The importance of discourse
The central assertion here of this chapter is of the critical importance of effective communication with clients at risk of suicide that transcends the two- dimensional nature of a risk assessment tool or questionnaire. The explorative nature of communication not only provides the best opportunity for the practitioner - and more importantly, the client - with an opportunity of sensemaking in relation to suicidal thinking, but also creates further opportunities for deeper exploration and helps position the client with greater opportunities for change. Discourse, in of itself, will not prevent suicide; it will, however, provide the narrative space for suicide to be explored in a meaningful way. Revisiting the work of Schneidman (1996, p. 6), he asserts,
... our best route to understanding suicide is not through the study of the structure of the brain, nor the study of social statistics, nor the study of mental diseases, but directly through the study of human emotions described ... in the words of the suicidal person. The most important question to a potentially suicidal person is not an inquiry about family history or laboratory tests of blood or spina! fluid, but “where do you hurt?’’ and “how can I help you?"
Exploring the “where do you hurt and how can 1 help you” is not a straightforward endeavour, however. In my own critical discourse analysis (Reeves et al., 2006), many practitioner-client assessment transcripts were analysed. They key findings of this study were that:
- • Suicide is often not disclosed explicitly by clients - at first mention - and is typically talked about implicitly using metaphor, e.g., “I wish 1 could get out of everyone’s way”
- • At the first reference to suicide by the client, practitioners - regardless of theoretical orientation - tend to revert to reflective responses rather than explorative ones, e.g., “So it seems as if ... 1 hear that ... you are saying that ...”
- • The predominant use of reflective responses following an implicit reference by a client to suicide typically hinders exploration, as the practitioner becomes defined in the dialogue by the client’s position, rather than enabling any meaningful dialogic shift, e.g., [client] “It just goes round and round in my head and I can’t seem to find a way forward”; [practitioner] “You feel really stuck - round and round - and you can’t find a way forward”. Both client and practitioner get stuck in the “round and round” metaphor, both defining each other and neither finding a way forward
- • Practitioners are often fearful of naming suicide - of making the implicit, explicit - for fear of “getting it wrong” or putting the thought into the client’s mind: explicit exploration becomes a feared prompt for suicide, where there is no evidence to support this. As institutions and individuals perhaps retreat into risk assessment tools to avoid the relational, practitioners retreat into the reflective to avoid the exploration.
This study, in itself a little dated now, has been replicated by me (unpublished), additionally focusing on working with young people. Even with intervening research, the findings were the same. The implications of avoiding an open communication around suicide with clients is that a number of professional responsibilities are more difficult to meet: the appropriate management of the contract of confidentiality: maintaining work consistent with procedural expectations of the organisation; consistent work with legal and ethical expectations; and missed opportunities for greater therapeutic exploration. The personal implications are often an increased sense of anxiety and a greater propensity to burnout.
Reflections on client work
Research aside, this chapter is fundamentally based on my experiences of working with people who are suicidal, which 1 have been undertaking for 30 years. I have experienced several client suicides across that time, each one impacting on me professionally and personally in a different way; ranging from an early traumatic response I experienced following the death of a client through suicide soon after a completed counselling session while I was a trainee, through an end-of-life suicide that had been communicated by the individual to all those involved in his care. 1 will offer an account of some work with a client, who 1 will call Jake, to illustrate some of challenges raised “in action”. Sufficient details of Jake’s story have been changed (as well as his name) to protect identity, as well as to illustrate some of the wider issues, not all of which were present in the original work.