Working with Suicidal Clients: Talk Over Tick Boxes
The focus of World Mental Health Day this year is suicide prevention. But when it comes to the accepted mainstream practice of risk assessment tools, are tick boxes and questionnaires getting in the way of potent therapeutic discourse? Dr Andrew Reeves, who has written extensively about working relationally with risk, calls for therapists to be brave, step forward, and really meet clients in their suicidal place.
How can therapists find their voice in working with people who are suicidal? I ask this question both literally and metaphorically in that I am interested in how we can work more relationally with suicide risk, as well as using our knowledge as therapists to help inform practice in this area.
As a therapist of 30 years standing, and also a Registered Social Worker with many years’ experience of working in mental health crisis services in statutory settings, I have been witness to changes in how we work with suicide over the intervening time. When I first began my professional life, volunteering as a Samaritans volunteer, the training message given very strongly to me was of the importance in talking to people about their suicidal experience. It seems to me, we have moved away from this relational position, instead trusting ‘science’ to do the job for us.
Many agencies, whether statutory or third sector, are increasingly relying on the application of science to make sense of suicide potential. In practice, this looks like the greater use of tick boxes and questionnaires to determine suicide risk based on risk factors. However, we also know from the literature, repeated over many studies, that the efficacy and validity of such risk factor-based approaches is questionable. For example, Large et al. noted that, according to their meta-analysis, many people who fall into the high-risk factors brackets do not end their life through suicide. Likewise, despite the intervening years and research, we still know very little more about who is likely to kill themselves, and why. Instead, we believe that the application of broad-brush risk factors in understanding an individual risk will help us with our intervention approaches.
I return therefore, to the question that I opened with: how do we find our voice. If I take the literal aspect of this question first, I challenge that we should return first and foremost to a dialogic/relational approach to working with risk. Put simply, we should have the courage and confidence to ask about suicidal thoughts to provide people with an opportunity to talk about them. One of the persistent myths in this area is that by asking about suicide, we potentially increase the risk by putting thought into the person’s minds. What nonsense. We know that asking about suicide will not promote it as an option for someone who has not considered it; additionally, by asking about it we are more likely to decrease its likelihood by providing an opportunity for people to talk about their feelings.
As therapists, we too can experience anxiety and fear about exploring another's suicide potential. The important but scarce literature on countertransferential responses when working with suicide potential is important here in that it flags how our own fears and anxieties can shape negatively our work with suicide risk – more importantly, backing away from any discussion. We need to use a reflexive position to enable ourselves instead, to step forward, to be brave, and to open the dialogue.
In that context, the metaphorical aspect of my question is how we, as therapists, could be contributing better to the development of good practice around suicide. In summary, we are bloody good at establishing meaningful, intimate, respectful and facilitative relationships with others – and we are also good at providing a safe and respectful space in which emotional distress can be explored. Using our expertise and know-how, we could be more actively contributing to the development of working with risk so that services can put science back in its place and, instead, reconnect with the importance of the relationship – one human being to another – in providing a safe space in which suicide can be honestly explored, and alternatives found.