Counselling Suicidal Clients

Andrew Reeves

• Publisher: SAGE Publications Ltd
• Year: 2010
• Print ISBN: 9781412946360, 9781412946353
• eBook ISBN: 9781446241943
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

"I have worked in psychiatry as well as in private practice with suicidal people. I found it poignant and true when Reeves points out that people do not have to be mad to be suicidal and ?…that assessing suicide potential fundamentally lies in engaging with the suicidal client at a deeper relational level?. So true. This thoroughly researched book is written with passion and compassion. It will be a valuable addition to the libraries of therapists and anyone else who works with suicidal people." -

Therapy Today, July 2010

"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. Excellent." -

Denise Meyer, developer and lead author of www.studentdepression.org

"Andrew Reeves brings together his experience as a social worker, counsellor and academic to explore the essential elements in working with suicidal clients. His openness and integrity in writing about this complex topic creates a valuable resource for reflective practice." -

Barbara Mitchels, Solicitor and Director of Watershed Counselling Service, Devon.

Counselling Suicidal Clients addresses the important professional considerations when working with clients who are suicidal. The ?bigger picture?, including legal and ethical considerations and organisational policy and procedures is explored, as is to how practitioners can work with the dynamics of suicide potential in the therapeutic process.

The book is divided into six main parts:

- The changing context of suicide

- The prediction-prevention model, policy and ethics

- The influence of the organisation

- The client process

- The practitioner process

- The practice of counselling with suicidal clients.

The book also includes chapters on the discourse of suicide, suicide and self-injury, and self-care for the counsellor. It is written for counsellors and psychotherapists, and for any professional who uses counselling skills when supporting suicidal people.

Part I

Contextual Aspects of Working With Suicide Risk

1	Suicide and Counselling: An Introduction

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Chapter overview

This chapter provides an overview for the rest of the book by discussing the role of counsellors with clients who are suicidal. It challenges the idea that counselling is generally not a helpful option for suicidal clients, or that counsellors generally should not see clients who are suicidal. It raises the dilemmas that counsellors face in managing and responding to suicide potential in their work. The overall structure of the book is outlined.

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I can recall many years ago, when still early on in my research journey, looking at counselling and suicide risk. I had attended a conference (not about suicide) and was offered a lift home by a consultant psychiatrist psychotherapist. As the journey progressed the conversation moved to my research, and she asked more about it. I explained that I was interested in how counsellors work with clients who are suicidal; that is to say, how they use current information to inform their assessment of risk, whether they formally assess risk at all, how the counselling discourse was altered as a consequence of the disclosure of suicidal ideation, what the implications were of this influence, and so on. My listener was attentive and interested, but also confused. She eventually interrupted me with her statement, ‘But counsellors would never see clients who are suicidal, they would be referred immediately to someone with greater competency.’

This made me reflect on my past and current client caseload. In secondary care nearly all of my clients had attempted suicide, and most were currently still actively suicidal. Since leaving secondary care and moving into higher education, a significant number of my current caseload (at the time of writing) had disclosed some degree of suicidal ideation, and a significant number had made attempts on their life. I didn’t have any reason to assume that my caseload was particularly different to most other counsellors working in a variety of settings: primary care, secondary care, social services, mental health services, further education, higher education, bereavement services, voluntary services, independent practice, and so on. Indeed, if we relate counselling agencies to suicide risk factors – bereavement, relationship breakdown, psychopathology, physical health problems, etc. – it seemed a fair bet that virtually all counsellors would have some profile of suicide potential in their past or current caseload. I returned to the statement made by my listener, and wondered how quiet my caseload would in reality be if I referred everyone who presented with some degree of suicidal thought/intent to ‘someone with greater competency’. I concluded, rightly or wrongly, that despite my listener’s own competency and experience, she seemed to understand little about the nature of counselling.

It is difficult to make a definite statement about how many counsellors will have actively suicidal clients on their caseload, or how many counsellors will have seen actively suicidal clients in their professional lifetime, as I am not aware of any research that provides us with this information. My own study (Reeves and Mintz, 2001) indicated that most counsellors will have experience of supporting a suicidal client, although this was small scale and any wider conclusions are based only on estimations and extrapolated figures. Seber (2000) found, by analysing GP and practice nurse referrals for counselling in primary care, that such referrals often included clients with a previous history of suicide attempts. I developed a one-day training programme for counsellors to help them work more effectively with suicidal clients. During the development of this programme, and subsequent delivery, I have met with in excess of 3000 counsellors to specifically talk about suicide potential. Barely any, whether they be post-qualified, experienced counsellors or counsellors in training, did not have some experience of working with suicide potential, and too many had experienced the trauma of client suicide.

It might be helpful therefore to consider my listener’s assertion in more detail.

Counsellors should not work with suicidal clients

Some might believe that the person who stated that counsellors should not work with suicide potential had a point. There are some interesting arguments that might contradict the accepted knowledge that counsellors are sufficiently competent to work with suicide risk. These might be summarized around four primary tenets: training around risk; knowledge of psychopathology; research awareness; and knowledge of relevant policy.

Training

I just feel quite sad that it is an issue that does not come up more in training. It wasn’t in ours but it is such an important thing that we should address. – Counsellor

Whether counsellors receive sufficient training to enable them to work effectively with suicide risk remains uncertain. Anecdotally, many counsellors will report that they did not feel sufficiently prepared by their core training to work with suicide potential. I undertook a questionnaire survey of all British Association for Counselling and Psychotherapy (BACP) accredited training programmes at that time to try to obtain a profile of risk competency development for counsellors (Reeves et al., 2004a), given that training courses have the task of preparing their trainees to become qualified and competent counsellors in a demanding and complex arena of helping.

There are many important and difficult areas to cover in training. Increasingly, as has been identified through the developments in mental health, risk assessment is one of these important areas (Department of Health, 1999b). No counsellor can ever accurately predict the behaviour or intent of their client, but counsellors must make use of their assessment knowledge and skills to maintain psychological contact with their clients as they explore these difficult areas of human experience. The completed questionnaires returned by the respondents provided insight into trends and ideas informing counsellor training, as well as trainers’/counsellors’ perceptions of the profession’s response to risk.

The courses accredited at the time of my questionnaire study represented several primary theoretical models of practice: person centred, psychodynamic, psychosynthesis and gestalt, with several courses defining their model as integrative or eclectic. Person centred courses were the single largest group (which parallels the trend in BACP membership, with some estimating that 50% of the membership work within a person centred orientation: Thorne, 2004), followed by psychodynamic, integrative/eclectic programmes, psychosynthesis and gestalt.

There was no apparent difference for non-response between the core theoretical models of the courses. This is worth noting, given that a person centred approach is less likely to embrace the concept of risk ‘assessment’ than other models. Merry writes that ‘issues concerning psychological assessment and “diagnosis” are complex, but the person centred approach tends to view these activities as unnecessary and even harmful to the development of a counselling relationship’ (2002: 75). In written feedback received, those involved in person centred courses commented on the nature and meaning of risk assessment more than those running other courses. For example, comments included the belief that risk assessment ‘pathologized’ groups of people, and that the presence of the three core conditions as stated by Rogers (1997) – empathy, congruence and unconditional positive regard in work with clients at risk – was more important than the development of ‘skills’. This philosophical difficulty with the questionnaire was further reflected by other comments stating that the questionnaire did not reflect the ‘style’ of training being offered.

Throughout the questionnaire the term ‘assessment’ was used frequently, chosen to reflect the language that is used in policy documents and mental health guidance, as well as within many medical and psychotherapeutic settings. However, it is important to acknowledge the potential philosophical difficulties that the term ‘assessment’ might have presented to some of the questionnaire respondents, and how that might in turn have influenced both the return rate and the nature of responses received. It might be the case that some courses or individual respondents did not see ‘assessment’ as having a relevant place within the philosophical context of a person centred training course. If this was an influencing factor, then other responses might have been received if different terms had been used, such as ‘evaluation’, ‘exploration’ or ‘consideration’ rather than ‘assessment’, for example.

Psychodynamic and integrative course respondents however were more likely to offer comments about the structure or design of the questionnaire. One respondent could not entirely understand the purpose of the questionnaire given that risk assessment was integral to their training and could ‘never understand how colleagues work without it’. Other courses valued the structure and purpose of the questionnaire and believed the research question to be of significant value.

The returned questionnaires in general terms acknowledged the importance of understanding risk in the counselling process, and the need for trainees to be provided with appropriate opportunities to acquire knowledge and develop skills. However, there was less evidence that the acquisition of knowledge and development of skills were located within the core curriculum of training. Instead, many respondents stated that supervision was the primary source of risk-based teaching and development.

Competency of supervisors in working with risk

There are important questions about how supervisors develop their own specialist knowledge and skills in risk assessment. Many counselling supervisors begin their work in supervision through a process of evolution from counsellor to counsellor supervisor without additional training. At the time of writing there is currently no legislative requirement for counsellors to be registered, and there is no requirement for counsellor supervisors to have training in either counselling or supervision. Through the work of professional organizations such as BACP, and the development of the supervisor accreditation scheme, ‘benchmarks’ for supervision have begun to emerge. As a consequence there is an increasing number of supervisor training courses, although such courses are not yet able to apply for ‘accreditation’ in their own right.

The competency of supervisors to work with trainees around the complexities of risk assessment in their clinical work, including the development and enhancement of skills, is uncertain. That is to say not that supervisors are not competent, but that we just don’t know. Due to the confidential nature of the supervisory relationship, the quality and standard of how risk is managed within supervision are also likely to be uncertain to the tutors on the training programme. In this context there is an argument to locate teaching about risk assessment and risk management more explicitly within the core curriculum. Supervision should build and develop knowledge and skills in working with clients at risk, rather than being the primary source of those qualities.

Importance of ‘risk competency’

Neimeyer et al. (2001) stress the importance of training counsellors in risk assessment skills. This view is reiterated by other studies that note the importance of counsellors across a range of disciplines, including counselling, psychology, nursing and teaching, having the opportunity to develop skills in risk assessment (Appleby et al., 2001; Morriss et al., 1999; K.A. Richards, 2000; Werth, 2002). In this context it is important to note that while 95.8% of respondents believed that a specific consideration of risk was an essential component of a counsellor training curriculum, 47.8% did not include or had not considered including in their generic skills development work any opportunities for trainees to develop and practise skills for working with risk.

This result suggests that a number of training courses do not provide their trainees with opportunities to develop and practise risk assessment skills in their core teaching curriculum. This reflects comments received from some respondents that skills acquisition is less important than the presence of the ‘core conditions’ in the therapeutic relationship, for example. Competency development in this area instead is often located in external supervision contracts outside the immediate remit of the training course.

With the increasing likelihood of counsellors being based within a variety of working settings, including multi-disciplinary teams, it is worth noting that a majority of respondents stated that they considered different approaches to the assessment of risk of suicide within the teaching programme. This diversity might reflect the variation in clinical practice between different professional groups in the assessment and management of risk. It is interesting to note that some respondents did not believe their students were competent to work with suicide risk on completing the diploma programme. This is a surprising result, and begs the question as to how they believed competency was to be developed.

Learning is an ongoing process, and the diploma in counselling structure is increasingly seen as a basic level training from which counsellors should seek to further develop (Dryden and Thorne, 1991). Within the structure of BACP individual counsellor accreditation, applicants need to provide evidence of continuing professional development. However, whether competency in working with risk in counselling is required at a basic level or could be acquired later is an interesting consideration. Within their work, counsellors have the potential to work with clients at risk from the beginning of their training placement as well as from qualification.

While regular supervision is a BACP requirement for ethical practice, it could be argued that counsellors need to be competent in responding to clients at risk not only when they are no longer working within the context of a training placement but also at the beginning of such a placement. If this is true then perhaps all heads of training courses should ensure that their qualifying trainees are competent to work with clients at risk.

Given the complexities and unpredictable nature of client work, there is little time to adequately cover all important practice areas within the limited structure of counselling training. In the light of this, course leaders possibly believe that core training cannot provide trainees with all that they need for working with clients at risk, and that instead this is an ongoing developmental area. Alternatively or additionally, course leaders may consider that the acquisition and development of skills in working with risk are best located in clinical supervision, as has already been discussed.

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Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of Figures and Tables
• Preface
• Acknowledgements
• Part I Contextual Aspects of Working with Suicide Risk
• Part II The Prediction–Prevention Model, Policy and Ethics
• Part III Organizations
• Part IV The Client Process
• Part V The Counsellor Process
• Part VI Key Aspects of Counselling with Suicidal Clients
• Part VII Conclusions
• References
• Index