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Saturday, November 15, 2008



V. George Mathew, Ph.D


Oriental Psychology consists of the psychologically relevant materials taken from ancient writings in the orient. During the early part of the present century, modern psychology emphasized sensation and perception and Indian Psychology consisted of largely Indian theories of perception. Later on when modern psychology started studying cognition, materials relevant to that also were taken from ancient scriptures and other documents. Still later theories of emotion also were included.

Climate perhaps has an influence on the goals and values of people. In the West people have an external orientation, their temperament being characterized by practical aggressive traits. In the East people are philosophically inclined. There is an internal orientation and the main concern of life is with the ultimates. Consequently ancient oriental writings are largely concerning religious and philosophical issues. Self-enquiry using holistic intuitive methods did not fall within the traditional framework of empirical psychology and so most of oriental material was supposed to be irrelevant for Psychology. But with the development of humanistic approach and the psychology of consciousness, almost the whole of oriental writings has become very relevant.

In Western psychology, the reference point was the average person. The normal was the average. But in the orient the normal was the ideal, the perfect. Cultivation of the quality of subjective experience was the main concern. The aim of life was considered to be self-realization.



The four asramas are Brahmacharya, Garhasthya, Vanaprastha and Sanyasa, the last one aiming at self-realization. The four motives are Kama, Artha, Dharma and Moksha, showing a rough correspondence to Maslow's hierarchy of needs. The concept of Nishkama Karma (action with detachment) shows a similarity to Maslow's concept of metamotivation.

The three components of temperament are Thamasik (characterised by lethargy), Rajasik (characterised by high drive) and Sathwik characterized by balance and stability. There is also a transcendental qualityless (gunatheetha) state conducive to self-realisation.

Six personality types are recognised in Buddhism: Ragacharith (attached), Doshacharith (envy, aggression), Mohacharith (dull, idle), Buddhicharith (rational), Vithakkacharith (imaginative), and Sadvacharith (disciplined).

Jain typology called Laisya or colour type theory grades people according to the colouration of soul by karmic passions: Black, Blue, Grey, Pink, Red and White. All these theories recognise a gradation with respect to the state of self-realisation.

Personality development consists of growth toward unity. The Indian view is similar to the views of Rogers and Maslow which hypothesise spontaneous growth given right conditions. Guru occupies a very important place and parallels have been drawn between the guru-sishya relationship and counsellor- counsellee relationship. The main difference is that the Guru is a person with a high degree of self-awareness instead of any factual knowledge or skill of a counsellor and in the Indian system total personality change is emphasized more than specific behaviour change. The guru is a person with steady awareness. Many modern therapies like the Gestalt therapy emphasise Nowness, Actuality, Awareness and Wholeness and emphasise the personality of the counsellor and these therapies come close to the Indian model.


Yoga means union. It is customarily used to denote methods used to attain superconsciousness. Several qualities like ability to discriminate the real from the unreal (viveka), disinterest and desire to know the truth (mumukshathava) are required in order to become a sadhaka (practitioner). The methods have been grouped into four.

1. Karma yoga
Every action has a reaction on the doer and the effect of actions remain in the person as his samskara. Good karma purifies the mind. Adler's method of developing social interest as a technique for personality development and personality development through improving social interactions (including counselling) can be related to karma yoga.

Actions can be classified into Nitya (daily routines), Kamya (desire-driven), Nishidha (sinful), Naimithika (occasional duties) and prayaschitha (compensatory). Another classification is into Sakama karma (desire driven) and Nishkama karma (action motivated only by a sense of duty, without any concern for the results. The concept of Nishkama Karma is close to Maslow's notion of Meta motivation (action stemming from fullness) as against deficiency motivation.

2. Bhakthi yoga
Bhakthi yoga is the yoga of emotions. It is controlled cultivation of higher emotions. It involves the awakening, actualising and controlling of libidinal forces. It draws out latent emotional potentiality, arouses experiencial capacities and merges suppressions, repressions and inhibitions.

Gods represent psychic forces. God is the symbol of one's own evolved self. It is Brahman (the absolute) relfected in Maya (the percieved reality). Through Bhakthi yoga you seek your own true identity. Each person is advised to select or conceive of a God suited to his personality requirements.

Bhakthas are of different types: The Artha prays to escape from suffering. The Jignasu does so out of curiosity. The Artharthi seeks material gain. The Jnani seeks deliverance. This classification is based on the aim of the Bhaktha.

Bhakthi or devotion has been broadly classified into Saguna Bhakthi (God with name & form) and Nirguna Bhakthi (God as the absolute consciousness). There is some agreement that Nirguna Bhakthi represents a higher type of Bhakthi than Saguna Bhakthi. In Dasya Bakthi, the bhaktha considers himself to be the servant of God. In Sakhya Bhakthi God is approached in a friendly manner. This has been further subdivided into relationships in which God is considered as a friend, a child or lover. In bridal mysticism, the sadhaka (regardless of whether he is male or female) considers himself a female and God as his lover. Love and hate are two sides of the same coin and there is Vaira Bhakthi in which God is contemplated as an enemy. Some sadhakas have mixed emotions; they shower praise as well as abuse on the chosen god.

The instruments of worship are the body (for puja, archana, vandana), word (for parayana, sravana, keerthana and japa) and mind (smarana). To a sadhaka following Bhakthi yoga, Bhakthi is a pleasurable experience and an end in itself. To him God is not just a device, but more real than any object of the senses.

The goal of Bhakthi is to replace fear by love.

3. Raja Yoga
This is the yoga of exercises and mind control. The term yoga is most often used to refer to Raja Yoga. This is also the type of yoga where a formal guru is considered essential. Usually there are initiation ceremonies to initiate a person into Raja yoga. Pathanjali's Yogasutra (1st century A.D.) is considered to be the best known treatise on yoga. It is also known as Astanga yoga or yoga with eight limbs as follows:

1. Yama (ethical condcut) - Ahimsa, Sathya, Astheya (non-stealing), brahmacharya and aparigraha (non-acceptance of gifts)
2. Niyama (practices and observances) - Soucha (cleanliness), Santhosha, Thapa (austerity), Swadhyaya (study) and Iswara Pranidhana (surrender to God)
3. Asana - yogic postures. Asanas, kriyas (stomach wash, etc.) and pranayama together are called Hata yoga.
4. Pranayama - breath control. This is supposed to purify the mind. This involves paying attention to breathing and regulating the duration of inhalation (Puraka), holding breath (Kumbhaka) and exhalation (Rechaka).
5. Prathyahara - Withdrawal of the mind from the objects of the senses.
6. Dharana - Concentration. Achieving one pointedness.
7. Dhyanam - meditation - achieving stillness of mind.
8. Samadhi - superconscious state. The person enjoysbliss, peace and freedom. There is lack of body consciousness and concern.

The different states of mind are Kshiptha (scattered), Moodha (slovenly and sleepy), Vikshiptha (oscillating), Ekagra (one pointed) and Nirudha (controlled). The different states of consciousness are Jagrath (waking), Swapna (dream), Sushupthi (deep sleep), Thuriam (superconscious) and Thuriatheetham (absolute). Samadhi itself is of three grades - Savikalpa samadhi involves retention of personal identity while in Nirvikalpa samadhi, there is the experience of pure consciousness, beyond time and space.

Sahaja samadhi is experience of samadhi within, all the time, even when the person interacts and behaves like an ordinary person. Ishta samadhi is samadhi at will. Bhavasamadhi is experienced by artists. Karma samadhi is experienced by karmayogis. Jada samadhi is not real samadhi; it is a state of numbness experienced by pranayama or meditation and often mistaken for real samadhi.

Kundalini Yoga:
It is supposed that consciousness has three sheaths - Physical body, astral body and causal body. There are seven psychic centres in the astral body along the spine. They are Muladhara (root of spine), Swadhistana (corresponding to sex organs, in spine), Manipuraka (corresponding to navel), Anahatha (corresponding to heart), Visudhi (corresponding to throat), Ajna (corresponding to pineal gland, at the base of the brain) and Sahasrara (slightly above the head). It is supposed that in ordinary persons, pschic energy lies dormant in the form of a coiled serpent in Muladhara chakra. By intense visualisation, the yogi attempts to arouse the kundalini sakthi and make it move along the spine upwards passing through the other chakras. Various siddhis are obtained when the kundalini reaches the different centres. The major siddhis are eight in number. Samadhi is experienced when the energy reaches sahasrara chakra. Many techniques of kundalini yoga involve pranayama. Kundalini is often visualised as moving up along with inhalation and it is visualised as coming down (in two different paths crossing each other at the chakras during exhalation.

Mantra Yoga:
In Mantra yoga, the yogi repeatedly utters a word or a few words constituting the mantra. The word may or may not have a meaning. It is supposed that thoughts have power and that the principle of autosuggestion makes for changes in the person who repeatedly utters a mantra with meaning. The mantra is a means to bring back the wandering mind and make it one-pointed. In yoga, the mantra is used to evoke higher states of consciousness by association, while in black magic the mantra is used to evoke psychic power. The commonly used mantras include Om, yogic aphorisms like Aham Brahamasmi and names of gods and goddesses. It is believed that silent utterance in the mind has more effect than loud utterance.

Tanthra Yoga:
This type of yoga flourished in north eastern India. Elements of manthra yoga and Kundalini yoga are included in Tanthra yoga. Some tanthric sects think that controlled indulgence of sense pleasures is a means to arouse Kundalini and that indulgence with awareness and with the aim of self-realisation enables the yogi to gradually transecend desires. Partial indulgence without full satisfaction is seen as a method of arousing and sublimating libidinal forces.

Meditation is the most important technique of Raja yoga. It is functioning in the passive, receptive mode, as against the active mode. It increases awareness and control and has some similarities with bio-feed back. It gradually reduces restlessness and reduces instinctual disturbances. Instincts cause mechanical, uncontrolled behaviour and meditating makes for more conscious behaviour.

A lot of modern scientific research has gone into the effects of meditation. Japanese scientists found that monks in meditation show alpha brain wave by reduction in heart rate, BP, respiratory rate, rate of oxygen consumption, muscular tension, electrical skin conductivity of the skin, lactate content in blood, etc. Meditators show increased perceptual ability, higher gains in IQ, creativity, academic achievement, adjustment, stress tolerance, work output and athletic performance. Meditating prisoners show better rehabilitation. A significant reduction in crime rate was observed in cities where a significant percentage of the people were meditating (Maharishi effect). Meditating drug addicts showed more improvement than control groups. Meditation techniques have been incorporated into many modern psychotherapeutic systems (like Autogenic Training of Schultz, Morita Therapy of Japan, and Zen Integration therapy).

4. Jnana Yoga
This is the yoga of the intellect. Some people think that each type of yoga is meant for people with a certain type of temperament while some others like Aurobindo speak of an integral yoga which combines all the four yogas as best. Still others think that there is a gradation. Initial preparation and readiness are required for the practice of any yoga, without which imbalances may develop. Karma yoga is for beginners and after achieving a degree of purity one becomes ripe for Bhakthi yoga when devotion spontanesously appears in the heart. Bhakthi yoga prepares one for practice of Raja yoga and mind control. Finally the person reaches the stage where the existential questions arise with force in his mind and he becomes a Jnana yogi. All intellectual effort, in a broad sense is Jnana yoga. Broadly conceived, all scientists and philosophers are Jnana yogis. Low living and high thinking go together and an austere life is part of Jnana yoga. It is said that if a person is genuinely curious about anything, that will in due course lead him to the same ultimate questions of existence the final answer to which lies in a transformation of personality leading to an alteration in consciousness. You can't know reality without becoming part of it.

The four stages of acquiring knowledge are sensory perception, testimony by somebody, reasoning and the last is insight. Sensory and intellectual knowledge is supposed to be indirect (Paroksha Jnana) while direct knowledge (Aparaoksha Jnana) is intuitive. Apara Vidya is wordly knowledge while truth is apprehended through Para vidya.

The first step in Jana yoga is developing a real urge to ralise the truth, or asking the one ultimate question: what is reality ? One has to discard wrong answers by reasoning - Neti, Neti (not this, not this). Intellectual blocks have to be surmounted. In the language of Advaitha, one has to experience Paramarthika reality, discarding Vyavaharika (empirical) and Prathibhasika (illusory). Dwaitha is unreal and the result of Maya. Truth is unitary; it is the Advaithic experience. The method is Sravana, Manana and Nididhyasa i.e., hearing, thinking and fitting what one has understood to one's actual experience. Finally one realises one's indentity with pure consciousness and the perceiver, perception and object of perception merge into one supreme experience.


Buddhism is said to be the most 'scientific' religion. It does not speak of a God. There is no soul, but only the continuation of experiences or karma or personality through different incarnations. The ultimate reality is described as vacuum or 'Sunyata'. The four noble truths are

Pain, Cause of pain (passion and lust), Annihilation of Pain (i.e., the possibility of ending pain or suffering), The eight fold path leading to cessation of pain.

The eight fold path consists of right views, right intention, right speech, right conduct, right livelihood, right effort (mental exercises), right mindfulness (of body, mind and actions) and right meditation. The capacity for moral sense is inherited but it has to be developed by pracitce.

Desirelessness is the key to nirvana and the path is moderation, not total indulgence or complete self-denial. One has to become indifferent to pain and pleasure.

Buddhism does not emphasise the guru-sishya system. It encourages free enquiry. Buddha told his disciples not to accept anything because he said it, but only if it appeared rational. His last words were, "Do not seek refuge in anything external, be a refuge unto yourself". One should not have any belief or preconception. But one should pierce all preconceptions like a diamond needle (Vajracheda) to experience truth.

Theravada (thera=elders) follows the orignal teachings of Buddha, while Mahayana sects admit innovations.

The Psychology of Zen
Zen is a variety of Buddhism which evolved in Japan from 6 th century A.D. The word Zen is derived from Dhyan meaning meditation. A novice has to take a vow to save all beings which induces the right motivation to realise truth. Zen practice involves different elements.

1. Zazen:
This is sitting zen. One has to sit in the cross-legged posture and take a few deep breaths. One may sway from side to side two or three times to become flexible and not rigid. Then there are several options. Just sitting (which is a very difficult, but highly valued practice), observing the body (cultivation body awareness by observing the sensations from different parts of the body), Watching the mind (feelings and thoughts which arise), watching the breath, counting the breath, etc.

2. Mobile Zen:
This is cultivating mindfulness. Learn to enter fully into every action, with maximum awareness, and presence.

3. Koan Zen:
A koan is a riddle with no clear answer. No answer is expected. The attempt is to break the tyranny of the intellect and the ego. Absorption and penetration into the koan leads to a change in consciousness. Most koans are in the form of a question, some are in action form. Some koans were asked by a Zen master at a certain point during a conversation which helped the disciple who was ready for enlightenment, but was having some block to get over the block and experience sudden enlightenment. Many koans clear the egoistic feeling resulting from bookish erudition. When a certain disciple was asking hair-splitting questions endlessly, a Zen master said, "Have you taken your breakfast? ... Then wash you bowl." In a similar context another Zen master went on pouring tea into a cup even after tea was overflowing. Some other well-known koans are, "Use the spade in your empty hand", "Talk without using your tongue", "What is the sound of one hand clapping?"

Every block is considered to be an opportunity for learning (gateless gate).

Other Zen practices include Concentration or contemplation (on various shapes, qualities, chakras in the body,mandalas symmetric geometric forms), manthras, etc. For tension release and getting rid of inhibitions, disciples are made to utter a calm cry followed by vigorous shouting.

The results of Zen are flexibility, clarity, serenity, peace of mind, work-efficiency, personality integration, self-control and self-realisation. Kensho is experiencing self-transparency and the final enlightenment (satori) may come all on a sudden on gradually. In the final stage the realised person sees perfection and significance in every thing (suchness) and everything is seen as beautiful. He is self-sufficient and the only thing which motivates him to act is compassion.

Jain philosophy also differentiates cognitive knowledge and intuitive understanding. The path to realisation of the Jain system has three main steps: right faith, right knowledge and right conduct (consisting of satya, astheya, ahimsa, aparigraha and brahmacharya. While Buddhism emphasises moderation, Jainism emphasises meditation. Buddhism advocates partial non-violence in the sense that even eating meat is permitted under special circumstances.

Taoism is a religion which flourished in China. Tao means "Way" or" How". Tao cannot be defined, because there is nothing to compare it with. It can be known by becoming aware of what is happening through meditation. Tao does not behave, does nothing at all, yet everything gets done. Tao applies to everything. All things and events are vibratory, but Tao is not a vibratory event. Tao can be realised by becoming aware of what is happening with an open mind. Tao has no opposites and polarities, Tao is One. Tao is unity. Nothing comes before Tao, Nothing made Tao. Tao is the law of all things, the common ground of all creation. Knowing Tao is not a learning process, but a process of subtraction. The yin-yang figure illustrates the principle of oneness which contains apparent dichotomies (ex. like & dislike, gain & loss).

Taoism is considered as one of the oldest religions of the world. Lao Tsu who lived in 6th century B.C. codified Taoism. The main guideline for living is to actualise the principle of Wei Wu-Wei (Action Non-action) which means cultivating an attitude of deterministic acceptance, detachment and transcendence.

Taoism considers intellect as a block and the path to enlightenment is a process of subtraction and not learning. The Taoist way of life involves living in harmony with nature.

Sufism is the mystic sect of Islam. It origninated in Persia and spread to all countries having Muslims, including India. Mysticism in all religions share the same basic features and Sufism is no exception. At the philosophical level, the dictum "Anal Haq" (meaning the same as Aham Brahmasmi) expresses identification with pure consciousness. At the emotional level Sufi mystics symbolise themselves as the bride and God as the lover and dance and sing in ecstasy. In India some Sufis even wear female costumes on ceremonial occasions. Sufi contribution to devotional poetry and music has been considerable. Many Hindustani ragas and the Quawali type of singing originated in Sufism. A large collection of Sufi teaching stories are available. The Sufi dance involves very fast whirling movements. Like in many other religions, Sufi mystics were considered heretics and subjected to persecution by orthodox Muslims. Many Sufi mystics are credited with paranormal powers. One power sometimes supposedly demonstrated is making wounds on one's own body which spontaneously heal quickly.




The term Indian Psychology refered to the Psychologically relevant materials in ancient Indian thought. Usually this term does not cover modern developments in Psychology in India.

Modern Psychology at the beginning of the century emphasized sensation, perception and psychologists in India took out Indian theories of sensation and perception from the classics and created an Indian Psychology. For example Indian theories emphasise the notion that in perception the mind goes out through the senses and assumes the shape of the objects. In 1934, Jadunath Sinha wrote a book on Indian theories of perception. As soon as Western Psychologists started studying cognition, Indian Psychologists started looking for Indian theories of cognition. In 1958, Jadunath Sinha wrote a book on Cognition. Later on modern Psychology started emphasising emotions, and in 1981, Jadunath Sinha wrote a book on Emotions and the Will.

The major part of ancient Indian scriptures (Hindu, Buddhist and Jain) emphasise self-realization, samadhi or nirvana. After 1960 Humanistic Psychology emerged and Psychologists became interested in paranormal dimensions of growth. Maslow's theory of self-actualization and transcendental self-actualization established the link to the major part of ancient Indian theories and methods and almost the whole of ancient Indian writings became psychologically relevant. Psychology of Consciousness, Parapsychology, Psychology of Mysticism, Psychology of Religion and Transpersonal Psychology borrow extensively from Indian writings. The terms Oriental Psychology, Buddhist Psychology, Yoga Psychology , Jain Psychology, etc. are frequently found in modern psychological literature now. Many book lists in Psychology now include books on Yoga, Buddhism and Zen. There seems to be a paradigm shift in Western Psychology, a shift from the notion of mental disease and healing to personal growth, the reference point shifting from the statistical average or "normal" to the ideal or upper limits of man's potentiality.

The rudiments of the theory of consciousness can be traced back to the Indus valley civilization (6000 to 1500 B.C.). Artifacts of a man sitting in Padmasana have been obtained in excavations. The Swasthika symbol was used in Indus valley script. Buddhist thought and methods (6th century B.C.) are in line with the objective spirit of modern science and the law of parsimony of science and Buddhism can be easily incorporated into a scientific framework. The Psychological relevance of the four noble truths and eight-fold path and Sunya vada of Buddhism and Buddhist techniques of meditation are of considerable relevance in modern Psychology. Similarly Jain scriptures also are found to be relevant to Psychology in more than one way. The Vedas date from about 1500 B.C. However, Upanishads (appendices to the Vedas, which date from 600 B.C.) which describe the Vedanta philosophy and provide the theoretical foundation of Jnana Yoga are of more direct relevance to Psychology. The Bhagavat Gita gives a quintessence of Indian way of life and philosophy and it describes the four yogas, Karma, Bhakthi, Raja and Jnana. Several books have come on the psychological relevance of Gita. Maslow's theory of Meta-motivation is very similar to the concept of Nishkama karma outlined in the Gita.

Patanjali's Ashtanga Yoga is a very systematic presentation of Raja yoga. Both Bhagavat Gita and Ashtanga Yoga are supposed to have been written around the turn of B.C. to A.D. Sankara's writings (8th century A.D.) on the different yogas as well as his Advaita philosophy are considered as classics in the area and are of great value to the Psychology of consciousness as well as personal growth. Modern interest in relaxation can be traced to studies on Savasana. Rising popularity of meditation practice links Psychology to Oriental religious practices and philosophy.

Indian literature on aspects of consciousness is broad, considering the classics and their commentaries. Mental states have been analyzed, classified and differentiated in detail. Similarly paranormal powers (siddhis) have been classified in detail. The process of personal growth and obstacles to growth have been examined thoroughly. There is a great deal of maturity resulting from long experience in these areas reflected in the writings. Indian theories of linguistics, social behavior, crime, etc. are all based on the holistic approach and the broad-based intuitive understanding of behavior in contradistinction to Western theories which are piece-meal, analytic and situation specific. The increasing importance given to the holistic approach and need for synthesis makes it possible to integrate modern Western Psychology with ancient Indian thoughts as well as methods.

The psychosomatic relationship was well known and salient in ancient times. The very first invocatory stanza of Ashtangahridaya (the main text in Ayurveda, written in 4th century A.D.) describes how emotions like desires lead to both physical and mental diseases.

Many attempts are being made to integrate ancient Indian Psychology with modern Western Psychology. More than 40 books have appeared in the field of Indian Psychology. There is a journal of Indian Psychology published from Andhra University which has an Institute of Yoga and Consciousness. At least five persons have developed personality inventories based on the Triguna theory (Satwa, Rajas and Tamas) of Kapila (Sankhya philosophy, 6th century B.C.)

Saturday, August 23, 2008


It is possible to reduce and manage our communication anxiety. Given below is a list of tips compiled from different sources.
1. Remember that communication apprehension or anxiety is a very natural and normal human emotion.
2. Accept that you have communication apprehension.
3. What are your fears? Make a list of your fears and see whether they are realistic.
4. Be determined to overcome your communication anxiety. Take steps immediately.
5. Practice breathing and relaxing. Deliberate slow breathing can reduce most fear.
6. Prepare ahead. Last minute preparation makes you feel uncomfortable in front of an audience.
7. Structure your presentation. It helps you reduce your fear to a great extent.
8. Use visual aids such as power point and videos; they can help you remember different parts of your speech. If your visual aids are effective, the focus of the audience will be on the visuals rather than on you.
9. Get support from your friends or teachers. Discuss your topic with them and get their guidance. It helps you gain confidence.
10. Have positive thoughts. Tell yourself that you are going to make a successful presentation.
11. Know your audience.
12. Don’t memorize your speech. This means, reduce your script to a key-word outline, constantly practicing reducing the notes to keywords. Eventually you might not even need notes.
13. Dress for focus. Wear comfortable and appropriate clothes.
14. Remember that you can learn from others. Watch your classmates and learn, but do not compare yourself to them and put yourself down.
15. Be aware of your time limit.
16. Remember you can become a successful communicator.

Wednesday, August 20, 2008

The Therapist as a Person

The Therapist as a Person

Index of Articles
Therapists as Patients: A National Survey of Psychologists' Experiences, Problems, and Beliefs [Professional Psychology]
This survey of psychologists found that of 84% who had been in therapy, 22% found it harmful, 61% reported clinical depression, 29% reported suicidal feelings, 4% reported attempting suicide, 26% reported being cradled by a therapist, 20% reported withholding important (mostly sexual) information, and 10% reported violations of confidentiality.

Therapists' Anger, Hate, Fear, and Sexual Feelings - National Survey of Therapist Responses, Client Characteristics, Critical Events, Formal Complaints, and Training [Professional Psychology]
Therapists reported frequencies of experiencing instances of feeling anger, hate, fear, and sexual attraction or arousal; encountering client events (e.g., client orgasm, client disrobing, client suicide, client assault on therapist or third party); and engaging in various behaviors (e.g., avoiding clients with human immunodeficiency virus, kissing clients, massaging clients, using weapons or summoning police for protection from clients), with findings differing according to therapist gender, client gender, and theoretical orientation.

National Survey of Psychologists' Sexual and Physical Abuse History and Their Evaluation of Training and Competence in These Areas [Professional Psychology]
This survey of clinical and counseling psychologists found that over two thirds of the women and one third of the men reported having experienced some form of physical or sexual abuse.

The Experience of 'Forgetting' Childhood Abuse: A National Survey of Psychologists [Journal of Consulting & Clinical Psychology]
Almost a quarter of this national sample of psychologists reported childhood abuse, and of those, about 40% reported a period of forgetting some or all of the abuse; major findings included (a) both sexual and nonsexual abuse were subject to periods of forgetting; (b) the most frequently reported factor related to recall was being in therapy; (c) about half of those who reported forgetting also reported corroboration of the abuse; and (d) reported forgetting was not related to gender or age of the respondent but was related to severity of the abuse.

Discussing Death With Children [U.S. Department of Health, Education, and Welfare, Office of Child Development, Children's Bureau]
Gerry Koocher, Ph.D., ABPP, discusses the developmental and other issues that arise in talking with children about death, whether the death of a parent, another relative, a friend, or even a school pet.

The Psychologist As Artist: Watercolors by Psychologist James N. Butcher
During a sabbatical, clinical and forensic psychologist Jim Butcher took up painting. This section includes 4 of his watercolors: Minnehaha Falls, Glacier Express, Bike Trail at Excelsior, and Vicksburg Courthouse.

Therapist's Guide To Making a Professional Will [American Psychological Association]
This chapter from the American Psychological Association's book, How To Survive and Thrive as a Therapist: Information, Ideas, & Resources for Psychologists, provides a step-by-step guide for preparing a professional will.

Clinical Practice Strategies Outside The Realm Of Managed Care [American Psychological Association annual meeting]
This paper by psychologist Steve Walfish presents ways to develop "a fee-for-service practice that does not take managed care clients at all so that clinical care and income will not be compromised."

What Therapists Don't Talk About and Why: Taboos That Hurt Us and Our Clients by Kenneth S. Pope, Ph.D., ABPP, Janet L. Sonne, Ph.D., and Beverly Greene, PhD., ABPP Publisher: American Psychological Association
"It is essentially a superb text about the practice of psychotherapy, with all its unexpected twists, turns, and difficulties for therapists and patients. From its excellent short courses on logical and ethical fallacies, to its astonishing variety of intensely provocative case examples with self-assessment questions, to its steamy discussions of therapists' sexual feelings, the book illuminates, in a non-threatening, conversational tone, the previously-avoided dimensions of the therapeutic endeavor. It belongs on the shelf of any therapist willing to learn or think critically about psychotherapy."Thomas G. Gutheil, M.D.Professor of PsychiatryHarvard University

How To Survive and Thrive as a Therapist: Information, Ideas, & Resources for Psychologists by Kenneth S. Pope, Ph.D., ABPP & Melba J. T. Vasquez, Ph.D., ABPP
Publisher: American Psychological Association
"This comprehensive practical guidebook is a must for all new and seasoned clinicians. From attorneys to ethics, from billing to possible errors in logic--it is all here. A remarkable compendium. Kudos to Pope and Vasquez!" --Donald Meichenbaum, PhD, University of Waterloo, Ontario, Canada

Sexual Issues in Psychology Training and Practice

Sexual Issues in Psychology Training and Practice

Links to Articles, Books, and Abstracts
Full-text Articles

Sexual Intimacy in Psychology Training: Results and Implications of a National Survey [American Psychologist]
This national study found that 17% of the women, compared with 3% of the men, reported sexual contact as psychology students with their psychology faculty; that 19% of the men, compared with 8% of the women, reported sexual contact as psychology educators with their psychology students; that 25% of recent female graduates reported engaging in sex as students with their psychology faculty; and that12% of the males, compared with 3% of the females, reported sexual contact as psychotherapists with their clients.

Sexual Attraction to Clients: The Human Therapist and the (Sometimes) Inhuman Training System [American Psychologist]
This national study found that 87% of the participants reported sexual attraction to at least one client; that 9.4% of men and 2.5% of women reported acting on such feelings (i.e., engaging in sex with a client); that a majority reported feeling guilty, anxious, or confused simply by feeling attracted; that about half reported receiving no guidance or training concerning this issue; and only 9% reported that their training or supervision was adequate.

Sex Between Therapists and Clients [Academic Press]
This 2001 chapter examines the history of this issue, reviews the research, discusses gender patterns, analyzes potential harm, and notes the profession's urgent, unfinished business in this area.

Prior Therapist-patient Sexual Involvement Among Patients Seen by Psychologists [Psychotherapy]
The findings from this national study suggested that harm occurred for about 90% of the patients who engaged in therapist-patient sex; harm occurred for about 80% when the sex began only after termination; 5% involved minor patients; 3% involved marriage to the therapist; 32% involved patients who had experienced child sex abuse; 10% involved patients with a history of rate; 11% required hospitalization of the patient; 14% involved patient suicide attempts; 1% involved completed suicides; and 12% involved formal complaints.

Therapist-Patient Sexual Intimacy Involving Children and Adolescents [American Psychologist]
In this study, the ages of the female patient ranged from 3 through 17, with an average of 14; the ages of the male patients ranged from 7 through 16, with an average of 13.

Therapist-patient Sex as Sex Abuse: Six Scientific, Professional, and Practical Dilemmas in Addressing Victimization and Rehabilitation [Professional Psychology]
This article uses historical quotes and data to examine 6 problems in adequately addressing issues of therapist-patient sex: (a) acknowledging the scope of the phenomenon, (b) affirming the notion and the mechanisms of accountability, (c) assessing the validity of allegations, (d) evaluating the nature and validity of research evidence, (e) overcoming perpetrator stereotypes and inclinations to collude with or to enable sex offenders, and (f) confronting the notion of victim responsibility.

Sexual Feelings In Psychotherapy:Explorations for Therapists and Therapists-in-Training by Kenneth S. Pope, Ph.D., ABPP, Janet Sonne, Ph.D. & Jean Holroyd, Ph.D. Publisher: American Psychological Association.
"Like a trusted confidant, this reassuring yet challenging book shows how research, theory, and the reader's own feelings can be used to guide clinical practice. It is that rarest of books with which the reader shares an intimate dialogue of personal discovery. Powerful, truthful, and adventurous, it will serve as an essential text to which seasoned therapists will return again and again and should be required reading in all training programs." -- Professor Jesse Geller, Yale University

Sexual Involvement With Therapists: Patient Assessment, Subsequent Therapy, Forensics by Kenneth S. Pope, Ph.D., ABPP. Publisher: American Psychological Association.
"A landmark contribution. The research, forms, and lists of cross-examination questions will be invaluable to subsequent therapists who appear in court. This unique resource is essential reading for expert witnesses and trial attorneys." -- Nancy Adel, Esq., Partner, Law Firm of Adel & Pollack

Sexual Intimacy Between Therapists and Patients by Kenneth S. Pope & Jacqueline Bouhoutsos
"A thoroughly unique, impressively comprehensive, and long-awaited contribution. A storehouse of information. Plaintiff and defense lawyers and expert witnesses would be well advised to be aware of its contents." --Jay Ziskin, Ph.D., LL.B. Past President, American Psychology-Law Society

National Survey of Social Workers' Sexual Attraction to their Clients: Results, Implications, and Comparison to Psychologists [Ethics & Behavior]
In this national study of social workers, most participants reported having experienced sexual attraction to a client, causing (for most) guilt, anxiety, or confusion; 3.6% of male participants and 0.5% of female participants reported sex with a client; training was related to likelihood of offending, though the effect was small and complex; an analysis of 8 national studies found significant effects for gender and year of study but not for profession.

Licensing Disciplinary Actions for Psychologists Who Have Been Sexually Involved with a Client [Professional Psychology]
This study of licensing disciplinary actions for psychologists who had been sexually involved with a client collected information about offender age, gender, and marital status; for each case, the number of clients involved and whether they were adults or minors are provided.

Therapists' Sexual Feelings and Behaviors: Research, Trends, and Quandaries. This chapter appears in Psychological Perspectives on Human Sexuality (pp. 603-658), edited by Lenore Szuchman and Frank Muscarella, published by John Wiley and Sons, 2000.
This chapter includes the following sections: introduction; Education About Sexual Feelings; A Topic Not Just for the Intellect (vignettes, exercises & discussion questions); What Percentage of Therapists Engage in Sex with Their Patients?; Common Scenarios of Therapist-Patient Sexual Involvement; History of the Prohibition; Initial Research; Gender Patterns; When The Majority Masks the Minority; How Therapist-Patient Sex Affects Patients; Special Treatment for Offenders; Research and Rehabilitation; What To Do When You Don't Know What To Do; References.

Sexual Behavior Between Clinical Supervisors and Trainees: Implications for Professional Standards [Professional Psychology]
This article notes that at least 4 areas need attention: the prevalence and nature of such sexual contact, its effects on clinical training, ethical implications, and the potential legal liability of supervisors who engage in sexual intimacies with trainees.

Therapist-patient Sexual Involvement: A Review of the Research [Clinical Psychology Review]
This article reviews research findings about the occurrence and effects of therapist-patient sexual intimacies, looking at such variables as gender, discipline, theoretical orientation, age, patient risk factors, and consequences for patients.

Responding to Suicidal Risk

Responding to Suicidal Risk
Ken Pope, Ph.D., ABPPMelba J.T. Vasquez, Ph.D., ABPP

View citation and copyright.
This chapter is divided into the following sections:
evaluating suicidal risk: 21 factors
10 steps to reduce risk
Avoidable pitfalls: advice from the experts (Norman Farberow, Marsha Linehan, Nadine Kaslow, Ricardo Munoz, Jessica Henderson Daniel, David Rudd, Daid Barlow, Erika Fromm, Larke Nahme Huang, Gary Schoener, Marla Craig, Jesse Geller, Don Hiroto, Helen Block Lewis, Hans Strupp, Michael Peck)
difficult scenarios & questions
related studies
Few responsibilities are so heavy and intimidating as responding to suicidal risk. The need for careful assessment is great. Suicide remains among the top dozen causes of death in the United States, as high as number two for some groups. Homicide rates seize popular attention, but far more people kill themselves than kill others. Authorities in the field are almost unanimous in their view that the reported figures vastly understate the actual incidence because of problems in reporting procedures.
Evaluating and responding to suicidal risk is a source of extraordinary stress for many therapists. This aspect of our work focuses virtually all of the troublesome issues that run through this book: questions of the therapist's influence, competence, efficacy, fallibility, over- or under-involvement, responsibility, and ability to make life-or-death decisions. Litman's (1965) study of over 200 clinicians soon after their clients had committed suicide found the experience to have had an almost nightmarish quality. They tended to have intense feelings of grief, loss, and sometimes depression as anyone—professional or nonprofessional—might at the death of someone they cared about. But they also had feelings associated with their professional role as psychotherapist: guilt, inadequacy, self-blame, and fears of being sued, investigated, or vilified in the media. In a similar study, both the short-term and permanent effects of a client's suicide upon the therapist were so intense that Goldstein and Buongiorno (1984) recommended providing support groups for surviving therapists.
Solo practitioners may be even more vulnerable than their colleagues who practice within the contexts of institutions with their natural support systems. Those in training may constitute one of the most vulnerable groups. Kleespies, Smith, and Becker (1990) found that "trainees with patient suicides reported stress levels equivalent to that found in patient samples with bereavement and higher than that found with professional clinicians who had patient suicides" (p. 257). They recommend that all training programs have a protocol for assisting trainees with client suicide: "There is a need for an immediate, supportive response to the student to prevent traumatization and minimize isolation . . . and . . . for a safe forum that will allow the student to express his or her feelings, will ensure positive learning from the experience, and will help the student to integrate it constructively into future work with high-risk patients" (pp. 262-263).
If the challenges of helping the suicidal client evoke extraordinary feelings of discomfort from many therapists, they also show the extraordinary efforts that some therapists take to help their clients stay alive. Davison and Neale (1982), for instance, described the ways in which "the clinician treating a suicidal person must be prepared to devote more energy and time than he or she usually does even to psychotic patients. Late-night phone calls and visits to the patient's home may be frequent."
Bruce Danto, a former director of the Detroit Suicide Prevention Center and former president of the American Association of Suicidology, stated: "With these problems, you can't simply sit back in your chair, stroke your beard and say, 'All the work is done right here in my office with my magical ears and tongue.' There has to be a time when you shift gears and become an activist. Support may involve helping a patient get a job, attending a graduation or play, visiting a hospital, even making house calls. I would never send somebody to a therapist who has an unlisted phone number. If therapists feel that being available for phone contact is an imposition, then they're in the wrong field or they're treating the wrong patient. They should treat only well people. Once you decide to help somebody, you have to take responsibility down the line" (Colt, 1983, p. 50).
Norman Farberow, one of the preeminent pioneers in the treatment of the suicidal client, described instances in which the therapist provided very frequent and very long sessions (some lasting all day) to a severely suicidal client as "examples of the extraordinary measures which are sometimes required to enable someone to live. Providing this degree of availability to the client gives the client evidence of caring when that caring is absolutely necessary to convince that client that life is both livable and worth living, and nothing less extreme would be effective in communicating the caring. In such circumstances, all other considerations -- dependence, transference, countertransference, and so on --become secondary. The overwhelming priority is to help the client stay alive. The secondary issues—put 'on hold' during the crisis—can be directly and effectively addressed once the client is in less danger" (Farberow, 1985, p. C9).
Stone (1982) describes a vivid example of the lengths to which a therapist can go to communicate caring in an effective and therapeutic manner to a client in crisis. Suffering from schizophrenia, a young woman who had been hospitalized during a psychotic episode continuously vilified her therapist for "not caring" about her. Without warning, she escaped from the hospital: "The therapist, upon hearing the news, got into her car and canvassed all the bars and social clubs in Greenwich Village which her patient was known to frequent. At about midnight, she found her patient and drove her back to the hospital. From that day forward, the patient grew calmer, less impulsive, and made great progress in treatment. Later, after making substantial recovery, she told her therapist that all the interpretations during the first few weeks in the hospital meant very little to her. But after the 'midnight rescue mission' it was clear, even to her, how concerned and sincere her therapist had been from the beginning" (p. 171)

Assessing Suicidal Risk

Awareness of the following twenty factors may be useful to clinicians evaluating suicidal risk. Four qualifications are particularly important. First, the comments concerning each factor are extremely general, and exceptions are frequent. In many instances, two or more factors may interact. For example, being married and being younger, taken as individual factors, tend to be associated with lower risk for suicide. However, married teenagers have historically shown an extremely high suicide rate (Peck & Seiden, 1975). Second, the figures are not static; new research is refining our understanding of the data as well as reflecting apparent changes. The suicide rate for women, for example, has been increasing, bringing it closer to that for men. Third, the list is not comprehensive. Fourth, these factors may be useful as general guidelines but cannot be applied in an unthinking, mechanical, conclusive manner. A given individual may rank in the lowest-risk category of each of these factors and nonetheless commit suicide. These factors can legitimately function as aids to, not as substitutes for, a comprehensive, humane, and personal evaluation of suicidal risk for a unique person. Again it is worth emphasizing a central theme of this book's approach to ethics: Perhaps the most frequent threat to ethical behavior is the therapist's inattention. Making certain that we consider such factors with each client can help us prevent the ethical lapses that come from neglect.

Direct verbal warning.

A direct statement of intention to commit suicide is one of the most useful single predictors. Take any such statement seriously. Resist the temptation to reflexively dismiss such warnings as "a hysterical bid for attention," "a borderline manipulation," "a clear expression of negative transference," "an attempt to provoke the therapist," or "yet another grab for power in the interpersonal struggle with the therapist." It may be any or all of those and yet still foreshadow suicide.


The presence of a plan increases the risk. The more specific, detailed, lethal, and feasible the plan, the greater the risk.

Past attempts.

Most, and perhaps 80 percent of, completed suicides were preceded by a prior attempt. Schneidman (1976) found that the client group with the greatest suicidal rate were those who had entered into treatment with a history of at least one attempt.

Indirect statements and behavioral signs.

People planning to end their lives may communicate their intent indirectly through their words and actions—for example, talking about "going away," speculating on what death would be like, giving away their most valued possessions, or acquiring lethal instruments.


The suicide rate for those with clinical depression is about twenty times greater than for the general population. Guze and Robins (1970; see also Vuorilehto, Melartin, & Isometsa, 2006), in a review of seventeen studies concerning death in primary affective disorder, found that fifteen percent of the individuals suffering from this disorder killed themselves. Effectively treating depression may lower the risk of suicide (Gibbons, Hur, Bhaumik, & Mann, 2005; Mann, 2005)
Hopelessness. The sense of hopelessness appears to be more closely associated with suicidal intent than any other aspect of depression (Beck, 1990; Beck, Kovaks & Weissman, 1975; Maris, 2002; Petrie & Chamberlain, 1983; Wetzel, 1976; however, see also Nimeus, Traskman-Bendz & Alsen, 1997).


Between one-fourth and one-third of all suicides are associated with alcohol as a contributing factor; a much higher percentage may be associated with the presence of alcohol (without clear indication of its contribution to the suicidal process and lethal outcome). Moscicki (2001; see also Kõlves, Värnik, Tooding, & Wasserman, 2006; Sher, 2006) notes that perhaps as many as half of those who kill themselves are intoxicated at the time. Hendin and his colleagues' study of " Problems in Psychotherapy With Suicidal Patients" emphasized that "Addressing and treating suicidal patients’ substance abuse, particularly alcohol abuse, is critical in effective treatment of other problems, including lack of response to antidepressant medication" (2006, p. 71).

Clinical syndromes.

As mentioned earlier, people suffering from depression or alcoholism are at much higher risk for suicide. Other clinical syndromes may also be associated with an increased risk. Perhaps as many as 90% of those who take their own lives have a DSM-IV diagnosis (Moscicki, 2001). Kramer, Pollack, Redick, and Locke (1972) found that the highest suicide rates exist among clients diagnosed as having primary mood disorders and psychoneuroses, with high rates also among those having organic brain syndrome and schizophrenia. Palmer, Pankratz, and Bostwick (2005) found that the lifetime risk for suicide among people with schizophrenia was around 5%. Drake, Gates, Cotton, and Whitaker (1984) discovered that those suffering from schizophrenia who had very high internalized standards were at particularly high risk. In a long-term study, Tsuang (1983) found that the suicide rate among the first-degree relatives of schizophrenic and manic-depressive clients was significantly higher than that for a control group of relatives of surgery patients; furthermore, relatives of clients who had committed suicide showed a higher rate than relatives of clients who did not take their lives. Using meta-analytic techniques, Harris and Barraclough (1997) obtained results suggesting that "virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders" (p. 205).


The suicide rate for men is about four times that for women (Joiner, 2005). For youths, the rate is closer to five to one (see, e.g., Safer, 1997). The rate of suicide attempts for women is about three times that for men.


The risk for suicide tends to increase over the adult life cycle, with the decade from the mid fifties to the mid sixties constituting the age span of highest risk. Attempts by older people are much more likely to be lethal. The ratio of attempts to completed suicides for those up to age sixty-five is about seven to one, but is two to one for those over sixty-five. Suicide risk assessment differs also according to whether the client is an adult or minor. The assessment of of suicidal risk among minors presents special challenges. Safer's review of the literature indicated that the "frequent practice of combining adult and adolescent suicide and suicide behavior findings can result in misleading conclusions" (1997, p. 61). Zametkin, Alter, and Yemini (2001) note that the "rate of suicide among adolescents has significantly increased in the past 30 years. In 1998, 4153 young people aged 15 to 24 years committed suicide in the United States, an average of 11.3 deaths per day. Suicide is the third leading cause of death in this age group and accounts for 13.5% of all deaths…. Children younger than 10 years are less likely to complete suicide, and the risk appears to increase gradually in children between 10 and 12 years of age. However, on average, 170 children 10 years or younger commit suicide each year" (p. 3122).


Generally in the United States, Caucasians tend to have one of the highest suicide rates. Gibbs (1997) discusses the apparent cultural paradox: "African-American suicide rates have traditionally been lower than White rates despite a legacy of racial discrimination, persistent poverty, social isolation, and lack of community resources" (p. 68). EchoHawk (1997) notes that the suicide rate for Native Americans is "greater than that of any other ethnic group in the U.S., especially in the age range of 15-24 years" (p. 60).


The suicide rates among Protestants tend to be higher than those among Jews and Catholics.

Living alone.

The risk of suicide tends to be reduced if someone is not living alone, reduced even more if he or she is living with a spouse, and reduced even further if there are children.


Brunch, Barraclough, Nelson, and Sainsbury (1971) found that 50 percent of those in their sample who had committed suicide had lost their mothers within the last three years (compared with a 20 percent rate among controls matched for age, sex, marital status, and geographic location). Furthermore, 22 percent of the suicides, compared with only 9 percent of the controls, had experienced the loss of their father within the past five years. Krupnick's (1984) review of studies revealed "a link between childhood bereavement and suicide attempts in adult life," perhaps doubling the risk for depressives who had lost a parent compared to depressives who had not experienced the death of a parent. Klerman and Clayton (1984; see also Beutler, 1985) found that suicide rates are higher among the widowed than the married (especially among elderly men) and that, among women, the suicide rate is not as high for widows as for the divorced or separated.


Unemployment tends to increase the risk for suicide.

Health status.

Illness and somatic complaints are associated with increased suicidal risk, as are disturbances in patterns of sleeping and eating. Clinicians who are helping people with AIDS, for example, need to be sensitive to this risk (Pope & Morin, 1990).


Those with poor impulse control are at increased risk for taking their own lives (Patsiokas, Clum & Luscumb, 1979).

Rigid thinking.

Suicidal individuals often display a rigid, all-or-none way of thinking (Maris, 2002; Neuringer, 1964). A typical statement might be: "If I don't find work within the next week then the only real alternative is suicide."

Stressful events.

Excessive numbers of undesirable events with negative outcomes have been associated with increased suicidal risk (Cohen-Sandler, Berman & King, 1982; Isherwood, Adam & Homblow, 1982). Bagley, Bolitho, and Bertrand (1997), in a study of 1,025 adolescent women in Grades 7-12, found that "15% of 38 women who experienced frequent, unwanted sexual touching had 'often' made suicidal gestures or attempts in the previous 6 months, compared with 2% of 824 women with no experience of sexual assault" (p. 341; see also McCauley, Kern, Kolodner, Dill, et al., 1997). Some types of recent events may place clients at extremely high risk. For example, Ellis, Atkeson, and Calhoun (1982) found that 52 percent of their sample of multiple-incident victims of sexual assault had attempted suicide.

Release from hospitalization.

Beck (1967, p. 57) has noted that "the available figures clearly indicate that the suicidal risk is greatest during weekend leaves from the hospital and shortly after discharge."

Lack of a sense of belonging.

Joiner's review of the research and his own studies led him to conclude that "an unmet need to belong is a contributor to suicidal desire: suicidal individuals may experience interactions that do not satisfy their need to belong (e.g., relationships that are unpleasant, unstable, infrequent, or without proximity) or may not feel connected to others and cared about" (2005, p. 97).

10 Steps To Reduce Risk

The risk of client suicide creates a special set of responsibilities. The themes stressed throughout this book gain exceptional importance: Failure of the therapist to take necessary steps can literally be fatal for the client. The following steps, which extend or supplement this book's themes, may be helpful in identifying and coping with the chance that a client may be at risk for suicide.
Screen all clients for suicidal risk during initial contact and remain alert to this issue throughout the therapy.Even clients who are seriously thinking of taking their own life may not present the classic picture of agitated depression or openly grim determination that is stereotypically (and sometimes falsely) portrayed as characteristic of the suicidal individual. Some suicidal clients seem, during initial sessions, calm, composed, and concerned with a seemingly minor presenting problem. Clients who are not suicidal during initial sessions and who sought therapy for a relatively minor problem may, during the course of therapy, become suicidal. The increase in suicidal risk may be due to external events, such as the loss of a job or a loved one, or to internal events, such as setting aside psychological defenses or the onset of Alzheimer's. What is crucial is an assessment of the client's suicidal potential at adequate intervals. In some cases, comprehensive psychological testing or the use of standardized scales developed to evaluate suicidal risk may be useful (see, for example, Beck, Resnick & Lettieri, 1974; Butcher, Graham, Williams & Ben-Porath, 1990; Lettieri, 1982; Neuringer, 1974; Nugent, 2006; Schulyer, 1974; Weisman & Worden, 1972). Range and Knott (1997) evaluated 20 suicide assessment instruments for validity and reliability. On the basis of their analysis, they recommended 3 most highly: Beck's Scale for Suicide Ideation series, Linehan's Reasons for living Inventory, and Cole's self-administered adaptation of Linehan's structured interview called the Suicidal Behaviors Questionnaire.
Work with the suicidal client to arrange an environment that will not offer easy access to the instruments the client might use to commit suicide. Suicidal clients who have purchased or focused upon a specific gun or other weapon may agree to place the weapon where they will not have access to it until the crisis or period of greatest risk is over. Suicidal clients who are currently taking psychotropic or other medication may be planning an overdose. The use of materials prescribed by and associated with mental health professionals may have great symbolic meaning for the client. Arrange that the client does not have access to sufficient quantities of the medication to carry out a suicidal plan.

Work with the client to create an actively supportive environment. To what extent can family, friends, and other resources such as community agencies and group or family therapy help a suicidal person through a crisis?
While not denying or minimizing the client's problems and desire to die, also recognize and work with the client's strengths and (though temporarily faint) desire to live.
Make every effort to communicate and justify realistic hope.Discuss practical approaches to the client's problems.
Explore any fantasies the client may have regarding suicide. Reevaluating unrealistic beliefs about what suicide will and will not accomplish can be an important step for clients attempting to remain alive.
Make sure communications are clear and evaluate the probable impact of any interventions. Ambiguous or confusing messages are unlikely to be helpful and may cause considerable harm. The literature documents the hazards of using such techniques as paradoxical intention with suicidal clients. Even well-meant and apparently clear messages may go awry in the stress of crisis. Beck (1967, p. 53) provides an example: "One woman, who was convinced by her psychotherapist that her children needed her even though she believed herself worthless, decided to kill them as well as herself to 'spare them the agony of growing up without a mother.' She subsequently followed through with her plan."
When considering hospitalization as an option, explore the drawbacks as fully as the benefits, the probable long-term and the immediate effects of this intervention. Norman Farberow (see Colt, 1983, p. 58), cofounder and former co-director and chief of research at the Los Angeles Suicide Prevention Center, warns: "We tend to think we've solved the problem by getting the person into the hospital, but psychiatric hospitals have a suicide rate more than 35 percent greater than in the community."
Be sensitive to negative reactions to the client's behavior. Alan Stone, professor of psychiatry and law at Harvard, has been a pioneer in the acknowledgment of the ways in which some overly fatigued therapists may react with boredom, malice, or even hatred to some suicidal clients. James Chu (quoted by Colt, 1983, p. 56), a psychiatrist in charge of Codman House at McClean Hospital, comments: "When you deal with suicidal people day after day after day, you just get plain tired. You get to the point of feeling, 'All right, get it over with.' The potential for fatigue, boredom, and negative transference is so great that we must remain constantly alert for signs that we are beginning to experience them." Colt notes that "Maltsberger and Buie discuss therapists' repression of such feelings. A therapist may glance often at his watch, feel drowsy, or daydream-or rationalize referral, premature termination, or hospitalization just to be rid of the patient. (Many studies have detailed the unintentional abandonment of suicidal patients; in a 1967 review of 32 suicides . . . Bloom found 'each . . . was preceded by rejecting behavior by the therapist.') Sometimes, in frustration, a therapist will issue an ultimatum. Maltsberger recalls one who, treating a chronic wrist-cutter, just couldn't stand it, and finally she said, 'If you don't stop that I'll stop treatment.' The patient did it again. She stopped treatment and the patient killed herself" (1983, p. 57).
Perhaps most important, communicate caring. Therapists differ in how they attempt to express this caring. A therapist (cited by Colt, 1983, p. 60) recounts an influential event early in her career: "I had a slasher my first year in the hospital. She kept cutting herself to ribbons—with glass, wire, anything she could get her hands on. Nobody could stop her. The nurses were getting very angry. . . . I didn't know what to do, but I was getting very upset. So I went to the director, and in my best Harvard Medical School manner began in a very intellectual way to describe the case. To my horror, I couldn't go on, and I began to weep. I couldn't stop. He said, 'I think if you showed the patient what you showed me, I think she'd know you cared.' So I did. I told her that I cared, and that it was distressing to me. She stopped. It was an important lesson." The home visits, the long and frequent sessions, the therapist's late-night search for a runaway client, and other special measures mentioned earlier are ways some therapists have found useful to communicate this caring, although such approaches obviously would not fit all therapists, all clients, or all theoretical orientations. One of the most fundamental aspects of this communication of caring is the therapist's willingness to listen, to take seriously what the client has to say. Farberow (1985, p. C9) puts it well: "If the person is really trying to communicate how unhappy he is, or his particular problems, then you can recognize that one of the most important things is to be able to hear his message. You'd want to say, 'Yes, I hear you. Yes, I recognize that this is a really tough situation. I'll be glad to listen. If I can't do anything, then we'll find someone who can.'"

Avoidable Pitfalls: Advice from Experts
A central theme of this book is that inattention or a lack of awareness is a—if not the—most frequent cause for a therapist's violation of his or her clinical responsibilities and of the client's trust. We asked a number of prominent therapists with expertise in identifying and responding to suicidal risk to discuss factors that contribute to therapists' inattention or lack of awareness when working with potentially suicidal clients. Careful attention to these factors can enable therapists to practice more responsively and responsibly.
Norman Farberow, Ph.D., cofounder and former co-director and chief of research at the Los Angeles Suicide Prevention Center, believes that there are four main problem areas. First, therapists tend to feel uncomfortable with the subject; they find it difficult to explore and investigate suicidal risk: "We don't want to hear about it. We discount it. But any indication of risk or intention must be addressed." Second, we must appreciate that each client is a unique person: "Each person becomes suicidal in his or her own framework. The person's point of view is crucial." Third, we tend to forget the preventive factors: "Clinicians run scared at the thought of suicide. They fail to recognize the true resources." Fourth, we fail to consult: "Outside opinion is invaluable."
Marsha Linehan, Ph. D., ABPP is a Professor of Psychology, Adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington and Director of the Behavioral Research and Therapy Clinic. Her primary research is development of effective treatments for suicidal behaviors, drug abuse, and borderline personality disorder. She believes that the single biggest problem in treating suicidal clients is that most therapists have inadequate training and experience in the assessment and treatment of suicidal behaviors. More distressing than that is that there does not appear to be a hue and cry from practicing therapists demanding such training. Deciding to limit one's practice to non-suicidal clients is not a solution because individuals can and do become suicidal after entering treatment. Secondary problem are as follows. 1) Therapists treating clients with disorders that make them high risk for suicide (e.g., depression, borderline personality disorder, bipolar disorder) do not ask about suicide ideation and planning in a routine, frequent way: depending on clients who have decided to kill themselves to first communicate risk directly or indirectly can be a fatal mistake. 2) Fears of legal liability often cloud therapists' abilities to focus on the welfare of the client: fear interferes with good clinical judgment. Many outpatient therapists simply "dump" their suicidal clients onto emergency and inpatient facilities believing that this will absolve them of risk. There is no empirical data that emergency department and/or inpatient treatmen reduces suicide risk in the slightest and the available literature could support a hypothesis that it may instead increase suicide risk. 3) Therapists often do not realize that when treating a highly suicidal client they must be available by phone and otherwise after hours: treating a highly suicidal client requires personally involved clinical care.
Nadine J. Kaslow, Ph.D., ABPP, Professor and Chief Psychologist at Emory School of Medicine, a well-funded researcher on the assessment and treatment of abused and suicidal African American women, and the recipient of the American Psychological Association’s 2004 award for Distinguished Contributions to Education and Training told us that assessment and intervention of suicidal persons needs to be culturally competent, gender sensitive, and developmentally informed. Our approach to suicidal individuals needs to consider both the relevant evidence base and sensitive attention to the person’s unique struggles, strengths, and sociocultural context. We need to interact with suicidal people with compassion and a desire to understand why their pain feels so intolerable that they believe that suicide will offer the only form of relief. It is always important to take suicidal concerns seriously, convey an appreciation for the person’s plight, and engage in a collaborative process. Since suicidal people often feel socially isolated and social support is a buffer against suicidal behavior, it is imperative that we assist suicidal men and women in mobilizing their social support networks. We must build upon people’s strengths, help them find meaning and hope, and empower them to overcome the trials and tribulations that lead them to feel and think that life is not worth living. As therapists, we will find our own countertransference reactions to be a very useful guide with regards to risk assessment, disposition planning, and the implementation of therapeutic strategies. Our own histories with suicide, whether that be our own suicidality, the loss of a loved one to suicide, or the death of a former patient to suicide, will greatly impact how we approach and respond to people who think actively about suicide, take steps to end their own life, or actually kill themselves. Our histories and reactions can also be instrumental in our efforts to help suicidal people heal from their pain so that they find life worth living. This in turn, enriches our own lives.
Ricardo F. Munoz, Ph.D., is professor of psychology at the University of California, San Francisco; is principal investigator on the N.I.M.H.-funded Depression Prevention Research Project involving English, Spanish, and Chinese-speaking populations; and is coauthor of Control Your Depression. Here are his thoughts:
First, clinicians often fail to identify what suicidal clients have that they care about, that they are responsible for, that they can live for. Include animals, campaigns, projects, religious values. Second, inexperienced liberal therapists in particular may fall into the trap of attempting to work out their philosophy regarding the right to die and the rationality or reasonableness of suicide while they are working with a client who is at critical risk. These issues demand careful consideration, but postponing them till the heat of crisis benefits no one. In the same way that we try to convince clients that the darkest hour of a severe depressive episode is not a good time to decide whether to live or die, clinicians must accept that while attempting to keep a seriously suicidal person alive is not a good time to decide complex philosophical questions. Third, don't overestimate your ability to speak someone else's language. Recently, a Spanish-speaking woman, suicidal, came to the emergency room talking of pills. The physician, who spoke limited Spanish, obtained what he thought was her promise not to attempt suicide and sent her back to her halfway house. It was later discovered that she'd been saying that she'd already taken a lethal dose of pills and was trying to get help.
Jessica Henderson Daniel, PhD, ABPP, Director of Training in Psychology in the Department of Psychiatry and Associate Director of the Leadership Education in Adolescent Health Training Program in the Division of Adolescent Medicine, at Boston's Children's Hospital states:
As some adolescents can be prone to be dramatic i.e. saying things that they do not mean, there can be a reluctance to take comments about suicide seriously. The adolescent may make several statements before actually engaging in suicidal behavior. The adolescent needs to know that such comments are in fact taken seriously and that action may be taken i.e. follow-up by their therapist, evaluation in the ER and/or inpatient hospitalization. Also, adolescents can become very upset about matters that may seem trivial to adults. Providers are reminded that the perspective of the patient trumps their views. When adolescents are in the midst of despair, minimizing the worry, hurt, and hopelessness can be problematic. Some providers may feel that life really cannot be that bad. Then, parents matter. With adolescents, state regulations can determine the legal role of parents. It is important to know this information. Should parents be legally responsible for their adolescent, providers may be reluctant to override the decision of parents who cannot bear to think that their child may be suicidal and who insist on taking them home. When the patient is a child or an adolescent, the parents are critical part of the management of the case and may need their own providers as well. Finally, consultation is critical in thinking through how to best provide under the particular circumstances.
M. David Rudd, Ph.D., is Professor and Chair of the Department of Psychology at Texas Tech University and Past-President, American Association of Suicidology and President-Elect of APA, Division 12, Section VII (Behavioral Emergencies). He told us:
One of the all too frequently neglected areas in suicide risk assessment is recognizing, discussing and implementing a distinction between acute and chronic risk. Assessment of acute risk alone is how the overwhelming majority of clinicians approach the task. Over the last decade, converging scientific evidence suggests it is important to address enduring or “chronic” suicidality in patients. More specifically, those that have made two or more suicide attempts likely have a “chronic” aspect to their presentation. Although acute risk may well resolve, it is important for the clinician to make a note about the individual’s enduring vulnerabilities and continuing suicide risk. It’s as straightforward as making a note such as: “Although acute risk has resolved, the patient has made three previous suicide attempts and there are aspects of the clinical scenario that suggest chronic risk for suicide. More specifically, the patient’s history of previous sexual abuse, episodic alcohol and cannabis abuse, along with two previous major depressive episodes, all indicate the need for longer-term and continuing care in order to more effectively treat these chronic markers of risk.”
David H. Barlow, Ph.D., is a Diplomate in clinical psychology and Director of the Center for Anxiety and Related Disorders at Boston University. He is former President of the Society of Clinical Psychology of APA, and maintains a private practice. He believes that there are 2 common problems often encountered in working with young or inexperienced therapists confronting a possible suicidal patient:
First, after forming an alliance with a new patient, some therapists begin to spin away from a professional, objective clinical stance and treat seemingly offhand comments about not wanting to live as casual conversation that might be occurring after work over a drink with a friend or in a college dormitory. Thus, they may respond sympathetically but not professionally, by downplaying the report. "Sometimes I feel that way too--I can understand how you'd get to that place..." Of course, one must always step back if this comes up and conduct the proper exam for intent, means etc., and take appropriate action. Second, some therapists undervalue the power of a contract, since patients sometimes say something like "Well…I'll say that if you want me to , but I don't know if my word is worth anything." The fact is--in the context of a good therapeutic relationship, the contract is very powerful, the occasional report to the contrary notwithstanding. The late Erika Fromm,Ph.D., a diplomate in both clinical psychology and clinical hypnosis, was professor emeritus of psychology at the University of Chicago, clinical editor of The Journal of Clinical and Experimental Hypnosis, and recipient of the American Psychological Association Division 39 (Psychoanalysis) 1985 Award for Distinguished Contributions to the Field. She stated:
Perhaps it's the countertransference or the highly stressful nature of this work, but some clinicians seem reluctant to provide suicidal patients anything more than minimal reassurance. We need to realize that the people who are about to take their own lives are crying out, are communicating their feelings that no one really cares about them. They are crying, in the only way they know how: "Show me that you really care!' It is so important for us to communicate that we care about them. When my patients are suicidal, I tell them that I care deeply about them and am fond of them. I do everything I can to let them know this."
Larke Nahme Huang, Ph.D., formerly on the faculty of the University of California, Berkeley, is currently an independent research and clinical consultant in the Washington, D.C., area. She stresses the problems involved in treating people with schizophrenia:
Especially as the treatment becomes a matter of years, there's a tendency to become less sensitive, to forget how painful their life can be. This can lead to problems as the clinician sets ever higher goals as the client continues to improve. A client can experience these goals as insufferable pressure. Frequently the client may make a very serious suicide attempt in an effort to escape the pressure. In working with people with severe disorders, clinicians may need to utilize hospitalization in times of crisis. Inpatient management issues, power struggles, rivalries between professional disciplines, and so on can aggravate the client's crisis. Don't wait until the last minute, when you're in the midst of a crisis, to learn about these realities and to take steps to prevent them from adding to your client's distress.
Gary Schoener, Clinical Psychologist and Executive Director of the Walk-In Counseling Center in Minneapolis for more than 33 years, consults, trains, and testifies around North America concerning professional boundaries and clinical supervision. He states:
Four most common deadly failures are (1) the failure to screen for the possession of firearms (it's not enough to ask about "weapons") with all distressed clients; (2) when acute suicidality becomes chronic, failure to appropriately refer to a DBT [Dialectic Behavior Therapy] program or qualified provider for cases of chronic suicidality; (3) reliance on the QPR [Question, Persuade, Refer] method with refugees and others, especially Muslems, for whom suicide is a serious sin and who should not be asked directly about suicidal thinking; and (4) over-reliance on "no-suicide agreements" despite the fact that they do not work. (No problem in using them clinically, but don't count on them.)
Marla C. Craig, Ph.D., psychologist and director of outreach services and special projects at the Counseling & Consultation Center, and an instructor and coordinator of a campus-wide suicide prevention program at St. Edward’s University. She reported that:
Most clinicians may not know that suicide is the second leading cause of death among college students. This information is important since there may be a tendency for clinicians not to take college students’ presenting concerns seriously enough. Presenting concerns such as academic and relationship difficulties may mask the underlying condition of depression. Also, stereotypes of college students’ being overly dramatic and emotional with fluctuating moods and situations can interfere with a clinician’s judgment to thoroughly assess for suicide. It also may be easy for clinicians to forget that traditional college students are still adolescents transitioning into young adulthood, and they may or may not be able to verbally identify what is going on internally/emotionally. Hence, it is important to assess for suicide even if the college student does not present as depressed. Finally, due to confidentiality and college students being 18 years of age and older, clinicians may be reluctant to get parents involved. If the parents are a source of support, do not hesitate to work with the college student to get them involved.
Jesse Geller, Ph.D., formerly director of the director of the Yale University Psychological Services Clinic and director of the Psychotherapy Division of the Connecticut Mental Health Center, currently maintains an independent practice. He told us:
One of the two main problems in treating suicidal patients is our own anger and defensiveness when confronted by someone who does not respond positively—and perhaps appreciatively—to our therapeutic efforts. It can stir up very primitive and childish feelings in us—we can start to feel vengeful, withholding, and spiteful. The key is to become aware of these potential reactions and not to act them out in our relationship with the patient. The other main problem seems to be more prevalent among beginning therapists. When we are inexperienced, we may be very cowardly regarding the mention of suicide in our initial interviews. We passively wait for the patient to raise the subject and we may unconsciously communicate that the subject is "taboo." If the subject does come up, we avoid using "hot" language such as "murder yourself" or "blow your brains out." Our avoidance of clear and direct communication, our clinging to euphemisms implies to the patient that we are unable to cope with his or her destructive impulses.
Don Hiroto, Ph.D., maintains a private practice, is chief of the Depression Research Laboratory at the Brentwood Veterans Administration Medical Center, and is a former president of the Los Angeles Society of Clinical Psychologists. He believes that a major area of difficulty involves alcohol use:
Alcoholics may constitute the highest risk group for violent death. The potential for suicide among alcoholics is extraordinarily high. At least 85 percent of completed suicides show the presence of at least some level of alcohol in their blood. There are two aspects to the problem for the clinician. First, there is the tendency for us to deny or minimize alcohol consumption as an issue when we assess all of our clients. Second, we are not sufficiently alert to the suicidal risk factors which are especially associated with alcoholics: episodic drinking, impulsivity, increased stress in relationships (especially separation), alienation, and the sense of helplessness.
The late Helen Block Lewis, Ph.D., was a diplomate in clinical psychology who maintained a private practice in New York and Connecticut; she also was professor emeritus at Yale University, president of the American Psychological Association Division of Psychoanalysis, and editor of Psychoanalytic Psychology. She believed that therapists tend to pay insufficient attention to the shame and guilt their clients experience. For example, clients may experience a sense of shame for needing psychotherapy and for being "needy" in regard to the therapist. The shame often leads to rage, which in turn leads to guilt because the client is not sure if the rage is justified. According to Lewis, the resultant "shame/rage" or "humiliated fury" can be a major factor in client suicides:
Clients may experience this progression of shame-rage-guilt in many aspects of their lives. It is important for the therapist to help the client understand the sequence not only as it might be related to a current incident 'out there' but also as it occurs in the session. Furthermore, it is helpful for clients who are in a frenzied suicidal state to understand that the experience of shame and guilt may represent their attempt to maintain attachments to important people in their lives. Understanding these sequences is important not only for the client but also for the therapist. It is essential that we maintain good feelings for our clients. Sometimes this is difficult when the client is furious, suicidal, and acting out. Our understanding that such feelings and behaviors by a client represent desperate attempts to maintain a connection can help us as therapists to function effectively and remain in touch with our genuine caring for the client.

Michael Peck, Ph.D., a diplomate in clinical psychology, maintains a private practice and was a consultant to the Los Angeles Suicide Prevention Center. He observes, "Many therapists fail to consult. Call an experienced clinician or an organization like the L.A. Suicide Prevention Center. Review the situation and get an outside opinion. Therapists may also let a client's improvement (for example, returning to school or work) lull them to sleep. Don't assume that if the mood is brighter, then the suicidal risk is gone." He stresses the importance of keeping adequate notes, including at least the symptoms, the clinician's response, and consultations and inquiries. "There are special issues in treating adolescents," Peck adds. "When they're under sixteen, keep the parents informed. If they are seventeen (when the client, rather than the parents, possesses the privilege) or older but still living with the parents, tell the client that you will breach confidentiality only to save his or her life. In almost every case, the family's cooperation in treatment is of great importance."
The late Hans Strupp, Ph.D., was a diplomate in clinical psychology, distinguished professor of psychology, and director of clinical training at Vanderbilt University. He believed that one of the greatest pitfalls is the failure to assess suicidal potential comprehensively during initial sessions. Another frequent error, he told us, is that there too often is a failure to have in place a network of services appropriate for suicidal clients in crisis: "Whether it is an individual private practitioner, a training program run by a university . . . , a small . . . clinic, or [therapists] associated in group practice—there needs to be close and effective collaboration with other mental health professions . . . and with facilities equipped to deal with suicidal emergencies. I'm not talking about pro forma arrangements but a genuine and effective working relationship. In all cases involving suicidal risk, there should be frequent consultation and ready access to appropriate hospitals."

Difficult Scenarios and Questions You've been working with a moderately depressed client for 4 months. You feel that you have a good rapport but the treatment plan doesn't seem to be doing much good. Between sessions you check your answering machine and find this message from the client: "I want to thank you for trying to help me, but now I realize that nothing will do me any good. I won't be seeing you or anyone else ever again. I've left home and won't be returning. I didn't leave any notes because there really isn't anything to say. Thank you again for trying to help. Goodbye." Your next client is scheduled to see you in 2 minutes and you have clients for the next 4 hours.
*** *** ****** *** ***
What feelings do you experience?
What do you want to do?
What are your options?
What do you think you would do?
If there are things that you want to do but don't do, why do you reject these options?
What do you believe that your ethical and legal obligations are?
Are there any contradictions between your legal responsibilities and constraints and what you believe is ethical?
To what extent do you believe that your education and training have prepared you to deal with this situation?
*****You have been working with a client within a managed care framework. You believe that the client is at considerable risk for suicide. The case reviewer disagrees and, noting that the approved number of sessions have been provided, declines, despite your persistent protests, to approve any additional sessions.
How do you feel?
What are your options?
What do you believe your legal obligations to client are?
What do you believe your ethical responsibilities to the client are?
What would you do?
*****You have been providing family therapy to a mother and father and their 3 adolescents for 4 sessions. After the fourth session, you find that one of the adolescents has left a note on your desk. Here is what the note says: "My father has molested me for the last 2 years. He has threatened to kill my mother and me if anyone else finds out. I could not take it if you told anyone else. If you do, I will find a way to kill myself." Your clinical judgment, based on what you've learned during the course of the 4 sessions, is that the adolescent is extremely likely to commit suicide under those circumstances.
How do you feel?
More specifically, what are your feelings about the client who left you the note? What are your feelings about the father? What are your feelings about the mother? What are your feelings about the other 2 adolescents?
What do you believe that your legal obligations are?
What do you believe that your ethical responsibilities are?
What, if any, conflicts do you experience? How do you go about considering and deciding what to do about these conflicts?
What do you believe that you would do?
*****A client you've been seeing in outpatient therapy for 2 years doesn't show up for an appointment. The client has been depressed and has recently experienced some personal and occupational disappointments but the risk of suicide as you've assessed it has remained at a very low level. You call the client at home to see if the person has forgotten the appointment or if there's been a mix-up in scheduling. You reach a family member who tells you that the client has committed suicide.
What do you feel?
Are there any feelings that are difficult to identify or put into words?
What options do you consider?
Do you tell the family member that you were the person's therapist? Why or why not?
What, if anything, do you volunteer to tell the family?
Do you attend the funeral? Why or why not? Do you send flowers? Why or why not?
If a family member says that the suicide must have been your fault, what do you feel? What would you do?
Do you tell any of your friends or colleagues? Why? What concerns, if any, do you have?
Do your case notes and documentation show your failure to assess accurately the client's suicidal risk? Why or why not? Do you have any concerns about your documentation?

***** You've been discussing a new HMO patient, whom you've seen for 3 outpatient sessions, with both your clinical supervisor and the chief of outpatient services. The chief of services strongly believes that the client is at substantial risk for suicide but the clinical supervisor believes just as strongly that there is no real risk. You are caught in the middle, trying to create a treatment plan that makes sense in light of the conflicting views of the 2 people to whom you report. One morning you arrive at work and are informed that your clinical supervisor has committed suicide.
What do you feel?
Are there any feelings that are particularly difficult to identify, acknowledge, or articulate?
How, if at all, do you believe that this might influence your work with any of your patients?
Assume that at the first session you obtained the client's written informed consent for the work to be discussed with this particular clinical supervisor who has been counter-signing the client's chart notes. What, if anything, do you tell the client about the supervisor's suicide or the fact that the clinical work will now be discussed with a new supervisor?
To what extent has your graduate training and internship addressed issues of clinician's own suicidal ideation, impulses, or behaviors?

Related Studies:
National studies containing at least one item about suicide that are presented in full-text form on this site:
Ethics of Practice: Beliefs & Behaviors of Psychologists as Therapists [American Psychologist]
Ethical Dilemmas Encountered by Members of the American Psychological Association: A National Survey [American Psychologist]
Therapists As Patients" A National Survey of Psychologists' Experiences, Problems, and Beliefs [Professional Psychology: Research & Practice]
Therapists' Anger, Hate, Fear, and Sexual Feelings: A National Survey of Therapist Responses, Client Characteristics, Critical Events, Formal Complaints, and Training [Professional Psychology: Research & Practice]
Prior Therapist-Patient Sexual Involvement Among Patients Seen by Psychologists [American Psychologist]