Week 7 Discussion

10 Most Common Errors in Suicide Assessment/Intervention Robert Neimeyer & Angela Pfeiffer

1. Avoidance of Strong Feelings – Diverting discussions away from powerful, intense emotion and toward a more abstract or intellectualized exchange. These responses keep interactions on a purely cognitive level and prevent exploration of the more profound feelings of distress, which may hold the key to successful treatment. Do not retreat to professionalism, advice-giving, or passivity when faced with intense depression, grief, or fear.

• Do not analyze and ask why they feel that way. • USE empathy! “With all the hurt you’ve been experiencing it must be impossible

to hold those tears in.” • Tears and sobbing are often met with silence of tangential issues instead of

putting into words what the client is mutely expressing: “With all the pain you’re feeling, it must be impossible to hold those tears in.”

• “I don’t think anyone really cares whether I live or die.” Helpers often shift to discussing why/asking questions as opposed to reflecting emotional content.

2. Superficial Reassurance – trivial responses to clients’ expressions of acute distress and hopelessness can do more harm than good. Rather than reassuring clients, these responses risk alienating them and deepening their feelings of being isolated in their distress.

• Attempts to emphasize more positive or optimistic aspects of the situation: “But you’re so young and have so much to live for!”

• Premature offering of a prepackaged meaning for the client’s difficulties: “Well life works in mysterious ways. Maybe this is life’s way of challenging you.”

• Directly contradicting the client’s protest of anguish: “Things can’t be all that bad.”

3. Professionalism – Insulating or protecting by distancing and detaching from the brutal, exhausting realities of clients’ lives by seeking refuge in the comfortable boundaries of role definition. The exaggerated air of objectivity/disinterest implies a hierarchical relationship, which may disempower the client. Although intended to put a person at ease, this can come across as disinterest or hierarchical. Empathy is a more facilitative response.

• “My thoughts are so awful I could never tell anyone” is often met with, “You can tell me. I’m a professional” as opposed to the riskier, empathic reply.

4. Inadequate Assessment of Suicidal Intent – Implicit negation of suicide threat by responding to indirect and direct expressions of risk with avoidance or reassurance rather than a prompt assessment of the level of intent, planning, and lethality. Most common among physicians and master’s level counselors – due to time pressures, personal theories or discomfort with intense feelings.

• What they’ve been thinking, For how long, Specific plans/means, Previous attempts

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• “There’s nowhere left to turn” and “I’d be better off dead” should be met with “You sound so miserable. Are you thinking of killing yourself?”

5. Failure to Identify the Precipitating Event – Pinpointing the specific occurrence that prompted the client’s decision to seek help can identify and prioritize issues in a way that more quickly restores a client’s sense of balance and equilibrium and facilitates action planning. This should be an extension of basic empathic concern. Ask about recent key incidents or life events; can help move toward necessary action steps.

• It sounds like everything collapsed when your brother died 3 years ago, but what has happened recently makes you feel even worse, that dying is the only way out?

• To the life-threatening client who complains at length that “life has been worthless” since the death of his wife, the counselor might respond, “Sounds like your world fell apart when your wife died...What has happened recently to make things worse, to make you think dying is the only way out?”

6. Passivity – 25% of counselors and helpers took a passive clinical stance. Failure to join with a client’s distress and taking a nonparticipatory role, even when the client clearly required higher levels of helper involvement. Early stages of suicide interventions need to be active, engaging, empathic, with the helper structuring the intervention.

• Go on, I’m here to listen; Call back some other time when you can talk more easily

• Client stammers, voice breaks, and silence ensues: “Go on. I’m here to listen” vs. reflecting the client’s distress, “It must be very hard for you to talk about what’s bothering you.”

• [Over telephone] “It’s hard to talk here, with all these people.” could be met with “Would it help if I asked questions.” or a paraphrase. “Call back some other time when you can talk more easily” could terminate the connection at a potentially dangerous moment, with no clear plan for follow-up. Try “I understand it’s really awkward for you to talk right now, but I’m really worried about you. Will you promise to call us back?” (variation on a pact when suicide is not discussed).

7. Advice Giving – Overly simplistic, rarely effective, and tends to convince the client that the counselor does not appreciate the gravity of the situation nor understand the actual or psychological constraints that prevent the client from following the advice. Action plans are worked out collaboratively, after the particulars of a client’s situation have been explored and assessed. concrete action ideas are good, after trust has been established. Action plans should come from the client’s tentative ideas, rather than from the authoritative advice of the helper.

• Remember, focus on the positive; Try not to worry about it; Just ignore the person who is bothering you.

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• “Considering all you have going for you, things can’t be that bad”, “Try not to worry about it”, “Look on the bright side”, and “Try to focus on the positive aspects of your situation” are patronizing and ineffective.

• “What would be one or two small steps you could take in the next few days to start to deal with this problem?” arouses less resistance and may reveal interventions not envisioned by the counselor.

8. Stereotypic Response – Making unwarranted assumptions about the client’s personality, pathology, or predicament. Interventionists should focus on clients’ individuality and unique emotional experience without trying to fit them into a typology of client problems. Helpers should focus on the individuality of each person; don’t use shortcuts.

• She’s a borderline, attention getting female • [Male sobbing] “I try so hard to keep from crying.” The response, “Do you think

it’s so hard for you to cry because you’re a man?” is based on a stereotypic assumption and misses the opportunity for reflection of feelings.

9. Defensiveness - Often arises when an angry or rejecting client directly or indirectly rebuffs attempts to help. Reacting personally as opposed to therapeutically erodes whatever level of trust might be established. Join with the client’s concern through empathy. The key is not to respond in an automatic, self-protective manner. Anger/rejection is common during intense crisis – avoid power plays or sarcasm; maintain a caring stance.

• Responding to, “How could you ever help me? Have you ever wanted to kill yourself?” with “Sure. But I’ve always found healthier ways to resolve my problem” is condescending. The empathic reply is, “Sounds like you’re afraid I won’t be able to understand and help you.”

• Outright rejection of client’s feelings: Responding to, “I can’t talk to anybody. Everyone is against me.” with “That isn’t true. There are probably lots of people who care about you.”

• “You don’t really care about me anyway.” can be responded to with a genuine expression of concern, “I think your death would be a terrible waste.”

10. Insufficient Directness – In dangerous, unpredictable situations, counselors must be attentive to the urgency. Emphasize the importance of continued interaction, or at a minimum, secure a verbal no-suicide contract. Effective crisis intervention often requires directive crisis management, particularly in terms of creating distance between a distressed, impulsive client and means of self-injury. At minimum, a verbal ‘no suicide’ contract should be obtained.

• If you keep feeling suicidal, remember you can call back, vs. OK, we have an appointment set up for you, you have my phone # for tonight, and I’ll stop by the school to see how it’s going tomorrow

• More than 1/3 responded to caller’s bid to end the call with “OK, but if you keep feeling suicidal, remember you can always call back” instead of parting.

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• “I have a gun pointed to my head, and I’m going to pull the trigger if you don’t help me” was met with a weak reflection of “you seem to be somewhat upset” as opposed to securing sufficient control for continued interaction, “I want you to put down the gun so we can talk.”

10 Most Common Errors During a Suicide Intervention. Retrieved from https://www.ndhealth.gov/presentations/suicide2/suicide2.PPT

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