EXPLORING AMBIVALENCE, REASONS FOR LIVING AND REASONS FOR DYING
Individuals who contemplate suicide typically experience an internal struggle over whether to live or die.This is like an “internal suicide debate” between reasons for dying (RFD) and RFL (Jobes 8c Mann 1999; Harris et al 2010). People contemplating suicide may be difficult to engage in treatment because of reduced motivation to live and therefore lowered interest in and energy for treatment (Britton et al 2011). If people are experiencing extreme emotional pain and anguish, they may not be able to identify any RFL or see a future. This may be particularly evident if the patient has a severe mental illness such as psychosis (Cole-King et al 2013). Most individuals who think about suicide are ambivalent; they want to die, but they also want to live with less pain. This ambivalence suggests that the underlying issue for those contemplating suicide may be a desire to escape from psychological pain and suffering, and if that pain were resolved, the desire to die would diminish. Secondly, people who are thinking about suicide often have obstacles to participating in treatment or barriers to engaging in treatment such as hopelessness or poverty. The ability to overcome these hurdles may be compromised by the restricted cognitive functioning that is often associated with the suicidal state (see Baumeister 1990; Wenzel et al 2009). Further, many patients who are thinking about or have already engaged in suicidal behaviour are often seen in acute settings (acute mental health services or EDs) which may not provide the time or resources necessary for complex and expensive treatments. Clinicians from different settings, therefore, may benefit from having practical tools and methods to address motivation to live and motivation for treatment.
Kovacs and Beck identified the wish to live and wish to die as part of suicidal conflict as early as 1977, and this was elaborated by Linehan et al (1983), who developed a RFL scale. Jobes and Mann (1999) coined the terms “Reasons for Living” and “Reasons for Dying”. RFL and RFD are important individual reasons for staying alive (e.g. family) or wanting to die (e.g. hopelessness) and reflect this internal motivational conflict of the suicidal mind. The ratio of the strength of the wish to live to the wish to die has been found to be a critical determinant of future suicide- related behaviour. When the wish to live is stronger than the wish to die, individuals who make a suicide attempt are less intent on dying and are less likely to die by suicide (Brown et al 2005). In addition to being associated with life-threatening behaviour, the ratio of the wish to live and the wish to die may also be related to engagement in life-sustaining behaviour, such as treatment.
Studies have shown that individuals with few RFL were at increased risk for developing suicidal thoughts (Zhang et al 2011) and attempting suicide (Galfalvy et al 2006). In a systematic review, Bakhiyi et al (2016) found RFL may protect against suicidal ideation and suicide attempts.The role of two specific RFL (“Moral Objections to Suicide” and “Survival and Coping Beliefs”) were particularly emphasised. They concluded that RFL may moderate suicide risk factors and correlate with resilience factors. Clinicians could develop therapeutic strategies aimed at enhancing RFL, like dialectical behaviour therapy and cognitive behavioural therapies, to prevent suicidal thoughts and behaviours and improve the care of suicidal patients. A recent study by Cwik et al (2017) found those who reported more RFL experienced less suicidal ideation compared to participants with only a small number of RFL. However, Briidern et al (2018) found the number of RFL did not correlate with suicide risk and, therefore, was not confirmed as a protective factor against suicidal ideation or further suicide attempts. They did find individuals with a high number of RFD were very prone to a suicidal crisis. They strongly recommend therefore that RFD, which serve as motives for someone to end their life, should be carefully assessed and treated. They also suggest psychological interventions for people in suicidal crisis should give priority to the reduction of RFD or to foster cognitive defusion from RFD, which could serve as motivational drivers in the suicidal process rather than the elaborating RFL.
Identify RFL and RFD in your assessment. This will inform your formulation of your patient’s suicidality and indicate how they can be helped by addressing RFD and enhancing RFL.
Britton et al (2011) argue it is critical to address motivation for treatment because it may be associated with long-term risk for suicide-related behaviour and can be very different from the motivation to live. For example, a client’s primary reason for thinking about suicide may be that they are tired of living with severe chronic pain, but their reason for living is that they value autonomy and have pushed through difficult times in the past. Their principal reason not to seek treatment is that they consider themselves autonomous and have always been able to resolve their problems on their own, but they are willing to consider treatment because of wanting to manage their severe chronic pain. In this scenario, the clients’ reason for living is aligned with their reason not to seek treatment. So this client will need to be engaged on the basis of learning ways to manage chronic pain and treatment presented very much as a choice.
Given the significant ambivalence in individuals who are thinking about suicide, MI is uniquely suited for working with clients who are considering suicide. Although originally developed for individuals with substance use behaviours, MI has been applied to other health-related behaviour, such as diet, exercise, medication adherence and treatment engagement (Hettema et al 2005). MI has a natural “fit” with addressing suicidality as it was developed to help clients align with their reasons for stopping harmful behaviours, or engaging in a beneficial behaviour, and to increase the likelihood that they will behave skilfully (Britton et al 2011). MI can help resolve ambivalence. In MI, clinicians strategically attend to both sides of clients’ ambivalence to ensure that client perceives that the clinician understands the complexity of their situation. If a clinician, for example, only encourages discussion about RFL, an ambivalent client may express his RFD to ensure that the clinician understands how he feels. Clinicians who use MI would elicit and reflect back clients’ RFD which frees clients then to explain their RFL. To build their motivation to live, clinicians help clients explore their RFL in greater depth. After exploring their RFD and RFL, clients often come to the realisation that they want to live, but that they need to make some changes to ensure that their lives will be worth living. When clients are ready to talk about making changes, clinicians explore potential changes, including their participation in treatment that addresses their RFD.
MI is client-centred and builds on Carl Rogers’ optimistic and humanistic theories about people’s capabilities for change through a process of self-actualisation. MI is rooted in a trusting relationship established between you and your client. The therapeutic relationship for motivational interviewers is a democratic partnership. Your role in MI is directive, to elicit self-motivational statements and behavioural change from the client (Miller 8c Rollnick 1991, 2002). Clinicians have a desired outcome and they strategically guide their clients towards the desired outcome. Explicitly directive techniques, such as providing information and making recommendations, are appropriate from an MI perspective, but only with the client’s permission. Miller and Rollnick wrote:
The motivational interviewer must proceed with a strong sense of purpose, clear strategies and skills for pursuing that purpose, and a sense of timing to intervene in particular ways at incisive moments.
(Miller 8c Rollnick 1991, pp. 51-52)
Principles of MI and how they apply to working with someone contemplating suicide
The fundamental principles of MI are:
- 1. Express empathy through reflective listening.
- 2. Develop discrepancy between clients’ goals or values and their current behaviour.
- 3. Avoid argument and direct confrontation.
- 4. Roll with any client resistance rather than opposing it directly.
- 5. Support self-efficacy and optimism that change is achievable.
Empathy is the clinician’s accurate understanding of the client’s experience and it facilitates change. Empathy “is a specifiable and learnable skill for understanding another’s meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning” (Miller 8c Rollnick 1991, p. 20). When practising MI, one has an attitude of acceptance but not necessarily approval or agreement. Although empathy is the foundation of a motivational counselling style, it is not identification with the client or the sharing of common past experiences (Miller 8c Rollnick 1991).
MI aims to help clients examine the discrepancies between their current behaviour and future hopes. “Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be” (Miller et al 1992). When someone can barely imagine a positive future, this needs to be addressed gently with open-ended question such as When you think about suicide what has held you back from always acting on those thoughts?
Suicide may well be in conflict with certain values the client has but may not always have articulated to themselves. This needs to be explored sensitively.
Roll with resistance and avoid arguing
In MI, the clinician does not fight client resistance, but “rolls with it”. Statements demonstrating resistance are not challenged. We do need to be concerned about “resistance” because it is predictive of poor treatment outcomes and sub-optimal engagement. One view of resistance is that the client is behaving defiantly. Another, perhaps more constructive, viewpoint is that resistance is a signal that the client views the situation differently from the clinician. This requires you to understand your client’s perspective and proceed from there. Resistance is a signal for you to change direction or listen more carefully. Try to avoid evoking resistance whenever possible and divert or deflect the energy the client is investing in resistance towards positive change. However tempting, resist trying to convince a client that suicide isn’t a solution as that could precipitate resistance. When it is the client, not you, who voices reasons for change, progress can be made. Arguments are counterproductive and resistance is a signal to change strategies.
MI has some wonderful strategies for responding when a client is defensive.
Agreeing with a twist. For example: “You’ve got a good point there...”
Client: I know you want me to give you the rope, but I’m not going to do that.
Clinician: It sounds like that’s a big step for you ... Thank you for talking about this ... Right now you don’t feel ready to get rid of the rope.
The twist is the addition of “right now”, i.e. hinting the client may feel differently in the future.
Shifting focus - just simply change tack. “OK let’s go back to...” Emphasising personal choice and control I’ve got some ideas about how you could keep yourselfsafe but it’s your decision whether to take those steps Coming alongside - Right now that just doesn’t seem doable Values exploration (seep) - It sounds like it’s really important for you to make this decision for yourself
Reframing - offering a new and positive interpretation of negative information provided by the client. Reframing “acknowledges the validity of the client’s raw observations, but offers a new meaning ... for them” (Miller 8c Rollnick 1991, p. 107). For example,
Client: My partner wants to get ah the knives out the house which annoys me.
Clinician: It sounds like he really cares about you and is very concerned about what you might do.
In MI we are aiming to foster in our client the belief that he or she can make positive changes. Engaging the client in the process of change is the fundamental task of MI. People who are considering suicide may not have a well-developed sense of self-efficacy and find it difficult to believe that they can manage their lives effectively. Enhancing self-efficacy requires eliciting and supporting hope, optimism and the feasibility of accomplishing change. This requires us to recognise their strengths and bring these to the forefront whenever possible. Because self-efficacy is a critical component of behaviour change, it is crucial that we “hold the hope”, especially when your client struggles to have hope.
Ways of instilling hope can be: 
When practising MI we use “OARS” to move the person forward by eliciting “change talk”, or motivational statements.
- • open-ended questions;
- • affirmations;
- • reflective listening;
- • summaries.
An open-ended question cannot be answered with a single word or phrase. Asking open-ended questions helps us understand our clients’ point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialogue and encourage the client to do most of the talking. They help us to avoid making premature judgements, and keep communication moving forward. Use open-ended questions wherever possible. Who/what/when/why/how/where? or tell me about....
So this week you've really struggled not to take an overdose. What helped you not take thatfinal step f
When it is done sincerely, affirming your client supports and promotes self-efficacy. More broadly, your affirmation acknowledges the difficulties the client has experienced. By affirming, you are validating the client’s experiences and feelings. Affirming helps clients feel confident about coping and behaviour change. Highlighting their past experiences that demonstrate strength or success can be helpful. Examples of affirming statements (Miller 8c Rollnick 1991,2002) include:
I appreciate how hard it must have been for you to decide to come here. You took a big step.
That must have been difficultfor you to tell me. Thank youfor your honesty. Client: I could move the pills into the shed.
Clinician: That’s a good idea.
Reflective listening, a fundamental component of MI, is a skill in which you demonstrate that you have accurately heard and understood a client’s communication by restating its meaning. “Reflective listening is a way of checking rather than assuming that you know what is meant” (Miller & Rollnick 1991, p. 75). It strengthens the empathic relationship between the clinician and the client and encourages further exploration of problems and solutions. It is particularly helpful in early sessions. Reflective listening helps the client by providing a synthesis of content and process. It reduces the likelihood of resistance, encourages the client to keep talking, communicates respect, cements the therapeutic alliance, clarifies exactly what the client means and reinforces motivation (Miller et al 1992).
Simple reflections repeat or slightly rephrase something you want to emphasise that a client has said, whilst complex reflections paraphrase meaning, or reflect a level of content or feeling not voiced. Complex reflections include:
Amplified reflection: The clinician amplifies or exaggerates the point to the point where the client may disavow or disagree with it. You can also understate a reflection.
Continuing anticipating the next statement not yet expressed.
Double-sided reflection: One response containing both sides of ambivalence (employing broad knowledge of the patient).
Culturally appropriate similes, analogies, metaphors and stories which can:
- • capture the essential nature of an experience;
- • express a complex idea in a few words and help a client to remember something;
- • enhance rapport;
- • enable clients to gain a new perspective on their problems;
- • increase personal impact and clarity of meaning;
- • be a less threatening way of exploring possibilities of change.
It is helpful to periodically summarise what your client has shared. Summarising is a reflection of two or more client statements to: 
“Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on” (Miller Sc Rollnick 1991, p. 78). Summarising can be helpful at the beginning and end of each session. Summarising can also be strategic, e.g. modulating up hope and modulating down hopelessness. You can select what information to emphasise and what can be minimised. If ambivalence was evident, this should be included in the summary.
There is a recency effect in memory and conversation, so it may be helpful (especially towards the end of a session) to start the summary with negatives and end the summary with something hopeful the client has given or indicated. Correction of a summary by the client should be invited, and this often leads to further comments and discussion. Summarising helps clients consider their own responses and contemplate their own experience. It also gives you and your client an opportunity to notice what might have been overlooked or misunderstood.
Elicit self-motivational statements
Our role is to encourage the client to voice personal concerns and intentions, not to convince him or her of what he or she should do. Successful MI requires that clients, not the clinician, ultimately argue for change and persuade themselves that they want to and can make changes.
There are four types of motivational statements (Miller Sc Rollnick 1991,2002):
- • recognition of the problem, for example “I guess this is serious”.
- • expression of concern about the perceived problem, for example “I’m really worried I might end up doing it”.
- • a direct or implicit intention to change behaviour, for example “IVe got to do something about this”.
- • optimism about one’s ability to change, for example “I know that if I try, I can really do it”.
You can reinforce your client’s self-motivational statements by reflecting them, nodding, or making approving facial expressions and affirming statements. Encourage clients to continue exploring the possibility of change. This can be done by asking for an elaboration, explicit examples, or more details about remaining concerns. Questions like “anything else?” are effective ways to invite further amplification.
-  celebrating their engagement in your session or intervention,attending, talking about this difficult matter; • identifying strengths they have that have enabled them to resistsuicidal urges; • identifying how current or future interventions may help.
-  communicate your interest in a client; • build rapport; • call attention to salient elements of the discussion; or • shift attention or direction.