网爆门

I can still remember with a mixture of amusement,听irritation and incredulity when a senior policymaker听in the mental health setting in which I was working听questioned the validity and relevance of my research:听how counsellors and psychotherapists work with suicidal听clients and whether a time-limited, cost-effective training听session could be developed to improve confidence and听capacity in working with such a challenging client group.

Indeed, it was with genuine bemusement that she looked听at me and said that therapists simply wouldn鈥檛 find themselves听in a position of working with suicidal clients because they听would, in every eventuality, refer them on to more 鈥榮pecialist鈥櫶�(and perhaps competent?) professionals. I tactfully explained听that the majority of therapists probably do work with suicidal听potential with their clients much of the time and, make no听mistake, we do an excellent job at it too. It clearly wasn鈥檛 a tack听that was intended to make friends with senior policymakers听and I soon shuffled on to pastures new.

But in this anecdote lie a number of important truths for听therapists in a range of settings, including private practice:听suicide potential is evident in a lot of the work we do and, given听how little (relatively speaking) we find ourselves in a position of听breaking a client鈥檚 confidentiality, we seem to be able to work听proactively with risk very effectively. That isn鈥檛 to say there听aren鈥檛 problems, however, and this is at the heart of my research.听To name these problems more specifically:

• suicide has enormous emotional and philosophical resonance听for most of us in some form or another, and there is a great听likelihood that this will find its way into the therapeutic听relationship听
• there is no legal requirement to disclose concerns of suicide听risk, yet the overwhelming majority of us working in private听practice will probably contract to limit confidentiality if we听consider risk of suicide an immediate possibility听
• the concept of capacity sits centrally to much of our thinking听around suicide, yet therapists generally receive very little听training in this area, and indeed, they receive very little training听at all in working with suicide potential^1听
• there is an increasing tension between the risk factor approach听to evaluating suicide potential (who is more likely to kill听themselves) and the discourse-based approach, with the听former generally structured around risk assessment tools听and the latter around a human exchange (the former usually听comes out on top because of its so-called 鈥榮cientific rigour鈥�)
• 听therapists are notoriously bad at articulating what they do.听That is not to say they are bad at what they do in response to听suicide risk, but rather that they struggle to clearly describe听it. In many instances, it seems to be shared wisdom that听evaluating suicide potential simply transfigures out of the听ether, emerging from some ethereal and instinctive dynamic听that only we are privy to. This, quite simply, isn鈥檛 true.

So, my research continued to reflect in more depth on the听process of therapy with suicidal clients. The final stage was to听develop an evidence-based, one-day training workshop for听therapists (and other mental health professionals) to explore听in detail their work with suicide risk and how they could bring听together all that we know through research and evidence, but听make it relevant to a relational process. In summary, how could听we move beyond the two-dimensional and uncertain efficacy听of risk assessment tools and instead build confidence in a听discourse-based approach to working with suicide potential?听Could we learn to talk about suicide and do what Shneidman^2听said was the most important thing we should do with suicidal听people: 鈥樷��our best route to understanding suicide is not through听the study of the structure of the brain, nor the study of social听statistics, nor the study of mental diseases, but directly through听the study of human emotions described鈥� in the words of the听suicidal person.鈥� Shneidman goes on to say: 鈥楾he most important听question to a potentially suicidal person is not an inquiry about听family history or laboratory tests of blood or spinal fluid, but听鈥淲here do you hurt?鈥� and 鈥淗ow can I help you?鈥濃��

The answer to my question was yes, and I have been听travelling around the UK and Europe for the last few years doing听just that. The purpose of this article is to flag some of the key听areas explored in the training and to respond to the problems听outlined above.

Personal perspectives: the hidden dynamic

I have left many people speechless when they ask me about my听research, usually at parties, it has to be said. I say, 'Working with听suicide.' They say, 鈥極h, how fascinating, you must tell me more.听I just need to get a drink and I鈥檒l come straight back鈥�, and I never听see them again. I am left standing alone contemplating what it听was I said. The fact is that suicide is not a 鈥榥eutral鈥� subject; it will听provoke a range of feelings and responses in us that will be听shaped and informed by many factors. These will include: faith听and spirituality; family experiences of crisis and suicide; our own听experiences of suicidal feelings; professional experiences; books,听music, films, and news stories; others鈥� perspectives, and so on.听It is not a fixed entity either, but rather one that is shifting and听changing as we brush alongside crises and new experiences.听Suicide is often a felt, rather than simply a thought response, and听our actions and reactions are often rooted at a very emotionally听visceral level.

Then there is another dynamic. I have read so often, and been听told the same, that it is possible for therapists to 鈥榣eave at the听door鈥� their own thoughts, feelings, judgments, prejudices, and so听on, when seeing a client. That somehow, and perhaps magically,听as we sit in our therapist chairs, we become some sort of blank听slate 鈥� without a personal history as it were 鈥� devoid of any prior听shaping and influence. I鈥檝e always thought this was bunkum.听I suspect we take everything about ourselves and our history听into the room with us. Instead, the challenge is to know of our听history and to find ways of working with it so that it does not听unknowingly become enacted as part of the therapeutic process.

If we bring these two ideas together 鈥� that we cannot leave听our thoughts, feelings and experiences at the door, and that we听will all have some perspective on suicide, such as whether听suicide is something we can make sense of, or something that we听might 鈥榙isapprove鈥� of 鈥� we can see the potential for our own views听becoming unwittingly predominant in the therapeutic process.听There is an emerging body of research³ discussing the concept听of unacknowledged countertransferential responses to suicide听potential that is important here. In not getting hooked on the听particular terminology used to describe the process, it can听be helpful as practitioners to reflect on how views on suicide听might inform our responses. Examples of unacknowledged听countertransferential responses in working with suicide risk听can include:

• underestimating levels of distress or intent听
• an active avoidance of an exploration
• being too quick to be reassured about lack of risk or claims听of improvement听
• assuming exploration will be experienced by the client as听clumsy or insensitive (we project our own fears)听
• minimising the importance of our relationship听
• premature ending of therapy听
• focusing on a perceived 鈥榤anipulation鈥櫶�
• feeling overwhelmed or hopeless听
• feelings of incompetence, fear, anger, anxiety and impotence.

Even though I have written about and researched therapy听with suicidal clients for many years, I am not immune to these听processes. I can recall many instances in work with clients where听these dynamics have been present. My point here is that they听are understandable and can be present at different times during听our work. In being open to their presence, we position ourselves听in a place where we can work more effectively to mitigate their听negative impact.

The importance of context

When the door is closed and we are engaged in the intricate听relational process of therapeutic work, it is easy to forget there听is a whole world beyond the therapy room. In becoming听immersed in the client鈥檚 world and perspective, the wider听factors that shape both the client鈥檚 and our own living and听functioning become less apparent. Yet the reality is that听therapy never takes place in a vacuum, but rather in a complex听system of interrelated and mutually dependent processes. The听professional challenge is often about how we respond to and听manage that fact while keeping the client鈥檚 process in focus.

The same is true for working with suicide potential. The听contracts we make with clients at the outset of therapy are听informed by a number of factors, such as: our training听experience; our modality; ethical expectations; what is听understood to constitute good practice; the particular client听group with whom we work; and how we construct the听鈥榦rganisation鈥� of our private practice. If we take this latter听consideration, we can see quickly how that one factor alone听can be so instrumental in how we work. As private practitioners听we are not simply meeting clients in our own paid-for space听and being paid, in turn, for the delivery of our service. We are听responsible for the tone and structure of our work, which will,听in turn, shape the culture of the services we deliver. This is听true also for how we work independently with suicidal clients.

One of the findings of my research and contact with听therapists working in organisational settings over the years听is that often we find ourselves having to practise in ways not听consistent with our own personal views. For example, if we听believe that an individual ultimately retains the right to end听their life, we might struggle with a policy expectation that we听should refer on any clients with suicidal thoughts. We may听believe the client has the right to kill themselves but are听directed to act in a more preventative role. The reverse can听also be true. What is interesting in my own research is that听counsellors were often more inclined to deal with this听dissonance by disregarding organisational policy rather than听challenging it, where appropriate. It would be foolhardy to听imagine that working privately might make us immune to such听dynamics. Rather, there is an ethical imperative for us to take听time, care and consideration in reflecting on the nature of the听confidentiality we offer our clients around suicide risk, how听that will be implemented, and why we have taken the position听we have. We might decide to offer an inclusive level of听confidentiality around suicide potential (ie never disclosing听concern without client consent), but we would need to carefully听reflect on the ethical and legal consequences of doing so, and听particularly when our clients might lack the capacity to make听informed decisions, perhaps through age, ill health or distress.

That leaves us with challenging choices: we have an ethical听duty to our clients to ensure that we will do what we say we听will do (and that we are competent to do so). If we contract so听that confidentiality is limited in the event of high suicide risk,听we have a duty to act on that transparently, honestly and,听wherever possible, in collaboration with our client, even if听that means going against a client鈥檚 expressed wishes as a听last resort. In such events, we need to be clear about the听rationale for our actions and not locate that rationale in听some magical thinking.

The bigger picture

While there is no UK statutory requirement to disclose听concerns regarding suicide risk (although assisting suicide听currently remains unlawful at the time of writing), the majority听of therapists have to manage a careful balance between the听rights of the client (autonomy, confidentiality, right to refuse听鈥榯reatment鈥�) set against the responsibilities inherent in the听role of being a therapist (a contract that limits confidentiality听where risk is immediately evident). The ethical position of听organisations such as 网爆门 is to respect the autonomy of the听client while working to safeguard their wellbeing. It is a difficult听tightrope to negotiate and the safety nets are not always as听apparent as we would like them to be. The fear of 鈥榞etting it听wrong鈥� with respect to suicide is one shared not only by听therapists, but by psychologists, psychiatrists and other听mental health workers. The spectre of a completed suicide of听a client known to us can sit heavily on our shoulders and, for听those who share with me the experience of the death of a client听through suicide, the trauma and distress can be palpable.

Mental health legislation is typically not the frontline听statutory instrument that counsellors and psychotherapists听would reach for in the event of difficulty or confusion. Whether听or not a client should be 鈥榮ectioned鈥� under the Mental Health听Act (1983, amended 2007) is not a duty placed on therapists听and, having worked as a social worker under the terms of听mental health legislation, I have found that it does not provide听simplicity and clarity as one might hope. The concept of听capacity is, however, a more pertinent concept for therapists听(as defined by the Mental Capacity Act 2005 (in England and听Wales), Adults with Incapacity (Scotland) Act 2008 and, under听discussion in Northern Ireland, The Mental Capacity (Health,听Welfare & Finance) Bill.

Adults have the right to make decisions about their life and听treatment if they have the capacity to do so, including making听鈥榰nwise鈥� decisions that might be detrimental to their health听and wellbeing. The capacity to make informed decisions about听treatment (which would include counselling and psychotherapy)听is determined if the individual:

• understands what the medical treatment is, its purpose听and nature, and why it is being proposed听
• understands the benefits, risks and alternatives听
• understands the consequences of not receiving the听proposed treatment听
• can retain the information and is able to weigh up the pros听and cons in order to arrive at a decision听
• can communicate the decision.

However, if a clear and appropriate contract is in place with听clients, therapists are not likely to attract criticism if they go听against a client鈥檚 known wishes regarding confidentiality in听response to serious and immediate concerns about a client鈥檚听wellbeing due to suicide risk. Such 鈥榖est interest鈥� actions are, as听the term implies, decisions made by a professional to act in the听best interests of the client in a situation where their immediate听safety might be compromised. However, it is very helpful for听therapists to make themselves aware of the concepts听surrounding and informing capacity (and Gillick competency听with children and young people), as reflecting on the client鈥檚听capacity to consent to therapy and their management of their听own confidentiality can be important aspects to capture in听record keeping. There is some excellent professional guidance听available for thinking about capacity.⁴

Suicide discourse: the hardest words

If we return to Shneidman鈥檚 assertion that the most important听question for a suicidal person is: 鈥榃here do you hurt and how听can I help you?鈥�, we go to what I believe is the heart and soul of听effective work with suicidal clients. The application of science听in the development of 鈥榦bjective鈥� measures and risk assessment听tools to evaluate risk potential is ultimately a misnomer: the听understanding of another鈥檚 feelings and potential behaviour is听always a subjective process. This was highlighted during the听delivery of a suicide workshop to a mental health team some听years ago. They asked me to use my case study material to help听them work through the risk assessment tool they were required听to complete with each client. This involved me being the 鈥榗lient鈥櫶齛nd answering their questions as they worked through the form.听Even though each member of the team heard the same听information at the same time, at the end of the process each one听had reached a different conclusion. However worthy the research听was that informed the development of this risk assessment tool,听it was still ultimately subject to good old human interpretation,听and vagaries inherent in that process.

At best, such tools can offer a structure within which a听discourse can be initiated, or some flagging of risk potential.听At worst, they can leave practitioners thinking they have听successfully ticked their 鈥榬isk assessment duty鈥�. That is, if a client听scores highly on risk (no matter how low risk they might actually听be) the imperative seems to be to prioritise their allocation; or听a high-risk client scores low on risk but may be imminently in听danger, yet may not be prioritised as it is hard to disregard the听numbers. We assume the science must have it right. However,听as Shneidman so eloquently asserts, the real understanding听and insight lies in the discourse.

This is not without problems, however. My own research听clearly indicated that clients will often refer to their suicidal听thinking in metaphor or by implication, and that therapists can听be reluctant to pick up on the metaphor and name suicide more听explicitly.⁵ The upshot is that suicide potential can often be听something that remains unexplored or unasked about and,听believe me, none of us are immune to that dynamic, no matter听how much we think we would always get it right. The therapists听in my study were all experienced and worked from a full range听of theoretical orientations, so this is not a modality issue.

Therapists need to be carefully supported to find their own听confidence and grounding to be able and willing to go to the听most difficult of places with their clients and have the emotional,听as well as professional capacity to name suicide, and then听explore it. Saying to a client something like, 鈥業 wonder if you have听ever had thoughts about harming yourself to cope with your听problems, or of wanting to end your life鈥� will not put the thought听into a client鈥檚 mind where it did not exist before but will, instead,听open a door of opportunity for both therapist and client to听explore and begin to understand the self-annihilatory pull. As听Shea6 notes: 鈥樷��when a [therapist] begins to understand his or her听own attitudes, biases, and responses to suicide, he or she can听become more psychologically and emotionally available to a听suicidal client.鈥� Shea goes on to state: 鈥楥lients seem to be able to听sense when a [therapist] is comfortable with the topic of suicide.听At that point, and with such a [practitioner], clients may feel safe听enough to share the immediacy of their pull towards death.鈥�

Ideas for good practice

As we have seen, the complexity of working with suicide听potential is difficult to overstate. Balancing clients鈥� rights,听capacity, contracting, professional and ethical considerations,听therapist responsibilities and so on is a challenging task that听can raise a range of feelings and responses in even the most听experienced practitioner. However, there are a number of听key principles we can keep in mind that can make a positive听contribution towards respectful and ethical practice and听informed and collaborative decision-making. Some pointers听for good practice in working with suicide include:

• ensure you take time and care over contracting and never听assume a client鈥檚 understanding without carefully checking听it out听
• don鈥檛 rely on 鈥榮tock鈥� phrases in contracting (eg 鈥榬isk to self听and others鈥�) that might be very familiar to us but less so to a听distressed and vulnerable client attending therapy for the听first time 鈥� explain what you mean in accessible language听
• be clear as to any factors that might inform or shape the nature听of agreements you might make with clients about therapy听(eg your working practices in response to suicide)听
• be aware of what services and options exist in your area for听onward referral, if necessary. Knowledge of these can help听inform risk management planning as well as onward referral听in crisis. Know of these services before you need them and, if听possible, make some form of contact with them to talk about听referral procedures (and how, as a private practitioner, you听might expedite a referral quickly if needed)听
• take time and opportunity to carefully reflect on your own听feelings and responses to suicide, and how you have reached听this position听
• think about how you might talk to clients about their suicidal听thinking and perhaps practise in supervision听
• be willing and open to ask all clients about the potential for听suicide, when appropriate听
• be aware of the apparently very good reasons we might come听up with for not having talked with a client about suicide (eg听they were too upset to ask) and reflect on the fact that there听are, in fact, very few good reasons why we might not ask听about suicide听
• asking about suicide will not put the thought into the client鈥檚听mind 鈥� instead it will more likely reduce risk
• if a client is vulnerable, think about collaboratively developing听a crisis plan with them: an 鈥榓ction plan鈥� that is rooted around听interpersonal support options (helplines, crisis teams, access听to a GP), and also intrapersonal support options (things the听client can do for themselves as self-support, such as听meditation, exercise, distraction or focusing techniques)听that they can take away that outlines risk triggers and lists听what actions and support they might access as a means of听supporting themselves (detailing those supports, such as听telephone numbers)听
• making decisions about how to respond to suicide potential听should never be informed by 鈥榞ut feeling鈥�, instinct or any other听potentially magical process. Instead, use your knowledge,听training, what the client says, what the client doesn鈥檛 say, how听they present, discussions in supervision (if time allows), and so听on, to develop an informed and explicit rationale for actions听that you can clearly articulate to yourself, your supervisor and,听most importantly, your client听
• ensure you record appropriately any concerns regarding risk,听how you responded and what the outcome was (including your听client鈥檚 part in that process)
• ensure you take the time and opportunity to reflect on the听ethical aspects of how you work and that you read relevant听guidance on legislation that might be pertinent in your work听with suicidal potential.

Finally, remember that working with suicide risk can make听very high demands on our own emotional and psychological听integrity. Indeed, research has suggested a link between听working with suicide potential and vicarious trauma.⁷听Paying听attention to our own needs and taking support and attending to听self-care wherever possible is not to be overlooked. Over-anxiety听in response to a suicidal presentation is probably only marginally听less concerning than no anxiety at all. Making contact with听another who is contemplating their very existence demands听some emotional resonance on our part. Dissociating from it,听or being overwhelmed by it, both contraindicate effective and听empathic therapeutic processing, whereas experiencing the听impact of the process, but in such a way that it facilitates rather听than inhibits psychological contact with another鈥檚 suicidal听process, is perhaps true relational depth.听

听

This is an edited version of an article that was first published听in Healthcare Counselling and Psychotherapy Journal. 2014;听14(1):14-19.

Dr Andrew Reeves is a 网爆门 senior听accredited counsellor/psychotherapist and听a freelance writer, trainer and supervisor.听He offers consultative support to听organisations that work with risk and is听author of, amongst other titles, Counselling听Suicidal Clients (Sage 2010).

References

1. Reeves A, Bowl, R, Wheeler, S. Assessing risk: confrontation or avoidance听鈥� what is taught on counsellor training courses. British Journal of Guidance听and Counselling. 2004; 32(2):235-247.
2. Shneidman ES. The suicidal mind. Oxford: Oxford University Press; 1998.听
3. Leenaars AA. Psychotherapy with suicidal people: a person centred听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听dialogue of suicide in the counselling process 鈥� a discourse analysis.听Counselling and Psychotherapy Research. 2004; 4(1):62-71.
6. Shea SC. The practical art of suicide assessment: a guide for mental health听professionals and substance abuse counsellors. Chichester: Wiley; 2002.
7. Fox R, Cooper M. The effects of suicide on the private practitioner: a听professional and personal perspective. Clinical Social Work Journal. 1998;听26:143-157

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