In one of my first sessions as a therapist, a 60-year-old outpatient with body dysmorphic disorder and chronic depression said to me: “This psychotherapy is the last chance that I’ve got.”
Her desperation was devastating, and her words placed an immense weight on me. How could I possibly respond to that? Initially, my approach was to lean on established therapeutic methods—but as our sessions progressed, I began to realise that the bond we were building was just as crucial, if not more so, in helping her.
“One of the most important things we can do is create a bond with a suicidal person,” emphasized Prof. Ute Lewitzka, a German psychiatrist, on World Suicide Prevention Day 2024. While it may seem obvious that the therapeutic alliance is important to help people at risk of suicide, this topic remains understudied in research. What do therapists and suicidal patients really think about their working alliance? Is it as simple as “Be nice to patients and they will get better?” Prof. Konrad Michel (2023), author of The Suicidal Person, offers straightforward guidance: “There is a name for it. It is called good clinical practice. It is about listening to our patients and developing a working alliance toward a shared goal.”
To recap, a therapeutic alliance is understood as a collaboration on shared goals, tasks, and emotional bond, as defined in Bordin’s pantheoretical model (1979). This process variable has been shown to be one of the most significant factors in psychotherapy outcomes, as demonstrated by a meta-analysis (Wampold & Flückinger, 2023). However, recent reviews on the therapeutic alliance in suicidality by Dunster-Page et al. (2017) and Huggett et al. (2022) reveal that findings are scarce and heterogeneous. While the Importance of the Therapeutic Alliance in psychotherapy for self-harm was discussed in another Mental Elf Blog, this new study by Huggett and colleagues (2024) is the first large, qualitative study to include perspectives from both patients and therapists, filling an important research gap.
A new systematic review and meta-ethnography synthesises both clients’ and therapists’ perceptions of the therapeutic alliance in suicide prevention.
Methods
The authors systematically searched for qualitative studies and conducted a meta-ethnography to compare, contrast, and synthesize relevant findings (Huggett et al., 2024). The study was pre-registered on PROSPERO (CRD42021268273). The literature search covered articles available from the inception of the databases—MEDLINE, PsycINFO, Web of Science, Embase, and CINAHL—through April 2024. Following the Critical Appraisal Skills Programme (CASP; 2018) checklist for systematic reviews, the authors included peer-reviewed qualitative studies focused on “client and/or therapist perspectives of the therapeutic alliance in the context of psychotherapy and suicidal experiences.” The quality of eligible studies was ensured by an adaption of CASP for qualitative evidence synthesis (Long, French, & Brooks, 2020). Data extraction and synthesis were performed according to a revised approach to the seven phases of meta-ethnography by Noblit and Hare (1988).
Results
After screening 3,654 titles, 37 out of 82 papers were evaluated as eligible and included in the systematic review and synthesis. The studies were conducted worldwide, primarily in Europe (n = 21). Overall, 22 articles reported only the therapists’ perspective, 11 articles reported only the client’s perspective, and four articles included both perspectives. The conducted data analysis strategies were Thematic Analysis, Interpretative Phenomenological Analysis, and Grounded Theory.
The translation and synthesis of the studies revealed two main themes: “Working on the Edge” and “Being Ready, Willing, and Able to Build an Alliance in the Context of Suicidal Experiences,” each with two subthemes, which will be summarised as follows:
Working on the edge
The first main theme, “Working on the Edge,” refers to a quote by a therapist who used the metaphor of standing on a cliff edge to describe the therapeutic alliance with suicidal patients, emphasising the “high-risk, life-or-death nature” of the collaboration (see Huggett et al., 2024; Therapist: Fogarty, Houghton, Galavan, & O’Súilleabháin, 2021, p. 12). This theme comprises two subthemes. Some of the key points are:
Sense of responsibility and control over a client’s life, e.g.
- Internal tension between the client’s free will and the therapist’s responsibility
- A sense of purpose and ‘heroism’ vs. lack of control in this “life-death situation”
Balancing empathy for ‘suicide wish’ and holding hope, e.g.
- Inner conflict to navigate the tension between empathising with the client’s suicidal feelings and fostering a shared sense of hope
- Importance of showing understanding for ambivalence of wish to live and wish to die
Being ready, willing, and able to build an alliance in the context of suicidal experiences
The second main theme had two subthemes of ‘human connection’ and ‘reciprocal trust’ to describe the quality of the therapeutic relationship. Key points included:
Human connection, e.g.
- Strong, emotionally invested connection with suicidal clients
- Therapists’ self-disclosure accompanied by feelings of vulnerability
Reciprocal trust, e.g.
- Trust needs time to be built up on both sides
- Negative previous experiences with reactions to suicidality need to be addressed
To synthesise the results, the dynamic of the client-therapist relationship was conceptualised within a complex model, which can be accessed here and in the paper by Huggett and colleagues (2024; p.8). This model provides an overview of the processes underlying relationship building, ranging from suicide-specific micro-processes to systemic macro-processes that influence the therapeutic alliance.
A key finding is that validating the emotional pain of the client—rather than solely focusing on their resources—is a crucial driving factor in establishing and maintaining the alliance.
The sense of readiness and ability of both therapists and suicidal patients was important to achieve a therapeutic alliance.
Conclusions
This is a very insightful and thought-provoking article that is the first one to synthesise the qualitative literature on the dynamics between therapists and patients at risk of suicide. The authors concluded:
Therapeutic alliance in the context of suicidal experiences is unique, fluid, potentially lifesaving, and influenced by multiple inter-connected internal and external processes and systems.
Huggett’s model (2024) not only enhances our understanding of the therapeutic alliance but also serves as a valuable tool for clinicians in tailoring their approach to better support clients at risk of suicide.
The authors concluded that “Therapeutic alliance in the context of suicidal experiences is unique, fluid, and potentially lifesaving”.
Strengths and limitations
The study’s strengths and limitations, as informed by the CASP criteria for synthesising qualitative evidence (Long, French, & Brooks, 2020) are discussed below:
a. Are the results of the study valid?
The review addresses a focused research question using an appropriate range of sources. While the data quality was rated as good to excellent, challenges in the revision process and limitations were openly described. There has been an ongoing discussion about the value of qualitative methods in suicidology (e.g., White, 2016; Kabir, Wayland & Maple, 2023) and whether they offer scientific rigour beyond “hypothesis generation” (Joiner, 2011, p. 471). However, qualitative methods can contribute valuable insights into lived experiences and underlying processes.
b. What are the results?
Huggett and colleagues aimed to develop a qualitative, conceptual model of the therapeutic alliance in psychotherapy with suicidal patients, incorporating both therapist and client perspectives. The findings offer detailed insights into therapist-patient dynamics but remain limited by their qualitative nature.
c. Will the results help locally?
In clinical practice, the results may be transferred to the local population with careful consideration. A strength of the review is the international scope of the collected studies. Despite the detailed description of the dynamics between therapist and patient, these findings cannot be generalised due to their qualitative nature and the lack of demographic data in the studies. Instead, they provide an outlook for further research that needs to investigate these proposed topics in more detail.
The authors developed an insightful conceptual model of the therapeutic alliance in psychotherapy with suicidal patients; however, limited by its qualitative nature.
Implications for practice
Forming a therapeutic alliance with suicidal clients is essential for suicide prevention and could be enhanced through targeted training for therapists in “suicide-specific alliance techniques”, in addition to the joint development of safety plans (Nuij et al., 2021). Moreover, the risk of therapist burnout should be kept in mind, especially for those primarily working with suicidal individuals. Effective communication and thoughtful language are crucial in assessing suicide risk, as they help maintain trust and prevent rigidity that could jeopardise the therapeutic relationship.
The authors concluded: “Clinical implications emphasise the need to improve training, supervision, and support for therapists to equip them with the additional skills required in navigating the intricacies of the therapeutic alliance with clients who have suicidal experiences.” Huggett and her co-authors (2024) further highlighted that “the nuances of the therapeutic alliance with suicidal clients are currently absent from guidelines.” They therefore advocate for the inclusion of both client and therapist perspectives in clinical guidelines, as well as a “multi-disciplinary team approach to suicide prevention.”
Future research should explore how these processes can be further operationalised in therapeutic settings to improve outcomes for clients facing suicidal thoughts and behaviours. For instance, micro-processes such as active listening and empathetic responses, alongside macro-processes like social support systems, play critical roles in fostering a strong therapeutic alliance. Additionally, it is important to report both sex and ethnicity, as their omission in previous studies has been criticised by the authors.
Looking back at the experience with my patient, I recognise both identified themes in working with her. I have learnt that it is important to be transparent and empathetic with a suicidal patient. To let them take responsibility for their own lives, but to do the best I can to offer support and create a bond. Also to reflect on the process with an advisor and prioritise self-care. Similar to the first author’s insights, I believe that many mental health professionals will find aspects of their own experiences reflected in this article.
The therapeutic alliance benefited from a flexible combination of suicide risk assessment and therapeutic conversations.
Statement of interests
Laura knows one of the authors (CH). She has written an article on the therapeutic alliance and suicidal ideation.
Links
Primary paper
Huggett, C., Peters, S., Gooding, P., Berry, N., & Pratt, D. (2024). A systematic review and meta-ethnography of client and therapist perspectives of the therapeutic alliance in the context of psychotherapy and suicidal experiences. Clinical Psychology Review, 102469. https://doi.org/10.1016/j.cpr.2024.102469
Other references
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, research & practice, 16(3), 252. https://psycnet.apa.org/doi/10.1037/h0085885
Critical Appraisal Skills Programme. (2018). CASP Cohort Study Checklist. Retrieved by the authors on March 29, 2023, from https://casp-uk.net/casp-tools- checklists/.
Dunster-Page, C., Haddock, G., Wainwright, L., & Berry, K. (2017). The relationship between therapeutic alliance and patient’s suicidal thoughts, self-harming behaviours and suicide attempts: A systematic review. Journal of Affective Disorders, 223, 165–174. https://doi.org/10.1016/j.jad.2017.07.040
Fogarty, B., Houghton, S., Galavan, E., & O’Súilleabh´ ain, P. S. (2021). Clinicians’ experience of collaboration in the treatment of suicidal clients within the collaborative assessment and Management of Suicidality Framework. Omega Journal of Death and Dying. https://doi.org/10.1177/00302228211020579, 302228211020579. Advance online publication.
Huggett, C., Gooding, P., Haddock, G., Quigley, J., & Pratt, D. (2022). The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review. Clinical Psychology & Psychotherapy, 29(4), 1203–1235. https://doi.org/10.1002/cpp.2726
Joiner, T. (2011). Editorial: Scientific rigor as the guiding heuristic for SLTB’s editorial stance. Suicide and Life Threatening Behavior, 41(5), 471–473. https://doi.org/10.1111/j.1943-278X.2011.00056.x
Kabir, H., Wayland, S., & Maple, M. (2023). Qualitative research in suicidology: a systematic review of the literature of low-and middle-income countries. BMC Public Health, 23(1), 918. https://doi.org/10.1186/s12889-023-15767-9
Long, H. A., French, D. P., & Brooks, J. M. (2020). Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine & Health Sciences, 1(1), 31–42. https://doi.org/10.1177/2632084320947559
Michel, K. (2023). The suicidal person: a new look at a human phenomenon. Columbia University Press.
Noblit, G. W., & Hare, R. D. (1988). Meta-ethnography: Synthesizing qualitative studies. Sage Publications.
Nuij, C., van Ballegooijen, W., De Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O’Connor, R. C., Smit, J. H., Kerkhof, A. & Riper, H. (2021). Safety planning-type interventions for suicide prevention: meta-analysis. The British Journal of Psychiatry, 219(2), 419-426. https://doi.org/10.1192/bjp.2021.50
Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World psychiatry, 22(1), 25–41. https://doi.org/10.1002/wps.21035
White, J. (2016). Qualitative Evidence in Suicide Ideation, Attempts, and Suicide Prevention. In: Olson, K., Young, R., Schultz, I. (eds) Handbook of Qualitative Health Research for Evidence-Based Practice. Handbooks in Health, Work, and Disability, vol 4. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2920-7_20
Photo credits
- Photo by Alvin Mahmudov on Unsplash
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- Photo by Julia Taubitz on Unsplash
