Suicide
Helping anyone with suicidal thoughts is extremely challenging and fraught with danger - doing nothing can be as bad as doing the wrong thing. A trained and experienced counsellor may help; but having the appropriate skills to deal with such situations can be as much about knowing when to refer a client to a better trained and experienced professional - as much as being able to help the person yourself.
Suicide is something of a controversial issue, and dealing with suicidal clients is something many counsellors dread. Some counsellors may think that it is perfectly acceptable for someone to choose to end their life whereas others may argue that anyone should be prevented from killing themselves – perhaps because they may be unable to think clearly whilst feeling suicidal. Regardless of your stance, you need to take suicide very seriously.
Individuals who attempt suicide repeatedly are likely to eventually succeed. Indeed those who have recently made an attempt are 100 times more likely to succeed in killing themselves during the next 12 months when compared to the general population (Kreitman and Foster, 1991).
Types of Suicidal Clients
There have been attempts to categorise suicidal clients into four groups as follows.
- Those with a dire quality of life e.g. in perpetual chronic pain, permanently disabled, living in abject poverty. This is an extremely high risk group.
- Those who have experienced a recent trauma e.g. rape, torture, death of a loved one. This group is high risk soon after the trauma.
- Those who use the threat of suicide as a means of manipulating others e.g. to persuade a separated spouse to come back. They often don’t wish to kill themselves but should still be taken seriously.
- Those undergoing a psychotic episode e.g. a schizophrenic hearing voices which instruct them to end their life. Obviously, this group needs help straight away.
Assessment of Suicidal Clients
This is something which becomes easier to do with experience, but nevertheless there are things the novice counsellor can look out for when looking to assess risk of suicide.
- Having a plan – a client who has made an achievable plan of how to commit suicide.
- Method chosen – a method which guarantees death if undertaken e.g. shooting one’s brains out is more concrete than one which allows for a change of mind or possible survival.
- Availability – a person who has already got themselves several prescriptions of sleeping pills has the means at their disposal.
- Previous attempts – this greatly increases the risk.
- Warning signs – the person may have given clues about their intention to suicide for some time.
- Suicide note – a prepared note is a clear sign of intent.
- Post-death arrangements – someone who is serious will often make financial arrangements, will adjustments, etc to care for loved ones after they have gone.
- Suicidal ideation – does the client talk frequently about suicide?
- Age group – most suicides occur in younger (below 18 years) and older (above 45 years) age groups.
- Family history – a suicide in the family or of a close friend increases risk.
- Trauma – an acute trauma such as being assaulted, being in a terrorist attack, surviving a car accident in which others died, or losing a loved one can escalate risk.
Other risk factors include psychiatric illness (especially depression), pre-occupation with songs and literature about death, poor social support network, substance or alcohol abuse, relationship issues, financial issues, abrupt changes to lifestyle, and irrational thinking.
Use of Counselling Skills
The building of a trusting and empathic relationship through building rapport and attending skills is the first stage in dealing with a suicidal client. At the end of the day, if the client truly wishes to end their life they will do so regardless of any intervention the counsellor might offer. Therefore, sometimes it is important to state this to the client so that you can join with them and help them to see that you are not working against them.
There are different possible strategies a counsellor might take:
- Opposing the client – this is where the client tries to convince the client that they are doing the wrong thing. You have to be very convincing if you take this approach because it’s difficult to work in opposition, though it may be more appropriate for some clients.
- Focus on the client’s ambivalence - it has been argued that any client who comes to counselling to discuss suicide is likely to hole some ambivalence around actually ending their life because if they didn’t, they would already have done so. Discussing this ambivalence has been found to be successful in staving off suicide with a number of clients. They are able to weigh up the pros and cons of living and dying.
- Cognitive behavioural interventions – these tend to focus on psychological disturbances such as poor interpersonal problem solving skills, impaired affect regulation, and hopelessness about the future.
- Dialectical behaviour therapy (Linehan, 1993) – this therapy was originally designed to treat females with borderline personality disorders but has been used to target aspects of suicidal behaviour through cognitive restructuring, problem solving, and reducing aversive moods. Suicidal attempts are analysed through detailed chain analysis of all events leading up to the attempt and hopefully this stimulates the client to derive alternatives to self-harm.
