Suicide: Can Counselling help?
By: James Foley
Suicide: Can Counselling help?
You believe that your loved one may need help.
Their mood is continuously down. They are self-critical. They are isolating. Activities they used to love they are no longer engaged with. Recently you have noticed they have what looks like self harm marks on their arms. When they do talk, they are hopeless and see no future for themselves.
You believe they are a suicide risk.
They have agreed to talk to a counsellor after a lot of coaxing.
So what are they to expect from counselling? What would you expect if it is you?
General counselling principles
All counselling therapy work starts on the basis of three core principles. First, understanding that comes from the counsellor’s empathy. The counsellor shows their care for the client through an unconditional positive approach. Both the counsellor and client being honest with each other helps develop trust and for the counselling to thrive.
In brief summary, all counsellors will first aim to move the suicidal client out of crisis. Once the crisis has been lifted the client will work through preventions for such behaviour again in the future.
There will always be a range of views held by different counsellors on what is helpful with the suicidal client. I can’t cover them all.
Most clients dealing with suicidal feelings will come voluntarily. This act in itself is an acknowledgement they want to live. It is always best in every counselling situation that the client goes voluntarily and is never forced or coerced.
Initially some clients may go to counselling reluctantly. In such a situation the counsellor will have to focus on gaining trust first before specific therapeutic work can be done.
Pieta House, the suicide support service, say the counsellor focuses on helping the client find that part of themselves that wants to live. The client’s will to die must be listened to and accepted by the counsellor. This helps gain the client’s trust. From there the work can begin on strengthening their will to live.
There is always some part of the client that wants to live. We just have to find it.
Assessing the risk of suicide
A key principle in working with suicidal people is risk assessment. Simply, what is the risk that the person will die from suicide while undergoing counselling?
Such risk assessment is especially important in the early sessions where the client is more acutely suicidal. The client will have ongoing assessment re their suicidal thoughts as the risk will always be there during the counselling work.
Risk assessment can be done using structured suicide risk assessment scales. Simply asking a client to grade their risk from 0 to 10 can be effective. The Positive and Negative Suicide Ideation Inventory is a well researched suicide risk assessment scale. It is a structured set of questions that indicate the client’s reasons to live and die.
Suicide by definition is a betrayer of logic. All may be going well. Then an event in the session or general life could trigger a negative response that the client may not be able to control. For this reason counselling for suicidal behaviour will only succeed with open honest communication between the client and counsellor.
Finding a reason to live
In counselling, the reasons a client has to live, despite their suicidal behaviour, are called life protective factors.
The goal of counselling the suicidal client is to identify and develop these protective factors. This work needs to be done gently. To be overly directive with the suicidal client may make them feel even more negative. They may sense they are useless at figuring out things for themselves. They may feel a failure even before they try if the counsellor is giving specific instructions as to what they should do.
The approaches the counsellor may use at this stage have to emphasise understanding and acceptance of what the client feels and why. Two such approaches are Motivational Interviewing and Solution Focused Brief Therapy.
Motivational Interviewing is a non challenging approach. The counsellor rolls with the resistance that the client has to seeing the positives in their life. The counsellor gently finds areas of motivation for the client to want to live. During a process of open discussion the client sees these areas and carefully moves towards them. The counsellor highlights how they make the client more positive about living so the client will be drawn to them. As they embrace motivating factors to live, their desire to die begins to wane.
Solution Focused Brief Therapy develops this further. It concentrates the client on the positives in their current situation. A suicidal client may believe there are no positives for them. The counsellor will identify degrees of suicidal feelings and the exceptions to when the client feels less suicidal. Theses exceptions are the what the counsellor uses to turn the client’s mindset around. The counsellor probes the client about the realities of when life seems at least slightly less bleak. “What are you doing at these times?” “What is your self talk about yourself in these less bleak moments?”
While these positive exceptions may be few and small there are always some to latch onto. The counsellor explains how these positives can form a basis for solutions. A plan is agreed by both client and counsellor to set small realistic goals to increase the rate and the enjoyment from these brief moments of reprieve. Achieving such small steps gives tangible hope to the client. Once there is hope the client can initiate more ambitious plans as life improves for them.
Strengthening the will to live
Once the client has achieved a balance in favour of wanting to live the counsellor will start to work on the client’s life protective factors that enable them to maintain and improve this balance. The client may waver on their motivations to live throughout this counselling process. The hope is that cumulatively over time their outlook will become more positive.
There are two approaches that a counsellor may use in working with a client at this stage.
These approaches are Cognitive Behaviour Therapy, and Dialectical Behaviour Therapy.
Cognitive Behavioural Therapy says suicidal behaviour comes from the persons total inability to see a solution to the problem that is causing them unbearable pain. This problem is however based on false beliefs held by the client. They perceive their situation through a skewed illogical lens. By correcting how the client is thinking through open but directive questioning the counsellor can help the client see their situation more positively and truthfully.
The counsellor builds up a picture of the client’s reasons to kill themselves. Throughout the process, the counsellor communicates that there are solutions to these reasons. The counsellor and client agree an understanding of the client’s desire to die. The validity of these reasons are then questioned. The client investigates how true their assumptions supporting suicide are.
Assumptions supporting suicide are generally based on false perceptions. When investigated such assumptions generally fall. The counsellor will present alternative beliefs based on true perceptions that teach the client life can be better. As the client learns these problem solving skills they are able to develop better life survival skills.
Dialectical Behaviour Therapy is an intensive suicide focused approach. First a systematic suicide risk assessment is done. This helps identify what are the actual problems for that client, that are causing them to want to take their own life. The counsellor communicates acceptance of the client’s perception of their problems.
Through combined approaches of counselling therapy and training of life skills the positives of living are worked through as the desires to die are overcome.
The life skills taught are varied. They generally fall under the four headings of regulating emotions, tolerating stress, building relationships and learning how to live in the moment.
In between sessions the client will keep detailed diary cards tracking their suicidal behaviour during the week. Also between sessions the counsellor, or a separate mentor, will briefly phone the client to support them in applying the appropriate life skills at that time.
Counselling therapy helps the client work through the difficulties that comes up through trying to apply the life skills they are being taught.
In summary the counsellor assesses risk, identifies the problems, develops the clients own motives to live, proposes solutions, challenges assumptions and works with the client to improve their skills in solving life’s big and small problems.
After the counselling therapist has stabilised the client and active suicidal ideation has passed, the work of preventing further suicidal behaviour begins. The counsellor works through the client’s current living conditions to identify their personal strengths and weaknesses. These areas could include, work/school, relationships, health, hobbies and spiritual beliefs. A person strong in these key areas is unlikely to die by suicide.
Please note there are other blogs on suicide here on the Prevail website that you may find helpful.
If any of this content has caused you to be concerned for yourself or others please do get help from a trusted friend or professional. This website may give you direct support if you are in current difficulties. https://www2.hse.ie/mental-health/