Running head: COMMUNICATION BARRIERS

Communication Barriers Between Suicidal Patients and Their Therapist

Olivia DeJesse
Loyola Marymount University

COMMUNICATION BARRIERS

2
Abstract

In this literature review I will synthesize suicide, specifically how it is talked about amongst
patients, how others perceive it, and the relationship between patient and therapist. The
communication between therapists and suicidal patients needs improvement since there are a
number of patients who follow through with their suicidal intention. The language used by our
culture and therapists, forms a stigma towards suicidal patients. By taking a new approach to
suicidal communication, these communication barriers between therapist and patient may be
identified and fixed, creating more effective communication and a stronger relationship between
the pair.
Keywords: suicide, psychotherapy, patient, therapist, stigma

COMMUNICATION BARRIERS

Communication Barriers Between Suicidal Patients and Their Therapist

Depressed or suicidal patients who seek psychiatric therapy are attending these sessions
in order to seek a specific type of help from a trained professional. Psychiatric therapists form a
relationship with their patients, with the incentive of cognitively treating their patient.
Unfortunately, many of these patients lack the sufficient help of recovery they need. Suicidal
patients specifically have a greater need for special attention due to the heavy weighted outcome:
life or death. The language used by American culture and by trained therapists is in need of
reform, in order to aid suicidal patients in a more sufficient manner (Sommer-Rotenburg, 1998).
The communication barriers between suicidal patients and their therapists are evident,
unfortunately there lacks incentive to discover ways that will reduce or eliminate these barriers.
The research that could resolve this problem and improve therapeutic strategies could
unmistakably save the lives of suicidal teens and adults.
Suicide Communication in General
An important aspect in determining suicidal patients esteem and depression is the
language used by our culture and by the patients themselves. (Sommer-Rotenburg, 1998;
Lienemann et al., 2012). The language used by others can shed a negative light on suicidal
patients, causing them to feel shame or guilt (Sommer-Rotenburg, 1998).
How we talk about suicide. This suicidal ideology originated as early as St. Augustines
suicide, which took place in the fourth century (McDorman, 2005). Since then, there has been a
moral and legal issue with suicide, encouraging the continuation of stigma towards those who are
suicidal (McDorman, 2005). Furthermore, he reasons that suicide as a crime could be seen as a
legitimate ideology in church-state societies, since taking death into ones own control was
challenging the ultimate being: God (McDorman, 2005). Sommer-Rotenburg (1998), also

COMMUNICATION BARRIERS

mentions this point by stating how killing oneself was viewed as criminal, because it disrespects
Gods intention of morality in humankind. Additionally, God was considered the only being with
the ability to create and destroy life, yet those who take their own life are questioning that ability
Sommer-Rotenburg (1998). Therefore, as these two authors conclude, suicide was originally
viewed as a crime because it challenged the ultimate being, and now suicide has transgressed
into an act of selfishness filled with stigma (McDorman, 2005; Sommer-Rotenburg, 1998). This
language has affected the way we view suicide, and how the language can at times determine the
outcome.
Currently, the language used by American culture when discussing suicide is out dated, at
times incorrect, and almost always stigmatizing (Sommer-Rotenburg, 1998). Sommer-Rotenburg
(1998) furthers this point by discussing the colloquial use of the phrase commit suicide
(p.239), and how this reduces the meaning of an act of killing oneself; this phrase is morally
imprecise (p. 239). Adding to this idea, Sommer-Rotenburg (1998) believes that those who are
suicidal have a disgrace thrust upon them by American culture. Mesner and Buckrop (2008) add
to the idea of disgrace, by concluding after examining suicidal notes, that the three main
rhetorical strategies in the notes were guilt, shame, and transcendence. This disgrace creates a
stigmatic view of the suicidal person, replacing the tragedy that has occurred from depression
(Mesner and Buckrop, 2008). The language used towards suicidal patients constructs their own
view of themselves (Sommer-Rotenburg, 1998). Sommer-Rotenburg (1998), also argues that by
changing this language, the number of incidents might reduce.
On the other hand, Pirkis, Blood, Skehan, and Dare (2010), discuss the medias role on
the discussion of suicide. They argue that suicidal incidents can in fact be glorified or be overly
detailed, which could actually increase the death rates (Pirkis et al., 2010). In addition, Pirkis et

COMMUNICATION BARRIERS

al., (2010) discusses how journalists and other media forms need to change the language they use
to deliver information about suicide to the public. Pirkis et al. (2010) argue that journalists need
to report suicide in a responsible way that avoids encouraging other suicidal patients to follow
through with their intent. Leonard and Toller (2012), state how those who committed suicide,
specifically parents, were discussed with stigma and shame, on social media sites. This judgment
for the deceased increases the guilt and depression that people with suicidal intentions already
undergo. The lack of sympathy for the deceased who took their own lives, encourages this stigma
to exist.
Sommer-Rotenburg (1998) continues to defend the needed change for how we talk about
suicide, by disagreeing with an article from the Financial Post. She says, In a recent article in
the Financial Post, suicide was described as the ultimate act of selfishness. The author can have
no understanding of the pain that drives someone to make this agonizing decision and then
execute it (Sommer-Rotenburg, 1998, p. 240). Sommer-Rotenburg (1998) is recognizing how
others focus more on those affected by the suicide, and less on the deceased. People lack
awareness of how that person felt during that time, or for a long period of time of depression, and
rather, focus on how it affects them (Sommer-Rotenburg, 1998). This, ironically, is selfish.
How patients talk about suicide and how others receive it. In addition to the language
used by others, the communication that suicidal people use is also significant to understand.
Unhealthy relationships can also be one of the root causes for suicide. Gareth, Belam, Lambert,
Donovan, and Rapport (2012) state, Previous research has demonstrated that a majority of
people who attempt suicide communicate their suicidal ideas and intent, either directly or
indirectly, to members of their social network prior to the act (p. 420). This proves that a

COMMUNICATION BARRIERS

majority of suicidal peoples either verbally or nonverbally communicate their intentions with
people that they are close to.
When suicidal patients disclose these struggles to close friends and relatives, their
struggle is most commonly received with skepticism and dismissal (Gareth et al., 2012). The
listener will most likely avoid discussing this in the future, and may decide to even end the
relationship (Gareth et al., 2012). Therefore, it is easy to understand why suicidal patients feel
alone or lack finding comfort in others, since there is rarely effective communication provided
through their intimate relationships.
According to Holmstrom and Burleson (2011), esteems intention is to improve how
others feel about themselves. Holmstrom and Burleson (2011) also state, effective esteem
support from significant others contributes to both the mental and physical health of adults who
face significant, potentially life-threatening illnesses (p. 326). Thus, when significant others
support the suicidal patient, they raise his or her self-esteem, aiding in their recovery.
Furthermore, this explains how there can be a lack of disclosure by suicidal patients, considering
the responses can be ineffective, inconsiderate, and lower their self-esteem (Gareth et al., 2012).
As stated by Mesner and Buckrop (2008), Suicide notes usually address a particular relationship
in the suicidal person's life. Often the relationship in question failed to meet the suicidal person's
needs, thereby generating intense feelings of abandonment, rejection, and loss (p. 5). If negative
relationships are part of the cause for suicidal feelings, than there is no doubt that suicidal
patients are in need of a healthy therapeutic relationship.
Patient Provider Communication
In addition to communicating to significant others, patients also communicate with their
therapist. Lienemann, Siegel, and Crano (2012), report that due to stigma, depressed people

COMMUNICATION BARRIERS

express embarrassment about seeking help from professionals, compared to people who are not
undergoing depression, because they fear that professionals will not respond in an encouraging
way. Bagley and King (2005) state, perceived stigma is depressed peoples perception of the
publics negative and erroneous attitudes and stereotypes about those suffering from depression
(p. 353). Corrigan and Watson (2002) further this idea by stating, self-stigma occurs when
depressed individuals internalize these negative attitudes and stereotypes (p. 43). Furthermore,
self-stigma affects more than just the desire to ask for help; it affects whether or not depressed
and suicidal patients will continue to use mental health services (Lienemann et al., 2012). Thus,
there is evidence that suicidal patients induce self-stigma on themselves because of the way the
public views them. Keijers et al. (2000) also noted that although patients found discussing their
personal problems helpful, they also felt ashamed of them, relating to the previous idea of stigma
among depressed or mentally unstable patients. This furthers the explanation of why
communication can be distant and difficult between therapists and why their patients feel
uncomfortable discussing their feelings; there is a sense of marginalization.
Isometsa et al. (1995) state, One cannot always expect the person in danger of suicide to
express such intent spontaneously (p. 922). Isometsa et al. (1995) discuss how suicidal intent
was rarely discussed in therapy sessions when they state, 41% were reported to have their last
contact with a health care professional within the 4 weeks prior to deathsuicide intent was
discussed in only 22% of these last appointments...partly because they are too depressed or
worried to tell someone else (p. 921). Isometsa et al. (1995) are therefore proving how little
patients desire to disclose one of the most important decisions they face with their therapist.
Health care professionals sometimes worry that they are over dramatizing their patients
communication about suicide, causing them to be skeptical about treatment (Isometsa et al.,

COMMUNICATION BARRIERS

1995). There is a comfort level not reached between the patient and therapist since this
communication barrier exists, and a large number of those who took their own life did seek help
from health care professionals (Isometsa et al., 1995). Yet, these patients were most frequently
seeking help for mental problems and not suicide intent specifically (Isometsa et al., 1995).
Mokros (1993) defines communications modern role in psychiatry. Mokros (1993),
states that psychiatrists often overlook communication for importance when diagnosing patients.
Instead, they search for the biological explanation, and see communication as an objective way
to treat a patient (Mokros, 1993). Furthermore, Isometsa et al. (1995) state, psychiatrists do not
always recognize the mental problems their patient may have, so suicide remains uninvestigated.
If intent is communicated, then treatment is immediately followed, so those who do not
communicate their intention usually follow through with killing themselves (Isometra et al.,
1995).
Patient therapist relationship. The patients role has changed in psychotherapy.
Previously, their role was viewed as one that is susceptive to any advice that their therapist told
them, and discussing what they assumed their therapist would want them to say (Keijers et al.,
2000). Furthermore, psychiatrists previously believed that the patient therapist relationship was
the structure that the patients production is understood (Mokros, 1993). Yet, this view is
marginalized now, hence, the value of their relationship has been negatively impacted.
There are specific characteristics that assist in patient-provider communication. These
qualities are offered from both the cognitive-behavioral therapist and the patient in order to make
a difference in the patients outcome (Keijers et al., 2000). Keijers et al. (2000), argue that it is
the patients responsibility to gain new skills that can change their life. However, the therapist
must obviously contribute to the change as well, and he or she must offer as a necessity,

COMMUNICATION BARRIERS

empathy, nonpossessive warmth, positive regard, and genuinenessfor the achievement of

patient change (Keijers et al., 2000, p. 266). For cognitive behavioral therapists specifically,
studies have proven that the relationship they form with their patient serves more value that other
techniques (Keijers et al., 2000). Orlinsky and Howard (1986), state that when patients disclosed
their problems with their therapists, they felt helped. Orlinsky and Howard (1986) also state that
when they looked at studies with a correlation between patient openness and psychotherapy
outcome, there was a positive association for fourteen out of sixteen findings. However, it is
important to note that quality is more important than quantity (Keijers et al., 2000). In other
words, it is not the length of discussion that is necessarily helpful, but rather how patients discuss
their problems with their therapists (Orlinsky & Howard, 1986). Yet, there is something missing
within those conversations, since many follow through with their suicidal intentions. Since
cognitive behavioral strategies are goal oriented (Keijers et al., 2000), it is understandable that
they offer more affection towards their patients, because they have a specific ideal for the patient.
Since it has been proven that patients value warmth, empathy, and high levels of support, then
more therapists should adapt to these strategies to improve the patients mental health. Depressed
and suicidal patients most likely lack this sense of support from others, therefore if the therapist
provides it, the relationship will be healthy and secure, saving multiple lives.
Conclusion
Through my analysis of the stigmatizing language used to discuss suicide, and the
unhealthy relationships that patients may have with their therapist, I have synthesized that there
is a need for healthier communication in psychotherapy to positively transform the outcome for
the patient. It is time to break the barriers.

COMMUNICATION BARRIERS

10

RQ1: How can the communication barriers between suicidal patients and their therapists
be eliminated?

COMMUNICATION BARRIERS

11
References

Bagley, C., & King, M. (2005). Exploration of three stigma scales in 83 users of mental health
services: Implications for campaigns to reduce stigma. Journal of Mental Health, 14,
343355.
Corrigan, P. W., & Watson, A. C. (2002). The paradox of self-stigma and mental illness. Clinical
Psychology: Science and Practice, 9, 3553.
Isometsa, E. T., Heikkinen, M. E., Marttunen, M. J., Henriksson, M. M., Hillevi, M. A., &
Lonnqvist J. K. (1995). The last appointment before suicide: Is suicide intent
communicated? The American Journal of Psychiatry, 152(6), 919-22.
Keijsers, G. P., Schaap, C. P., & Hoogduin, C. A. L. (2000). The impact of interpersonal
patient and therapist behavior on outcome in cognitive-behavior therapy : A review of
empirical studies. Behavior Modification, 24(2), 264-297.
doi: 10.1177/0145445500242006
Leonard, L. G., Toller, P. (2012). Speaking ill of the dead: Anonymity and communication
about suicide on mydeathspace.com. Communication Studies, 63(4), 387-404. doi:
10.1080/10510974.2011.629274
Lienemann, B. A., Siegel, J. T., & Crano, W. D. (2012). Persuading people with depression to
seek help: Respect the boomerang. Health Communication, 1-8. doi:
10.1080/10410236.2012.712091
McDorman, T. F. (2005). Controlling death: Bio-power and the right-to-die controversy.
Communication and Critical/Cultural Studies, 2(3), 257-275. doi:
10.1080/14791420500198571
Messner, B. A., & Buckrop, J. J. (2000). Restoring order: Interpreting suicide through a

COMMUNICATION BARRIERS
burkean lens. Communication Quarterly, 48(1), 1-18.
Mokros, H.B. (1993). Communication and psychiatric diagnosis: Tales of depressive moods
from two contexts. Health Communication, 5(3), 113-127.
Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy.
In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior
change (3rd ed., pp. 311-381). New York: John Wiley.
Owen, G., Belam, J., Lambert, H., Donovan, J., Rapport, F., & Owens, C. (2012). Suicide
communication events: Lay interpretation of the communication of suicidal
ideation and intent. Social Science & Medicine, 75(2), 419.
Pirkis, J. R., Blood, W., Skehan, J., & Dare, A. (2010). Suicide in the news: Informing
strategies to improve the reporting of suicide. Health Communication, 25(6). doi:
10.1080/10410236.2010.496771
Sommer-Rotenberg, D. (1998). Suicide and language. Canadian Medical Association
Journal, 159(3), 239-40.

12