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Current context

As we enter the third year of the COVID pandemic, the last two years have hit students in colleges and universities particularly hard. The consequences of the pandemic, in addition to ongoing sporadic restrictions on face-to-face teaching and social distancing may lead to several risk factors for suicidality including isolation, loneliness, economic fallout and fear.¹

Although at the time of writing there is no evidence of an increase in suicides, either within general or student populations in the UK, it has been suggested that the mental health implications of the pandemic may peak far beyond the current phase, with suicide potentially adding to the fatality burden.² Durkheim’s theory of suicide has been mapped to highlight the increased risk of the pandemic, with social distancing and quarantine linked to egoistic reasons for suicide (insufficient integration within social groups); extreme loss and change and disruption of way of life caused by lockdown linked to anomic suicide (lack of social regulation, unexpected stress); pandemic restrictions and regulations linked to fatalistic suicide (extreme regulations and expectations); and self-sacrifice due to concerns about infecting loved ones linked to altruistic reasons for suicide. The pandemic also presents biological risk factors for suicide, with social exclusion triggering the hypothalamic–pituitary–adrenal axis (HPA axis), and the resultant stress and inflammation being potential linking pathways with immunity, COVID pathogenesis, mental health problems and increased suicidal risk.²

The majority of students in colleges and universities are aged 25 years and under (57%³ and 68%⁴ respectively). Although adolescence is still categorised as the period between 10 and 19 years of age,⁵ major changes which take place within the adolescent brain extend into the mid 20s and are associated with emotional reactivity and risk-taking behaviours.⁶ Adolescence is also a key stage when several risks for mental health and suicidal ideation emerge, with suicide being a leading cause of death in adolescents.Ìý

In terms of prevalence of suicidal ideation and behaviour, a multinational survey of 13,984 first-year students, with an average age of 19, found that 32.7% had thought about suicide at some point in their lives, 17.5% had made plans and 4.3% had made a suicide attempt, with the average age reported for the onset of suicidal behaviour being 15.7 years.⁷

A survey of over 700 students in Northern Ireland, with an average age of 21,⁸ returned similar findings, with females reporting significantly higher levels of suicidal ideation and self-harm behaviour than males. Consistent with other studies, students who reported a history of adverse childhood experiences (ACEs), or who identified as gay, lesbian, bisexual, asexual, or not sure, reported a significantly higher likelihood of suicidal thoughts and attempts. However, other researchers have reported lower prevalence rates of suicidality among students aged between 18 and 22 years, with a 7.2% lifetime prevalence of suicidal ideation, 2.3% for suicide plan and 1.9% for a suicide attempt. Furthermore, these figures are lower than for an age matched population who do not attend college or university.⁹

Individual risk factors, for example a history of mental health problems and drug and alcohol use, combined with transitional periods at the start and end of the academic year, disrupted academic progress, fear of failure and perfectionism, increase vulnerability to suicide.¹⁰ Furthermore, perfectionism may be over-represented in cases of suicides which take place without warning.¹¹

Exploring personal experiences when working with suicidal students

Considering the context outlined above, the potential exists for therapists working in college and university settings to be increasingly likely to see students who are experiencing suicidal thoughts. Kalsi notes that working with suicidality in HE is akin to walking a tightrope; one wrong step could result in disaster.¹² This tension is exacerbated by the understandable concerns of the wider institution, within which counsellors work, to prevent student suicides. Kalsi’s research concurs with existing literature, which notes that there is a reticence among therapists about discussing suicide, with the experience of working with suicidal students cited as the most anxiety-provoking professional issue. Therapists also report fear and anger when a client discloses they have been contemplating suicide, and Kalsi argues that therapists need to start talking about suicide and to explore barriers within themselves in their work with suicidal clients.¹²

Kalsi’s article prompted reflection on my own personal and professional experience of working through suicidal ideation. I had not planned to work in mental health. After leaving school with ambitions to be either a vet or a rock star, I found myself running my father’s business after his unexpected death, instead. After several years of working seven days a week, unrelenting stress, a series of traumatic incidences and a history of childhood adversity finally caught up with me. I experienced a severe mental breakdown; a two-month psychiatric hospitalisation, combined with medication side effects, resulted in me becoming perilously close to ending my own life.

Never had I felt more alone or in need of a companion to help me navigate the terrifying pit of despair from which I believed I would never emerge. However, I still recall the sense that no one was willing or able to meet me where I was and explore my experience. Perhaps, as Reeves suggests, this was because entering the metaphorical ‘cave’ of the client’s suicidal process may be perilous not only for the client, but also for the therapist, who may be forced to face some of their own demons.¹³ I believe that my personal experience of navigating suicidal terrain nearly three decades ago ultimately helped me in my professional life. Having negotiated a suicidal landscape myself and found a way out which did not involve self-destruction, I no longer feared entering into the world of a suicidal client.

After working with children and young people as a therapist for several years, I spent 12 years working in a university mental health team with students presenting in crisis and with severe and enduring mental health conditions. During my training, the importance of avoiding self-disclosure was heavily emphasised. I recall the first time I broke this ‘rule’, with a male client who expressed strong feelings of isolation and aloneness, was actively suicidal and held no hope of his life improving. He angrily pronounced that no one really understood how desperate he felt, that he was trapped and had no possible alternative to suicide. As I shared my understanding of his experience – the existential despair, the hopelessness for the future, the terror of being alive and the fear of carrying out the final act to bring the pain to an end, I drew on my own experiences. He looked shocked, agreed that was how he felt and asked me how I knew.

Instinctively, I knew it was important to tell the truth, although I also felt conflicted, because I had been taught this was ‘wrong’. I disclosed I had experienced being close to suicide myself, and that this had been what it had felt like to me, too, including feeling anger when I was told I would recover, because I didn’t believe it possible – and yet, here I was. As he asked me how I had emerged from my own suicidal abyss, I immediately felt something shifting. A connection and rapport between us had formed, and we were then able to start working on a pathway through the despair, which led away from his overwhelming desire to end his life. Since then, and following regular discussions in supervision, I have been less reticent to disclose my past experiences, under certain circumstances.

A review of therapist self-disclosure research suggests that 90% of therapists self-disclose, particularly more experienced therapists, and that overall, self-disclosure has a positive effect on clients and may build rapport and therapeutic alliance; this includes a therapist’s past difficulties, relevant to the client, which have been successfully resolved. However, therapists need to ensure that their reasons for self-disclosure are aligned to the best interests of the client, therapeutically indicated, carefully considered, deliberate, infrequent and that the therapist is responsive to the client after the self-disclosure and returns the focus to the client.¹⁴

The importance of personal reflection on attitudes towards suicide is highlighted by Reeves,¹³ who urges therapists to acknowledge and manage their own personal judgments about suicide, to help prevent them unconsciously contaminating work with clients. Reeves advises attendance to and working through transference and countertransference, regardless of theoretical orientation, arguing this is essential when supporting clients who are suicidal. Recent research supports this assertion, finding that therapists who manage countertransference respond more positively to clients who are at risk of suicide,¹⁵ with therapists’ negative emotional responses to suicidal patients being predictive of near-term suicidality.¹⁶

Dickens and Guy caution against judgment and comparison of student distress against personal experiences, which may lead to either a reduction in sympathy or feelings of hopelessness.¹⁷ Instead, be who you would want to have beside you, should you ever be in suicidal despair; listen well and validate the student’s experiences. Evidence suggests that the following qualities may help to reduce risk:

‘Survivors consistently reported that the manner in which the intervener spoke to them was as important as the words spoken, if not more so. Calmness (not showing alarm), authenticity (just being themselves, being ‘real’), steadfastness (‘not budging’) and sincerity were traits that were mentioned again and again and that had the effect of making the person feel safe, valued and connected.’¹⁸

Other factors to consider when working with suicidal clients

Perhaps the most important action to determine if someone may be at risk of suicide is to ask them. Not only is there no evidence that asking about suicide might increase risk; asking may in fact reduce suicidal ideation and result in a lower likelihood of suicidal behaviour.¹⁹ However, once a client admits that they are experiencing suicidal thoughts, how might we determine whether they are at risk of suicide? Reeves highlights the flaws and lack of predictive power of risk assessment tools,²⁰ with NICE guidelines explicitly stating that risk assessment tools should not be used to predict suicide.²¹ Once again, engaging in dialogue with the client is imperative; has the client had any thoughts about methods they might use to end their life? Do they have a current plan? Do they intend to act on that plan, either imminently or at some point in the future? Reeves encourages the further use of dialogue to facilitate the client’s understanding of the factors which make their suicidal thoughts stronger, or weaker.²⁰

Offer to help the student prepare a ‘crisis plan’, also called a ‘suicide safety plan’, covering the interpersonal and intrapersonal actions the client will take in the event that their risk of suicide increases.²² The Students Against Depression website includes a link to a comprehensive suicide safety plan self-help resource, which therapists can use with their clients.²³ Betterridge and Cole-King²⁴ have identified six steps for developing a safety plan specifically for students.

1. Identify the student’s warning signs
2. Create a safe environment and remove access to lethal means, which are likely to involve the input of other people
3. Identify positive coping strategies that are personally meaningful and can be undertaken without supervision
4. Encourage social distraction when despairing
5. Identify and use trusted others to help resolve suicidal periods
6. Engage with health professionals and emergency services, if required

Although it is also important to be aware that no mental health professional can ever accurately predict the behaviour or intent of their client,¹⁶ an awareness of some of the factors which may trigger the transition from suicidal ideation to a suicide attempt is important. Building on previous theories including the Interpersonal Theory of Suicide,²⁵ the Three-Step Theory (3ST),²⁶ explains the transition from suicide ideation to suicide attempt in the context of four variables: pain (usually psychological), hopelessness, connectedness (as a protective factor), and capability for suicide, which requires overcoming innate self-preservation reflexes, which is more likely if the individual has experience of painful or difficult life events, previous suicide attempts or self-harm.

As depression can be an underlying source of suicide ideation, Students Against Depression, a project from the Charlie Waller Trust, has created a series of training modules which provide a step-by-step pathway to managing depression. Modules include making a safety plan, building a support network, self-help first steps, healthier daily routines, understanding depression and changing your thinking.²³

From my own personal and professional experience, it is crucial to be aware of physiological factors which may be exacerbating or even masquerading as a mental health problem. I have known numerous clients who have presented with very low mood, high levels of anxiety and suicidal ideation, who had recently seen a GP or psychiatrist, in some cases had been prescribed psychiatric medication, but had not had blood tests to rule out any underlying physiological issue. Examples have included vitamin D deficiency, which is associated with depression²⁷ and suicidal behaviour,^28,29 and thyroid dysfunction, which was a major (and undiagnosed) factor in the aetiology of my own historic psychiatric problems, and is also associated with depression and suicidality.^30,31 Although there is no suggestion here that therapists attempt to assume the role of medical professional, awareness of these and other issues is important, and it may be appropriate to refer students to their GP to rule out any underlying physiological problems.

A whole-university approach to mental health and wellbeing

The responsibility for suicidal students cannot solely lie with their therapists; Kalsi¹² argues for shared responsibility around suicide, with far greater collaboration between university counselling services and university departments. McLafferty and O’Neill³² recommend that institutions take a whole-university approach to student suicide prevention, with an emphasis on learning, living, support and the development of compassionate communities. Many universities have already made progress, particularly since Universities UK published the Stepchange framework in 2017³³ and Suicide-Safer Universities in 2018,³⁴ and Student Minds published the University Mental Health Charter.³⁵

The Stepchange framework recommends that all student-facing staff are trained in suicide awareness, including how to have conversations with students and intervene as necessary when a student who presents in distress may be at risk of suicide. It is also essential for student support staff to receive adequate support, including the opportunity to reflect on their experiences of supporting students who present in considerable distress, particularly those who disclose suicidal thoughts.

Social support for students is also essential to reduce the isolation and loneliness associated with suicidal ideation, exacerbated by the pandemic, where students have been encouraged to avoid socialising to prevent transmission of the COVID virus. Student peer support programmes may be one way of decreasing isolation and providing mental health support, facilitating students’ interaction (perhaps online at first), to connect with and provide support to each other.³⁶

Finally, remember that supporting suicidal students is stressful, and engaging in self-care activities is crucial.³⁷ Supervision and reflective practice groups help to facilitate this process.