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Why does no-one want to talk about suicide?

This was the key question that I grappled with when I experienced a student suicide over 10 years ago. Working as a mental health advisor in a university at the time, suicide risk assessment was an important, albeit routine, part of my role. Nevertheless, blinded by naivety, the idea of a student actually completing suicide seemed inconceivable to me. With this in mind, when the inconceivable became a reality, I was impacted profoundly, overcome by immense sadness, grief, shame, guilt and fear. I was also plagued by a multitude of questions; did I miss something? Could I have done anything else? Will I lose my job? How will others view me? Alongside my doubts about my competence in working with suicidality, I also became acutely aware of colleagues’ responses to suicide; I was surprised to see the topic of suicide brushed under the carpet in team meetings and was struck by my colleagues’ silence and reluctance to ‘sit with’ the phenomenon of suicide.

This experience led me to consider the powerful impact of working with suicide, not only on individual therapists, but also the counselling service and the wider institution. I questioned if we, as mental health professionals, struggled to talk about suicide in team meetings, then what was happening in our consultation rooms when we were faced with a suicidal student? Why was suicide so difficult to process? And what did it mean for the institution that those best qualified to work with suicide were in fact unable to talk about it? My curiosity was piqued, and I contemplated, once again, ‘Why does no one want to talk about suicide?’.

Current landscape in higher education (HE)

It is important to contextualise my research and consider the landscape in higher education (HE) presently. Despite university being described, by some, as the ‘best days’ of one’s life^1,2 and often thought to represent a time when dreams can be realised, the reality is actually quite different. In recent years, universities in the UK have witnessed a steady proliferation of the prevalence of mental health issues in the student population,³ with student suicide reported to be at an all-time high in 2018.⁴

Initial concerns about student suicide date back to 2011, when an influential report⁵ identified student suicide risk as an ‘increasing concern’ among mental health professionals working in higher education institutions (HEIs), and underlined the ‘pressing need for increased provision for suicidal students’. More recently, guidance on preventing student suicides for universities was published by Universities UK (UUK) and Papyrus. Titled Suicide-Safer Universities, the document encompassed a ‘whole-university approach’ framework and urged universities to make suicide safety ‘an institutional priority’.⁶ This increasing focus on student suicide suggests that these are worrying times for the HE sector.

The suicide literature

Unfortunately, suicide prevention and research have ‘...not received the financial or human investment they desperately need’,⁷ and as a result, research on therapists’ experiences of working with suicidal clients, to date, remains fairly limited.^8–10

The existing suicide literature reveals that suicide is the most cited cause of anxiety among therapists,^11,12 and it is well documented that, in addition to anxiety, the communication of a suicidal thought by a client leads to fear and anger among therapists.^13–17 Therapists also report losing a sense of professional competence, and experiencing a feeling of professional impotence, fear of threat of litigation and accusation of malpractice, and anxiety regarding organisational policies on confidentiality.¹⁶

My research

While the suicide literature sheds some light on working with the phenomenon of suicide, the voice of the therapist working with suicidality in the HE sector has not received an adequate platform. My research set out to provide such a platform, offering unique insights on working with student suicidality, including facilitating and impeding influences, and on the wider meaning that therapists attributed to their experiences of working with suicidal students. In this article, I hope to illuminate therapists’ work with suicidality in HE by highlighting some of the challenges that therapists face in HE and sharing my own thoughts, emanating from my research, all of which I hope will help therapists reflect on their own practice with suicidal students.

Recruitment

I recruited participants through placing an advertisement on the mailing list for members of the Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ’s Universities and Colleges division (Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ UC). Potential participants were screened for suitability for the study, using the following criteria:

• Currently working in an HE institution in the UK, with experience of working with suicidal students
• Five years or more post-qualifying experience
• Accreditation by relevant professional bodies (Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ, BPS, UKCP etc).

Mindful that speaking about potential vicarious trauma could be retraumatising for some therapists, I also asked all potential participants to ensure that they were able to access clinical supervision and personal therapy, if necessary.

The initial recruitment process proved challenging, resulting in a poor response rate. Although disappointing, the response rate was unsurprising, given the societal taboos around suicide. Nevertheless, despite such taboos, I attempted to improve the response rate by expanding my selection criteria and undertook a second recruitment drive. During the second recruitment drive, priority was given to those who met the criteria on a ‘first come, first served’ basis, and following screening, nine therapists in total were interviewed for the study. Note: one participant was withdrawn from the final data analysis.

Given the sensitive nature of the phenomenon under investigation, ethical research practice was at the forefront of this study, and as such, my attention was focused squarely on participants’ psychological wellbeing and minimising potential for harm to participants (intentional or otherwise) where possible. Protection for the rights and welfare of participants was also achieved by viewing consent as an active and ongoing process, and by ensuring confidentiality for all participants.

Interviews

I used semi-structured, one-to-one interviews lasting up to 90 minutes to elicit rich, detailed, first-person accounts of working with suicidal students. The interview schedule comprised open-ended questions relating to clinical practice, student population, organisational issues and the therapist self, and interviews were completed between March 2017 and November 2017, during office hours at therapists’ places of work. All interviews were audio recorded and verbatim transcripts were produced. Each transcript was then analysed for emerging themes, in accordance with the principles of interpretative phenomenological analysis.

Walking a tightrope

The metaphor of walking a tightrope perfectly epitomised therapists’ experiences of working with suicidal students in HE. Just as walking the tightrope is a balancing act, in every sense of the word, therapists working in HE too spoke of the challenges they faced in balancing a number of complex issues when working with suicidal students.Ìý

Like walking a tightrope, working with the phenomenon of suicide was experienced as anxiety provoking and burdensome. For most therapists, the stakes of working with suicidal students were high, in the sense that if they made one wrong move, there was a risk of falling to their metaphorical death. Impotence and censorship also emerged as important themes, pointing to the underlying shame associated with suicide. When assessing suicide risk, therapists relied on intuition and implicit communication, rather than risk assessment tools. Additionally, therapists described the long-term effects of working with suicide as being life changing, and advocated the need for self-care and support when working with suicide over a long period of time.

Just as a tightrope walker needs tools or equipment to improve their performance, therapists identified several aspects as facilitative in their work when supporting suicidal students. These included opportunities to share/consult with others, having supportive colleagues or supervisors, and a high level of self-care. Interestingly, therapists’ relationships with suicide also played an important part in working with suicidality, with many therapists reporting that having a previous experience (professional or personal) of suicide was helpful in increasing their empathy with suicidal students.

In the same way that external conditions, ie weather, wind speed etc, impact a tightrope walker’s performance, external factors in the form of organisational context and needs, also largely influenced therapists’ experiences of working with suicidal students. To clarify, the organisational context referred to the university counselling service, the wider university and the student population.

Firstly, therapists reported the need to hold and manage several tensions presented by the university counselling service and spoke at length about the various barriers they faced that were presented by the service itself. These barriers included navigating increasing demands for the service, challenges associated with using a brief therapy framework in working with suicidality, inadequate or poor risk management practice, and communication difficulties arising from joint-working with external service.

Secondly, therapists discussed the wider university, which they felt placed undue, additional pressures and responsibilities on them, resulting in therapists feeling overwhelmed. The wider university’s agenda, often deemed to be conflicting with the ethos of university counselling, and unrealistic expectations of university counselling, were experienced as ‘uncontaining’ by therapists. Anxiety extended from the consultation room to the wider institution, with most therapists reporting panic-ridden responses to suicide from their respective universities. Increasing concerns around scrutiny and accountability were also noted in therapists’ stories. As a result of the scrutiny and accountability, therapists disclosed a ‘need to do something’, in part to reduce anxiety in themselves and their institutions, and protect themselves in the event of a suicide. Interestingly, this compulsion to ‘do something’ was also reflected in HEIs’ responses to suicide, which were concerned primarily with protecting the reputation of the institution.

Lastly, suicidal students themselves were an important factor in therapists’ experiences of working with suicidality in HE. Most therapists discussed the multifaceted nature of student suicidality and the complexities associated with this client population. Specifically, they highlighted how students’ impulsivity and their rapidly changing internal environments, and the academic context itself (ie lengthy academic breaks) presented challenges to the therapy work. Despite any anxiety or fear reported by therapists, there was an air of optimism and degree of hope in working with suicidal students, which was partly linked to therapists’ perceptions about increased capacity for change within the student population.

The unspoken

Although I focused on the actual words and phrases used by therapists when exploring issues central to therapists’ experiences of working with suicidality, I also received a wealth of information about the nature of the suicide phenomenon through therapists’ non-verbal communication. Therapists’ non-verbal cues spoke volumes about the potency of suicide, and I noted that ‘something happens’ when we start to talk about suicide. Unsurprisingly, anxiety was palpable in interviews. It manifested itself through displays of caution, hesitation or stuttering, and therapists resorted to a variety of strategies to defend against any anxiety, including using humour or seeking reassurance. The dissociative effect of suicide was also evident, with some therapists speaking about suicide in a detached manner or struggling to identify or articulate their feelings, and others experiencing memory loss in regard to suicidal students or interview questions.

Additional observations

Remarkably, what happened directly after the audio recorder was switched off at the end of the interview was noteworthy. I was intrigued to see that some therapists spoke more candidly about their experiences of suicide, and others disclosed more personal information such as their personal attitudes towards suicide. This observation really brought to life just how powerful suicide can be in silencing individuals, and highlighted the impossible task, as a researcher, of trying to engage others in a discourse about a subject enveloped in shame.

Therapists’ feedback about the process of being interviewed, too, was enlightening. Most therapists felt validated by participating in the interview and found the interview gave them invaluable insights into working with suicidality. Others valued the opportunity to sit and reflect on their work, commenting that this experience highlighted to them the lack of space for active reflection in their typical working days.

Implications

The implications of this research are far-reaching and will prove useful to therapists and supervisors working in HE, and managers of university counselling services and HE institutions, in improving the care of suicidal students in university counselling services. Given the recurrent experience of powerlessness reported among therapists, and the potential for suicide to destabilise, supporting and strengthening the therapist role is crucial moving forwards. For therapists to work effectively with suicidal students, a ‘safety net’ of containment and safety needs to be in place. Institutional containment, in particular, has been identified as a major facilitator in the work, and this can be provided in the form of institutional protection and support in the event of a suicide, firmer professional boundaries by managers of counselling services in regard to managing risk, and clearer institutional protocols and policies on managing suicide risk. Containment can also be provided through other means, such as ensuring that therapists are given adequate time for reflection, support from team, peers, supervisors or professional networks, and suicide training and education.

Moreover, with increased demands being placed on university counselling services, this raises an important debate about how much university counselling services can realistically support those students requiring help beyond their expertise or means. I wonder whether, in trying to be a ‘fit-all service’, universities are simply trying to do too much? If so, perhaps university counselling services need to start accepting their limitations in supporting suicidal students, particularly in relation to the brief model framework. With my research findings pointing to university counselling services becoming increasingly reliant on onward referrals to NHS services to support suicidal students, improved communication and co-ordination between such services is also necessary, to ensure a continuity of care and avoid students ‘falling through the net’.

Reflections and recommendations for practice

In an unprecedented year, where students have had to endure multiple lockdowns, adapt to online teaching and miss out on the classic university experience, it is unsurprising to see recent media reports of increases in psychological difficulties in the student population as a result of COVID-19.¹⁸ As a result of the uncertainties presented by the current climate, universities, more so than ever, have a responsibility to address the issue of student suicidality, and explore ways to improve support for mental health professionals working in HE.

Looking to the future, I would like to share some reflections and recommendations for practice, based on my findings:

• We need to start talking about suicide. Even though giving voice to the implicit is at the very heart of what it means to be a therapist, the truth is, talking about suicide is difficult. The recurrent theme of voicelessness evident across the interviews has revealed the power of suicide in silencing both individuals and institutions. The silence in institutions around suicide needs to be broken by pushing it up the university ‘agenda’, and actively creating a space for a discourse on suicide in universities through fostering an environment and culture where both students and staff are not ashamed to talk about suicide.
• We need to share the responsibility for suicide. This research has shown that suicide is a complex phenomenon, which can result in destabilisation, dissociation and fragmentation, not only in the students themselves, but also in therapists and institutions as a whole. Suicide is burdensome, and a burden which cannot be managed in isolation. There is no ‘we-ness’ when it comes to suicide – it can be splitting and deeply personalised, and therefore the coming together and sharing of responsibility for suicide are key. Suicide is a collective responsibility, and this responsibility extends not only to therapists, but also to HE institutions. Supporting the concept of a ‘whole university’ approach, I advocate for institutional ownership of student suicide, and recommend greater collaboration and communication between university counselling services and university-wide departments.
• As therapists, we need to start engaging more fully with the topic of suicide, including exploring and challenging our own personal views of suicide. Given that a therapist’s own sense of engagement with the client is the most frequently identified facilitator in working with suicidal clients,¹⁹ it is imperative that, as responsible practitioners, we explore any barriers within ourselves and the wider contexts or institutions to which we belong, which may prevent us from being fully engaged with our suicidal students. Working with death-related issues remains the cornerstone of therapy practice, and therefore it is essential that we accept that working with suicidality is an occupational hazard and embrace the powerlessness that comes with working with it.

Concluding thoughts

This research has highlighted that, like walking the tightrope, working with suicidal students in HE is, in essence, a balancing act. A major challenge for therapists lies in how they manage the tensions, and sometimes conflicting needs, between themselves, the counselling service, university and students, against the backdrop of shame associated with the suicide phenomenon. While I appreciate there are some places that we won’t allow our minds go to, my hope is that this research will encourage all therapists working in HE to reflect on their own experiences of working with suicidal students, and perhaps even acknowledge their ‘own’ relationship with suicide.

Finally, we cannot underestimate the power of the unspoken element of suicide. Given that so much about suicide can be communicated implicitly, on an embodied level, perhaps we cannot simply rely on words alone. On this note, I invite you to close your eyes, sit quietly, and contemplate the word suicide… and observe what happens. In moving into the implicit realm, my hope is that we can begin to shape a narrative around the phenomenon that is suicide.Ìý