Monthly Archives: July 2010

Confronting the threat of suicide

By Lynne Shallcross July 25, 2010

HeartinHandsAt age 16, Kim Johancen-Walt became a suicide survivor after her brother, Kevin, took his own life through carbon monoxide poisoning in 1988.

Johancen-Walt, who grew up in a suburb of Denver, recalls being both deeply saddened and incredibly angry with her brother for ending his life. “I remember [a friend’s father] telling me the night Kevin was found that there would never be a day in my life that I wouldn’t think about my brother and the circumstances surrounding his death,” says Johancen-Walt, an American Counseling Association member who works in private practice in Durango, Colo., and serves as a senior counselor and assistant training director at Fort Lewis College. “Although I am happy to say that I actually have had days — many, in fact — that I have not thought about Kevin or his suicide, those words were my first lesson in coming to terms with how much my life was going to be changed. Accepting the full impact of my brother’s decision to commit suicide has been an essential part of my own healing process.”

After her brother’s death, her own life took an altered path, Johancen-Walt says, which included developing a passion for suicide prevention. Growing up, Johancen-Walt was sexually abused by her brother. Although it was never confirmed, her family believes Kevin was also sexually abused at a babysitter’s house when he was a child. “Kevin had untreated anxiety, had developed a substance abuse problem with alcohol and was having problems at work and in meaningful relationships at the time of his death,” Johancen-Walt says. “I believe that Kevin’s death may have been prevented if he had received early treatment that not only addressed his symptoms but also the psychological pain that fueled them. Furthermore, treatment may have provided him with additional information and skills that may have ultimately made a difference in his decision to end his life.”

In 1999, 11 years after Kevin’s death, the surgeon general declared suicide a public health crisis in the United States. But in more than a decade since that pronouncement, not enough has changed, says Darcy Haag Granello, a professor of counselor education at Ohio State University and a member of ACA. “There are some pockets of excellent programming, but as a nation, we have not taken this on,” she says.

Nationwide, Granello says, more than 34,000 people die each year from suicide — about 90 people per day. In a report based on a 16-state survey and published by the Centers for Disease Control and Prevention in May, suicide was found to be the leading cause of violent death in 2007, putting it ahead of homicides.

Adding to the problem, Granello says, is that although people in crisis often turn to counseling, not enough counselor training has been focused on suicide prevention. “The average amount of training in counselor education is less than one hour on suicide prevention and intervention. The absurdity of that is that as counselors, these are the people we see — these are our clients — yet we are not preparing our graduate student population sufficiently to handle these clients,” says Granello, adding she is pleased that the new CACREP Standards include suicide prevention and intervention.

Granello and her husband, Paul, conduct training for a variety of groups, including counselors, psychologists, teachers and emergency room personnel, and in those sessions, the Granellos offer a distinct, bottom-line message. “The No. 1 thing we tell counselors is to ask the question — ask it often and ask it in different ways. Ask if they’re feeling suicidal. Ask if they’re thinking of killing themselves. The take-home message everywhere we go is ‘Just ask,'” says Granello, coauthor of Suicide, Self-Injury and Violence in the Schools: Assessment, Prevention and Intervention Strategies, being published by ACA this summer.

Counselors can inadvertently make assumptions about whether clients are suicidal, and those assumptions are often wrong, Granello warns. She tells the counselors she trains to ask the question every time they meet with a client, even if it’s during a career counseling session. “Many times, people say no the first time. They don’t know you, they don’t feel comfortable. And by the time they get to know you and trust you, you don’t ask it anymore.” Counselors need to ask the question even after they become familiar with a client, Granello says, not just the first time they meet that client.

Research shows that talking about suicide decreases the actual risk, Granello says. In fact, she says, 80 percent of people who die by suicide tell someone about their plans in the week prior to their death. Unfortunately, Granello says, individuals confronted with these revelations most often respond with silence, ridicule or minimizing. People have very few places they can talk about their thoughts and feelings openly, so counselors have a real opportunity to serve as that outlet, Granello says. “Engage people in the conversation. … There’s no magic to it. Ask the question [and] open the conversation.”

“From my experience, there is great opportunity for the counselor who has a suicidal client who is talking about [his or her] suicidal thoughts or behaviors,” concurs Johancen-Walt. “This is not only an opportunity for a counselor to gather more information about actual risk, such as determining whether the client has an actual plan and the means to carry out the plan, but it is also an opportunity to challenge irrational beliefs that the client’s life will be better if [he or she is] dead. I am much more concerned about the client who is not talking about suicide if I have determined that clusters of risk factors are present.”

In these types of crisis situations, it’s important for counselors to understand that dying isn’t the client’s true desire, Granello emphasizes. “People who are suicidal don’t want to die. That’s not the goal,” she says. “People who are suicidal want the pain to end.” The feeling has been called “psycheache,” Granello says, and clients battling it might be unable to envision themselves going another day with the deep, intense pain that it involves. “The fact that people who are suicidal are telling people, reaching out in a way they know how, means that they are looking for some relief. From a counseling perspective, that’s a really positive thing. What it means is we can help people work through that intense psychological pain and find a way through it. That’s fantastic.”

On alert for risk factors

The potential threat of suicide cuts across all lines, regardless of the counselor’s setting, says ACA member Jason McGlothlin, associate professor at Kent State University and coordinator of the university’s counseling and human development services master’s programs. “Research says if you haven’t had a suicidal client yet, you will at some point.”

With that in mind, it’s important for all counselors to gain an understanding of the risk factors and to stay alert for potential tip-offs with clients. McGlothlin, author of Developing Clinical Skills in Suicide Assessment, Prevention and Treatment, published by ACA, offers five key emotional risk factors typically found among individuals who are suicidal. He adds that these risk factors are common across all age ranges. One is hopelessness, which might involve a client being unable to see a future. Another is helplessness — a feeling that no one can help and there is no way out. A third is worthlessness, which might encompass a client feeling that he or she isn’t worth saving or that life isn’t worth living. Fourth is loneliness, which isn’t necessarily indicative of a lack of friends or support. Instead, McGlothlin says, a client might feel empty inside, as though something is missing. The fifth emotional risk factor is depression.

To date, research has identified more than 100 risk factors leading to the possibility of suicide, Granello says. Although acknowledging that it is difficult to assign a degree of significance to every factor, she believes certain factors are worth spotlighting. For instance, 90 percent of people who die by suicide have some kind of psychiatric disorder, most commonly depression or bipolar disorder, she says. Additional major risk factors include substance use and abuse, a sense of hopelessness, a rigid cognitive structure leading to poor coping skills or the inability to problem solve, and perfectionism and impulsivity, especially in young people, Granello says. A previous suicide attempt is another major risk factor. However, Granello adds, only about one-third of people who complete suicide have made a previous attempt. “So it’s a good statistic,” she says, “but it doesn’t account for two-thirds of the people.”

That said, Johancen-Walt believes a client’s previous suicide attempt is a risk factor strongly deserving of counselors’ attention. “Edwin Schneidman, a great pioneer in the field of suicide research, wrote about how the ‘unresolved core-wounding’ associated with the previous suicide attempt puts someone at great risk of further attempts or completion. Counselors working with clients who have previously attempted suicide must address the unresolved feelings and thoughts that may have contributed to the original attempt.”

Other risk factors Johancen-Walt cites include history of trauma, untreated depression and anxiety, history of suicide in the family or peer group, substance abuse, other self-harming behaviors and problems with primary support systems. “Risk factors that counselors may not always be aware of include the loss of meaningful relationships and issues related to sexual identity or sexual orientation,” she adds. “Furthermore, a client who is impulsive or has issues with out-of-control rage may also be at risk.”

The most important first step as a counselor in determining suicide risk is to conduct a thorough assessment, according to McGlothlin. Some counselor education programs promote a triage approach to assessment, he says. PIMP (which inquires whether the client has a Plan, the Intent and the Means to complete suicide, and has made Prior attempts) is one example of a suicide-risk screening that can be completed in a matter of minutes. That might be appropriate in a triage situation when a quick assessment is needed, such as in a hospital or an inpatient clinic, but if a counselor is going to see the client more than once, McGlothlin says, a much more thorough assessment should be used.

The “simple steps” model, which McGlothlin created, takes a more global approach and considers life factors, diagnosis and common emotional factors of suicide. McGlothlin’s assessment model is not a one-time approach, he says, but rather a tool counselors can weave into treatment planning. He says his model brings in all the factors of the client’s life and addresses whether those factors equate to a higher potential for suicide.

“Suicide is so complex that if you don’t grab all parts of it, you might be missing something,” McGlothlin says. “And if you’re missing something in the assessment, you might miss it in the treatment. The more thorough your assessment, the more thorough your treatment.” The three foundations of good treatment, he adds, are having a good therapeutic relationship with the client, assessing thoroughly and then following up on any issues that arise.

As for specific treatment modalities that have proved effective, McGlothlin points to person-centered approaches, solution-focused approaches and other models that focus on the counselor/client relationship and keeping clients in the here and now. “Lately, dialectical behavioral therapy has shown promising outcomes in the treatment of suicidal ideation,” McGlothlin adds.

Granello says interventions with a suicidal client are always two-tiered. The first tier involves helping the client through the immediate suicide crisis; the second tier involves addressing whatever issues are underneath. Granello developed a seven-step model for the first tier of intervention, which is aimed at preventing death or injury and restoring the client to a state of equilibrium. The seven steps (each of which involves specific strategies) are assessing lethality, establishing rapport, listening to the story, managing the feelings, exploring alternatives, using behavioral strategies and following up.

Johancen-Walt offers several treatment suggestions to counselors. First, she says, give unconditional acceptance. “Early in treatment, I offer clients my belief that they are doing the best they can to survive painful thoughts and feelings. Suicidal and other self-destructive behaviors serve as coping strategies for many clients desperate for emotional relief. By framing behaviors this way, we can create a therapeutic container absent of judgment while also targeting feelings of shame that may contribute to the isolation many suicidal clients feel.”

Next, ask the client direct questions and create a safe space for talking about feelings, Johancen-Walt says. Also helpful is exploring client supports and resources. “To foster an environment in which change is possible, it is important to help the client identify supportive others in their life while also capitalizing on the client’s inherent strengths,” she says. “For example, through the exploration of how a client may have survived a previous crisis, the counselor can assist the client in creating a list of specific skills and strategies that can help the client survive current challenges.”

Strive to understand the client’s unique experience, she adds, because the client might be more willing to try out new skills and strategies with a counselor who “gets it.” Finally, teach clients effective coping skills. “Many clients engaged in either suicidal or other forms of self-destructive behavior have a limited toolbox of coping strategies,” Johancen-Walt says. “Counselors must offer clients additional tools such as stress management or emotion regulation skills and encourage clients to practice using the skills in between sessions. Time should regularly be spent in session going over coping strategies.”

Simply being open to talk goes a long way toward preventing clients from attempting suicide, Granello says. “The most important thing that we can do with our clients is to let them know that they can talk about suicide and suicidal thoughts,” she says. “Suicidal thoughts are remarkably common. We have to open up the door to let people have the conversation in a safe and healthy way.”

Hope is another key ingredient, Johancen-Walt adds. “We have to hold hope for even the most hopeless of clients. To fully understand our clients, we have to be able to go into the depths of the pit with them. The trick, however, is to be able to climb back out. If you find yourself losing hope for a high-risk client, then consult or seek out supervision. On more than one occasion, I have asked other counselors to come into session with me and my client when I was caught in the pit.”

From the big picture perspective, Granello says making efforts to reduce the stigma attached to mental health issues and suicide is highly important. Granello, whose brother-in-law died by suicide in 1999, wears a suicide survivor pin to encourage conversation about mental health and available help. At the societal level, she says, counselors should take action and advocate for mental health care by working with school boards to implement suicide prevention education, pushing for insurance companies to pay for mental health coverage and making sure colleges with budget strains don’t cut counseling center staff. “As states were cutting budgets for mental health over the last year, ask yourself what you did,” Granello says. “Did you contact your legislators? Write letters to the editor? Get involved with local grassroots efforts? What sort of education and outreach can you provide?”

Suicide in the schools

Schools are in a prime position to address suicide prevention and aftermath because they have ongoing, close contact with students, says David Capuzzi, a past president of ACA and senior faculty associate at Johns Hopkins University’s Department of Counseling and Human Services. “The key to facilitating both prevention and post-vention is to thoroughly prepare all the adults in a school building — teachers, counselors, administrators, janitors, cafeteria workers, secretaries, bus drivers, etc. — to recognize the signs and symptoms, as well as the risk factors, and to know when an immediate referral to the building counselor should be made. All adults in contact with young people in a school can be taught what to look for, what to say and not say to a student they are concerned about and how to facilitate a referral. This can be a powerful way to keep students safe.”

Capuzzi recommends that school counselors trained in suicide prevention go on to provide in-service training for the other adults in their schools. “You can’t start anything until all the adults know what to do,” he says. “You never, never, never go into an auditorium or classroom and start talking about suicide until all the adults are prepared way ahead of time.”

When a counselor identifies a student who may be at risk, an important first step is to conduct a risk assessment interview with specific questions and indicators, Capuzzi says. Without one, he says, a counselor cannot be certain who is truly suicidal. “Counselors have to use their own professional judgment after conducting a risk assessment interview focused on potential suicidality,” says Capuzzi, who is also a professor and core faculty with the Walden University School of Social and Behavioral Sciences. “If there is uncertainty on the part of the counselor, a second assessment should be done by another counselor who has the skills to conduct such an assessment. After that, immediate next steps should be arranged for the purpose of preventing the client from inflicting self-harm.”

The job of the school counselor is to discern whether a student is potentially suicidal and, if so, to make a referral and get help for the student right away. “Children and teenagers often don’t delay their attempts very long,” Capuzzi warns.

Major risk factors for adolescents include psychiatric disorders, poor self-efficacy and problem-solving skills, sexual or physical abuse, concerns over sexual identity or orientation, the easy availability of firearms, substance abuse, exposure to violent rock music and parental divorce, according to Capuzzi. However, an important theory has emerged in the past decade that it may be more effective to increase protective factors in an adolescent’s life rather than trying to reduce the risk factors, says Capuzzi, whose second edition of Suicide Prevention in the Schools: Guidelines for Middle and High School Settings was published by ACA last year.

Among the protective factors that have emerged out of recent research are social network and external support, reasons for living, self-efficacy and self-esteem, emotional well-being and problem-solving skills, Capuzzi says. Knowing about the protective factors may open up opportunities for school counselors to help students. For instance, Capuzzi says, if social networks and external support are helpful, a counselor could help teach a student how to make friends and reach out to people for support. Likewise, a counselor could support a student in improving self-esteem, enhancing problem-solving skills or overcoming depression.

Rather than offering potential techniques for working with adolescents, Capuzzi believes it is more important to challenge school counselors to seek education and supervision regarding suicide prevention and post-vention. Although taking a course is helpful, he says the only way for counselors to develop the necessary skills is to work with an experienced mentor under supervision.

One of the unique aspects of effective suicide prevention in school settings, McGlothlin says, is addressing the developmental issues that invariably arise with students, such as dealing with hormones and adolescents’ desire for admiration from their peers. “As adults, we want to fit in, but it’s not as high on our priority list,” he says. School counselors should make themselves aware of how students interact and which students might feel like outsiders, McGlothlin says. He is careful to note that “outsiders” aren’t the only students at risk for suicide, but being aware of those who don’t appear to have true peer support is important.

In addition to implementing and tailoring a suicide prevention program for their schools, McGlothlin suggests that school counselors take advantage of the opportunities they have to be hands-on with the students. “One of the big issues about school-age suicide is that they become more isolated and, depending on their age, they might not know about the resources out there,” he says. “Having the school counselors out there being visible, talking to kids, showing that they are a resource, that’s a huge factor in school suicide prevention.”

To some degree, suicide prevention in schools begins with the administration, McGlothlin says. Principals and superintendents must realize that suicide is a prevalent issue that needs attention. One of the big myths, he says, is that if no one talks about it, suicides won’t take place. “It’s going to happen whether you talk about it or not,” he insists. “So talk about it.” Having a plan of action for the worst-case scenario is essential, he says, adding that the school counselor needs to understand exactly how the plan would unfold should a suicide occur, including when and how to inform the administration, teachers, students, community and media.

Antistigmatization is a key element in the trainings Granello conducts at schools. Only 25 percent of adolescents report that they would tell an adult if they knew a peer was considering suicide, she says, so teaching students to speak up is important. Granello recalls one student who had a light bulb moment during one of the suicide prevention seminars. “He said, ‘I get it. It’s better to lose a friendship than to lose a friend.'”

Meanwhile, Granello is making suicide prevention a campuswide responsibility at Ohio State, where she is project director of the university’s Campus Suicide Prevention Program, which launched in 2006. The unique program utilizes more than 60 campus “partners,” ranging from administrative and academic departments to student groups and community partners, each of which agrees to incorporate suicide prevention into their work. “It takes the whole idea of suicide prevention away from the sole venue of the counseling center and makes it a shared responsibility of the campus community,” Granello explains.

Training others to act as gatekeepers on college campuses is pivotal, Granello says. “They’re not counselors, but they’re people who have their finger on the pulse of what’s going on.” Gatekeepers can be trained to recognize warning signs and then reach out and ask the student to come with them to get help. “We have to be more proactive about being out in the university, not waiting for people to come to us,” Granello says. She points out that in the past decade, none of the students who died by suicide at Ohio State had been to the counseling center. “They fall under the radar. Counselors can’t wait for them. [That’s why] gatekeepers are important.”

The period after a suicide takes place is a “very dangerous” time in schools, Granello says, because of the possibility of suicide contagion. Granello and her husband were called recently to a small college campus after a student completed suicide. As might be expected, the college community had organized memorial services and candlelight vigils, flown the flag at half-staff and participated in other tributes in the aftermath of the suicide.

“It comes from the heart and comes from the right place, but it’s exactly the wrong thing to do,” Granello says. “They had a copycat suicide a month later. The point is that all of us have to be very careful that we are following empirically validated post-vention procedures, not what we feel we should naturally do. Schools aren’t trying to encourage contagion; they just don’t know.” She emphasizes the importance of following the specific protocols for post-vention procedures put out by the American Association of Suicidology (see “Resources on the Web” below).

Heading off the threat

Assessing for the threat of suicide can be a complex and anxiety-inducing task for any counselor. These experts pooled their knowledge to come up with a list of do’s and don’ts for counselors working with suicidal clients.

  • DO ask about suicide with all your clients, McGlothlin says. “Sometimes that’s a scary thing to talk about for new counselors … [but] take time to do it.”
  • DO read all you can on the topic, Capuzzi says.
  • DO get advanced training in suicide prevention programming, risk assessment and intervention strategies, Granello says.
  • DO ask why. “It is important to ask clients why they are feeling suicidal instead of only focusing on their behaviors,” Johancen-Walt says. “Many clients may have unresolved feelings surrounding earlier traumas and need to have these issues addressed in treatment. We need to treat the client, not just the symptom.”
  • DO document. “The more you document, the better,” McGlothlin says. “Document how you assess, how you treat and how you follow up.”
  • DO ongoing assessment. “Through ongoing assessment, we are able to also highlight our clients’ success while identifying potential roadblocks to recovery,” Johancen-Walt says.
  • DO get other people involved. “Frame this not as ‘breaking confidentiality’ but as bringing in all possible resources to help keep the client or student alive,” Granello says. “This can actually help facilitate the development of rapport if clients or students believe that you care so much about their well-being that you will do everything in your power to help keep them safe.”
  • DO work under supervision if you are treating a suicidal client and don’t have the necessary experience, Capuzzi says.
  • DO realize that the help has to be immediate, Capuzzi says.
  • DO follow up, McGlothlin says. Asking about suicidal thoughts should not be a one-time thing.
  • DO know the services available in your school or community to help clients or students who may be suicidal, Granello says. “Have an action plan developed ahead of time for what you will do if someone you are working with is suicidal.”
  • DO create realistic treatment goals. “It is important that we are helping our clients set themselves up for success in regard to their therapeutic treatment goals,” Johancen-Walt says. “Counselors need to also educate clients about the treatment process in a way that incorporates information about relapse and ongoing commitment to recovery.”
  • DON’T ever promise someone who is suicidal that you won’t tell anyone else, Capuzzi says.
  • DON’T lecture, critique or criticize. “It’s futile to get into conversations about blaming clients,” McGlothlin says. “They feel bad enough. They don’t need to hear lectures.”
  • DON’T be afraid to bring up the topic of suicide. “It will not put the idea in anyone’s head,” Granello says. “There is solid research that talking about suicide, in appropriate ways, actually lowers risk. Don’t wait. Ask the question.”
  • DON’T work in isolation, Johancen-Walt says. “Whether you are in private practice or part of a team, it is important for counselors to seek ongoing consultation with other practitioners and to create treatment teams that include psychiatrists, medical and mental health professionals, family members, teachers, coaches, etc.”
  • DON’T assume that suicide is about death, Granello says. “In fact, most people who are suicidal are ambivalent. They don’t want to die; they just want the unbearable pain to end. As counselors, we can use that ambivalence to help keep them alive.”
  • DON’T leave a potentially suicidal person alone, even for a moment, Granello says.
  • DON’T assume that someone else in your community, organization, agency or school will take responsibility for suicide prevention programming and awareness. Step up and get involved.
  • DON’T give up, Johancen-Walt says. “It is important always to communicate to our clients that their lives are worth saving, even if they do not believe it in a painful moment. We can hold hope for our clients until they are ready to hold it for themselves.”

All recommendations aside, Johancen-Walt says it is important to remember that both the counselor and the client share responsibility in preventing suicide. “As a counselor and also as a survivor of suicide, I believe that if a client has committed suicide, it is important to look at our responsibility as mental health providers and as a larger community that strives to prevent suicide. Through this process, I believe we may find opportunity to strengthen our prevention efforts.”

But no less important, she adds, is the subsequent ability to let it go. “In fact,” Johancen-Walt says, “I routinely tell counselors that they will not last in this field if they are not able to ultimately give responsibility for the client’s life back to the client.”

Granello echoes these thoughts, saying people are responsible for their own choices, and counselors shouldn’t try to carry that burden for others. But at the same time, she adds, if counselors know how to help, they should try. “Suicide is the most preventable type of death,” she says. “We can do a heck of a lot better than 34,000 a year.”

 

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Letters to the editor: ct@counseling.org.

 

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Myths surrounding suicide

The following list is adapted from Jason McGlothlin’s book, Developing Clinical Skills in Suicide Assessment, Prevention and Treatment.

Myth: The suicidal person wants to die and feels there is no turning back.
Fact: Suicidal people are usually ambivalent about dying and frequently will seek help immediately after attempting to harm themselves.

Myth: All suicidal people are deeply depressed.
Fact: Although depression is often closely associated with suicidal feelings, not all people who kill themselves are obviously depressed. Ironically, some suicidal people appear to be happier than they’ve been in years because they have decided to “resolve” all of their problems by killing themselves.

Myth: Most elderly people who die by suicide are terminally ill.
Fact: Most elderly people who die by suicide are not diagnosed with a terminal illness. More often, they are suffering from depression and sometimes experience somatic symptoms related to depression.

Myth: Suicide is very common among individuals in lower economic classes.
Fact: Suicide crosses all socioeconomic distinctions; no one class is more susceptible to it than another.

Myth: Suicide is a problem that is limited to the young.
Fact: Suicide rates rise with age and reach their highest levels among White males in their 70s and 80s.

Myth: Suicidal people rarely seek medical attention.
Fact: Research has consistently shown that about 75 percent of suicidal people will visit a physician within one month before they kill themselves.

Darcy Haag Granello also provided some common misconceptions about suicide during an interview with Counseling Today.

Myth: Suicidal people keep their plans to themselves.
Fact: More than 90 percent of people who die by suicide show clear warning signs; more than 70 percent (more than 80 percent of adolescents) tell someone they are planning to kill themselves.

Myth: Asking someone if they are suicidal will put the idea in their head.
Fact: A direct and caring approach to asking the question lowers suicide risk.

Myth: People who talk about suicide don’t actually plan to do it; they are just seeking attention.
Fact: Talking about or threatening suicide is a significant risk factor. Most people who die by suicide tell someone else they are planning to kill themselves. Counselors must take all suicide threats and behaviors seriously.

Myth: Suicidal thoughts are relatively rare.
Fact: Each year in the United States, approximately 8.3 million adults (nearly 4 percent of the population) seriously consider suicide; about 1 percent make a suicide plan, and about half of those individuals attempt suicide.

— Lynne Shallcross


Resources on the Web

  • School-based Prevention Guide: theguide.fmhi.usf.edu (A resource with free checklists, programs and resources for schools)
  • American Association of Suicidology: suicidology.org (Up-to-date information, professional conferences and suicide research)
  • Suicide Prevention Resource Center: sprc.org (Resources, magnets, posters, fact sheets and other information)
  • American Foundation for Suicide Prevention: afsp.org (Research, education about suicide and mood disorders, policy promotion)
  • NotMyKid.org (sponsored by the American Association of Suicidology) (Information for parents and resources for families)
  • National Institute of Mental Health: nimh.nih.org (Research and professional information)
  • Suicide Prevention Advocacy Network: spanusa.org (National hotline, public policy)
  • Substance Abuse and Mental Health Services Administration: samhsa.org (Grant opportunities, best practice guidelines, research dissemination)

ACA resources

  • Suicide Across the Life Span: Implications for Counselors (order #72807), edited by David Capuzzi, offers detailed information on topics such as identifying the risk factors for suicide, suicide assessment, ethical and legal considerations, and counseling techniques for work with children, adolescents, adults, and survivors and their families ($35.95 for ACA members; $56.95 for nonmembers).
  • The second edition of Suicide Prevention in the Schools: Guidelines for Middle and High School Settings (order #72884) by David Capuzzi includes a step-by-step framework of essential information for school counselors, administrators and faculty ($24.95 for ACA members; $29.95 for nonmembers).
  • Developing Clinical Skills in Suicide Assessment, Prevention and Treatment (order #72861) by Jason M. McGlothlin covers assessment interviews, legal and ethical issues, case examples, discussion questions and much more ($33.95 for ACA members; $49.95 for nonmembers).
  • Suicide Assessment and Prevention (order #78217) is an hourlong DVD presentation by John S. Westefeld that includes the latest data on suicide and suicide prevention and covers how to assess for suicide risk and how to conduct a suicide intervention ($149 for ACA members and nonmembers; produced by Microtraining Associates Inc.).

All three books and the DVD can be ordered directly through the ACA online bookstore at counseling.org/publications or by calling 800.422.2648 ext. 222.

  • “Suicide Assessment: Sharpen Your Clinical Skills” is a 47-minute podcast featuring Jason McGlothlin. He addresses questions about how to conduct a suicide assessment face-to-face; differences between assessing children, adults, older adults and families; and some of the issues of treatment planning with suicidal clients. To access this podcast, visit the ACA website at counseling.org

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Game might make difference in matters of life and death

Nick Rogers July 2, 2010

A school counselor’s introduction to advising a student at risk for suicide can be a trial by fire. After all, a young person’s life is possibly hanging in the balance of carefully chosen questions, inflections and body language.

A computer-simulation game developed at Purdue University offers virtual training for such emotionally charged situations in a setting that realistically reflects a counselor’s everyday responsibilities.

“The game is an emotional equalizer, with the idea of promoting self-efficacy and self-competence among counselors,” says Carrie Wachter Morris, an assistant professor of counseling and development at Purdue’s Department of Educational Studies and a former counselor at facilities throughout North Carolina. “The more we’re worried about ourselves, the more we focus on us and not the clients.”

Morris, a member of the American Counseling Association, began developing the Suicide Risk-Assessment Game (SRAG) in 2008 with the aid of what was then known as a digital-content development grant from Information Technology at Purdue (ITaP), Purdue’s central information technology organization. Of 34 applications submitted in 2008, Morris’ was one of 10 accepted, earning $15,000 and the use of ITaP resources toward developing the game.

Morris came up with the concept for and content of SRAG. A team of student developers led by Terry Patterson, an educational technologist with ITaP’s emerging technologies group, oversaw the graphic design and programming, with Morris providing feedback.

“It wasn’t only the social impact on a very serious issue that appealed to the grant committee about the idea,” Patterson says. “This was a great opportunity for students to create a framework for a game that could be reused for other experience simulations. SRAG has been one of the most successful projects developed in the grants program, and we’d like to continue seeing projects as innovative and impactful.”

Bridging the gulf between counselor training, professional expectations

Morris aims to regularly use SRAG in her graduate-level school counseling seminar this coming fall, but it’s also her response to a gap between counselor training and professional expectations.

Statistics from the U.S. Centers for Disease Control and Prevention show that in 2007, 14.5 percent of high school students seriously considered suicide in the previous 12 months, while 6.9 percent of high school students reported making at least one suicide attempt in the previous year. A 2002 Brigham Young University survey of school counselors found that 35 percent of respondents had received no graduate education training in crisis intervention, and 57 percent felt either “not at all” or “minimally” prepared for such intervention.

In response to this need, the Council for Accreditation of Counseling and Related Educational Programs now requires that school counselors demonstrate suicide-response skills as part of their training.

“To undertake such training with something like role-playing may feel contrived to students and lack realism,” Morris says. “And it wouldn’t be ethical for me to find 10 individuals with suicide ideation and have my students practice with them. There is also the possibility that some educators may not be comfortable with, or have a background in, crisis response themselves. As a field, we have to generate teaching tools that those without the background can effectively use.

“Studies show that students we’re matriculating have spent more time during school playing video games than reading. Now that these students are entering graduate school, why not develop a tool from which they can learn in a medium with which they’re familiar?”

Simulating counseling’s realities

Usable in PC, Mac or Linux format, SRAG places the player in the role of a high school counseling intern with typical resources (for example, student files, a planner and live Internet links). In gamer parlance, SRAG is a “beat-the-clock” title: A note has been found from a student planning to commit suicide Friday after school.

Beginning at the start of Monday’s workday, the player has 40 in-game hours (30 to 45 minutes in real time) to assess which one of five students is at imminent risk of suicide and which one is at false risk — meaning there might be danger signs to monitor in the future but no worry of immediate harmful action.

Of the remaining students, one is academically at risk, one is personally or socially at risk with peer problems, and one is “normal” but still exhibiting some risk signs. Shrunken for simulation purposes, the sample is randomized for names, genders, ethnicities, personalities and inclinations with each new session. Also randomized are the traits of in-game peers with whom players must converse along the way.

The game logs the player’s path to assessment — gathering information through investigation such as observing graffiti, visiting classrooms and querying teachers. Players must discern the relevant information because pursuing fruitless leads takes crucial time from the clock.

Asking each student outright whether they’ve had suicidal thoughts will yield correct answers but not a passing grade. “We want to prevent the easy outs,” Morris says. “We want users to navigate the school as they would have to in real life.”

Further complications come from daily tasks generally required of counselors in the real world, ranging from lunch duty to small-group counseling. Players can field counseling-related tasks themselves or ask peer characters (who may seek a favor in return) to cover those that aren’t counseling-oriented. Failing to complete these tasks yields a time-consuming penalty from upset parents or scolding administrators.

“If you cross a teacher, they will be less likely to help you,” Morris says. “If you cross a principal, you will be disciplined and lose time that way. If you miss other students’ appointments and meetings, you will lose time with calls from angry parents and have to re-establish rapport with the student. We’ve tried to make these consequences true to life.”

Should a player not correctly identify the imminently suicidal student before the clock runs out, SRAG offers a deus ex machina — or “out of the blue” — element to save the student.

Striving to set a standard for gaming tools

Although no statistics exist that study the effects of gaming in counseling work, Morris hopes SRAG will be a useful tool for pedagogy and a barometer of where student services are developing. After discussion at professional conferences, SRAG already has generated interest from school-district counselors nationwide.

Morris envisions SRAG one day helping resident advisers in college residence halls, other mental health professionals and, perhaps, middle and high school students to recognize risk behaviors. The game could also expand to additional crisis responses (students coping with a divorce, for example) or a larger scale combination of concerns.

“These current iterations must assess playability and effectiveness: Are students learning from it?” Morris says. “We can always go in and add elements and bridge gaps, but I have to see whether this is immediately engaging.”

This past December in her school counseling seminar, Morris introduced SRAG to nine graduate students, most of whom had participated in counseling internships and practicums. Although some made suggestions to improve SRAG, the students generally appreciated the game’s accuracy and its interface.

Ebony Gilbert says SRAG incorporated many aspects of counseling that were similar to her actual experience, such as asking teachers what they noticed and observing behavior. Adam Guebert says that SRAG accurately represented the counselor “being pulled in all different directions into a wide variety of activities and roles.” Ashley Bigelow also gives high marks to the game’s realism but adds she’d like to see an expansion of assessment options. (Morris plans that for future expansions of SRAG and is currently pursuing external funding.)

“It’s so difficult to get hands-on training for this sort of thing,” Guebert says. “You don’t just want to throw somebody in there with someone’s life on the line. You can do this without putting a life at risk, and it’s a good bridge to real-world application.”

Adds Morris, “SRAG is that half-step between in-class instruction and a student in front of you where it’s in the moment and you have to think on your feet.”

This story originally appeared in a slightly different form in Purdue University publications and is being reprinted here with permission.

Nick Rogers is a technology writer at Purdue University in West Lafayette, Ind. Contact him at 765.496.8204 or rogersn@purdue.edu.

Letters to the editor: ct@counseling.org.

When much is given, much is expected

Lynne Shallcross

At the tender age of 9, Marcheta Evans was already a budding counselor.

Evans, whose family was living in Washington, D.C., at the time, would occasionally accompany her mother, a psychiatric nurse, to her job at a local hospital. During those visits, she played cards and made friends with some of her mother’s patients. Sitting across from those patients, Evans had a habit of wondering what they might be thinking and what life path they had traveled to arrive at that hospital.

“The human mind always intrigued me,” says Evans, who begins her term as president of the American Counseling Association July 1. “I remember sitting there as a kid and wondering what was going on in that person’s head. Even as a little kid, I was always inquisitive.”

That sense of intrigue and curiosity never waned as Evans grew up. In fact, she followed it all the way to the University of Alabama, where she earned her doctorate in counselor education and supervision. Now associate dean for the College of Education and Human Development at the downtown campus of the University of Texas at San Antonio, Evans says her entry into the counseling profession stemmed from her upbringing — the same upbringing that motivated her to eventually run for ACA president. “It was almost an expectation for me to (run) given how I was raised,” Evans says. “When much is given, much is expected.”

Another motivating factor behind Evans’ journey to the ACA presidency was a desire to bring about change and accomplish goals at the national level. “I chose to run for the presidency mainly to serve the profession and to be instrumental in continuing the movement of the association toward its strategic initiatives,” says Evans, who previously served as president of the Association for Creativity in Counseling, a division of ACA. “Additionally, I wanted to serve as an example of the association’s willingness to appreciate diversity in leadership positions. You can come from all types of backgrounds and be a national leader.”

One of the initiatives on Evans’ to-do list focuses on New Orleans, the location of the 2011 ACA Annual Conference & Exposition. “I don’t want it to be a conference that does drive-by community service, but rather one that leaves an impact when we are gone,” she says, adding that she plans to work with ACA’s divisions and regions on this effort. One idea, she says, is centered on the education front and could include helping to explore best practices to address truancy and behavioral issues in the classroom.

Technology is another area Evans hopes to focus on as ACA president. She’s putting together a task force to investigate how the association can promote better use of technology in counseling, which could include everything from using improved technology on the ACA Governing Council to helping individual counselors make technological advances in their work with clients, Evans says.

Global collaboration and development warrant a closer look during her term in office, as does ACA’s strategic plan, says Evans, adding that she plans to ensure that all efforts made this year tie back into the strategic plan. Another initiative on her list is making sure that ACA has a crisis intervention protocol in place so the association can move forward and provide help quickly if and when disasters occur.

Evans also wants to put a spotlight on wellness and self-care for counselors while she is in office. She will use her presidential columns in Counseling Today to emphasize these and other important topics with ACA members. “People come to counselors with problems, rarely because they are happy,” Evans says. “So how can the profession promote better wellness skills and share ideas that work?”

A source of support

Evans assumed her position as associate dean in September 2009 after having served for more than five years as the chair of UTSA’s Department of Counseling, Educational Psychology and Adult and Higher Education. Her professional path, which began with a bachelor’s degree in psychology from the University of Alabama and two subsequent master’s degrees, has included stops at which she has filled a variety of university and community roles. Among the lines on her résumé: working as a rehabilitation counselor for Goodwill Industries and the state of Alabama, teaching at Auburn University at Montgomery and serving as director and founder of UTSA’s Women’s Resource Center. Additionally, Evans has been a licensed professional counselor since 1993 and has consulted for organizations such as the United Way, the Intercultural Development Research Association and the Mexican American Legal Defense and Education Fund.

Evans’ long-term dedication to ACA is apparent and includes serving in a variety of leadership positions at the state, regional and national levels. ACA is an incredibly worthy cause, Evans says, because the association provides so much to its members. “ACA is a place where members are able to come together as professionals and network,” she says. “One of the main benefits that ACA offers is member resources that aid them in becoming more effective counselors. The benefits are too many to highlight.”

ACA ably addresses its diverse membership, from students to faculty members to clinicians, through the variety of programming it offers, while also advocating for the profession and giving counselors a voice, Evans says. But she believes the camaraderie is one of the true highlights of belonging to ACA. “By being a member, you realize that you have a support system in place. You have others like yourself who are dealing with similar situations, and you can explore the universality of counselor experiences by attending the annual conferences and by being an active participant.”

Likewise, Evans says she is proud of the counseling profession for a number of reasons. “To name a few, our emphasis on wellness, the positive impact we can have on people’s lives and our commitment to serving others who may be struggling with life’s problems.” At the same time, Evans admits she would like to change the profession’s level of recognition. “What I want to [do is] amplify the visibility of our profession and clarify what counselors do on a day-to-day basis. We need to ensure that the public perceives our work as critical to mental health wellness efforts throughout the United States and beyond.”

As Evans takes the helm at ACA, she anticipates at least one major hurdle. “A year goes by very quickly,” she says, “Time is the biggest challenge.” ACA is an organization built largely on the efforts of volunteers, she points out, and these members have other jobs and other parts of their lives that require time and attention. “Making sure it’s as convenient for people to give of themselves as possible will be a priority,” she says, adding that she hopes her goal of improving technology might help on that front.

Thelma Duffey, professor and chair of UTSA’s Department of Counseling, says she is reminded of the Tom Petty song “Won’t Back Down” when she thinks of Evans. “She is determined,” says Duffey, an ACA fellow as well as the founder and inaugural president of ACC. “This trait can be especially helpful when she is invested in something she values. Marcheta is tenacious. She has a sharp wit and a keen sense of humor. She can inspire hard work in others, while at the same time generating a lot of fun. She doesn’t have much patience for behaviors she considers ’wishy-washy,’ to use her words. If someone comes to her with a problem, she wants them to come with potential solutions.”

Duffey believes that Evans will make her mark as president of ACA. “I can see Marcheta inspiring fiscal efficiency. I can also see her increasing international collaboration and development within the profession. Given her interest in technology, I suspect she will use it to increase ACA’s productivity and effectiveness. Marcheta is so smart, and she is passionate in her efforts to develop emerging leader programs. Given that, I feel sure she will invite leaders across divisions and regions to participate in innovative programs and invest in students and new professionals who are also interested in assuming leadership roles.”

Jamie Satcher, professor of counselor education at the University of Alabama, was Evans’ major professor and dissertation chair. “I have known Marcheta for almost 20 years. As a person, Marcheta is wonderful. She is one of the few former students with whom I have maintained close ties after graduation. She is a warm, caring person who is a dedicated counselor and counselor educator. As a leader, I believe that Marcheta has the people skills to motivate and inspire, as well as to build collaborative partnerships among counselors.”

Dennis Haynes, interim dean of the College of Public Policy at UTSA, believes Evans’ commitment to collaboration will be a strong point of her presidency. Haynes had the opportunity to work with Evans when he was chair of the university’s Department of Social Work and she was chair of the Department of Counseling. “Although the social work and counseling professions have at times engaged in a competitive relationship, Marcheta has been consistently collaborative and supportive in her relationship with social work,” Haynes says. “She chaired the UTSA Graduate Council Committee that recommended the establishment of a social work program and has continued to advocate on our behalf as we sought social work accreditation.”

“For me, the epitome of Marcheta’s collaboration with the UTSA community was our joint effort in providing mental health support to Katrina evacuees in San Antonio,” Haynes continues. “Marcheta invited social work, along with other professional entities across UTSA, to come together to support the city of San Antonio’s Katrina evacuee response when the first evacuees arrived. Many more evacuees arrived in San Antonio than expected, and the city government sought UTSA assistance. Marcheta coordinated this universitywide effort in collaboration with the broader city and professional community.”

“I value Marcheta’s personal and professional commitment to interdisciplinary collaboration across university departments and colleges,” he says. “She is a fierce advocate and leader of diversity initiatives within our university. She is innovative and creative in promoting relevant university-community engagement. I applaud ACA’s selection of [Evans] as your incoming president.”

A family focus

As dedicated as she is to the counseling profession, Evans makes sure to set aside time to focus on her own wellness, and much of that centers on her family. Evans and her husband, Ed, who live in San Antonio, have six children and nine grandchildren. Five of the children have graduated college, and one is a junior biomedical engineering major at the University of Texas at Austin. Evans laughingly describes it as “chaos” when everyone is together, but it’s the good kind of chaos that comes with love, she says. “We have tons and tons of fun when everyone is together. It’s just a wonderful, wonderful time.”

Another place you’ll find Evans is on the tennis court, although not as much as she’d like given her more demanding position as associate dean. “I would love to play a minimum of once a week,” she says. “I used to play at least three times a week. Hopefully, this summer, I will get to play with my daughter while she is home from college.”

A self-identified “outdoors person,” Evans says one of her family’s favorite pastimes is camping. “We love to visit the state parks and just enjoy the beauty of nature. My most favorite time is when I have all the children together at a campsite late in the evening and we are all sitting around the fire pit. The laughter and the stories are awesome!”

Family is important not only in Evans’ daily life but also to the path she traveled to arrive at the ACA presidency. When asked who inspired her to become the counselor and person that she is today, Evans says her grandmother immediately comes to mind. “I grew up in the late fifties and early sixties,” says Evans, who spent much of her childhood living in Washington and San Antonio but also spent time with her grandparents in Mobile, Ala. “She taught me how to be confident and proud of who I was as an African American female. And we needed that during the times in which we were living, to know that I was not ’less than.’ In some cases in her mind, I was ’better than’ and ’more than.’ She was definitely at the crux of that inspiration.”

An aunt provided inspiration for the go-getter attitude that eventually brought Evans all the way to the ACA presidency. “My aunt did anything and everything,” Evans says, mentioning her aunt’s degrees in music and pharmacy, as well as the asbestos inspection and house moving companies she started. “She was always open to trying anything. She inspired me to do any and everything. She just enjoyed life to its fullest and taught me, ’Don’t be afraid to fail.’”

It is a lesson Evans took to heart and a lesson that has helped pave her pathway to success.

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org.

Meeting member needs at every step

Richard Yep July 1, 2010

Richard Yep

Each July, we welcome a new group of volunteers to the leadership ranks of ACA. The level of enthusiasm I have already witnessed among these volunteer leaders encourages me. Leading our organization at the national level is Marcheta Evans, who will serve as ACA president through June 2011.

President Evans, a counselor educator from the University of Texas at San Antonio, has been a longtime leader in ACA at the branch, region and national levels. This past year, she served as our president-elect, and I found that she was engaged and very committed to preparing for the role of president.

As I have done occasionally throughout the past several years, I would like to solicit your opinion as to what you want your ACA to provide. We know that in an economy that has resulted in a loss of buying power, reduction in disposable income and a tightening of the job market, we need to do what we can to meet needs in a way that minimizes any additional financial burden on ACA members.

ACA has been fortunate to see an overall increase in membership during the economic crunch, which says a great deal about our members. It is also an indicator that our mix of products and services are resonating with those who choose to belong to the “world’s largest organized body of professional counselors.”

Our growth pattern has also provided a few surprises. For example, when broken down by membership category, ACA has seen phenomenal growth in the percentage of graduate students who are members. We expect continued growth this year. This means that as an organization, we have an obligation to provide the resources and services these individuals need to be successful as students and to prepare for their role as emerging professionals.

We also have to do our best at meeting the needs of midcareer professional counselors. Our members have embraced our use of new technologies and methods of communication such as blog posts, podcasts and an enhanced library of information available via the ACA website at counseling.org. This includes posting on our website many of the PowerPoint presentations given at the ACA Annual Conference this past March in Pittsburgh. For the 2011 conference in New Orleans (March 23-27), we hope to continue that service.

We also believe that those who need continuing education credits to maintain their state license appreciate the “CE of the Month” program we launched this past year. Simply by reading an article and taking a test (all online), ACA members can receive up to $240 worth of CE credits at no additional cost, all from the comfort of their homes or offices.

For counselor educators, the American Counseling Association-Association for Counselor Education and Supervision Syllabus Clearinghouse continues to add to an already-considerable library of course outlines submitted by your colleagues nationwide. Later this year, we will post a student membership recruitment video on the ACA website for use by counselor educators and others.

More than 20,000 of our members hold ACA professional liability insurance through Healthcare Providers Service Organization. We will continue working with HPSO and the ACA Insurance Trust to ensure that your policy’s benefits are the very best on the market.

Clearly, member needs vary depending on whether individuals are studying to become professional counselors, are in the prime of their careers or have become “elders” in the profession. I am confident that as the 2010-2011 ACA year progresses, our members will continue to excel at the services they provide. And as the economy improves, you will be exposed to new opportunities. You will need various resources, and ACA wants to be your partner in that endeavor.

As always, I hope you will contact me with any comments, questions or suggestions that you might have. Please contact me via e-mail at ryep@counseling.org or by phone at 800.347.6647 ext. 231.

Thanks and be well.