Unit 4: Counselling Applications: Child Counselling; Family Counselling; Career
Counselling; Crisis Intervention: suicide, grief, and sexual abuse
CHILD COUNSELLING
Counselling and related interventions are aimed at improving the mental health of children and
young people. In the educational context they are linked to learning, achievement, attendance
and behaviour (Ofsted 2004). Counselling and other psychological therapies are found to be
useful in relieving emotional and psychological problems in adults (Fonagy, 1999,
MellorClark, 1998). However, there may be difficulties in applying adult therapy research to
children and young people due to the nature of child and adolescent development and
perceptions of therapy (Fonagy, 1999). In practice, counselling is concerned with prevention
and de-escalation of problems and focuses on enabling the child or young person to develop
self-esteem and the internal resources to cope with their difficulties more effectively. This
includes the remediation of mental health symptoms and problems.
Broadly speaking, therapies used with children fall into three categories. Each has distinct
philosophical underpinnings and underlying assumptions about the nature of human behaviour
and change. Cognitive-behavioural therapy (CBT) combines techniques from cognitive
therapy with behavioural therapy and is based on the premise that cognition is related to mood
and behaviour. It is one of the most widely researched therapies for children and young people
and CBT studies are published in many high quality journals (Southam-Gerow and Kendal
2000). This particular type of therapeutic intervention lends itself well to the scientific method
and is often carried out by psychologists trained in the quantitative research paradigm.
Cognitive-behavioural therapy seeks to promote emotional and behavioural change in children
and young people by helping them to change their thinking in ways that are interactive and
based on problem-solving. Techniques and strategies are used to enhance self-control, increase
personal efficacy and rational problem solving. The aim is to develop more effective social
skills and increase the child’s participation in pleasurable, satisfying activities (Freeman and
Reinecke 1995).
Humanistic therapies emerged from humanistic psychology as an alternative to
psychoanalytical and cognitive-behavioural approaches (McLeod 2003a). These therapies
embrace a range of approaches including person-centred, existential and gestalt (Clarkson
2004, Rogers 1959, van Deurzan 1997). Fundamental to the humanistic approach is a concern
to meet the deficiency and growth needs of the child or young person (Maslow 1970). Placing
an emphasis on the development of the whole child (physical, intellectual, emotional, spiritual
domains), the quality of the therapeutic relationship is perceived as central to the efficacy of
this approach. The counsellor is responsible for creating an environment in which the child
feels cherished, contained and able to grow.
Creative approaches to therapy may be found mainly but not exclusively within
psychoanalytic and humanistic approaches to counselling children. They involve play, art,
clay modelling, movement, music and other forms of creative expression. The major
research paradigm for these therapies is qualitative. In research terms, the
psychoanalytic/dynamic approach has predominantly used the single case study and focused
on the processes taking place, whilst the humanistic therapies may focus on the
phenomenological world of the child or young person (McLeod 2003b).
The research literature covers a wide range of issues experienced by children and young people.
These issues share some of the characteristics of adult issues such as depression, anxiety, low
self-esteem, sexual abuse, physical and emotional abuse, eating disorders and difficulties with
relationships. However, some issues are more context-specific to the younger client, for
example, school phobia, bullying and behavioural problems. Children and young people suffer
a variety of psychological problems and difficulties. Therefore, it is encouraging to note that
most young people follow a relatively untroubled psychological development and that a third
of problems are intermittent or temporary. However, 11% of young people have serious,
chronic difficulties (Ebata and Moos 1990). Moreover, psychological problems are more
common in adolescence, with nearly half reporting difficulties in coping with situations at
home or school. Conflicts regarding the transitional nature of adolescence and the lack of
control over physical, social and physiological changes are more likely to lead to stress,
depression, alcoholism, drug misuse, eating disorders, self-harm and suicide amongst young
people (Steinberg 1996).
Depression in adolescence is related to youth suicide rates, which account for over onefifth of
all deaths in young people. According to Steinberg (1996), one in three young people have
contemplated suicide with one in six actually making a suicide attempt. Furthermore, figures
from the Oxford Centre for Suicide Research (1998) estimate that 24,000 adolescents self-
harmed in 1999 and that deliberate self-harm is more prevalent amongst girls. Eating disorders
are common amongst young people, particularly adolescent girls and create challenges for
teachers, support staff, counsellors and medical practitioners (Abraham 2001) and the often
catastrophic effects of bullying on children and young people is well documented, particularly
in relation to those who are already vulnerable. For example, children with learning
difficulties/disabilities (Norwich and Kelly 2004) or other vulnerabilities based in gender or
sexuality (Ellis and High 2004).
Although counselling has strong connections with education, traditionally as an intervention in
child guidance clinics for children with special educational needs, it is closely associated with
psychology and psychoanalysis/psychotherapy.
Children frequently experience learning difficulties in school as a result of inner turmoil. Some
of these children suffer from anxiety over broken homes and disturbed family relationships.
Children who display behaviour problems, such as excessive fighting, chronic tiredness,
violent outbursts, extreme withdrawal, inability to get along with peers, and a neglect of
appearance need to be properly managed. In small groups, children have the opportunity to
express their feelings about a wide range of personal problems. If the group is structured
properly, these children can receive psychological assistance at an early age, and will stand a
better chance of dealing effectively with the tasks they face later in life.
Children and adolescents facing trauma like physical, emotional or sexual abuse are the most
vulnerable individuals in society. They have many emotional challenges, issues and concerns
to deal with on a day-to-day basis. It is therefore extremely important to provide them with
proper emotional care and counselling. Child and adolescent counselling is a process between
a child or adolescent and a counsellor in a trusting relationship to help that child or adolescent
explore and make sense of a traumatic experience that has happened to them (e.g. death of a
parent, abusive situations). Child and adolescent counselling focuses on supporting the
behavioural, emotional and social growth of children and adolescents. Child and adolescent
counselling aims to assist children and adolescents recover their self-esteem and confidence. It
helps them understand that the trauma was not their fault and to address any fear or anger they
are feeling. If children have a positive counselling experience when they are young, they are
more likely to ask for help at other times in their lives.
CAREER COUNSELLING
Counselling programs in schools are important in three critical areas: academic,
personal/social, and career. Their services and programs help students resolve emotional, social
or behavioural problems and help them develop a clearer focus or sense of direction. Effective
counselling programs are important to the school climate and a crucial element in improving
student achievement.
The following are the objectives of career counselling:
To develop in students an awareness of opportunities in the personal, social and
vocational areas by providing them with appropriate, useful information.
To help students develop the skills of self-study, self-analysis and self-understanding.
To help all students in making appropriate and satisfactory personal, social educational
choices.
To help students develop positive attitudes to self, to others, to appropriate national
issues, to work and to learning.
To help students acquire the skills of collecting and using information.
To help students who are underachieving, use their potentials to the maximum.
To assist students in the process of developing and acquiring skills in problem solving
and decision making.
To help build up/or sharpen the child’s perception of reality, development of a sense of
autonomy and to whip up the motivation for creativity and productivity.
To identify students with learning problems, so that different individualized methods
can be used for effective teaching and learning.
To work with significant others in the life of the child, helping them to understand the
needs and problems of the child. This aids in creating, arousing and sustaining their
interest in and their understanding of the child’s needs, problems and goals so that the
child could be optimally helped to attain those goals, handle those problems and meet
those needs.
To help route the nations human resources into appropriate useful and beneficial
channels and identify and nurture human potentialities in various fields of study
endeavours, thus ensuring adequate manpower in the various sector of the
nation’s economy.
Career counselling is ongoing face-to-face interaction performed by individuals who have
specialized training in the field to assist people in obtaining a clear understanding of themselves
(e.g., interests, skills, values, personality traits) and to obtain an equally clear picture of the
world of work so as to make choices that lead to satisfying work lives.
Career counsellors help clients within the context of a psychological relationship with issues
such as making career choices and adjustments, dealing with career transitions, overcoming
career barriers, and optimizing clients’ work lives across the life span. Career counsellors are
cognizant of the many contextual factors present in the lives of their clients and of the ways in
which social and emotional issues interplay with career issues. It was Frank Parsons who
developed a systematic way of helping individuals to find appropriate work that still has much
influence on the way in which career counselling is conducted today.
Parsons theorized that there were three broad decision-making factors:
a clear understanding of oneself, including one’s aptitudes, abilities, interests, and
limitations;
a knowledge of the requirements, advantages, disadvantages, and prospects of jobs;
ability to reason regarding the relation of these two sets of facts.
These three factors have had an enormous impact on how career counselling has been practiced.
There are several types of theories of vocational choice and development.
John L. Holland hypothesized six vocational personality/interest types and six work
environment types: realistic, investigative, artistic, social, enterprising, and conventional.
When a person's vocational interests match his or her work environment types, this is
considered congruence. Congruence has been found to predict satisfaction with one's
occupation and academic environment or college major.
The Theory of Work Adjustment (TWA), as developed by Dawis and Lofquist, hypothesizes
that the correspondence between a worker's needs and the reinforcer systems and the
correspondence between a worker's skills and a job's skill requirements predicts how long one
remains at a job. When there is a discrepancy between a worker's needs or skills and the job's
needs or skills, then change needs to occur either in the worker or the job environment.
Social Cognitive Career Theory (SCCT) has been proposed by Lent, Brown and Hackett.
Person variables in SCCT include self-efficacy beliefs, outcome expectations and personal
goals. The model also includes demographics, ability, values, and environment.
Career development theories propose vocational models that include changes throughout the
lifespan. Gottfredson proposed a cognitive career decision-making process that develops
through the lifespan. The initial stage of career development is hypothesized to be the
development of self-image in childhood, as the range of possible roles narrows using criteria
such as sex-type, social class, and prestige. During and after adolescence, people take abstract
concepts into consideration, such as interests. A career counsellor employs certain tests and
inventories to help clients get to know themselves, self-assess their personal resources, enable
them for decision and planning their own careers. They purport to understand aptitudes
(intellectual, verbal, numerical, reasoning, reaction speed, special talents, etc.), personality,
interests and special needs, values and attitudes, assessment of academic acquisitions (learning
skills and methods), interpersonal relations, self-image, decision making etc.
In other words, the assessment instruments can help clients with:
awareness of personal aptitudes, ability, skills or knowledge;
choosing education and training pathways in accordance with their projects and results
regarding their career in given life contexts;
identifying occupational alternatives complementary to their structure of interests,
aptitudes and dominant personality traits;
drawing up a positive and realistic self-image;
identifying the causes, the nature and the amplitude of barriers in their occupational
area;
preparing for decision-making and autonomous career planning development;
compensating the gap in information, incomplete or erroneous information and
diminishing the stereotypes regarding the world of work;
identifying possible sources of professional dissatisfaction, social misfit or difficulty in
carrying relationships and role performing.
CRISIS INTERVENTION
A "crisis" has been defined as an acute disruption of psychological homeostasis in which one's
usual coping mechanisms fail and there exists evidence of distress and functional impairment.
It is the subjective reaction to a stressful life experience that compromises the individual's
stability and ability to cope or function.
The main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but two other
conditions are also necessary:
(1) the individual's perception of the event as the cause of considerable upset and/or disruption;
and
(2) the individual's inability to resolve the disruption by previously used coping mechanisms.
Crisis also refers to "an upset in the steady state." It often has five components:
a hazardous or traumatic event
a vulnerable or unbalanced state
a precipitating factor
an active crisis state based on the person's perception, and
the resolution of the crisis.
The four stages of a crisis reaction, as described by Caplan (1964) include:
initial rise of tension from the emotionally hazardous crisis precipitating event,
increased disruption of daily living because the individual is stuck and cannot resolve
the crisis quickly,
tension rapidly increases as the individual fails to resolve the crisis through emergency
problem-solving methods, and
the person goes into a depression or mental collapse or may partially resolve the crisis
by using new coping methods.
Crisis intervention has now evolved into a specialty mental health field that stands on its own.
Based on a solid theoretical foundation and a practice that is born out of over 50 years of
empirical and experiential grounding, crisis intervention has become a multidimensional and
flexible intervention method. In conceptualizing the process of crisis intervention, Roberts
(2005) has identified seven critical stages through which clients typically pass on the road to
crisis stabilization, resolution, and mastery. These stages, listed below, are essential, sequential,
and sometimes overlapping in the process of crisis intervention:
1. Biopsychosocial and lethality/imminent danger assessment: At a minimum, this
quick but thorough assessment should cover the client's environmental supports and
stressors, medical needs and medications, current use of drugs and alcohol, and internal
and external coping methods and resources. Rather than grilling the client for
assessment information, the sensitive clinician or counsellor uses an artful interviewing
style that allows this information to emerge as the client's story unfolds. A good
assessment is likely to have occurred if the clinician has a good understanding of the
client's situation, and the client, in this process, feels as though he or she has been heard
and understood.
2. Establishing Rapport: Rapport is facilitated by the presence of counsellor-offered
conditions such as genuineness, respect, and acceptance of the client. This is also the
stage in which the traits, behaviours, or fundamental character strengths of the
counsellor come forward in order to instil trust and confidence in the client. Although
a host of such strengths have been identified, some of the most prominent include good
eye contact, non-judgmental attitude, creativity, flexibility, positive mental attitude,
reinforcing small gains, and resiliency.
3. Identifying the major problems, including crisis precipitants: Crisis intervention
focuses on the client's current problems, which are often the ones that precipitated the
crisis. This stage involves not only inquiring about the precipitating event but also
prioritizing problems in terms of which to work on first. In the course of understanding
how the event escalated into a crisis, the clinician gains an evolving conceptualization
of the client's "modal coping style"—one that will likely require modification if the
present crisis is to be resolved and future crises prevented.
4. Exploration of feelings and emotions: The counsellor strives to allow the client to
express feelings, to vent and heal, and to explain her or his story about the current crisis
situation through "active listening" skills like paraphrasing, reflecting feelings, and
probing. Very cautiously, the counsellor must eventually work challenging responses
into the crisis- counselling dialogue. Challenging responses, if appropriately applied,
help to loosen clients' maladaptive beliefs and to consider other behavioural options.
5. Generate and explore alternatives and new coping strategies: If Stage IV has been
achieved, the client in crisis has probably worked through enough feelings to re-
establish some emotional balance. Now, counsellor and client can begin to put options
on the table, like a no-suicide contract or brief hospitalization, for ensuring the client's
safety; or discuss alternatives for finding temporary housing; or consider the pros and
cons of various programs for treating chemical dependency. It is important to keep in
mind that these alternatives are better when they are generated collaboratively and when
the alternatives selected are "owned" by the client.
6. Restore functioning through implementation of an action plan: Obviously, the
concrete action plans taken at this stage (e.g., entering a 12-step treatment program,
joining a support group, seeking temporary residence in a women's shelter) are critical
for restoring the client's equilibrium and psychological balance. However, there is
another dimension that is essential to Stage VI, and that is the cognitive dimension.
Working through the meaning of the event is important for gaining mastery over the
situation and for being able to cope with similar situations in the future.
7. Plan follow-up and booster sessions: Crisis counsellors should plan for a follow-up
contact with the client after the initial intervention to ensure that the crisis is on its way
to being resolved and to evaluate the post crisis status of the client. Follow-up can also
include the scheduling of a "booster" session in about a month after the crisis
intervention has been terminated. Treatment gains and potential problems can be
discussed at the booster session.
SUICIDE
Even the definition of suicide presents difficulties. The “suicidal patient” may be one who
successfully commits suicide, unsuccessfully attempts suicide, threatens suicide, demonstrates
suicidal ideation, or behaves in generally self-destructive patterns. “The expression ‘suicidal
act’ is used . . . [by the World Health Organization] to denote the self-infliction of injury with
varying degrees of lethal intent and awareness of motive...
‘Suicide’ means a suicidal act with fatal outcome, ‘attempted suicide’ one with non-fatal
outcome.” Operationally, some possibility of self-inflicted fatal termination is most commonly
the distinguishing criterion of the term “suicidal.” Thus, most investigators define successful
or committed suicide as a violent self-inflicted destructive action resulting in death. Attempted
suicide is usually defined similarly, except that there is no fatal termination; but, as Stengel has
pointed out, the action must have a “self-destructive intention, however vague and ambiguous.
Sometimes this intention has to be inferred from the patient’s behavior.” The suicidal gesture
is similar except that persons performing such an action neither intend to end life nor expect to
die as a result of their action, although the action is performed in a manner that other persons
might interpret as suicidal in purpose. In suicidal threats, the intention is expressed, but no
relevant action is performed; in suicidal ideation, the person thinks or talks or writes about
suicide without expressing any definite intent or performing any relevant action. (The term
“parasuicide,” to designate attempted suicide and related actions, has recently come into vogue.
That term is, however, ambiguous and should be deleted.)
Studies have indicated that successful suicides are more common among older people, males,
and single, divorced, or widowed persons; reported unsuccessful suicidal attempts are more
likely to occur among younger people, females, and the married population. In the United
States during the past fifty years, about two-thirds of the persons who successfully committed
suicide used the two methods of shooting or hanging; most persons reported to have attempted
suicide unsuccessfully used ingestion of poison, cutting or slashing, or inhalation of gas—all
less efficient than shooting and hanging, which only rarely fail to cause death.
Although many people who communicate suicidal intention may not commit suicide, it is clear
from such studies and those of Shneidman and Farberow that most people who actually commit
suicide communicate their intention beforehand. Gardner et al. also noted that in the high-
frequency, successful suicide groups of older patients with depression, chronic alcoholism, or
paranoid schizophrenia, there is a tendency to deny illness and to communicate any suicidal
intention or need for help in an indirect, distorted manner. Shneidman and Farberow found a
critical period of about three months following a severe emotional crisis during which persons
are most likely to commit suicide. An increase in psychomotor activity, therefore, does not
necessarily indicate “improvement” in the long run.
Litman and Farberow have noted that the potential for successful suicide increases specifically
with age, prior suicidal behavior, loss of a loved person, clinically recognizable psychiatric
disorder, physical health problems, and lowered interpersonal, social, and financial resources.
They emphasize as warning signs withdrawal from and rejection of loved ones, suicide threats
(particularly those giving details of time and place), and overt expressions of suicidal intention,
plus such behavior as putting effects in order, making out a will, and writing notes and letters
with specific instructions. They suggested: “The most serious suicidal potential is associated
with feelings of helplessness and hopelessness, exhaustion and failure, and the feeling I just
want out.” Others have stressed that the feeling of “being a burden” to one’s family or friends
is also a special danger sign.
However, the intensive small-N investigation by Weiss et al. has indicated that the many social,
ecological, and personality factors that appear to relate to the seriousness of suicidal attempts
in large-scale nomothetic studies do not for the most part seem to be useful for prediction with
limited samples or individual patients. The only statistically significant indicators of the gravity
or danger of the suicidal attempt for individual attempters appeared to be
(a) attempts in which the psychological intent was “serious”;
(b) attempts of older adults;
(c) of those who attributed the act to concern about personal “mental illness”; and
(d) of those who were diagnosed as suffering from a clinical psychotic process of any nature,
but especially depression.
In a ten-year follow-up study of the same patients, Weiss and Scott found the risk of subsequent
successful suicide to be much higher among those who had earlier made such serious attempts
than among those who had made non-serious attempts, that persons who made any kind of
attempt tended to have continuing psychosocial problems after the attempt, and that the
lifestyle of suicide attempters generally showed little change when followed over that long
period and no change significantly different from that evidenced by matched controls. The
attempts of younger persons, of those whose method involved solely the ingestion of
barbiturates or other substances of limited toxicity, and of those who attributed the act to the
precipitating stress of “family trouble,” were generally not psychologically serious or
medically dangerous. The presence of a “death trend” (one or more close relatives of the
attempter being dead) and the presence of nonpsychotic clinical depression appeared to be
functions of increasing age rather than substantive indicators.
The WHO expert committee stated, “Persons with [endogenous and involutional] depressive
illness appear everywhere to constitute a high risk group. In suicide-prevention programs, high
priority should therefore be given to improvement in recognition and treatment of these
conditions and organizations of after-care for treated cases.” Rosen noted that insomnia prior
to the attempt is an additional sign of high risk. Sainsbury also emphasized that suicidal risk is
correlated with depression and with the primary medical symptom of insomnia, especially in
the elderly.
Although such information provides a guide to probabilities, the fact remains that every
emotionally disturbed person who indicates suicidal intent should be evaluated by a competent
psychiatrist. Any depressive reaction may carry with it some danger of suicide, and no suicidal
talk should be taken lightly. Almost all experienced clinicians indicate that, if there is any
suspicion at all of suicidal intent, the patient should be questioned about it. Such a procedure
will not give the patient any ideas of suicide that he does not already have, and his response
will often help to determine his intent. If his response is bizarre, illogical, or delusional, or if it
includes ideas of worthlessness or indicates a preoccupation with thoughts of suicide and with
actual concrete procedures for carrying out the act, one should consider the danger of a serious
or successful suicide attempt to be great.
Clinicians who deal with suicidal patients would, of course, find a valid and reliable screening
test predictive of both the possibility of suicidal attempt and the degree of lethality of such
attempt extremely useful. A considerable number of investigators have developed such suicide
risk assessment schedules, indices, rating scales, and even biochemical tests (exemplified in
Refs. Bolin, Buglass, Bunney, Cohen, Dean, Farberow, Litman, Pöldinger, Resnick, Sletten,
and Tuckman), but neither the specificity nor the sensitivity of such instruments has been
adequate for general acceptance. Rosen has pointed out the many limitations which make the
prediction of infrequent events such as suicide so difficult. Perhaps the most promising
technique to this end is being developed by Litman and his colleagues, who are using actuarial
methods to quantify the concept of suicidal risk as part of a mathematical model for predicting
suicidal behavior. This model will assign a suicide probability both to individual subjects and
to groups for any coming year, utilizing multiple factors input with an output providing an
index of present risk and a guide for predicting future self-destructive behavior. Litman wrote,
however, that “suicide probably is too complex and variable a problem to be handled by any
general or unitary scale or testing device,” that any such scale would need to be adapted to each
different setting and utilized only to supplement the clinical judgment of professional workers
with experience in that particular setting.
Many psychiatrists feel that, if suicidal intent is suspected, immediate hospitalization of the
patient on a psychiatric inpatient service is mandatory. Other well-trained psychiatrists take a
calculated risk with such patients and follow them as outpatients. Such a decision, however,
must be made on the basis of special knowledge—knowledge of the probabilities and
prognoses in similar cases, and knowledge of the particular patient, based on intensive
interviews, psychological tests, social histories, and similar data. It seems obvious that persons
who express suicidal intentions or make suicidal attempts are so emotionally disordered that
they are willing to consider risking their lives in a gamble with death, and it is the responsibility
of physicians and other professional workers who come in contact with such persons to assess
the meaning of each suicidal communication or attempt, with respect to how best to respond to
the implied need for help.
Treatment
Just as the suicidal act must be considered in terms of the psychological, clinical, and
sociological aspects of the person involved, so must be his treatment. The therapy of the
suicidal patient can be successful only if all these factors are investigated and the pertinent ones
so modified that the self-destructive tendency— arising out of an acute emotional crisis, as well
as a life-long accumulation of experience, a set of social circumstances, and most often a
clinically recognizable psychiatric disorder—is reduced to non-deleterious proportions. Social
measures and somatic therapies may be necessary in some cases and helpful in others, but
psychotherapy directed toward understanding the need for a suicidal act appears to be a sine
qua non in almost any rational treatment program for suicidal patients. Farberow and
Shneidman and their collaborators, in discussing the varieties of therapy useful in treating such
patients, have noted that successful treatment may vary with the kind of patient, the nature of
the suicidal attempt, the psychodynamic and psychosocial factors involved, the nature and
degree of associated psychiatric disorder, and to some extent the theoretical framework within
which the therapist operates.
Kessel has stressed that there is considerable advantage in making a thorough psychiatric
assessment of all suicidal cases admitted to emergency medical services as soon as possible, at
least within a few hours of admission. At that time, inquiries are made into the situation while
its impact is still very strong and before the family and patient attempt to cover up the
underlying factors. And at that time, such patients can be screened and their further care
discussed with the family and other persons most closely concerned. Frederick and Resnik have
developed a well-reasoned therapeutic approach based on evidence that many aspects of
suicidal behaviors may be learned and that treatment techniques founded in general learning
theory can be useful, and Frederick and Farberow have also found that group psychotherapy
can be very useful with suicidal persons, although some modifications of standard group
methods are probably requisite. In dealing with suicidal behaviors in children, one should
remember that the first goal is seldom prevention of death or injury (since completed suicides
in young children are rare) but rather—according to Glaser—assessment of the behavior as a
sign of emotional disturbance. The presence of depression is not necessarily a prerequisite for
suicidal acts in childhood, and persons other than the psychiatrist are most likely to be in a
position first to deal with the problem. Whether one is treating children or adults, however, the
clinician should note that almost all authors emphasize the importance of a therapist who
manifests sensitivity, warmth, interest, concern, and consistency.
In the hospital environment, success in treating suicidal patients is more likely with a
therapeutic milieu having easy lines of communication than with the previously utilized
strictures of rigid “suicide precautions.” As Stengel and Cook pointed out, the suicide rates of
the resident population of mental hospitals in England and Wales for the years 1920 to 1947
were about three to five times those among the general population, remaining steadily at about
50 per 100,000 patients per year. Those were the years when psychiatrists took away from their
patients shoelaces, belts, safety razors, and any other articles that might conceivably be used
for self-destruction. And yet, the rates remained consistently high within the closed doors of
the mental hospitals of those days. The introduction of electroshock treatment in the late 1930s
and 1940s had little or no direct influence on the frequency of successful suicidal acts per se in
mental hospitals (although other studies clearly have indicated the clinical value of such
therapy, especially in psychotically depressed older persons). In the 1945-1947 period, when
EST was in widespread use, the suicide rates in mental hospitals in England actually increased
slightly to 51.5. Surprisingly, in 1953 these in-hospital suicide rates dropped to 27.3, and have
remained comparatively lower ever since. A significant decrease in suicide rates therefore
occurred in a period when the English mental hospitals were adopting more liberal policies,
including “open-door” and “therapeutic community,” before the widespread use of the newer
psychoactive drugs, and in spite of an increased admission rate during that period for patients
with psychotic depression, as well as higher average ages of resident patients who therefore
might be expected to be more suicide-prone.
