The therapist’s role in bringing up sensitive topics in therapy

There is a view in the literature that the suggestion to a client of a no suicide contract can lead them to think there is a prohibition of their suicidal thoughts, feelings and fantasies. The client will adapt to the therapist’s perceived implication that suicidal thoughts and feelings are viewed as negative and undesirable and thus will be repressed in the client. Hence they will never be brought out fully and discussed and thus resolved to at least some extent.

My personal view of this is that it is simply not true. If there is any sign of suicidality in the client I usually will bring it out early in the sessions and advocate openly talking about it. Often in the first session I may ask a client if they have ever felt suicidal. In my view the client sees that I am quite comfortable talking about such matters and so the whole area becomes a non issue. Suicidality, level of risk and so forth are openly discussed even if some kind of no suicide contract is used.

The same applies for other issues like eating disorders and self harm. Some people who report these issues will feel shame about their behaviour in this way. If there is some sign that these types of difficulties are being experienced by them then I will ask the question directly if they do engage in such behaviours. Obviously it is done with tact and care but the issue is brought out into the open often by me.

eater

If they answer yes they do suffer such things then the issue is discussed. If they answer no, one accepts that but keeps an open mind as one may not be getting a fully candid response from the client at that time. This of course is OK. If I was being asked quite personal questions by someone I reserve the right to be less than candid at times if I want to as well.

I wrote an article in the UKATA newsletter, The Transactional Analyst (2012) about shame. My view as to working shame through is to bring out what the client sees as their ‘shameful behaviour’ and discuss it freely. This of course initially causes some angst and disquiet for the client, they may re-experience the shame again. It is for this reason that the client may avoid talking about it for long periods of time. My view is then it is up to the therapist to bring it out into the open.

Shame picture

Of course some may then apply the same logic as expressed above about the no suicide contract. Such an intervention by the therapist may lead the client to withdraw in this way. Again I have found the opposite. If the therapist brings it up, then openly asks questions about the behaviour and discusses it the client sees that the therapist is ok about it. Then usually after not a long period of time (maybe 2, 3 or 4 times of bringing it up) it can be discussed by the client the same way they may talk about their depression of insomnia. It becomes a non issue. This is indeed my view about how one works through shame.

If one allows the client to avoid it for long periods of time and addresses it in a very a tepid way that may empower the shame. The client sees the therapist is very cautious and views the client as fragile in this way which can lead them to thinking the behaviour is ‘really bad’ or their response to it was some how momentous. It makes the problem worse. I am not for a moment suggesting the therapist be brutal and pushy at all. But the therapist needs to bring it out in the open in a  timely manner if the client is not. Then in usually quite a short amount of time they are talking about it in an open manner and the shame is no where to be seen anymore. Or at the very least the level of shame has reduced significantly.

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