Tag Archives: suicide prevention

The need for standardization in suicide risk assessment

By Gregory K. Moffatt April 14, 2020

“I am afraid I might actually do it,” the 31-year-old woman told me. Abigail (not her real name) was referring to ending her own life. For years she had struggled with depression, and she teetered on the brink of suicide. Medication had helped her only minimally. Her ideation was unquestioned and her plan was clear.

These were frightening words to me, and for weeks I held my breath, fearing a phone call from her husband announcing that Abigail had completed suicide. A brief hospitalization had somewhat stabilized Abigail’s life, but she was worn out. Upon her release from the hospital, her husband and I worked together to form a safety plan in an attempt to ensure that he wouldn’t be left a widower and her two children left motherless.

I have seen many clients like Abigail over the span of my career as a licensed professional counselor. Managing clients who are suicidal is a common occurrence in therapy. Data are scarce regarding the percentage of suicidal clients a clinician in general practice might have. However, most of the numbers indicate that up to half of an average client caseload is on the worrisome side of the suicide risk continuum. That percentage is far greater, of course, among clinicians who work with specific populations or disorders that have been shown to have increased risk for suicide. Abigail fell into one of these high-risk categories. Yet as recently as 2006, a meta-analysis by Stefania Aegisdottir and colleagues published in The Counseling Psychologist basically indicated that clinicians aren’t very good at assessing risk. That is frightening.

Equally disturbing is research showing that about one-quarter of us will experience the loss of a client to suicide during our careers, but many (if not most) of us are poorly prepared to manage suicide risk. In a 2013 study by Cheryl Sawyer and colleagues of 34 master’s-level counseling students, 15% reported no confidence at all and 38% reported little confidence in their ability to assess for suicide risk, whereas only 3% reported feeling fully competent to manage suicide risk.

But the problem isn’t just with graduate counseling students. In spring 2017, I presented a workshop for my state professional counseling association’s annual conference. The workshop focused on assessing risk of harm to self or others. I asked the 85 or so participants if they regularly worked with clients who were suicidal. Every hand went up. I then asked if they felt that their training had adequately prepared them for assessing suicide risk. Only two people in the entire group indicated that they felt prepared.

This response is consistent with an article titled “Psychologists need more training in suicide risk assessment” that appeared in the April 2014 Monitor on Psychology. The article, which detailed a task force report and summit organized by the American Association of Suicidology (AAS), said in part, “After three years of study, the AAS task force … called for accrediting organizations, state licensing boards, and new state and federal legislation to require suicide-specific training for mental health professionals.” The article went on to say that “many psychology graduate students are trained only on suicide statistics and risk factors, not in clinical methods of conducting meaningful suicide risk assessments.”

Something is amiss. Not only does it appear that mental health professionals receive inadequate training in this area, but some researchers even question whether the little training we do get has any efficacy. Robert Cramer and colleagues, writing in 2013 about suicide risk assessment training for psychology doctoral programs, stated that “no existing training methods have been investigated specifically in traditional clinical or counseling psychology training settings and samples.”

Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders addresses suicide risks by diagnosis, it does not provide any risk assessment tools for clinicians. Given the picture I’ve painted, how can it be that in 2020, we do not have any clear standard — often referred to as best practices — for suicide risk assessment?

Looking back

To identify what blind spots the counseling profession might have, I try to imagine what people will say about our field 50 or 100 years from now. After all, it is easy to look at the past and recognize our errors and oversights. As developmental psychologist Jerome Kagan wrote in Three Seductive Ideas (2000), “If you had lived in Europe as the fifteenth century came to a close, you would have believed that witches cause disease … and that pursuit of sexual pleasure depletes a man’s vital energy and guarantees exclusion from heaven.”

These ideas sound ridiculous today. If you are younger than 30, the following facts from the more recent past will sound equally ridiculous to you:

If you were a mental health person in the 1930s, “moron” and “idiot” were formal classifications of what we now call developmental delay. In addition, you believed ice water baths and jumping on a person’s chest could cure schizophrenia.
If you were practicing in the 1950s, common treatments for depression included prefrontal lobectomies. Some physicians literally lined patients up and performed these barbaric procedures in 10-15 minutes each.
If you were practicing therapy in 1970, you believed that homosexuality was a mental illness. Just a few years ago, some people believed in and actually practiced praying homosexuality out of a person (one of the milder techniques used in so-called “conversion” therapy).
In the early 1980s, hardly anyone had heard of AIDS, stalking, Munchausen syndrome by proxy, or autism.
When I was in graduate school in the mid-1980s, none of my master’s or doctoral professors even mentioned what we now call “evidence-based” therapies. Cognitive behavior therapy was leading the way, but most of us described ourselves as “eclectic,” and after our supervision hours were satisfied, we all basically did whatever we thought worked.

The lack of exactitude in the mental health field doesn’t end there. When I was a regular lecturer at the FBI Academy in the 1990s, I began receiving calls from around the country about various applications of counseling to law enforcement. One call came from a sheriff’s department. Five officers had been involved in a shooting, and departmental procedure required a fitness-for-duty assessment. The sheriff was asking me to do the assessments, so I began researching this facet of risk assessment and discovered there was no standard whatsoever in the field regarding fitness for duty. It was simply a judgment call on the part of the clinician. Hard to believe, isn’t it?

Apparently, we have a lot to learn. I’m hoping that in the not-too-distant future, therapists will be saying, “Remember back when there was no standard for suicide risk assessment? Unbelievable!”

Risk assessment tools

It would be easy to confuse lack of a standard with lack of tools. We have lots of tools. Among the assessment tools commonly used are the Beck Scale for Suicide Ideation, the Reasons for Living Inventory, the Suicide Probability Scale, the Suicide Intent Scale and the SAD PERSONS scale, to name just a few. However, there is very little, if any, data clearly demonstrating that one tool is better than another or that assessment tools have any efficacy at all.

One exception is the Beck Scale for Suicide Ideation, which is as well-researched and as validated as any instrument available. But there is still no assumption that clinicians use “evidence-based” assessments. Does that sound a little crazy to anyone but me?

In a 2016 article in the Journal of Psychopathology and Behavioral Assessment, Keith Harris, Owen Lello and Christopher Willcox identified a number of issues with the standard practice of suicide risk assessment, but again, there is no consensus in the field. The authors noted that “an American Association of Suicidology task force … and other experts have called for improved teaching guidelines on valid risk assessment. The findings of this and related studies bring to light weaknesses in current suicide risk assessment and conceptualization, and concerns that some clinical educators and practitioners may be unaware of the limitations of popular tests. There is a clear and present need for updating core competencies for accurate assessment and risk formulation.”

How do we know our assessments are effective?

I’ve never lost a client to suicide, and it would be tempting to suppose that this indicates my system of suicide risk assessment and intervention is effective. However, there are multiple factors unrelated to my competence that might lead to the same outcome. For instance, clients who come to counseling might simply be more motivated to live than those individuals who don’t come to counseling. In such cases, perhaps any adequate therapist would have been effective.

There may be other factors in my clinical work that are the cause of my fortunate success. In other words, perhaps I have been doing something else that works (maybe good rapport or social support), but I’m not aware that this is what is actually helping as opposed to my suicide assessment and intervention. And, of course, I could have been wrong in assuming risk at all. These potential false positives could mean that my clients didn’t kill themselves because they weren’t really suicidal to begin with. And these are just three possibilities.

This is why we need research and standardization. Standardization adheres to accepted research format. My students often start comments and questions with “I think …” or “I feel …” I never let that slide. I don’t care what we think or feel. What do we know? That is what research — evidence-based practice — helps us answer.

I understand that my words may be hard to hear. Before evidence-based therapies became the ethical standard, all of us in mental health were doing what we thought worked. Any challenge to our practice was met with a defensive posture, and I was among the clinicians taking that stance. We felt or believed (just like my students) that our methods worked because our clients appeared to get better. We were certain we were right, and maybe we were, but we had nothing concrete on which to base our assumptions. That seems obvious in hindsight, but the thought was new to us at the time.

Some of our clients might have seemed better but really weren’t. Their desire for improvement might have masked symptoms, and we also know that clients want to please us. They might easily have presented their cases in a brighter light than they should have. Other times, they might have been better temporarily but regressed after terminating therapy. We can easily misinterpret our positive feelings about our work as evidence that it is effective. Could we be making similar mistakes right now in risk assessment for suicide?

A perfect case in point is no-harm contracts. One of the things that clinicians seem to agree upon widely is that there are benefits to using no-harm contracts — also called safety contracts — with our clients who are suicidal. Yet years of attempts to validate the efficacy of no-harm contracts have turned up nothing. M. David Rudd, Michael Mandrusiak and Thomas Joiner Jr. noted in a 2006 article in the Journal of Clinical Psychology: In Session that “no-suicide contracts suffer from a broad range of conceptual, practical, and empirical problems. Most significantly, they have no empirical support for their effectiveness.” A 2005 article by Jeane Lee and Mary Lynne Bartlett reported the same thing. In other words, the one thing that almost all of us do has no data supporting its efficacy.

What we risk

When I’m working through clinical issues, I find it helpful to think of what I would say if I were sitting in front of the ethics committee of my licensing board or if I were being scrutinized in court by a hostile attorney. How hard would it be for an attorney to find 10 clinicians who would propose that I made the wrong decision? If all you can say is, “I thought this was a good idea,” then you have a very weak defense.

In such cases, we risk losing a lawsuit and perhaps having our licenses censured, suspended or revoked. The more important risk, however, is that we might fail our clients and they might lose their lives when we could have served them better.

A standard approach

I’m not the first person to notice this problem, of course. AAS, among other groups, regularly focuses on the development of reliable and valid processes for assessing suicide risk, but as of yet, the solutions are elusive. A number of research studies have attempted to address the issue. James Christopher Fowler summarized well in a 2012 article in Psychotherapy when he wrote, “We are not yet in possession of evidence-based diagnostic tests that can accurately predict suicide risk on an individual level without also creating an inordinate number of false-positive predictions.” This summary brings us right back to where we started.

Combing through the research over the years, I’ve narrowed what we know about risk into a three-factor risk model and five components of risk in my assessment process as a starting place for evaluating the efficacy of risk assessment. I’m not supposing that my work is original or that my system is better than another. I’m only proposing that what I present here is consistent with what we know and that it can serve as a starting point for collecting evidence and producing a standard of best practice.

Three-factor model: The three-factor model proposes that clients are at risk or protected from risk in three global arenas: presenting factors, personal factors and protective factors.

Presenting factors include diagnoses (depression, for example), loneliness, divorce, prior attempts, suicidal ideation and other situational factors that put clients at higher risk for suicide.

Personal factors include pessimism, weak problem-solving skills and minimal coping skills that put clients at higher risk for suicide. Included here are actuarial data. Some populations, such as female African Americans, have been shown to have very low risk for suicide, whereas others are statistically very high (e.g., Native Americans, male Caucasian teens, the elderly).

Finally, protective factors counterbalance presenting and personal factors. This would include healthy relationships, strong social support networks and religious commitment.

Moffatt’s HM⁴: The model for assessing risk that I use addresses all three factors. My HM⁴ model has five components of examination — hopefulness, method, means, motivation and mitigating circumstances.

The research is clear. People without hope are at high risk. Sometimes this is called “future orientation.” Regardless, the question is, “What does my client have to look forward to tomorrow, next week or next year?” If the answer is “nothing,” then I’m worried.

Method refers to one’s plan. The more specific and clear the method, the more I’m concerned. “I sometimes think the world would be better if I just didn’t wake up” is a vague plan. “I have been collecting my mother’s medications a little at a time. I have them hidden in my room, and I plan to take them all at once when everyone leaves for work and school” is a very precise plan.

Means has to do with the tools to be used and the ability to carry out one’s method of dying by suicide. One of the children in my practice once said he wanted to kill himself. His method was to invent a robot that would kill him in his sleep. His method was clear, but the means of executing that plan were completely unrealistic. Even if he could have invented such a robot, the likelihood that he would be able to carry out this plan without attracting his parents’ attention was minimal. On the other hand, teens and adults often have much more realistic means and, because of freedom of movement and access to weapons, drugs and other resources, are much more likely to succeed in a suicide attempt.

Motivation refers to the level of desire to follow through and complete suicide. Fortunately for us as counselors, most of our clients don’t want to die. Their motivation is low even though their emotional pain is high. This is why suicide hotlines work. People are so highly motivated to find a solution (having low motivation to complete the act of suicide) that they will call a complete stranger to seek help.

Finally, mitigating circumstances are issues that are so weighty that they override the other areas of assessment. Mitigating circumstances can either increase or decrease risk for suicide. My concern for a high-risk client might be overshadowed by the person’s religious beliefs about suicide or by their desire to avoid hurting their children, spouse or parents. “I couldn’t do that to my children” is something that I’ve heard many times from high-risk clients. “My uncle committed suicide, and it devastated my father’s family” is another. Readers might recognize that hope is a mitigating factor, but it is such an important one that it has its own place in my model.

Assessment of Abigail

Abigail’s risk was clear. She was in a high-risk gender, age and diagnostic demographic; she had been contemplating suicide for a very long time; and she had a clear plan. She had been in emotional pain for many years and, most frightening to me, she had little hope of anything ever getting better. Her efforts to improve and the efforts of others to help her, in her estimation, had been futile. She had purchased a poison specifically to have it available if she decided to kill herself (method), and it was presently in her possession (means). I am positive she was motivated to follow through because getting the poison was not easy. She was willing to work hard to prepare for her own death, so I could have little confidence that she wouldn’t follow through.

Among several mitigating factors in Abigail’s case was that she loved her children and didn’t want to abandon them. Also, she was certain that her religion did not permit suicide, and she feared “an eternity in hell” if she killed herself. Also working in her favor was that she possessed at least enough hope to keep our appointments. She was willing to at least try to let me help her even though she was unsure it was getting her anywhere. She came to therapy several times a week and was willing to trust that life might improve. Finally, she pursued medication for her depression and continued to engage in the business of life.

Abigail is still alive today, and even though she struggles at times, she reports that she is doing better, that her depression has been managed, and that (now a grandmother) she is finding some happiness in life with her grandchildren.

Conclusions

If I sound overly critical of our profession, it is unintentional. It isn’t that I think we don’t know anything about suicide and risk assessment. On the contrary, there are mounds of data on statistics, risk factors, assessing and so forth. I attended a fantastic education session on suicide risk assessment at the American Counseling Association’s 2018 conference. The session was packed out, the presenters were fabulous, and the information provided was very helpful, but the very nature of the workshop demonstrated that we lack clear standards. Nearly all of us seem to be asking the same question: What do we do?

Without a standard for suicide risk assessment, clinicians face two very serious risks. The first and most important is that failure to standardize may leave our clients at risk for self-harm. Just because we have individualized systems that we believe are working doesn’t mean that they are working. The second issue is self-protection in the event of a lawsuit or a complaint against us with our licensing boards. The existence of best practice standards would allow us to defend ourselves.

Although there is no standard assessment for suicide risk currently, it isn’t beyond our grasp. In the 1990s, the medical community began looking at the use of a research-based protocol in emergency room heart treatment. Malcolm Gladwell described this process in his 2007 book Blink. Physicians resented the simple three-question protocol and were incredulous that anyone would suggest that such a simple tool could offer better triage than their professional experience did. Yet data proved that the protocol was superior in saving lives. The protocol is now standard in the medical field. The same process can be achieved in our field as well, but it depends on our profession’s willingness to study it and to accept the results.

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Gregory K. Moffatt is a veteran licensed professional counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University in Georgia. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. He also writes the monthly Voice of Experience column for CT Online. Contact him at Greg.Moffatt@point.edu.

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.

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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 prevention strategies with the military-affiliated population

By Duane France and Juliana Hallows October 29, 2019

Every suicide is a tragedy affecting families, friends and whole communities, but when everyone works together to help those in need, suicide becomes preventable. All of us have a role to play in preventing service member, veteran, and military family (SMVF) suicide.

Within the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the community, professional counselors play a critical role in providing support to this population. Through a community public health approach with dedicated partners and a willingness to learn and adapt to the changing needs of veterans, we can prevent suicide and help individuals live, work and thrive in the community of their choice. Because professional counselors approach mental health from a wellness perspective, they are uniquely qualified to not only support military-affiliated clients, but to advocate for wellness approaches in the communities where they live and serve.

The federal government is working diligently to address suicide in a number of different ways. The Centers for Disease Control and Prevention (CDC) has released a number of strategies created to reduce the number of deaths by suicide, and last year, the VA published a 10-year strategic plan outlining how all parts of the country can work together to support veterans. Additionally, President Trump recently signed an executive order known as the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS), which establishes a task force to engage stakeholders nationwide in suicide prevention efforts.

Using a public health approach

Suicide prevention remains the VA’s top clinical priority, but the fact remains that no one person, organization or program can do it alone. The public health approach asks all facets of the community, including mental health professionals, to work together toward a solution. The VA, as a member of the community, has a critical opportunity to meaningfully connect to community stakeholders to save neighbors, family members and friends.

Every VA facility has a suicide prevention coordinator who is asked to step out of their facilities and into their communities to build relationships with community partners that are vested and connected to service members, veterans, their caregivers and their families. Through this model, researchers, clinicians and partners collaborate for suicide prevention by identifying community issues, developing and implementing strategies to address those issues (through maximizing protective factors and minimizing risk factors related to suicide), and creating an evaluative process for those implemented strategies.

Of the 20 million veterans nationwide, less than half use Veterans Health Administration services. That makes it challenging to identify veterans who may be at risk for suicide and to connect them with mental health care professionals, peer networks, employment, and other resources known to bolster protective factors and help with coping. As large and robust of a network as the VA is, this challenge cannot be solved by the VA alone.

Community hospitals, clinics, and health care professionals across the nation play a key role in preventing suicide because they are integrated into the local fabric of the SMVF community. VA partnerships with community health care providers expand access to care to SMVF members in the communities where they live, work and thrive. In addition, not all those who die by suicide necessarily access mental health care services prior to their deaths. This means that community organizations such as veterans groups, recreational teams, faith-based centers, and myriad other community supports can serve as potential collaborators to build on suicide prevention efforts.

Part of improving access and building a public health approach is identifying those who are part of the SMVF community. For example, the New Hampshire Legislative Commission on Post-traumatic Stress Disorder and Traumatic Brain Injury created an initiative for stakeholder agencies to add a question about service member and veteran status, thus improving referral and access to services within the SMVF community. By adding the question “Have you or a family member ever served in the military?” to intake, enrollment and health history forms, counselors create opportunities to discuss military experiences and their impact on clients’ lives. This provides the benefit of informing treatment and connecting individuals to SMVF-specific resources (see askthequestionnh.com/about/why-ask). Identifying the SMVF community can also happen across varying community services, thus strengthening care coordination and supports.

In addition to asking clients about their military status, professional counselors can be particularly helpful in building the public health approach by asking the following questions:

How is the community collecting and reporting data on SMVF suicides?
How are the local emergency rooms collecting data on suicide attempts?
Does the community have a strategic initiative to address SMVF suicides?

If there are no answers to these questions, counselors can work with their communities to implement more effective strategies. Communities can also implement these strategies beyond the service member and veteran populations to include caregivers and loved ones. There still is a long way to go in identifying and understanding all of the risk factors and protective factors for suicide among the spouses and children of service members and veterans.

Although the VA is expanding community care for the SMVF population, community health care providers need to develop the same level of military cultural competence as exhibited by providers within the VA. It is essential that health care providers understand the cultural issues related to military service that may give veterans mixed feelings about receiving health care. These cultural issues include:

1) Concerns that seeking care, particularly mental health care, will harm their careers, whether military or civilian.

2) Fears about how they could be perceived by others for seeking care, such as being seen as “weak” by their peers.

3) The belief that overall mission success is a greater priority than their own well-being.

In Phoenix, VA teams have partnered with the Arizona Coalition for Military Families to provide military culture training to local behavioral health providers. In Richmond, Virginia, the McGuire VA Medical Center partnered with the Richmond Behavioral Health Authority to include VA resources on the state’s behavioral health website.

In addition to building cultural competency, community health care providers need to be able to offer the SMVF population the same type of evidence-based practices provided through the VA. This may be achieved through partnering with local VA providers on trainings that build on clinical skills for suicide prevention. The VA developed a Community Provider Toolkit (see mentalhealth.va.gov/communityproviders/index.asp) to help community providers, including counselors, gain a deeper understanding of military culture.

Through the public health approach, everyone has a role to play in preventing SMVF suicide. By considering level of risk and the factors beyond mental health that contribute to suicide, communities can deliver resources and support to SMVF populations earlier, before they reach a crisis point.

Maximizing protective factors

A critical component of SMVF suicide prevention is identifying the protective factors that prevent these individuals from getting into crisis. As noted in the CDC’s Preventing Suicide: A Technical Package of Policies, Programs, and Practices (2017), there are many strategies to build up protective factors. Some of these protective factors include promoting connectedness, improving economic stability, and increasing education and awareness about suicide within the population and throughout the community. These strategies fit well into Thomas Joiner’s interpersonal-psychological theory of suicidal behavior, in which he proposes that individuals die by suicide when there is a desire and capacity to do so. He posits that a sense of isolation, feelings of burdensomeness, and an ability to engage in self-harm all correlate with increased risk of suicide.

Connectedness

Promoting connectedness in the military population helps to reduce a person’s sense of isolation. This strategy has two critical components: peer norm programs and community engagement activities.

Counselors in the VA leverage community partnerships, promote family engagement, and encourage those around SMVF populations to ensure they remain connected to their loved ones and peers. The Veteran Resource Locator, for instance, links veterans and their loved ones, or community providers, with programs and services in their area, both within the VA and in the community. Counselors consistently look to engage family members in veterans’ treatment to increase their support systems. Local VA facilities conduct extensive outreach in the community to form partnerships with organizations in which veterans and service members are involved. For example, in Billings, Montana, the VA and community teams developed a local veterans meet-up group to help service members stay connected to their community during transition from active duty. Group members meet regularly for cookouts and conversation.

Counselors in the community can also support efforts to improve connectedness. For example, counselors can become familiar with peer support programs in their communities or get involved in the development of such programs if none exist. If organizations exist within the community that provide opportunities for the SMVF population to engage with others while supporting their community (e.g., Team Rubicon; Team Red, White & Blue; The Mission Continues; Travis Manion Foundation), counselors can get to know who is in the organization. Counselors can provide referrals to these organizations and invite representatives to speak to their colleagues.

Economic stability

A suicidal crisis in a member of the SMVF population does not happen in a vacuum. Increasing economic stability is a significant protective factor in preventing suicide. As service members transition out of the military, whether they have served for four years or 24 years, the majority are young enough to be able to continue in another career. When housing, employment and finances are not stable, this can cause additional stress for this population and increase feelings of burdensomeness.

Counselors in the community can maintain a list of referral agencies that support housing, employment and financial support. These organizations play an important role in reducing SMVF suicide, whether they realize it or not. If a service member or veteran is in financial crisis, they may be in a psychological crisis too.

The VA is increasingly working to support veterans in financial distress through the Financial Assistance for High Risk Veterans program. This program, available at many VA facilities, creates a partnership between local VA facility suicide prevention coordinators and revenue staff. Should a veteran with high risk of suicide also require assistance related to financial distress, the suicide prevention coordinator would connect the veteran to revenue staff. These staff would work personally with the veteran to apply for a VA financial hardship program that best fits the veteran’s financial situation.

As counselors in the community and the VA become aware of how financial stressors are interacting with the sense of burdensomeness in their clients, they can incorporate clinical moments to discuss and assess suicide risk while also developing strategies to build economic support. Together, clinicians inside and outside of the VA can bolster the network of housing, employment and financial assistance through reviewing what is available in the community and developing strong referral processes.

Education and awareness

A third protective factor is increasing community education and awareness about SMVF suicide and suicide prevention. This is yet another area in which professional counselors can make an impact. Counselors who are familiar with suicide prevention efforts can help others become familiar with them too. Providing greater awareness in the community is important. It is also critical to educate medical professionals about the problem. A large number of those who have died by suicide saw their primary care providers a month or less before their deaths (see ncbi.nlm.nih.gov/pubmed/12042175). Counselors can support their communities by facilitating or promoting gatekeeper training for those serving the military-affiliated population.

The VA has invested significantly in education around suicide. VA employees take annual suicide prevention training. VA facilities also conduct extensive community outreach to ensure that partners are aware of resources available to veterans and their families.

Counselors in the community can also take the initiative to become educated on SMVF suicide. The VA has partnered with PsychArmor Institute to provide free online access to the S.A.V.E. suicide prevention training (available at psycharmor.org/courses/s-a-v-e). In addition, VA suicide prevention coordinators partner with community providers to offer in-person training to those who need it. In their role as advocates, counselors can work with local leaders to provide clinical expertise connected to community suicide prevention efforts, whether that be public awareness campaigns or participation in local SMVF suicide prevention efforts.

Minimizing risk factors

Unfortunately, no matter how much we invest in preventive efforts, the possibility still exists that a member of the military-affiliated population will experience a suicidal crisis. When this happens, the community needs to be just as prepared to identify and reduce risk factors as it is to identify and implement protective factors. Both the CDC and the VA have identified more than a dozen risk factors that may lead to suicidal thoughts and behaviors, but there are three areas where professional counselors can be especially helpful.

Access to care

Of all the risk factors and protective factors identified here, the area in which counselors are most likely to be naturally involved is improving access to safer care. When it comes to the military-affiliated population, this means improving culturally competent care, reducing barriers to care, and reducing the mental health provider shortage for those organizations that serve this population.

The VA has done much to improve access to care for veterans, including the expansion and promotion of the Veterans Crisis Line (VeteransCrisisLine.net), a 24-hour service that veterans can call, text, or chat with at any time to receive immediate support. The VA also provides same-day access for veterans in need of mental health care and has built a robust telemental health and call center network that can direct veterans to get the care they need. In addition, the VA sponsors Coaching Into Care (mirecc.va.gov/coaching), a free service that educates, supports and empowers family members and friends who are seeking care for loved ones who are veterans. In addition, the DoD expanded nonmedical mental health services for the SMVF population up to a full year after leaving active duty.

Counselors in the community must be just as ready as their colleagues in the VA to improve access to care. It is incumbent upon counseling professionals to ensure that they develop and maintain an understanding of the unique psychological challenges faced by the SMVF population and that they are available to serve those individuals who do not access care through the VA or DoD.

Community counselors also have the ability to be important advocates for the profession through mentorship, collaboration and consultation. Increasing the number of veterans and military family members who consider careers in the mental health field is an excellent way to improve access to care for this population.

Lethal means safety

One area that deserves discussion but often goes unmentioned is the need for counselors to address the ability of clients to engage in self-harm. This includes talking about lethal means safety, particularly with those in the military-affiliated population.

Veterans are more likely to die from ﬁrearm-related suicide than are those in the general U.S. population, according to the VA’s 2019 National Veteran Suicide Prevention Annual Report (see mentalhealth.va.gov/suicide_prevention/data.asp). Safe storage of lethal means is any action that builds in time and space between a suicidal impulse and the ability to harm oneself. It addresses how to be safe from any lethal means, including firearms, prescription medications, and suicide hot spots.

This topic can be sensitive, especially because veterans have experience with and are comfortable with firearms. Effective lethal means safety counseling is collaborative, veteran-centered, and consistent with their values and priorities. Although the most preferred way of preventing SMVF suicide is to keep these individuals from going into crisis in the first place, lethal means safety plans are critical to preparing for suicidal crises should they arise.

The VA has made significant efforts to impact the conversation around lethal means safety. For example, it distributes free gunlocks to veterans and provides safe medication disposal envelopes at facilities across the country. The VA also recently instituted a nationally standardized safety planning template that ensures veterans have high-quality suicide prevention safety plans. Veterans and their providers work together to complete the plans, which identify innovative and feasible actions that can be taken to reduce access to lethal means. Suicide prevention coordinators within the VA have participated in firearm shows and fairs, providing materials and gunlocks directly to gun owners in their communities through partnering with local firearm groups.

Counselors in the community must be just as informed and prepared as counselors in the VA to discuss lethal means safety. They should be aware of locations that provide out-of-home firearm storage in the community and be able to have honest discussions with clients about when and how to use these resources. Counselors can partner with other community agencies to identify these resources. For example, the Colorado School of Public Health and the University of Colorado School of Medicine at the Anschutz Medical Campus have established the Colorado Gun Storage Map, provided for those community members seeking local options for temporary, voluntary firearm storage (see coloradofirearmsafetycoalition.org/gun-storage-map).

Counselors must take the same care when it comes to storage of prescription medications. In addition, community counselors may be more able than their VA counterparts to partner with local law enforcement to identify and mitigate suicide hot spots.

Postvention

A final area that counselors must address to reduce the risk of suicide in the SMVF population is postvention. Engaging service members, veterans, families, and providers after a suicide loss can promote healing, minimize adverse outcomes for those affected, and decrease the risk of suicide contagion. Postvention is critical to preventing additional suicides in the immediate social network of the person who died by suicide. Those bereaved by another person’s suicide have a greater probability of attempting suicide than do those bereaved by other causes of death. Those bereaved by another person’s suicide are also at increased risk for several physical and mental health conditions.

Community providers play a significant role in postvention. Clients who have attempted suicide are at a higher risk for future attempts unless the underlying problems that led to the attempt are addressed. Community providers are also important in addressing postvention needs in those left behind because of a death by suicide, such as the spouse and child of a service member or veteran. Whereas veterans may be served through the VA and service members may be served through the DoD, spouses and children of service members and veterans may not have access to the resources they need. This is where professional counselors in the community can offer support. For example, SAVE (Suicide Awareness Voices of Education) has excellent postvention resources for coping with loss (see save.org/find-help/coping-with-loss).

The VA has implemented processes to increase postvention efforts in its facilities. The VA provides its staff with suicide postvention guidance that can be tailored to meet the needs of each individual facility. Postvention efforts should include everyone who might have been affected by the death, including veterans, their families, and employees. Following a suicide, efforts are made to promote healing and support the deceased veteran’s family. Many local VA organizations have partnerships with the American Foundation for Suicide Prevention (afsp.org) and the Tragedy Assistance Program for Survivors (taps.org/suicideloss) to provide support to veterans’ family members and friends.

Additionally, the free, confidential Suicide Risk Management Consultation Program (mirecc.va.gov/visn19/consult) is available to assist staff with training on postvention. This program provides consultation, support and resources that promote therapeutic best practices for providers working with veterans at risk of suicide. It offers tailored, one-on-one support with consultants who have years of experience with veteran suicide prevention.

Suicide prevention is everyone’s job

The strategies to prevent suicide in the SMVF population are as complex as the risk factors for suicide itself. Unlike other challenges that SMVF clients face, such as homelessness and unemployment, success in reducing suicide is not clearly defined. If clients are housed, they are no longer homeless, and if clients are employed, they are no longer unemployed. The measure of success in suicide reduction is not just the absence of suicidal self-harm, however, but the presence of a life worth living and an overall level of wellness in the client.

This is where professional counselors can play a role in their clients’ lives and in their communities. Members of the military-affiliated population have sacrificed and served, regardless of when, where and how they served. It is necessary — and possible — to serve them in return, providing them the life of wellness and stability that they desire and deserve.

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For more information and resources, visit mentalhealth.va.gov and veteranmentalhealth.com. Additional resources for veterans, families, and community providers can be found at BeThereForVeterans.com and MakeTheConnection.net

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Duane France is a retired Army noncommissioned officer, combat veteran, and licensed professional counselor. He is the director of veteran services for the Family Care Center, a privately owned outpatient mental health clinic in Colorado Springs, Colorado, that specializes in serving the military-affiliated population. He also writes and speaks about veteran mental health on his blog and podcast, Head Space and Timing (veteranmentalhealth.com), and writes the monthly “From Combat to Counseling” column for CT Online.

Juliana Hallows is a national board certified and professionally licensed counselor. She serves veterans, their families, and communities through the VA National Suicide Prevention Program, where she is a health system specialist for policy and legislation.

Letters to the editor: ct@counseling.org

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Related reading: Counseling Today‘s September cover story, “Making it safe to talk about suicidal ideation”

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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.

Fighting suicide: The importance of hope

By David Kaplan January 7, 2019

Scary numbers about suicide have been splashing across the headlines for some time now. Many of us have seen the Centers for Disease Control and Prevention (CDC) data indicating that suicide rates have been rising and that suicide is now the 10th-leading cause of death in the United States. According to the CDC, nearly 45,000 lives were lost to suicide in 2016 in the U.S.

Statistics provided by the American Foundation for Suicide Prevention indicate that, on average, 129 Americans die per day by suicide.

These numbers — and the severity of this public health issue — hit home for many people following the self-inflicted deaths of celebrities such as fashion designer Kate Spade and celebrity chef Anthony Bourdain.

The instinctive reaction

The knee-jerk reaction when fear arrives at our front door is to distance ourselves from the problem causing the fear. That keeps us from having to think that something could happen to us or our loved ones — and provides a buffer from having to become involved.

In the face of more self-inflicted deaths, the defense mechanism for many individuals has become blaming suicide on mental illness.

“Suicide is rarely caused by a single factor,” the CDC reported earlier this year. “Although suicide prevention efforts largely focus on identifying and providing treatment for people with mental health conditions, there are many additional opportunities for prevention.”

The opportunity of hope

Along with its 2018 report on suicide, the CDC released “Preventing Suicide: A Technical Package of Policy, Programs and Practices,” which offers a core set of strategies to help inform states and communities as they make decisions about prevention activities and priorities.

At the start of that document, hopelessness is identified as one of a number of risk and protective factors associated with suicide.

Let’s take a closer look at the other side of hopelessness. Let’s focus on hope.

Someone who has hope is not likely to end his or her life. Things may be miserable at the moment, but individuals will hang on if they know there is a light at the end of the tunnel and a chance that things will get better. It is the person who has lost hope who sees suicide as a viable option.

The possibility of instilling hope is one reason that counseling is so important for people who are thinking about suicide. Professional counselors are experts at helping people see that suicide is a permanent solution to a temporary problem — and that there is hope for the future.

Everyone can help prevent suicide

If you, a loved one, a friend, a co-worker or someone else you know is discouraged, losing hope and possibly considering suicide, call the National Suicide Prevention Lifeline at 800-723-8255. The Lifeline staff members answering the phone — and the professionals to whom they refer clients — focus on instilling hope and, through that, preventing a tragic loss.

If you realize that a person you know may be suicidal, don’t distance yourself. Become involved, contact the Lifeline and help the person see that things can get better. By providing hope, you may help save a life.

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Warning signs of suicide

Talking about wanting to die
Looking for a way to kill oneself
Talking about feeling hopeless or having no purpose
Talking about feeling trapped or in unbearable pain
Talking about being a burden to others
Increasing the use of alcohol or drugs
Acting anxious, agitated or recklessly
Sleeping too little or too much
Withdrawing or feeling isolated
Showing rage or talking about seeking revenge
Displaying extreme mood swings

The more of these signs a person shows, the greater the person’s risk of attempting suicide. Warning signs are associated with suicide, but they may not be what causes a suicide.

What to do

If someone you know exhibits warning signs of suicide:

Do not leave the person alone
Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt
Call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255)
Take the person to an emergency room, or seek help from a medical or mental health professional

(Warning signs and recommendations from reportingonsuicide.org)

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David Kaplan is the chief professional officer of the American Counseling Association, the world’s largest association exclusively representing professional counselors in various practice settings.

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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.

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.

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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

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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

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.

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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

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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.

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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.