such a [practitioner], clients may feel safe enough to share the immediacy of their pull towards death.’
Ideas for good practice
As we have seen, the complexity of working with suicide potential is difficult to overstate. Balancing clients’ rights, capacity, contracting, professional and ethical considerations, therapist responsibilities and so on is a challenging task that can raise a range of feelings and responses in even the most experienced practitioner. However, there are a number of key principles we can keep in mind that can make a positive contribution towards respectful and ethical practice and informed and collaborative decision-making. Some pointers for good practice in working with suicide include:
- ensure you take time and care over contracting and never assume a client’s understanding without carefully checking it out
- don’t rely on ‘stock’ phrases in contracting (eg ‘risk to self and others’) that might be very familiar to us but less so to a distressed and vulnerable client attending therapy for the first time – explain what you mean in accessible language
- be clear as to any factors that might inform or shape the nature of agreements you might make with clients about therapy (eg your working practices in response to suicide)
- be aware of what services and options exist in your area for onward referral, if necessary. Knowledge of these can help inform risk management planning as well as onward referral in crisis. Know of these services before you need them and, if possible, make some form of contact with them to talk about referral procedures (and how, as a private practitioner, you might expedite a referral quickly if needed)
- take time and opportunity to carefully reflect on your own feelings and responses to suicide, and how you have reached this position
- think about how you might talk to clients about their suicidal thinking and perhaps practise in supervision
- be willing and open to ask all clients about the potential for suicide, when appropriate
- be aware of the apparently very good reasons we might come up with for not having talked with a client about suicide (eg they were too upset to ask) and reflect on the fact that there are, in fact, very few good reasons why we might not ask about suicide
- asking about suicide will not put the thought into the client’s mind – instead it will more likely reduce risk
- if a client is vulnerable, think about collaboratively developing a crisis plan with them: an ‘action plan’ that is rooted around interpersonal support options (helplines, crisis teams, access to a GP), and also intrapersonal support options (things the client can do for themselves as self-support, such as meditation, exercise, distraction or focusing techniques) that they can take away that outlines risk triggers and lists what actions and support they might access as a means of supporting themselves (detailing those supports, such as telephone numbers)
- making decisions about how to respond to suicide potential should never be informed by ‘gut feeling’, instinct or any other potentially magical process. Instead, use your knowledge, training, what the client says, what the client doesn’t say, how they present, discussions in supervision (if time allows), and so on, to develop an informed and explicit rationale for actions that you can clearly articulate to yourself, your supervisor and, most importantly, your client
- ensure you record appropriately any concerns regarding risk, how you responded and what the outcome was (including your client’s part in that process)
- ensure you take the time and opportunity to reflect on the ethical aspects of how you work and that you read relevant guidance on legislation that might be pertinent in your work with suicidal potential.
Finally, remember that working with suicide risk can make very high demands on our own emotional and psychological integrity. Indeed, research has suggested a link between working with suicide potential and vicarious trauma.7 Paying attention to our own needs and taking support and attending to self-care wherever possible is not to be overlooked. Over-anxiety in response to a suicidal presentation is probably only marginally less concerning than no anxiety at all. Making contact with another who is contemplating their very existence demands some emotional resonance on our part. Dissociating from it, or being overwhelmed by it, both contraindicate effective and empathic therapeutic processing, whereas experiencing the impact of the process, but in such a way that it facilitates rather than inhibits psychological contact with another’s suicidal process, is perhaps true relational depth.
This is an edited version of an article that was first published in Healthcare Counselling and Psychotherapy Journal. 2014; 14(1):14-19.
Dr Andrew Reeves is a BACP senior accredited counsellor/psychotherapist and a freelance writer, trainer and supervisor. He offers consultative support to organisations that work with risk and is author of, amongst other titles, Counselling Suicidal Clients (Sage 2010).
1. Reeves A, Bowl, R, Wheeler, S. Assessing risk: confrontation or avoidance – what is taught on counsellor training courses. British Journal of Guidance and Counselling. 2004; 32(2):235-247.
2. Shneidman ES. The suicidal mind. Oxford: Oxford University Press; 1998.
3. Leenaars AA. Psychotherapy with suicidal people: a person centred approach. Chichester: Wiley; 2004.
4. www.rcpsych.ac.uk/healthadvice/problemsdisorders/mentalcapacityandthelaw.aspx. Accessed 14 April 2014.
5. Reeves A, Bowl R, Wheeler S, Guthrie E. The hardest words: exploring the dialogue of suicide in the counselling process – a discourse analysis. Counselling and Psychotherapy Research. 2004; 4(1):62-71.
6. Shea SC. The practical art of suicide assessment: a guide for mental health professionals and substance abuse counsellors. Chichester: Wiley; 2002.
7. Fox R, Cooper M. The effects of suicide on the private practitioner: a professional and personal perspective. Clinical Social Work Journal. 1998; 26:143-157