The following article was is based around Dr Andrew Reeves’ workshop hosted in February 2016 on counselling suicidal clients. It was written by our guest blogger Farrah Collins.
Suicide is the biggest killer of men under 45 in the UK. One in four people who kill themselves have been in contact with mental health services – this means three out of four have not. As therapists how do we address such evocative subject matter, support our clients and take care of ourselves?
Brighton Therapy Partnership hosted an event with Dr Andrew Reeves entitled Tight Ropes and Safety Nets: Counselling Suicidal Clients. During this presentation, Dr Andrew Reeves used clinical vignettes, videos, group discussion and his own research to allow us to consider what it means for our clients to feel suicidal, how we might best support them whilst considering our organisational contexts and how to care for ourselves as practitioners working with high levels of distress.
How do therapists respond to suicidal clients?
With suicide rates increasing, practitioners often see clients who have considered suicide. When therapists are confronted with this reality a range of responses are elicited. Therapists can feel worried for their clients, anxious about how best to respond, concerned about the responsibility they are taking on, and be fearful of being blamed. All of these responses can leave therapists feeling deskilled and uncertain about how best to proceed.
Whilst holding these concerns, how are we able to support our clients if they are suicidal? How can we hold our responsibilities to our clients, rather than taking responsibility for them?
Policy and Procedure around suicidal clients
As practitioners and individuals we all have our own personal views on suicide and self-determination. However, for many therapists these views are secondary to the organisational policies of the contexts within which we work. At an institutional and service level, organisational policies dictate the procedures when a client talks about suicide. These policies can be difficult to work with and should be contested if practitioners disagree with them.
However, if there is a policy and procedure then it is important to follow it. Good practice means negotiating and walking the tight rope between the rights of our clients and our professional responsibilities. It also means exploring our client’s capacity and working in their best interests.
The Discourse of Suicide
As therapists engaging in the ‘talking cure’, how we position ourselves and the language we use is of utmost importance.
If we look at the discourse of suicidal clients, research has shown that they do not disclose openly but use metaphors. As therapists, we respond by reverting to typically reflective responses (Reeves, Wheeler, Bowl and Guthrie, 2004). These reflective responses often hinder the exploration of risk.
Some practitioners can be fearful of directly naming suicide as they fear it puts the idea into the client’s mind. This contributes to inhibiting exploration as the practitioner fears knowing and talking about suicide, and client feels that the topic is off limits.
An exploration of our unacknowledged countertransference as therapists is the key to be able to explore suicide freely with our clients. It is crucial that we feel able to directly ask our clients if they do not want to be alive anymore or are considering killing themselves.
Supporting Suicidal Clients
Most practitioners will encounter a suicidal client during their career, and it is important to feel confident and competent in explicitly addressing suicide and working to help clients create a safety net.
Working with suicide risk is a balance between exploring with clients’ experiences of distress and responding. As therapists we respond by identifying factors that make suicide more or less likely, assessing an individual’s understanding of the implications of their actions (capacity), being aware of organisational expectations and balancing these factors to form an intervention.
Risk Factors – Factors that may make suicide more likely
- Self-harm or previous suicide attempts
- Openly discussing methods of suicide or planning
- Dwelling on problems that seem insoluble
- Giving away possessions
- Changes in sleeping or eating patterns
- Withdrawal from relationships and usual activities or interests
- Violent, aggressive or disruptive behaviours
- Substance Misuse
- Boredom, restlessness or self-hatred
- Lack of personal hygiene, self-care
- Over cheerful presentation during a period of depression
Protective Factors – Factors that may make suicide less likely:
- Attending counselling
- The nature and quality of the therapeutic relationship
- The client’s willingness or capacity to talk about their thoughts and feelings
- Both formal and informal support networks within a client’s community
- Family support and important attachments
- Involvement and engagement with interests and activities
- Established and successful coping strategies
- Key individuals a person can and will access
- Options for out of hours support
- Physical activity engagement
- A collaboratively agreed crisis or safety plan
Crisis Plans – A crisis plan is an intervention created collaboratively between client and therapist. A good crisis plan will:
- Carefully outline risks, focusing on the inter and intra-personal nature of risks and self-support
- Highlight times where risk might be elevated or diminished
- Include support options
- Encourage clients ownership and control of plans
- Be presented so that the client can access it outside of their session
- Be reviewed regularly and inclusive of others where appropriate
Supporting Ourselves as Practitioners
Therapeutic practice highlights the importance of self-care to both practitioner and client. Supporting others at times of crisis, like suicides, can take its toll on even the most experienced therapist.
Vicarious trauma is what happens to your neurological, cognitive, physical, psychological and emotional health when you listen to traumatic stories or respond to traumatic situations whilst having to control your own reaction. In order to protect against vicarious traumas, we as therapists need to be mindful of…
- Managerial issues – workload, deadlines, working environment and professional relationships.
- Therapeutic issues – supervision, impact of clinical work, vicarious trauma and the potential for burnout.
- Career issues – ensuring our own CPD, acquiring more skills and knowledge, and the planning and facilitating of our career development.
Responding to Suicide Potential
Finally, here are some take away points for our clinical practice:
- Understand the policies, procedures and professional expectations of the context in which you work.
- Ensure that you contract carefully and clearly with clients.
- Ensure you have knowledge of high risk groups, including warning signs and risk factors.
- Be able to identify and discuss risk factors and protective factors.
- Be willing to openly and explicitly discuss suicide, using direct and open questions.
- Discuss your work with others where appropriate, such as in clinical supervision and with your managers.
- Record your concerns and actions carefully and be aware of having to articulate your thinking and position if it is needed.
- Obtain consent from your client for any action taken where possible.
- If in doubt about immediate safety – act.
For more on counselling suicidal clients we recommend Andrew Reeves’ books:
Reeves, A., Bowl, R., Wheeler, S.,& Guthrie, E. (2004). “The hardest words: exploring the dialogue of suicide in the counselling process- a discourse analysis.” Counselling and Psychotherapy Research 4(1)