What’s with the attitude?

Summary: Part 1 of two articles exploring the role of attitudes in ethically sound service delivery. Based on Carmen’s personal experience, What’s with the attitude? highlights the risk to others that ignorant and naive attitudes can have in a clinical setting (one could argue harm to the community and beyond…) and importantly, on our clients.

This article might ruffle a few feathers. In fact, it might ruffle a whole bird. It’s about the attitude and beliefs we take into our practice with our clients with respect to suicide. I’m writing it after encountering a number of people in the last month who just didn’t get it and that didn’t get that their attitude does harm. Not just failed to assess or respond to suicidality, like a benign oversight – DOES HARM.

I have the opportunity in what I do to meet a lot of people, from all walks of life in addition to providing training, supervision and consultation around matters related to suicide. I also work directly with suicidality. I get that it’s a tough job at times and there are times when I have felt confused and wondered what approach might achieve the best outcomes. Regardless of the kind of challenge before me, I have to carry with me determination to do what’s right for the client and hold the hope that might be flagging for them. One of the other insights I developed years ago through my studies in Indigenous Health, is that my social and cultural upbringing has influence the manner in which I perceive, interpret and respond – to anything – but most importantly others. With that awareness, I feel stronger in metaphorically stepping out of my shoes and into another’s.

The first encounter I had was with a provisional psychologist. Yes, she was a mature woman, at the end of her training, but she was technically still “learning” and under the guidance of someone who should work to mould and support her development as a therapeutic being. I was involved with the practitioners on another matter. When we first spoke of suicide, her brusque response I took to be an expression of her cultural heritage rather than condemnation of the suicidal person. The second time we spoke of the suicidal client, her aggressive comments appeared inconsistent with what she was trying to say, and again I thought it must be cultural or reflective of language conventions. However, when the suicidal state was raised again in general conversation, it became apparent that it was her attitude and beliefs around the suicidal person that was affecting her relationship with the client. What was of concern to me was firstly her “observation” that assessing for suicide is “the latest fad hitting psychology”.

I beg your pardon? Yes, you heard right!

Durkheim’s theory on suicidality has been around since 1897… not exactly new and to my mind, suicide risk assessment has been part of my practice since I entered the field over 15 years ago. Because it appears to have a recent emphasis to her learning, she appeared to have determined that risk assessment was a passing necessity what wasn’t inherent to her practice.

But what was she really saying? I enquired into her “observation” and she stated that “all clients are at risk and it’s impossible to predict suicide”. This I can almost agree with – clients attending to see a Psychologist and particularly within an acute mental health setting, generally speaking, are experiencing some difficulties in their life where they can’t cope and there may be an increased risk for suicide. However, I differ in my beliefs and this informs my approach – with enquiry, we have the capacity to understand the individual, how acute their difficulties are, the potential timing of a suicidal behaviour and whether they too, see themselves at risk. It is not about predicting the suicide but better understanding the severity of their distress and how they see their options through this time. Understanding this informs how directive our actions may be. Believing that everyone is at risk and that the sole purpose of a suicide risk assessment is to predict the suicide, demonstrates ignorance. We want to understand their psychache (again an “old term” from a well respected suicidologist Schneidman (1993)) and the depth to which the client feels they are not coping and whether they see opportunity to change the status quo. Risk assessment is not about prediction!

What the provisional psychologist was also saying to me (in her rather aggressive approach) is that she felt overwhelmed by the potential response of the client. That she felt hopeless to make a difference. I don’t know how or why she felt this way. What I do know is that she was failing to understand the client or the potential imminence of risk and this barrier creates harm.

There is a lot more that could be said about the provisional psychologist, but let me move to the next clinician who made me sit back and reflect. This person immediately tapped into the old myth “if I ask the question, I’ll give them ideas”. I was offering supervision to this clinician and they confirmed that they asked about suicide but were reluctant to ask about mechanism in case it gave the client “ideas”. The clinician said “what if I ask them for details and they get the idea and go home and kill themselves – what if I make it happen sooner – what if in talking about it they get a better plan?”. This clinicians concern is valid and real. But my response is “what if you don’t ask details – what can you really do with vague answers? How can you take proactive stance to understand and address the risk?”. From which the clinician said – “even with details, ***** Crisis Team won’t do anything either, it’s a waste of time”…

The attitudes and beliefs behind this appear to be a fear that we are solely responsible for our clients, that trying to engage other services is ineffective and that again, working with suicidality is somewhat hopeless. My response to the clinician was twofold – ask the question and if the clients response indicates imminent intent, make the referral or intervene as appropriate – don’t make a decision for the Crisis Team – let them do their job and if they don’t respond the way you expected or wanted, talk with them to understand why. In digging deeper, the Clinician had made referrals in the past which were not validating to him – the clinician had receded and believed that his opinion and assessment wasn’t correct, valid or fair to the client. Indeed, the client’s refusal of service with the crisis team negatively impacted on the therapeutic relationship between the clinician and client. So my second act, was to validate the assessment process that he can undertake, bust some myths and support a clearer perspective on how to work collaboratively with the client even in the face of the crisis team not responding in the way he hoped. I also imparted my insight, that sometimes crisis teams make decisions on what they can work with, that have nothing to do with the client but everything to do with their resourcing. It may also reflect the competence, skill and rapport they acknowledge the clinician to have with the client; to hold them in this higher risk state while their resources are few. It doesn’t make it any easier, but with this information, the clinician has the capacity to change his belief about himself and what he can do.

The last example relates to two older gents who were both rather influential in my decision to write this piece. The first gentleman assumed an air of “I’ve been around the block and there is nothing you can tell me that I don’t already know”. Don’t get me wrong, this guy knew his stuff and had lived a lifetime working with clients with complex presentations. What struck me was how this air created a barrier between him and the team – where the team appeared intimidated rather than inspired by his knowledge. The attitude also enforced a hierarchical approach to client assessment and intervention with him firmly at the top. We need decision makers. We need a “full stop” when it comes to client management practices, but our practitioners also need the opportunity to develop skills which are not implemented in a fixed and standardised way according to clients’ who “tick the box” or not – suicidality doesn’t fall under a set presentation, it can’t always be managed according to a fixed set of rules and rigid adherence to policy. To manage it according to “one size fits all” fails to see those clients who may be outliers….

In contrast, another older gent attended one of the workshops SRAA were delivering on suicide risk and substance use. When he registered, his pre-workshop responses made me wonder what I could possibly teach him? He had also been working with complex presentations for about 40 years and in the AOD sector there is frequently trauma and suicidality. The pre-workshop questionnaire asked what he hoped to learn from the workshop whereby his response was “A refresher” and “latest research”. So, fair enough, perhaps the insights I could offer wouldn’t be ground breaking for him, but it was something that I could certainly achieve. But what he renewed in me was the absolute importance that as clinicians, we see our client through the lens of their experience – not the diagnosis, substance use or any other “boxing” perspective. His attitude throughout the workshop was respectful of the developing clinicians and showed great flexibility and strength in how he works with clients. I am pleased to say that he identified a few gems in our training that he could walk away with, but from the experience, I also walked away with some gems; renewed vigour in what I do.

These two gentlemen demonstrated to me the stark contrast in how attitudes and beliefs influence not only our practice but that of our peers/team.

My key points from these encounters are

Pessimism and scepticism has no place in working with vulnerable clients, whether they are at risk of suicide or not. If you don’t believe a client has the capacity to change or there’s no hope, you’re in the wrong job
There is no place for complacency
Reflect on your practice – Ask yourself what stops you from asking certain questions? What influences how you interpret the behaviour or presentation? Does your attitude or belief about suicide get in the way of understanding clients? Be open to receiving supervision or therapy to better understand how your beliefs and attitudes influence your practice
Don’t make decisions on behalf of other services based on how you think they may respond
Again! Reflect on your practice – Does your approach to other clinicians hamper their capacity to learn and develop? Does it prevent them from working collaboratively? Does it instill in them a sense of hopelessness or incompetence?
Look at what the client needs from you – does your hope or lack of hope reflect the client’s perceptions of themselves and is there a bigger dynamic at play?
For those seasoned practitioners, share your experience in a way that allows everyone to grow – including yourself!
Finally, if you feel ill equipped, out of your depth or that you don’t have the knowledge and resources to ask the questions needed or respond effectively – then get training (and supervision)! Consult with your peers and challenge any systems that hold rigidly to hierarchy that may be damaging the way in which you assess risk

These observations are not aimed to shame anyone, but it should stimulate thinking and reflection. Keep an eye out for our next article which will examine some of the research behind attitudes influencing outcomes in suicide risk assessment and intervention.

First published 6 April 2016

By Carmen Betterridge