Jake is an 18-year-old male client you have been seeing for three months. He does not get on well with this family, has few friends, and generally talks of his sense of isolation and detachment from others. He smokes cannabis to ‘calm himself down’, and binge drinks. He is unemployed, having left school with few qualifications.
He referred himself because he was depressed, and has attended two thirds of the appointments made (the rest DNA). He seems ambivalent about therapy, which you have unsuccessfully tried to explore. He tells you that while he doesn’t have any specific plans at present, he wishes to be dead. He cannot see the ‘point’ any more and feels hopeless. He refuses you permission to speak to his GP and does not explain why.
Working with suicide risk challenges even the most experienced practitioner. Having made a contract with a client at the beginning of therapy, which is usually limited by risk to self (amongst other factors), knowing when and how to implement that contract is extremely difficult and requires careful judgment. Jake’s distress is typical of many clients who present in therapy, with a number of ‘risk factors’ associated with him, such as age, gender, social isolation and drug use. The responses here offer different perspectives of how to work with Jake.
Barbara Day, psychodynamic counsellor
My sense of working with Jake is based in my psychodynamic training and experience. The relationship between Jake and me as a female counsellor is a good basis to begin to think about his struggles from his presentation of family difficulties and friendships, and his internal struggles of ‘what happens next’ as he continues the transition from boyhood to manhood.
What has Jake said he would like from the counselling? Is it to feel better, to have more friends, and maybe to find a job? We need to establish his commitment to not smoking cannabis or binge drinking, explaining a working agreement that I will not tolerate this in our sessions. Boundaries are important and his commitment to regular on-time attendance is to be brought into the room, in order to address his level of responsibility to himself.
The first positive step has been taken and gives a clear message that Jake recognises he is in difficulty and has sought help. In the transition from boyhood to manhood, earlier anxieties, including the anxiety of separation and fear of relying on his own resources, have resurfaced and now there is an opportunity for these to be acknowledged and understood in a containing relationship with me, which has the potential of a sound attachment, thereby enabling a mature separation.
The three-month term reminds me of the first trimester of life. The safe and secure attachment to the womb is a condition for viability and the continuation of life itself, just as the continuity of the counselling sessions can be a reliable source of an unconditional provision of a safe and secure attachment as a prerequisite to further development, and eventual separation at the time of birth, when mother helps baby to ‘leave the nest’.
I have ambivalence towards Jake in that I empathise and yet also feel angry at his apathy. Why, as a competent counsellor, would I wish to have recourse to his GP? Do I feel inadequate, lacking in my own ability and in need of advice from another ‘parent’? These are useful tools in the countertransference in that this is how the client feels. This indicates to me that our work needs to take account of early dependency. Jake feels safe enough at a deeper level to show his ambivalence in the missed sessions, which also indicates he has enough trust to be able to stay away and risk managing alone. His refusal to consent to my contacting the GP is an attempt at control and appropriate assertiveness in making his own choices. I have an image of two parental figures discussing him, which, whilst intended to be helpful, may be perceived as interference, even intrusion, by the client. Certainly at the moment, the client cannot tolerate the idea.
Interpretation of what is happening in the client/counsellor relationship is appropriate, indeed vital, if handled sensitively and firmly and with the counsellor questioning the client’s behaviour and enabling him to accept there are two people in this relationship, each with commitment, generosity and frailty, and our actions impact on each other. The work of the counselling is to recognise and understand Jake’s fears, and to confront and challenge them realistically as and when they present.
Emma Mann, BACP accredited counsellor
While my heart goes out to people like Jake, I’m not sure what the dilemma is here. I work in an FE college in a deprived area and Jake shares many similarities with a number of clients with whom I am currently working. While I find clients like Jake challenging to work with, I wouldn’t consider the situation as a dilemma that would require me to take any action over and above what I would ordinarily do in my work, except to ensure that he had out of hours contact details, such as Samaritans, for someone to talk to between sessions. I would also provide him with information and offer him a referral to a local drugs and alcohol team as a further option.
I don’t think that the dilemma here is that Jake is refusing to give permission to speak to his GP, because this may not help Jake anyway. GPs, as well as clients, vary a great deal in their attitude to prescribing antidepressants and there is research to suggest that antidepressants may in fact precipitate suicidal behaviour in young people (there is also contradictory research evidence in this area). In any case, Jake may not actually be suicidal. He, like many of my clients, expressed a wish to be dead because he couldn’t see a way out. As death would be a way out it seems almost inevitable to me that his thoughts would turn to suicide at some point, which is not the same as an intention to kill himself. This is something I would closely monitor and if Jake talked about plans for suicide I would consider involving the Crisis Team. However, at 18 years of age, there is no legal requirement to take action on Jake’s behalf.
Jake is in a sad and desperate place and my hope would be to continue to work with him through the depression. Attending two thirds of appointments is not ideal but at least he is motivated enough to attend much of the time, and in doing so is expressing some hope of getting better. He hasn’t given up altogether so I would give this more time. Trying to persuade him to do one thing or another may be counterproductive and jeopardise an already shaky therapeutic alliance. He will be aware of the options available to him, including visiting the GP, and I would respect his autonomy in making his own decisions about what is right for him.
Elaine Davies, cognitive behavioural therapist, NHS
I notice a range of thoughts and feelings in response to Jake. I worry about all my clients when they are expressing hopelessness, whether it is overt or not. Research informs me that men under the age of 25 with few protective factors are vulnerable to suicide. When I think of Jake, or clients like him, I always get anxious. I am a therapist who believes in looking after life. I feel my symptoms of anxiety low down in my gut. I hear thoughts of, ‘Oh no, please don’t kill yourself’, but I also hear thoughts that are about me: ‘I hope I get this right’, ‘What if he does kill himself, what will others think of me?’, ‘I must be a bad therapist’.
Working in the NHS does give me some structure around risky clients like Jake. I have already informed Jake in the first session that I will have to disclose both to my supervisor and the GP if risk is confirmed both verbally and through questionnaires. Within an NHS setting I am contracted not only to the client but the organisation, where risk is concerned. So even if Jake is ambivalent about therapy – not attending regularly and refusing permission for me to speak to his GP – in view of the previous sessions and the historical content, I would divulge to Jake’s GP the concerns I had about aspects of risk he presented in therapy.
I would speak to my supervisor and record all my details in Jake’s notes, and write to Jake informing him of my decision. In this correspondence I would ask him to re-visit the contract that I would have made with him on his first visit to therapy. In my experience sometimes telling clients about the rationale of breaching confidentiality around risk shows the client that these issues can be spoken about freely, thus giving the client permission to talk about hopelessness. Of course, I would have liked to meet with Jake face to face to do this but the fact is he disengaged with therapy. My greatest hope would be that he re-engages with another GP at his surgery and continues his exploration.
Teresa Raven, BACP accredited counsellor
I work with students at a college and it is not uncommon for clients to ask me not to contact their GP when they are having suicidal thoughts. My experience in working with young people has taught me that their feelings can be very raw as they have not been buried for years and that they do sometimes act on their emotions. However, when I contact GPs I am usually pleased with their knowledge, support and advice, and their willingness to speak to and see the student as soon as possible.
But this is a difficult situation. Jake has said he does not want his GP to know his wish to be dead. In this instance I always refer back to our original counselling agreement in which confidentiality is explained. Wishing to be dead is named as a limitation to confidentiality. I would ask Jake why he doesn’t want his GP to know and work with what he says; maybe he is afraid of being sectioned, being put on medication, being sent to hospital?
I would look at how real his sense of wanting to be dead was and do a risk assessment with him: looking at his support network (few friends, doesn’t get on well with his family); whether there was an actual intention to kill himself (no specific plan, but feels hopeless); any future losses he is facing (not known); any risk behaviours (he binge drinks and smokes cannabis); and his sense for the future (he feels hopeless). I would explain why I thought it was necessary to contact his GP, given there was a risk, and that our initial agreement was in place to support him in this instance. I would explain that I would like to carry on working with him, and that because he has told me, this does not mean I’m passing him off to someone else to deal with him. I would explain to him that I will be with him during this exploration into his ‘depression’ so that we can come to an understanding about it and look at what he wants to do, given that he referred himself to counselling. I would hope to engage that part of him that wants to live differently.
I would ask again for his consent to contact his GP, having been through that process with him and explaining my ethical and professional standards. But I would contact his GP if he didn’t give me his consent, as I would stand by the counselling contract. In exploring this in detail in supervision, I feel it is important to have that confidentiality agreement as a framework for both the client and myself.