Where do we go from zero?
Therapy Today, September 2018 Volume 29 Issue 7

When writing about working with suicide risk, the temptation is to focus only on the practical details – contracting, managing confidentiality and so on – as these are often at the forefront of practitioners’ minds. However, in this article I want to explore working with suicide potential from a more relational perspective – once we move beyond the risk assessment tools and questionnaires, where do we go next?

Jake is 18 and walks tentatively into the counselling room. He has completed all his registration forms and, according to his CORE form, has scored zero on risk. He has also scored very low on the specific risk assessment form. That’s a relief, I think. He tells me he has been building up to coming to counselling for some time – two years in fact – but has never felt confident enough, until now. He says he feels ‘rubbish’ and is unable to think of a single thing of value in his life. He begins quietly to cry.

That Jake has now found his way to counselling is a major step for him, particularly given how he feels about himself and his life. Like many people who walk into our rooms, he has reached the point of despair and can see no positives in his life; he feels, literally, hopeless. Nor is Jake’s presentation unusual; many of our clients present in crisis and look to counselling, and us as their counsellor, to help them find a way forward. This is what we do and this is why counselling changes lives: we have the willingness and capacity to meet another in a relational space, without judgement, to help them find ways forward when, to the client, such choices appear so elusive.

It is also not uncommon for our clients to present with degrees of risk that we need carefully to explore and understand. This risk assessment imperative is often directed by employing agencies or by national mental health strategies, such as the current ‘zero suicide’ policy in statutory mental health settings.¹ In addition, of course, there are the ethical frameworks that underpin our work, the contracts we agree with our clients (which typically boundary our work with the client’s safety) and, no less importantly, our human wish for our clients to be safe from harm. This multifaceted drive to assess for risk is also a pretty difficult balance to maintain in real-world practice settings.

Risk assessment, it seems, has become an increasingly scientific endeavour, where we can rest assured in the accuracy and robustness of our risk assessment tools – shaped and informed by research – to help guide us to a clearer and more certain position. Institutionally and individually, we confidently employ a raft of tools to determine the likelihood of someone’s suicide potential through the positivist identification of risk factors.

It was surely a relief when Jake scored zero on the tried and tested risk assessment tools. Yet, Large and colleagues’ meta-analysis of such tools concluded that 95% of people deemed at high risk of suicide do not go on to take their own lives and, more startlingly, there has been no meaningful increase in these tools’ predictive accuracy for suicide over the past 40 years.² It seems that identifying risk factors is a limited mechanism by which to understand suicide potential and the tools we use aren’t really very good. This leaves the counsellor – and client – with a conundrum: if the score says zero, where do we go next?

The problem with risk

The problem with risk is that it is too often talked about in binary ways: either risk is present or it isn’t. Yet risk is multifaceted and, when known and supported, can be an important factor for change. I have previously argued that most counsellors adopt a positive risk-taking position, working in collaboration with their clients.³ I have also offered some thoughts on different types of risk,⁴ which can be broadly categorised as:

• situational – risks that relate to specific potential events or situations
• relational – risks that emerge in the therapeutic relationship
• contextual – risks that relate to the context in which therapy takes place
• professional – risks that relate to professional behaviour or action
• personal – risks to the wellbeing of the practitioner.

Situational

Situational risks are those most often thought about in counselling and psychotherapy. They relate to specific events or situations, or their potential. It is situational risks that are most commonly specifically referred to when contracting with a client. They can include:

• potential for client suicide or self-injury
• safeguarding concerns
• risk of violence to others.

Relational

Relational risks are embedded in the therapeutic relationship and are typically representative of some dynamic between client and therapist. Sometimes they may be very obvious; at other times they emerge slowly, without being noticed. This is where therapist self-reflection (the internal supervisor) and formal supervision can be invaluable in identifying areas of concern before harm is caused. Relational risks might include:

• sexual attraction
• financial mismanagement or inappropriate interaction
• unacknowledged or mismanaged relational issues.

Contextual

Contextual risks relate to the context in which therapy is delivered and can arise because of a number of factors in the delivery of counselling. Organisations that deliver counselling and practitioners who work in independent practice all have a responsibility to ensure that the delivery of therapy is ethical, safe, accessible and appropriate. Contextual risks might include:

• inconsistent or inequitable delivery of services
• lack of clear ethical position in relation to the therapy offered
• inconsistent expectations of practitioners working in the setting.

Professional

As therapists, we have a duty to our clients to safeguard their wellbeing not only during therapy itself but also before and after the therapy has finished. Additionally, our own behaviour can have far-reaching consequences for our professional integrity and for the validity of the therapeutic relationship itself. Actions that seem to be unrelated to our work as therapists can bridge back into our professional roles very quickly. They include:

• positions we take or things we write about on social media
• failing to pay due attention to aspects of our worldview so that they are acted out in the therapeutic relationship – for example, our views about suicide
• failing to reflect critically on our work.

Personal

Finally, we need to think about the personal risks that present as a consequence of our work as a therapist. These typically centre on the impact of our work and how we attend to our own needs. While effective self-care is an ethical requirement, it is not uncommon for therapists to either not think about this explicitly at all or fail to have a systematic mechanism for looking after themselves. Personal risks can include:

• vicarious trauma
• bringing personal material into client work
• inappropriate self-disclosure.

The reality is that we, as counsellors, need to maintain a careful balance of these aspects of risk all of the time, yet often the focus for the counsellor and their employer is on the situational risks. We often start and stop with the question, ‘Is Jake at risk to himself?’, rather than the risks that Jake and I, as his counsellor, might be experiencing.

And so to dialogue

Counselling is a relational endeavour, supported (for the most part and when relevant to the modality) through the use of discourse – that subtle, intimate and intricate verbal exchange between client and counsellor. We train for as long as we do to ensure that this discourse is as unburdened as possible by factors that might distort meaning or direct the client from a misguided position. Yet, our willingness to abandon discourse when it comes to suicide risk in favour of risk questionnaires – or not talking about it at all – is notable. That is not to say all counsellors are guilty of this all of the time; rather, research and experience points in that particular direction. My own research⁵ demonstrated how counsellors, regardless of theoretical orientation, typically actively avoid an exploration of risk when presented with a suicidal client, and other helping professionals can demonstrate this tendency too. The discursive landscape around suicide is littered with hazards and potholes that can trip even the most experienced counsellor.

Jake continues to tell his story – a story of neglect, abuse and being moved from pillar to post throughout his upbringing. No one ever really showed an interest long enough to notice him. He has learnt he is invisible, unworthy and unenviable. I want to ask him how desperate he feels but it seems clumsy and insensitive to do so. I would hate to put the thought of suicide into his mind; it could be like another indirect rejection.

Leenaars⁶ identified a number of risks inherent in working with suicidal clients that, without application of thought or careful use of supervision, can impact on the therapy process. These include:

• underestimating the seriousness of the client’s suicidal thoughts/actions
• allowing oneself to be lulled into a false sense of security by a client’s reassurance
• seeing suicidal thoughts as ‘attention seeking’ rather than an indication of real distress
• denial of the importance of counselling to the client
• disengaging from counselling or not working to maintain the client’s engagement (the ‘hard to reach’ client)
• having a sense of one’s own hopelessness and helplessness in response to a client’s situation
• being pleased with the client’s claims to have solved all their problems when this is inconsistent with their ongoing experience
• fearing that asking about suicide will increase the risk or put the thought into the client’s mind
• feeling incompetent on behalf of a counsellor about working with suicide risk.

Yet, if we are to reposition our attitude to risk assessment tools as supportive mechanisms for understanding suicide risk and accept that they are not the central or leading components we have grown to believe they are, the need to ‘be brave’, as I heard one counsellor call it, and ask our clients about risk becomes the relational imperative. I have previously described this by using a potholing metaphor,³ which I shall reproduce here.

‘Counselling is a bit like potholing in pairs or groups. The task is to explore cave systems, caverns, passageways and pathways. These represent client experiences, memories, histories, fears and joys. Many will be familiar to the client, as they introduce them to you and describe them in some detail. As counsellor – as co-potholer – you bring a new perspective and can reflect on the journey to these places and what you find on arrival in ways that might provide the client with new insights. In the course of that journey you might uncover new cave systems or passageways that take you both into unexplored territory. The client may have known that these new areas existed but felt too overwhelmed or frightened to explore them on their own. Your task is to accompany them on that journey. Of course, your task is also to pay careful attention to safety: to ensure that you have ropes and a means of exiting this place when you need to, and that you give due consideration to the capacity of you and the client to manage this journey safely.

‘The suicidal journey makes this cave system profoundly perilous and unpredictable. Again, this particular cave system may be familiar to the client – a place where they spend a great deal of their time, or perhaps one that is unknown and thunders out of the darkness in a newly menacing way. In this cave system the footing can feel precarious, the handholds limited, and we are exploring at the limits of the rope: the limits of our sense of safety. The temptation to retreat to safer ground is very strong, or perhaps to wander past the entrance to this particular cave system, knowing it is there, but best avoided. We might feel aghast at the thought of asking our clients to go in and explore it on their own, but that is often what we do through our own fear and terror.’

I say to Jake: ‘So tell me, as I hear how you feel, I wonder how bad does this get for you? Are there times you think of hurting yourself in response to how you feel or of killing yourself?’ Jake pauses and holds my gaze; it is as if, in this moment, he has become visible for the first time. ‘Yes, I do, a lot. I think of it all the time.’ ‘Do you want to talk about it more, or tell me what you might do?’ ‘Yes, because I’ve never told anyone this…’

The journey to this point has been perilous and unpredictable for Jake. Even though it has not been witnessed before by others, it has been there all along, always present for him. The zero score on his risk assessment forms had acted like a camouflage, hiding the entrance into this most awful place. It was only in the dialogue that he felt safe enough, prepared enough, to reveal this space and invite me in. That I was prepared to go in and, perhaps, face some of my own demons demanded a lot from me; it was a risk we were both prepared to take and our doing so perhaps affirmed Jake sufficiently to make that exploration worthwhile.

‘Keep safe’ plan

In the training I deliver on suicide and risk, I have always maintained that, unless a client lacks capacity to do it for themselves, in which case we have a duty to temporarily act for them to safeguard their wellbeing, it is not the counsellor who will keep them alive but the client himself or herself. In my view, mental health interventions have become so paternalistic over the years that the autonomy of the client is profoundly eroded through a process of well-meaning, intentionally caring but ultimately undermining positions taken by the ‘helper’. The reality, as I have experienced it, is that counselling is both fundamentally important to a client but also one small part of their jigsaw puzzle. Beyond the 50-minute hour lies the rest of the client’s life. It is in that space that the suicidal ideation is likely to become most predominant: following an argument with a loved one; an experience of a daily crisis; in the dark, impenetrable heaviness of the early hours of the morning. It is at those times, when the counsellor is nowhere to be seen, that the client needs to draw on sufficient resources to keep themselves alive.

A dialogic approach to understanding suicide helps the client understand it for themselves. Through its insights, a client can be supported to understand the factors that can make their suicidal thoughts stronger (loneliness, conflict, etc), or weaker (human contact, exercise, etc). Drawn together into a ‘keep safe’ plan, this understanding can become a resource for the client to take with them when they leave the counselling room – a resource that not only affirms what exacerbates and alleviates their wish to end their life but also tells them what they can do to support themselves at any particular time. These plans can be written with the client or downloaded as a template and completed in discussion with the counsellor. A good example can be found on the Students Against Depression website.⁷ What is most important, however, is that the dialogue provides the structure within which the client can make sense of their experience, rather than the counsellor judging the likelihood of suicide based on a number of so-called predictive factors – suicide risk exploration, rather than suicide risk assessment, if you like. It is through this approach that clients can more fully be supported to support themselves.

Jake said he had never spoken the word ‘suicide’ out loud. Once he began to say it, however, it spilled out in his thinking and feeling, as if a dam had burst and released a torrent after all those years of holding on to this toxic misery. Jake continued at times to come to counselling and continued to feel suicidal. But he had found a voice and had discovered that he had resources. He also said he didn’t feel ashamed any more.

Part 2, on working with suicidal ideation in the counselling room, will be published in the November issue. BACP has recently updated GPiA 057 Suicide in the context of the counselling professions in England and Wales, available free to members.

Andrew Reeves is a BACP senior accredited counsellor/psychotherapist, registered social worker and Associate Professor in the Counselling Professions and Mental Health at the University of Chester. He is Director of Further Education and Universities for the Charlie Waller Memorial Trust, and Chair, Trustee and Fellow of BACP. He has worked with clients at risk for many years and has authored many books, book chapters and articles on this subject, including BACP’s Good Practice Guidance. His latest book, the second edition of An Introduction to Counselling and Psychotherapy: from theory to practice, has just been published by Sage.

References

1. Deputy Prime Minister’s Office. Nick Clegg calls for new ambition for zero suicides across the NHS. Press release, 19 January 2015. [Online.] London: DPMO. www.gov.uk/government/news/nick-clegg-calls-for-zero-suicides-across-the-nhs (accessed February 2016).
2. Large M, Kaneson M, Myles N et al. Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time. PLoS ONE 2016; 11(6): 1–17.
3. Reeves A. Counselling suicidal clients. London: Sage; 2010.
4. Reeves A. Working with risk in counselling and psychotherapy. London: Sage; 2015.
5. Reeves A, Bowl R, Wheeler S, Guthrie E. The hardest words: exploring the dialogue of suicide in the counselling process – a discourse analysis. Counselling and Psychotherapy Research 2004; 4(1): 62–71.
6. Leenaars AA. Psychotherapy with suicidal people: a person-centred approach. Chichester: Wiley; 2004.
7. See www.studentsagainstdepression.org/wp-content/uploads/2018/04/my_safety_plan.pdf

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