I am sitting with Vanessa who has just turned 60. Vanessa has been depressed many times over the years and she currently has numerous physical problems that are well-managed. Vanessa has been referred to me by a psychiatrist. We have an intense first meeting where I have been asking a lot of questions in a direct but tactful way. Vanessa tells me that all of her major relationships in life have withered. I want to help her but when I inquire to find the level of her difficulties in a specific area, with the idea of some potentially helpful intervention in mind, then nothing seems to be possible. Because of the way she has described her situation, it now appears to be hopeless to me also. For her, there are no options and she feels resigned to her fate of death by suicide: She sees no other option. I comment that it is her understanding that stops her moving forward and I tell her so. Vanessa agrees. She is certain she will kill herself one day. Vanessa is suicidally depressed.

On further questioning, it appears that she is in danger of suicide because only six weeks ago she tried to take her life with an overdose but it didn’t work and she woke up in a hospital bed. I ask about her personal history . One of her daughters died in a tragic accident and her remaining daughter, although she only lives 1 km away, will have nothing to do with her mother after they finally fell out after 40 years of arguing where the topics were always the same. When I inquire into the amount of risk through suicide, Vanessa says she won’t kill herself. But I’m not so sure as I can see that there is nothing for her to look forward to, and the more I ask about her circumstances and personal history, the worse her situation appears. I am worried that she may try to kill herself and ask if she has a plan to do so. She says “yes” and that it might happen any time if something else goes wrong. So I ask if she would be willing to ask for help. Vanessa is clear that she won’t be ringing any telephone help lines in the middle of the night but would prefer to die. I ask her if she would ask for help if she were to feel suicidal because I believe that she is at risk, and although it wouldn’t be my wish to make her feel worse, I guess that inadvertently our discussions could create in her a state of despair where she might feel that all is hopeless and so she might be motivated to die. Vanessa says “no”. She will not be calling to ask for help if she is actively suicidal. So while Vanessa has accepted her psychiatrist’s advice in coming to see me, I am wondering what there is to work with, as she isn’t motivated to ask for help and if she were to feel sufficiently suicidal then she is saying that she will kill herself. Vanessa feels beyond help, won’t ask for help and holds the idea of suicide as an escape because for her death is a blessed release from suffering. Then Vanessa asks me, while looking me straight in the eyes, “what is to be done then?” I want to help her but there are some dilemmas from practical and ethical points of view. What is the central question about this example from the philosophy of practice?

My answer is that setting aside the ethical answer of whether a person has the right to kill themselves, and the question of her lack of willingness to ask for help when she is actively suicidal, and of other problems about how to treat her because of her physical problems, then the central issue is how to know psychological being in general and in her specific case. The immediate problem is that some decisions need to be made now, in what to say and do to create safety for her in a way that builds her trust in me. We have only been talking for 40 minutes and I don’t know her and her capabilities. In philosophical terminology there are epistemological, ontological and hermeneutic problems of how to make sense and how to consult with helpful bodies of knowledge, given that if she really did want to kill herself then she could make it happen. The type of thinking around how to help Vanessa, or anyone in general involves knowing in advance, even before meeting with a specific person, what would generally help people with a specific type of distress. Qualitative psychological research can provide information about the motivations that people have to kill themselves and provide factual information. But, like any psychotherapy case, Vanessa’s problem is a meaning-oriented experiential question of what intentionalities clients’ use, what objects appear and what contexts can be brought to bear to rationalise and alter these meanings.

Technically, the first meeting with clients is called “assessment”, a procedure for finding out the level of clients’ difficulties and beginning to think with them in a collaborative way about what will help. Interpreting a person’s psychological being also connects with “clinical reasoning” . For what is being attempted by therapists at assessment is taking general clinical knowledge picked up over the years and held at a pre-reflexive level, and bringing it to bear on the current discussions with the unique person who wants help. For instance, in this case there are a number of unclear aspects of what Vanessa is presenting. Firstly, she is not asking for help in a clear way. There are difficulties knowing how she might respond in the future if a session might make her feel very depressed and hopeless. If something will not help, then it should not be offered. This aspect of clinical reasoning is around understanding her motivations and tendencies to act through questioning and empathising the level of her despair. What brings on her despair? How does she deal with it herself? What sense does Vanessa make about her own suicidal thoughts and feelings? The inquiry is finding if there are specific things, emotions or situations that might motivate or trigger her in taking another overdose. For the next time Vanessa wants to kill herself, then she might act with a more lethal means than before. Six weeks ago her husband was able to find the empty bottle of pain killers that she had taken and call an ambulance. But this type of medication is available from any pharmacy for a small price. The formal way of working out how to help her is clinical reasoning and that aims to grasp her psychological being . Clinical reasoning about suicide works by consulting larger bodies of general knowledge on suicidal motivation , the being of suicide and its social contexts and then tailoring such knowledge for the unique individual (Appleby 1999; Harris and Barraclough 1997). The outcome is that clinical reasoning produces works towards making an “intervention” which refers to any speech or action from therapists. Most interventions are designed to alter connections of sense and meaning and form part of an agreed strategy referred to as a “treatment plan” that requires clients’ informed consent concerning how to help them. In the British National Health Service it is ethically unacceptable to assess or offer treatment without previously getting informed consent (Department of Health 2001). While therapists do not tell clients what to do, it is necessary get informed consent for assessment and treatment in advance of any specific collaboration that works on altering specific meanings and behaviours. One aim is clarity and collaboration, for if these were absent they would impede treatment.

As an illustration of how to deal with this instance and explain principles, the clinical reasoning goes as follows for helping Vanessa. Vanessa is on anti-depressant medication but since her suicide attempt she is being prescribed small doses of types that are not poisonous. Biologically speaking, her depression acts at a physical level as well as influencing her emotionally, in her selection of memories and ability to imagine the future. Her speech is slowed and her physical experiencing of her body and the world is heavy, exhausted and difficult. She speaks after long pauses as though everything were difficult to say. The general clinical reasoning of how to help people who are depressed is that one intervention would be to explain that she could improve her mood by being more physically active . But this is impossible because of her physical condition. Another intervention would be to allow her to talk in the hope that discussion may provide a spontaneous change in the very same meanings that she currently experiences and by which she is tormented. For instance, Vanessa blames herself for the state of her marriage, misses her daughter who died 20 years ago and she is estranged from her remaining daughter. A talking treatment might be possible but the means of talking would be to speak with her and comment on how she presents herself and feels herself to be in her view of the world, in the hope that a strong and influential relationship can be built where she might permit me into her world. This is an option where I am cautious because she is not clearly willing to ask for help and if she were to be actively suicidal, such a form of treatment may be likely to bring out more and more meanings that would only spell out to her how much of a ‘failure’ that she feels herself to be. In this light, open-ended discussion of her problems is contra-indicated in advance because Vanessa seems convinced of her own worthlessness and believes she has failed as a mother, wife and human being.

Other choices in clinical reasoning are as follows. One option would be to explain that therapy cannot help her at the moment because there are no interventions that meet her needs. Another would be to formulate it verbally or on paper by asking questions about the function of her thinking about suicide, in that it is still an open question as to what her reasoning is, what motivates her to take her own life and explore the conditions of its possibility before going any further. Another would be to refer her back to the psychiatrist for medication or a home care treatment where services could visit her and provide mental health support and physical help. Another potential intervention would be to consider electroconvulsive therapy where she may lose aspects of her memory and personality permanently, although it might have a curative effect of bringing the depression to a close. This drastic form of treatment works through using electricity to induce fits, but even that that might not work for her. If she were able to go out by herself, then an intervention called behavioural activation, which encourages people to be more physically active is a research-proven way that can be highly effective in helping people gain improvements in their mood (Jacobson et al. 2006). Another way forward is to keep on assessing Vanessa and ask about her motivations to help her overcome her own low mood and rebuild her self-esteem. It would also be possible to speak with her husband and wider family, or provide couples therapy where they could both go to try and work on their marriage which seems to be a factor that maintains her low mood. Or perhaps another way forward would be to have Vanessa meet with her husband and daughter, informally by themselves, or formally in family therapy, and to discuss how to proceed and overcome the alienation that has beset them.

But what else needs to be born in mind is that given the current state of her psychological being as suicidal despair, and given that she had made a recent suicide attempt, and that she has a number of maintaining factors of her despair and it is unclear if she will ask for help if she were to have the intent again, then it would seem too risky to go down a route that is likely to make her feel worse. What would be helpful is if it was possible to know with more certainty how to help her, and through formulation and clinical reasoning , be able to specify how and where to begin helping her, and how to enlist her participation in her treatment before getting down to the detail of the interventions that should be used. If therapy is to be effective and safe in promoting her best interests, then it would seem that the only way forwards is to put back these dilemmas to her, so she can become active in her own treatment. At the moment, it seems that she is somewhat passive in how she is treating herself and this can be understood as part of her overall picture of being depressed, feeling bad about herself and that she cannot see any future. Although this is a case of how to work with suicidal intent as part of severe depression, the general principles of formulation and clinical reasoning are philosophical and theoretical in nature and involve her representing intentionalities towards meaningful objects in complex contexts. The example concerns how to synthesise and apply general knowledge to the individual case in a situation of uncertainty where there are no guarantees of success.