Building Confidence When Working with Clinical Risk: Supporting the Therapist Helps Support the Client

• A client tells you they have been self-harming.

• Someone quietly says they aren't sure they want to be here anymore.

• A young person tells you something that immediately makes you wonder whether you need to tell somebody else.

Even when we have training and experience, there can be a moment when something changes inside us.

Perhaps your stomach tightens.

Your thoughts speed up.

You suddenly become very aware of the responsibility you're holding.

What do I need to ask?

How serious is this?

Am I doing enough?

What if I overreact?

What if I don't act and something happens?

Working with clinical risk can feel daunting because it matters. Becoming more confident isn't about reaching a point where these conversations no longer affect us. It's about developing enough knowledge, awareness and support that we can remain alongside our client while still being able to think about what needs to happen next.

Our clients may notice our anxiety before we do

Imagine finally finding the courage to tell somebody:

"I've been hurting myself."

Then imagine watching their face change.

Their body stiffens.

They sit forward.

Their voice changes.

Suddenly the questions come more quickly.

"How often?"

"When did you last do it?"

"Are you thinking about suicide?"

"Do you have a plan?"

These can be important questions. Something else is happening at exactly the same time though. The client is reading us. They may be wondering:

Have I frightened you?

Do you think I'm dangerous?

Are you going to take control away from me?

Do you still see me, or do you just see the risk now?

Our words are only one part of the conversation. Our facial expression, posture, breathing, tone, pace and ability to sit with silence are communicating too.

That's one reason practitioner confidence matters so much.

Our nervous system comes into the room too

Therapists are human.

When someone tells us they may not be safe, our own nervous system can react.

• We might feel an urge to rescue.

• We may become more directive.

• We might ask question after question because gathering information helps us feel safer.

• We might become frightened of saying the wrong thing.

• Or we might move in the opposite direction and avoid asking directly about suicide because we're worried about what the answer might be.

These responses don't make us bad therapists. But noticing does them matters.

Recognising:

"I'm getting anxious here."

Provides more opportuntieis to be respond compassionately with yourself as well as the client.

I can feel my feet against the floor.

Notice my breathing.

Relax my shoulders.

Slow my speech.

Allow myself a moment before asking the next question.

Remind myself:

I don't have to solve everything in this second.

We don't need to be perfectly calm.

We need to be steady enough to stay alongside the person and think about what they need from us.

Building Confidence When Working with Clinical Risk doesn't mean knowing exactly what to do

I think this is one of the biggest misconceptions around confidence and clinical risk.

Confidence isn't:

"I always know the answer."

It might be closer to:

"I can stay with this, ask what I need to ask, think about what I'm hearing and seek support when I need it."

That gives us room to be curious:

What's happening for this person?

What's changed?

What might this behaviour be helping them cope with?

What's making things harder?

What's helping them keep going?

What might help them feel a little safer?

Who else might the client want to be involved?

What are my responsibilities here?

Risk assessment then becomes part of understanding somebody rather than something we suddenly start doing to them.

When talking is difficult, creativity can bridge the gap

Sometimes the person sitting with us simply can't find the words.

• They may be overwhelmed.

• Frightened.

• Shut down.

• Ashamed.

• Unsure what they're feeling themselves.

They might know that something feels unbearable without being able to explain why.

And sometimes we respond by asking more questions.

More questions don't necessarily make the words easier to find. This is where I think creative approaches can be incredibly valuable. Creativity can bridge a gap in communication when thinking and talking feel difficult.

A young person might struggle to answer:

"Tell me what's happening inside."

But give them a body outline and some colours and they may be able to show you.

Someone may struggle with:

"How strong is the urge to hurt yourself?"

but recognise their experience immediately when looking at an urge wave.

Instead of:

"Rate how bad things are from one to ten."

we might explore an emotional weather map:

Drizzle → Cloudy → Storm → Hurricane → Tornado

and simply ask:

"Where does it feel like you are today?"

We can use:

• drawing

• colours

• body maps

• visual scales

• cards

• objects

• metaphors

• writing

• sensory materials

• urge waves

• safety circles

• needs pictures

• timelines.

Creativity isn't about avoiding difficult conversations. It doesn't replace asking directly about suicide or self-harm when we need to. It gives us another way into the conversation.

It can help somebody show us something they may not yet be able to tell us. From there, we can begin trying to understand it together.

Looking underneath self-harm

Self-harm can understandably frighten us. When we're frightened, our focus can quickly become - How do I stop this?

There's another question that can be incredibly important:

What is this behaviour trying to help with?

Self-harm may have different purposes for different people.

It might temporarily:

• release pressure

• interrupt overwhelming thoughts or feelings

• create sensation when someone feels numb

• provide comfort or calm

• express something that doesn't yet have words

• give a sense of control

• respond to shame or self-criticism

• communicate how much someone is struggling

• help someone get through something that feels unbearable.

Understanding the purpose doesn't mean saying self-harm is safe or that we shouldn't take it seriously.

It means recognising that if we simply try to remove someone's way of coping without understanding what it has been doing for them, we may leave the underlying need untouched.

Instead, we can become curious:

"What does it do for you?"

"What changes afterwards?"

"What do you think you needed in that moment?"

And eventually:

"I wonder whether we can find some other things that might help with that same need too."

Ethics can be something we lean on

Another big source of anxiety around clinical risk is responsibility.

• Confidentiality.

• Safeguarding.

• Information sharing.

• Consent.

• Record keeping.

• Competence.

• Legal responsibilities.

When we're frightened of getting something wrong, our ethical framework can start feeling like a list of rules waiting for us to break. However our ethical frameworks can actually help us think.

• They give us questions to consider:

• What is my responsibility?

• What is within my competence?

• What information do I need?

• Can I involve the client in this decision?

• Do I need supervision or consultation?

• What guidance applies here?

• What needs documenting?

• Does somebody else need to be involved?

We don't have to hold all of this information in our heads. Part of working confidently is knowing where our ethical guidance is, understanding the policies relevant to our work and knowing who we can speak to when we're uncertain.

Sometimes being professionally responsible isn't about immediately knowing the answer. It's knowing where to go when you don't.

From safety planning to Hope in Crisis

Safety planning is important, but it can easily become another form to complete.

• Telephone numbers get written down.

• Coping strategies get listed.

• The client leaves.

The more important question is:

Will any of this actually help when things become really difficult?

That's why I like thinking about a Hope in Crisis Plan collaboratively with the person.

We might explore:

I notice things are getting harder when...

My body tells me...

When the urge starts building, sometimes this helps...

People who feel safe enough to contact are...

Places where I feel a little safer or less alone are...

Things that help me get through the next few minutes are...

Things that remind me there might be another moment after this one are...

If things become more dangerous, this is what we can do...

Hope doesn't have to mean feeling positive.

Sometimes hope is tiny.

A pet waiting at home.

Tomorrow's football match.

A programme they haven't finished.

A person they promised to message.

Somewhere they'd still like to visit.

Or simply wondering whether tomorrow might feel different.

We're not looking for somebody to suddenly feel hopeful about their entire future. We're helping them find enough hope for right now.

What can greater confidence give the therapist?

Greater confidence can help us:

• ask difficult questions without panicking

• hear difficult answers

• notice when our own nervous system is becoming activated

• slow ourselves down

• stay curious rather than immediately jumping into fixing

• understand the person as well as assessing risk

• use creative approaches when words aren't working

• make more thoughtful ethical decisions

• recognise when we need supervision or additional support

• work collaboratively where possible

• document our thinking more clearly

• feel less alone with the responsibility.

Confidence isn't certainty. It's having enough knowledge, awareness, resources and support to keep thinking when things feel uncertain.

And what might that give the client?

This is perhaps the most important part.

Imagine the difference between a client leaving the room thinking:

"I frightened my therapist."

and:

"They could hear what I needed to tell them."

Between:

"I wish I'd never said anything."

and:

"I'm glad I didn't have to keep that to myself."

Between:

"They're trying to control me."

and:

"We're trying to work out what might help together."

Between:

"I'm a risk."

and:

"I'm a person having a really difficult time and somebody is trying to understand."

Being compassionate doesn't mean avoiding difficult decisions.

Being collaborative doesn't mean we will never need to act.

Understanding the purpose of a behaviour doesn't mean minimising its seriousness. We can take risk seriously without allowing the risk to become all that we see.

Building Confidence: Working with Clinical Risk

These ideas sit at the heart of the Towards Tranquility Therapy Building Confidence: Working with Clinical Risk workshop.

This two-hour interactive online workshop is for counsellors, therapists, trainees and support professionals who would like to feel more grounded and confident when working with self-harm, suicidal thoughts and emotional crisis.

Together we'll explore:

• how clients may respond to our body language

• what happens in our own nervous system when we become worried about risk

• simple ways of helping ourselves stay grounded enough to think

• how creative approaches can bridge the communication gap when thinking and talking feel difficult

• understanding what may sit underneath self-harming behaviour

• using our ethical frameworks to support our thinking

• legal and professional responsibilities

• collaborative Hope in Crisis Plans

• practical mental-health and clinical-risk resources.

This isn't training designed to make you believe you'll always know exactly what to do.

I don't think that's realistic.

Instead, it's about building something much more useful:

the confidence to stay present, ask what needs asking, listen to the answer, think carefully, recognise our responsibilities and know when we need support too.

If you would like to find out more about this workshop and next available dates please email us at:

info@towardstranquility.com

One final thought

When somebody tells us they're self-harming, thinking about suicide or struggling to keep themselves safe, they may be watching carefully to see what happens next.

Without ever saying it, they may be wondering:

"Can you cope with knowing this about me?"

Whilst perhaps one of the most important things our confidence can communicate is:

"Yes. We can talk about this. I'm still here, and we can work out what needs to happen next together."