Sunday, February 5, 2012

The assumption of change in therapy

There continues to be much coverage of suicide in the press where I live in relation to the well known woman who recently suicided. The focus has now moved onto why and what can be done so that such a thing does not happen again. There is talk about diagnoses, what drugs could be used, other treatments and so forth.

From what has been said about her it seems it could have been a case of chronic suicidality. As I say in my book there are three common suicidal timelines.
Acute suicidal crisis. The suicidal urges appear quickly and usually in reaction to an event such as marital breakdown or incarceration. Suicide watch is very useful here as the urges can disappear after a not too long a period of time.

Slow suicidal crisis. The suicidal urges develop over time but tend to be cyclical over months. They come and they go due to treatments or spontaneous remission.

Chronic suicidal crisis. The suicidal urges appear and stay. They do not remit or come and go. Treatments have little or no effect. Suicide watch is of little use here. The woman under discussion seems to be of this kind.

Pacifier cigar

There is an underlying assumption in all the current discussion about her in the press - that a solution exists to her suicidality. I am now going to say something that one rarely sees in the literature in the counselling industry. I may be labeled a heretic for doing so.

Sometimes clients don’t get better.

This is rarely said, let alone accepted. Psychological theories are so constructed such that there is always hope and always an explanation of why change is not currently occurring and what can be done such that it should. However some clients do not get better or they obtain only minimal positive result to treatment. This is probably a small group of clients but they certainly exist.

These people will report they have spent often years in different treatments including drug treatment, behavioural therapy, insight therapies, spiritual approaches and they have not gotten any better. I am reminded of one woman who suffers from chronic insomnia which she has had for years and no treatment has ever made it any better.

Man in seaweed
Some clients will try all kinds of different treatments to ease their angst

This is bad enough which leads to the horrible effects of sleep deprivation but sometimes people have suicidal urges which do not get any better no matter what treatment is used. Hence one has the chronic suicidal crisis.

Underlying all the discussion about the woman mentioned before is the assumption that something can be done. Sometimes people just don’t get better and hence the assumption in this case may be wrong. Of course we all like to believe there is hope and a solution but is that to make us feel better or the suicidal person feel better. How long does one persist with treatment that has so far had no positive effect?

It can be very hard to accept that sometimes clients just don’t get better.



  1. Hi Tony!

    Was feeling little down as feb 9 is my Dad's death anniversary. So thought of visiting you!

    Great blog as usual.


  2. Hi Shruti, sorry I did nt get back to you earlier but my computer has had some problems which are now fixed. Also sorry to hear you are down and thanks for your visit. Good to hear from you again