EMDR Therapy Quarterly

We need to talk about suicide, whether it’s about clients who are at risk of taking their own lives, our friends or family, about ourselves, or – especially acute for many of us this past year – where fellow therapists might be involved, including in our own tight-knit EMDR community.

As many readers of ETQ will know, a close colleague of ours took her life on 25 July, 2023. Since then, many of us have grappled with how best to bring this topic to ETQ readers, finding just how hard it is to talk about something so sensitive without breaking confidentiality.

And yet, we must talk. Since the coroner’s inquest, this one individual tragedy is now in the public domain. Our suggestion, therefore, is that we have a duty to discuss its implications. And where would be the best venue for such a discussion, if not ETQ?

In our line of work, there’s a sad truth about suicide, which is that there are perhaps two kinds of therapists: those who have already lost a client to suicide and those who, with time, will almost certainly share that experience. Of this article’s joint authors, Mark is in the first category, and Annabel is in the second. So, what we would like to do here is consider the science of why people kill themselves, whether it’s safe to use EMDR where there’s serious suicidality in the mix, the statistics, and offer some reflections from a group of EMDR therapists who met online earlier this year to try to make sense of it all.

Of course, all of us working as EMDR therapists with trauma have at least one, or maybe several, clients who are actively talking about suicide, either their own suicidal ideation or that of someone in their circle.

As our colleague Simon Proudlock puts it, “Death by suicide continues to be a leading cause of premature death across the globe.” (Proudlock & Peris, 2020, p.1). A government report recorded 6,588 deaths by suicide in the UK in 2022, noting that the suicide rate in England and Wales had declined by 26% since 1981, most of that fall occurring before 2000 (Baker 2024, p.1).

In 2022, however, the rate increased again (Baker, 2024, p.2). “Suicide in England and Wales is three times more common among men than among women” (Baker, 2024, p.4).  Proudlock & Peris (2020, p. 1) add that “the loss of a person by suicide has a significant emotional impact on friends and families, as well as an estimated economic and social cost in the region of £1.7million per death.”

According to the Centers for Disease Control and Prevention (CDC) and the National Institute of Mental Health (NIMH) in the United States (where in these online days some of us now have clients), suicide is the tenth leading cause of death overall. It is the second leading cause for individuals aged 10–34 and the fourth leading cause for individuals aged 35–44.

Therapists are not only not immune to suicide but may even be at a higher risk. Stacey Freedenthal wrote in 2021 that a significant proportion of therapists had contemplated suicide at some point.

“Studies of psychologists have found that at least 18 to 25% have experienced suicidal thoughts since they began practicing clinically. In a study of therapist trainees attending a suicide prevention training, 59% reported they’d experienced suicidal ideation, and 5% indicated they’d attempted suicide. There’s some evidence that psychologists, and perhaps other mental health professionals too, may be at higher risk for suicide than the average person, though studies have yielded mixed results” (Freedenthal, 2021).

 In America, in the aftermath of two clinician suicides, the American Psychological Association set up an ad hoc committee “to investigate the incidence of psychologist suicide and its impact on colleagues, students or interns, patients or clients, and the profession. […] The committee concluded that there is evidence suggestive of an elevated risk of suicide for psychologists in past decades” (Kleespies et al., 2011). Noting also the impact that a psychologist’s suicide can have on many people, including family, colleagues, students and patients or clients, the committee called for further research to explore particular risk factors for psychologists. (Kleespies et al., 2011).

UK conversation about an EMDR colleague’s suicide

This profound ripple effect is indeed what we found when nearly 100 of us gathered online on Easter Monday 2024, and again on the anniversary, to reflect on the death by suicide of our colleague, Nadia Wyatt, in July of last year. As readers may recall, Nadia’s death was particularly poignant, coming just days after she posted an urgent appeal on JiscMail (the listserve of up to 6000 EMDR therapists around the world), which included a description of her own experience of EMDR therapy as “lethal.”

Recognising that where someone has died, their informed consent to a wider discussion of their story is clearly not possible, we do have permission from Nadia’s husband to share the basics of what happened, and we can confirm that in the months before her death, she had reached out for help with EMDR for panic at the prospect of taking a planned holiday flight with him and their daughter.

Colleagues who had over time worked with Nadia – including in live workshop demonstrations in the online presence of dozens of fellow therapists – recalled how that fear had led in EMDR therapy to earlier life experiences of intense formative distress.

Many at the Easter Monday meeting shared their own experiences of suicide: as a family member, as a therapist, as a friend, as a colleague or as someone yet to lose a client or loved one to suicide.

While some had come to share personal memories of Nadia, especially remembering her colourful and joyful presence at the 2023 EMDR UK Conference in Cardiff, all were keen to learn lessons from her death, exploring the critical question: what do we specifically need to bear in mind when considering EMDR therapy with someone who presents with suicidal ideation?

EMDR trainer and consultant Simon Proudlock attended as an expert on EMDR with suicidal ideation, having pioneered ground-breaking research in the NHS. His 2020 study determined that “EMDR therapy can be an effective treatment for patients experiencing a mental health crisis who have a trauma picture, resulting in significant improvements in their mental wellbeing and substantial cost savings for the National Health Service (NHS)” (Proudlock & Peris, 2020, p1).

Simon’s findings have recently been further validated by Burback et al. (2024), who, in a small randomised controlled trial, investigated online EMDR for adults with suicidal ideation, finding “promising preliminary evidence that web-based EMDR may be a viable delivery approach to address SI (suicidal ideation).” In this complex population, they confirm that a short treatment course was associated with reductions in suicidal ideation and other symptoms across multiple diagnostic categories.

Mark Brayne spoke of losing a longer-term client to suicide in 2019 and of working with Nadia in live demonstrations during his own attachment-informed EMDR courses. Mark noted how therapists with the best of intentions can miss red flags that become clear only later, and sometimes too late.

In that context, Simon explained that there are two kinds of suicide: those that are planned and those that are impulsive. Most, he said, are actually planned. People contemplating ending their own lives may normalise self-harm by making preparations that they may not disclose and that those working with them can therefore miss, such as going to cliffs and train stations to reduce their fear.

Simon referred us to the insightful work of Thomas Joiner in his book Why People Die by Suicide (2005). “People appear to work up to the act of lethal self-injury. They do so over a long period of time, by gradually accumulating experiences that reduce their fear of self-harm, and they do so in the moment, by first engaging in mild self-injury as a prelude to lethal self-injury” (Joiner, 2005, p2).

As was confirmed in the coroner’s report on Nadia’s death (Mundy 2024), this is something she too had done in the days before she took her life.

In referencing Thomas Joiner’s book, Simon explained that there are three core aspects of a suicidal person’s perception: previous behavioural habituation to the idea of physical self-harm; perceived burdensomeness; and failed belongingness. Many believe the pain will never stop, so one of our jobs as therapists is to stabilise and facilitate an awareness that this moment too will pass.

Hopelessness can also play a role, although “an emphasis on hopelessness cannot tell the whole story (an issue that Beck and colleagues understand well). What in particular are suicidal people hopeless about? If hopelessness is key, why then do relatively few hopeless people die by suicide? In my view, the reply to the first question is burdensomeness and failed belongingness, and the reply to the second is that hopelessness is not sufficient; hopelessness about belongingness and burdensomeness is required, together with the acquired capability for serious self-harm” (Joiner, 2005, p. 39).

Proudlock and Peris also found that these core perceptions shifted with EMDR treatment. “Another primary focus of the research was to explore the effect of treatment on suicidality. This was achieved, and participants’ feelings of perceived burdensomeness and thwarted belongingness reduced following treatment. As per Joiner’s model, a reduction in both of these constructs indicates a reduced desire for suicide. This reduction, coupled with a corresponding reduction in depression, indicates patients were at a decreased risk of suicide after treatment with EMDR therapy (depression being one of the main risk factors for suicide).” (Proudlock & Peris, 2020, p. 6).

The Easter Monday meeting

As chair of our online gathering and as a therapist, Annabel has a personal passion for working with death anxiety, grief and Internal Family Systems (IFS)-informed EMDR. She chose therefore to open with an IFS-inspired meditation as a way of welcoming everybody with all their parts and mixed emotions: parts that missed Nadia or another loved one or client; parts that felt guilty they might not have personally done enough; and parts that might feel anger towards Nadia.

Over our two hours together on Easter Monday, there followed an open, honest, compassionate and moving conversation – a ‘sacred’ space that was not recorded to make it safe to share openly during the meeting.

Some used the space to remember Nadia. Others shared the pain of losing a sibling, a friend, or a parent, or of having been suicidal themselves in the past. Simon reflected on how surprised he was by just how many colleagues were touched by suicide themselves. Linda Sunderland, on our small organising group, who had been in touch with Nadia close to her death, shared how vibrant, colourful and attractive she was as a human being. All of us agreed that it was hard not to like her, and it was ironically powerful to hear how active Nadia had herself been around suicide prevention for clients, making videos and posting on social media.

Tragically, and after understanding her story again with the language of IFS, that wise and compassionate dimension of her being was ultimately unable to reach the parts that persuaded her that ending her own life was the only way to end the pain and anxiety.

So, what had Nadia meant by posting on JiscMail the shocking comment that EMDR therapy can be “lethal”?

Several of us offered the thought that it was not so much the EMDR itself that could kill, but the deep attachment wounds that can surface in EMDR targeting and processing. This brought to mind a presentation by two Dutch colleagues, Ludwig Cornil and Olivier Van Limbergen, at the EMDR Association annual conference in York in March this year, who discussed the term ‘affect-focused EMDR,’ and how this invites a therapist to bring a client’s most intense and deepest pain into the work to be explicitly and powerfully felt and processed.

Might that have helped Nadia? Again, sadly, we’ll never know.

Simon encouraged participants to explore in depth the real cause of clients’ pain, as well as engendering hope and the prospect of the pain ending. He encouraged those using EMDR with such clients to do so in a person-centred way.

One participant shared how her own journey with having attempted to take her own life in her 20s led her to become a therapist. She found that helping clients to access and express their anger and even the rage that’s held by parts of them is central to the therapy she offers.

Mark told us that he was in contact with Nadia’s husband, who was grateful to hear that our meeting was taking place. Although it was too early for him to join himself, he let us know he was sure Nadia was going to be with us in spirit. He also recommended an animal welfare charity, Tower Hill Stables Animal Sanctuary in Asheldham, Essex, which had meant a great deal to Nadia and who, he was sure, would welcome donations made in her memory.

Commitment to keep talking about suicide

In closing, attendees at our Easter Monday meeting committed to keeping this conversation going, tackling the taboo of suicide and being open with each other about our own struggles and proximity at times to burnout, and perhaps even about our own suicidal moments and shame about our own therapeutic competence. In the spirit of this, we met again on the anniversary of Nadia’s death. Sally-Ann Soulsby noted how important it is for supervisees to feel safe sharing their struggles with their own EMDR consultants.

As two of the organisers of the meeting, we feel deeply grateful to have such amazing colleagues. As with all end-of-life work, with fellow organisers Linda and Sally-Ann, we find that talking about death can help us to live better today and make the most of the precious moments of our own life, as ourselves and with loved ones.

The Dalai Lama says that it is crucial to be mindful of death and, in his words, to contemplate that you will not remain long in this life. 

“If you are not aware of death, you will fail to take advantage of this special human life that you have already attained. It is meaningful since, based on it, important effects can be accomplished.”

The Dalai Lama

Although the meeting was confidential, there was a desire to share the message, the lessons and the resources. We have chosen to only share the names of the organisers and guest speaker here, and add below a comprehensive set of resources, groups and reading that emerged from our meeting.

Annabel is an international trainer, author, EMDR UK & Australia Accredited EMDR Consultant and psychotherapist in private practice. Mark Brayne is an EMDR UK accredited and EMDRIA-approved consultant. He also provides workshops in Attachment-Informed EMDR.