Suicide - A Fact of Life. Recognising & Working with the Suicidal Client
This is an article I wrote in 1994, in response to a generalised view amongst many that hypnosis and hypnotherapy were contraindicated for the suicidal client. Things have moved on over the years, and it's no longer such a taboo subject - we can even talk about assisted suicide. But for Hypnotherapists, I believe it's still relevant today, and would welcome any comments or feedback.
Although most of us prefer to regard suicide as something unlikely ever to touch our personal world, it remains, nevertheless, a fact of life. Britain's annual suicide rate of over five thousand may not seem high, but suicide is the third largest cause of death (after accidents and cancer), and as many people take their own lives as die in road traffic accidents. (Because of anomalies in methods of certifying death and of collecting and preparing data, the suicide figures may even be underestimated by as much as 25 per cent).
Is it not naive, then, to assume that we can somehow sidestep the issue of suicide? It is something which we may well encounter during our work as therapists, whether in the form of threats, attempts or the actual completed suicide of a client - so it is important that we do not overlook identifiable risk factors without being aware of their significance. These factors may not, in isolation, mean that a client is suicidal - but how do we assess the level of risk? Should we take expression of suicidal intent seriously - and how would we cope with it? Can we differentiate between popular myth and the facts about suicide? This study attempts to answer such questions and to look at some of the issues surrounding therapy, and in particular, the use of hypnotherapy, with the suicidal client.
The Anatomy of Suicide
Seventeenth century sociologist Emile Durkheim believed that the suicide rate reflected the state of society, with a rise indicating problems in the social structure. In his work 'Le Suicide' (1897), he categorised the act into 3 types: Egoistic suicide (motivated by feeling that one has failed oneself and society), Altruistic suicide (motivated by a sense of duty, as in the captain who goes down with his ship) and Anomic suicide (reflecting a loss of contact with society's values and a feeling that life no longer has meaning). 
In the early 1900's, the psychoanalysts debated the question of suicide. Adler believed the motive was the urge to inflict pain and suffering on ones' friends and family, whereas Freud, even before developing his concept of the 'death instinct', interpreted suicide as being partly an act of homicide, turning homicidal feelings about another towards the self. Others saw suicide as the ultimate form of self-assertion - a bid for immortality whose goal was not self-destruction, but self-preservation, or 'Nirvana'. 
Attitudes have varied throughout the ages from outright condemnation to calm acceptance. Aristotle considered suicide an offence against the state, whereas Plato suggested that it was both justifiable and rational if life became intolerable. Both the Koran and the Talmud see suicide as a violation of the sanctity of life. Early Christian suicides became martyrs, and it is interesting to note that although St. Matthew recorded the suicide of Judas Iscariot without comment on its' morality, others later believed his sin in taking his own life to be greater than that of betraying Christ. Indeed, from the year 562, the Christian church refused suicides all funeral rites (though these were granted to even the lowest criminals). 
In some cultures, even today, suicide is accepted, but in England (where attempted suicide has not been a crime since 1961), it still tends to be considered socially unacceptable. The stigma may be even greater in some circumstances - for example, in a staunchly religious community, suicides may be granted 'the benefit of the doubt' by the church, family and perhaps even the local doctor.
Before we look at statistics, we must make the distinction between the terms suicide, attempted suicide and parasuicide. Suicide is the fatal outcome of a deliberate attempt to take one's own life. Attempted suicide is the non-fatal result of an act of self-harm, made with apparent intent to die. However, many suicides are characterised not by an absolute intent to die, but by ambivalence - life is perceived as so bad that it does not matter if one lives or dies. This does not mean, however, that attempts should not be taken seriously - indeed, many who 'fail' later go on to make a further, fatal attempt. The term parasuicide describes a subgroup of attempts which represent a 'cry for help' rather than a serious intent to die, where motivation often seems manipulative, aggressive or defensive (though this is rarely a conscious motive). However, misjudged parasuicides may still result in death. For example, self-poisoning carries a real risk of severe or even fatal damage - a danger especially prevalent with the tricyclic antidepressants, which have a very low lethal-dosage to therapeutic-dosage ratio. 
The seriousness of any previous suicide attempts by a client (and therefore, the possibility of further attempts) can be gauged by considering the following criteria:
- Planning in advance
The more careful the advance planning, the more serious the attempt is likely to have been.
- Precautions against being discovered:
The more thorough the precautions, the more serious the attempt - and therefore the risk of a repetition.
- No attempt to seek help afterwards:
If there was no attempt to get help, this suggests serious intent.
- Dangerous method:
The more dangerous the method, the more serious the attempt - though we must also assess the risk which the person believed was involved, as this belief may have been inaccurate.
- 'Final acts":
Where a person carries out 'final acts' such as making a will or writing a suicide note, the risk of a further, fatal attempt is increased. 
Suicidal acts contain an element of appeal and there is a tendency to dismiss all attempts as being attention-getting exercises (known as the 'appeal effect') - as if this, and not the wish to end life, were the only motive in all suicidal acts. Some believe suicide to be a projection of anger and guilt towards others. In his study of suicide 'The Savage God", A. Alvarez states:
"A man may take his own life because he feels the destructive elements inside him are no longer to be borne; so he sheds them at the expense of the guilt and confusion of his survivors .... suicide is simply the most extreme and brutal way of making sure that you will not be forgotten - a kind of posthumous rebirth in the memories of others". 
The appeal and projection factors are not usually conscious motives, although those with hysterical or psychopathic personalities are often aware of this and may tend to exploit it. (See Chapter 4, page 16).  Most others do not consciously consider these aspects, however family and friends may still experience feelings of guilt and responsibility. The 'appeal effect' also extends to 'completed' suicides, even though this may not have been a conscious intent on the part of the deceased. As therapists, we should not dismiss suicide attempts as being 'only' cries for help, but focus instead on the fact that there is an urgent need for help, and do our best to provide it.
Chapter One - References
 Stengel, E., 'Suicide and Attempted Suicide' (Penguin, 1983), p.48
 Ibid., pp. 51-53
 Ibid., pp. 65-73
 Beck, A.T., Rush A.J., Shaw, B.F. & Emery, G., 'Cognitive Therapy of Depression' (Guilford, 1979), p.357
 Gelder, M., Gath, D., & Mayou, R., 'Oxford Textbook of Psychiatry' (Oxford University Press, 1984), pp.414-417
 Alvarez, A., 'The Savage God' (Weidenfeld & Nicolson, 1972), p.94
 Stengel, E., 'Suicide and Attempted Suicide' (Penguin, 1983, p.113)
Statistics, Truth and Myth
Every year, some 5,000 people in Britain take their own lives. In 1988, there were 4,971 recorded suicides - that is, 96 a week, 14 a day or one every two hours - with male suicides outnumbering female by three to one. There are also an estimated 200,000 known attempted suicides every year. Attempted suicide (as distinct from suicide) is common in young adults under 25, accounting for an incredible 10 per cent of all admissions to hospital - with between 15 and 25 per cent of these patients being readmitted within a year.  In suicide attempts, the Male:Female ratio is reversed, with 80 to 90 per cent of attempts made by young women in their late teens to early twenties, a large proportion of whom are judged to be using suicidal acts as a form of appeal, usually following acute emotional upset. No definitive explanation has arisen as to why young women should be more prone to this than young men.
Occasional contradictions in statistics may be due to varying methods for the collection and preparation of data. (For example, Norway's suicide rate is half that of Sweden - although the reason becomes clearer when one discovers that Norway's 'accident' rate is twice Sweden's).  However, certain factors are definitely shown to be either positively or negatively linked to the suicide rate. Positively correlated factors (i.e. increasing risk) are: being male, increasing age, widowhood, being single or divorced, childlessness, alcohol or drug addiction, a high standard of living, social isolation, economic crisis, a broken home in childhood, physical illness, and mental disorder (especially depression). Negative correlations include: being female, youth (suicide is quite rare in childhood), being married, religious devoutness, a large number of children, and membership of the lower socio-economic classes.  An even higher risk exists in certain sectors of the population, with older people at greatest risk, particularly following bereavement. The suicide rate amongst young men (under 25) has risen steeply, with a 75 per cent increase between 1982 and 1991 (believed to be linked to unemployment and poor economic climate).  In terms of occupation, the highest risk group are those in professional/managerial positions - particularly doctors, vets, psychiatrists, dentists, and anaesthetists (perhaps because of easy access to the means to take their lives). There is a high risk among those suffering from chronic painful illness and the suicide rate among epileptics is roughly 4 times that of the general population. 
Perhaps the major risk factor is mental illness - nine out of ten suicides have a mental health problem.  This may cause some to breathe sighs of relief, believing that if they do not work with the mentally ill, they will not encounter suicidal feelings. However, the definition of 'mental illness' is incredibly elastic and covers such things as anxiety, panic, phobias, depression, obsession, anorexia and bulimia, as well as the more severe psychoses, and since most psychiatric disorders do not exhibit obvious physical symptoms, our first indication of a problem might be the client's own admission of a previous diagnosis.  To illustrate the extent of 'mental disorders', in 1990/91, over 91 million working days were lost in Britain through sickness certified as mental disorder.  Thus it is clear that we may well encounter many such disorders in our work, without necessarily thinking of clients as mentally ill.
Depression is probably the most common of these disorders, and certain features distinguish the high risk client from the low. High risk cases are likely to exhibit extreme pessimism, loss of usual interests, social withdrawal, feelings of worthlessness and hopelessness, guilt, self-reproach, 'depressed posture' and weight loss. Many depressed clients also suffer persistent insomnia and may have been prescribed potentially lethal barbiturates hypnotics - proof of the importance of taking a medical history at the initial consultation. If we choose to treat clients who are depressed, we must remember that suicidal feelings are common in depression.
To quote the work of Beck et al:
"Since suicide is the lethal complication of depression, the clinician requires specialised skills in recognising the suicidal patient and determining the suicide risk." 
As we begin to build a picture of suicide, there are several other points worth noting. For example, men tend to choose more violent methods of committing suicide than women do. Another surprising fact is that the suicide rate is prone to regular seasonal fluctuations. One might expect the rate to be at its' highest in the gloomy months of Winter, but it actually reaches an annual peak during April, May and June. No single theory has emerged to account for this, or for the fact that a depressed person is at most risk of suicide when depression begins to lift. (Also see p.10).
A seven year study by Dr. Ghada Karmi of the North Thames Regional Health Authority indicates that the suicide rate amongst young Asian women living in Britain has increased to roughly 3 times that of the general population. Causes are still being investigated, but pressures of the dual cultures of East and West are a likely factor. The study shows that many of the trends associated with suicide in Britain are reversed within the Asian community - those most at risk are young women, there is rarely any history of mental illness and these young women are usually married. They also tend to choose violent methods - hanging or setting fire to themselves (interpreted as a statement about the difficulties of such factors as arranged marriage in a Western society). It is also felt that British agencies and health professionals often do not understand those pressures and are unwilling to intervene in cultural or religious practices. A more detailed study into the causes of the increased suicide rate is to be published in 1995 - but existing findings provide an interesting insight into issues involved in work with a multi-cultural client base. 
There are many myths surrounding suicide, some of which are worthy of mention: The suicide rate is not, as was once believed, related to bad weather - in fact, it reaches an annual low point in November, perhaps the gloomiest month. Suicide is not confined to young lovers - in fact, the highest risk is to those, especially men, aged between 55 and 65. These are both fairly trivial myths - however, there are at least three major common, and potentially dangerous, misconceptions:
The first myth which must be dispelled is that those who talk about suicide will not actually do it. The absolute reverse is true - over two thirds of suicides have told someone of their intentions, often in quite specific terms.  (It may be that discussion of suicidal feelings makes others feel so uncomfortable that they treat any expression of intent lightly or dismissively, thereby avoiding having to cope with something they do not understand, or are afraid of?).
The second myth is that by talking to someone about suicide, you put the idea into their mind, increasing the risk. There is no evidence to support this belief - in fact, the opposite is true. The Samaritans specifically train volunteers to ask whether callers have suicidal thoughts, to explore whether they have a plan, or the means to carry it out, and to establish whether previous attempts have been made. In 1988, Samaritans received over 2.5 million calls (43 per cent from men and 57 per cent from women). Suicide was discussed with 76 per cent of first-time callers, of whom 32 per cent were feeling suicidal.  Further reassurance comes from Beck et al:
"Many professionals still believe the myth that questioning a depressed person about the presence of suicidal ideas may 'put the idea in his head', or make the idea of suicide more acceptable if he is already thinking about it. Actually, we have found that encouraging a patient to talk about his suicidal ideas generally helps him to view them more objectively, provides necessary information for therapeutic intervention, and offers some degree of relief." 
The third myth is that improvement in the client's moods and behaviour following a suicidal crisis diminished risk. In fact, the time of highest risk is about three months after improvement begins. This is widely believed to be because energy levels have increased, enabling the client to translate intent into action.  However, many now dispute this suggestion that suicidal action is determined by energy levels rather than degree of hopelessness, considering it to be outdated. 
It can be seen, then, that people do talk about their suicidal feelings, and should not be dismissed. We should not be afraid to discuss the subject of suicide openly, or to ask a client if he or she has such feelings - and we should not assume that apparent rapid improvement in the client necessarily indicates that the risk has passed.
We may feel that statistics on suicide hold few surprises, since many of the factors linked to the suicide rate would probably cause most of us to feel increased stress. Although we must guard against generalisations, we may understand how a married person with several dependent children might be less inclined towards suicide than the single, jobless, childless alcoholic. Their feelings of hopelessness may be as great, but perhaps faith and a responsibility to dependents acts as a kind of additional (if sometimes fragile) barrier against suicide. However, to another person, this same responsibility may be an intolerable burden, tipping the balance the opposite way. The important consideration is an awareness of factors which might constitute a risk, and how these apply to each individual. By combining this knowledge with information about our client's background and emotional state, we can assess the level of suicidal risk in each case.
Chapter Two - References
 Samaritans Teachers Pack, 1989. (in-house publication)
 Alvarez, A., 'The Savage God', (Weidenfeld & Nicolson, 1972), p.2
 Stengel, E., 'Suicide and Attempted Suicide', (Penguin, 1983), pp. 25-27
 'Health of the Nation' series (Mental Illness): 'Sometimes I Think I Can't Go On Anymore' (H.M. Government Dept. of Health, 1993), p.7
 Stengel, E., op. cit., p.103
 'Health of the Nation' series (Mental Illness), op. cit., p.3
 Gelder, M., Gath, D., & Mayou, R., 'Oxford Textbook of Psychiatry' (oxford University Press, 1984), pp.1-3
 'Health of the Nation' series (Mental Illness): 'What Does It Mean?' (H.M. Government Dept. of Health, 1993), p.2
 Beck, A.T., Rush, A.J., Shaw, B.F. & Emery, G., 'Cognitive Therapy of Depression' (Guilford Press, 1979), p.2
 Patel, S., (Producer, BBC Radio 4) and Karmi, Dr. Ghada, (North Thames Regional Health Authority - in conversation with Carol, L., following broadcast on 24.2.94.
 Samaritans (In-house figures, 1993/4)
 Samaritans Teachers Pack, 1989 (In-house publication)
 Beck, A.T., Rush, A.J., Shaw, B.F. & Emery, G., op. cit., p.209
 White, J., 'The Masks of Melancholy' (Inter-Varsity Press, 1985), pp.162-68
 Yapko, Dr. M., 'Hypnosis and the Treatment of Depressions - Strategies for Change' (Brunner-Mazel, 1992), pp.24-29
The Right To Die?
Before considering therapy with the suicidal, we would be well-advised to establish our own feelings on the subject of suicide. Dr. Eustace Chesser stated that:
"It has been a painfully slow process to arrive at a humane and rational attitude. Throughout the ages untold suffering has been caused by a superstitious emphasis on the sanctity of life. Even now that attempted suicide is no longer punished the traditional stigma remains. It still has to be generally understood that there is nothing necessarily discreditable in taking ones' own life. Nor is it true that to do so must be a sign of unsound or unbalanced mind." 
How does this compare with our own views? Do we feel that suicide is sinful? Would we experience a sense of guilt, or of being personally responsible because we 'should have done more'? And what of the client's family and friends, who may blame us for failing to somehow prevent the tragedy? Some believe that the suicidal should be forcibly restrained in order to enforce treatment - how do we feel about this?  We must be aware of our own feelings, and able to cope with such eventualities. Perhaps one of the most important considerations is whether we feel a person has the right to end his or her own life. If we believe that one of the aims of therapy is to make life bearable for the client, then how would we feel if that client made a successful suicide bid, despite attempts at therapeutic intervention? Professional competence and a sense of duty towards clients should cause us to examine our own beliefs about personal responsibility. We do indeed have responsibilities towards clients, but these should not extend so far that we consider ourselves personally and solely accountable for the client's life and happiness. Indeed, we have no right to usurp that final responsibility.
My own belief, explored and reinforced during several years as a Samaritan, is that ultimately, the decision to end his or her life rests with the individual, although I do all that I can to try to help them through the crisis period. I personally know of several people who, once desperately suicidal, have been helped through crisis and are very glad to be alive today, so I am not inclined to accept statements of suicidal intent without some attempt at intervention. However, others have different beliefs and it is important that we each identify our own. If we are harbouring negative attitudes or reactions towards the potentially suicidal, this will interfere with our ability to help the client devise the alternative options which might lead to a decision against suicide as a solution to problems.
There are many possibilities which may suddenly cause a client to reconsider the decision to end his or her own life. The client's own perspective might alter during therapy; personal or environmental factors may change; friends and family may lend support. Drug therapy, psychotherapy, or a combination of both for depression can ease the feelings of despair and hopelessness which are so characteristic of the suicidal, allowing the client to explore new approaches to problem situations. Generally, suicidal feelings persist for only a limited period of time and if a person can be helped through this period, suicide may be averted. However, we should not assume that it will be possible to prevent suicide in all cases, as this is not so. 
Therapy aims to make people responsible for their own lives and actions - but there may be some who do not respond, despite the efforts of all involved. Some individuals show an absolute determination to take their own lives, taking extreme care to plan and time everything to avoid discovery or rescue. Others, saved following a suicide attempt, may go on to make a further, successful attempt. Regardless of our own beliefs, skills and sensitivities, we cannot physically prevent a person from suicide and must recognise that what brings hope to one person may be insufficient to tip the balance for another.
Chapter Three - References
 Chesser, E., 'Living with Suicide' (Hutchinson & Co., 1967), pp.121-28
 White, J., 'The Masks of Melancholy' (Inter-Varsity Press, 1985), p.177
 ibid., pp.162-65
A study which considers suicidal risk so broadly may be criticised on the basis that it somehow implies exaggerated risk. However, my purpose is not to create an obsession with suicide, but rather an awareness of the possibility, in some clients, of an element of risk. With many clients, this will be unnecessary - but if we work with depressed clients, or those under severe stress, then we must be aware of the potential for suicidal feelings. Furthermore, some clients may be receiving medication from their G.P. to stabilise depression or relieve insomnia and if the client is severely depressed, these may provide the means for a suicide attempt. We will know of this from our consultation, but if we believe a client is at risk, we must be aware that prescribed medication may increase the likelihood of risk becoming reality. No therapeutic strategy will be of any benefit unless we can recognise and assess the level of risk. We have seen that many factors can contribute towards increased suicidal risk, and as early as the initial consultation, we should have some idea of which risk factors may apply with each client.
It should be noted that suicidal clients frequently demonstrate a kind of cognitive rigidity - seeing things in terms of polar extremes (dichotomous thinking), adopting rigid irrational beliefs and attitudes, which contribute to the hopelessness and despair these clients often feel. The following is a list of one psychiatrist's criteria to suggest impending suicide risk :
There are many similar lists to provide us with a concise form of reference, though with experience, our most valuable assessment tool will be our own intuitive 'gut feeling'. There are also many scales, inventories and questionnaires available to help assess the level of depression or suicidal risk. Some can be completed by the client, whilst others require interpretation by the therapist. They include Beck's Inventory for Measuring Depression, Zung's (Self-Rating) Depression Scale, the 'D' (Depression) Scale of the M.M.P.I. (Minnesota Multiphasic Personality Inventory) and the Hamilton Rating Scale for Depression. These should not be used in isolation, but rather to complement our own assessment skills and knowledge of the client, since such scales are not infallible. Examples and details of some of the tables listed can be found in John White's 'The Masks of Melancholy'' , and are widely available in medical, psychiatry and psychology textbooks.
Perhaps the most obvious sign of risk is a direct statement of suicidal intent, although this may not necessarily lead to suicidal action. Unfortunately, there are those who threaten suicide as a form of emotional or moral blackmail of significant others or of the therapist. In such cases we must be caring, but firm.
Many clients find it difficult to express their feelings. If we suspect a client may have suicidal thoughts, then we must explore further, remembering that talking about suicide will not precipitate it, but will help the client view his situation more objectively. Reiterating this, the 'Oxford Textbook of Psychiatry'' states:
"The first requirement is a willingness to make tactful but direct enquiries about a patient's intentions. The second is an alertness for the general factors that signify an increased risk. Asking a patient about suicidal inclinations does not make suicidal behaviour more likely. On the contrary, if the patient has already thought of suicide he will feel better understood when the doctor raises the issue, and this feeling may reduce the risk. If a person has not thought of suicide before, tactful questioning will not make him feel suicidal." 
We must be alert to client's feelings, since there may be things which they lack the courage to state bluntly. Samaritans training suggests looking for clues in overt behaviours and words and phrases like "it's hopeless","I can't go on any longer", "I wish I could go to sleep and never wake up", etc. If a client makes such statements and we feel unsure about their meaning, we must clarify the situation by asking. We need not ask "do you mean you're going to commit suicide?". However, a natural response to the statement "I feel so low I don't want to go on anymore" might be: "You say you don't want to go on - do you feel so low that you have thought about harming yourself / taking your own life?" The suicidal client is often glad to share feelings which have previously been considered taboo. The client who has not had such thoughts will not be offended by the question, but will probably go on to clarify what (s)he actually meant. Either way, we will have a clearer picture of the situation.
If a client is feeling suicidal, we must follow up this admission. An embarrassed "oh....." followed by silence will be a clear indication that we are flustered, which will not help the client. To fully assess the situation, we must establish whether the client has planned a suicidal act and should ask what they intend. If the client has a plan and the means to carry it out, then obviously, the situation must be judged serious.
Chapter Four - References
 Stengel, E., "Suicide and Attempted Suicide" (Penguin, 1983), pp.61-62
 White, J., "The Masks of Melancholy" (Inter-Varsity Press, 1985), pp.65-74
 Gelder, M., Gath, D., & Mayou, R., "Oxford Textbook of Psychiatry" (Oxford University Press, 1984), p.404
Crisis Management and Therapy with the Suicidal
In Chapter Three, we acknowledged that some therapists may prefer not to work with those who represent a high suicide risk and may wish to refer such clients elsewhere. However, if suicidal thoughts come to light once therapy is well underway, the client may wish to continue with the existing therapist, and referral may not always be advisable. Clients have often come to us as a 'last resort' and a decision not to work with them may be perceived as rejection, increasing negativity and despair. Psychotherapist Anthony Storr advises:
"If the patient is coming regularly and a psychotherapeutic relationship has been established, it is inappropriate and harmful to the patient if the therapist suddenly changes from a person who is encouraging independence and freedom of choice into a doctor with special powers to confine people in mental hospitals, against their will." 
In our own practices, we may not have such powers of confinement, but the issue of 'letting down' the client remains the same. However, we must also guard against working with clients if we suspect, for whatever reason, that our own resources are not adequate to the task ahead - for we may still be obliged to let them down if, having begun therapy, we find that we do not feel able to continue.
Suicidal crises usually only persist for a limited time (Chapter 3, p.14), so we must distinguish between crisis management and psychotherapy. Crisis management is the delaying of suicidal impulses, instilling some form of hope and establishing therapeutic and environmental support until the crisis passes, although this may not in itself lower the possibility of further suicidal crises. Once an initial crisis has passed, psychotherapy can address underlying issues, such as the negative distortions and poor problem-solving abilities which may underpin the client's view of suicide as a realistic solution to problems.
Crisis management requires swift action and close monitoring of progress, but regardless of how good the therapeutic relationship, we cannot be with clients 24 hours a day and must utilise all available resources. We can increase therapy sessions and stay in close telephone contact with the client during the period of crisis, but we must also ensure that some additional form of support network exists, perhaps comprising the G.P. and a network of family and friends. However, a client may not have family or friends to whom they can turn and so therapists must have a broad knowledge of local and national support groups which clients may approach.(e.g. Cruse for the bereaved, Rape Crisis, Alcoholics Anonymous, etc.). In addition, the Samaritans operate a 24 hour telephone service and daytime drop-in facility, 365 days a year.  Although primarily a listening service, clients might find this particularly useful at night, when support may not be available elsewhere. Many areas publish a directory of self-help and support groups - in my own area, (N.East England) this is part-funded by the Regional Health Authority, and is an invaluable reference aid. 
We should also be aware that if suicidal clients suddenly begin to behave in a calm, tranquil manner, this is not necessarily a mark of our success, but should alert us to possible danger. A sudden period of calm often indicates an increased determination or resolve - to commit suicide - and if we decrease vigilance because we assume that the crisis is over, this may be a mistake.  &  However, suicide is believed to be rare whilst a client is actually undergoing therapy, as long as there has been time for rapport to be established between therapist and client. 
In considering treatment methods, we must be aware of the necessity to work rapidly and to start to deal therapeutically with suicidal wishes immediately. To formulate a treatment schedule, we must first evaluate the following criteria in relation to the client:
The principal affect is likely to be depression, often accompanied by anger.
Identifying automatic negative thoughts, tendency to dichotomous thinking, etc.
Medical / Organic Factors:
Is there a previous diagnosis of depression or mental disorder? Is depression being treated / responding to medication?
Identifying behavioural deficits such as alcohol / drug dependency, poor problem-solving skills, etc.
Identifying problem issues / situations relating to client's environment and support network.
Depressed clients are often advised to visit their G.P. to obtain stabilising medication before therapy commences, although their relationship with the G.P. may not be conducive to easy discussion of their problems. Two thirds of suicides visit their doctor in the month before their death (40 per cent the week before).  Obviously, opportunities exist for intervention, but many G.P.s have limited time and resources, restricting the amount of time they can spend with patients. (Some feel this may even make it easier to obtain the medication to carry out a planned suicide attempt).
Until quite recently, treatment of depression has been largely confined to the administration of medications such as tricyclic antidepressants (effective in only 60 to 65 per cent of cases) , with the risk of the client becoming reliant upon chemical intervention, to the detriment of his or her personal coping mechanisms. Clients on antidepressants alone will not develop new coping mechanisms and, in up to 50 per cent of cases, may suffer relapse once drug treatment is discontinued. This is less likely to occur if drug therapy is combined with psychotherapy. In 'Cognitive Therapy of Depression', Beck et al state:
"Conventional wisdom suggests that an effective course of psychotherapy might be more beneficial than chemotherapy in the long run because the patient can learn from his or her psychotherapeutic experience. Thus, such patients might be expected to cope with subsequent depressions more effectively, to abort incipient depression, and conceivably might even be able to prevent subsequent depressions." 
Since suicidal and depressed clients will exhibit extreme pessimism and hopelessness (Chapter 2, p.7) and tend to have a negative view of self and a negative way of responding to life experiences, interventions offering the greatest chance of success seem to be those based upon a cognitive approach, often combined with some form of medication. Aaron T. Beck's Cognitive Therapy is an active, directive, short-term psychotherapy, usually time-limited to around 20 - 25 sessions over 10 to 15 weeks. It utilises a variety of cognitive and behavioural techniques and is based upon a trilogy of concepts - the cognitive triad (negative views of one's self, one's experiences and the future), schemas (our attitudes and assumptions about situations) and cognitive errors (errors in interpretation of events and situations). The therapist can explore with the client the advantages and disadvantages of the suicide option. Discussion of disadvantages will usually produce positive statements illustrating the client's cognitive distortions, so that (s)he can then learn to monitor negative automatic thoughts and recognise the connection between these thoughts and subsequent behaviours. Cognitive distortions are then 'tested out' against reality, and the client learns to substitute them with more functional cognitions. Cognitive therapy is particularly suited to working with the characteristically negative expectations of the suicidal and depressed, with their inability to believe in a positive future. However, in the course of therapy, we must not invalidate the client's feelings and emotions, since invalidation may well lead to the client 'dropping out' of therapy, feeling threatened and convinced that "nobody understands". Instead, we must accept their individual perspective, whilst challenging their dysfunctional beliefs.
If we imagine the degree of a client's suicidal intent as a point on a continuum between absolute intent to die and absolute intent to live, then therapy seeks to help the client move towards the choice to live (see Fig. 1 below). Cognitive therapy emphasises action rather than analysis, engaging the client's interest and involvement by adopting a collaborative approach, encouraging him or her to play an active part in the process of therapy. A useful strategy with the depressed and suicidal is that of ending each session with an outline of positive plans for the next, providing the focus and direction which was previously lacking. This emphasises the forward-moving nature of therapy, introducing an element of hope and an atmosphere conducive to exploration of valid reasons for living. A further advantage of this approach is it's lack of emphasis on the past - to a suicidal client, indulging in 'psychological archaeology' may only serve to unearth further misery and negativity.
"I want to live" "I want to die"
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