Tag Archives: Suicide

Suicide, substance abuse and medical trauma

By Bethany Bray September 3, 2019

Gunshot wounds, injuries from automobile accidents, a fall from a ladder, cooking burns or other incidents, either self-inflicted or unintentional: These are a few examples of the medical trauma that brings patients to the Wake Forest Baptist Health (WFBH) Medical Center in Winston-Salem, North Carolina.

Elizabeth Hodges Shilling and Olivia Smith are part of a team of counselors who talk with trauma patients at WFBH and assess them for suicidality and alcohol or substance use. The counselors have a laundry list of questions to ask patients as part of the assessment, but patients are often reeling from the traumatic incident that brought them to the hospital. At the same time, the counselors have a limited amount of time to work with each patient because patients are usually under their care for only 24 to 48 hours.

The solution? Shilling and Smith say they use a lot of “tell me” or “tell me more” questions and prompts. It’s a gentle way of getting the information they need and connecting the patient to additional resources.

For instance, instead of directly asking patients whether they drink or use drugs, Smith might say, “Tell me about when you’ve used alcohol or drugs to help you calm down or when hanging out with friends.” These types of inquiries make patients more likely to respond and open up, according to Smith, a coordinator and counselor on the adult and pediatric trauma screening and brief intervention team at WFBH.

This can be especially true with teenagers and young adults, who can be quick to put defenses up. “Sometimes we preface our questions with, ‘I’m not here to try and stop you. I just want to understand and try and support you,’” Smith notes.

Shilling and Smith are both licensed professional counselors and licensed clinical addictions specialists. They say that framing their assessments as “conversations” can help to form a connection with patients who might be overwhelmed by all the questions they’ve been getting from doctors and other medical personnel.

“Tell me about” questions are a gentle way of building rapport and opening the door to get more information from patients, says Shilling, an assistant professor in the department of surgery at Wake Forest School of Medicine. It also lets patients know that the issues with which they might be struggling aren’t unusual; other individuals are struggling with them as well.

The counselors may use prompts such as, “Tell me about the last time you thought about hurting yourself” or “Tell me about the times you’ve tried to cut down on your drinking,” says Shilling, a member of the American Counseling Association.

“Just throwing it into the conversation and bringing it out in the open gets them thinking about it,” Smith says. “[Also,] it eases up on the stigma about these thoughts and normalizes that it happens. We often hear embarrassment, and [patients who say,] ‘I’m having these thoughts, and I don’t know what to do with them.’”

Roughly 50% of the trauma patients they see at WFBH are admitted because of an accident or incident related to alcohol, Shilling says. This includes suicide attempts while under the influence of alcohol, intoxicated driving or being a passenger in a car with an intoxicated driver, or a variety of injuries that occur after a person has been drinking. Hospitalwide, one-third of patients are admitted for a medical condition related to substance use, she says. This includes conditions exacerbated by long-term alcohol use, such as pancreatitis.

“We often see people who have never thought about making a change, or others who have been injured several times and it’s a wake-up call and they want to change. Alcohol use can be a big part of their situation but also a small thing, as they’re dealing with so many things at once,” Smith says. “Being in the hospital posttrauma really facilitates the opportunity to think about making changes in your life. … It’s a teachable moment and opportune time to reassess [your choices].”

 

Alcohol and suicide

Smith and Shilling urge mental health practitioners to include questions about alcohol and substance use when screening clients for suicidality. This is a vitally important area of risk that often gets overlooked in suicide assessment, Shilling says.

Substance use problems are one of many suicide risk factors included on a list on the American Foundation for Suicide Prevention website, afsp.org.

Substance use can increase a person’s impulsivity, and it numbs the parts of the brain that trigger thoughts and behaviors that keep a person safe, Shilling says. “We see patients who, when sober, say they would not have taken those pills or used their gun, etc. But when they drink, that rational piece [of brain function] gets overridden. Using substances puts you at particular risk.”

Additionally, substance use can have negative effects on the overall mental health and wellness of patients, even if they do not exhibit signs of a substance use disorder. Asking questions about substance use can help patients understand how their drinking or substance use affects the whole picture, including mental health and mood, Shilling says.

“Substances impact their mental health in a lot of ways. They may be using substances in a way that’s not risky per se, but it may be affecting their mental health,” she adds.

Shilling urges practitioners who want to learn more about substance abuse — especially those who work with vulnerable populations such as teens — to seek continuing education or even additional licensure (such as becoming an addictions specialist).

 

Asking the right questions

Smith and Shilling’s cohort at WFBH uses several screening tools to assess for substance use in the patients in the hospital’s trauma, burn and medicine units.

The first is the Alcohol Use Disorders Identification Test (USAUDIT) developed by the U.S. Substance Abuse and Mental Health Services Administration. Available to the public at ct.gov/dmhas/lib/dmhas/publications/USAUDIT-2017.pdf, the assessment places users into one of six categories, ranging from “low-risk alcohol use” (no more than 14 drinks per week for men and seven per week for women) to “alcohol dependence” (which includes a cluster of symptoms indicating dependence on alcohol).

The Wake Forest team also uses the CAGE Substance Abuse Screening Tool developed by the Johns Hopkins School of Medicine. Smith says this mnemonic screening tool helps prompt patients with open-ended questions:

Cut down: Have you ever felt you should cut down on your drinking?

Annoyed: Have people annoyed you by criticizing your drinking?

Guilty: Have you ever felt bad or guilty about your drinking?

Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Read more about the CAGE screening tool at hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdf

 

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Call for help

The National Suicide Prevention Lifeline offers free and confidential support around the clock, seven days a week, at 800-273-8255 or via chat at suicidepreventionlifeline.org.

 

Read more about addressing the topic of suicide with clients in Counseling Today‘s September cover story, “Making it safe to talk about suicidal ideation.”

 

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Contact the counselors interviewed for this article:

 

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Bethany Bray is a senior 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.

 

Making it safe to talk about suicidal ideation

By Bethany Bray August 26, 2019

“Counseling is both a science and an art, but that’s really true when it comes to [preventing] suicide,” says Julia Whisenhunt, a licensed professional counselor (LPC). “There’s a lot of solid research out there on the topic, but figuring out the complex constellation of suicide warning signs in a specific individual is an art. It’s based on science, but it’s also an art.”

Recognizing suicidal ideation in clients and meeting their unique needs comes not only from being trained and up to date on suicide prevention and response, but also from a measure of professional intuition, says Whisenhunt, an associate professor and director of the doctoral program in professional counseling and supervision at the University of West Georgia (UWG). Suicide is a complex issue, and counselors must do their utmost to ensure client safety and maintain client trust while asking tough questions that probe people’s lowest moments.

Above all, suicide is a topic that counselors should not tiptoe around or be fearful of, stresses Whisenhunt, a member of the American Counseling Association. Practitioners bear a responsibility to screen for suicidal ideation and to address the topic with sensitivity.

“Most people aren’t necessarily going to directly reach out and ask for help. [They] will communicate distress in other ways, and it’s a matter of whether we’re paying attention,” says Whisenhunt, who routinely conducts suicide prevention workshops and trainings on the UWG campus and surrounding community. “As humans, we tend not to see it. We can’t imagine the people in our lives would think about it [dying by suicide]. If you’re not trained in suicide prevention, you might know something’s off but not fully understand what it is and what the warning signs are. That’s the importance of training — so you can make that connection and know how to support them.”

No population untouched

According to the Centers for Disease Control and Prevention (CDC), suicide is the 10th-leading cause of death in the United States. For many age groups, however, it ranks much higher. Consider:

  • Suicide is the second-leading cause of death among those in the 10-14, 15-24 and 25-34 age groups.
  • Suicide is the fourth-leading cause of death among those in the 35-44 and 45-54 age groups.
  • Suicide is the eighth-leading cause of death among those ages 55-64.

In 2017, the most recent year for which CDC statistics are available, more than 47,000 Americans died by suicide — an average of 129 people each day. These numbers reflect a 33% increase in rates of suicide over the past 18 years, according to the CDC. America’s age-adjusted suicide rate rose from 10.5 deaths per 100,000 people to 14 deaths per 100,000 people between 1999 and 2017.

Statistics are even more dire for certain populations, including military veterans. The U.S. Department of Veterans Affairs (VA) reports that there were more than 6,000 veteran suicides each year from 2008 to 2016. In 2016, the suicide rate among veterans was 1.5 times higher than the rate among the civilian/nonveteran population. According to the VA, an average of 20 veterans die by suicide daily.

Issues related to suicide have grabbed headlines in recent years, not only as news outlets have reported on statistics and trends, but also as notable figures such as Robin Williams, Kate Spade and Anthony Bourdain have died by suicide.

With rates of suicide increasing across geographic regions and almost all ethnic groups, people may reach the conclusion that suicide prevention programming isn’t working or isn’t worth the effort. That simply isn’t true, stresses Jenny L. Cureton, an assistant professor of counselor education and supervision at Kent State University. People often cite outreach programs, crisis hotlines and even signs on bridges as things that interrupted them on their path toward suicide, she says. The National Suicide Prevention Lifeline answered 2.2 million calls in 2018 and a total of 12 million calls in the first 12 years after it was established in 2005.

“When we believe that we can cope and that people care about us, when we have hope and reasons to be here, we can more easily choose life. Great prevention efforts target these goals, and laypersons and professionals alike can target them too, every day,” says Cureton, a member of ACA.

“For the most part, as a society, we understand [now] that talking about suicide doesn’t cause suicide,” Cureton says. “But what we might not understand as a profession is that empathizing with a client’s reasons for wanting to die is not the same as agreeing with them.”

“Empathy and trust are a huge factor in suicide work. Empathizing with a client’s situation is not [the same as] endorsing their suicidal thoughts,” she continues. “You have to balance the client’s reality while acknowledging all the facets of it. Take the time to be with them in the scary, angering and sad places where suicide usually resides. And then say, ‘When you escape this place, even for one moment, what do you find there? What’s a moment that you thought would be the end and it wasn’t? Who was there for you? Can you imagine something shifting even the slightest bit? What does that hope look like?’”

Using empathy to acknowledge a client’s pain helps counselors better understand what the client is experiencing and can inform their work together in counseling to help the person stay safe going forward. “I want to see the world from their eyes so I can help them have the world they want for themselves,” Cureton says. This also demonstrates “that I care about them staying here. I care about them having a life that is so worth living that they live it.”

Exploring risk

Assessing for suicide risk is a vital procedure that should be undertaken with every client. However, forging a bond with the client ought to be the first step that professional counselors take before launching into detailed assessment questions, says Kristin Bruns, an LPC who is an assistant professor in the Department of Counseling, School Psychology and Educational Leadership at Youngstown State University.

Practitioners should also endeavor to understand the client’s full situation before intervening. Bruns acknowledges that this may require counselors to overcome an instinct to take action immediately, especially when clients express thoughts and feelings about killing themselves. But what clients need most in that moment is a practitioner who will listen, Bruns says, not one who reacts or recoils.

“Don’t jump in to assist too soon because the client may shut down,” says Bruns, an ACA member who presented a daylong learning institute on suicide assessment, treatment and safety planning at the ACA 2019 Conference & Expo in New Orleans. “[Demonstrating] empathy and being able to sit with [the client’s] discomfort is critical for counselors to do. … Fully listen to the client’s story to feel what they’re carrying. We have to be human in the [counseling] room. Work against the alarm bells going off in your head.”

When it’s time to move into the questioning phase with clients, Bruns recommends that counselors use an evidence-based suicide risk assessment tool and then stick with it. Practitioners shouldn’t go off of memory, even if they have used the same tool for years, she cautions. Numerous evidence-based suicide assessment and treatment tools are available. Bruns suggests that clinical counselors simply choose one that is a good fit for their style and client population.

As the client is answering questions, counselors can probe for detail, such as how long the client has been experiencing suicidal thoughts and what might have led to those thoughts in the first place, such as a life change or personal loss, Bruns says. It’s also important to ask if those thoughts are constantly present with the client or are more fleeting in nature.

“Don’t tiptoe around the issue,” Bruns says. “Starting with clear language from the beginning makes it easier: ‘Do you want to kill yourself? Have you ever thought about how you would die [by suicide]? Do you have a plan? What would it look like?’ Open and clear communication is important. It’s also an opportunity to educate [the client] on the brain and how it doesn’t make rational decisions in a crisis.”

Bruns says that when asking such questions, counselors should remain sensitive to the client’s needs and presenting issue. “We have questions that we know we need to ask, but at the same time, pay attention to the client and don’t overwhelm them. Put yourself in their shoes. If they’re struggling, be thoughtful about how many questions you’re asking [and] your volume and type of questions,” Bruns says.

Certain clients might be particularly wary of disclosing suicidal thoughts because they fear the revelation could affect their athletic or job status (e.g., college or professional athletes, law enforcement personnel, military personnel). Counselors should ensure that they fully explain the limits of client-counselor confidentiality during the informed consent process but also reassure clients that they won’t be institutionalized or “taken away” — like in the movies or television dramas — for acknowledging that they have or have had suicidal thoughts, Bruns says.

“Don’t buzz through conversations about confidentiality,” she says. “Explain that there’s a continuum [of suicidal ideation]. Just by telling me that you’ve thought about suicide doesn’t mean that you’ll be hospitalized. … If there’s any kind of hesitancy [from the client], don’t just barrel through with questions. Pause and reassess, and pick up on why they’re uncomfortable.”

Suicide prevention literature lists dozens of risk factors sorted by environmental and other factors, including feeling hopeless or helpless; experiencing a stressful life event such as divorce or financial trouble; experiencing prolonged stress from bullying, unemployment or other issues; having a family history of suicide; and experiencing a death by suicide of a family member or close personal acquaintance. (Find detailed lists of suicide warning signs and risk factors at the websites of the American Foundation for Suicide Prevention, afsp.org, and the National Suicide Prevention Lifeline, suicidepreventionlifeline.org.)

Clients who have a suicide attempt in their past are at higher risk for another suicide attempt. Co-occurring issues that put clients at higher risk of suicide include depression, bipolar disorder, a substance use disorder, and other mental illnesses that are untreated or are not being properly managed, Bruns notes.

Probing for details of past suicide attempts can help inform counselors’ understanding of an individual’s current suicide risk, Whisenhunt adds. She recommends asking if prior attempts were planned or impulsive, what means the person used to carry out the attempts, and whether the attempts were intentionally or unintentionally interrupted. “Ask about their thoughts and feelings preceding, during and following [the attempt],” she says. “When it didn’t work, did they feel anger or relief?”

Access to lethal means, such as firearms or drugs, also puts a client at higher risk of suicide. Firearms were involved in slightly more than 50% of nationwide suicide deaths in 2017, according to the CDC. The VA reports that 69.4% of veteran suicide deaths in 2016 involved a firearm.

Firearms can be a polarizing issue, but as part of suicide assessment, professional counselors should not hesitate to ask clients if they have access to firearms, Bruns says. These discussions are an opportunity to talk about brain science and how the human brain doesn’t operate rationally in a crisis, she says. Even if clients say they would never touch a gun, they may make an irrational decision if, during a moment of crisis, firearms are easily accessible or are not secured, Bruns points out.

Whisenhunt discourages counselors from asking clients to rate their suicide risk on a scale of zero to 10 during assessment. “[Clients] can’t rate their own [suicide] risk for a number of reasons. Things may change at any given moment. Life is fluid,” says Whisenhunt, who presented a session on suicide prevention at the ACA 2019 Conference & Expo.

Clinical counselors are more likely to understand the full picture of a client’s suicidal ideation if they also screen for depression, anxiety, impulsivity, major life changes (such as job loss or divorce), past trauma, addiction or substance use disorders, other co-occurring issues, and whether the client has a solid support system, Whisenhunt says. “There’s a huge relationship between interpersonal stress and relationship issues and suicide. We need to look at the whole person, not just the suicidal thoughts,” she says.

Counselors must also resist the urge to try to pin a client’s suicidality to a single cause or reason, Bruns adds. Risk factors often come from multiple areas of life, she points out. “Don’t be too narrow-minded in [the] assessment process. Don’t think that there’s one single cause. … Suicide is complex in nature, and too often it gets oversimplified,” Bruns says.

Safety planning

Once a client’s suicidal ideation is recognized and explored through assessment, the next step is for counselors to design a safety plan with the client, Bruns says. She emphasizes that it is critical to create this safety plan in the same session in which suicidal ideation is identified. Counselors should also make sure that the client takes a copy of the plan home.

Safety planning templates are available online (for example, see the Suicide Prevention Resource Center website at sprc.org) and can serve as an evidence-based starting point, Bruns notes. In addition to including the names and phone numbers of friends, family members and professionals whom the client can contact if in crisis (plus contact information for a 24/7 hotline), the plan lists individualized warning signs that a crisis might be developing, protective factors, and coping strategies to fall back on when things start to escalate. Safety planning is considered a best practice and is preferred over the “no suicide contract” method that counselors sometimes used with clients in years past, Bruns notes.

“This is of paramount importance. [Safety planning] gives them coping skills but also a way to reach out for more help,” Bruns says. “It’s an empowering approach. [Clients] are able to identify their triggers on their own. If they’re able to get to step two and go for a run or use a breathing technique to minimize their suicidal thoughts, it’s empowering to realize that they did that on their own. Or, if that didn’t help, they are empowered to take the next steps” and seek help from someone listed on the plan.

Counselors should also be careful to check in with these clients regularly to ensure that their safety plans are still applicable and working. As Bruns notes, clients’ personal emergency contacts may change over time, as might their triggers and coping mechanisms.

Protective factors

Assessment and a counselor’s “focus on the why” are important parts of suicide work with clients. But equally important, Cureton contends, is exploration of clients’ protective factors. Each client will have a combination of things that can bolster and carry them through low moments. Not identifying or asking about these factors does a disservice to the client, Cureton argues.

“If we don’t explore both risks and what has protected them and kept them alive, we are really missing the whole person,” she says. “Only focusing on lessening risk factors is only half the picture — less than half. For those who have a suicide attempt [in their past], they are still here, and there was something that carried them through. To not explore that, address that, is missing something.”

Cureton urges practitioners to listen carefully when clients talk about their low points or past suicide attempts in counseling. The client might use language such as “I don’t know how I got through that moment.” Counselors should use that as an opportunity to help clients talk through and focus on the elements, large and small, that interrupted them on their path to suicide, she says.

Suicide prevention is both a professional and a personal area of passion for Cureton, who lost her grandfather to suicide when she was in middle school. Cureton co-authored an article with Matthew Fink on suicide protective factors in the July issue of the Journal of Counseling & Development.

Cureton and Fink developed a mnemonic, SHORES, for mental health practitioners to use when identifying and discussing protective factors with clients:

  • S: Skills and strategies to cope (emotional regulation, adaptive thinking and engaging in interests)
  • H: Hope (including goals for the future and ways to meet those goals)
  • O: Objections (moral or cultural objections)
  • R: Reasons to live and Restricted means (motives for staying alive, such as responsibility to family or children, and reducing access to firearms, poisons, medications and other means of suicide)
  • E: Engaged care (receiving care and finding a meaningful connection with a counselor, physician or other medical or helping professional)
  • S: Support (supportive social environments and relationships, including family and caregivers)

Support can also include professional and career connections, political or activist groupings, and other nonfamilial relationships, Cureton adds. She says counselors should explore support systems even with those clients who appear to have a large number of friends. Clients can often feel alienated from friends who have moved or had life changes, such as getting married or having children, she notes.

Cureton acknowledges that the second point, hope, can sometimes seem nebulous. So, in addition to engaging clients in goal-setting and thinking of the future, Cureton directs them to visualize what their version of hope looks like. In session, she sometimes cups her hands together and holds them out to the client, asking the client to describe what, for them, makes up the “ball of hope” she holds in her hands.

Cureton then asks where the client would like to keep this hope. She and the client visualize taking the hope from her hands and “storing” it in the client’s purse, pocket or heart. With younger clients, it can be effective to create a “hope jar” in session or to have them design a room in a video game where they keep their hope, Cureton adds.

Counselors should aim to prompt discussions that help clients envision that circumstances can change for the better in their lives, Cureton says. She suggests asking clients to think of a time when they did have hope and then exploring that answer in more depth together. Alternately, she might ask a client, “Do you dream of a time when you will be self-sufficient and connected?” or “What’s one goal we could set, even if it’s something small?”

“It’s looking into the future and imagining something slightly different,” she explains.

Regardless of how it’s done, exploring protective factors brings a positive narrative and a focus on resilience to a tough topic with dark connotations, Cureton says.

Similarly, Whisenhunt looks for ways to incorporate positive themes into suicide prevention work. She adds a measure of lightheartedness to some of the programs she organizes by calling them “suicide prevention fairs.” With the help of graduate counseling student volunteers, she sets up a series of tables. Participants earn badges as they stop at each table and complete a puzzle or activity to learn about an aspect of suicide prevention. Once they collect all the badges from the fair, participants are eligible for a prize.

“It might sound odd, but you would not believe how many people we get involved. It makes [the topic] more approachable, and people respond,” Whisenhunt says.

When it comes to suicide prevention, positivity and patience can attract interest to a tough subject, she adds. “Know that we might be passionate about it, but it might take the layperson a little while to warm up to talking about it,” she says. “If you’re passionate about something, it comes across. The more I enjoy doing suicide prevention work, the more people enjoy being part of that. I don’t invalidate suicide loss, but I explain that I’m not talking about death and dying. I’m talking about how to save lives. It’s empowering — focusing on hope and the fact that we can do something.”

A delicate subject

Cureton acknowledges that introducing the topic of suicide and suicidal ideation in session can be “prickly.” She prefaces her questions to clients by allowing that it is a touchy subject — but one that is important to deal with.

“I say, ‘You may assume that even if we talk about it, I’ll respond in a negative way, be shocked at what you’re sharing or brush it off because I’m uncomfortable. But none of these things will be true. I’m used to talking about it, and it needs to be covered.’”

When it comes to suicide, counselors need to think both in terms of the individual and systemically, Cureton says. The subject may be even more uncomfortable for clients who come from a culture or religious background that shames or stigmatizes suicide, viewing it as a personal failing or sin. Cureton lets these clients know that it is her responsibility as a professional counselor to learn about their culture and how suicide might be perceived within it.

“If I’ve done that work, it should be easier for me to say … ‘I know that this is an uncomfortable topic to talk about for everyone, but especially in your culture. I know that it might be harder for you to talk about it in here than [it is] for me.’”

She also works with these clients to identify someone from their cultural group with whom they might feel comfortable talking about suicidal thoughts — for example, a pastor or elder perhaps. As a counselor, Cureton says, “I can’t be the only person they talk about this with. It’s important to have someone in their cultural group.”

On the flip side, cultural factors can also influence how counselors view the issue of suicide and clients struggling with suicidal ideation, Bruns notes. As with all issues, it is important for practitioners to put their own attitudes and beliefs aside and to respond to clients with empathy and without judgment, she says.

Elizabeth Hodges Shilling is an LPC and licensed clinical addictions specialist who works as part of a counseling team in the trauma center at Wake Forest Baptist Health Medical Center in Winston-Salem, North Carolina. She also urges counselors to drop any assumptions they may harbor about suicide, especially in connection to client demographics.

“One of the things that is not frequently talked about is [suicide and] older adults. We do see a fair number of [older] individuals who are struggling with both suicidal ideation and substance abuse. We find that older adults at times, in fact, have a greater risk of completing suicide and dying by suicide,” says Shilling, an ACA member. “Frequently, people make assumptions about death with older people or assume that it was an accident or natural [cause]. Keep your assumptions about people in check, especially when it comes to who’s at risk. … It’s not doing that person any good
to assume.”

Whisenhunt agrees and stresses that counselors need to have conversations about suicide with their clients that are free of judgment or expectation. “Just talking about suicidal thoughts and distress can be helpful [for the client]. A lot of people feel a lot of shame about these feelings,” Whisenhunt says. “Be open to talking about suicide without getting nervous and inadvertently shutting down the conversation.”

The long term

Is a client who has experienced suicidal ideation ever not at risk? Bruns recommends checking in with clients periodically, even if they seem to be long past their lowest point. She tells clients that she would rather annoy them with repeated questions about suicide risk than somehow not ensure that they are still safe or not offer them the space to continue talking about it.

Bruns also urges practitioners to be mindful of a client’s triggers and to use clinical intuition to broach the subject, if needed. For example, perhaps a client previously experienced suicidal ideation after a painful break-up with a partner, and now the client is dating again or facing relationship struggles.

At the same time, counselors shouldn’t assume that because a client experienced suicidal ideation in the past that he or she will continue to have suicidal thoughts, Whisenhunt says. Life is fluid, and risk factors may increase, decrease or sometimes change altogether.

“Whatever was contributing in the past might have resolved, but maybe not. For me, a best practice is to screen with all clients at intake and then periodically screen throughout treatment,” Whisenhunt says. “It’s our responsibility to communicate that we can talk about this. We are not afraid of talking about [suicidal ideation], if you need it.”

The silver lining

Cureton acknowledges that suicide prevention work is challenging and can induce fear, even for those who specialize in it or have years of experience. However, as rates of suicide continue to increase across the U.S., counselors have the much-needed skills to address and destigmatize the issue with each client who sits in front of them.

“The unfortunate reality is that suicide is everywhere. It has the potential to be present in any person we are working with, at any point in their life,” Cureton says. “The positive side to this is that anyone can play a role in addressing that — career counselors, school counselors, all practitioners. … The great thing is that we can all do something about this. It’s a misnomer that suicide work is only for certain types of practitioners, such as addictions or clinical mental health counselors. It’s important for all of us to say, hey, we can do something about this.”

 

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Call for help

The National Suicide Prevention Lifeline offers free and confidential support around the clock, seven days a week, at 800-273-8255 or via chat at suicidepreventionlifeline.org.

Calls are routed to the nearest location in the Lifeline network of more than 150 crisis centers across the U.S. Help is offered in Spanish at 888-628-9454 and for callers who are deaf or have partial hearing loss at 800-799-4889.

The Lifeline website also has information on best practices for mental health practitioners, downloadable brochures and other resources.

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For more information on suicide prevention, access ACA’s webpage of resources at counseling.org/knowledge-center/mental-health-resources/suicide-prevention-resources.

CT Online also offers a variety of past articles on the topic, including:

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Suicide, substance abuse and medical trauma

Counseling Today interviewed members of a team of professional counselors embedded in a trauma center in a busy hospital facility in North Carolina. Read more about their work and their insights on the intersection of suicidality and substance abuse in an online exclusive, “Suicide, substance abuse and medical trauma.”

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ACA participates in federal suicide screening panel

Carrie Wachter Morris, an associate professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, represented the American Counseling Association in June at an event titled “Building Robust Systems for Suicide Screening and Treatment Pathways for Youth in Pediatric Settings.”

Organized by the federal Substance Abuse and Mental Health Services Administration, the event’s goal was to inform and shape a guide to suicide screening in pediatric primary care settings. Wachter Morris was the only professional counselor on the event’s expert panel. The audience was primarily composed of medical doctors but also included nurses, social workers and others.

“We talked about a range of things over the two days that we met, including screening instruments, clinic flow, the role of other medical and nonmedical personnel, financing and sustainability,” Wachter Morris says. “Much of what we talked about included the need to really support primary care providers in the process of assessment and referral of youth who are contemplating suicide. … Discussion centered around the importance of appropriate referral and [how] immediately placing a youth who discussed suicidal ideation in an inpatient placement was likely to be counterproductive, unless it was necessary to maintain that individual’s immediate physical safety.”

“This is really where counselors can make a huge difference,” Wachter Morris says. “We can engage with the medical professionals in our community so that they know the resources that we have to support children, adolescents and their families when they are struggling. So many of the [physicians] at the table expressed frustration at not knowing where to connect youths who are in need of support and lacking the time and expertise to intervene on their own. Particularly when coupling this with the industry standard that pediatricians should spend approximately 10 minutes with each patient, it’s easy to see how suicide screening and treatment has not been well-integrated into primary care visits. I spent a good bit of my time educating the medical providers at the table about what counselors are able to do and what a strong support we can be for them. … I also helped advocate for the needs of all our children and adolescents, including the specific needs and risks of those in minoritized communities, and particularly those who identify as LGBTQI+. We had an engaging dialogue about how to promote openness and reduce the likelihood that a youth might feel further silenced.”

Wachter Morris says she came away with an appreciation for the potential for collaboration between professional counselors and pediatricians on suicide prevention.

“Professional counselors have the power to support individuals who are experiencing crisis and trauma, wrestling with mental health issues or experiencing challenging transitions. As a field, we are dedicated to helping people not only survive but also thrive. We have training that pediatricians and family medical providers don’t,” Wachter Morris says. “That was something that really struck me. I’d always thought that because they had rounds in psychiatry that [physicians] had a strong working knowledge of mental health issues and suicide. But that was clearly an assumption of mine that isn’t necessarily reality for every medical provider.

“There are some who are exceedingly skilled, but there are also those who may not ask suicide screening questions for fear of what to do if a child or adolescent answers that they are thinking about suicide. Counselors can be a group that pediatricians’ offices can connect with when they have a child or adolescent who is struggling, not just with suicidal thoughts, but with other challenges that are outside that physician’s scope of practice.”

— Bethany Bray

 

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Contact the counselors interviewed for this article:

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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.

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.

Voice of Experience: Losing a client

By Gregory K. Moffatt October 22, 2018

My colleague sat across from me, teary-eyed, in the conference room where we had met so many times before while she was under my supervision. Now, only a few months into her new life as a fully licensed clinician, she had lost a client to suicide. She was understandably distraught.

The client was high risk from the beginning, but my colleague hadn’t missed anything. She had covered every base she could. She had developed a thorough safety contract with the client that included an emergency plan, coping skills for the client to use and an emergency contact person for the client. The last time my colleague had seen her client, he had appeared slightly improved. He had assured her that he would attend to the safety contract and would be back the following week for his appointment. Sadly, he took his own life two days later. Perhaps his perceived improvement was simply resolve to follow through with a suicide. We will never know.

I have never lost a client under my care to suicide, but I suppose that even now, in the twilight of my career, such a loss would be devastating to my heart and my esteem. My young colleague was just beginning to gain some confidence in her clinical skills. Approval from the licensing board had helped nudge her professional esteem into a reasonably healthy place — only to have this happen.

The tragic loss of a human being and the lifetime of pain such an act brings to family members is our primary concern, of course. But we counselors have to manage such tragedies too.

What did I miss? If only I’d hospitalized! Maybe more frequent sessions would have been better. These are among the obsessive thoughts that plagued my friend and brought her to tears that day in my conference room.

But the fact is, we cannot control the private lives of any of our clients. Some will be success stories, and others will not. All we can do as counselors is to guide them. A client’s life is their own.

When I began my career, I had a client who was having an affair but wanted to get his marriage back in order. Obviously, to reach that goal, the affair needed to end. But he chose to continue the affair, no matter how many times he acknowledged the damage it was doing to his family. The outcome was inevitable. Predictably, he and his wife eventually divorced.

Perhaps a better therapist could have helped him succeed in achieving his stated goal, but even in hindsight, I think not. He was determined to do what he wanted to do, and there was little I could do to stop him.

In a similar manner, I helped my colleague to see that even her client’s wife — someone who was with him most of every day, someone who slept in the same bed with him — couldn’t stop him from harming himself. He had been determined.

Saying “the client chooses” doesn’t remove responsibility from us as counselors. Therefore, she and I reviewed her procedures with the client to ensure that she hadn’t missed something. She had not. I suspect that even hospitalization wouldn’t have kept her client from eventually taking action.

Our clients will make their own choices. Sometimes they will relapse into addictions, return to abusive relationships and, yes, if you are in the field long enough and work with high-risk clients, some will even take their own lives.

Although we must have compassion for our clients, we must also develop something I call “disinterestedness.” This simply means that we must remain apart from the choices our clients make. We are “disinterested” in the sense that we won’t thrust our ideals upon them. Being compassionate usually comes naturally for counselors. That is why most of us pursue this career. Practicing disinterestedness, on the other hand, is difficult, but it is equally important.

Coping with this loss won’t be easy, but my friend is putting it behind her. So to you, my colleagues, I encourage you to remember disinterestedness in your practice, especially when your clients move in a hazardous direction. You cannot control them, and even if you could, that would overstep our ethical boundaries.

Yes, it is necessary for us to review such cases. If errors were made, put systems in place so that you won’t make the same errors again. But then move forward and do your job. Your clients’ decisions aren’t about you.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. 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. Contact him at Greg.Moffatt@point.edu.

 

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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.

Infusing hope amid despair

By Laurie Meyers September 24, 2018

In 2015, two Princeton University economists, Anne Case and Angus Deaton, published a study in the Proceedings of the National Academy of Sciences of the United States of America that made a shocking claim: After decreasing for decades, the mortality rate for white non-Latinx middle-aged Americans was actually increasing. They ascribed this reversal of fortune in part to what they dubbed “deaths of despair” caused by an increase in alcohol abuse, opioid use and suicide. Their findings grabbed headlines and fueled furious debate in the public health and other research communities, particularly when they published a follow-up report in 2017 in the Brookings Papers on Economic Activity. Some researchers questioned the authors’ interpretation of mortality data. Other experts argued that the factors contributing to the rise in suicide rates and in opioid and alcohol abuse were too complex to be attributed to “despair.”

However, despite their narrow focus on a particular demographic slice, Case and Deaton were perhaps tapping into a greater sense of instability among the American populace. Since 2007, the American Psychological Association (APA) has conducted an annual nationwide survey — Stress in America — gauging both the overall level and leading sources of stress in the United States. The 2017 report revealed that two-thirds of the 3,440 adult Americans surveyed that August were significantly stressed about the future of the country. More than half of those surveyed — a group that spanned generations — said they considered the current time to be the lowest point in U.S. history that they could remember. Nearly 6 in 10 adults reported that the current climate of social divisiveness was a serious source of personal stress. Other significant sources of worry included money, work, health care, the economy, trust (or lack thereof) in government, hate crimes, conflicts with other countries, terrorist attacks, unemployment/low wages and climate change/environmental issues.

Although Americans may not be drowning in despair, research such as APA’s report indicates that many people are feeling more insecure than ever. That sense of walking a tightrope without a safety net can cause significant psychological distress, which can in turn lead to health problems and mental illness. Many experts say the burden of general societal unease is often magnified for disenfranchised groups such as communities of color or those of low socioeconomic status. And trauma — whether caused by being a member of a disenfranchised group or by a history of abuse or violence — takes an even more significant toll on health and well-being. Any or all of these issues may be related to the rise in opioid addiction and suicide across the U.S.

A poverty of health and well-being

To some degree, most people in the so-called 98 percent — those not in the top 1-2 percent of individuals possessing the majority of the nation’s wealth — worry about money: affording a mortgage, sending the kids to college, saving for retirement. The Great Recession may be over, but recent research from the Federal Reserve Bank of San Francisco (FRBSF) indicates that the economy hasn’t fully recovered. In its Aug. 13 economic letter, the FRBSF states, “A decade after the last financial crisis and recession, the U.S. economy remains significantly smaller than it should be based on its pre-crisis growth trend.”

The letter goes on to speculate that this is due to substantial losses in the economy’s productive capacity post-crisis. These losses were so significant, FRBSF researchers assert, that they could result in a lifetime income loss of $70,000 for each American.

This is staggering news for most Americans, but for those who live in poverty — 40.6 million Americans according to a 2016 U.S. Census Bureau study — such an amount is catastrophic. The poverty threshold is broadly defined as any single individual younger than 65 earning less than $12,316 annually and any single individual 65 or older living on less than $11,354 annually. The poverty threshold for two people under the age of 65 living together is $15,934, and the threshold for two people over the age of 65 living together is $14,326. For a family of three — one child and two adults — the poverty threshold is $19,055. For a family of three with one adult and two children, the threshold is $19,073.

For people who have never been impoverished, it can be difficult to comprehend all the ways in which poverty can affect health and well-being. Forget vacations, higher education and saving for retirement. People living in poverty are often unable to access basic needs such as safe shelter, food and, in some cases, even running water, says Chelsey Zoldan, a licensed professional counselor (LPC) practicing in Youngstown, Ohio. She has also counseled clients in the rural, impoverished Appalachian region of Ohio.

“I’ve worked with many clients over the years who have had their utilities turned off and lived in homes without water, heat or electricity,” says Zoldan, an American Counseling Association member. Missing that foundation at the bottom of Abraham Maslow’s hierarchy of needs, these clients struggle to stabilize their mental health symptoms, she explains.

People living in poverty often have to reside in low socioeconomic status areas with higher levels of violence and crime. Zoldan says many of her clients have lived in supportive housing and regularly heard gunshots in their neighborhoods at night. Although some clients seemed to get used to it, others — particularly those with trauma histories — had trouble feeling safe in their own homes.

Those who live in poverty also often lack access to quality health care. “Not only are individuals limited in terms of health care coverage, but they may also struggle to obtain transportation to get to health-related appointments,” Zoldan says. “In my area, there was such a high demand for medical transportation to appointments that they stopped providing door-to-door transportation and only provided bus passes.”

Instead of a 15-minute ride to appointments, Zoldan’s clients now had to navigate public transportation, which could take up to two hours each way with a change of buses. Riding the bus also poses another significant challenge — having to walk numerous blocks to the stop, which during winter in northeast Ohio means navigating “tons of snow” and double-digit subzero windchills, Zoldan says. Even in more clement weather, many of Zoldan’s clients were unable to devote two to four hours a day to traveling to health-related appointments, so they stopped receiving services.

Self-care can also prove challenging for those living in poverty, and it doesn’t include vacations or nights out. Zoldan works with individual clients to identify free activities that they enjoy and can engage in at least weekly, such as taking a bath, attending a Bible study, going for a walk in the park, meditating, and reading books or magazines at the library. Unfortunately, some of these activities may not be available to all clients, either because they live in rural areas with few resources or because they are unable to arrange child care, Zoldan points out.

Zoldan advises counselors working with this client population to get outside the walls of their offices. It is critical that counselors make community connections, she says, so that they can help clients access resources such as shelters, housing authorities, food banks, clothing providers, programs that offer financial assistance for utilities, medical transportation and vocational services.

“In connecting our clients with these resources, we can work to build a safety net for our clients and create some more stability in their lives so that they can thrive,” she says.

The legacy of racism

Racism happens on both a micro and macro level, says Cirecie West-Olatunji, a past president of ACA. Microaggressions are more nuanced and under the radar and involve everyday interactions with individuals who exert privilege. It might be the shop clerk who ignores an African American person in favor of a white shopper or a student of color who is consistently not called on, despite raising her hand. Macroaggressions are overt and meant to intimidate members of a group, such as neo-Nazis marching in the nation’s capital and people openly using racial slurs. Together, the macro- and microaggressions create pervasive, chronic stress that is handed down through intergenerational trauma, explains West-Olatunji, an associate professor at Xavier University of Louisiana and director of the Center for Traumatic Stress Research.

Over the past 20 years, researchers have been studying a phenomenon they first witnessed in some of the grandchildren of Holocaust survivors. Despite not having experienced the Holocaust themselves, and instead having grown up in a middle-class environment in the U.S., these individuals displayed survivor-like trauma symptoms. The findings were startling but have proved not to be unique. After 9/11, researchers studied children who had not been born at the time that their parents served as first responders at one of the attack sites. Like the grandchildren of the Holocaust survivors, these children of 9/11 trauma survivors displayed corresponding symptoms despite not experiencing the trauma themselves, West-Olatunji says.

Chronic, pervasive stress and trauma can be seen in changes at the DNA level, she says. Some researchers believe that these DNA changes play a part in handing down the trauma from generation to generation.

For African Americans, the trauma is also handed down on a systemic level, West-Olatunji says. “It is evident in social structures, education, lack of power and aggressive acts that threaten the psyche of individuals who are culturally marginalized,” she says. Slavery still casts a long shadow, its legacy evident in the school-to-prison pipeline, the number of African American children who are in low-resource schools, their overrepresentation in special education and the disproportionate diagnosis of behavioral disorders. “Children are being tossed out of the American dream by a lack of resources,” she says.

The effects of openly expressed racism are also manifesting in society, West-Olatunji says. “We’re anxious and irritable and feeling less hopeful about the world,” she says. These “symptoms” match those displayed by culturally marginalized groups.

Courtland Lee, also a past president of ACA, believes the effects of racism extend beyond the targeted group. In fact, he contends that racism can be considered a mental illness.

Lee began thinking of the concept of racism as mental illness after reading Stamped From the Beginning: The Definitive History of Racist Ideas in America, a book by Ibram X. Kendi that examines the intellectual roots of racism. Although many people may consider racism the purview of poor, white, rural Southerners, it has historically been handed down from the best and brightest minds in science, medicine, philosophy, religion and psychology, Lee explains. Racism is woven into our intellectual and social fiber and is used to manipulate people through fear of the other, he continues.

Lee says that targets of racist behavior are ground down by the constant micro- and macroaggressions, leading to “cultural dysthymia,” or collective low-grade depression. This collective depression is manifestly not conducive to mental health, and he argues that its effects aren’t felt solely by those who are targets of racism.

Lee believes that the fear and hatred of those who perpetrate racist acts is also mentally traumatizing — not just to those who are targeted but to the perpetrators themselves — and that the trauma must be addressed to treat the mental illness of racism. Counselors can do this on a systemic level through advocacy and on an individual level by helping people who are racist see that the agitation, irritability, hostility and hypervigilance they experience is caused by their beliefs. The challenge is getting perpetrators of racism to see that the defensiveness and fear inherent in racist thought can also bring those fears to life, Lee says.

For instance, one commonly cited reason to block immigration from Mexico is that these immigrants are stealing American jobs and damaging the economy. However, a lack of visas and fear of anti-immigrant violence have kept Mexican seasonal workers away from sectors such as the Maryland crab industry. In their absence, merchants who sell crab meat to restaurants and stores cannot recruit enough employees to clean and process their haul, even at high wages. That means the crabs cannot be sold, which is a major economic blow to the industry.

As a country, the United States needs to discuss racial issues, Lee says. Counselors, who are trained to encourage conversation, can and should facilitate these dialogues in their communities, through churches or community centers, he suggests. “We really do live in a sick society,” Lee says. “We can help people get well, but the only way to get well is to cure the society.”

As individuals, counselors can also play an important role in validating the experiences of people of color and speaking out when they witness micro- or macroaggressions, West-Olatunji says. She also urges counselors to explore non-Eurocentric methods, such as using the tradition of storytelling in the Latinx community or testifying in the African American community. Non-Western traditions can be applied effectively across cultures, making them a useful addition to any counselor’s toolbox, West-Olatunji says. 

Touched by trauma

“Life is a traumatizing experience,” says Cynthia Miller, an LPC in Charlottesville, Virginia, whose practice specializes in trauma. “It’s full of challenges, unexpected and uncontrollable events, and losses. I don’t think any of us gets through it unscathed.”

Miller, an ACA member, says trauma is on a spectrum that begins with ordinary stress and gradually progresses to completely overwhelm a person’s ability to cope. Eventually, it can even put them at risk of death.

A seminal study that the Centers for Disease Control and Prevention and Kaiser Permanente began in 1995 established a link between adult health problems and adverse childhood experiences such as emotional and physical neglect, sexual and physical abuse, exposure to violence in the household, and household members who had substance abuse problems or had been in prison.

These experiences fall on the more extreme end of the spectrum — often referred to as “big T” traumas. However, Miller cautions against discounting the “little t’s” as sources of distress. Where a trauma falls on the spectrum is individual and variable. “Some people might experience the loss of a job as stressful but wouldn’t be completely overwhelmed by it,” she explains. “Others might experience it as very overwhelming and become immobilized. So one person’s stressful event is another person’s traumatic event, and one person’s traumatic event is another person’s ordinary stressful event.”

Miller notes that mental health professionals recognize events such as the loss of a job, economic insecurity, divorce and family problems as sources of stress but often don’t accord them the same level of treatment as “real” mental illness. “It’s really a false distinction,” she says.

Someone who has lost a job or is going through a divorce is experiencing significant stress and is likely flooded with cortisol in the same way that a person who has experienced violence is, Miller asserts. “It’s really the chronic stress from either a ‘little t’ trauma or a ‘big T’ trauma that eats away at us and sets us up for depression, anxiety, anger problems, health problems and substance use,” she explains.

“There are a lot of things going on in society that could be experienced as traumatic,” Miller continues. “Globalization and automation are rapidly changing communities and workplaces, eliminating some industries and leaving workers scrambling for jobs that pay less and offer less job security. Economic inequality is growing, and housing costs keep rising. People feel increasingly insecure and like their futures are being threatened. That’s leading some people to feel helpless or hopeless. Others are angry and lashing out.”

Trauma-informed counseling is critical to recovery from both “big” and “little” traumas, Miller says, as well as for building ongoing resilience.

“I think that the biggest thing that trauma-informed counselors bring to the treatment process that less-informed counselors may not is an alternative explanation for behaviors that are often seen as purely manipulative, obstinate, oppositional, attention seeking or antisocial,” Miller says. “Trauma-informed counselors may be more likely to view a client’s reactions and behaviors as attempts to cope or protect themselves rather than chalking them up to resistance, treatment noncompliance or poor motivation. They also bring an awareness of the importance of creating a sense of safety and control for a client, and they work to create environments in which clients have as much autonomy and input into their treatment as possible.”

Miller also decries the traditional “split” between substance abuse and mental health treatment. Although she doesn’t believe that all substance abuse is caused by mental illness or trauma, she says these are often underlying factors that go untreated, which puts clients at risk of relapse.

Regardless of the cause, substance abuse is an illness that needs to be treated, she asserts. “For far too long, substance abuse has been treated as a problem of weak moral character rather than an effort to soothe emotional pain that someone doesn’t feel able to cope with,” she observes.

Miller also points to the contrasting public reactions to the crack and opioid epidemics. Whereas the crack crisis of the 1980s and early 1990s was considered a criminal problem, the current opioid epidemic is recognized as a public health problem, she notes. Miller ascribes this difference not only to the traditional judgment of substance abuse as a moral failing but also to the reality that crack was seen largely as affecting African Americans, while opioids are generally viewed as affecting white Americans. (Some researchers and commentators have also begun noting that the growing number of opioid-related overdoses and deaths among African Americans has largely been left out of the national narrative.)

Seeking solace

Just as crack enveloped areas that were economically devastated — at the time, predominantly African American urban neighborhoods — opioids are most common in rural areas that can no longer depend on the industries that once sustained them. West Virginia is one of the epicenters of the opioid crisis, and Carol Smith, an ACA member and past president of the West Virginia Counseling Association, believes that isolation and the lack of opportunity in much of the state are helping to fuel opioid abuse.

A frequently spun narrative of the crisis is that of unsuspecting people who get addicted after being prescribed opioids for pain after injury or surgery, but those cases make up a small percentage of those who are addicted to opioids, according to Smith. Indeed, people have been using opioids for pain relief for decades without becoming addicted on a large scale, notes Smith, a counseling professor and coordinator of the violence, loss and trauma certificate of studies at Marshall University. The people who do get addicted after being prescribed opioids usually already have substance abuse problems, she says.

However they first encounter opioids, the people most at risk for addiction are those who lack good coping skills and social support, Smith says. They typically also have a certain degree of existential despair, which is only reinforced by the long-term abuse of opioids.

Smith explains that West Virginia is particularly vulnerable to this sense of despair because its topography of mountains and waterways makes building roads and installing cables prohibitively expensive. This isolates the state not just physically but virtually because of the lack of high-speed internet access, she says. This lack of connectivity discourages new economic development, further reinforcing the cycle of poverty. As a result, many of the state’s inhabitants don’t feel that they have a lot to lose or much to strive for, Smith says, leaving them vulnerable to anything that might make the day go by faster or easier.

With its emphasis on treating the whole person, counseling is integral to the effort to stem the tide of addiction, Smith says. Counselors can help clients fight despair by guiding them to regain a sense of purpose through goal setting and identifying reasons for living. In addition, counselors can aid clients in dispelling their sense of isolation by teaching them relationship skills and helping them build support networks. Smith also stresses the importance of combining counseling with medication-assisted treatment, which addresses the physiological aspects of addiction.

Dying of despair?

According to the Centers for Disease Control and Prevention (CDC), 45,000 Americans 10 years and older died by suicide in 2016, the most recent year for which statistics are available. In the June CDC Vital Signs report, the agency said that from 1999-2016, the suicide rate rose by more than 30 percent in 25 states. While acknowledging that those suicide statistics are the most accurate figures available, the American Foundation for Suicide Prevention has stated that it believes actual rates are much higher.

Case and Deaton’s study connected the rise in the suicide rate in part to despair caused by a dearth of employment and lack of opportunity, but some experts say that causation is far from clear.

“It is hard to pinpoint a specific cause,” says ACA member Darcy Granello, a professor and director of the Ohio State University suicide prevention program. “Frankly, the numbers are increasing at such an alarming rate and across so many different demographic groups that we have to be careful not to paint broad brushstrokes and assume that specific factors apply to all of these different groups.”

Granello, whose research focuses on suicide prevention, does believe that Americans are feeling more isolated and disconnected, however. “That pervasive sense of loneliness is especially dangerous for those who already struggle with depression,” she says. “We know that social connectedness, feeling supported and having a sense of belonging all are protective factors that help minimize the risk for suicide. When those are taken away, suicide risk increases.”

Granello says myriad factors may be contributing to the rise in suicide, but recent research has caused experts to question their understanding of suicide. For example, historically, 90 percent of those who kill themselves have some kind of mental illness — often undiagnosed or untreated. However, more and more people who die by suicide do not have a diagnosable mental illness at the time of their death, Granello says.

“This is challenging to everyone in the field, and it causes us to rethink much of what we know,” she says. “It means that suicide is more and more the result of people who simply do not have the resources to cope with life’s problems, whether this inability to cope is because they are living with a mental illness or simply because they are overwhelmed by life and have never developed healthy coping strategies.”

Granello urges counselors to focus on helping clients develop those strategies. Those at risk for suicide are often ill-equipped to face life’s challenges, make long-term plans and envision a future, she says. For many people, the key to survival is getting through the crisis period — that window when they are most tempted to end their lives, she continues.

Counselors can teach clients to move out of their isolation, reach out to others and develop healthy coping strategies, Granello says. But to do that, counselors need to be adequately trained in suicide prevention, assessment and intervention — something that Granello doesn’t think is happening often enough. She stresses the need to push for comprehensive, empirically supported suicide prevention training in counselor education programs and through continuing education.

“We have to do this,” Granello says. “We are, quite literally, fighting for our lives.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books and DVDs (counseling.org/publications/bookstore)

  • A Contemporary Approach to Substance Use Disorders, second edition, by Ford Brooks and Bill McHenry
  • Counseling for Social Justice, third edition, edited by Courtland C. Lee
  • Multicultural Issues in Counseling: New Approaches to Diversity, fifth edition, edited by Courtland C. Lee
  • Suicide Assessment and Prevention, DVD, presented by John S. Westefeld

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Trauma and Disaster
  • Suicide Prevention
  • Substance Use Disorders and Addiction

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “Counseling African-American Males: Post Ferguson” presented by Rufus Tony Spann (ACA285)

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Traumatic Stress and Marginalized Groups” with Cirecie A. West-Olatunji (CPA24341)
  • “Dissociation and Trauma Spectrum” with Mike Dubi (CPA24333)
  • “ABCs of Trauma” with A. Stephen Lenz (CPA24329)

Competencies (counseling.org/knowledge-center/competencies)

  • Multicultural and Social Justice Counseling Competencies

 

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

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.