When confidentiality meets suicide risk: why this is never as simple as “respect refusal”

I recently commented on a post quoting an older text, suggesting that if an adult client with mental capacity is actively suicidal and refuses consent for information to be shared, the therapist is under a legal obligation to respect that refusal.

I responded to say that this doesn’t reflect current UK practice, where confidentiality is vital, but not absolute and where guidance and professional frameworks are clear that information can be shared without consent to protect life.

But afterwards, I reflected that my response, while technically accurate, was quite dry.

Because suicide risk in real life, and in clinical practice, is anything but theoretical.

Having worked for many years in NHS mental health services, I’m very aware that managing risk in multidisciplinary environments is complex and imperfect — but there is at least shared responsibility, collective thinking, and systems around you. There are colleagues to consult, crisis teams to escalate to, and structures that hold some of the risk.

Private practice is different.

When a client tells you they are actively suicidal, you may be the only professional involved. You may be reliant on a GP you’ve never met, an emergency service that doesn’t know the person, or next of kin who are suddenly pulled into a crisis. The emotional weight of those decisions sits heavily — and often alone — with the therapist.

And beyond professional experience, this topic is also deeply personal for me.

I have supported two close family members with long-term mental health difficulties, both of whom have been actively suicidal and have attempted suicide. One of the most striking things I’ve learned is this:

When someone is truly intent on ending their life, they may tell nobody.

But when someone says, “I don’t want anyone to know — don’t tell anyone — don’t get help”, there is often another part of them present too. A part that is communicating distress. A part that is reaching out. A part that is not as certain as the suicidal thinking makes it feel.

In suicidal states, thinking narrows. Hopelessness becomes absolute. The urge feels permanent ..even though, in many cases, it is not.

I remember having a conversation with someone very close to me who described being actively suicidal and adamant that they didn’t want anyone to intervene. At the time, they believed they were thinking clearly and rationally.

A few days later, they felt differently.

They were profoundly grateful that others had noticed cues, checked on them, and stepped in even though at the time they had insisted they didn’t want help.

This is something we see again and again in suicide prevention research and clinical work: suicidal crises are often temporary states. Intense. Real. But not fixed.

And that’s why the idea that capacity alone should mean “do nothing” is so risky.

Of course, autonomy matters. Of course, confidentiality matters. But when someone is in acute suicidal distress, we are not just dealing with a stable, fully reflective decision-making process. We are dealing with a mind under the influence of despair, tunnel vision, and cognitive constriction. Our Classic CBT theory helps us understand this.

As clinicians, whether in the NHS or private practice, our role is not to override people lightly. But it is also not to stand back when someone’s life is at serious risk.

Often, the most therapeutic stance is collaborative honesty:

• acknowledging the distress
• validating the wish for privacy and control
• while also being clear that safety sometimes requires involving others

Creating safety plans together. Exploring who could be contacted. Being transparent about the thresholds at which we would need to act. Holding both compassion and responsibility.

And yes, sometimes gently challenging the suicidal thinking itself by naming that this state may not last forever, even if it feels unbearable right now.

For me, this is why modern ethical frameworks emphasise proportionality, judgement, collaboration and the duty of care, rather than rigid rules.

Because suicide risk is not a tick-box capacity issue.
It’s a human crisis.

And while respecting autonomy is vital, preserving life and supporting people through the storm of suicidal despair is too.

Perfectionism, Social Media, and Social Media Holidays

How have you spent your lock-down?

It seems looking out there, that a huge amount of people have spent their time during lock-down as productively as possible. The self-improvement in either their bodies or minds appears to have been accelerated by the fact that they cannot go out rather than inhibited and, via social media, there is increasing exposure to this new standard they exhibit.

Driving this, appears to be inspirational quotes and stories, such as Shakespeare writing King Lear during the plague and social media itself through trending hashtags such as #bodygoals, which place emphasis on using the lock-down as a time for weight loss or ‘getting healthy’ as there is currently no distraction.

Though social media and the media have been shown to negatively skew our opinions of our bodies since long before the lock-down (Fernandez and Pritchard, 2012), it can also feel that individuals are starting to demonstrating their success in other areas too such as their parenting achievements or their accomplishments in DIY. This can lead us to some unhelpful conclusions:

I should be doing something.

I am worthless

I am lazy/fat/ugly

People have always compared their achievements with each other. However, this has risen dramatically in recent years. In a study conducted by Curran and Hill (2019), unfavourable comparison was demonstrated to have risen since the 1980s. Curran and Hill (2019) explain that young people perceive others to demand more of them, demand more of others and are more demanding of themselves.

We are becoming increasingly perfectionist.

Curran and Hill (2019) explain that as society has become more individualistic, this perfectionism has come from a desire to demonstrate our self-worth. This is at the cost of our mental health. A study by Padoa et al (2018) found that young mothers with perfectionist tendencies found engaging in social media had significant negative impact for both their mood and their anxiety level. In a study by Fardouly and Vartanian (2016), the use of social media over time is consistently and positively correlated with negative body image. The more you use social media, the worse you feel and think about your body.

During lock-down, we have maybe been placed in a Catch-22 situation a little bit: needing to use social media to feel connected to others, but feeling more and more worthless as we do.

I propose a simple exercise. Imagine you meet someone at a social event. Within ten seconds of meeting them you just instantly click, after a lengthy conversation they leave you feeling happy and excited and you can imagine being friends with them for years. What qualities or characteristics do they have? Write a small list.

Now imagine the opposite. Imagine that within ten seconds of meeting this new person, you just know that you will not get on. They annoy and upset you. You feel awful being around them and want to leave the social event. What qualities do they have? Write another small list.

Now appearance obviously matters, especially in romantic relationships and achievements obviously have value, but what is often clear from doing this exercise is how much it matters and the answer is: not that much.

Often, we do not focus on other’s achievements when we asses how much we value them, but on their qualities. Regularly when people complete this exercise, they forget to consider appearance or achievements at all.

What frequently gets identified is how kind, funny, loving or loyal the other person is, and from the negative end of the spectrum, qualities or characteristics such as violent, judgemental, or unloving are identified.

Our use of social media can make us feel that all we care about, and all that matters, is other’s achievements or how beautiful they are, but when we are asked, often what we truly value are things that are inherent to us as human beings. Imagine a funeral where people talked about how much they would miss the deceased because of their body fat percentage! Or how they were a horrible person to be around, but they had a lovely huge house. It is a bit ridiculous! Go back to your lists and have a go at asking yourself what qualities you have. You maybe more valuable than you thought (remember that we are all flawed in at least some way when doing this). Maybe next time your on social media and feeling like you should do something, it might be helpful to remind yourself what really matters to you. You are probably OK as you are, just like everyone else.

Beginning to return to normal life - A confusing time

It is expected that today the lock-down measures may begin to be rolled back as they have in Wales. As we move forward into this next phase of the lock-down, it may be difficult to adjust to these new measures, just as initially it was difficult to adjust to the lock-down itself. Many of us may have become accustomed to living within our homes and have begun to feel safe there. It is obviously important to stay safe but as the lock-down begins to get withdrawn it is also important to be mindful of the development of safety behaviours.

What is a safety behaviour?

Imagine a six-year-old boy. He desperately wants a puppy and asks his parents repeatedly if they can get one. They explain to him that dogs are dangerous. He does not believe them as he has seen dogs on TV and in the park and at other people’s houses and is sure that dogs are nice. One day, as his parents bring in the shopping, he sees a dog tied up outside their house. He goes to stroke this dog and the dog bites him. He is hurt and upset and runs inside. His parents clean him up and give him a cuddle and say ‘We told you! You have to be careful around dogs!’.

As the years progress, this message becomes important for this young boy and he begins to avoid going into spaces where he might find dogs. This could be a park, a friend’s house, a high street or pretty much anywhere outside. As the years go by, he begins to associate being outside with being at risk of seeing dogs and spends more and more time at home. By the time he is 26, he only goes outside if he absolutely must.

Anxiety is a bad barometer

What is key here is that if we asked this young man why he does not go outside, he would most likely say ‘it isn’t safe’. If we asked him how he knew this, he would most likely say ‘it doesn’t feel safe’. As we go through our lives, we are told to trust our emotions and our bodies. Sayings like ‘trust your gut’ and ‘do what you feel is best’ mean that we begin to associate the way we feel as indicative of what is happening. For example:

‘I feel anxious, something is wrong.’

‘I feel calm, everything is great today!’

However, the emotion of anxiety is a BAD barometer! A barometer is a scientific machine that tells people what the weather is going to be. We tend to see our emotions in the same way. As indicators of what is happening, will happen, or has happened. But our emotions are unreliable! Think about the following examples:

·        Steven has smoked and drank excessive alcohol for 24 years but has had no symptoms associated with this and feels calm and relaxed.

·        Hannah has a phone interview for a new job and feels her mouth go dry as she tries her best to answer the questions.

·        Jamie is walking home from work and gets mugged by a group of three people who ask for his phone. His heart begins to pound.

Most of us know that drinking alcohol and smoking are bad for us and put us in danger, but very rarely do we feel anxiety about these behaviours. Often people may have a cigarette or drink to calm down! Many of us dread job interviews, but how much danger are we in, compared to how much anxiety we have? Is it proportionate? However also (just to make it confusing), in the example of Jamie, his anxiety does match the situation, as he is in danger. So, what does all this mean? What this shows is that anxiety cannot be relied on to indicate our safety. It is a bad barometer and not to be trusted all the time.

What does all this have to do with the lock-down measures? Well, going back to the boy that wanted a puppy, he is using his anxiety to confirm that he is in danger. Now obviously, there is a chance that he could be bitten by a dog and maybe even killed. But would we then recommend that he stay at home forever to make sure he is safe? Probably not, as the chance seems low and it would be a low quality of life trapped at home.

As we go into the beginning of the end of the lock-down era and are granted more freedoms to return to our normal lives, there may be a temptation to go the ‘extra mile’ than the recommendations just to ‘be on the safe side’. To stay home, even though we can return to work or see friends and loved ones. However, after a little while, we could start to end up in a situation where our quality of life begins to drop. A situation where we are missing out on times with loved ones or not enjoying the activities that we used to, despite being allowed.

So, what to do? If I cannot trust my gut what can I trust?

Remember the golden rule:

If it is true for others, it must be true for me

If it is OK for others to start to see loved ones or do fun activities when lock-down begins to lift, it is probably OK for you too, even if it does not feel like it. If the government ( and more importantly the science!) says it’s OK for others to begin to go out more, it is probably OK for you too.

Lock-down Low Mood

As we enter our seventh week of lock-down, the impact of this bizarre situation on our mood may be becoming obvious to both ourselves and those around us. The cumulative effect of an extended period spent predominantly indoors may be, for many of us, either the beginning of difficulties with low mood or the exacerbation of a struggle that already existed.

On this blog last week, we talked about social isolation. We talked about how our relationships with others are like natural anti-depressants and that without them we can find our happiness and joy in life impaired. We then looked at what steps we can take to overcome the isolation that we might be experiencing. But what if we do not have the motivation that we used to? What if we don’t feel like socialising with others or doing the things that we used to do that brought us joy?

Why might we be feeling this way?

For Knapen et al (2014) depression is characterised by, amongst other symptoms, a loss of interest, motivation and energy, generalised fatigue, low self-worth and confidence and a fear to move. We may be struggling to motivate ourselves and feel drawn to a lethargic state, with little interest in taking part in new activities.

Though experiencing these symptoms is very common and we shouldn’t necessarily think that we have depression if we experience the above without consulting a GP or mental health service, I was struck this past week by one of my friends saying that everyday has become a ‘pyjama day’. As a result of the lock-down, we have been forced to, at least with our behaviour, replicate many of the above symptoms. We have been confined to our homes for over 6 weeks with many of us not currently working or furloughed (a loss of purpose) and with a restricted freedom to be able to do what we love.

Another significant factor may be alcohol. Many news outlets have reported that there has been an increase in alcohol consumption. Though (as talked about previously in this blog), this is not the same thing as scientific evidence, if individuals have been consuming an increased amount of alcohol, it is important to note that it is scientifically proven that increasing alcohol use increases risk of depression (Boden and Fergusson, 2011).

Essentially, the combination of decreased social contact, an inability to engage in new activities, an increase in lethargic behaviour and increased alcohol use, may place us at high risk of experiencing symptoms of depression. A kind of ‘lock-down low mood’.

What to do?

In order to cope with this, we can engage in a CBT approach called Behavioural Activation. Behavioural Activation is the process whereby we reconnect with the things that we used to enjoy doing. It is the process of developing an action plan to overcome the avoidance that can occur when we begin to feel that things are too difficult. After identifying a list of activities that are routine, pleasurable and necessary, these are then graded in order of difficulty and then planned out for the week to help it become more manageable.

You can use this link to help figure out these activities: https://www.getselfhelp.co.uk/docs/BehaviouralActivation.pdf

And this one to help organise them: https://www.getselfhelp.co.uk/docs/WeeklyPlanner.pdf

It may seem that this is too obvious to help, but Behavioural Activation is scientifically proven to lift low mood and offset the symptoms of depression (Ekhers et al, 2014). As you go through this activity, it is important to remember to pace yourself, many of us have adjusted to lockdown and though we may remember being far busier, it is important to go steady to prevent becoming overwhelmed and then just abandoning the process all together. It helps to go into these activities as a scientist running experiments. I have tried sitting at home and watching Netflix and know how that makes me feel, I know the outcome of the experiment. Maybe trying out Behavioural Activation might get different results and maybe make me feel a little bit better.

Proactive Anti Loneliness, Social Distancing Doesn’t Mean Social Isolation

At the Happiness Research Institute in Denmark, they study (as you might have guessed), happiness. In a study published by the Happiness Research Institute for the United Nations, the World Happiness Report (which you can read here https://www.happinessresearchinstitute.com/publications) proved, using scientific methods, that relationships are the biggest impact factor for how happy we feel. Even in far poorer countries, relationships come second to wealth.

Due to the current lock-down situation however, in order to be safe and keep others safe, we are required to social distance, to keep ourselves away from others. This is a serious issue for mental health. Prior to the lock down, social isolation was already a big concern within the UK, with loneliness and social isolation proven to have a detrimental effect on not only physical but also mental health (Courtin and Knapp, 2015, Mushtag et al, 2014). During our current situation it is very likely that loneliness and social isolation have increased and that, for some, the biggest impact factor for our happiness has either reduced or been taken away.

1)      ‘Proactive anti-loneliness’

In a study conducted by Pettigrew and Roberts (2007), they found that interventions that ameliorated loneliness among older adults were:

·         Using friends and family as an emotional resource.

·         Engaging in eating and drinking rituals as a means of maintaining social contacts.

·         Spending time constructively doing reading and gardening.

Taking an approach of ‘proactive anti-loneliness’ by engaging in these activities (albeit in an adapted way) could really help how we experience this lock-down and how happy we feel as a result. Modern technology like Skype and Zoom allow us to connect socially without having to be physically present. Using these resources to maybe have virtual dinner together with friends, or to create a pub quiz with family members living in different homes means that social distancing doesn’t have to mean social isolation.

But what about those that don’t have an existing social group to lean on? Well, the third suggestion in the study by Pettigrew and Roberts (2007) is a solitary activity that is proven to reduce loneliness and doesn’t require another participant.

Secondly, though we are social distancing, this is also a time when we can boost our happiness and help others with one activity.

2)      Doing something for others

Doing things for others is proven to increase our happiness and increase our sense of community and social connection (Helliwell et al, 2014). However, not everyone is fortunate enough to have strong relationships with family or friends and often we find ourselves isolated, frequently due to circumstances beyond our control, lock-down or no lock-down.

This does not mean that we need to remain that way. During this crisis, and when it has finished, there is always a need for people to volunteer their time to help others. Not only is there benefit to those receiving this help, often hugely significant, but also there is a scientifically proven benefit to help reducing our own experiences of loneliness and isolation. Take some time and think about how you could help others and it might also be a bit of help to you too.

https://www.gov.uk/government/get-involved/take-part/volunteer

Managing Uncertainty with Cognitive Behavioural Therapy and Acceptance and Commitment Therapy.

We are currently living through a situation that, for the vast majority of us is completely new.  There exists a new threat to our physical and mental health. For many of us, financial instability has become a new norm and the guidance for how we ‘should’ live our lives seems to have done a 180 degree turn. We have transitioned from being encouraged to socialise and connect with others, to being asked to isolate ourselves to protect our services. We have been advised to limit our exercise outdoors, rather than engage in activity out of the home and we have shifted from a society that tells us to buy what we want, to government messages that tell us to only buy what we need.

These transitions create great uncertainty in our lives and though we may try to regain control, there is very little that we can do as individuals about events such as a global pandemic and changes in the economy. This can, of course lead to us feeling anxious, frustrated and distressed.

Further to this, and perhaps most devastatingly in terms of our mental health, turning on the news causes us to experience a significant increase in exposure to scary and difficult information. Daily death statistics and projections obviously cause us to worry and feel that the future is bleak. CBT can help us with this in two ways.

Firstly, Separating Fact from Unhelpful Thought.

Often when we experience high levels of anxiety or panic it can lead us to unhelpful thoughts and behaviours. We have seen this at the early stages of the pandemic where people began panic buying, despite there being no shortages of food or toilet paper. As a result, it is important to recognise what is fact and what is unhelpful thought. An easy way to test for this, is to remember that if our thoughts or understandings are true, they will be true for others. Illustrating this with a few examples may help:

Unhelpful thought:

‘I am going to die from Covid-19’

Fact:

Is it true that everyone else will also die? The World Health Organisation has said that less than 5% of people will die from the disease. Thus the vast majority, over 95% of us, are not in life threatening danger from the pandemic.

Unhelpful thought

‘I will never be safe again’

Fact:

Is it true that others will never be safe again? Throughout history there are examples of pandemics that have been dangerous to human life but human life has continued. Further to this, health care is currently the best that it has ever been.

Unhelpful thought:

‘I will lose my job because of the economy’.

Fact:

Some other people may lose their job, but as above, there have been global recessions before and the economy (and employment rates) have returned to normal.

Unhelpful thought:

‘I feel so anxious; I am sure when I panic that I have symptoms’

Fact:

When other people experience anxiety, it does not place them at risk of becoming physically unwell. There is no proven correlation between having anxiety symptoms and Corona Virus.

Secondly, Recognising What We Can and Can’t Control

To manage this uncertainty, it is also so important in situations like these to use CBT skills that can help us recognise what we can and can’t control. If the current pandemic is confirmation of anything, it is proof that it is impossible to predict the future.

When we turn on the news, however, there are consistent reports of how bad things are and how bad things may become. It is not a shock to hear that the media has a significant impact on the way that we feel fear and uncertainty. In a study by Nellis and Savage (2012) it was demonstrated that consumption of media related to terrorism increased individual’s worry about their own and others, level of safety.

But why is it negative? Well, studies have shown that we are more likely to listen to negative than positive information from the media and so news media that focuses on this will, by definition, be more successful (Suroka and McAdams, 2015). With the media filling us with negative information about the world and the pandemic, it might be helpful to have a look at what we can and can’t control.

What we can’t control:

The content of the media.

The actions of politicians.

The impact or changes to the economy.

The impact of the pandemic on society.

The creation of a vaccine

Whether a lockdown exists

What we can control:

Our own consumption of the media.

Our own behaviour to others.

How healthy our lifestyle is.

How we spend our time at home.

Attempting to manage this uncertainty by trying to control the world around us and predict the future, can lead us to anxiety and panic and feeling helpless. This can be helped by recognising the difference between what we can do something about and then accepting what we cannot. As the above table demonstrates, there is very little that we can do about the impact of the pandemic on a national scale, but we can do something about the way that we behave day to day in our own lives, the way that we treat others and the way that we consume information.

Imagine being late for a flight. You are already in the taxi, you have your passport and boarding pass in hand. There is nothing else you can do in this situation to speed up the taxi, it will take as long as it takes. Worrying will not change the time the journey to the airport takes, but it will change how distressing it is.

Our current situation is similar. The pandemic is happening. Worrying about how it will impact on our lives is not only distressing, but it does not change the pandemic itself, only how distressing it may be for us. It may be difficult to stop seeking stories of what may happen during or after this period of lockdown, but taking a little break and returning to areas of life where you do have control, may make life feel a little more certain and a little less worrying.

Covid-19 update for therapy

Given the recent coronavirus advice from the government regarding limiting social contact, we are now offering phone or Skype/zoom sessions only until further notice. There's a link below to the statement by the BABCP about covid-19 and face-to-face therapy although I'm module it'll be updated.

https://www.babcp.com/About/Press/COVID-19-BABCP-Statement.aspx?dm_i=5J93,Q7I,FFBDD,2H8B,1

Is’s an unprecedented time, and as much as possible we want to support people and offer whatever we can whilst looking after yourselves and ourselves. Please contact us if you have any questions and we send warm wishes and care out to everybody x

Welcome to CBT mindfulness!

This is the first blog post from the CBT mindfulness. I'm beginning to think about being more connected we have decided to start a regular blog (I'm not sure how regular yet as I'm new to these things but I'm hoping to post every week). As a good CBT therapist I've made a plan and I'm starting on a Monday so I've got a regular day to make my goal easier to achieve! The aim of this blog is to talk about the experience of being a CBT therapist what's going on in my world and perhaps what's going on in the world of CBT too! Hopefully I'm going to offer information insight and other titbits…

I hope you enjoy