Barriers to positive outcomes in treating patients at risk of suicide in Aotearoa/New Zealand: perspectives from ‘positively inclined’ clinicians

ABSTRACT

In light of Government endeavours to transform New Zealand’s (NZ) mental health system and services, this short communication reports on secondary qualitative data on barriers to positive outcomes in treatment of patients at risk for suicide (PRS) from the unique multi-disciplinary perspective of 12 positively inclined clinicians. According to grounded theory, interview data were collected and analysed iteratively until we reached data saturation. We present these data in two categories, distal barriers, that is those emanating from the context of practice, and proximal barriers, that is those emanating from clinicians themselves. Overall, the 12 clinicians interviewed converged in describing experiencing the NZ mental health system as interfering rather than supporting their clinical endeavours with PRS, and NZ clinical training as partially failing to prepare them for clinical suicidology. Despite limitations due to the secondary nature of these data, this short communication provides insights into the subjective experience of positively inclined clinicians, a unique professional group, in relation to a health challenge of national importance, and invites consideration that positively inclined clinicians might represent a valuable source of information in relation to improving suicidal patients’ care in NZ.

KEYWORDS:

• Clinical suicidology
• suicide
• NZ public mental health system
• barriers to positive outcomes
• qualitative research

Introduction

New Zealand’s (NZ) persistently high suicide rate was one of the catalysts for He Ara Oranga, the Government Inquiry into Mental Health and Addiction (Paterson et al. 2018). Released subsequently, NZ’s current Suicide Prevention Strategy promotes facilitating access to the mental health system, including interventions that respond effectively to suicidal behaviours, to assist with reducing the incidence of suicide in NZ (Ministry of Health 2019). The assumption that trained clinicians are willing and able to help patients at risk for suicide (PRS) underlies this strategy.

However, evidence shows that suicidality in patients, particularly the way PRS relate in clinical contacts, tend to elicit negative emotional responses in clinicians (Ellis et al. 2018), often associated with a reluctance to treat them (Levi-Belz et al. 2020). Given that establishing a strong therapeutic relationship is considered essential to assessing suicide risk and treating suicidal behaviours (Barzilay et al. 2019), clinical guidelines recommend that clinicians learn to manage their emotional responses when working with PRS (APA 2003).

Another view, emanating from prominent experts in the field contends that treating PRS requires an exceptionally active and warm stance that goes beyond an ability to manage adverse emotional responses (Shneidman 1981; Linehan 1997; Maltsberger 2001). Yet, despite corollary evidence that clinicians’ positive feelings of affiliation and respect are associated with better treatment outcomes in psychotherapy in general (Machado et al. 2014), clinicians’ positive inclination is rarely studied in the context of clinical suicidology.

To address this gap, our research used a sequential mixed methods design to examine clinicians’ positive inclination to PRS. Firstly, we assessed the prevalence of positive inclination to PRS by asking a group of psychiatrists, psychologists and psychotherapists to rate the statement ‘overall, you would say that you like working with suicidal patients’, on a five-point Likert scale. This single item assessment suggested that positive inclination was uncommon, representing 14.7% of a sample of 267 clinicians currently treating PRS (Soulié et al. 2018). The subgroup of positively inclined clinicians thus delineated, endorsed significantly higher levels of positive emotional responses and lower levels of negative emotional responses to PRS than other clinicians in the sample did (Soulié 2019).

In a follow up investigation, we used grounded theory to understand the subjective meaning of positive inclination for clinicians (n = 12), and the impact of this on the therapeutic encounter. We developed a middle-ground explanatory theory, which identified a deep connection reflecting a state of emotional synchrony between clinicians and patients as the core process facilitating therapeutic change in treatment. This state of emotional synchrony provided an intersubjective emotion regulation associated with symptom reduction in patients and deep satisfaction in clinicians, reinforcing their positive inclination towards PRS (Soulié et al. 2020).

Additional secondary qualitative data emerged pertaining to systemic and personal factors preventing positive outcomes in treatment of PRS. In the context of Government’s current policy goals of improving mental health systems and reducing NZ’s suicide rate, this short communication reports on these secondary data, with a view to providing insights into the subjective experience of barriers to positive outcomes in treatment of PRS from the unique perspective of positively inclined clinicians. That is clinicians who find working with suicidal patients to be otherwise deeply satisfying and meaningful.

Material and method

The University of Otago Human Ethics Committee approved the study.

Participants

We interviewed 12 clinicians (10 women), from nine locations in NZ (Table 1). All clinicians treated both acute and chronic cases of suicidality, with four of the six clinicians working in private practice having worked previously in public settings.

Table 1. Sample characteristics (n = 12).

Characteristics	Participants (n = 12)
Profession
Psychiatrist	2
Psychologist	5
Psychotherapist	5
Method of recruitment
National survey	9
Snowball sampling	3
Location
NZ north island	6
NZ south island	6
Gender
Female	10
Male	2
Ethnicity
Māori/NZ European	2
NZ European	8
African European	1
Other European	1
Work setting
Public	5
Private	6
Both	1
Primary theoretical orientation
Insight based	4
Learning based	3
Eclectic	5
Experience in years
< 5	1
> 11	11
Average hours with patients per week
5–10	1
11–15	8
> 15	3
Patient(s) who died by suicide
None	4
Between 1 and 3	6
> 3	2

Procedure

We used an online survey in a previous study (Soulié et al. 2018) as well as snowball sampling to recruit psychiatrists, psychologists and psychotherapists who feel positively inclined towards treating PRS. For the purpose of the study, we defined a ‘suicidal patient’ as ‘a person who shows or has shown suicidal behaviours (including suicidal ideation); or who has attempted suicide before AND who seems [to the clinician] to be at risk of suicide’ (Soulié et al. 2018). We deemed clinicians to be ‘positively inclined’ when they endorsed the statement that overall they ‘like’ working with suicidal patients (see introduction section).

Data collection and analysis

All participants provided written consent for the study.

We collected data in 90 min in-depth interviews using a conversational style of interviewing to encourage free association of ideas, which allowed secondary data to emerge. In line with grounded theory (Bryant and Charmaz 2019), we collected and analysed data iteratively according to the constant comparative method until we reached data saturation after 12 interviews. The initial coding progressed line by line to ensure that codes emerged from the data. We turned the most significant set of codes into the categories that we used to move onto focus coding, on new and existing data. In the latest stages of the analysis, categories had evolved into the concepts that informed a middle-ground explanatory theory on positive inclination to PRS (Soulié et al. 2020). In this model, data on barriers to positive outcomes appeared to be ‘secondary’ in the sense that they did not answer our research question per se, about clinicians’ subjective experience of liking working with PRS. Rather, they emerged indirectly when participants reflected on the development of their skills, or when they attempted to interpret why less than 15% of 267 clinicians endorsed ‘liking’ working with PRS in the previous study (Soulié et al. 2018). All interviews were audio-recorded, transcribed, anonymised, and imported in NVivo 11 software for qualitative analysis. Data on barriers to positive outcomes emerged from analysing the 12 narratives using the constant comparative method, and are embedded into the ‘possible outcomes’ subcategory in the original model (Soulié et al. 2020).

Results

We identified two types of barriers to positive outcomes in treatment of PRS: distal barriers (i.e. those emanating from the context of practice), and proximal barriers (i.e. those emanating from clinicians themselves). We illustrated these data with selected excerpts from participants, to whom we refer using pseudonyms generated randomly online.

Distal barriers

We distinguished three distal barriers: issues in system’s goals, lack of resourcing, and issues in getting emergency services involved.

First, positively inclined clinicians argued that the NZ public mental health system has the wrong goals. That is, the system was viewed as aiming to stop people killing themselves rather than help them build a life worth living; with only the latter being amenable to treatment.

Nolan [Clinical psychologist]: I would say the pressure is how do we make sure we keep off the front page of the paper, we keep off the coroner asking hard questions, we … [Pause] it’s a very cynical way of saying we stop people dying rather than, how do we actually help people’s mental health.

This barrier was associated with a systemic aversion to risk, which positively inclined clinicians found counter-therapeutic, viewing the focus on suicide risk as tending to make patients feel misheard, and potentially reinforcing their suicidality.

Natalia [Clinical psychologist]: [looking back on when she started practising] If I tried to immediately jump in and look at how can we keep you alive […] that didn’t tend to go very well, and […] kind of tended to exacerbated the suicidality for some people.

An aversion to risk can also obstruct clinical strategies that would be in patients’ best interest. For instance Hassie, a psychiatrist, explained that at times she trusted her clinical judgement that, despite the associated risk, discharging patients represented their best chance for recovery, in that they needed to experience life outside of the hospital to build a life worth living. Yet, in her experience, services are sometimes reluctant to discharge PRS, which she viewed as potentially counter-therapeutic.

Second, positively inclined clinicians did not always feel appropriately resourced to treat PRS. In the public setting where he worked for 20 years, Landon, a psychotherapist, had to comply with a six-session framework, despite evidence that addressing suicidality often requires more extensive work. Others expressed the fear that their resources could be threatened in the near future, despite benefiting from adequate ones at the time. For instance Bernice, a clinical psychologist, found her service management team to be ‘business savvy but perhaps not mental health savvy’. She argued that while Dialectical Behavior Therapy (DBT) includes a high level of resourcing that might not seem ‘cost effective’, the ‘treatment gains and the progress that the young people are making tell a different story’.

Third, positively inclined clinicians experienced difficulty in getting emergency services involved. In NZ, Crisis Resolution Services (‘crisis teams’), offer 24 h psychiatric assistance throughout the country. In principle, clinicians are expected to refer PRS to the crisis team when they see fit. Yet, in positively inclined clinicians’ experiences, crisis teams were not always responsive or helpful. Oceane, a clinical psychologist who worked in the public system previously, found that practicing outside of this system made getting the crisis team involved particularly difficult.

Oceane [Clinical psychologist]: The part that is really difficult is getting the mental health service to do their job, and to be available or to admit the person to the system when you need them to. [Pause] but the actual suicidal person is fine. It’s working with the system that’s the hard part.

Proximal barriers

We distinguished two types of proximal barriers: a lack of emotional literacy, and weaknesses in training and mentorship of clinicians.

First, positively inclined clinicians identified a lack of emotional literacy as the most common pitfall in treatment of PRS. In order to be present in the room and focused on their patients’ needs, clinicians described needing to manage their own latent emotions towards death and suicide, as well as their emotional responses to PRS’ behaviours. Only by achieving emotional literacy for themselves did clinicians feel able to navigate the emotional complexity of the clinical encounter, and build the therapeutic relationship with potentially non-collaborative patients in high-risk situations.

Adelia [Psychotherapist]: […] if people don’t have a sense that they’re open to their own difficulties and their own lives, then I don’t think they’d be open to the difficulties on, clients, patients’ sides.

Clinicians’ contended that empathy also needed to be extended to PRS’ relatives. Especially when working with youth, a lack of collaboration from patients’ relatives was viewed as potentially undermining treatment. Renee, a psychotherapist, explained that, although necessary, getting to a place of feeling warm towards the client’s family was sometimes very challenging.

Renee [Psychotherapist]: I have to get something really different going in myself, and get to understand them, and feel warm and get to love them as well so that I can take the whole family in, and work with them as a family even if I am seeing the child.

Second, positively inclined clinicians pointed at weaknesses in training of clinicians in relation to treating PRS, which they remembered from their own training as well as observed in their supervisees. Specifically, trainees lacked emotional literacy training, which could be developed through encouraging personal therapy as a pre-requisite to treating PRS.

Linnett [Clinical psychologist]: […] So, having been on the other side of the therapeutic alliance has incredible value […] And quite frankly I think that’s crucial for anybody doing therapy. I think they need to do their own work as well. And that needs to be ongoing. So I’m very much committed to that as well. My own ongoing personal work.

In addition, Linnett argued that trainees would benefit from a level of mentoring that matches the level of emotional involvement required in treatment of PRS, which may go maybe beyond standard supervision practice.

Discussion

This short communication reports on barriers to positive outcomes in treatment of PRS identified consistently within the unique perspective of positively inclined clinicians; that is clinicians who find working with PRS profoundly satisfying and meaningful. Although non-positively inclined clinicians can also make invaluable contributions, we argue that positively inclined clinicians provide an unexplored important perspective in that they remain deeply satisfied with this work, despite both the systemic and personal challenges, so it is unlikely that their views reflect burnout or other disaffection that may compromise objectivity in this area. With respect to distal barriers to positive outcomes in treatment of PRS, positively inclined clinicians identified a discrepancy existing between PRS’ clinical needs and NZ mental health system’s goals, poor resourcing, and issues in getting emergency services involved. Proximal barriers included insufficient emotional literacy levels for working with PRS, and the contribution to this from clinical training programmes.

The main finding to emerge from these secondary data is that positively inclined clinicians experienced the mental health system as the ‘hard part’ in their work with PRS. By aiming at the wrong goals and failing to support clinicians, the very system supposed to help PRS could be in fact inherently suicidogenic. In this sense, these data provide insights into clinicians’ subjective experience of treating PRS that illustrate some of the pitfalls identified by He Ara Oranga, the Government Inquiry into Mental Health and Addiction (Paterson et al. 2018). Moreover, in line with the literature, positively inclined clinicians contended that emotional literacy was essential to building the therapeutic relationship in the context of PRS’ way of relating (APA 2003). The exceptional emotional skills found in positively inclined clinicians (Soulié et al. 2020) could be studied further and applied to developing training programmes for the assessment and treatment of PRS.

There are limitations inherent in drawing results from a sample of only 12 clinicians. Yet, clinicians’ exceptional positive motivation to work with PRS is likely associated with an increased ability to achieve positive treatment outcomes (Soulié et al. 2020), rendering them an important source of information about mechanisms of effectiveness in treatment of PRS. Further caution is warranted in extrapolating these findings given the secondary nature of these data. To extend these findings, future work could examine barriers to positive outcomes systematically, either by collecting additional qualitative data from a bigger sample of positively inclined clinicians, or by testing hypotheses derived from these preliminary findings.

Despite the variety of locations, work settings, patients’ types, and treatment modalities, the 12 positively inclined clinicians in our sample converged in describing NZ mental health system as interfering rather than supporting clinical endeavours, and clinical training as partially failing to prepare mental health professionals for clinical suicidology. These secondary qualitative data provided preliminary practice-based evidence from which to draw to further our understanding of PRS’ needs, and improve the care they receive in NZ.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was supported by the Suicide and Mental Health Research Group, University of Otago Wellington, Wellington, New Zealand [Doctoral fellowship], and the Center for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices (CRISE), Department of Psychology, University of Quebec at Montreal, Montreal, Canada [postdoctoral fellowship].