While the construct of countertransference has been established in psychodynamic theory since its inception, it has received relatively little attention from cognitive-behavioral theorists. However, it is generally agreed that therapists’ reactions to patients powerfully influence treatment, for better or worse. Suicidal patients in particular are likely to evoke negative reactions in therapists. In this paper, we briefly review the theoretical literature on countertransference, with particular attention to suicidal patients, from standpoints of psychodynamic and cognitive-behavioral theory and research. We argue that the cognitive-behavioral perspective, together with the RAIN model proposed by mindfulness authors (Recognition, Acceptance, Investigation, and Non-Identification), opens avenues to assess, distance from, and perhaps modify cognitions that could lead to counter-therapeutic emotions and behaviors in working with suicidal patients. We conclude that, while work with suicidal patients can be challenging, cognitive-behavioral therapists can potentially improve effectiveness and enhance their own well-being by managing their reactions in a manner consistent with their theoretical orientation.
“I’m glad you accept referrals of suicidal patients. I quit seeing them after I got sued.”
“Let’s be honest – if someone is really intent on killing himself, there’s nothing you can do to stop him.”
“It wasn’t serious – just a manipulative gesture.”
These overhead comments, all by intelligent, well-meaning clinicians, reflect the varied, often strong, emotional reactions evoked by suicidal patients. Anxiety (accompanied by avoidant behavior), hopelessness, anger, disdain, and other emotions are perhaps inevitable in this high-stakes context. The combination of work with desperate individuals suffering from multiple, complicated disorders and life circumstances, together with life-and-death implications rarely faced in the practice of psychotherapy, set the stage for significant stress in treatment providers.
Surveys of mental health clinicians consistently place working with suicidal people at the top of lists of work stressors (e.g., Deutsch 1984); indeed, patient suicide has been recognized as an “occupational hazard” for therapists (Chemtob et al. 1989). An assortment of “what-ifs” face the clinician, including feared scenarios, not only of losing a patient to suicide, but also the wrath of surviving family members, lawsuits, reactions of colleagues, and feelings of guilt and inadequacy. Such apprehensions are not unwarranted; studies of clinicians who have lost a patient to suicide sometimes exhibit stress reactions similar to survivors of a loved one’s death (e.g., Kleespies et al. 1993).
Patient suicidality is common in psychotherapeutic practice (Brems and Johnson 2009). Schmitz et al. (2012) review several studies indicating that a majority of social workers, psychologists, psychiatrists, and trainees, in both inpatient and outpatient settings, report experience working with patients with some form of suicidal ideation or behavior, with exact figures ranging from 50 to 95%, depending on the time frame and the nature of suicidality assessed (Feldman and Freedenthal 2006; Kleespies et al. 1993; Ruskin et al. 2004; Jacobsen et al. 2004). Suicidal ideation and behavior is also observed among college and graduate student populations (Drum et al. 2009) and those seeking primary care services (Ahmedani et al. 2014); so mental health professionals working in these settings are also likely to encounter patients dealing with the issue of suicide. Making matters worse, clinicians are well aware that their power to control outcomes is limited (e.g., Bongar and Sullivan 2013). Indeed, a significant portion of mental health professionals lose a patient to suicide at some point in their careers, with several studies indicating that this tragic outcome is more commonly reported by psychiatrists and psychiatry residents (approximately 50%), compared to psychologists, social workers, and counselors (20–30%) (Ruskin et al. 2004; Chemtob et al. 1988; Jacobsen et al. 2004).
A combination of responsibility without control is, of course, a recipe for stress and stress-related emotions, including reactions commonly labeled “countertransference.” Although much has been written from a psychodynamic standpoint about emotional reactions to patients, relatively little has been presented from a cognitive-behavioral perspective, and even less about reactions to suicidal patients. Considering the negative impact that therapist emotions can have on the course of therapy (Briggs and Munley 2008; Hayes et al. 2011; Guy et al. 1989; Raab et al. 2015), as well as contributions of patient-related stress to emotional and health problems for clinicians (Raab et al. 2015), this is an important gap in the literature.
Our purpose in this paper is to acknowledge the emotional costs of working with suicidal patients and make the case for conceptualizing such reactions from a cognitive-behavioral perspective as an alternative to a traditional psychodynamic framework. We will then describe common cognitive contributors to such reactions, followed by suggested strategies for managing them from a mindfulness/acceptance standpoint. We will close with a brief statement on the importance of a broad self-care orientation for cognitive-behavior therapists working with suicidal patients.
Conventional Views of Countertransference
Although countertransference has long been viewed as a key aspect of psychodynamic psychotherapy, a good deal of ambiguity about the concept remains (Holmes 2014). Freud (1910/1988) defined countertransference as the analyst’s unconscious reactions to the patient’s transference. In this context, it was viewed solely as a negative influence on the therapeutic process, with analysts’ unconscious reactions stemming in large part from their own unresolved conflicts. Psychotherapy for the therapist was viewed as a necessary means of ensuring that unresolved issues not interfere with the patient’s treatment (Freud 1912/1989; Singer et al. 1989).
This early view of countertransference as essentially “the therapist’s problem” and an impediment to therapy has since evolved in complexity and nuance. Heimann (1950), for example, described countertransference as a broader phenomenon that “cover(s) all the feelings which the analyst experiences towards his patient (p. 81).” She further argued that, so viewed, countertransference can actually be used to facilitate the therapeutic process; she noted, “the analyst's emotional response to his patient within the analytic situation represents one of the most important tools for his or her work. The analyst's countertransference is an instrument of research into the patient's unconscious (p. 81).” Indeed, it is widely believed that attention to the therapist’s feelings in response to the patient can promote a deeper understanding of the patient’s personality, unconscious conflicts, interpersonal relationships, and even diagnosis.
Consistent with Heimann’s view, Winnicott (1949) proposed that countertransference has both “objective” and “subjective” components; that is, separate from the therapists’ own unconscious processes, patient behaviors also naturally evoke emotional responses from the therapist. Indeed, recent research has shown that clinicians tend to have consistent and similar responses to different personality disorders and patient symptoms (Betan et al. 2005, 2005; Betan and Westen 2009; Tanzilli et al. 2015; Lingiardi et al. 2015; Brody and Farber 1996; Rossberg et al. 2010), suggesting that objective countertransference may shed some light on patient diagnosis. Support also exists for a relationship between self- and supervisor-rated countertransference and patient outcome among therapist trainees (Gelso et al. 2002), as well as the idea that symptom improvement is positively correlated with positive countertransference and negatively correlated with negative countertransference (Rossberg et al. 2010).
Countertransference and Suicidal Patients
Notwithstanding the variability of countertransference theory, it is generally recognized that suicidal patients often evoke strong feelings in therapists. In a now classic paper, Maltsberger and Buie (1974) asserted that therapists often feel extreme anger, mixed with a desire to abandon suicidal patients, a constellation of reactions that they named “countertransference hate.” They proposed that this reaction results from projection of the patient’s own self-hatred onto the therapist; this is thought to reduce the patient’s anxiety and deeply rooted fears of both abandonment and closeness. They noted that all people, but especially therapists, find feelings of hate distressing and thus often use defense mechanisms unconsciously to alleviate the discomfort. Examples of defensive maneuvers thought to occur in the context of countertransference hate include (1) repression (difficulty paying attention or feeling bored or tired with the patient), (2) turning against the self (feelings of inadequacy and helplessness), (3) reaction formation (excessive efforts to rescue or cure the patient), (4) projection (preoccupation with or dreading the patient’s suicide even in the absence of suicidal risk factors), and (5) denial/distortion (devaluing the patient such that feelings of indifference, pity, or anger toward the patient feel warranted). Maltsberger and Buie (1974) noted that when therapists are not fully aware of their negative thoughts and feelings they may be unable to refrain from acting upon them. In such situations, they may prematurely refer suicidal patients to other professionals or inappropriately take responsibility for them, thereby confirming their patients’ greatest fears of rejection or engulfment and perhaps increasing suicide risk in the process.
A substantial body of research with therapists, as well as retrospective case studies, now supports Maltsberger and Buie’s assertion that many therapists manifest negative, hostile, and intrusive reactions to suicidal patients. These studies indicate that therapists often experience anxiety, hostility, and helplessness, as well as concern and protectiveness toward suicidal patients (Gurrister and Kane 1978; Modestin 1987; Richards 2000; Yaseen et al. 2013). In a qualitative study, Richards (2000) examined open-ended survey and interview responses of therapists who had worked with patients who expressed suicidal ideation or had died by suicide. Her results revealed a wide range of reactions; while some therapists expressed strong negative feelings such as hopelessness or a sense of failure, others expressed a desire to intrusively nurture their suicidal patients. Regardless of the nature of the reaction, most therapists noted the importance of recognizing emotions before acting on them, which they reported most often took the form of shifting boundaries of the therapeutic relationship, behavior they felt had been damaging to therapy. Other researchers have found that therapists working with suicidal individuals often hold mixed feelings toward them, including simultaneous feelings of distress and concern. In an anonymous Internet survey of clinicians, Yaseen et al. (2013) found that therapists of suicidal patients were more likely retrospectively to report having felt a “paradoxical combination of hopefulness and distress/avoidance” (p. 7) in response to patient suicide attempt or death. In fact, they found that this combination of reactions was a significant discriminator between therapist reactions to suicidal patients and patients who died of unexpected non-suicidal deaths, with 90% sensitivity and 56% specificity. These results, while retrospective, are consistent with Maltsberger and Buie’s (1974) assertion that a unique constellation of reactions is associated with working with suicidal patients, and that it is important to manage such reactions appropriately.
Regarding the construct of countertransference, extant literature reveals that, even within traditional psychodynamic contexts, different theorists emphasize different aspects of the therapist’s experience. Thus, the term may refer to (1) therapist reactions specifically to the patient’s countertransference vs. therapist reactions to patient behavior in general, (2) negative therapist reactions to patient behavior vs. both positive and negative reactions, and (3) objective (expectable) reactions to patient behavior vs. subjective reactions that reflect the therapist’s issues). In this context, we are choosing to retain the term countertransference, as opposed to a more generic term such as “therapist reactions to patient behaviors” for the sake of economy and familiarity. Although we sometimes use the term in the broadest sense, as it applies to both objective and subjective reactions to patient behavior in general, our main focus here is more narrowly on negative reactions, specifically to suicidal patients, reactions likely to have an adverse impact on both therapists and the therapeutic process. (See Prasko et al. 2010 for an analysis of positive countertransference within cognitive-behavioral therapy.)
Cognitive-Behavior Therapy and Countertransference
CBT has devoted considerably less attention to countertransference compared to psychodynamic therapies. This is likely a reflection of differences in views of mechanisms of change, with CBT viewing changes in cognitions and behaviors as central. While countertransference may not be a primary focus in CBT relative to psychodynamic approaches (Ivey 2013), this is not to say that CBT views that therapeutic relationship as unimportant. Emphasis on a sound therapeutic relationship can be traced back to early work in CBT, such as the chapter devoted to the topic in Beck et al.’s classic Cognitive Therapy of Depression (Beck et al. 1979). More recent theorists, noting that CBT had acquired an undeserved reputation as mechanical and impersonal, have stressed the importance of approaching therapy in a person-focused manner (e.g., Leahy 2008).
Indeed, one of the most basic tenets of cognitive-behavioral therapy is collaboration: The therapist works collaboratively with the patient to assess the patient’s needs, provide interventions and homework activities, monitor progress, and adjust treatment strategies as treatment progresses. A strong alliance is clearly needed for this work to succeed. CBT theorists have noted that countertransference reactions are likely to impact the quality of the therapeutic alliance (Cartwright 2011); further, empirical evidence supports a correlation between therapeutic alliance and positive change in cognitive-behavioral as well as other schools of psychotherapy (Martin et al. 2000; note, however, DeRubeis et al. 2005 for comments on the direction of causality).
Recent research further suggests that therapists’ emotional reactions are not only related to the strength of the therapeutic relationship, but also impact patient engagement in therapy. Westra et al. (2012) found that therapists’ positive emotional reactions early in cognitive-behavioral treatment were linked to less patient resistance, regardless of therapist competence. In contrast, the relationship between negative therapist emotions and patient resistance was mediated by therapist competence, suggesting that negative therapist reactions likely interfere with the skillful delivery of treatment. Thus, attention to countertransference seems important to consider, regardless of one’s therapeutic orientation (Hayes et al. 2011).
It should be noted that some have expressed concerns regarding the continued use of the traditional countertransference model in the context of CBT. Rudd and Joiner (1997) and Kimerling et al. (2000) observe that some countertransference assumptions contradict the basic tenets of CBT, including those regarding the model of psychopathology and purported mechanisms of change. The psychodynamic model also is thought to place greater emphasis on potentially unknowable, unconscious processes, in both the patient and therapist, in contrast to the CBT model (Rudd and Joiner 1997).
In response, some researchers have proposed alternate views of therapists’ reactions to their patients, based on the cognitive-behavioral framework. Unlike the conventional view that countertransference is a result of therapists’ unresolved unconscious conflicts, CBT views such reactions as products of the individual’s meaning-making and information processing (Singer et al. 1989). From this perspective, therapists’ emotional reactions can be understood as derived largely from underlying schemas and core beliefs.
Schemas organize large amounts of information into manageable categories to help one to anticipate and manage situations; they are influenced by unique factors such as particular childhood experiences and shared factors such as culture, gender, and professional training. Leahy (2008) notes that many therapists have schemas and core beliefs with demanding standards that lead to assumptions like “I have to cure all my patients” and “I must always meet the highest standards.” Leahy (2008) has further described several cognitive distortions that occur in the context of therapy, such as personalization (“The patient isn’t getting better because I’m not a good therapist”) and mind-reading (“The patient thinks I am incompetent.”). A slippery slope from such cognitions to strong emotional reactions to suicidal patients is obvious.
As an alternative to the conventional psychodynamic model of countertransference, Moorey (2014) has proposed the notion of “interpersonal schema,” containing information about the self, the other, and the relationship between them that readily applies to countertransference in CBT. Moorey (2014) further suggests the use of the Interpersonal Schema Worksheet to help therapists prepare for, and work through, countertransference issues with patients. Rudd and Joiner (1997), similarly proposed a comprehensive cognitive-behavioral model, conceptualized in terms of a Therapeutic Belief System (TBS); this model maintains that therapists’ beliefs regarding themselves, their patients, and the treatment can lead to such problem emotions as sadness, fear, and hopelessness.
Like Moorey (2014) and Rudd and Joiner (1997), we see distinct advantages to approaching reactions to patients from a cognitive-behavioral perspective. First and most obvious, the CBT model offers consistency with the theoretical assumptions of the CBT therapist’s approach to treatment, specifically, one of cognitive mediation rather than unconscious conflicts and motivations. This brings intuitive appeal and familiarity to the understanding of emotional reactions to patients. Equally important, the CBT perspective makes clear the fact that therapist reactions are the “fault” of neither the patient nor the therapist, but rather results of an interaction between patient behaviors and therapist attributions. Moreover, this less pathologizing approach predictably leads to less shame, stigma, and resistance to exploring, and making needed adjustments, compared to a view of such reactions being products of unresolved unconscious conflicts. Less stigma is likely to reduce reluctance to exploring thoughts and feelings with colleagues and/or supervisors; indeed, employing a vernacular consistent with CBT is likely to facilitate such collegial conversations (Cartwright 2011). Finally, articulating automatic thoughts and other cognitive processes leads naturally to a vast array of possible strategies for “defusing” from (see below) or modifying problem attitudes and beliefs. Such strategies often can be applied through self-help modalities; however, as discussed below, pursuing psychotherapy to address them remains a viable option as well. In any event, the CBT framework provides an invaluable tool to help therapists explore the sources of their emotional reactions to patients in a manner consistent with CBT, leading to better understanding of both patient and self, and potentially to enhanced treatment outcomes.
Cognitive-Behavioral Therapy and Reactions to Suicidal Patients
CBT conceptions of countertransference are easily extended to understanding emotional reactions to suicidal patients; they are consistent with many of the themes discussed by Maltsberger and Buie (1974), but redefined in cognitive-behavioral terms, making therapist reactions more readily recognized and potentially modified. Rudd and Joiner (1997) have applied their theory of the therapeutic belief system to therapists working with suicidal patients. The model begins by identifying therapists’ core beliefs about themselves, their patients, and the treatment in general. These core beliefs can include healthy conceptualizations of self, patient, and treatment that revolve around themes of collaboration. They also suggest two sets of problematic core beliefs that are likely to emerge when working with suicidal patients and center around themes of hostility and helplessness: (1) “The patient is hostile, I am a victim, the treatment is hopeless” or (2) “The patient is a victim, I am a savior, treatment is the only solution.” These kinds of core beliefs can lead to automatic thoughts such as “I’ll get hurt if I work with this patient” or “Without me he/she won’t make it.” Such automatic thoughts may lead to anger, depression, fear, and behaviors that are potentially harmful to treatment, such as premature termination or overly zealous interventions or caretaking.
Complementing Rudd and Joiner’s TBS is the work of Cureton and Clemens (2015), who integrate the psychodynamic concept of affective constellations with cognitive-behavioral constructs. They opine that people express surface emotions that are tolerated by significant others, and disallow others that are considered unacceptable. These interrelated feelings are linked through underlying schemas. The authors describe two pathways of connected emotions common among therapists after a patient’s attempted suicide or suicide threat: (1) anger-sadness-shame and (2) sadness-anger-guilt. Therapists who attend to only surface level emotions regarding suicidal patients may unwittingly ignore other interrelated emotions. For example, those who only acknowledge feelings of sadness in response to a suicidal patient may be missing their angry feelings and the associated guilt. The authors note, “[N]ot attending to such strong emotions is harmful to the counselor and patient and can stand in the way of a life-saving collaborative alliance” (Cureton and Clemens 2015, p. 355).
Altogether, cognitive-behavioral models suggest that suicidal patients can trigger both normative and idiosyncratic emotional reactions in their therapists; the former are considered largely situational, the latter rooted in underlying schemas specific to the therapist’s beliefs about self, his or her patients, and the treatment. These emotions may be complexly layered through affective constellations. In the next section, we explore ideas for cognitive-behavioral therapists working with suicidal patients based on cognitive-behavioral conceptions of countertransference, both in general and specific to suicidal patients.
Management of Countertransference in CBT
Therapists have many options for managing countertransference in ways to benefit both patients and themselves. Conventional psychodynamic approaches encourage therapists to seek supervision or psychotherapy (Freud 1912/1989; Hayes et al. 1991, 2011). Supervision is also a prominent approach in dialectical behavior therapy (DBT), a cognitive-behavioral treatment with empirical evidence of efficacy with suicidal individuals (Linehan et al. 2015). DBT incorporates weekly therapist consultation teams “to enhance therapist motivation and skills and to provide therapy for the therapist,” (Linehan et al. 2006, p. 259). DBT also encourages therapists to engage in mindfulness and radical genuineness as techniques for preventing or managing therapist behaviors triggered by reactions that might interfere with therapy (Chapman and Rosenthal 2016).
Aside from DBT, suicide-specific interventions say relatively little about the emotional needs of the therapist (Wenzel et al. 2009; Bateman and Fonagy 2009). While supporting both therapy and supervision of CBT therapists, and recognizing some limitations in the scope of existing CBT approaches, we offer the following framework as a CBT-consistent means of addressing emotional reactions that accompany work with suicidal individuals.
In recent years, mindfulness and acceptance approaches have become increasingly prominent in both clinical and research arenas. (See Prochaska and Norcross 2014, for a recent overview.) These approaches are characterized by a CBT-consistent view of psychological functioning, together with an emphasis on experiential awareness and stress management, that is well-suited to the management of emotional reactions to challenging patients. The “RAIN” model has been proposed by mindfulness authors (e.g., Brach 2013; Kornfield 2008) as a practical means of capturing key aspects of the mindfulness approach. The acronym stands for Recognition, Acceptance, Investigation, and Non-identification. Each will be discussed in turn below, together with an additional component, Taking Action.
To address therapist reactions to suicidal patients, therapists first must notice their own thoughts, feelings, and behaviors in response to patients. A first step in this process, as suggested by Brems and Johnson (2009), is for therapists working with suicidal patients to maintain a regular habit of self-exploration and awareness, facilitated by such activities as meditation and journaling. Specific to CBT, thought listing provides an opportunity to identify and articulate thoughts and beliefs associated with strong emotions toward patients; indeed, it is these very emotions that serve as cues to devote time to exploring such cognitions. Making a regular practice of self-reflection allows therapists to notice potential warning signs of being unduly impacted by patient behavior. The universe of possible emotion-activating cognitions regarding patients is, of course, quite large; Table 1 lists samples of various emotions and behaviors that may signal a need for thought listing and other forms of self-exploration.
Once aware of thoughts and feelings (and prior to taking any steps toward modifying them), the next step is to cultivate acceptance. “Acceptance” in this context has very specific connotations, and is not to be confused with resignation or passivity; to the contrary, to accept thoughts and feelings is to acknowledge that they are present and to let go of judgments that they should not be here or cannot be faced. This stance toward inner experience becomes especially crucial to the extent that such experience is unwanted, as is generally the case regarding negative thoughts and feelings toward suicidal patients. Indeed, guilt and shame regarding negative reactions to patients is likely to prevent therapists from dealing with these reactions in a constructive manner. In contrast, an attitude of acceptance (i.e., “It’s ok to acknowledge these feelings”) potentially opens the door for clearly articulating, and then addressing, one’s thoughts and feelings. Paradoxically, accepting a thought such as, “This patient is hopeless,” sets the stage for examining it (see next step); secondary thoughts/emotions, such as “I’m a terrible therapist for having thoughts like this” only interfere with addressing them in constructive ways. Acceptance merely means allowing them to exist, and not making matters worse by adding guilt and shame to the mix. This is facilitated by recognizing that negative thoughts and feelings about suicidal patients are common and are understandable in context. Acknowledging this reality is not the same as endorsing such thoughts; to the contrary, acceptance often sets the stage for change.
A closely related construct is self-compassion. Neff’s pioneering work in this area highlights the need for therapists to acknowledge openly and attend to their own feelings (Neff 2004; Neff and Germer 2013). She notes that, “an individual must have compassion for the self in order to have the emotional resources available to give compassion to others (p. 28).” She further suggests that self-compassion involves three components: (1) being understanding, rather than judgmental toward oneself, especially during difficult times, (2) accepting one’s experiences as human, and (3) being aware of one’s experiences rather than denying or being overwhelmed by them (Neff 2004). Research on interventions designed to increase self-compassion among various health-care professionals, including psychotherapists, has demonstrated an association between improvements in self-compassion and reductions in empathic distress and burnout and maintenance of well-being (Boellinghaus et al. 2014). Being able to accept one’s human responses to patients appears to be a helpful approach to working through such feelings, encouraging the growth of the therapist both personally and professionally.
Once the therapist has adopted an accepting stance toward negative thoughts and feelings, the stage is set for investigating and gaining a fuller understanding of one’s reactions to suicidal patients. CBT excels in this arena, starting with thought listing. As CBT therapists routinely teach patients, the task is to “let loose” with thoughts (in writing), especially as these occur in the context of a strong emotional reaction, such as anger in response to an unkind remark or hopelessness when working with a chronically suicidal patient. Once these thoughts are acknowledged, the process turns to the task of detecting and labeling cognitive distortions. Examples of such distortions appear in Table 2.
The cognitive-behavioral model of countertransference in general, and in the suicidal context in particular (reviewed above), suggests several additional avenues to help therapists investigate their reactions to suicidal patients. First, it may behoove therapists to look beyond automatic thoughts for underlying schemas and core beliefs, i.e., whether general themes exist that may permeate such thoughts. Such themes may represent schemas such as perfectionistic ideals, beliefs about personal control, helplessness, or excessive self-sacrifice (Leahy 2001). For example, a thought such as, “If my patient dies by suicide, my colleagues/supervisors will think I am incompetent,” may reflect a counter-therapeutic schema regarding need for approval. While it is true that fellow professionals may be concerned about a suicidal outcome, it may also be the case that they will be understanding and supportive.
Second, Rudd and Joiner’s (1997) therapeutic belief system suggests another avenue for exploration: What are the therapist’s views of the patient, themselves, and the treatment in general? A therapist may have the thought, “My patient is deliberately sabotaging treatment. What a hostile thing to do!” This thought may involve the distortion of personalization. According to Rudd and Joiner, such a belief about the patient may be linked to the therapist’s beliefs about himself or herself such as, “I am a victim.” Together, these maladaptive beliefs about patient and self may culminate in catastrophic thoughts about the treatment in general, such as, “Treatment is useless.”
Finally, therapists may recognize underlying thoughts by exploring Cureton and Clemens (2015) notion of affective constellations. Consider a therapist who may be aware of feeling depressed in response to a suicidal patient. The thoughts underlying these feelings may include, “I'm doing something wrong; otherwise, my patient would not feel suicidal. I am not a good therapist” (arbitrary inference, overgeneralization). The affective constellations model suggests that the therapist’s automatic thoughts and associated feelings may not stop here. Instead, they might be connected to angry feelings and such thoughts as “My patient’s situation is so bad that he’s making us both miserable…maybe he should kill himself!” Finally, these kinds of thoughts and feelings may ultimately result in shameful emotions and thoughts of blaming oneself for feeling depressed and angry about the patient’s situation (invalidation, over-responsibility).
Cognitive-behavioral models offer therapists multiple avenues to identify and investigate their reactions to suicidal patients, preventing them from overlooking potentially significant, but not always obvious, responses that may influence their work and contribute to stress. But it is not enough merely to identify and examine problematic ways of thinking. In the next section, we share suggestions for managing thoughts evoked by suicidal patients and move beyond them.
This last step in the RAIN process overlaps with the ACT construct of “defusion” (Hayes et al. 2012) and with Beck’s earlier notion of “cognitive distancing” (Beck 1976). It emphasizes gaining perspective on thoughts and emotions as something the individual experiences, rather than something the individual is. Once the individual is able to experience thoughts as something other than facts or truths, this creates a context in which one is able to recognize more clearly thinking errors and correct them through cognitive restructuring (the traditional CBT model) or “hold thoughts lightly” through defusion and mindfully choose behaviors driven by values rather than “fused” thoughts and emotions (the ACT model).
Prominent teachers of the CT model urge practitioners to “use it on yourself” (Ellis and Dryden 1997; Beck 2011), reasoning that the experience will both improve understanding of the experience to the patient and help the therapist to identify dysfunctional cognitions in need of attention. Cognitive restructuring of the therapist’s own maladaptive beliefs is no different from that done between therapist and patient; for our purposes here, it involves two essential components: (1) identifying the rigid and distorted thoughts that underlie emotional and behavioral reactions to suicidal patients and (2) examining these thoughts and considering whether to replace them with more adaptive ones. Several examples of counter-therapeutic thoughts, feelings, and behaviors are shown in Table 2, along with adaptive alternatives. Engaging in the process of cognitive restructuring potentially will allow therapists to better care for their suicidal patients and themselves as well.
As noted above, “third wave” behavior therapies have introduced an alternative (some might say derivative) approach to problem thoughts and emotions, by pointing out shortcomings in the conventional process of challenging and modifying internal processes, and maintaining that a preferable path is to cultivate a stance of accepting thoughts and feelings, gaining distance from them (defusion), and focusing on making behavioral choices that are consistent with one’s cherished values. This path with respect to suicidal patients is straightforward: The task is to regard negative thoughts and feelings as “something I am having, but not me,” and shift attention to taking action guided by values. It stands to reason that therapists value contributing to the well-being (indeed, survival) and happiness of their patients. Cultivating “willingness” to allow negative thoughts and feelings regarding suicidal patients to exist, while continuing to engage in therapeutic helping behaviors becomes part and parcel to the process.
It is important to note that the introspective processes of the RAIN model, while sometimes sufficient, also can set the stage for behaviorally addressing negative reactions to suicidal patients, as well as promoting self-care in general. Below, we describe two categories of behavioral responses to negative reactions to suicidal patients, supervision/consultation/peer support and clinician self-care.
While cognitive therapists are well advised to pay attention to beliefs and attitudes, those who focus exclusively on cognitive strategies risk overlooking valuable interpersonal resources for guidance and coping. In a word, we refer here to the importance of talking. Allen (2005) has written extensively on the emotion regulation functions of interpersonal connection, wherein social interactions present, not only the opportunity for learning, but also the experience of community. While supervision and consultation are always prudent when working with suicidal individuals, for both optimal care and liability risk management (e.g., Bongar and Sullivan 2013), interactions with colleagues provide the added comfort of knowing that one is not alone in struggling at times with emotional reactions to patients. Considerable research supports the notion that seeking social support and professional consultation (Hendin et al. 2000; Kelleher and Campbell 2011; Richards 2000) is vital for therapists working with suicidal patients. Such support not only reduces feelings of embarrassment and shame, but also can be invaluable in detecting and addressing distorted thinking that otherwise might go unrecognized.
This process is never more critical than in the early years of one’s career. During this formative period, new clinicians working with suicidal patients are more likely to personalize negative outcomes and attribute difficulty with patients to a lack of experience. The young clinician may think, “I’m not ready to work with a suicidal patient,” or, “My patient would do better with a more experienced clinician.” It may be beneficial for therapists in training to work with their supervisors to evaluate the validity and utility of these kinds of doubts. The tendency of trainees to hide their fears from supervisors may be reinforced by the reluctance of more experienced colleagues to discuss openly negative outcomes. However, the frequency of such outcomes is well known: Roughly 20% of psychologists and half of psychiatrists report having lost a patient to suicide (Chemtob et al. 1989; Brown 1987; Ruskin et al. 2004).
Experienced clinicians sometimes fail to realize the enormous benefits that candid sharing of past losses or struggles offer the new clinician. Hearing from respected mentors that it is okay to struggle and seek consultation, and that this does not equate to weakness or incompetence, can be an invaluable lesson for trainees and colleagues alike. It also is important for clinicians to recognize that patients are not the only ones who slip into dysfunctional thinking in the context of a suicide attempt or a setback of some kind. It behooves clinicians to remain aware of such thoughts and supervisors and colleagues to encourage trainees and peers to use their CBT skills to manage self-doubt. As stated previously, this perspective has been best represented in DBT (Linehan 1993), which stipulates routine use of a consultation team, not only for technical consultation, but also to provide support for the therapist.
As noted elsewhere, work with suicidal patients is inherently stressful (e.g., Deutsch 1984; Meichenbaum 2005). Therapists who do not take self-care seriously are at risk, not only of suffering negative health consequences themselves, but also of providing substandard care (Barnett et al. 2007). While trait-like attitudes and beliefs may indicate need for cognitive strategies such as those described above, “state” disturbances such as irritability, impatience, and cynicism may be more situational, i.e., signs of compassion fatigue (Figley 2002) or burnout (Linehan et al. 2000). In addition to the steps listed above, which focus on recognizing, accepting, intervening, and not identifying with thoughts, therapists may also consider recharging and renewal as vital parts of managing countertransference with suicidal patients.
Therapist self-care is a growing topic of discussion in the clinical arena (e.g., Norcross 2000). Although a full discussion is beyond the scope of this paper, it is worth noting that self-care is increasingly presented as an ethical imperative for clinicians (e.g., Norcross 2000; Wise et al. 2012). Beyond the issue of countertransference, it is well-established that clinician stress and burnout compromises clinical effectiveness (e.g., Irving et al 2009). Self-care represents an intersection of clinician values of personal well-being, competent care, and saving lives.
Self-care activities, such as meditation, getting adequate rest, and reasonable scheduling are associated, both with improved therapist well-being (Shapiro et al. 2007), and with reduced countertransference behaviors during sessions (Baehr 2004). Indeed, evidence showing benefits to both clinicians and patients (e.g., Wise et al. 2012; Norcross 2000; Irving et al. 2009) has become rather compelling, leading one group of authors to endorse mindfulness-based practices as “the how of effective self-care” for psychologists (Wise et al. 2012, p. 487).
Guides to therapist self-care are plentiful (e.g., Kottler 2011; Norcross and Guy 2007), and apply equally as well to work with suicidal patients and psychotherapeutic work in general. In addition to time management and mindfulness strategies typically recommended in such guides, we would join Norcross (Norcross 2000; Norcross and Guy 2007) in urging therapists (especially those working with suicidal patients) to include personal therapy as an option for managing negative reactions to suicidal patients, as well as stress in general. While we would not agree that any and all negative reactions to suicidal patients indicate the need for therapy, we are well aware of the empirical literature (summarized by Norcross 2000), showing that (a) personal psychotherapy is more the rule than the exception among psychotherapists, and (b) psychotherapists typically report strong satisfaction with the benefits of personal therapy. Clearly, personal therapy should be considered as a viable option for any cognitive therapist whose negative reactions to patients have not responded to self-help measures, such as the RAIN approach described above.
Please see Table 3 for an overview of the RAIN approach to managing countertransference reactions.
Summary and Conclusions
While the notion of countertransference originated with psychodynamic theory, attention to emotional reactions to patients (particularly suicidal patients) is no less essential to the practice of CBT. Conceptualizing and articulating reactions to suicidal patients within a cognitive-behavioral framework can reasonably be expected to improve outcomes with suicidal patients. Attending to one’s thoughts through the lenses of underlying schemas, the therapeutic belief system, and affective constellations provides cognitive-behavioral therapists with a language and way of understanding their reactions that is consistent with the theoretical assumptions of CBT. Incorporating the RAIN model from a mindfulness/acceptance perspective may also allow therapists to identify, accept, and defuse or modify maladaptive cognitions experienced in working with suicidal patients.
In addition, a cognitive-behavioral approach to understanding reactions to suicidal patients ultimately may prove helpful to therapists themselves. Several researchers have indicated that, while the work is difficult and sometimes painful, many therapists ultimately find their work with suicidal patients to be both personally and professionally gratifying (Richards 2000; Gutin et al. 2011). In fact, clinicians sometimes comment that they are “older but wiser” (Ellis and Patel 2012), and researchers have employed concepts such as “post-traumatic growth” (Munson 2014) to characterize therapists’ experiences with suicidal patients. Viewing therapist reactions within a cognitive-behavioral framework is likely to enhance the kind of development that therapists can experience when working with suicidal patients. Rogers (2001) argues that suicidal patients often struggle with existential issues around choice and personal autonomy, the meaninglessness of existence, existential isolation, freedom, and limits of personal responsibility. By extension, therapists working with suicidal patients are also faced with profound questions of the meaning of life and who is ultimately responsible for life and death decisions. When these issues are addressed from the vantage point of core schemas and beliefs, such existential issues become less obtuse and can be more concretely addressed.
CBT offers a wide assortment of interventions and strategies to help patients reduce suicidal ideation and behavior, including safety planning and skill building (Stanley et al. 2009); group skills training and crisis management (Linehan et al. 2015); and collaborative treatment planning and problem-focused interventions (e.g., Ellis et al. 2017). In addition to these interventions, approaching therapist reactions systematically may provide therapists with the skills and avenues for professional support that they need to navigate the difficult waters of working with suicidal individuals.
It is important to note in closing that many of the perspectives and strategies proposed in this paper warrant empirical study. Although the literature provides considerable support for the strong association between the therapeutic relationship and treatment outcomes (e.g., Leahy 2008; Martin et al. 2000), we are aware of no empirical demonstration of a causal relationship between changes in therapist thoughts and emotions toward patients and (a) changes in therapist behaviors toward patients, (b) enhanced treatment outcomes, or (c) benefits to therapists in the form of decreased emotional distress, fatigue, or job burnout. This is certainly true in the context of suicidal patients. We hope that such studies might follow from the articulation of the framework and strategies put forth in this paper.
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The authors gratefully acknowledge the support of the Bernice Peltier Huber Charitable Trust and the Menninger Clinic Foundation, without whose support this work would not have been possible. We also thank two anonymous reviewers for their helpful comments on an earlier version of this paper.
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Ellis, T.E., Schwartz, J.A.J. & Rufino, K.A. Negative Reactions of Therapists Working with Suicidal Patients: a CBT/Mindfulness Perspective on “Countertransference”. J Cogn Ther 11, 80–99 (2018). https://doi.org/10.1007/s41811-018-0005-1
- Therapist reactions
- Stress management