Tony White has been a registered psychologist in private practice for the past 29 years, and is a teacher and supervisor of Transactional Analysis psychotherapists. He has worked with suicidal individuals for many years, including spending three years working in a prison identifying and managing suicidal and self-harming inmates.
Here he answers some questions about his new book, Working with Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support.
How did you come to work with suicidal individuals?
My counselling and therapy background is unusual in that both my parents were trainers and psychologists. I began my university and therapy training early and began running my first therapy groups with a co-therapist at age 22. I am now 53. It was a private practice setting and people kept coming so I kept running therapy groups even at that quite young age.
In private practice one takes whomever walks in through the consulting room door. Often you have no idea of what the problem is until the person sits down and starts talking. People presenting with suicidal thoughts and urges was not uncommon and this was my first introduction to the area of the suicidal individual. In this way over the years I have worked with a lot of depressed and many quite suicidal individuals.
However, I also had a personal interest in the area and began to specialise in working with the suicidal individual which culminated in 1991 when I wrote a book about the ‘no suicide contract’. At the personal level when I was about 17 and 18 years of age I made two suicide attempts. As an adult I have never made a suicide attempt and I am not a suicidal person. It is simply not an option for me. In my adult years there have been some very low times with the loss of loved ones and so forth. At these times I have never even thought of suicide let alone planned anything.
How could I make two attempts as a teenager and yet not be a suicidal person in my adult years? This is why the book includes a discussion of teenage suicide. The usual reason given for teenage suicide is that it is a time of extra stress, where these young people are neither adults nor children, their bodies are changing, and so forth. Whilst I agree with this explanation, it is simplistic and certainly an incomplete explanation of why adolescence is a high risk stage for suicide. Through my own experience and study of teenagers I suggest that there is a more comprehensive explanation in that teenagers think of suicide differently than mature adults.
In more recent years I worked in the prison system. My role was to co-ordinate the At Risk Management System. This was the organisational process set up to manage and identify suicidal and self harming inmates. How I came to do this was sort of by accident. A friend of mine worked in a prison and they needed someone for the co-ordinator’s job. He asked me if I wanted to do it, and feeling like I needed a new project I said yes. This meant I was working with suicidal and self harming men each and every day. My knowledge of the psyche of the suicidal person from age 18 to 70 increased at an exponential rate as a result of this. And that is how I ended up working with suicidal individuals.
Why did you decide to write the book?
Over the years I had accumulated extensive knowledge of the area. I had written many articles for journals and magazines, and had presented at many workshops and conferences. In essence the book was already written.
Also, over the years I had developed some new ideas and methods of understanding and working with the suicidal. The literature on the suicide to my mind has been quite stagnant for some time. There are few new, innovative ideas stated and most of it tends to be picture straightening. I decided to produce the book so as to include some of these new ideas which I have never seen in the literature before.
The book is written in a user-friendly style with theory that is readily understandable. It certainly is for anyone who works with or has to deal with suicidal people in the course of their work or day to day activities.
As it is easily understandable by the layman it would also give the family and loved ones of a suicidal person a framework by which to understand what is going on with their distressed friend or relative. At least half of the book provides this framework, while the other half discusses the treatment of and therapeutic management of the suicidal individual.
What is the most accurate way to assess suicide risk?
This book covers two different approaches to assessing suicide risk, the quantitative and qualitative approaches. In the literature one often sees the quantitative approach used which usually includes a list of features found in high risk groups. The unmarried, prisoners, the mentally ill, the depressed, substances users and so forth. These are covered in-depth in this book with a lot of new information added that I have accumulated over the last 20 years of working with the suicidal.
In the literature one rarely, if ever, sees the qualitative approach discussed, especially outside the transactional analysis literature. This approach identifies the definitive aspect of the suicidal individual, that of the ‘suicide decision’. If one can make such a determination then a significant step in assessing the suicide risk of the individual has been achieved. One knows that the individual has suicide in their mind as a viable means to solve a problem at some time in their life.
This adds an extra dimension to suicide risk assessment. The vast majority of suicide risk assessments look only for those people who are at imminent risk of a suicide attempt. Whilst this is obviously very important the qualitative approach to suicide risk assessment allows one to ascertain the person’s longer term suicide risk. If the suicide decision is identified then that person is a higher, longer term suicide risk. Once diagnosed then monitoring the person is possible such that the suicidal crisis can be avoided earlier, rather than waiting for the imminent suicide risk to arrive. Or treatment can be applied so as to reduce the power of the suicide decision in the personality of the individual, thus reducing the longer term suicide risk level.
Is it possible to ‘cure’ someone who is suicidal?
People display suicidal behaviour and make suicidal statements for a variety of reasons. There is a group of people who have made what is known as the suicide decision in childhood. From a psychological point of view this person could be considered the ‘truly’ suicidal person. Their psychological make up is structured such that suicide is a viable option for them to solve difficult problems at some point in their life. These people can be treated such that they can make a change to that early suicide decision and thus the likelihood of suicide being used as a problem solving technique in the future is greatly reduced.
As mentioned before the suicidal teenager has a different comprehension of what suicide is compared to the mature adult. Teenagers in this way are more managed through their difficult adolescence rather than cured of their suicidality.
Others may suicide because of command hallucinations. That is the person who is engaging in suicidal behaviour because they are experiencing hallucinations that command them to. In such instances if one ‘cures’ the psychotic hallucinations then the threat of suicide greatly reduces which is usually done with some regime of medication. There are other motives which can lead to suicidal actions and these are dealt with in a variety of ways.
How do you address the ‘no-suicide contract’ in the book?
The literature has an enormous amount written about this topic and it is indeed a very divisive one. There has been much heated debate about the usefulness, or lack of usefulness, with the no-suicide contract. This book provides an explanation of why there has been such debate. The main reason is because many writers on the topic do not understand the theory underlying the no-suicide contract. The no-suicide contract originated within the Transactional Analysis literature. Those who are not well informed about Transactional Analysis theory do not understand what the term no-suicide contract actually means.
This book explains the theory behind the no-suicide contract so that much of the heated debate can be avoided. For instance a no-suicide contract is no different from any other behavioural contract used in counselling. Any treatment contract is useful in certain circumstances and not in others with the no-suicide contract being the same. Those circumstances when the no-suicide contract is useful are articulated in this book. Then one is provided with a procedure to follow when the no-suicide contract is indicated and a procedure to follow when the no-suicide contract is contraindicated.
Copyright © Jessica Kingsley Publishers 2010.