Attitudes & Practice – Considering the evidence
Summary: Part 2 of two articles exploring clinicians attitudes and how they influence the therapeutic relationship. In this articles, we draw on evidence that negative attitudes towards suicidality and certain diagnoses lead to poorer clinical outcomes for clients, while conversely, positive attitudes towards change and recovery are aligned with improved clinical outcomes.
Take some time to think about your beliefs about suicide – How do you feel about a middle aged mother of four who is suicidal? What if you saw an elderly person who said they had lived a good life, and that they had a plan to suicide? Do you feel differently about the person who frequently cut themselves over someone who presents to hospital repeatedly for asthma?
Now consider how these attitudes might shape your approach to client management – can you see how the judgements we make could influence how we approach their care?
What are the facts? There is a plethora of research in this area (indeed the systematic review by Saunders and colleagues (2011) included 73 studies). Research investigating attitudes towards suicidality and self injury define “positive” attitudes as being generally more compassionate and understanding whilst “negative” attitudes reflect more discriminatory beliefs and low empathy (Carmona-Navarro & Pichardo-Martinez 2012; Gagnon and Hasking, 2012; Saunders et al 2011).
The consequences of negative attitudes in clinical practice are;
- Reduced willingness to provide care
- Ineffective risk assessment
- Ineffective provision of care
- Overt expression of irritation, anger or antagonism towards clients
- Dismissive practitioner response styles
- Poor interpersonal engagement (eg. disrespect, judgement)
- Greater potential for burnout and career dissatisfaction
- Stronger responses to repeat presentations/admissions
- (Carmona-Navarro & Pichardo-Martinez 2012; Gagnon and Hasking, 2012; Mendes 2015; Saunders et al 2011)
How can negative treatment shape our client’s attitudes and beliefs?
- Increased distress → desperate behaviours → repeat self injury/suicide
- Compounding negative beliefs about self, hopelessness and potential for change
- Fear, aggression and violence towards practitioners
- Reluctance, resistance or refusal to engage in treatment
- Poor communication
- (Carmona-Navarro & Pichardo-Martinez 2012; Gagnon and Hasking, 2012; Saunders et al 2011)
It is certain that there are further consequences not identified in the research.
While there are multiple factors that may influence a clinicians attitude and beliefs around suicidality and self injury, it is known that demographics (age, gender, cultural beliefs etc), level of exposure to clients who are suicidal or whom self injure, and personal history and experience of suicidality can all play a role (Kadaka et al 2013; Saunders et al 2011). Indeed, those clinicians with personal exposure to suicide (through a family members suicide for example) were more likely to condemn suicide, holding the strongest negative attitudes (Abbott & Zakriski 2014; Saunders et al 2011). We also know that we have the capacity to enhance and modify attitudes through education and awareness programs (McCann et al 2006).
And positive attitudes? Positive attitudes generally support the provision of sound assessment, treatment and intervention with suicidal people; instilling hope, acceptance and potential change to clients. Empathy towards a client facilitates increased communication for example. However, there are some risks associated with certain positive beliefs. These include permissive attitudes towards suicide and the right to die which correlate with poorer suicide specific counselling skills and acceptability of a client’s right to die (Kadaka, Inagaki & Yamada 2013).
What about how the client’s behaviours and attitudes affect us?
Yes, it is true that some clients are tricky. Some clients are even difficult. Bodner and colleagues (2015) investigated the attitudes of practitioners working with clients at increased risk of self injury and suicide; those with Borderline Personality Disorder (BPD). They found that the diagnosis itself was associated with negative attitudes; attitudes that a person with BPD who was distressed, somehow didn’t feel real distress and that their behaviour was “manipulative”. Indeed, the research identified the transference-counter transference experience and polarisation of relationships as being significant challenges for clinicians engaging with clients diagnosed with BPD. The consequence for using BPD as a label is the stigma which brings with it negative treatment; including a reduced likelihood of hospital admission, shorter client contacts and clinician avoidance of the client. Stigma is serious. Consider clients with substance use problems (ie. addictions) – they are also treated with disdain by mainstream health (Saunders et al 2011), despite also carrying high risk for suicide and serious health risks.
There are clients who are likely to have repeat presentations to mental health services due to their self injurious behaviour or suicidality. They need us to provide quality services where change may not be achieved through the first, second or even third contact, but at each contact foundations are laid for change to become real and attainable. We can only do that with an attitude that respects the client and believes that suicide (and self injury) is not an option.
How can we improve our attitude?
- Personal reflection – pure and simple. Understand what you believe and how you feel about suicide. Consider how your beliefs are likely to affect the way to see the client. Developing your emotional intelligence, empathy and knowledge around the factors that influence the expression of self injury or suicide will allow you to practice without judgement. If your values and beliefs are inconsistent with providing support or treatment to suicidal clients – change jobs!
- Go to training (and have supervision) – clinicians who had undertaken training in suicide and self injury prevention tended to demonstrate more positive attitudes towards the client than those not having undertaken training. This equips clinicians with skills to better assist the client. Attitude change and skill development is maximised in meaningful and practiced methodology.
- Assume an attitude of hope – even when things seem hopeless. We must support the client to tolerate the distress and transcend the moment. Give them hope, and feel confident that if they need help in the future, they can have it.
- Challenge negative attitudes –. Change is difficult, but a negative culture can contaminate a workplace so a client feels that nowhere is safe. Act to support positive attitudes and defeat negative beliefs in the workplace. This was confirmed with another study which emphasised the importance of challenging stigma around suicidality and the promotion of positive attitudes in the mental health sector, to improve help seeking behaviour (Reynders, Kerkhof, Molengerghs & Van Audenhove, 2014).
- Ensure acceptance is for the client – not for suicide
Attitudes matter. The greater the conversation, the more significant opportunity we have for reflection and potential to influence the attitudes in a manner that benefits our clients.
Abbot, C. & Zakriski, A. (2014). Grief and attitudes towards suicide in peers affected by a cluster of suicides as adolescents. Suicide and Life Threatening Behaviour, 44(6), 668-680.
Bodner, E., Cohen-Fridel, S., Mashiah, M., Segal, M., Grinshpoon, A., Fishcel, T. & Iancu, I. (2015). The attitudes of psychiatric hospital staff towards hospitalisation and treatment of patients with borderline personality disorder. BMC Psychiatry, doi.org/10.1186/s12888-014-0380-y
Carmona-Navarro, C. & Pichardo-Martinez. C. (2012). Attitudes of nursing professional stowards suicidal behaviour: influence of emotional intelligence. Rev Latino-Am Enfermagem, 20(6), 1161-1168.
Gagnon, J. & Hasking, P. (2012). Australian psychologists’ attitudes towards suicide and self harm. Australian Journal of Psychology, 64, 75-82.
Kodaka, M., Inagaki, M. & Yamada, M. (2013). Factors associated with attitudes toward suicide among Japanese pharmacists participating in the board certified psychiatric pharmacy specialist seminar, Crisis, 34(6), 420-427.
McCann, T., Clark, E., McConnachie, S. & Harvey, I. (2006). Accident and emergency nurses’ attitudes towards patients who self-harm. Accident and Emergency Nursing, 14, 4-10.
Mendes, A. (2015). Being equipped to care for patients at risk of self-harm and suicide, British Journal of Nursing, 24(15), p.787.
Reynders, A., Kerkhof, A, Molenberghs, G. & Van Audenhove, C. (2014). Attitudes and stigma in relation to help seeking intentions for psychological problems in low and high suicide rate regions. Social Psychiatry Psychiatric Epidemiology, 49, pp.231-239.
Saunders, K., Hawton, K., Fortune, S. & Farrel, S. (2011). Attitudes and knowledge of clinical staff regarding people who self-harm: A systematic review. Journal of Affective Disorders, 139, 205-216.
First published 14 April 2016
By Carmen Betterridge