When Suicide Comes Up: Regulating Therapist Reactivity in High-Stakes Sessions with IFS, Ep. 264

um where I'm I lead a IFS internal family systems service and I've been involved in um a fair amount of um small but kind of growing studies at Cambridge Health Alliance, uh using you know doing groups um and individual sessions uh using IFS for folks with Trump. And in that setting I certainly interact with a lot of people that have um suicidal parts or parts that sort of want to give up. So it's an important it's an important What else? Anything else I'm missing in terms of my

Um, I have been my first training, which I'll maybe wave in a little bit, was acceptance and commitment therapy. I mean, I was trained in many different models, but that was my first modality. But I've been working with I IFS internal family systems for about eight years now. as my primary modality. And so today as we talk about this topic, which I'm also really also know can be a heavy topic, but want to bring some hope.

into this as well. Um, hope that we as clinicians have a lot of skills and that we can really bring those skills to even very, very difficult situations. Um, so really my goal for today, I'm gonna quote Houston uh from nineteen ninety, whatever seems most likely to send you away more aware, more informed, skilled, and encouraged.

than you were when you came in. So that's our goal for today. So we'll weave we're gonna weave in some research that um has shows some of the reality of what can happen sometimes in the room with therapists when our clients are suicidal and also weave in the real strengths that we have as clients. So today we are going to be talking about, again, therapist reactions to client suicidality. We're not going to be talking about what to do with the client very much.

Um, we might leave that in a little bit. And we're also not going to be talking then about suicidal suicidality interventions for the client. or what h what therapists can do if their client does commit suicide. Hannah is there any any any sense anything you want to flow in with around that?

And I've been really, really grateful to be working with her. I for forgot to mention I'm also a research fellow now at Cambridge Health Alliance's Center for Mindfulness and Compassion, which is where Hannah works. So I'm really grateful to be involved with some internal family systems research.

So I Han and I just our natural way of thinking about things now is through the internal family systems lens. So I'm going to talk a little bit about what this means. So for listeners who are familiar with mindfulness-based ex interventions for clients, including acceptance of commitment therapy and DBT, you'll be already be familiar with some of these concepts. So in fine in mindfulness based therapies, we help clients to be able to notice in the moment.

when they're having an internal experience like distress or joy, but also to notice, importantly, that they can notice that experience. In the mindfulness-based therapies, that's often called the notice yourself. And really key to this is that these other experiences that any of us might have, our distress, our joy, is not the totality of who we are.

There's also that self that can notice any of our experiences. So for example, our distress is not our entire our entire internal experience. It's just a part of our experience. We also have a core self, as we call it in IFS, our notice or self that has capacities such as perspective, compassion, calm, and curiosity. So in IFS we call those internal experiences that are we know are just a part of us parts. We call them parts of ourselves.

And we notice that we may have many internal experiences see that seem to be contradictory. Like wanting to stay up later to watch that next episode of that show that we really like. But knowing that we're gonna be really tired, we do that. And so knowing maybe that's not the best idea. So we have both of those experiences at the same time and we might be able to even notice both of those.

And that idea is time tested, that we have different parts of ourselves. So as we go through this episode, you'll probably hear Hannah and I flowing between talking about client and our internal experiences, things like distress. and also therapist internal experiences like distress or anxiety or whatever and will flow between talking about that as like for example distress or talking about parts of the therapist or parts of the client.

I also want to just mention that as we talk, if we weave in some ideas, some experiences from clients or from consultees that we may have,'cause I think Hanna and I also both provide consultation to therapists around the internal family systems model. The idea identity of um anyone that we talk about has been changed. So none of the names are the same, none of the identities. All right, Hanna, anything else you wanna flow in with?

Um and then this wise mind, right? This observing is other is another um model of that I think is really uh helpful. So

That's right. Thank you. So I think the next thing I'm going to talk a little bit about is just w you know, us as clinicians, us as therapists, and what is the likelihood that we're going to have a client express suicidality?

So I wanna just acknowledge that oh probably most of us have had this happen and that this topic again is something that can bring up some concern for clients, for therapists. So I just wanna really acknowledge that this is very common that sixty three percent of female clinicians reported having clients with non fatal suicidal behavior. So this is, you know, so not even talking about like they have attempted, but having, you know, some ideation, some intent. Really, really common.

And that it's also something that can really bring up concern in therapists. So, you know, one of those landmark studies back in nineteen ninety-three, Top Pope and Tobocnik surveyed three hundred therapists and found that ninety-seven percent listed significant fear of client suicide. So it's you know, if we experience some distress like we'll be talking about when our clients express that they have some suicidal ideation or intent going on, of course we do. It's really common.

So also, um predicting and preventing suicide death remains pretty limited. Fox and all studied this in twenty twenty. And we also know that the experience of suicide for clients can change really rapidly. So Coppersmith et al. in 2023 studied this. and found that elevated suicidal ideation or desire could change to suicidal intent within hours or even just minutes, usually when they're not in the therapy room with us.

So that time between desire and intent represents a potential window for intervention to reduce risk. And in response, researchers have been trying to find risk factors for it changing to that intent. that are uh modifiable, something we can do something about to protect clients against suicidal death. So as therapists, we can't be there in the room with them when that's happening the vast majority of the time.

We as therapists bring to our own selves in how we're able to choose really consciously what we do when we're with the So that's what we're going to be talking about today. Yeah.

IFS model that there'd be some part that would need an out or an exit. And so I guess I just want to say that unfortunately I think because of some of our like reaction in the field, it's almost like we hear less of it. Um probably than is out there. So I just wanna just highlight, I think that's important. Um and so anytime, you know, when we lead these IFS groups or I'm sitting with someone, anytime someone mentions suicide, that's like one of the first things I say is, oh wow.

So glad you named that. You know, because sometimes and often it's just an important reality that we have inside of

that leads to healing, actually. The heal leads to something positive. So I'm not assuming that I it's it sort of reminds me of like the if you're work if you work with couples and I And a couple is like, are we just done? And if you can say, hmm, are we just done? That there could be some then new beginning. Yeah. Does that make sense?

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And bars allay at all in twenty twenty two kind of uh found, you know, kinda narrowed that in a little bit. The therapists can in can both experience increased distress and then also decreased emotion regulation, their own. when clients express suicidality and that these emotional reactions can be things like fear, anger, hopelessness, and a sense of failure. Um so these intense experiences inside the therapist, which again I just want to normalize.

You know, I think that in our training programs we're not necessarily given a way to talk openly about what it can do for us if a client does it. if a client says that they have suicidality. So they've found then, they've looked at do does the therapistic internal experience the therapist parts that come up when a client expresses suicidality? Does that affect the therapist's decisions about behavioral treatment for the client? And they found that in indeed it does.

that therapist treatment choices change when they're more dysregulated about their client's suicidality. So Barsley again in twenty twenty one found that when therapists were distressed and dysregulated around their own, you know, inside themselves They increased the recommended treatment intensity for the client. regardless of the client's level of suicidality. So it wasn't tracking what what what was actually going on for the client, but instead was in response to their own distress.

And Nap, Gottlieb, and Handelsman in twenty twenty four also found that when therapists are distressed, they can choose not to work with suicidal clients at all. So I want to just mention that in Clearly Clinical episode two forty nine with me, I kind of walked through a lot about why therapists might do some harmful behaviors. Um, and just bring a lot of care to the fact that this is really normal for us as therapists to have distress come up and that it might affect our own behavior.

I don't want to ever have to go through that. So to say that it's a really hard thing as a therapist to feel a sense of I mean there's a lot that goes into that, but uh like one other little m thing that I remember as a trainee at Cambridge Health Alliance is every year there was a a a some sort of suicide. on our team. And um and those conversations after the suicide actually were some of the most meaningful experiences.

as a trainee because of how everyone really held um the the trainee or the ex whoever was having that you know, who had that experience. But really what we were doing in those moments were coming to terms with our how much we don't how much we can't control. You know, some of them live really scary lives and It's a h it's just a really important thing, I think, to ign one acknowledge what we can't control and and um and it's har and it's hard.

And I I definitely had parts that were like started to ask some of this the risk assessment questions and and the c and my, you know, client had said something like, I'm not gonna get myself sexual. Um, and I had to, you know, that wasn't, you know, just I had to sit with a whole lot of this is not fun. I don't know what's gonna happen and and in the end they were help they were do saying the things that allowed me to feel like I didn't need to do anything.

Um and then the next day they didn't show up somewhere that I thought they were gonna show up to. So I thought, uh oh. Turns out they're okay, but anyway, it's scary.

there in a way that isn't helpful. So Um Michad et al in twenty twenty three did a study and found that react sui you know therapist reactivity, unhelpful reactivity to client suicidality can actually res result in increased suicidal behaviors. Um and Barzolay found that that it's probably really due to this disruption of therapeutic alliance, right? If we're bringing our own distress, we're interrupting that connection with with the client.

And she found that the therapeutic alliance or a reduction in it was the reason why the clinicians negative emotional responses resulted in increased suicidal ideation in their clients a month later. that it it mediated it we call. It was it was what was going on. So as therapists we know all about like I think clearly clinical people know about that therapeutic alliance and that's the good news is that that's really what we can keep tuning into.

Um, the other really interesting point of that is that the therapist view of the alliance actually wasn't what was related to the client suicidal ideation a month later. It was the client's view of the therapeutic alliance. So I want to give another shout out to another clearly clinical episode, 260, with Dr. Jordan Harris.

on the need for feedback informed treatment so that we as therapists can be learning about our clients' view of what's happening in the therapy room to not assume that we know what's going on.

Um really great. So Hugget et al. in 2022 found that helpful clinician behaviors are protective of client suicidal attempts. So what we do matters. It's really like when we can learn what to do that's helpful in ourselves, it's really helpful. And um this is a just another thing. Counselor increases an oxytocin in session.

But sometimes these other experiences that can come in and blend so that that core self isn't as available in session. And that's probably what's what's harmful to clients. So Hannah, what do you notice either in yourself or with people you've done consultation with that can

supposed to follow some kind of rule am I a and am I breaking the rules? Yeah. Um, or am I going to break the rules? It's this kind of yeah. So those are some of the

in professional psychology research and practice. The American Su Association of Suicidality has good information about suicide risk factors assessment and intervention. Um, and then also Deborah Pinalls, um, who is a professor of psychiatry, law and ethics at the University of Michigan, has a twenty nineteen article on risk management called Liability and Patient Suicide.

So we're not going to be talking about the viability piece itself, but instead what happens within us. And Hannah I know that you have some things that you bring. as a therapist in that moment or even earlier around risk management. And I wonder if some of that also helps you stay centered when a client has suicide.

Because I care about my license and my, you know, it's important myself, you know, I it's important, it's protective. And so um so when I meet with someone, especially if it's someone who has chronic suicidality, I'll say and be very clear about that, that Look, I realize that you are you have your own autonomy, that I am not, I cannot stop you if you were to decide to do something. That is the truth. You can um and if you tell me these things

I have no choice but to intervene in some way because I need to protect myself. It's about um one, I care. I mean I don't I don't only say it that way, but I I do care about the person, but but I'm not interested in um taking over their autonomy.

You know, I don't think that goes so well. Um, but I will say, yeah, this is what this is a signal to me. If you share this with me, uh this is when I'm gonna act. And these are the ways in which Um and and if you can engage at all with some kind of way of helping you be safe, even a little bit, I'm not gonna Right. So um you could even say I yeah, that's another thing I think that's really important is like there's a lot of things you can share with.

So it's not like don't share a suicidality at all. I want you to tell me, you know, are you having thoughts? Even if you're having thoughts with plans, feel free to share it with me. Um, but when you start to say, I'm going to do this on this date or um, you know, then I I really can't, you know, then I need to do so I don't that's a long winded way of saying it, but um but yeah. So I'm I'm clear I'm just clear with um with whoever I'm with around that and it means that when it happened

But, you know, this conversation on suicidality is a much more rich thing. It's it's throughout sessions with uh you know, with clients. And I know I would have even then uh especially earlier in my career a desire to not talk about it, not not go there. So that's one of those things that I think would happen inside me. Um, I know sometimes there can also be that sense of, um, I care about the client.

It's my responsibility to stop them. I'm bad if I don't stop them. Like I have I have to do everything I can to stop them. And um that is something that's a very, very large responsibility kind. And Hannah, you've spoken about this really wisely before.

You know, what are we gonna do? And then you know, it's so I I think that there's something when people I mean, this we haven't really said this yet, when people share these things, they're there's a part looking for help. I mean, this is one of the reasons why it doesn't feel hard To not section, because as long as

someone is help seeking, future oriented, you know, you're c you're okay. Right? It it's even though it can shift. I wanna go back to what you said before about how someone can shift really fast. um from, you know, thinking about it to doing it. Um but still I have to believe that if there If they're with you talking to you, they're getting hopefully um that's giving'em a sense of of I can go to someone with this stuff. You know, I can there's some help available.

then I'm also able to again, those multitudes within us acknowledge that for the client. Just like you're saying, Hannah, we can acknowledge that to the client. So I'm I'm notic I'm hearing that both of you have this impulse, this part of you that wants

that is bringing this idea of killing yourself. And you're also here in the room with me. And you're also telling me. So I'm I'm sensing there's a part of you that doesn't want to do that. And that allows an opening of the conversation. Right. Right. And yeah.

sort of had a recent, you know, sort of like I wonder if we could if we could bring a little relief. Like is there is there a need for some relief and and see if we could help you get that right now and um and there was this big worry like oh god if I let if I let you give me relief then I won't then I won't kill myself and that would be that's a huge I need to have that as a tool. And so we were like, okay, you can have that as a tool as a possibility. Could it be not now?

They are like fully inside their, you know, from an act perspective they're fused with that sense of wanting to kill themselves. They don't have a perspective on the a you know, the parts of themselves that don't want to. So in if we can increase their ability to notice that, then in that moment when they're not with us, they may be able to draw a net. And in fact I've had clients tell me, uh, I really

had suicidal intent starting to creep in and I even thought about reaching for the XYZ and I said, Well, okay, so in that moment, why didn't you? And they'll say, Well, I guess I'm able now to recognize that that's actually happened I can notice it, like I can see that that's what was happening. So I think as therapists, that ability in us to bring our own warmth, our own curiosity, the holding space so they can notice their own experience can be really protective.

Love that. There's also s just something about like when there's a crisis inside. um and I started to talk about this I think sort of before. There's like a whole other possibility that crisis is i is often uh when things are willing to change you know, when we're willing to change. And so it

So I g it's just you know, going back to this idea of hope that when someone's suicidal, you know, this is something that Martha, I think, had said, uh Martha Sweezy in our our p podcast that we do together. Um

So I want to just take a moment here to talk a little bit about IFS. So IFS is at its heart a method to create internal attachment bonds between our own compassionate notice her self and any other of our experience. IFS has an emerging evidence base with small randomized clinical trials, quasi-experimental single-arm studies, and pilot studies. It does have peer reviewed published studies including client concerns such as depression, PTSD, rheumatoid arthritis, substance use, other addiction.

And it's been found in the study that Kana's a clinical lead for her that does that it has high participant satisfaction and strong attendance. So uh Delara Alley and all in twenty twenty five on a paper including HANA found that after three months of therapy, participants rated the IFS intervention of ninety two percent of them willingness to refer a friend.

Like that's a really high rating of liking that therapy model. And also retaining seventy percent of participants after thirty m three months of therapy. And that's in a c it's not your like sterile research like they haven't excluded everyone, right? This is in the people who are in the trenches with the hard stuff. So that's actually quite a good retention rate of IFP.

There's a feeling like like oh wow, I can bring this here, you know, that this is okay here. We're not Um, we're not gonna you know,'cause well, there are a lot of really models good models that know how to do this too. Um, more often many of us are trained to get pre scared and to respond in more of a controlled way. And the whole group could have easily looked and went, oh God, something bad happened. Oh God, you know, someone's gonna, you know, whatever.

And especially along race lines and along socioeconomic li you know, around, you know, the these these people that are gonna come and you know, this like take your autonomy or

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therapists can do when we how first of all, how we notice our own experience in session. You know, we hear a client say, Yeah, I'm thinking about killing myself. So both we need to be attending to what the client's saying, we but we also need to notice what's going on inside ourselves. So I do talk about this in my other um two uh episodes on on Clearly Clinical, but Hannah, I wanna hear how you do this. How do you notice in the moment your own experience?

Um, I might even, as someone's talking, like get my voice in there just to stop the talking for a moment and then pause and then talk again. So I'm so I'm uh just I'm literally scrolling. slowing everything down. And and when I honestly also when I um lower my voice, I'm feeling more calm myself. Like it it there it does something to my nervous system. Um I and I have fillers. I have literal like things I'll say like, um, oh wow, this is really important, let's slow this down.

In a way I'm telling the th the client that and I'm telling my own nervous system that like whatever comes up here right now, we're gonna s we're gonna we're gonna kinda work through this together.

And in IFS trainings, so IFS level one training through the IFS Institute and its partner, Cambridge Health Alliance, Center for Mindfulness and Compassion, one of those things that we do is we have practice sessions of practicing IFS. And we s um in those triads, those practice sessions, the the IFS trained person who's there, the program assistant, stops the person who is in the therapist role every so often and says, What are you noticing right now about yourself?

And so it's literally learning a new habit. And so I had that post-it note on my screen to remind me to stop and look inside, to take a moment. And I still do that. I've in my eight years of doing I NFS with clients now, it's b had become much more of a habit. But I still regularly, especially when something really big is happening, I will say to the client, I'm gonna take just a moment. and just get clear about what I'm sensing here.

And I will go inside and just check and make sure, see what's coming up inside You know, and and I will notice sometimes one of my big tells for that it's not my open hearted curiosity is I feel an agenda coming in and I feel a sense of urgency. Which I think would make so much sense when a client tells us they're suicidal. And I know that sense of urgency, if I'm talking out of that, I'm gonna talk fast. I'm not gonna be attuned to the client and that's gonna impact our relationship.

So I think I hear when Han and what you're saying too is that slowing down really allows the addition.

they're sort of getting to see what's happening. That's they're much less li I mean, that's the anti um, you know, quick movement towards suicide, right? That's the it's like helping people notice apart, you're much less likely to have an impulsive one step in and move towards acting fast if they can learn to So I also think like doing this practicing or being with part

Or being with whatever it is that comes up for for people around suicide outside of sessions is important. And so just like coming like I I have just come to terms. And it's a hard thing to come to terms with, but I've come to terms with the fact that my clients could do this. And I and I don't want them to, but they could. They might. And so

I lose the repa the relationship and um, you know, but then maybe there's a chance I save this person's life. I mean probably not. And based on where things were left, it didn't make sense. In the long run, it was not the right choice. So I didn't do it. I didn't do a wellness check in this case.

So I want to just talk a little bit now about a couple cool research things around therapists learning about their own experience. because uh these are there's ideas of what we can do in session, but it as therapists it's actually really important for us to learn about our own systems, our own emotions, our own thoughts, and to do that outside of session too. So uh Assan et al. in 2022 did a study of a meditation intervention for healthcare providers.

And they found that that intervention resulted in improved um the healthcare providers had an improved ability to manage their personal vulnerability. So kind of kinda like what you're describing. It's a vulnerable place as therapist.

to really sit vulnerable. To sit compassion and to not like just go ba this is what we're gonna do now we're gonna section you um and that their own knowing their own experiences better resulted in pro managing of their personal vulnerability, including their own feelings of inadequacy, the the healthcare providers being better at setting clearer boundaries. and practicing self care and more acceptance of situations others in themselves.

So healthcare providers, therapists learning about our own you know, having mindful narrow awareness of our own experiences results in our own improved behaviors. And possibly even I well some other research bars shown improved ability to be for clients to be safe. So another really neat thing, if we look at it from an IFS perspective, I brought in how IFS training actually helps to establish this habit of checking with our own internal experience.

So clinical training as therapists in IFS. And Carl Moda and colleagues in 2014 did a qualitative study of seven counselors who took a three-credit master's program course on IFS. And they what these therapists reported was that um as a result of this IFS training, they had a improved ability to identify their own internal processes in session. including personal agendas for the clients, which are not necessarily based on the client's needs, but in you know, their own.

um giving they were had a better ability themselves to have tools to manage their own internal processes and to bring those two tools to the client. and to help the therapists identify for themselves when their own internal experiences were hindering therapy. And what they report, this is not from the the client's perspective, but what the therapist reports seeing in their clients.

is that they h that there was an enhanced therapeutic relationship with their own clients, that the clients had increased awareness of their own internal experiences And the clients had an increased ability to model self awareness and that you know, the c they were able to model as well, the therapist could model that self awareness for their clients. So it was just

you know, I just encourage anyone listening to look into whatever way makes most sense to you. Han I and I both found IFS training to be effective for this. There's my evidence that mindfulness based training can also bring some of these skills in as a way to know our own experiences and make a conscious choice, that values based decision in the moment about what we're going to do with our Han, is there anything that rises for you?

the more space I've gotten from those parts that get scared. You know, first what came was acknowledging to the client I can't I'm limited in my control. Just sort of letting them know I get that that they have And and then but then what comes with that after is and I care about You know, just that that's another and I don't know, would I say that to everybody? I don't know if I w what I would say to everyone, but there's there's like a I don't know, there's an ability then to be human.

Right? That like um with people in this in those moments. Like when you can accept in a way that you're not actually in sh in control. that you could be present and then you can also be human and that that's I think that is is probably a more powerful intervention. In a moment when someone's questioning whether they want to live.

to keep connecting with our clients and to make those treatment decisions that are based on the clients needs and not based on our own distress. And um I just really, really appreciate that wisdom that you bring, Hannah. Um So so I guess in this in you know, to wrap it up here, Hannah, let's is there anything else you wanted to add or should we start with how people can bind us?

through the Center for Mindfulness and Compassion, which you can find at www.chacacmc.org slash connect. Lots of great things there. And Also, um I have a Spotify IFS Vibes.

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