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Tight ropes & safety nets Shame, incompetence and inadequacy are universal feelings reported after a client's suicide. Here Andrew Reeves and Sue Nelson argue for better support systems and training to help counsellors dealing with the emotional trauma of a clientęs suicide
Over the last decade, the policy imperative within the British mental health system has been the prevention of suicide and the reduction of the number of completed suicides.2,3 High suicide rates, and how they are perceived by the media to negatively reflect upon the care offered by statutory mental health services, is a widely recognised political difficulty.4 The National Service Framework for Mental Health and Suicide Prevention Strategy for England sets targets for suicide reduction of 20 per cent by 2010 – the NSF stated that this reduction would prevent 4,000 deaths.5,6 The task defined by UK and international mental health policy is for all mental health workers to recognise, assess, intervene and prevent suicide risk when confronted with it in practice. An exploration of suicide related literature produces a wealth of studies that examine different factors correlated to a heightened suicide risk. The juxtaposition of social policy and suicide research, therefore, is an approach to suicide based on a prediction and prevention model. Counsellors can often perceive a subtext of this approach as being, 'as it can be predicted, it therefore should be prevented'. Little space within policy documents attends to the philosophical or faith-based perspectives on suicide: whether suicide should always be prevented. Consequently, counsellors can often experience a client's suicide as a personal 'failure' and this belief can be further reinforced in the context of the prediction and prevention imperative. The 'bump on the head' This subtext might be usefully deconstructed by Leenaars's7'bump on the head' metaphor. If it is possible to strongly correlate a factor or combination of factors with suicidality, prediction becomes a more informed task. If counsellors can identify specific factors in an individual that have been demonstrated to correlate with a heightened suicide risk, then predicting the likelihood of actual suicide in that individual becomes a more clinically efficacious process. The prediction of suicide becomes as clear as feeling for the right 'bump on the head'. However, in the same way that general risk factors rarely help us predict the actions of an individual, no such 'bump' exists. The reality is that counsellors do their best to understand an individual's suicidality and that sometimes individuals act to end their own lives. The anguish felt by clinicians at the loss of a patient can be one of the most profound and disturbing events in their professional lives.8 Shame, incompetence and inadequacy are universal feelings often reported following a client's suicide.9 Other reported feelings and responses can include numbness, shock, denial, depression, disturbed sleep patterns and nightmares. Counsellors have often described how a client's suicide has shattered their confidence in their therapeutic abilities, losing faith both in their ability to be with clients and in the value of counselling more generally. Such responses do not exclusively belong to trainee or newly qualified counsellors. More experienced counsellors sometimes assume that their professional experience might protect them from self-doubt, fear and guilt. They can be further shaken to discover just how much the suicide of their client affects them. Consequently, counsellors can be reluctant to work with suicidal clients as a means of avoiding their own emotional risk. The fear of 'getting it wrong' can be persistent and pervasive for many counsellors – perhaps it is reinforced and contextually affirmed by the 'prediction/prevention' culture already highlighted? Other professionals are not immune to such emotional difficulties. There can be a feeling in the psychiatric field that, if a patient suicide occurs, you probably did something wrong.8 In a paper by Alexander et al, one consultant psychiatrist talked about the terrible sense of failure he felt at having 'let his client down'.10 Fear of litigation Increasingly counsellors fear blame and litigation. Whilst this is a more common occurrence in the USA and remains a rare event in the UK, the perception of such dangers is high. The danger is of counsellors retreating into corners, watching out for attack and ensuring their back is covered. Some counsellors have been reluctant to consult with colleagues in the aftermath of a patient's suicide because they feared the conversation could be used against them.11 There is a clear argument for better support systems and training to help counsellors deal with the emotional trauma of client suicide. It is essential that counsellors consider self support strategies prior to client suicide so that they are already in place. It is of course impossible to predict the shape, form, frequency or nature of the support that might be required, but putting strategies in place at an individual and organisational level can be invaluable at a time of need. 'Chain of care' policy to reduce anxiety When counselling is offered within an organisational setting, it is important that a 'Chain of Care' policy – one that recognises all links in the process – is put in place to ensure the emotional and psychological wellbeing of those affected by a client suicide. Currently, many policies parallel the 'prediction/ prevention' culture by outlining increasingly sophisticated structures in which 'high risk clients' can be managed. Many counselling services adopt an 'at risk register' approach, used for many years within child protection agencies. Whilst such 'registers' can allow for a systematic service review of the client's well-being, clients are often not informed that their name is on the register or do not have right of appeal against it, unlike within child protection procedures. Additionally, dangers can exist, in that whilst services adopt well-intentioned ways of responding to suicide risk, they might be developing systems that further expose practice by affirming a 'right' way and a 'wrong' way of doing things. For example, there may be particular difficulties for counselling agencies when a client on their 'at-risk register' commits suicide. We need look no further than the scapegoating and blaming culture fuelled by 'at risk registers' in child protection. It is not that a register is inherently wrong, but that it can be a double-edged sword. We would advocate policies that fundamentally support practice and that are based within the philosophical and practice reality that suicide essentially remains an unpredictable phenomenon. Far from taking a 'back covering' stance, if counsellors can feel supported by their organisational policy when working with suicidal clients, they are much less likely to act out their anxiety in sessions and will instead more readily be able to maintain therapeutic dialogue, in which any exploration of risk needs to be based. However, suicide always remains a reality. A 'Chain of Care' policy should incorporate statements focused on the wellbeing of all concerned when a suicide occurs. The following areas might be considered: Organisational and practical implications Any organisational policy or guidance document attending to suicide risk needs to include a statement affirming the importance of counsellor care following a client suicide. This might include time away from work, time out from clinical work, time allowed to attend a funeral, individual or group time to process the implications of the suicide, a commitment to put in place a named contact person(s) for specific support, additional supervision and personal therapy. Indeed, it might be beneficial to have a 'menu' of strategies in place, so that those primarily involved in the suicide would retain the choices about what they need most. Some counsellors see their colleagues as being most helpful to them following the suicide event, alongside supervision. Case reviews When conducted in a constructive climate and geared towards learning rather than blaming, case reviews can be experienced as very positive. Hendin8 et al suggest, however, that whilst talking to colleagues was helpful, case reviews can deliberately or inadvertently provide an opportunity to offer blame or false reassurances, and can compound guilt instead of alleviating it if not managed appropriately. It is unhelpful to apportion blame; openness should be encouraged so that some learning can be gained from the suicide event. It might also be helpful to acknowledge the possibility/probability/ inevitability of some suicides that will undoubtedly leave counsellors in an unenviable position. Therefore, the best way forward would appear to be to create a supportive environment for those counsellors affected by their client's suicide, which allows them time to grieve, discuss feelings or thoughts and share the experiences with others. Attending the funeral Following the death of a client by suicide, there is often a dilemma as to whether or not to attend the funeral. Many counsellors report that attending a funeral helped by offering a sense of 'closure'. It can provide an invaluable opportunity for counsellors to reconcile a sense of fractured experience in the aftermath of a sudden death. However, for others the fear of blame or a sense of responsibility can mean that meeting a client's family and friends might be a daunting prospect. At a time of extreme grief, and often in the context of a suicide, the fear of blame from family and friends of the deceased client is not always an unfounded fear. The value of supervision Given the integral place supervision has within the context of any counselling process, we suggest that a session should be organised as soon after the suicide as possible. Supervision provides an essential space for the counsellors to explore their fears and fantasies of the suicide, particularly when their supervisor is experienced as empathic and supportive. Part of the time can be used to voice those aspects of the counsellor's emotional or intellectual processing that might feel too difficult to voice elsewhere. For example, the images or thoughts that might be held regarding the suicide, the rage that might be experienced towards the deceased and any feelings of incompetence or shame held. Supervision as delivered within the 'counselling field' is usually facilitated by an experienced counsellor who might also have a supervision qualification. However, within other professional arenas a manager often conducts case management and may not have had any training in therapeutic approaches. There appears to be general agreement that it is good practice for counsellors, following a client's suicide, to have time and space to discuss their feelings in a supportive and empathic environment.10,12,13 Therefore, it seems entirely appropriate to suggest that those trained within recognised therapeutic models might be best placed to undertake this specific function. Training and continuing professional development It is essential that counsellors are provided with the opportunity to meet to explore their individual and shared fears about suicide. Training spaces can help support counsellors through the provision of information and guidance. Case studies can further help counsellors consider important practice areas such as record keeping and confidentiality, whilst also providing an invaluable space to reflect on countertransferential aspects of working with clients at risk of suicide and the post-suicide dynamic. It is impossible for counsellors to immunise themselves against the emotional demands experienced when working with suicidal clients, or the grief that is felt following a client suicide. Without a good network of support – externally and internally experienced – there is a danger that counsellors will 'act out' their anxiety within the therapeutic relationship and move into defensive practice. Knowing that we are supported and contained can ultimately enable us to maintain relational 'contact' with our most distressed clients and find ways of intervening that maintain a client-centred approach, regardless of our own theoretical modality. Yet walking a tight rope can feel a scary business. Whether new to it or having walked it many times before, the precarious nature of balancing on a tense yet movable edge can be an overwhelming experience. The fears inherent in such an activity are usually to do with the implications of falling. Whatever safeguards are in place, the fear can remain. The right policy or guidance document – whether generated at an institutional, team or individual level – can be the safety net: it won't prevent the fall but will contain the counsellor and keep him or her safe in time of need. Andrew Reeves, RSW, MA, CQSW, DipCouns, CertSup, MBACP (Accred). Andrew is a counsellor and supervisor at the University of Liverpool Counselling Service. He also worked for many years as an approved social worker in secondary care psychiatric services and within a mental health crisis intervention team. Counselling suicidal clients has been his research focus for 10 years and he is currently finishing a PhD in this area. Email: A.Reeves@liverpool.ac.uk Sue
Nelson, MA, RGN, Adv Dip Couns, DipSup. Sue is a freelance counsellor
for organisations offering EAP as part of their welfare system. She
also worked for over 10 years as a counsellor, a supervisor and, finally,
Director of Clinical Standards for a leading alcohol and drug service.
She is in her 5th year of a Doctorate in Counselling course at the
University of Manchester. Her main focus of research is Alcohol Misuse/Dependence
and Para suicide. Email: docsue@blueyonder.co.uk References
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