Tag Archives: suicide prevention

Raising awareness of suicide risk

By Jerrod Brown and Tony Salvatore December 6, 2017

Suicides have increased steadily in the United States during the past decade. Suicide research has also grown, but pertinent findings are sometimes slow to reach mental health professionals and providers. Many misconceptions and gaps in the knowledge base remain. The role that mental illness plays in suicide is an area of research that both the public and many clinicians must better understand. This article touches on 10 aspects of the relationship between suicide and mental illness that mental health professionals should be aware of and should be able to share with others.

1) Serious and persistent mental health disorders sometimes contribute to suicidal behavior, but they generally are not the cause of suicides on their own. A suicide risk factor is a personal or demographic attribute found to be prevalent among suicide victims; a cause is a condition that brings suicide about. When suicide and serious and persistent mental illness are inappropriately linked, it can result in enhancing associated stigmas and misdirecting the focus of suicide prevention. Mental illness is sufficient to contribute to suicide but not absolutely necessary. Myriad factors and reasons, separate and aside from mental illness, can account for suicidal behavior. Keep in mind that antidepressants and other psychotropic medications may effectively reduce suicide risk only for the psychiatric disorder for which they are prescribed.

2) Many individuals who die by suicide do not have a diagnosed serious and persistent mental illness at the time of death. The Centers for Disease Control and Prevention’s National Violent Death Reporting System has found that just over 40 percent of those who die by suicide have a mental health diagnosis.

Despite methodological flaws, psychological autopsy studies that attempt to assign psychiatric diagnoses post-mortem through interviews of those who knew the deceased have routinely found that an overwhelming number of victims of suicide had a diagnosable, although perhaps not documented, mental illness. Nonetheless, this mode of research may sometimes exaggerate the role that mental illness plays in suicide. Mental health providers must understand that although mental health services are a critical component of suicide prevention, they should be only part of a comprehensive approach to deterring the onset or progression of suicide risk.

3) The rate of suicide and suicidal behavior has been found to be higher among people with a serious and persistent mental illness than in the general population, but the majority of those with a serious and persistent mental illness neither attempt nor complete suicide. Every mental health professional and provider organization must be sensitive to the potential for suicide risk and behavior in their clients regardless of their psychiatric histories. Retrospective studies of those who have died by suicide have found that not all of these individuals possessed discernible signs of any form of mental illness as identified by family members or friends. Therefore, outpatient providers must be careful not to minimize signs of possible suicide risk in the absence of mental illness.

4) Psychiatric hospitalization may stabilize and ensure the safety of people who are acutely suicidal. However, it does not in and of itself constitute long-term treatment or reduce the risk of suicidality in the future. Inpatient settings can reduce suicide risk through appropriate use of psychotropic medication when indicated. Psychoeducation about suicide and support groups should also be part of a treatment plan for a client who is suicidal. Community-based providers accepting referrals from inpatient facilities should review the attention given to a potential client’s suicidality while hospitalized and make sure that a predischarge suicide risk assessment was performed.

Suicide prevention must also be part of aftercare in the community. Outpatient providers should engage the client on this objective prior to discharge. Outpatient providers should be thoroughly familiar with the client’s discharge plan, and particularly those elements relating to ongoing suicide risk. If appropriate and with the client’s consent, the outpatient provider should consider a family conference to ensure that the client’s support system understands the individual’s ongoing suicide risk, the family’s role in managing it and what family members should do if the client shows signs of suicidality.

Most important, outpatient providers must maintain continuity of care and resume treatment as soon as possible. When short-term resumption of treatment cannot be accomplished, contact should be initiated by telephone or other means to support the client.

5) The first 30 days after discharge from inpatient psychiatric care is a period of high suicide risk irrespective of the reason for admission. Suicide risk has been found to be especially high in the first week after discharge. This must be acknowledged in outpatient discharge plans. Patients and families must be made aware of this risk, and providers must ensure that patients returning to the community engage quickly with outpatient services and adhere to medication regimens as applicable. Those leaving hospitals must be made aware of 24/7 hotline and crisis services that they can turn to if needed. The National Suicide Prevention Lifeline (at 800-273-8255) is one such resource.

6) Contracting for safety is a technique in which at-risk clients agree to notify their mental health providers or take other steps (e.g., calling a hotline or 911) rather than making an attempt on their life if they have thoughts of suicide. Many counselors, therapists and mental health practitioners continue to use this technique despite an absence of research supporting its efficacy. At best, safety contracts give mental health providers a questionable, if not groundless, sense of security regarding their clients’ potential risk.

Providers are better advised to use thorough suicide risk assessments and personal suicide safety plans with patients and clients. Providers and clients can collaboratively develop personal suicide prevention safety plans, and they have therapeutic value. These plans generally document factors such as warning signs, triggers, coping methods, supports, providers and sources of emergency help.

7) Many mental health providers do not have suicide prevention policies that mandate routine training or outline requirements for client and patient suicide risk assessment. In some instances, mental health providers lack guidance on what should be done in the event of the suicide of a client. This is a serious deficit given our exposure to potential client suicides. Agencies should have a formal suicide prevention policy stating the measures to be taken to prevent suicide and postvention actions to be initiated with staff affected by a client’s suicide. Providers should encourage licensed staff to include suicide prevention trainings among their required continuing education.

A client suicide is perhaps the most traumatic experience that a mental health provider can endure. Taking a risk management stance after a suicide is not sufficient and may be harmful to all concerned. Providers should supply grief support resources, such as Survivors of Suicide, to both staff members and to the deceased client’s family members.

8) Care of individuals who are suicidal has been delegated to the mental health system for evaluation and treatment. This has resulted in many at-risk individuals being assigned one or more diagnoses from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. These diagnoses often become the focus of subsequent care, which may overshadow the person’s ongoing suicide risk and the need to address his or her suicidality. The mental health field has access to some evidenced-based therapies that can assist in reducing suicide risk and deterring future suicidal behavior, but more research and education are needed.

Those who survive a suicide attempt have an elevated short-term suicide risk and a continuing lifelong suicide risk. It is imperative for treating mental health professionals not only to provide therapeutic services but also to connect these clients with available community resources to reduce the likelihood of subsequent suicide attempts. Support groups made up of survivors of suicide attempts are optimal, but these groups are appearing only slowly in communities. In the absence of peer groups or provider-led support groups, consideration should be given to warm lines, chats and other online resources, or to videos and texts created by survivors of suicide attempts.

9) Effective treatment of serious and persistent mental health disorders may lessen suicide risk among impacted individuals. However, treatment for these disorders may not be the only answer. It is imperative for mental health professionals to also address other issues such as substance misuse, traumatic loss, shame, social disconnectedness, feelings of hopelessness or the belief that one is a burden to others when present. Suicide risk should be assessed whenever clients experience any adverse life events, regardless of clients’ adherence to therapy or counseling regimens. Assessing for risk of suicide may require ongoing attention throughout the entire treatment process.

10) The intense and persistent desire to die is experienced by some individuals with serious and persistent mental illness. However, by itself, desire to die is insufficient to bring about a potentially fatal suicide attempt. The person in question must also have overcome the inherent resistance to lethal self-harm. The mitigation of this resistance can occur through life experiences such as abuse, a history of violence, self-injury or traumatic grief, any of which individually can create a capability for significant self-harm up to and including suicide.

Conclusion

Certainly, some individuals with serious and persistent mental illness die as a result of suicide. Nonetheless, suicide is preventable. Mental health treatment providers are well-positioned to minimize the impact of suicidality after onset and to address any ongoing suicide risk. Several steps can be taken to accomplish this.

Every provider should have a suicide prevention policy that outlines measures to identify suicide risk in clients and appropriate responses to such risk. Such a policy should detail what must be done in the event of a client suicide. A suicide risk assessment should be considered as part of new client intake depending on prescreening responses. This involves both clinical judgment and an evidence-based risk assessment instrument.

All staff need to be able to recognize possible warning signs of suicide in clients. We recommend requiring all clinical staff to complete a continuing education course on suicide prevention on a regular basis. Providers might also consider participating on suicide prevention task forces at the city, county or state level. Participation may provide additional access to suicide prevention experts and other resources.

Finally, clinicians must adopt what might be called suicide prevention literacy. They must rely only on evidence-based reports about suicide from researchers in their disciplines and related fields. They must be able to assess these sources and use them to develop evidence-based treatments and programs. Suicide prevention literacy means employing these skills to make suicide prevention a practice reality. It goes beyond participating in suicide prevention walks and runs, conferences and trainings to create a provider mentality that is prevention-oriented. It means using what is available to try to mitigate suicide risk and amplifying suicide protective factors in clients and in the community — not just talking about it.

 

****

 

Jerrod Brown is the treatment director for Pathways Counseling Center Inc., which provides programs and services for individuals impacted by mental illness and addictions. He is also the founder and CEO of the American Institute for the Advancement of Forensic Studies and the editor-in-chief of Forensic Scholars Today and The Journal of Special Populations. He holds graduate certificates in autism spectrum disorder, other health disabilities and traumatic brain injuries. Contact him at Jerrod01234Brown@live.com.

Tony Salvatore is the director of suicide prevention at Montgomery County Emergency Service, a nonprofit crisis intervention and psychiatric emergency response system in Norristown, Pennsylvania. He has a particular interest in post-psychiatric hospital suicide prevention and has served on a number of suicide prevention task forces at the state and county levels in Pennsylvania.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Suicide statistics highlight veteran population’s acute need for counseling, inside and outside of the VA

By Bethany Bray September 12, 2016

The rate of veteran deaths by suicide increased 32 percent between 2001 and 2014, according to a recent report by the U.S. Department of Veterans Affairs (VA). When compared with the U.S. civilian population, veterans have a 21 percent higher risk of dying by suicide.

The VA is calling the report, released in August, its most comprehensive analysis of rates of veteran suicides. The agency compiled data from more than 55 million veterans records from 1979 to 2014 from every U.S. state.

Among the findings was that between 2001 and 2014, the rate of suicide deaths among U.S.

U.S. Navy photo by Seaman Clark Lane/defense.gov

U.S. Navy photo by Seaman Clark Lane/defense.gov

veterans who used VA services increased 8.8 percent, whereas the suicide rate among veterans who did not use VA services increased 38.6 percent during that time frame.

In 2014, an average of 20 veterans died by suicide each day; approximately six per day were users of Veterans Health Administration (VHA) services.

“The VA’s latest report on veteran suicide is the most comprehensive to date and should be a call to arms for everyone in our profession who works with this population,” says Jeff Hensley, a Navy veteran who is an American Counseling Association member and a licensed professional counselor (LPC) in Texas.

“The data clearly shows that getting help, helps,” continues Hensley, a leadership fellow with Iraq and Afghanistan Veterans of America (IAVA) and director of clinical and veteran services at Equest, a therapeutic riding program in North Texas. “Those veterans who seek care have a suicide rate significantly lower than those who get no care at all. However, the VA is stretched to capacity — and many of those veterans who need help the most are either not registered with the VA or ineligible due to their discharge status. This leaves a significant gap between those who need help and the resources available to provide it. As professional counselors, we can step in and meet this need. Whether we work in community agencies serving veterans or volunteer our time with nonprofits like Give An Hour, counselors are in a unique position to significantly lower this troubling statistic.”

Other key findings in the VA report include:

  • In 2014, veterans made up 8.5 percent of the U.S. adult population, yet they accounted for 18 percent of all deaths by suicide. In 2010, veterans composed 9.7 percent of the U.S. population and accounted for 20.2 percent of deaths by suicide.
  • In 2014, roughly 67 percent of all veteran deaths by suicide involved firearms.
  • Roughly 65 percent of veterans who died by suicide in 2014 were age 50 or older.
  • In 2014, rates of suicide were highest among veterans ages 18 to 29. Rates of suicide among veterans age 70 or older were lower than were rates of suicide for the civilian population in the same age group.

Overall, U.S. rates of suicide have increased by 24 percent during the past 15 years.

The rate of veteran suicide gained public attention in 2012, when the VA released a report saying that 22 American veterans died by suicide every day of the year. That number has decreased to 20 per day (in 2014) in this most recent report.

In response, the VA has beefed up support services, including the creation of a toll-free crisis hotline and expanding telemental health care programs.

However, these efforts don’t address one glaring omission: Professional counselors are often excluded from jobs at VA facilities. A 2006 law recognized “licensed professional mental health counselors” and “marriage and family therapists” as mental health providers within the VA health care system. However, 10 years later, few VA job postings include counselors as candidates to fill those positions, and even fewer licensed counselors are actually hired.

“It’s noteworthy that within the ‘nation’s largest analysis of veteran suicide,’ there is no mention of words such as ‘medication,’ ‘pharmaceuticals,’ ‘counselor’ or ‘counseling,’” says Natosha Monroe, an Army veteran and Texas LPC who is a co-leader of ACA’s Veterans Interest Network. “I would be interested to know what exactly isn’t working in current treatment trends. I would love to see veterans have just as much access to nonpharmaceutical treatments such as professional counseling as they do VA psych meds.”

As Monroe recounts, “While working at the Pentagon [as an operations noncommissioned officer for comprehensive soldier fitness], I was literally told by a decision-maker that licensed professional counselors are not needed in the Army and that I should stop asking because that wasn’t going to change. I was told that ‘the current behavioral health providers are adequate.’ Well, the statistics say otherwise. I think it’s time to allow LPCs and licensed marriage and family therapists (LMFTs) to do our jobs. Our professions are the most specifically qualified to address the issues that troops and their families most often face: cognitive issues, transition issues and family challenges.

“It’s unfortunate that counselors and therapists are the only [mental health] professions completely excluded from every military branch,” Monroe says. “It’s frustrating that I am not allowed to be a behavioral health officer because I am a highly qualified LPC,” she continues. “Our professions are also the only ones blatantly discriminated against within the VA system despite Congress mandating our equal hiring — it still isn’t happening.”

“I’m not saying that correlation is causation, but I am definitely saying that veteran suicide rates are increasing, and there is persistent discrimination and exclusion of our profession,” Monroe concludes.

 

****

 

Read the VA report in full here

 

Read a VA press release about the report here

 

Contact the Veterans Crisis Line or find out more at veteranscrisisline.net

 

Get involved with or find out more about ACA’s Veterans Interest Network here

 

****

 

Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

****

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

 

Addressing ethical issues in treating client self-injury

By Julia L. Whisenhunt, Nicole Stargell and Caroline Perjessy July 24, 2016

AuthorsAs professional counselors, we enter this field with a desire to understand and help others. There comes a time in every counselor’s career, however, when intellectual understanding is overpowered by the need for empathic understanding. This is particularly true when counselors work with clients who intentionally cut, burn, scratch, hit or otherwise injure themselves.

Jennifer Muehlenkamp and colleagues found that this coping skill, known as nonsuicidal self-injury (SI), may be used by as much as 18 percent of the general population. Furthermore, Laurie Craigen and colleagues found that as many as 39 percent of adolescents may self-injure. It is important to note that SI is separate from socially sanctioned body modification practices (e.g., piercings, tattoos), substance use or physical fighting, which can also seem intentionally harmful but have different underlying purposes.

Purpose of SI

For those who do not purposefully inflict physical harm on themselves, the concept of SI can be both foreign and confusing. As counselors, we need to know that SI works for some people, most often to help them manage intense and often painful emotions. In fact, David Klonsky, a pioneer in SI research, found that emotion regulation is the single most common function of SI. Emotional pain is linked with physiological arousal (e.g., pounding heart, headache), and SI can ease this tension, channel the pain and bring arousal to a bearable level.

Researchers such as Klonsky, Muehlenkamp, Janis Whitlock, Brianna Turner, Alexander Chapman and Brianne Layden have also examined other functions of SI. For example, SI can serve as a method for transforming emotional pain into physical pain, which can be easier to cope with for many people. SI can serve as a way to validate feelings and create a visual representation of the pain within them. Some people who self-injure may do so to cope with feelings of dissociation or depersonalization — to help themselves feel “real” or “alive” again. This is especially relevant for people who feel numb because of depression or trauma. SI can be used to vent anger privately or to channel anger toward the self as a form of punishment.

Finally, although less common, SI can serve as a means of communicating with or influencing others. Despite popular stereotypes, SI is rarely meant to be intentionally manipulative. Most often, clients who self-injure for this reason do so because they do not know more effective ways of communicating their needs and distress. In fact, the majority of clients who self-injure do so in private and are very secretive about it. Admittedly, some people self-injure to either intentionally or unintentionally influence others, but this is not the primary motivation for most clients. Consequently, assuming malicious intent behind SI can be grossly invalidating to clients’ experiences and can severely damage the therapeutic relationship.

Although the motivations for SI are complex and unique for every individual, the lay community has often equated SI with suicide. Whitlock and colleagues found that as many as 60 percent of people who self-injure may experience suicidal thoughts or behaviors. Although SI is a strong predictor of suicide, a large portion of people who self-injure do not struggle with suicide.

Several differences exist between SI and suicide regarding intent, means, frequency, severity, and emotional antecedents and consequences. Researchers such as Chapman and Katherine Dixon-Gordon have found that the emotions experienced prior to and following SI and suicide attempts are largely different. Furthermore, Muehlenkamp and Peter Gutierrez found that people who self-injure are often able to identify more reasons for living than are people who are suicidal. In fact, for some people, SI may serve an anti-suicidal function that is life preserving.

Counselors working with clients who self-injure are likely to encounter some ethical dilemmas regarding safety concerns and duty to warn/protect. With that in mind, we want to discuss some ways for counselors to address common ethical concerns that tend to emerge in this type of work. This list is not comprehensive, however, so counselors should use an established ethical decision-making model and consult or seek supervision as necessary.

Counselor values

Although counselors are trained to nonjudgmentally join with their clients, counselors may have intense reactions to SI. Doreen Fleet and Rita Mintz found that shock, sadness, anger, anxiety, frustration and diminished professional self-confidence are common responses to SI.

It is important to remember that the therapeutic relationship can be damaged beyond repair if clients feel judged. Even if counselors temper their initial reactions and support clients who self-injure, other counselor values can be damaging to the client and the therapeutic relationship. For example, it is unhelpful to assume that every client who uses SI needs to be hospitalized. We will discuss safety assessment later in this article, but counselors should remember that SI and suicidality are not equivalent.

Some counselors might feel that a contract specifying no SI would encourage clients to use healthier coping skills, but that can stem from a counselor’s anxiety surrounding the behavior and can lead to clients feeling judged by the one person who is supposed to be nonjudgmental. Moreover, SI works as a coping skill for some clients, and asking them to give up their most effective coping skill in the absence of other ways of coping can leave them feeling scared and helpless. In addition, nonharming alternative behaviors (e.g., snapping a rubber band, using a red water-soluble marker) may reduce risk, but they are not effective ways of addressing the underlying mental health issues.

Out of concern, some counselors may lecture clients on the dangers of SI and the fear that SI evokes for loved ones. Although psychoeducation can be used very effectively with clients who self-injure (e.g., dangers and wound care), there is a fine line between psychoeducation and lecturing. Many people who use SI experience self-imposed shame and guilt or have it imposed on them by others. Consequently, lecturing clients on the consequences of SI or otherwise attempting to convince clients not to self-injure can be harmful.

Similarly, chastising clients for doing permanent damage to their bodies is also unhelpful because SI is commonly a way for some people to connect with their bodies and find physical and emotional relief. It can also be unhelpful to insist on seeing a client’s wounds. If the client would like to show you his or her wounds, that can be therapeutic in itself. However, we are not medical doctors, and we should refer physical assessments to someone who is properly trained.

Overall, counselors should work toward empathic understanding of SI and reduce stereotypes or countertransference in the relationship. Working with clients who self-injure presents unique considerations for clinicians, who must manage their own reactions and beliefs about SI while simultaneously providing sound therapeutic care. Supervision, consultation and treatment teams are key sources of support and monitoring when working with these clients.

Confidentiality

The issue of confidentiality can be complicated when working with clients who self-injure, especially if those clients are minors. Confidentiality and privacy should be explained clearly in informed consent, which is an ongoing process.

At intake, or when SI is disclosed, counselors should explain techniques and interventions that will be used specifically to address SI. Counselors should also be very clear about the duty to protect and how SI might lead to mandated reporting, such as if the client develops suicidal intentions or if SI results in a major health risk (e.g., large, infected wounds).

If the client is a minor and caregivers are aware of the SI, an open discussion should occur to determine what types of information will be shared (e.g., types of interventions, progress toward goals) and how this will be shared with caregivers (e.g., privately over the phone, after session with the client present). If the caregivers of a minor are not aware that the client is using SI, counselors might need to disclose this information to parents because of the possibility of foreseeable harm. Again, however, it is important for the client to feel empowered throughout the treatment process, especially when the counselor must notify parents or loved ones.

Foreseeable harm and safety planning

Although it is important to temper counselor anxiety and methodically work through the counseling process with clients who self-injure, it is also important to actively monitor and continually assess client suicide risk. Clients sometimes minimize their use of SI, and counselors must astutely tune in to the serious nature of this behavior, understand the possibility of increased harm in the future and put adequate interventions in place.

Relatedly, clients might disclose SI before they are ready to work toward goals related to the behavior. Counselors must explore the paradox between autonomy and nonmaleficence, constantly assessing for the point at which risk outweighs the client’s readiness to change. As mentioned previously, it is generally not helpful to ask clients to stop self-injuring in the absence of other effective coping skills. So, part of this process typically involves diminishing risk while simultaneously enhancing the client’s other strengths and coping skills.

Ongoing formal and informal suicide assessment should be part of the therapeutic process. However, it is critical that counselors do this in a way that is neither assumptive nor judgmental. It is also helpful to develop a safety plan with all clients who self-injure. Clients can
use the safety plan during times of distress, regardless of whether suicidal ideation is present. A major component of providing care to clients who self-injure involves the counselor’s efforts to ensure the appropriateness of services through consistent consultation, supervision and referrals.

Assessment of SI and suicide

Assessment of SI begins at intake. We believe it is important to ask all new clients about their history of intentional SI. There are a number of assessment instruments for SI, some of which screen for SI, some that monitor risk of suicide and some that assess the functions of SI. Examples include Kim Gratz’s Deliberate Self-Harm Inventory, Matthew Nock and colleagues’ Self-Injurious Thoughts and Behaviors Interview, Marsha Linehan and colleagues’ Suicide Attempt Self-Injury Interview, and Catherine Glenn and David Klonsky’s Inventory of Statements About Self-Injury. As is the case with any therapeutic issue, counselors should document their use of established assessment instruments, consultation or supervision, and a reputable decision-making model to uphold proper standards of care.

In consideration of the elevated risk of suicide and the sometimes conflicting feelings about life and living that some clients who self-injure may experience, it is important for professional counselors to use recursive suicide risk assessment practices. Without assuming that clients who self-injure are suicidal, counselors should conduct suicide risk assessments at intake, at Branding-Images_injuryperiodic intervals and as indicated throughout the therapeutic relationship. Counselors should remember that suicide risk assessment involves more than asking a quick close-ended question. Rather, it should involve use of a reliable and valid instrument and should include dynamic, ongoing discussions about stress, coping and ideas about living.

When working with clients who self-injure, we ask counselors to remain attuned to the risk factors and warning signs of suicide so that they can respond most appropriately if risk elevates. Safety plans (as opposed to no-harm contracts) are an effective way to build the counseling relationship and minimize client risk. At a minimum, safety plans include identification of warning signs, internal coping strategies, positive distractions, people to ask for help, professionals/agencies to ask for help and ways to make the environment safer.

Competence

As professional counselors, we are charged with practicing only within the boundaries of our competence based on education, training, supervised experience, state and national professional credentials, and appropriate professional experience. However, clients who self-injure usually present with multiple treatment issues that are complicated for both novice and seasoned clinicians to conceptualize.

Clients who self-injure often have trauma and abuse histories. Consequently, they can also struggle with eating disorders, poor body image, personality disorders, anxiety, depression and suicidal ideation. Because clients who self-injure may present with complex symptomatology and even acute distress, counselors may doubt their clinical competence and ability to meet the therapeutic demands of this client population.

Efforts to improve feelings of competence can be addressed in a variety of ways. First, we can encourage counselors to remember that the best way to understand clients’ lived experiences is to create a safe context in which clients feel free to share their stories. Counselors can promote clients’ sense of safety by exhibiting humanistic qualities such as unconditional positive regard, which can both strengthen the therapeutic relationship and convey understanding and acceptance of the client.

Next, counselors engaging in ongoing supervision and consultation can improve their clinical skills related to working with this population. Discussing clients who self-injure, in supervision or consultation contexts, provides counselors with new and different perspectives on their work, which can help them modify their treatment planning and clinical interventions. Consultation and supervision also offer counselors opportunities to reflect on how they feel toward their clients. Considering how strongly our value systems shape our work with clients, this is an invaluable exercise.

It is also imperative that counselors who work with this population review the existing literature on SI, seek continuing education on SI and remain current on emerging SI research. Competent counselors should practice treatment strategies that are evidence based and well-grounded in the literature, and access reputable resources, such as those stemming from the International Society for the Study of Self-Injury.

Finally, in situations in which clients are not progressing or a therapeutic impasse cannot be resolved, competent counselors should understand how and when to refer to another provider. Often, when counselors are unable to promote a strong therapeutic alliance or further treatment goals, it is the result of a lack of training or experience that can be remedied through additional training, supervision and consultation.

Evidence-based practices

SI is a complex treatment issue and, for obvious reasons, counselors may feel ill-equipped to effectively intervene when clients self-injure. However, just like with any treatment issue, effective intervention begins with having a safe and nonjudgmental relationship. This is not to say that knowing the complexities of SI and how to intervene appropriately are unimportant. Rather, we hope readers will remember to start with the relationship and use interventions and treatment strategies that are grounded in the literature.

In the next section, we provide a brief introduction to a few therapeutic strategies that have shown promise with clients who self-injure. It is important to note, however, that no specific treatment interventions have proved largely effective for the treatment of SI. So, counselors often rely on theoretically grounded interventions and those proposed by leaders in the field of SI. For a more detailed yet succinct review of evidence-based practices in the treatment of SI, see the ACA Practice Brief on nonsuicidal self-injury by Julia Whisenhunt and Victoria Kress (see counseling.org/knowledge-center/practice-briefs). The practice brief provides references to a number of researchers who have

examined SI intervention. Additionally, we recommend a recent publication by Catherine Glenn, Joseph Franklin and Matthew Nock, who examined the evidence base of SI treatments for youth and rated their effectiveness using the Journal of Clinical Child and Adolescent Psychology standards level system.

Individual interventions: Dialectical behavior therapy (DBT), created by Marsha Linehan, improves emotion regulation skills and intrapersonal awareness by challenging and modifying one’s cognitions, emotions and behaviors. As mentioned earlier, emotion regulation is the single most common function of SI, so learning to regulate emotions in healthier ways can decrease SI behaviors. DBT interventions are most successful when clients feel supported and accepted by their counselors and when counselors believe in their clients’ ability to change. The evidence base on DBT for SI is still limited, and some results are conflicting, but DBT may be useful for managing some of the emotion dysregulation and alexithymic aspects of SI.

Because of the maladaptive and distorted cognition seen in many people who self-injure, cognitive interventions may be well-indicated. Both David Klonsky and Nadja Slee independently suggest that cognitive therapy has been found to be most effective when focusing on the specific SI behavior and on emotion regulation skills. Problem-solving therapy, a type of cognitive therapy, may be effective when combined with cognitive, behavioral and interpersonal interventions. However, Jennifer Muehlenkamp and others have noted that the long-term results are mixed and inconclusive.

Other empirically based treatment approaches focusing on the behavior of SI include behavioral management strategies, functional assessment analysis of SI and means restriction/delay of SI. Klonsky, Muehlenkamp, Stephen Lewis and Barent Walsh provide a nice overview of these interventions in their book Nonsuicidal Self-Injury, which is part of the Advances in Psychotherapy Evidence-Based Practice series. All of these interventions promote the use of learning new behaviors in an effort to reduce the occurrence of SI.

Pioneered by William Miller and Stephen Rollnick, and applied to the treatment of SI by Victoria Kress and Rachel Hoffman, motivational interviewing (MI) is a humanistic-based therapy that can be used to enhance client motivation to change. At its core, MI is a client-centered approach that demands counselor nonjudgment and acknowledges that every client who comes to counseling is at a different place of readiness for change. Although the application of MI to the treatment of SI has not been researched well, counselors may find MI particularly useful for fostering a strong therapeutic alliance and working with clients who may not be willing or ready to cease self-injuring.

Family interventions: Family support can be a protective factor against SI and suicide. As such, family therapy can promote client change and well-being. Family members who engage in therapy can learn how to communicate with their loved ones in ways that are affirming and nonblaming. Counselors can help educate family members on the reasons that their loved ones engage in SI behaviors.

Family therapy can also help counselors explore family dynamics and how those patterns may have influenced clients’ propensity to self-injure. Trauma, abuse, unhealthy communication patterns, inappropriate alliances and other family dynamics can occur in the family of origin and create toxic relationships that are dysfunctional and in need of repair. Counselors can help clients mend these broken relationships, which in turn can potentially decrease the clients’ desire to self-injure. Klonsky and his co-authors provide a brief overview of the support for applying family therapy to the treatment of SI in their book.

Summary

To help ensure a growth-promoting experience and minimize both risk and liability, counselors should keep a number of things in mind when working with clients who self-injure. These include the following:

  • Monitoring one’s own values when working with clients who self-injure for the purpose of avoiding making the client feel unsafe or creating inappropriate therapeutic conditions
  • Identifying when and how to make disclosures of confidential information regarding SI
  • Identifying foreseeable harm regarding severe SI or suicide
  • Using reliable and valid assessment instruments to identify and monitor SI
  • Monitoring one’s own competence to treat SI
  • Using evidence-based therapeutic interventions

Above all else, we hope readers will remember five key points about SI from this article:

1) SI is often used as a coping skill, but it always has a function (and sometimes multiple functions). For most people, that function is emotion regulation. Therefore, identifying the function or functions can help to guide intervention.

2) Treatment that focuses exclusively on stopping the SI behavior fails to address the underlying reasons for the behavior and is not likely to produce long-term change.

3) Counselors’ reactions — both verbal and nonverbal — communicate clear messages to clients who self-injure. If counselors want their clients to feel safe and not judged, counselors should start by identifying their biases regarding SI.

4) Counselors need to be specially educated and trained in how to intervene with clients who self-injure. There are risks and therapeutic pitfalls that can be minimized with adequate understanding of SI.

5) SI and suicide are not equivalent, but counselors should work to monitor suicide risk without assuming that all clients who self-injure are suicidal.

The information provided in this article is not exhaustive, but we hope readers will be stimulated to continue learning about SI so that when (not if) a client presents with SI, they will feel better able to intervene.

 

****

We would like to extend a heartfelt thanks to our friends and colleagues Victoria Kress and Chelsea Zoldan for their contributions to this article.

 

****

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Julia L. Whisenhunt is an assistant professor of counselor education and college student affairs at the University of West Georgia. She is an editorial board member for the Journal of Counselor Leadership & Advocacy and serves Chi Sigma Iota (CSI) International through committee membership. A licensed professional counselor (LPC), national certified counselor (NCC) and certified professional clinical supervisor (CPCS) in Georgia, she specializes in the areas of self-injury, suicide prevention and creative counseling. Contact her at jwhisenh@westga.edu.

Nicole Stargell is an assistant professor in the Department of Educational Leadership and Counseling at the University of North Carolina at Pembroke. She is a member of the CSI International Counselor Community Engagement Committee, the ACA Practice Briefs advisory group and the editorial board for the Counseling Outcome Research & Evaluation journal. She is an LPC, NCC and licensed school counselor.

Caroline Perjessy is an assistant professor of counselor education and college student affairs at the University of West Georgia.  An editorial board member of the Association for Specialists in Group Work, she has presented and published on dialectical behavior therapy and postmodern approaches to counselor practice and pedagogy. She is an LPC and CPCS in Georgia.

Letters to the editor: ct@counseling.org

 

 

‘We must do more’: Counselors have part to play in stemming U.S. suicide increase

By Bethany Bray May 19, 2016

After more than a decade of almost constant decline, the rate of suicide deaths in the United States has increased 24 percent over the past 15 years. In fact, the country’s rate of suicide is at its highest point since 1986, according to data released recently by the U.S. Centers for Disease Control and Prevention (CDC).

Between 1999 and 2014, rates of suicide death increased for both males and females for all ages between 10 and 74. The highest rates of increase occurred between 2006 and 2014, according to the CDC.

In 2014, the age-adjusted suicide rate for males (20.7 for every 100,000 population) was more than three times that for females (5.8).

In the male population, suicide rates are most prevalent among those 75 and older. For females, suicide rates are highest for those in the 45-64 age range, which was also the case in 1999. But the greatest rate of increase for suicides took place among females ages 10-14. Although the total number of suicides among that population was comparatively small (150 in 2014), it represented a threefold increase between 1999 and 2014.

 

Counseling Today contacted Doreen Marshall of the American Foundation for Suicide Prevention (AFSP) to discuss these statistics and what professional counselors can do to help bring an end to this concerning trend.

Marshall, vice president of programs for AFSP, holds a doctorate in counseling psychology. Prior to joining AFSP, Marshall served as associate dean of counseling at Argosy University.

 

Doreen Marshall, vice president of programs for the American Foundation for Suicide Prevention

Doreen Marshall, vice president of programs for the American Foundation for Suicide Prevention

As someone who has worked in suicide prevention for many years, what is your reaction to these statistics?

We have known that the numbers have been on the rise, although it is sobering to see this increase over time, particularly in light of our ongoing efforts to prevent suicide. It is important to recognize that while other causes of death — such as those from HIV/AIDS, heart disease and breast cancer — have decreased over this time period, the suicide rate continues to rise. The data presented in this report is just one cross section of what we need to get a full picture of the suicide rates across America. We know that suicide prevention efforts that are concentrated and strategic can be successful. We have seen that targeted efforts can reduce suicide rates, and many of these can be expanded for wider impact and more lives saved. As a nation, we need to invest our time and resources in such prevention efforts, as well as in research to better understand the problem of suicide.

 

There is a lot of data packed into this report. What are some of the main takeaways you would want to point out to professional counselors?

We must do more to prevent suicide in our local communities, and this is where counselors can have a key role, both in terms of providing treatment to those who need it [and in] educating the public about suicide risk. All counselors need to be knowledgeable about the factors that contribute to suicide risk.

Suicide is a complex phenomenon, and assessment also needs to consider risk factors in the context of the individual who is being assessed. Suicide risk increases when several life stressors and health factors converge at the same time. For example, 85 to 90 percent of those who die by suicide had a mental health condition, whether diagnosed or not, at the time of their death, so we know that the detection and proper treatment of mental health conditions can plan an important role in suicide prevention. Other factors that should be assessed include a person’s past history of suicide attempts or behaviors, access to lethal means, past history of child abuse or trauma, present substance use and current life stressors.

 

What do you want professional counselors to know about this situation? What should they keep in mind and be aware of?

In short, suicide is on the rise in the U.S. In terms of trying to explain the increase, suicide experts consider a few possible contributions. One thing we know for sure is that a large contributing factor is untreated mental health conditions. Another factor is the economic downturn and job losses that occurred during that same period of time, resulting in increasing stress. There may also be a cohort

effect for the baby-boomer generation, in which suicide rates and other problems like substance use problems and other health conditions, and higher rates of life problems like divorce, have unfortunately followed this demographic population from their earlier stages of life. Despite these considerations, it is hard to know all of the factors that may have contributed to the increase. But we do know that the suicide rate is higher now than in the past.

 

From your perspective, is there anything counselors could or should be doing differently in their work with clients in light of this data?

Many of us may not have had extensive training in suicide prevention as part of our graduate work, so it is important to seek more information and training on how to effectively counsel someone who is experiencing suicidal thoughts or has engaged in a suicide attempt. Given the numbers, it is very likely that we will encounter someone who is suicidal or who has been affected by a suicide death in the course of our counseling work, so all counselors need to improve their knowledge and skills in this area.

 

What advice would you give to counselors who work with populations that showed a sharp increase in suicide deaths — for example, girls ages 10-14, Native Americans, middle-aged adults?

It is important to keep this report, and the increases noted, in context. While suicide does happen in young girls, it is fairly rare compared to the suicide rates in middle-aged and older adults. While the rise is of concern, it was based on an exceedingly low base rate in 1999 of 0.5 per 100,000. It was a total of 50 girls in 1999 and 150 in 2014 across the United States. The overall numbers of suicide deaths in girls ages 10-14 remain low.

In the U.S., most of the persons who die by suicide are middle-aged and older adults, and terms of race/ethnicity are Native Americans, Alaskan Natives and Caucasians.

That said, I think counselors should be aware that there is no one age, race or ethnicity that is immune from suicide, and risk should be assessed across all demographics and ages. In children and adolescents in particular, early detection and adequate treatment of mental health conditions such as depression, bipolar disorder and anxiety can go a long way in helping to reduce their lifetime suicide risk.

 

What would you want school counselors, in particular, to know and keep in mind?

School counselors should encourage their schools to have a policy for responding to suicide in students. They should also encourage regular training of school personnel to know the risk factors and warning signs of suicide as well as how to refer a student for further assessment if they encounter a student who is suicidal. School counselors often play an important role when a student is suicidal, so it is important that they expand their knowledge in this area as well.

 

From your perspective, how can counselors play a part in combating these statistics and preventing suicides?

First, I would encourage counselors to familiarize themselves with risk factors and warning signs for suicide, as well as seek additional professional training in evidence-based interventions for those at risk for suicide, such as cognitive behavior therapy for suicide prevention (CBT-SP), dialectical behavior therapy (DBT) and collaborative assessment and management of suicide (CAMS), among others.0001-245393381

At the minimum, all counselors should build their skills in assessing for suicide and assess their clients regularly. They should also learn about ways to effectively help their clients to manage their suicidal feelings between sessions, such as by using safety planning as a brief intervention. Counselors and other clinicians have an obligation to familiarize themselves with how to best work with those who are suicidal in a way that is compassionate, responsive and effective.

I think one of the biggest barriers to prevention is that people, including counselors, are sometimes afraid to ask their clients directly about suicide. Asking about suicide does not increase an individual’s risk for suicide. More likely, asking them conveys that you are paying attention to the difficulties they are experiencing and are willing to take steps to help them. It is important that we, as counselors, use our knowledge of suicide risk and of mental health conditions to work to educate the general public about suicide prevention.

I would also encourage counselors to get involved with local and national advocacy efforts that support suicide prevention efforts. More information about advocacy and how to get involved in suicide prevention can be found at our website at afsp.org.

 

****

 

Graphic via the U.S. Centers for Disease Control and Prevention

Graphic via the U.S. Centers for Disease Control and Prevention

 

 

Read more

 

Find out more and view and the CDC’s breakdown of data at http://1.usa.gov/1qG5IZf

 

Via NPR, “Suicide rates climb in U.S., especially among adolescent girls” http://n.pr/1Vqxlm9

 

For more insights on this topic, see Counseling Today’s cover story, “Facing the specter of client suicide

 

Did you know the Substance Abuse and Mental Health Services Administration (SAMHSA) has created a smartphone app with suicide prevention tools and resources for practitioners? Find out more here.

 

****

 

Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

Fresh thinking on old issues

By Laurie Meyers April 23, 2015

Trauma, suicide and bullying are not new topics for most counselors, who at some point in their careers have likely worked with clients on each of these issues. However, as research and practice Paint-Splatter_Brandingcontinue to progress, some counselors are using emerging approaches or perspectives to tackle these problems.

At the American Counseling Association’s 2015 Conference & Expo in Orlando, Florida, Counseling Today attended several sessions that presented some of these fresh approaches. We then caught up with three presenters after their sessions to get a more in-depth look at their ideas so we could share them with readers.

Complex PTSD

As far back as the ancient Egyptians, the chronicles of war have noted trauma-induced psychological symptoms. Samuel Pepys wrote about them in the wake of the Great Fire of London. Historians think that the author Charles Dickens may have experienced them after a horrific train accident. We now know these symptoms as indicative of posttraumatic stress disorder (PTSD), but until relatively recently, the cause of trauma-induced behavioral changes was thought to be purely internal and was sometimes even referred to as cowardice.

Trauma-induced psychological symptoms were not officially labeled as a disorder until 1952, in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which identified it as “gross distress reaction.” However, in 1968, as the memory of World War I and World War II faded, the diagnosis was dropped from the DSM. It wasn’t until scores of Vietnam veterans returned with severe psychological trauma that researchers began a deeper examination of the condition and its causes. The term PTSD officially entered the lexicon in 1980 with publication of the DSM-III. Defined, in essence, as a common set of symptoms brought on by extremely traumatic events such as combat, natural disasters, accidental disasters or personal catastrophes, PTSD has more recently gained greater recognition, both in mental health circles and the public eye, because of the struggles of veterans returning from the wars in Iraq and Afghanistan.

At the same time, many mental health experts have come to believe that another, more common, form of trauma exists that is often misdiagnosed as PTSD. Referred to as complex trauma or complex PTSD, this type of trauma is caused by repeated exposure to abuse or other traumatic events over time.

Despite the urging of many trauma experts, complex trauma was not included in the DSM-5. However, the disorder is very real and distinct from the current definition of PTSD, asserts Cynthia Miller, an ACA member who presented on “Recognizing and treating complex PTSD” at the ACA 2015 Conference.

Complex PTSD is typically the result of cumulative trauma and abuse that started in childhood. Miller’s interest in complex PTSD was first piqued when she was counseling women in the corrections system, where many of her clients — and many of the incarcerated women in general — had histories of trauma and childhood abuse.

“I got interested [in complex PTSD] in my work with the prison population, but even in my community work, I saw that histories of trauma were way more common than we realized and also at the root of so many things that we were treating,” she says.

Clients with trauma histories are often misdiagnosed not only with single-incident PTSD but also with borderline personality disorder, bipolar disorder or major depression, Miller says. These disorders — along with alcohol and substance abuse — can accompany complex trauma, but counselors need to understand that the trauma colors everything the client is experiencing, explains Miller, a licensed professional counselor with a private practice in Charlottesville, Virginia. At the same time, treating complex trauma by immediately turning to protocols for PTSD, such as eye movement desensitization and reprocessing (EMDR), prolonged exposure therapy and cognitive processing therapy, is not going to work as well and may actually result in retraumatizing the client, she says. Methods such as EMDR may be helpful for some clients later in the treatment process, Miller says, but only after they have been through an initial stabilization process.

“One of the most common mistaken impressions [when treating trauma] is that someone who has been through trauma needs to talk about and process it,” explains Miller, who is also an assistant professor of counseling at South University in Richmond. By doing this, she says, “counselors are trying to help clients, but they [may] open up trauma that neither the counselor nor the client is ready to deal with. When dealing with complex trauma, the first thing you need to do is to help them live in the present, not the past.”

Although PTSD and complex trauma share certain symptoms, they also feature significant differences — differences that are crucial for counselors to understand, Miller says.

PTSD is typically caused by a single or time-limited event. Its symptoms include intrusive thoughts, avoidance behaviors, negative alterations in mood and cognition, and alterations in arousal and reactivity.

Complex trauma, on the other hand, is caused by long-term traumatic experiences such as child abuse, intimate partner violence, community violence (including living in a society at war), experiences as a refugee or displaced person, trafficking and forced servitude, chronic illness and disability necessitating invasive treatment, and bullying. Symptoms may partially mirror those for PTSD but also feature additional severe problems such as:

  • Difficulty regulating emotions
  • Disturbances in attention and consciousness
  • Affect dysregulation
  • Altered self-perception, including feelings of guilt and worthlessness
  • Difficulty interacting with other people
  • Chronic dysphoria or dissociation
  • Engaging in self-destructive behavior
  • Difficulty with self-soothing

People who are experiencing complex trauma do not have the emotional skills necessary to address the issues they’re facing, so before moving forward, a counselor must first help the client to stabilize, Miller says. Stabilization begins with establishing a sense of safety, including addressing the client’s most basic needs.

“You really almost have to go through Maslow’s hierarchy with [these clients] to find out if food, clothing and shelter are concerns,” Miller says. “If so, how can you help the client address it? Because it’s hard for someone to build skills if they don’t have a place to sleep.”

After the client’s basic needs have been addressed, the counselor should help the individual establish a sense of safety with “self,” Miller explains. This requires the counselor to probe for self-injurious behavior, suicidal behaviors or urges, risky sexual and other behaviors, and attendance to the health and integrity of the body. Assessing for self-protective behavior is also important, Miller continues. For example, is the client locking his or her house or bedroom door at night? Does he or she go running alone at night in crime-ridden areas? Safety with others is also important, she notes. For instance, is the client in a relationship in which he or she is being abused or exploited?

The third element of safety — without which the counselor cannot help the client with the first two — is feeling safe in therapy, Miller emphasizes. The client must feel that he or she is in control of what is going on.

“There must be a mutually designed treatment plan, informed consent throughout and the promise that the therapist is not going to do anything that the client doesn’t want to do or push them into doing something that they don’t want to do,” Miller says.

As the counselor and client address safety skills together, they should also work on other stabilization elements, such as reducing the acuity of trauma symptoms, Miller says. Symptom reduction involves developing coping skills and may or may not include medication, she adds.

Miller has found that dialectical behavior therapy (DBT) is particularly effective when teaching clients emotional coping skills. DBT helps clients learn that their symptoms are not their fault but rather a natural reaction to what has happened to them. This helps remove the attendant stigma and the clients’ sense that something is really wrong with them, Miller explains.

Because complex trauma causes dissociation, dysphoria, physical agitation and cognitive distortions, grounding skills — both physical and mental — are essential for reconnecting clients with themselves and their surroundings, Miller says. For instance, when a client’s nervous system is overloaded or aroused, his or her cognition is disrupted. To help these clients ground and re-engage, Miller directs them to say their ABCs backward, name the 50 states and state capitals, or name the different makes of automobiles.

To counteract physical disruption and the dissociation that sometimes accompanies it, Miller teaches clients grounding methods that engage the senses, such as touching physical items that have texture, describing what they see in their immediate physical surroundings or listening to soothing music. She also suggests physical stretching and movement, even if it’s just having clients stomp their feet while sitting down, or the sensory experience of running warm or cool water over their hands.

Miller also uses other soothing strategies such as safe place imagery with clients who have complex PTSD. Clients imagine a place, real or imaginary, where they feel safe, and Miller asks them to put themselves there by describing what they see, hear, feel, smell and taste.

Another soothing visualization technique involves picturing a nurturing and protective figure who has made the client feel cared for. Miller says this might be a relative, a friend, a pet or even a fictional or spiritual figure, just as long as the client can envision this figure during a time of need.

Clients with complex trauma also struggle with intrusive thoughts, so Miller asks them to visualize a container — whether it is a box, a safe, a vault, a dumpster or a tractor trailer — that is big enough to hold all of the things that disturb them. “It has to be as real as possible, and they have to be able to ‘lock’ it,” she says. Miller directs clients to visualize the container, set it aside and then walk away. “When they walk away, I have them walk to their visualized safe place,” she says.

Clients who are struggling with complex trauma also need to learn to relate to themselves and to others in different ways, Miller says. DBT can help in this area by teaching clients skills for managing intense emotions and interpersonal relationships. These skills include distress tolerance, emotional regulation, mindfulness and greater interpersonal effectiveness.

After clients are stabilized and feel safe, counselors can help them to integrate their traumatic memories so that the clients are no longer controlled by these memories, Miller says. She emphasizes that the aim of integration is to resolve the traumatic symptoms without retraumatizing the client.

Miller cautions that counselors should proceed carefully, helping the client to re-evaluate the meaning of the trauma and having the client demonstrate the ability to remember experiences while still remaining physically, emotionally and psychologically intact. The re-evaluation may involve an organized recounting of events using methods such as prolonged exposure therapy, cognitive processing therapy, narrative exposure therapy, traumatic incident reduction, EMDR and art therapy, she says.

After successfully stabilizing and integrating traumatic memories, the client and counselor can then work on enhancing the client’s relationships and planning for the future, Miller says.

Miller reiterates that complex trauma is more common than most helping professionals might realize, so she recommends that counselors screen for it routinely. “Counselors should be prepared. … Clients are not necessarily going to tell them [about their trauma] right away,” she says. Even if clients do bring up traumatic experiences on their own, it’s unlikely that they will reveal everything to a counselor initially, so counselors need to create a safe space and be patient, Miller says.

Miller adds that if a counselor suspects a client is experiencing complex trauma, the counselor should ask about it — but carefully. “Ask behaviorally,” she says. “Don’t ask clients if they were physically or sexually abused. Instead, ask them if anyone has ever punched, slapped, kicked or touched [them] in a way that [they] didn’t like or want.” Initially, clients struggling with complex trauma may not recognize or be willing to identify these behaviors as abuse, Miller says.

Because the trauma focus in counselor education is typically on PTSD and not complex trauma, Miller urges counselors to seek further training through continuing education and conferences. “It’s one of those things that you can’t afford not to know about and not know how to treat because, whatever work you do, you’re going to see it,” she says.

Understanding and assessing clients who are suicidal

It’s a counselor’s worst fear: a client who dies by suicide. Yet, as any counselor knows, there is no research that can definitively tell practitioners how to prevent suicide. But what if prevention starts with acceptance rather than assessment? What if connecting with a client who is suicidal requires accepting and understanding that there are circumstances under which many people might consider suicide? These are the questions that ACA member Eric Beeson explored in his conference session, “How do I know if someone is suicidal? A discussion of suicide theory, attitudes and interventions.”

Beeson, a licensed professional counselor and lecturer at the University of North Carolina-Greensboro, thinks that accepting the validity of such feelings is key to understanding why a client believes suicide is the answer. When faced with a client expressing suicidal thoughts, many mental health professionals instead focus on immediately shutting those thoughts down, he says. Although acknowledging there are certain cases that require emergency treatment such as hospitalization, Beeson says an immediate focus on preventing suicide may actually alienate the client and hinder treatment. He believes that approach is often based in the mental health professional’s fear — not only of losing a client but also of having to deal with and consider the subject of suicide. To understand and, hopefully, redirect a client’s suicidal urges, counselors must first examine their own attitudes, he asserts.

Beeson started asking such questions early in his counseling career during a four-year stint at a hospital, where dealing with death and the aftermath of suicide attempts was a regular occurrence. “Watching the way some of the staff interacted with people after a suicide attempt, some of the judgments I saw, got me curious about people’s attitudes toward suicide and then, eventually, how … that attitude influences practice,” he says.

With more than 41,000 reported suicides in the United States in 2014, these are urgent questions to answer. Beeson, a contributing faculty member at Walden University, began his presentation by asking attendees to consider the following questions as a way to examine their own attitudes about suicide and people who die by suicide.

  • How can I tell if my client is suicidal?
  • Why do people attempt or die by suicide?
  • Is suicide a singular event or a process?
  • Can suicide be rational and/or permitted?
  • What is my role when working with someone experiencing suicidal behaviors?
  • Am I capable of suicide?
  • Even though you would prefer another way to die, painful circumstances in life might lead to suicidal ideation. How do you estimate the probability that you sooner or later will die by suicide?

a) I am sure I never will die by suicide.

b) I hope I will never die by suicide, but I am not absolutely sure.

c) Under certain circumstances, I consider suicide as a possibility.

d) I consider suicide as a possibility for the future.

n  What suicide attitudes do you think are most helpful to counseling practice?

a)  More/less acceptance of suicide

b)  More/less condemnation of suicide

c)  More/less belief in the preventability of suicide

Beeson notes that even within the mental health field, the stigma and avoidance surrounding suicide remains strong. People who have died by suicide or attempted suicide are typically viewed as weak. This represents an empathy gap — one that counselors need to close, Beeson asserts. So, he challenges counselors to ask themselves about their personal suicide potential.

During his session, Beeson used humor to demonstrate circumstances that might cause a person to consider suicide as a viable option. In a clip from the old TV sitcom Cheers, four characters — Sam, Woody, Norm and Cliff — are preparing to sky-dive. But when the time comes to jump, they’re all petrified, realizing that they could die. Suddenly, skydiving doesn’t seem like such a good idea. However, for various reasons — to prove something, to not look like a coward, because everyone else is doing it — they each eventually jump. Cliff is the last and the most hesitant. Seemingly nothing will make him jump. But then the plane starts to sputter and the pilot says it’s going to go down. Cliff decides to take his chances — to, in essence, take control of how he will die — and jump.

Beeson asked the audience to think about which character they identified with. What might motivate them to get out of that plane? Beeson says he does this to help counselors recognize that under certain circumstances, anyone might consider dying by suicide. In turn, that helps them better understand why a client might consider suicide a viable — or even the only viable — option.

Beeson notes this is not just theoretical for him. During his time working with clients who were suicidal, he found that the more he focused on prevention, the less effective he was. However, once he started focusing on acknowledging the client’s struggle and the resilience it had taken to come this far, he was better able to take that resilience and direct it toward other methods of coping.

“I don’t know what it’s like for … any person to walk in their shoes, and who am I to say that they’re walking in their shoes wrong?” Beeson asks. “Who’s to say if I wasn’t in a similar situation, that my shoes might get a little uncomfortable? … And [if they] become more uncomfortable than I’d like to bear and I can’t find a new pair of shoes, then who’s to say that I might not take those shoes off?”

“I don’t believe that people just want to kill themselves,” he says. “It’s just that last-ditch effort to attain something that seems unattainable.”

Beeson believes counselors need to view suicidal intent on a continuum. “Suicidal is a misleading term. There’s no research to suggest that there’s any way to truly decide when someone is or is not — quote, unquote — ‘suicidal,’” Beeson says.

The better question, he asserts, is how likely is someone to die. Dying is painful and goes against the natural human instinct to preserve life. Beeson explains that research by psychologist and suicide expert Thomas Joiner posits that suicide requires overcoming that instinct and becoming capable of killing oneself. When that capability is combined with circumstances that seem intolerable, the risk of suicide is very high, Beeson explains.

Some people, such as those in high-risk, high-intensity jobs, including police officers, firefighters and emergency services personnel, already have a greater risk of death because they are regularly exposed to and habituated to it, Beeson contends. In addition, people in these jobs are routinely exposed to others’ experiences of pain. This engenders a certain comfort level with pain that also increases the person’s likelihood of dying, Beeson says.

But working in one of these high-intensity professions is not the only way that people habituate themselves to pain and the risk of death. Nonsuicidal self-injury, prior suicide attempts, intravenous drug use and prostitution have all been linked to suicidal behavior, Beeson says.

He adds that research by Joiner and others has shown that suicidal risk factors fall under three main categories.

Biopsychosocial

  • Mental disorders — particularly mood disorders, schizophrenia, anxiety disorders and certain personality disorders
  • Alcohol and other substance use disorders
  • A sense of hopelessness
  • Impulsive or aggressive tendencies
  • History of trauma or abuse
  • Some major physical illnesses
  • Previous suicide attempt
  • Family history of suicide

 

Environmental

  • Job or financial loss
  • Relational or social loss
  • Easy access to lethal means
  • Local clusters of suicide that have a contagious influence

 

Sociocultural 

  • Lack of social support and sense of isolation
  • Stigma associated with help-seeking behavior
  • Barriers to accessing health care, especially mental health and substance abuse treatment
  • Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma)
  • Exposure to suicide, including through the media, and the influence of others who have died by suicide

Beeson says counselors should evaluate clients for these risk factors and also look for the following warning signs.

Talk: The client talks about killing himself or herself, having no reason to live, being a burden to others, feeling trapped, having no hope or being in unbearable pain.

Behavior: New or increased episodic behavior, especially if related to a painful event, loss or change; increased use of alcohol or drugs; looking for a way to kill themselves, such as searching online for materials or means; acting recklessly; withdrawing from activities; isolating from family and friends; sleeping too much or too little; visiting or calling people to say goodbye; giving away prized possessions; and displaying aggression.

Mood: Displaying depression, anxiety, rage, irritability, humiliation or sudden calmness.

Beeson also explained that there are five levels of risk for suicide:

Nonexistent: No or few risk factors, no previous attempts and no suicidal behaviors.

Mild: A previous attempt but no other risk factors, or no previous attempts but demonstrating short-term, mild suicidal behaviors.

Moderate: A previous attempt with other notable risk factors, or no previous attempts but exhibiting ambivalent plans or preparation, suicidal desire or two other notable risk factors.

Severe: Previous attempt with two or more notable risk factors, or no previous attempts but having moderate or severe symptoms of resolved plans and preparation.

Extreme: Previous attempts with severe symptoms of resolved plans and preparations, or no previous attempts with severe symptoms of resolved plans and preparations and two or more other risk factors.

If a counselor has a client who is displaying suicidal risk factors, the first step is to ensure immediate safety, which in some cases may require hospitalization. Otherwise, the counselor and client can work to develop emergency plans that the client can follow if he or she is feeling suicidal, Beeson says.

It’s also important for counselors to establish a rapport with these clients and listen to their stories without judgment, he emphasizes. Counselors should then help clients manage their feelings by acknowledging their pain and encouraging them to use the session as a time to consider all options, including suicide, Beeson says.

Another critical factor is to guide clients in exploring alternatives to suicide by helping them envision future possibilities. Beeson says counselors should emphasize future plans by asking questions such as: How are you going to stay alive in the next week? Will you be back to see me next week? He adds that helpful behavioral strategies include drawing up a short-term positive action plan and using safety or wellness plans.

Beeson gives presentations on suicide frequently because he feels the topic is so important. “I just want to foster tough conversations about what we believe about suicide and the implications for practice,” he says. “I want people to live. That’s my goal. But I also believe in autonomy and the client’s right to choose. I think as we acknowledge that autonomy, we are better able to connect with people. I just think that one of the best ways to promote those types of interventions is to address what it is that we believe so that we can promote life-giving conversations. Then maybe we can promote that hope that the unattainable might just be attainable in some other direction.”

A playful approach to bullying prevention

Bullying prevention often focuses on punitive measures. The bully is identified, chastised and punished — with little or no consideration given to why the bullying occurred in the first place, says ACA member Ruth Ouzts Moore. And if counselors, teachers and other educators don’t address the underlying reasons, the likelihood of preventing bullying over the long term is low, she adds.

But how can counselors and educators learn the real reasons for bullying? Those who bully and those who are bullied often are too ashamed, scared or just plain angry to talk honestly about what is driving the bullying, Moore notes. That’s why she has come to believe that play, not punishment, is the best way to address and reduce bullying.

As a licensed professional counselor, counselor educator and part-time school counselor in the Savannah, Georgia, area, Moore has implemented this creative approach with young students and found it to be very effective. She described her experiences in a session at the ACA 2015 Conference.

Moore, an ACA member, began her presentation by clarifying the definition and different types of bullying. At its root, she said, bullying is an intentional, abusive act or attempt to inflict injury or discomfort on another person. She further explained that bullying can take the form of physical, verbal, relational or cyber abuse.

Bullying is fueled by the imbalance of power between the person doing the bullying and the person being bullied. Moore, a core faculty member in the mental health counseling graduate program at Walden University, noted that research suggests targets of bullying are at a disadvantage in this power differential for various reasons, which include:

  • Being perceived as different or weak and defenseless
  • Experiencing depression, anxiety or low self-esteem
  • Being less popular
  • Being perceived as annoying or attention seeking

Bullies, on the other hand, are generally students who are easily angered or frustrated, have family issues or are overly concerned with popularity.

For the targets of bullying, the gap between them and their tormentors must seem huge, but Moore notes that the bully and the bullied usually have similar backgrounds. For instance, children who come from abusive or violent backgrounds, grow up in neglectful environments in which there is little parental involvement or are caught in the middle of a high-conflict divorce face a higher likelihood of being bullied and bullying others, she says.

Bullying has serious and long-lasting effects on both the bully and the bullied, Moore points out. These effects include anxiety, low self-esteem, depression, suicidality, fear, mistrust, truancy, academic decline and nonsuicidal self-injury. In addition, the bully and the bullied are not the only ones affected. Bystanders, teachers, parents and siblings also suffer the consequences, directly or indirectly, she says.

Counselors face myriad challenges with both populations when working to address the issue, Moore says. Research has found that those who bully:

  • Often minimize or deny their aggressive acts and behaviors
  • Can be reluctant or resistant to disclose sensitive issues such as family violence or emotional problems that may be at the root of the bullying
  • Are sometimes repeating behavior that is intergenerational
  • Are often handled punitively and therefore may be distrustful of counselors

Similarly, research has found that those who are targets of bullying:

  • Often won’t tell anyone they are being bullied
  • May present in counseling with other issues such as depression, anxiety or school avoidance that may complicate or obscure the bullying issue
  • May have difficulty verbalizing their feelings
  • May not want to disclose bullying because they are ashamed and humiliated
  • May not disclose family problems that are at the root of or complicating the bullying

In her private practice, Moore has worked extensively with adolescents who bully or who have been bullied. She recently took on a school counseling position that allows her to address bullying with prekindergarten-age children through eighth-graders, both from a group and individual perspective. She notes that early education and intervention are the most effective means of preventing bullying.

Moore was hired specifically to address bullying at a private school that was having serious problems. Her goal was to help prevent bullying through identifying the sources of the problem, providing education and implementing active classroom strategies.

Moore presents weekly classroom sessions in which she combines educational sessions and activities in the form of games. She says the students enjoy the activities because they’re fun and provide a break from classroom work. The games also give Moore an opportunity to observe the classroom and identify the children who act out. She will often follow up by providing individual therapy to the most disruptive children.

Her activities focus on neutralizing bullying by increasing self-esteem and developing anger management skills. The self-esteem building activities include things such as a written quiz with 10 questions: 1) What’s good about you? 2) What’s good about you? 3) What’s good about you? And so on, with the same question repeated 10 times.

“It makes them laugh,” Moore says. “Kids often get stuck and can’t think about what’s good, so we’ll talk about how it’s hard to say good things about yourself because people will think you’re bragging, but it’s really important.”

In another game, Moore hands out Riesens caramels when students tell her the reasons or “Riesens” they like themselves.

During her presentation at the ACA Conference, Moore handed out balloons to audience members to demonstrate another activity she conducts for anger management. She asks the students to blow into the balloons to represent how stressful their day has been. The balloons end up being anywhere from just a tiny bit full to completely blown up.

“We talk about how amazing it is [to see] how quickly the balloons can fill up,” Moore says. She then goes on to talk with the students about how to moderate anger.

Another activity, “Bullying Bingo,” has helped students learn about the different types of bullying. Moore has also led students in activities to strengthen their sense of collaboration, such as by working together to build a peanut butter sandwich without looking at one another.

The activities seem to be having an effect. In the two years since Moore started working at the school, it has witnessed a huge decline in incidents of bullying.

Moore credits the creative approach for the results. She believes it works because the approach is nonthreatening, allows kids to express things they have trouble verbalizing and helps to build their confidence. On top of that, the activities are fun.

Moore encourages counselors to explore the creative approach when addressing issues of bullying. She also urges counselors who want to learn more to join the Association for Creativity in Counseling, a division of ACA for which Moore currently serves as secretary.

“Be open to new approaches,” she concludes.

 

****

 

Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org