Amy is 27 and has been diagnosed with multiple sclerosis. Her physical health has deteriorated quickly since the diagnosis and she has sought help from the third sector counselling service where you work, to try to make sense of the changes in her life. There are times when she feels she just can’t see the point of going on, given the inevitable progression of the disease.
One of the biggest anxieties for therapists working with clients who are suicidal is how best to talk to them about their thoughts and feelings. The persistent myth about working with suicide is that, if we name it as a possibility, we inevitably increase the risk that our client will take their own life. However, as I explored in my previous article, in September’s Therapy Today,1 the reality is that, for many clients, having an opportunity to talk about their suicidal feelings is an immense relief. At worse, it leaves the risk of suicide unchanged; more often, it leads to a lessening of its possibility.
However, talking about suicide is not the only concern of practitioners: managing contractual issues; meeting the needs of organisations; working ethically; doing the ‘right’ thing and, ultimately, not ‘getting it wrong’ can all be sources of significant anxiety.2 Indeed, research has suggested that the emotional and psychological impact of working with suicide risk is as significant for the practitioner as their feelings when a client actually ends their life by suicide.3
Policies and procedures
Amy talks in counselling about her thoughts about suicide. She does not want to die now but struggles to see herself as having any meaningful future. She wants to talk about this in confidence and reassures you that she has no plans to ‘do something’ in the immediate future.
Private practitioners will have explicit policies and practices on what they will do if a client discloses suicidal thoughts and feelings, which they share with all new clients. So too, of course, will organisations that employ therapists. Institutions and organisations are no less anxious than their employees about suicide. They try to ‘pin down’ practice, to reduce the risks by applying ‘science’ to the process and retreating into tick boxes, procedural flowcharts and a manualised approach: ‘If client says A, the therapist does B.’ This is not necessarily helpful as suicide risk is located mostly in the realms of the unpredictable; a great deal of practitioner anxiety can stem from a sense that, despite their best efforts, the client isn’t thinking and feeling in the way the procedure suggests they should.
Research has suggested that, when therapists disagree with organisational policy, they manage this dissidence by disregarding the policy.4 This is not going to be helpful; it places both the therapist and client in a potentially difficult situation where practice ceases to be held by the contractual expectations in which it was originally located.
Rather than disregarding policy simply because it does not seem to be a good fit with the ethos and philosophy of therapy, practitioners have three options: to work with the policy unquestioned; to work within the policy but challenge it with their employer; or, if they cannot change the policy and feel it contradicts their view of how therapy should be, to stop working for that organisation. I am very aware of the challenges therapists face in finding paid employment; walking away from work is never an easy option and nor should it be the first one you take. However, ultimately, ethical practice cannot be compromised.
The personal views of the therapist
Amy explores her suicidal thoughts in the context of her inability to reconcile living with her illness with what she sees as a fulfilled way of being. She feels depleted. You have your own experiences of illness and its impact on your sense of self. You have not disclosed this to Amy.
I remember being told in my own training that when we, as therapists, enter into the counselling room, we leave ourselves at the door. If there is one thing that I have learnt since I qualified as a therapist, it is that this assertion is entirely untrue. Indeed, it is my own view that who I am as a therapist, within the context of a professional therapeutic relationship, is an essential component of the relational process. If I’m not present, who does the client relate to?
However, this position brings particular challenges for us when working with clients who are suicidal. All of us, surely, hold some personal position in relation to suicide; many will have been touched by it personally and professionally. My own route into working with suicidal clients, and how I came to be writing about it for the last 25 years, was my own trauma following the death of a client by suicide during my counsellor training.
It is unrealistic to expect us not to have a view on suicide – and, specifically, an ethical and moral position: whether it is the individual’s right to choose to end their life or that suicide is by definition an expression of mental distress or disorder and we are bound to intervene in every case. It is entirely realistic to expect that we should be engaged reflexively with our views. They will change, of course, over time and in response to myriad life experiences, personal and professional, and including our own relationship with and experience of suicide and our mental health.
The challenge for us is to be constantly aware of how our personal views might shape and influence our work with our clients. Paradoxically, in my experience and as seems so often to be the case with other unconscious processes, those who believe their own views on suicide would never ‘creep’ into the counselling process are the ones to whom it is most likely to happen. Work with another person’s pull towards death often evokes strong emotion, poignancy, anxiety and – sometimes – fear. Our views about suicide in and of themselves are not the issue here; what is important is that we are aware that our unacknowledged views may shape and inform what we do with clients.
Managing confidentiality
Amy’s thoughts of suicide continue but she says she finds the discussion with you helpful in allowing her to voice her inner fears. You feel that the possibility of her suicide is ever-present, sitting alongside you in the sessions, even though she continues to say she does not intend to act on her thoughts.
Most of us will guarantee our clients confidentiality other than in the event of risk of harm to self or others (with additional particular considerations around specific legal requirements, such as those relating to anti-terror legislation, for example). In agreeing this contract, we are, of course, taking on a very heavy weight of responsibility in relation to the client’s wellbeing. We are, effectively, saying that we are able to determine the presence and likelihood of risk of harm to the client, and that we will act to safeguard the client’s wellbeing should we believe it is necessary.
My experience of client work over the years and from talking to the many thousands of therapists I have trained is that, while the details of the contract trip lightly off our tongue in that first therapy or assessment session, the realities of the commitment present highly complex dilemmas when risk is strongly suspected. This is when personal views about suicide, as discussed above, become particularly pertinent. What if, like Amy, a client discloses a determination to end their life due to enduring and deteriorating physical health problems or a terminal diagnosis, or following a major and traumatic bereavement? At one level, a part of us may understand the pull towards suicide; it is very easy to slip into making decisions about the ‘rights’ and ‘wrongs’ of the client’s decision-making process and lose sight of our original contractual obligations.
However, there is another side to that contractual coin. My own experience (one that, I suspect, is similar to that of many other therapists) is that most of my clients may present at some point with some degree of suicidal thought or risk. If I were to break my client’s confidentiality simply because they have used the word ‘suicide’ and explored it with me, I would routinely refer on 80–90% of my clients. Simply put, in every case and within the context of my own and my organisation’s contractual limits, I make an informed decision to work with my client’s suicidality in the belief that the therapeutic process will provide a restorative and safe space into which they can move to escape their risky thinking.
Positive risk-taking
Your work with Amy is all about positive risk-taking – allowing her a space to voice her most difficult fears while, at the same time, paying careful attention to helping her keep safe. You work with her to develop a Keep Safe Plan that she can use between sessions at times when she is feeling in deepest despair.
I argue that all therapists take positive risks with their clients much of the time. That is, they make informed decisions with their clients to work proactively with suicide potential, with a view to supporting them to this safer space. To do this, we carefully evaluate a number of factors: the risk factors (the factors that might make suicide more likely); the protective factors (those that might make suicide less likely); our experience of the therapeutic relationship and process with this client; our judgement of the client’s capacity to engage with therapy and to take active steps to help themselves stay safe; the contract and policy in which therapy is situated, and our capacity to hold our own anxiety in this uncertain situation.
There is an important premise underpinning this assertion of positive risk-taking: it is not the therapist who will keep the client alive; it is the therapy that will equip the client to safeguard their own wellbeing. If an adult client has capacity, as defined by the Mental Capacity Act 2005,5 the work focuses on enabling them to take steps to keep themselves safe. There is a creeping sense at times, and particularly in the case of suicide risk, that we are responsible for our clients, as opposed to having a responsibility to our clients. This is not semantic juggling; it is a significant factor that underpins our therapeutic and contractual relationship with our clients.
That said, working with children and young people brings additional challenges. The judgement as to whether a young person is competent to make decisions about their own wellbeing is, of course, informed by legal and other factors, such as the Gillick principles.6 The context in which the therapy takes place will also have an influence: a school’s safeguarding policies, for example, may place additional responsibilities or limits on the work of the therapist. However, in reflecting on my own supervision of counsellors in schools and as governor safeguarding lead in a large comprehensive school for many years, I am aware that young people very often present with suicide risk and counsellors are routinely weighing up this risk to ensure they offer the best therapeutic experience they can for their clients. With adults and young people alike, the weighty responsibilities that therapists can feel are ever present.
Supervision and self-care
Your work with Amy is having a very profound impact on you. Supervision provides a crucial space for personal and professional exploration and helps you manage the anxieties of respecting Amy’s wish for confidentiality.
Supervision sits at the heart of all therapy, helping us to reflect on both the therapeutic process and our part in it. It is fundamental to shaping how we work with suicidal clients, in that it offers a space into which we can step away, albeit temporarily, from our personal responses and potential anxieties and reflect on the process of the work from a more objective position.
However, as ever, it is not as simple as that. All that has been written about organisational and practitioner anxieties above applies also to the supervisor. As with counsellor training, supervisor training includes very little on working with risk, and supervisors can feel just as anxious about risk in therapy as their supervisees.
The importance of an early, open and honest dialogue about risk with your supervisor cannot be overstated. This is the space to explore and reflect on your organisation’s position in relation to risk; your own view of risk; how your client is presenting specifically with risk, and your supervisor’s expectations, before it becomes necessary to make quick decisions in a high-risk situation. This will, in my view, ensure that supervision and the supervisor are positioned to offer a truly challenging and supportive space that enables the supervisee to work as effectively as possible with their clients and be best positioned to attend to their own self-care.
Responding to suicide potential
I propose three particular scenarios to consider here, with regard to suicide potential: where risk is immediate; where risk is high but not immediate; and where risk is low but still present.
Where risk is immediate – that is, when a client expresses their intention to leave the counselling room and end their life immediately, the therapist should act straight away. Wherever possible, you should consult a manager and/or your supervisor first, but if this is not possible, you should not let this delay you from acting to safeguard the client’s (and potentially others’) wellbeing. In the rare situation that a client leaves the room with a stated intention to end their life and immediate consultation is not possible, you should contact the emergency services to request an immediate response. It is better to be in a position where you are defending positive action to safeguard the client’s wellbeing than defending a failure or delay in acting that might have contributed to a client coming to harm.
When risk is high but not immediate – a familiar scenario for many therapists, this is where we move towards positive risk-taking. No Harm Contracts, which stipulate that the client undertakes not to self-harm, are generally viewed as potentially being emotionally coercive and introducing fractures into the therapeutic process.7,8 However, Keep Safe Plans, where the therapist and client together consider the risks and protective factors and agree and write down actions the client can take between sessions, can support effective therapy. (A good example can be found on the Students Against Depression website.)
Where risk is low but still present – low risk and even no risk should never be assumed, as any client has the potential to present with suicide risk and there is always the possibility of low risk moving to higher risk. As I illustrated in my previous article,1 therapists should feel confident to talk openly and honestly about suicide. It does not heighten the risk of suicide; rather, it invites clients to feel they can do the same. If the client feels they have permission from their therapist to talk about suicide if they need to, there is much more chance that their risk of taking their own life remains low or, indeed, disappears completely.
Final thoughts
Amy continues to struggle with her physical health and, at times, with her suicidal thoughts. For the moment, however, she has been able to articulate and explore the changes she is facing and, by doing so, feels better able to face her uncertain future.
I have outlined here a number of significant challenges that working with suicidal clients presents. The work requires us to approach it less as a science and more as a relational process that is inevitably uncertain and unpredictable; to follow good practice guidelines; to remain focused on our ethical responsibilities and take active steps; and to proactively engage with our clients. Last, but not least, having worked in mental health services for many years, my view is that counselling and psychotherapy can offer very important relational spaces for clients to explore feelings they may not feel able to discuss safely with anyone else. The challenges are very real, but the opportunities to truly help and support clients move past
a point of crisis are significant and should not be undervalued.
For further guidance, see BACP’s Good Practice in Action resources:
042: Working with suicidal clients in the counselling professions
057: Suicide in the context of the counselling professions in England and Wales
058: Assisted death: issues for the counselling professions in England and Wales
Andrew Reeves is a BACP senior accredited counsellor/psychotherapist, registered social worker and Associate Professor in the Counselling Professions and Mental Health at the University of Chester. He is Director of Further Education and Universities for the Charlie Waller Memorial Trust, and Chair, Trustee and Fellow of BACP. He has worked with clients at risk for many years and has authored many books, book chapters and articles on this subject, including BACP’s Good Practice Guidance. His latest book, the second edition of An Introduction to Counselling and Psychotherapy: from theory to practice, has just been published by Sage.
References
1. Reeves A. Where do we go from zero? Therapy Today 29(7): 30–33.
2. Reeves A. Working with risk in counselling and psychotherapy. London: Sage; 2015.
3. Fox R, Cooper M. The effects of suicide on the private practitioner: a professional and personal perspective. Clinical Social Work Journal 1998; 26(2): 143–157.
4. Reeves A, Mintz R. Counsellors’ experiences of working with suicidal clients: an exploratory study. Counselling and Psychotherapy Research 2001; 1(3): 172-176.
5. HM Government. The Mental Capacity Act 2005. London: the Stationery Office; 2005.
6. Care Quality Commission. Brief guide: capacity and competence to consent in under 18s. London: CQC. bit.ly/2xoXqdE
7. Beulow G, Range LM. No-suicide contracts among college students. Death Studies 2001; 25(7): 583-592.
8. Miller MC, Jacobs DG, Gutheil TG. Talisman or taboo? The controversy of the suicide-prevention contract. Harvard Review of Psychiatry 1998; 6(2): 78–87.