'Liking' working with suicidal patients: A mixed methods research investigation of clinicians' positive inclination to patients at risk for suicide and the effect of this on the therapeutic encounter

Background: A strong therapeutic relationship is associated with better outcome in therapy/treatment, including with patients at risk for suicide (PRS). However, to build a strong therapeutic relationship with PRS, clinicians’ need to manage the emotional responses, also called countertransference (CT), that PRS tend to elicit in them. Conversely, evidence shows that positive CT, such as feeling of closeness and affiliation towards patients, are associated with better outcomes in therapy/treatment. However, such positive inclination from clinicians is rarely studied in relation to PRS, which represents an important knowledge gap. General aim: To advance knowledge in clinical suicidology by studying the stance of clinicians who feel positively inclined towards, or “like working” with PRS. Methodology: Sequential mixed methods design. Study 1 Nomothetic Aims: To explore systematically the nature of CT to PRS while estimating the prevalence of positive inclination to PRS among clinicians. To recruit positively inclined clinicians for the second study. Method: National online survey using the Therapist Response Questionnaire (TRQ) (Betan, Heim, Conklin, & Westen, 2005) and a clinical questionnaire. Results: Two hundred and sixty-seven clinicians took the survey online, 46 psychiatrists, 147 psychologists and 74 psychotherapists. Exploratory factor analysis (EFA) yielded a seven-dimension model of CT to PRS. However, clinicians endorsed CT dimensions only mildly on average, except for the positively connoted factor, expressing feelings of fulfilment and desire to engage with PRS (factor 2 - fulfilled/engaging). These patterns were interpreted as potentially reflecting a “CT montage”, where clinicians experience aspects of the suicidal state emotionally while preserving their willingness to engage despite the suicide risk. A minority of the clinicians surveyed (14.7%, n = 39) reported liking working with PRS, of which 29 consented to be contacted about the subsequent study. Study 2 Idiographic Aim: To develop an in-depth understanding of clinicians’ positive inclination to PRS. Method: Constructivist approach to grounded theory method (GTM) applied to interview data. Results: The study interviewed 12 clinicians, including two psychiatrists, five clinical psychologists and five psychotherapists. The analysis placed clinicians’ experience of forming a deep emotional connection with PRS at the core of the clinical encounter. This connection, named in this research an “aroha connection”, appeared to be satisfying for patients (i.e. soothing) and for clinicians simultaneously. It consisted of an interpersonal emotional regulation that could evolve into a therapeutic attachment. The findings suggested that suicidality decreases as connectedness grows. Conclusions: Combining research methods provided a rich understanding of clinicians’ positive inclination to PRS, which inferred the development of a novel working model that formulates the interdependence of clinicians’ satisfaction and of PRS’ improvement in treatment. This project indicated the emotional nature of clinical suicidology, hereby providing new evidence for the importance of “CT literacy” in clinicians. Whilst reaffirming the pivotal role of relationship factors in treatment of PRS, this research highlighted the gaps in our understanding of how they operate. Further research is needed to fathom these processes. Ultimately, this project invites to reconcile the study of the mind and that of the brain by reaching across disciplines to move the field of clinical suicidology forward