Psychotherapy Articles

Psychotherapy Articles

The Role of Humility in Treating Suicidal Patients

Seasoned psychotherapists have all had the experience of sitting in a room with patients who have serious thoughts of killing themselves. Some may have already had a suicide attempt or multiple attempts and continue to have access to the means to kill themselves. They may feel like others would be better off if they were dead, feel a sense of entrapment, or a belief that their emotional pain is unbearable and will never end.

Compassionate and trained healthcare professionals will immediately desire to alleviate their patient’s pain. Well-trained psychotherapists will give their patients a chance to tell their stories and try to establish meaningful connections with them. Part of the treatment may be to give their patients hope that their emotional pain will end by conveying a sense of confidence in their ability to help.

Fortunately, outcome studies have identified several treatments with proven effectiveness in reducing suicide attempts (such as cognitive-behavior therapy, the collaborative assessment and management of suicide, and dialectical behavior therapy), and other interventions show promising evidence for their effectiveness as well (Calati et al., 2016). Collaboratively developed safety plans (Nuij et al., 2020) can reduce suicide attempts, and lethal means counseling can increase the safe storage of firearms (Anestis et al., 2021). Also, evidence suggests that medications can reduce suicide attempts in patients with bipolar disorders (although their effectiveness in reducing suicide attempts with other disorders is less certain; Maris, 2019).

Despite these advances, some patients will attempt suicide, and a few will die from suicide even while in treatment. Leitzel and Knapp (2020) found that 29% of psychologists had a patient attempt suicide while in treatment in the last year, and 6% had a patient die from suicide while in treatment in the previous year. One can assume that some of these deaths occurred while patients were being treated by highly competent psychotherapists using state-of-the-art interventions delivered with compassion and skill.

Suicide is a mighty foe. Psychologists and treatment providers should never underestimate its power and should be cautious about our ability to prevent suicides. Despite the advances made in the study of suicide, there is much that we do not know about suicide, except that it could follow many different pathways and involve the complex interaction of many circumstantial, genetic, and psychological factors.

Even if we did know how to prevent suicides, we cannot always identify who has suicidal thoughts or how severe those thoughts may be. Psychotherapists rely primarily on what patients tell them about their lives, but patients often withhold information or minimize the extent of their suicidal thoughts (Knapp, 2022). Family members or close friends may provide important information. Still, they are often unaware of their loved one’s innermost thoughts or can only report information through their perspectives, which have limitations. Psychometric screening instruments, such as the Columbia Suicide Rating Scale or the Ask Suicide Screening Questions (AsQ), have a role in assessing suicidal patients. However, all have high rates of false positives or false negatives and can only supplement, not replace, the psychotherapists’ judgment (Runeson et al., 2017).

All effective interventions with suicidal patients have some limitations as well. Although they can significantly reduce the risk of a suicide attempt, they cannot prevent all attempts. For example, cognitive behavior therapy shows it is one of the most effective and well-researched treatments for preventing suicides. Nonetheless, some patients receiving cognitive behavior suicide from competent providers will still attempt suicide (Rudd et al., 2015).

Furthermore, every psychotherapist has limitations, and no one can be equally proficient in all areas of practice. For example, Kraus et al. (2011) evaluated the performances of psychotherapists across 12 domains of problems and concluded that effectiveness as a psychotherapist was not a global construct. Instead, a psychotherapist could be proficient in one practice area but lack proficiency in another. Those who were effective in treating anxious patients, for example, might not be equally effective in treating suicidal patients.

Even psychotherapists who are proficient in treating suicidal patients need to ensure that their skills do not degrade over time. The knowledge base for psychology is constantly changing. Neimeyer et al. (2014) estimated that it takes about nine years for half of the knowledge base of a psychologist to become obsolete. However, the length of time could become shorter in the future and could vary according to specialty. Probably nowhere is this truer than in the study of suicide, where research has expanded rapidly in recent years.

Finally, all psychotherapists are susceptible to thinking errors or may have implicit biases outside their immediate awareness that could limit their effectiveness. They may engage in confirmation bias, sunk-cost bias, the availability heuristic, or other cognitive shortcuts that could lead to inaccurate interpretations of information. They may, despite good intentions, show implicit biases against persons of different ethnic, linguistic, or cultural backgrounds or those who do not conform to their preferred notions of sexual or gendered behavior.

Effective Psychotherapists Show Humility

An acceptance of the limitations of our ability to prevent suicides does not mean that we should just throw up our hands in despair. Paradoxically, psychotherapists can enhance their effectiveness by recognizing their limitations and adopting an attitude of humility.

Davis et al. (2017) defined humility as “having an accurate view of oneself, particularly of one’s limitations” (p. 243), and DuBois et al. (2013) added that humility involves “self-knowledge and an openness to the perspectives of others” (p. 925). It seems likely that seeing oneself and one’s capabilities accurately, knowing one’s limitations, and being open to other perspectives should help psychotherapists deliver a higher quality of service.

Humility is implicit in the title of an article by Nissen-Lie et al. (2015): “Love yourself as a person, doubt yourself as a therapist” (p. 48). The title implies that psychotherapists should engage in a non-judgmental evaluation of their skills, recognizing that they may have limitations and motivating them to seek feedback or the perspectives of others to improve their performance.

Galef (2021) described the importance of humility by using the metaphor of scouts and soldiers. Scouts question the accuracy of their information and continually strive to make their “maps” more accurate. Soldiers, on the other hand, adopt strategies to reach their goals and conscientiously pursue them. Scouting psychotherapists will solicit new information, question the information that they have, and change their interpretations as new evidence arises. Soldiering psychotherapists prioritize adherence to a treatment plan, even at the risk of minimizing or ignoring disconfirming evidence. No effective psychotherapist always has a complete scout or soldier mindset, and effective psychotherapists probably have a mixture of both. But problems can occur if psychotherapists fail to incorporate the scout mindset into their decision-making. Scouting psychotherapists will acknowledge their limitations, continually solicit patient information, and keep their optimism grounded in reality.

Acknowledge Limitations

Patients also benefit when psychotherapists ask questions or solicit information about them, including their cultural background and how it may influence their life circumstances. Part of working effectively with cultural minorities is to adopt an attitude of cultural humility, wherein, among other things, psychotherapists welcome their role as a learner.

Effective psychotherapists welcome feedback from patients and others as a way to continually self-monitor and improve. Getting routine, standardized feedback from patients appears to improve outcomes (McAleavey et al., 2019), and psychotherapists may even benefit by routinely asking patients about their experiences in sessions, such as whether they got to talk about things that were important to them (Sparks & Duncan, 2019).

Accept the Patients as Experts

Effective psychotherapists consider patients to be the co-creators of the psychotherapeutic experience. Often, psychotherapists will use a narrative approach to assessment, giving patients the time to tell their stories at a comfortable pace (Bryan & Rudd, 2018). These psychotherapists seldom interrupt their patients and prioritize open-ended questions during the process. The underlying belief is that the patient is “the expert in his or her own experience” (Michel, 2011, p. 6). Patients often feel great relief when their psychotherapists stop trying to be the expert on everything and allow them to tell their own stories in their own words. Patient contributions are also seen as essential to effective treatments. Jobes (2023) tells his patients that the answers to their problems are within them. They and their psychotherapists will collaborate as partners in treatment to help them identify solutions and create lives worth living.

Recognize Our Skills and Ability to Help

Humility means an accurate understanding of oneself; it does not mean debasing one’s skills unnecessarily. Well-trained psychotherapists using evidence-informed treatments should have confidence that they can save lives and improve patient well-being. Therefore, psychotherapists can give hope to their suicidal patients by accurately reviewing the outcome data on how these treatments may help them. As Jobes wrote, “while we can never guarantee a nonfatal outcome, we can nevertheless provide the best possible clinical care to every patient, including those with suicidal thoughts (2023, p. 60, italics in original). This brief quotation has substantial implications for psychotherapists. It accepts the limits of our power: we cannot prevent a suicide attempt; only our patients can do that. Yet it promises that we have much to offer our patients by delivering high-quality services resulting from years of study, supervised practice, and a mindful concern for our patients.

Summary

The ever-present risk of a patient’s suicide forces psychotherapists to accept their role with humility, recognizing that even the most effective and conscientious psychotherapists cannot guarantee that they can save the lives of every patient. Nonetheless, effective psychotherapists can turn the recognition of their limitations into helpful strategies by

  • Continually seeking feedback from patients on their progress and their experiences in psychotherapy and
  • Recognizing patients as the experts on their own experiences while nonetheless
  • Valuing their contributions in providing high-quality and evidence-supported interventions and

Knowing that they can help many suicidal patients create lives worth living.

Cite This Article

Knapp, S. (2023, December). The role of humility in treating suicidal patients. Psychotherapy Bulletin, Volume (59)1, 5-9. 

References

Anestis, M. D., Bryan, C. J., Capron, D. W., & Bryan, A. O. (2021). Lethal means counseling, distribution of cable locks, and safe firearm storage practices among the Mississippi National Guard: A factorial randomized controlled trial, 2018-2020. American Journal of Public Health, 111(2), 309-317. http://doi.org:10.2105/AJPH.2020.306019

Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive therapy for suicide prevention. Guilford.

Calati, R., & Courtet, P. (2016). Is psychotherapy effective for reducing suicide attempt and non-suicidal injury rates? Meta-analyses and meta-regression of literature data. Journal of  Psychiatric Research, 79, 8-20. http://doi.org/1016/j.jpsychires.2016.04.003

Davis, D. E., Hook, J. N., McAnnally-Linz, R., Choe, E., & Placeres, V. (2017). Humility, religion, and spirituality: A review of the literature. Psychology of Religion and Spirituality, 9(3), 242-253. http://doi.org/10.1037/rel0000111

DuBois, J. M., Kraus, E. M., Mikulec, A. A., Cruz-Flores, S., & Bakanas, E. (2013). A humble task: Restoring virtue in an age of conflicted interests. Academic Medicine, 88(7), 924-928. http://doi.org/10.1097/ACM.0b013e318294fd5b

Galef, J. (2021). The scout mindset. Penguin.

Jobes, D. A. (2023). The collaborative assessment and management of suicide (3rd ed). Guilford.

Knapp, S. (2022). Six strategies to help suicidal patients disclose their thoughts. Practice Innovations, 7(4), 293-302. http://doi.org/10.1037/pri0000174

Kraus, D. R., Castonguay, L., Boswell, J. F., Nordberg, S. S., & Hayes, J. A. (2011). Therapist effectiveness: Implications for accountability and patient care. Psychotherapy Research, 21(3), 267-276. http://doi.org/10.1080/10503307.2011.563249

Leitzel, J., & Knapp, S. (2020). Results of the 2020 survey of members of the Pennsylvania Psychological Association. Unpublished data.

Maris, R. W. (2019). Suicidology: A comprehensive biopsychosocial perspective. Guilford.

McAleavey, A. A., Xiao, H., Bernecker, S. L., Brunet, H., Morrison, N. R., Stein, M., Youn, S. J., Castonguay, L. G., Constantino, M. J., & Beutler, L. (2019). An updated list of principles of change that work. In L. Castonguay, M. L. Constantino, & L. E. Beutler (Eds.). Principles of change: How psychotherapists implement research in practice (pp. 13-37). Oxford University Press.

Michel, K. (2011). General aspects of therapeutic alliance. In K. Michel & D. A. Jobes (Ed.). Building a therapeutic alliance with the suicidal patient (pp. 13-28). American Psychological Association.

Neimeyer, G. J., Taylor, J. M., Rozensky, R. H., & Cox, D. (2014). The diminishing durability of knowledge in professional psychology: A second look at specialization. Professional Psychology: Research and Practice, 45(2), 92–98. http://doi.org/10.1037/a0036176

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1 Comment

  1. Matthew Horrocks

    Thank you Samuel for this article, wiser words regarding working with suicidal thoughts, behavior and risks would be very hard to find

    Reply

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