Working with the ultimate crisis
Therapy Today, December 2021 / January 2022

James, a 21-year-old student at the University of Newcastle, experienced a rapid decline in his mental health following a routine operation. Feeling distressed, he sought help and was advised at a walk-in centre to attend A&E. There he was asked to wait. He left shortly after, without being seen by any medical staff. Two days later, he died by suicide. His parents, Clare Milford Haven and Nick Wentworth-Stanley, strongly believe that, with the right help, their son’s death could have been prevented.

After several years of raising awareness of anxiety, depression and suicide, James’ parents wanted to create a service that could have helped their son. Liverpool was chosen to host the service because of the active network of organisations and individuals in the suicide prevention community, including Mersey Care NHS Foundation Trust, Liverpool John Moores University and Liverpool City Council.

In 2018 they set up James’ Place in Liverpool, a community-based therapy centre for men in suicidal crisis. Following the success of the Liverpool centre, a second centre opened in east London in April 2021.

Around three-quarters of registered suicide deaths in 2020 were for men, which follows a consistent trend starting in the mid-1990s.¹ Before the COVID pandemic, male suicide was at a 20-year high. The centres are needed more than ever and my work as a therapist at James’ Place has shown me that therapy can make a difference to suicidal men.

Environment matters

People working in health or community contexts will know that therapy can often take place in both overly clinical and, let’s face it, quite shabby settings. I still vividly recall the errant mouse that ran across the room I was practising in as a trainee, just out of my severely depressed client’s eyeline. Before I worked at James’ Place, I’d never really thought about why environment matters, but now I can see why it does. I have spoken to men who find the prospect of being in medical places intimidating. They think they will embarrass themselves, that people will look at them, that they will be expected to talk to lots of people – or even that they will be sectioned and taken into hospital.

James’ Place in Liverpool is peaceful and calm, designed with the help of a focus group of men to get it right. Clients talk about it feeling like a ‘homely, safe space’.² It is easy to see why. It is housed in a beautiful Georgian building; clients are greeted with a hot drink, and taken to a comfortable reception room while they wait. There are beautiful prints on the wall, not the usual posters telling them how to stay healthy. They can use the private, landscaped garden at the back to sit and take some time out. It is vastly different to A&E.

Filling a gap

James’ Place has so far seen more than 400 clients, with approximately one-third of referrals coming from A&E. This tells us that, in Liverpool at least, suicidal men are presenting to A&E and practitioners in A&E view therapy as an appropriate source of help. James’ Place is not aiming to replace 24/7 emergency provision, however, and the service will always signpost to A&E and crisis support through the Samaritans or Shout 85258 for people at imminent risk. What we are trying to do is to fill a gap.

We do that by providing an intensive service for men in acute suicidal distress who do not need psychiatric care but whose crisis precludes services such as IAPT. We don’t operate a waiting list, as the men we see may be in the aftermath or on the brink of a suicide attempt. They may have concrete plans and be taking steps to put those plans into action – for example, stockpiling prescription drugs in order to overdose. It’s crucial they are seen quickly.

We respond to all referrals on the same working day and aim to invite men in for assessment within two working days. The focus of the service is on men who aren’t already being supported by secondary care services, such as hospitals or community care teams – in other words, those without access to a suicide prevention intervention. The reality is that most people who die by suicide are not under the care of specialist mental health services.³ A third of those who die by suicide have not been seen by health services in the 12 months before their death.³

It’s one reason why the Liverpool service accepts self-referrals, although making sure men know about James’ Place is a challenge. Word of mouth and communications campaigns accelerated by social media can help, and we are working with stakeholders to identify and reach out to specific groups of men. Work with voluntary organisations such as the male wellbeing charity Men’s Sheds can be a route to reaching men from particularly marginalised groups. But we will always need to do more work to find the men that need help the most.

Trusted supporters

Once a man is accepted by the service, he will have an hour-long assessment with a therapist within two working days. James’ Place is not always the right place for the men who come to us. If a man is assessed and we think he is unable to keep himself safe, we will support him to get the help he needs. In some cases, this means calling an ambulance. However, what we find in practice is that, once men are engaged, we can work with them to keep them safe, without the situation escalating.

When working with men, we routinely provide information about 24/7 crisis support and support them to create safety plans. As we are a charity founded by parents bereaved by suicide, we encourage all the men who attend to tell their family and friends that they are getting support from us. This reflects a belief that involving a trusted ‘supporter’ will increase the likelihood of success.

Research indicates social isolation is a risk factor for suicide, so there is a logic to involving others in the lives of people feeling suicidal.⁴ Intuitively, the idea of involving friends or family feels right to me, but I am aware it challenges traditional boundaries around confidentiality. We are also aware that clients experiencing suicidal crisis may feel ashamed and could easily be overwhelmed at the prospect of reaching out. We will, of course, still work with a man who cannot provide the name of a supporter. In Liverpool, a network of peer mentors has been established, so that a man who prefers not to involve friends or family may find a supporter through this route.

Perceived burdensomeness

The integrated motivational volitional (IMV) model of suicidal behaviour is one way of understanding how suicide happens and is instructive on why involving a supporter is significant. It highlights ‘perceived burdensomeness’ – the perception that you are a burden, particularly on loved ones, as a core psychological factor in suicidality.⁴

I notice this playing out when clients tell me they are wasting my time. The way I respond depends on the client, but I may ask: ‘What would it be like to continue with counselling, even if you are wasting my time?’ or ‘I wonder if you think counselling might be a waste of your time?’ I hear clients readily say things like, ‘… it would be better for everyone if I wasn’t here,’ and I have spoken to colleagues who have responded by asking: ‘What does “not being here” look and feel like?’

Cue cards

Clients see their therapist twice or three times a week initially, and then weekly, for up to 10 sessions. This frontloading of sessions recognises that clients need intensive support. A frank approach to talking about suicide that starts with the assessment continues with therapists encouraged to weave in a specific intervention that asks men to ‘lay their cards on the table’, and involves cue cards designed to prompt or guide conversation. This intervention was designed specifically for James’ Place, led by Jane Boland, the clinician who also helped establish the service.⁵

I’ve found that using the cards to ask men to reflect on questions such as ‘How did I get here?’ and to offer possible answers, such as ‘I feel overwhelmed by my responsibilities,’ can accelerate the process of unpacking what is going on, both externally and internally.

Throughout our work, we focus on the ending of therapy and plan for what support the men can access next, should they require it. If someone was in an acute suicidal crisis at the end of 10 sessions, there would be a discussion about whether the client could benefit from further sessions or be better helped elsewhere.

Keeping men alive

Clients arrive at therapy in different outward states – desperate, upset, bleakly humorous, in denial and angry. The changes I see or that clients notice about themselves can be small. By the end of 10 sessions, a client may have tolerated letting someone into their life for an hour a week and no longer be actively planning to kill themself but still feel utterly hopeless and have suicidal ideation. The work is not predictable or straightforward, and it is demanding. I feel physically tired at the end of a working day, which I put down to the emotional ‘rushes’ I am experiencing.

For instance, a DNA (did not attend) takes on a whole new meaning in this role. In previous roles, when clients did not show up, I used the space (where I could) to reflect on the client, what might be going on for them and what their non-attendance might mean. Now, I experience an unmistakable flutter of concern. When a client did not attend recently and I was considering how long to leave it before calling the supporter (allowing the client to get in touch), I recalled the experience of James’ mum, and her belief that it would have helped if someone had contacted her and shared their concern. It reminded me what our purpose was – James’ Place has a clear ambition to stop men dying by suicide. It is driven by the idea that therapy might be a crucial intervention in the fight to keep men alive.

However, while we exist to help men in suicidal crisis, we can’t stop men dying if they are determined to end their lives. There is a strong culture of support for staff within the organisation, with each therapist having an external supervisor, paid for by the organisation, as well as a separate line manager. This is heavy-duty work and needs heavy-duty support.

Measuring outcomes

There is little evaluative research into suicide prevention work with men, so much more needs to be done to understand the mechanics of why therapy might help. A small-scale evaluation for James’ Place suggests that clients completing therapy experienced significant positive change, with results from the CORE outcome measure indicating that, on average, clients’ distress levels reduced from severe to mild.² Clients spoke to us about positive changes to do with ‘their feelings of hope, improved relationships with family members, and ultimately reduced suicidal thoughts’.² Pinning down exactly how and why the James’ Place model is effective will be a focus over the next couple of years as the organisation seeks to grow and help more men. In the meantime, the experiences of men such as Liam* tell of a need for something like James’ Place, and keep us going:

‘I wasn’t going anywhere… I just had one thing on my mind and one thing only. I wouldn’t have survived. [Without the service] I might not be talking to you now. So that’s the sort of impact that it’s had.’

* Client consent obtained; name has been changed.