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Working with suicidal clients

Posted on October 17, 2014 at 5:02 PM Comments comments (98)
Presentation given by Dr. Eoin Galavan at the Psychological Protection Society, at Aislin Hotel Dublin, 17/10/2014

Here are my notes from this workshop. 

Between 20%and 50% of mental health practitioners will lose a client to suicide during our professional life, depending on the context in which we work. 
What characterises the suicidal mind is: they always want to live and they always want to die. We can get caught up in the thinking that because a client called out the ambulance after ingesting medication she didn’t really want to die. It’s important to keep this in mind: both wanting to live and wanting to die.
The way we approach suicidality has to be thought out. We can’t throw everything we have at someone. It can be confusing and overwhelming. We do it because we want to be covered.
Thomas Joiner model from "Why people die by suicide"
Perceived burdensomness+thwarted belongingness combined with developed fearlessness and ability leads to serious attempt or death by suicide
Development of fearlessness – the suicide person has gone through a journey that has allowed them to override the natural instinct for self-preservation and to overcome fear.

Fearlessness of physical injury is developed by habituation – getting used to threat of bodily harm to the point that it no longer provokes fear but may induce states that are pleasurable. One has to suppress or depress the fear response. 
Reduction of the fear response through repeated exposure to violence/injury/physical pain/provocation/abuse. Emergence of an opponent process which is the exact opposite reaction to the same stimulus. Eventually overtime the idea of self-harm does no longer evoke the fear response, it evokes feelings of pleasure or calm.
Anorexia nervosa is a good example of how habituation works
There is a high rate of suicide in AN (a study looked at 240 women. 9 died of suicide. This is very high). This is because they have already been through a process of habituation and are likely to use incredibly lethal means because they are habituated thr
Different channels for habituation: Numbing of the body sensations in young children who are neglected. Physical abuse early in life leaves people with a high level of tolerance for physical pain but little tolerance for psychological pain.
It is important to decouple biological death and lethal self injury from the suicidal risk. A ‘slow graceful swan dive into nothingness’ is NOT the same as jumping off a cliff. Suicidal people are not thinking about the actuality of what they are doing. A realistic description awakens the fear response.
Societal and cultural expectations and in some countries (US) legal statues which almost state that a counsellor must  stop a suicidal person from killing themselves as if we have that innate capacity.  It works its way up into the legislative and complaint process. In fact, we don’t have that capacity to stop people from killing themselves. We should stop being anxious about that and stop buying into this fantasy. 7% of all suicides occur in psychiatric hospitals under increased surveillance.
“Perhaps what makes all of this so complicated is the fact that unlike medicine, surgery or dentistry the mental health clinician is the instrument of care – there is no equipment failure, no pathogen, no virus to otherwise blame. We are the instrument of care; it does not get any more personal than that” (Jobes, 2011)
This impacts on how we feel towards the patient and the therapeutic relationship, which is the most precious thing we have.
Israel Orbach – “Therapeutic empathy with the suicidal wish”.
Two elements are always required when we work with the suicidal person. It is important both to empathise with the suicidal wish and at the same time to confront the self-destructiveness and state that biological death is not a solution to life’s problem.
Outdated model of working with suicidal people was reductionistic. Suicide was seen as symptom of depression involved but this is an insufficient explanation.. The clinician was seen as the ‘expert’ and in a one-up position. Inpatient hospitalization, treating the psychiatric disorder and using of ‘no-suicide’ contracts.
There is no evidence that inpatient stays are in and of themselves effective treatment for suicidality. In fact they become risk factors. In fact people are more suicidal when they come out of hospital. The group in society most likely to die by suicide are those who have just left psychiatric hospital. 3 out of 100 will kill themselves. The general population is 15 out of 100.000
There is a belief going around that we can stop people from killing
Using the CAMS (Collaborative Assessment and Management of Suicidality) model authored by prof. David Jobes
This is an overall process of clinical assessment, treatment planning and management of suicidal risk with suicidal outpatients.
Key component
-       clinical assessment of risk
-       treatment planning around what is most relevant to a person with suicidality.
-       management of suicidal risk
-       advocates a collaborative stance: sitting side by side and putting suicide on the table
-       suicide status form: pain, stress, agitation, hopelessness, self hate
-       identifying reasons for living vs reasons for dying.
-       intensive outpatient care that is suicide specific
-       developing other means of coping and problem solving
-       systematically eliminating the need for suicidal coping
Risk assessment:
-       Individual rating their own risk of suicide. We are really bad at guessing where the individual think they are
-       Crisis response plan
-       Separate risk assessment from predition. Risk assessment is NOT prediction.  We are terrible at predicting suicide. It’s such a rare behaviour that it’s very hard to predict even with people who are in a high risk category
-       How invested are they in the plan? What is the intent? Have they got access to means?
-       A risk assessment is simply a best guess – current and static risk factors
-       Clinician’s ‘gut’ intuition needs to be contextualised
-       Risk assessment will dictate the type of treatment and the frequency of contact
-       Most designated high risk are unlikely to kill themselves! (3 out of 100 of those who just come out of psychiatric hosp will kill themselves, but WHICH 3? That is impossible to predict) Many who kill themselves are designated low risk. It’s extremely difficult behaviour to predict.
-       We can’t make people divulge what is going on internally!
-       We shouldn’t be too hard on ourselves if we get it wrong.
When should hospitalisation be considered
   - extremely high risk of suicide
-       is the person at clear and imminent danger of risk
-       person is unwilling to work collaboratively and work at resolving problems and putting suicide behaviour ‘off the table’
When are we negligent?

-       If there is clear and imminent danger by death and we do nothing to try and avert this, that is negligent

The act of suicide - changing attitudes

Posted on January 31, 2013 at 5:18 AM Comments comments (0)
A brief history of changing attitude towards the act suicide from "There's no shame in suicide. There's no glory either" (published on the 30th of January, 2013)

"The Bible contains no obvious condemnation of suicide and reports the suicides of Saul and Samson without any apparent sense of condemnation. It was Augustine who first argued that it contravened the sixth commandment, popularly translated as "thou shalt not kill" (though "thou shalt not murder" is a much better translation). Later, Aquinas intensified this prohibition with the insistence that suicide was unpardonable. And it wasn't until the mid-16th century that those who took their own lives were denied a Christian burial.

As it happens it was the dean of St Paul's, the priest and poet John Donne, who first signalled a change in the church's attitude towards suicide with his essay Biothanatos in 1608, encouraging "a charitable interpretation of theyr Action, who dye so". It took a while for attitudes to shift, but slowly the belief that suicide was a sin began to break down. And a good thing too.

However, from the mid-18th century onwards, and particularly with the advent of Romanticism, a different problem presented itself: the glorification of the suicidal person as a romantic hero. In 1774, Goethe published the literary sensation, The Sorrows of Young Werther, the story of a painfully earnest young man, tortured by unrequited love, who ends up shooting himself. All over Europe, other young men started to dress up in yellow trousers and blue jackets, following Werther. They also began to imitate the manner of his death, and Goethe's book was banned in several countries."

Client suicide. Online resources for therapists in training

Posted on November 30, 2012 at 4:57 PM Comments comments (99)
The impact of client suicide on therapists in training



Treatment of high-risk clients
An Overview of Dialectical Behaviour Therapy in the Treatment of Borderline Personality Disorder by Barry Kiehn and Michaela Swales(

How psychiatry became a damage limitation exercise Darian Leader

The Myth of Confidentiality Judy C. Roberts, M.A.  

Suicide and the law

Posted on November 20, 2012 at 8:02 AM Comments comments (149)
To follow through with the topic of suicide, here is a summary of the chapter titled "Suicide and refusal to accept life-saving treatment" from the book "Standards and Ethics for Counselling in Action" by prof. Tim Bond.

Tim Bond is an expert in professional ethics applied to counselling. He is the architect of the BACP Ethical Framework for good practice in Counselling and Psychotherapy

In the chapter on suicide, the author considers the dilemmas concerning working with a suicidal client, when the client refuses additional help or treatment, and discusses the law's in relation to autonomy, consent, mental capacity and confidentiality. 

Life is sacred
Therapists generally find themselves in two different camps. Some take the stance that life is sacred and has intrinsic value and the therapist's duty is to preserve it. Questioning the value of one's life is symptomatic of mental illness. The individual should be protected against suicidal feelings, which are often transient. This stance is embraced by many mental health professionals who work within the remit of preventing suicide. 

The alternative view is that every person has a right to choose, and suicide is an expression of choice. There are occasions when death may be preferable to life. The therapists that embrace this view tend to disagree with the medicalisation of mental illness.  

Tim Bond suggests that becoming entrenched in one position or other may be more for the benefit of the therapist, who is attempting to control their own anxiety about dealing with a client's death. In fact, the appropriate response is to weigh each individual case and be sensitive to each client's individual circumstances, thus allowing for a degree of flexibility and adaptability which is more facilitative than taking a rigid position. 

The English law
The held assumption that the therapist's duty of care is to protect the client from suicidal intent, may be based on misapplications of US law, says Tim Bond. In the states counsellors are required to breach confidentiality to report suicidal intent, but "there is no equivalent in Britain". "There is no general or automatic legal obligation to intervene on behalf of an adult who is suicidal or refusing medical treatment" (p.119)

Individual autonomy
In fact the English law is strongly favours the individual's autonomy unless there is evidence that the person is of unsound mind, that is suffering a diagnosable mental illness or is being coerced. 

Counsellors may suggest that the client access their GP, psychiatrist or community mental health team, but should be extremely cautious in breaching confidentiality against the clients' wishes. Clients frequently refuse to be treated by their GP because of a fear that their medical reports will be disclosed to their employers. 

If the counsellor insists on breaching confidentiality against the client's wishes they "could be liable for substantial damages for loss of earnings if the client's career were to be adversely affected by an inappropriate disclosure" (p. 107)

Therapists working independently of the NHS mental health services have no general duty to intervene. However therapists working with patients receiving compulsory mental health treatment under the Mental Health Act 2007 may have to follow the protocols agreed as part of the terms of their employment. 

For breaching of confidentiality against the client's wishes to be defensible, the therapist hast o believe that the client is seriously at risk of committing suicide and is suffering from a mental disorder (depression, schizophrenia, bipolar affective disorder). 

My note on this: although some psychotherapists are familiar with the DSM and have embraced the use dual diagnosis, we do not have the same remit as a trained psychiatrist to ascribe diagnostic labels. So arguing that a client has a mental disorder when in fact they have not been so diagnosed by their GP or an assessing psychiatrist may be problematic as far as I can see. We could easily be contradicted by a psychiatry expert. 

Crucially, the Mental Health Act excludes promiscuity, alcohol and drug abuse from compulsory treatment. 

Adult clients have the right to refuse life saving treatment. Therapists may challenge and explore the client's views but have to respect the client's right to make a decision for themselves, if they have the capacity to do so (evidence of capacity depends on whether the someone can retain information long enough to make a decision and whether they are able to weigh different options). Tim Bond stresses that the Mental Health Act cannot be used to achieve "the detention of an individual against her will merely because her thinking process is unusual, even apparently bizzarre and irrational, and contrary to the views of the overwhelming majority in the community at large".

Uncomfortable tension
What Tim Bond's exposition highlights for me is what I see as an uncomfortable tension between the law's respect for personal autonomy going all the way back to the Magna Carta and the current medicalisation of psychotherapy. The Department of Health policy to prevent and reduce suicide seems to create a culture in which NHS staff are pressured into standards of care and management of risk that may be at odds with the principles of confidentiality and autonomy. The latest report I have read on Schizophrenia suggests that the use of coercive treatment is on the rise. My own experience working for IAPT has informed me that even for clients without a formal psychiatric diagnosis, prevention is placed above the principle of confidentiality. 

It is understandable that clients seek treatment in an alternative, non-medical culture, but the independent provision of psychotherapy and counselling services is increasingly under the influence of a medical-model. Perhaps independent therapists begin to subscribe to this because the standards of care set by the medical model are part of a government-backed policy and thus appear to have legitimacy. There is also a fear of being accused of malpractice, and yet considerable confusion about what constitutes good practice, as different therapists have different views on this. Furthermore, therapists may want to do everything they can to avoid for themselves the pain and extreme anxiety caused by a client's suicide, which would throw into question of their competence by peers and supervisors and make them vulnerable to criticism and maybe even prosecution. 

Bereaved relatives of clients who have completed suicide may project their anger and grief onto the therapist, making accusations of incompetence or not caring. The therapists may feel torn between ethical, moral and legal principles that may at times feel at odds with each-other and make ethical dilemmas around suicide extremely difficult to navigate. 

Death and the doctor

Posted on November 19, 2012 at 4:52 PM Comments comments (1)
After hearing dr. Elaine Kasket on Digital Human I became interested in her research on the many facets of how we experience death and mourn. I found two articles Death and the Doctor published by Dr. Kasket in the Journal of Existential Analysis (2006). These are extracts from her doctoral thesis. (Death and the Doctor I and II) I was excited to find this research because it links in with my current interest into how the death of a client through suicide is affecting mental health clinicians such as psychotherapists, counsellors psychiatrists and clinical psychologists. 

Ultimate rescuer
Dr. Kasket is reflecting on the status of the physician in relation to the modern experience of dying.  She says: “With the modern decline of religion and elevation of science and technology, the fight against death is a war, with the charge led by the physician. Society and patients cast physicians in a highly pressurized role that is both potentially rewarding and potentially awkward” (p. 137) The doctor thus  becomes the "ultimate rescuer" (Yalom, 1980), a role both imposed and eagerly accepted by the physician, who may himself be motivated to enter the medical field by a personal need to overcome his death anxiety. 

"Be strong" as a professional norm
Dr. Kasket reviews the existing literature on how doctors' responses to their patients and their suffering or demise is subtly shaped by their training and work culture. Physicians supervise their own emotional response by considering informal professional norms and client expectations.
“When emotional expression is discouraged and not allowed space, when faculty members do not ask about students’ affective responses, when it is explicitly stated that too much emotional involvement will interfere with good patient care, and when hard work and academic pressures are so strong as to cause emotional blunting, medical students get the message that negative emotions and their management are a private matter and their own “problem”, to be dealt with by themselves and not part of their professional development” (p. 140)

Physicians are expected to maintain “affective neutrality” – a highly valued aspect of professional identity, associated with power, knowledge and being above challenge. The underlying assumption seems to be that an effective physician does not become emotionally involved with patients. 

Strategies against the experience of emotional pain
Defense mechanisms such as intellectualisation, use of scientific technical language, thinking about the patient as a "case",  black humour and  suppression of feelings are learned and employed, leading to blunted emotional awareness and a reduced capacity to communicate effectively. 
Other emotion management strategies employed by doctors are: deflecting attention from personal feelings, blaming the patient, making the patient responsible for the doctor’s feelings, projecting. Some doctors may choose specializations where they believe they are less likely to be confronted by death – such as psychiatry, cosmetic surgery, pathology.

Dr. Kasket conducted a qualitative research into the experience of eight doctors and found that they are impacted deeply by the death of their patients and become frequently experience grief and a radical re-assessment of their professional capacity. 
“The dying patient challenges physician’s carefully constructed and reinforced view of themselves that they are experts, who know what is wrong and who know what needs to be done to cure the patient. Not being able to effect that cure can lead to identity confusion, feelings of personal failure and self-esteem crises. (…) After a death, physicians are left doubting themselves: Did they do something wrong? Could something more have been done to prevent the death? Is their grief reaction abnormal? Will it interfere with their work?” (p.144)
Physicians who lose clients become uncertain about diagnosis and about treatment. Terror of making a mistake that could result in death, which could provoke a crisis of identity and have important consequences legally and professionally.
Common coping strategies include: seeking support socially, self-talk, avoidance and wishful thinking. Negative strategies: lashing out, blaming self and others, taking alcohol or drags, intellectualisation, avoidance, crying. They may not be able to take time to reflect or have a private emotional moment. Other behaviours: heroic attempts to sustain life, resuscitation at any cost, unnecessary tests for a patient who is dying, over-prescribing medication.

Suicide prevention polemic

Posted on November 19, 2012 at 9:08 AM Comments comments (0)
To follow up on my earlier posts on suicide, I three more contributions to the polemic whether suicide is preventable or not. Two were published in the October 1994 of the BMJ, before the Department of Health published its prevention strategy plans. 

Greg Wilkinson contribution to the debate is that better treatment of mental illness is a more appropriate aim. It is "difficult to resist the conclusion that suicide is not morally wrong" and that "suicide may be rational". Although we understand better the suicide risk factors (such as a diagnosis of mental illness including severe depression, Bipolar Affective Disorder, schizophrenia, personality disorder, PTSD, previous suicide attempts, gender etc) we are still finding it difficult to predict suicide. The reasons may be that suicide intent is not constant, many people with whom we associate high risk factors do not commit suicide, and "when an event is as rare as suicide even a predictive factor with high specificity and sensitivity includes too many false positives for practical purposes". 

Wilkinson believes that our resources should be concentrated on treating clients with mental illness "properly".

H. G. Morgan in response argues that prevention is possible if doctors are taught how. Whilst we cannot prevent all suicides, we should try to avoid those suicidal deaths that might be avoided. Morgan believes that this does occur, and yet we may not be able to quantify this effect because the patient lives. In other words it is easier to count the failures to prevent suicide than the success in facilitating someone staying alive. 

Morgan also argues that those who are suicidal remain ambivalent until the end, and that we need to support the part of the patient that wants to live. He also urges us to hold onto the hope that even the worst circumstances can change for the better. The distressed cause to survivors may be "disabling for many years". Risk factors are invaluable tools and all mental health practitioners can be trained to incorporate them in their practice. 

The third article comes from the Psychiatric Times, and raises the question whether there is enough evidence that psychopharmacology (drugs) can help prevent suicide. Leonardo Tondo (et. al) focus on Lithium, a drug used to treat Bipolar Affective Disorder and other psychotropic drugs.

Reviewing the available research Tondo has found that the potential anti-suicidal effect of psychotropic drugs is "strikingly limited" and that in particular there is inconclusive evidence that antidepressants help prevent suicides. Lithium however seems to have a stronger evidence base as many studies support the impression that risk of suicide and suicide attempt is far lower during treatment with this drug. "Neurobiological mechanisms that might be involved in apparent anti-suicidal effects of lithium include decreased impulsivity and hostile or aggressive behavior that may be mediated by enhanced functioning of the central serotonin system." Interestingly though, suicide risk is also lowered significantly when the patient is treated with a placebo. 

The study concludes that "altered suicide risk may be obtained with some modern antipsychotic and anticonvulsant drugs commonly used to treat patients whose illnesses include suicidal ideation. However, such applications, and even use of lithium, require further systematic study for both positive and possible adverse effects on suicidal behaviours."

The clinician-survivor of suicide

Posted on November 19, 2012 at 8:15 AM Comments comments (0)
How are mental health professionals responding to client suicide? "The mental health professional as suicide survivor" by Norman Farberow is a review of the available research on the incidence of patient suicide experienced by clinicians and their reactions. The article also draw's on Farberow's personal experience of losing a client whilst he was leading a survivor therapy group. 

Although the incidence of client suicide amongst mental health professionals is significant (as little as one in four and as high as one in two), this is still an area that is under-researched and therapists in training are ill-prepared for the complexity and depth of feeling and reactions associated with losing a client. 

A clinician's reactions to the loss resemble those of family and friends. They range from shock, denial, numbness, confusion, disbelief, sadness, anger, shame and guilt, but are further complicated by responses that stem from their professional position. Many therapists feel they have failed in their responsibility, they doubt their clinical competency and feel deeply anxious about reprisals such as litigation and criticism from colleagues. They feel depressed ashamed, isolated and judged or rejected by their peers. 

The experience has a profound existential impact and may radically alter the way clinicians work. Many become conservative in record keeping, reluctant to take on clients at risk of suicide and quick to refer or section clients who may not in fact be at high risk. 

Help for the therapist-survivor
Mental health institutions working with clients at risk have detailed protocols about the management and treatment of suicidal risk, however they fail to include any information about the aftermath of such an event and how it may impact the responsible clinician. 

Clinicians get through the event by conducting a thorough "psychological autopsy", going through notes and talking with other colleagues and supervisors. Reading research and testimonies of other clinician-survivors helps normalize the experience of intense feelings associated with grief.

Online has a dedicated page for clinician-survivors and many testimonies. 

Suicide prevention: realistically possible and and always desirable?

Posted on November 16, 2012 at 6:08 PM Comments comments (177)
One in five counsellors, psychologists and psychotherapists and one in two psychiatrist will experience a client's suicide in their career. (Clinicians and suicide loss by Nina Gutin, on

Prediction-prevention culture

How we experience a client's suicide is influenced not only by our own values but also the wider cultural context in which we work. Andrew Reeves (Counselling Suicidal Clients) refers to this as the "prediction-prevention culture" (p.44) 

In the UK several policy documents issued by the Department of Health (Saving our lives: our healthier nation and the National Suicide Prevention Strategy) make reduction and prevention of suicide key principles at the heart of health provision. 

The National Suicide Prevention document states that: "Each suicide represents both an individual tragedy and a loss to society. Suicide can be devastating forfamilies and other ‘survivors’ – economically, psychologically and spiritually. For these reasons the Government has made suicide prevention a health priority." 

As Andrew Reeves points out the policy takes a singular view on suicide and ignores the many shades of grey that become apparent when considering the circumstances around suicide and individual free choice. Some clients are not mentally ill - they have full mental capacity when taking a decision to end their life. They may suffer from a condition that will lead to a progressive loss of function or mental capacity that is incompatible with their sense of self and dignity. 

I think this "allways" approach may constrict and inhibit individual counsellor's willingness to explore alternative statements such as: "suicide should not always be prevented" or "suicide can only be understood ethically by looking at the particular circumstances of a particular individual". 

Counsellors and psychotherapists that work within the National Health System have no choice but to adopt suicide prevention, as it is their contractual duty to follow the protocols of the organisation for which they work. These protocols outline how suicide risk should be assessed, what constitutes suicide risk and what steps neet to be taken with a client who is at risk.

As a consequence of the tenets of the prevention-reduction culture, a counsellor who loses a client through suicide is strongly invited to consider that this reflects a professional failure. 

Is suicide preventable?

It is perhaps understandable that policy makers think in such optimist positivist terms but is this wishful thinking or reality? Can we really predict and prevent suicide? On what basis do policy makers assume that we can? Is this assumption setting counsellors, psychologists, psychotherapists, psychiatrists and social workers up to feel a deep sense of professional failure? 

It is highly unlikely that this question can ever be investigated in a scientific manner simply because one cannot envisage a research in which a control group of suicidal clients is subjected to prediction-prevention. Although we do have statistics to alert us to factors that suggest that a client is at higher risk (male, living alone, unemployment, alcohol or drug misuse, mental illness, access to means), this doesn't mean that we can automatically predict who will carry out a suicide act and when. Reeves suggests that trying to predict suicide is like trying to predict the winner in a horse race. Even with detailed information, it is difficult. 

Suicide statistics are about averages, whereas people processes are highly idiosyncratic and may not neatly fit with the average data. Reeves suggests that even allowing for this, we do have to weigh the facts and ultimately make a decision and, crucially, be prepared to back that decision up and show exactly how we went about considering a course of action. This is because when dealing with suicide there may be no clear right or wrong way. The ethical values we hold sometimes contradict each other. Sometimes we have to prioritise one over another. How we decide in an individual case cannot be dictates solely by statistics - it involves a careful consideration of each individual case in its own right. 

A radical thinker on the subject of suicide prevention, Thomas Szatz goes as far as to suggest that suicide prevention is doomed to fail because: "No one can prevent a person who wants to kill himself from doing so." (Suicide Prohibition p.7) He has a point. Patients who are in high security units manage to take their lives in spite of draconic measures to remove every harmful object or means. It is also known that a high suicide risk period is right after the patient is discharged from the hospital. So sectioning is not necessarily a fool-proof way of stopping someone from committing suicide. If used simply as a means to cover the counsellor's back and avoid the pain and anxiety of holding a suicidal client, it  is a way of handing over the problem to someone else. 

However an aspect not mentioned by Szatz is that some clients are grateful for the containment offered by a psychiatric ward and are willing to temporarily hand over responsibility for their wellbeing to someone else. These are the clients who give consent to be admitted temporarily in a psychiatric hospital. Again a sound decision can only be made by considering the client, their wishes and how they might respond to this type of care.