Counselling Suicidal Clients

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Andrew Reeves

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  • Counselling in Practice

    Series editor: Windy Dryden

    Associate editor: E. Thomas Dowd

    Counselling in Practice is a series of books developed especially for counsellors and students of counselling, which provides practical, accessible guidelines for dealing with clients with specific, but very common, problems. Books in this series have become recognized as classic texts in their field, and include:

    • Counselling for Grief and Bereavement, Second Edition
    • Geraldine M. Humphrey and David G. Zimpfer
    • Counselling and Psychotherapy for Depression, Third Edition
    • Paul Gilbert
    • Counselling for Post-Traumatic Stress Disorder, Third Edition
    • Michael J. Scott and Stephen G. Stradling
    • Counselling Survivors of Childhood Sexual Abuse, Third Edition
    • Claire Burke Draucker and Donna Martsolf
    • Career Counselling, Second Edition
    • Robert Nathan and Linda Hill
    • Counselling for Eating Disorders, Second Edition
    • Sara Gilbert
    • Counselling for Anxiety Problems, Second Edition
    • Diana Sanders and Frank Wills
    • Counselling for Alcohol Problems, Second Edition
    • Richard Velleman
    • Counselling for Stress Problems
    • Stephen Palmer and Windy Dryden

    Copyright

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    List of Figures and Tables

    Figures
    • 3.1 Suicide rates by age and gender, UK, 1991–2006 23
    • 3.2 Rates of suicides and open verdicts for men in England and Wales, 1968–2007 25
    • 3.3 Numbers of suicides and open verdicts for women in England and Wales, 1968–2007 25
    • 3.4 Evolution of global suicide rates, 1950–2000 26
    • 3.5 Distribution of global suicide rates by gender and age, 2000 26
    • 3.6 Changes in the age distribution of global cases of suicide, 1950–2000 27
    • 7.1 Release of information form 68
    Tables
    • 3.1 Age-standardized suicide rates for men by age group, UK, 1991–2006 24
    • 3.2 Age-standardized suicide rates for women by age group, UK, 1991–2006 24
    • 4.1 Factors associated with higher suicide risk 33
    • 4.2 Suicide risk factors with illustrative research 34
    • 4.3 Outline structure for assessment at the beginning of counselling 40
    • 9.1 Sample guidance document for working with suicidal clients in organizational settings 86
    • 10.1 Suicide as a means of ending existential crisis: an example from a transcript 94
    • 10.2 Suicide as a means of removing a sense of being ‘stuck’ with the negotiations and manoeuvrings of life: an example from a transcript 95
    • 10.3 Suicide as a means of ending apathy and fatigue generated by the burdensome nature of life: an example from a transcript 97
    • 11.1 Ways in which clients talk about suicide 102
    • 11.2 Predominant counsellor responses to client expressions of suicide 104
    • 11.3 Counsellor deflection and retreat: an example from a transcript 105
    • 11.4 An exploration of suicide potential: an example from a transcript 106
    • 15.1 The difficulty of naming suicide: an example from a transcript 139
    • 16.1 Breaking Josh's confidentiality 147
    • 16.2 Maintaining confidentiality with Josh 148
    • 18.1 Counsellor competencies for working with suicide risk 159

    Praise for the Book

    ‘Counselling suicidal clients is one of the most difficult tasks that we face, and Andrew Reeves approaches this subject with openness and integrity, writing about this difficult topic with warmth and empathy for the experiences of both counsellors and clients. There are no absolute, universally applicable answers to the complex issues that surround suicidality. This aspect of therapeutic work requires ethical awareness, a sound knowledge base and calm objectivity in assessing situations and at the same time, giving the very best we can each provide in therapeutic counselling skills. This book reflects these therapeutic requirements, as the author brings together his experience as a social worker, counsellor and academic, to create a very valuable resource for reflective practice.’ Barbara Mitchels, Solicitor and Director of Watershed Counselling Service, Devon.

    ‘A uniquely accessible, comprehensive and practical guide. Essential reading for counsellors and psychotherapists and all helping professionals who work with clients at risk of suicide.’

    Mick Cooper, Professor of Counselling, University of Strathclyde

    ‘A “must read” for counsellors of all experience levels, offering sound practical strategies alongside thought-provoking case studies and discussion points. Reeves addresses this difficult topic with depth, breadth and integrity, questioning the over-simplifications of the “prediction-prevention” culture and challenging counsellors to develop context aware practices as well as personal position awareness. Excellent.’

    Denise Meyer, C. Psychol & MBACP (Snr Accred), developer and lead author of award-winning website http://www.studentdepression.org

    Preface

    In my early career I would not have considered spending nearly 20 years of my life thinking, learning, talking and writing about suicide. For the most part I had not been touched by suicide, and it had remained almost entirely an intellectual consideration for debate and discussion, like politics or the economy. There had been quiet talk in my family of my cousin, living abroad, who had tried to ‘top herself – generally hushed and secretive discussions that I was excluded from as a child. Her ‘activities’ were not appropriate for my ears and as such suicide remained a distant knowledge, untouched by any sense of personal reality. My first real experience of death had been through early employment as a care assistant in a home for older people with severe and enduring mental health problems. This was the first time I had seen a dead person, and had come into personal contact with the process of living and dying. During the two years of this work I became familiar with the process of dying and cared for many dying and dead people. However, death had been as a consequence of age or disease, and as such had represented something of the natural progression of life.

    Suicide began to impinge more closely on my life during my training and early work as a social worker. During training we had discussed the philosophical and legal implications of suicide, and had meandered through several enlightening and well-meaning debates about what were the ‘rights’ and ‘wrongs’ of the choice to take life. A social work placement in a hospice and oncology ward began to illustrate in a far more significant way the human realities and existential crises that contribute to an individual considering ending their own life. Many patients, diagnosed with terminal cancer, were torn between following the natural process of their disease, and reclaiming control over their dying.

    The next transition, from the confinement of suicide to the safety of a textbook and classroom debate into my own experience, occurred in my contact with a 32-year-old man I was assigned to work with in my early social work career. Following a devastating diagnosis of a progressive condition, he quickly lost independence and autonomy over his life. We talked extensively about his wish to be dead, and his longing to act quickly while he could still complete suicide by his own hands.

    With his permission I had talked to his counsellor with whom he also shared his suicidal desires. She was concerned for his safety, but felt that maintaining his confidentiality and not triggering an evaluation of his mental health state was the last dignity she could offer him. Due to a change in my working location I had to finish seeing him as his social worker. Four months later I heard of his death through an overdose. I battled with an internal debate about the nature of the dignity his counsellor's confidentiality had provided him – his right to choose set against an institution's capacity to prevent him from acting in such a way. I know that his choice and subsequent actions were informed and ultimately inevitable. However, the ethical questions were not easy to resolve, and many years on, this remains the case.

    Suicide had grown much closer to my experience in the same way that our own mortality creeps into all of our awareness as time passes. Then, during my training as a counsellor I wrote the following, an extract taken from a case study:

    ‘I'm sorry to have to tell you that Isobel was found dead last night – she had taken an overdose.’ This phone call abruptly and violently brought to an end six months of counselling which had touched on many painful and distressing life events, and had also shone light on Isobel's humanity and sensitivity which she so rarely felt able to recognize. Her fragile and painful grasp on life finally ended, leaving behind all that had brought her misery and despair. She left me with a cocktail of emotions and traumas – my own grief and anger at her actions, my own personal losses and bereavements and my overwhelming feeling of incompetence and failure as a counsellor.

    Our last session together had obvious signs of danger and imminent annihilation – Isobel was so positive and had a new energy, saying that she felt good – ‘very, very good’ – as she left the counselling room. I recall my own sense of lightness, exchanging a smile as the session finished, and feeling a completeness with a sense of some healing for her: that her pain today was not so great as it had been and that perhaps I had played some part in enabling that to happen.

    Possibly with a similar sense of lightness Isobel that night placed into her mouth large quantities of tablets which she washed down with a bottle of vodka and fell into sleep, and then death: perhaps for the first and final time feeling good – very, very good.

    I felt the tidal wave of her process the following morning. As I heard the news I felt a sense of sickness, almost like wanting to throw up something bad that I had swallowed. My stomach and throat creased into a tight knot and I felt a sense of separateness from what was happening around me – that I was spectating from a distance not quite making the connection. Someone asked me if I was okay, and I replied ‘fine’ as I left the room feeling devastated.

    My relationship with suicidality had taken another, dramatic step forward. Isobel had been a client with whom I was working when based within a community mental health team (CMHT) and mental health crisis response service. Her death had personal and professional repercussions for me, and began a process of enquiry into suicide that I might never have otherwise anticipated.

    Supervision, personal therapy and support from family and friends were invaluable in enabling me to consider the implications of Isobel's suicide in my personal and professional life, and regain the confidence to continue with counsellor training and in my work as an approved social worker (ASW) under mental health legislation. I was aware that my capacity to support myself with my anxieties and fears with regard to subsequent potential suicides was diminished. As I read about suicide, I became increasingly aware of the power of it in the life and work of professionals. This power was evident not only in the devastating experience for anyone working with someone who ends their life, but in my experience of building and maintaining a relationship with someone contemplating suicide.

    As part of a masters degree, I embarked on a qualitative study to explore the experiences of counsellors who worked with suicidal clients. With a mixture of reassurance, identification and astonishment, I heard counsellors telling me that when a client talked about or alluded to their suicidal thoughts, they experienced a range of responses including fear, incompetence, impotence, anger, anxiety, sleeplessness, nightmares, intrusive thoughts and anticipated grief (Reeves and Mintz, 2001).

    I had experienced a range of difficult feelings as a consequence of suicide, as had the counsellors in my masters study. It seemed likely that other counsellors might also experience similar things and if they did, how might that influence their ability to work with suicidal clients? How did counsellor training help them in this process – for my own counsellor training had not attended to suicide in any explicit way? A review of the available research indicated that the results found in my own masters degree study had been found elsewhere (Panove, 1994; B. Richards, 2000). Several important factors were emerging as my own questioning continued:

    • My own experience of working with suicidal clients seemed closely related to that of other counsellors in their work with suicidal clients.
    • Suicidality in counselling often initiated powerful and difficult emotional responses in therapists.
    • My own experience of counsellor training was of little time spent exploring the implications of suicide in a counselling relationship, or acquiring and developing the necessary skills and knowledge to enable me to work effectively with suicidal clients.
    • Other counsellors felt ill equipped by their counselling training experiences to work with suicidal clients.
    • Given that most counsellors work within a contract of confidentiality that would require them to refer if their client was thought to present a ‘harm to self or others’, little research existed that explored how counsellors respond to suicidal clients within sessions or how decisions about ‘harm’ were made.
    • While post-qualification risk assessment training programmes existed, they appeared to be either targeted at health care professionals, or generic in their target audience. Through an investigation of the literature and the professional journals, there was little evidence to suggest that resources existed specifically for counsellors to help them consider suicidality from a therapeutic perspective.

    As will be discussed in later chapters, the plethora of resources and literature that attend to suicide predominantly do so from a risk-factor-based approach. That is, how can we predict suicide potential by applying generic risk factors (gender, age, employment status, etc.) to an individual? How can we incorporate those risk factors into questionnaires and assessment tools that will enable us to know who is more likely to kill themselves than others? To some extent these resources are invaluable in helping to create a broad understanding of an individual's distress. Yet, I would argue that for all the research and enquiry, there is only one way by which true understanding of suicidality can be reached, and that is by talking to the suicidal person about their experience.

    That is not to say that this is an easy process. For a start, it is likely that the suicidal client will not necessarily understand their distress in an articulate way; some intrapersonal phenomena are extremely difficult to put into words. Additionally, it is possible that that ‘helper’ – counsellor, social worker, psychologist and psychiatrist, for example – will be inhibited by their own responses to suicidal potential to feel sufficiently confident to articulate their concerns. As we have seen, such responses can include fear, anxiety, anger, impotence and a sense of professional incompetence. These are difficult feelings to ‘allow’, and often the helper is caught in a process of denying their own responses, but still acting them out in the assessment encounter.

    I am therefore interested in several areas, and hope that this book will provide the practitioner with sufficient provocation to facilitate a self-engagement in their journey into the world of the suicidal client. It is important that we are able to recognize our responses when thinking about suicide; are able to acknowledge those parts of ourselves that are fearful, judging or angry; are willing to ask the difficult questions; and know how to respond to the answers we might hear.

    I am a registered social worker, and have for many years worked in multi-professional settings. I have worn my counsellor ‘hat’ while writing this book. However, it is important to stress that almost all of the factors that I discuss and explore about working with suicidal clients can be applied to most settings and helping professionals. I have tried to outline what we all do well, and areas that we can pay attention to. I hope that, whatever your professional background or working context, there is something in these pages that speaks to you.

    There is no ‘right’ and ‘wrong’ position to take regarding suicide – just our own position. Throughout this book I will endeavour to draw out some of the difficulties and dilemmas faced by counsellors when working with suicide potential. These will, inevitably, be defined by context, amongst other factors. I will try to articulate my own position: however, that is not to say that other perspectives are less valid. I hope that in reading this book you will be encouraged or facilitated to engage with your own views, for ultimately it is those that you will take into your work with suicidal clients.

    Andrew ReevesLiverpool, UK

    Acknowledgements

    I am grateful to a number of people and organizations for their help in writing this book. To Rita Mintz, Sue Wheeler and Ric Bowl, who guided me through a personal and professional journey in my research. To Peter Jenkins and Barbara Mitchels, who kindly provided feedback on the first draft of Chapter 7, ‘Confidentiality, Capacity and Consent’. To the team at Sage, and in particular Susannah Trefgarne and Alice Oven, for their support in preparing the manuscript. To BACP, for kind permission in allowing me to base Chapter 6 ‘The Ethical Imperative of Suicide’, on an article I had previously published in CPJ1. To the World Health Organization, the Oxford Centre for Suicide Research, and the Office of Public Sector Information for permission to reproduce statistical information. To Taylor and Francis who provided permission for me to use material previously published in the following three articles:

    Reeves, A., Bowl, R., Wheeler, S. and Guthrie, E. (2004). The hardest words: exploring the dialogue of suicide in the counselling process – a discourse analysis. Counselling and Psychotherapy Research4(1), 62–71. http://www.informaworld.com.
    Reeves, A. and Mintz, R. (2001). The experiences of counsellors who work with suicidal clients: an explorative study. Counselling and Psychotherapy Research2, 37–42. http://www.informaworld.com.
    Reeves, A., Wheeler, S. and Bowl, R. (2004). Confrontation or avoidance: what is taught on counsellor training courses. British Journal of Guidance and Counselling32(2), 235–247. http://www.informaworld.com.

    To the thousands of counsellors I have talked to over the years about their experiences of working with suicidal clients, and therefore for their huge contribution to the writing of this book. Finally, to Diane, Adam, Katie and Emily for putting up with the familiar sight of me sitting at the computer … again.

    1 Reeves, A. (2004). Suicide risk assessment and the ethical framework. CPJ May, 25–28.

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