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Rick Strait, a licensed professional counselor (LPC) in Southeast, Missouri, tried to take his life on his 20th birthday. It was July 18, 1993, and Strait, then a lance corporal in the Marine Corps, spent the morning at the beach with his wife and son.
“That [trip] was kinda my goodbye to her and my son,” Strait says. “She didn’t know what I was thinking.”
When the family returned home, Strait attempted to take his own life by suicide, but his wife interrupted him. After seeing how distraught his wife was from the experience, Strait made the decision to never try to take his life again. “And I never did,” he says. “I honored that.”
Strait, the substance use division director and suicide prevention coordinator at the Community Counseling Center in Cape Girardeau, Missouri, says the combination of the death of his younger brother in a car accident only a few months earlier that year and ongoing family struggles became too difficult for him to handle.
“I didn’t know how to move forward,” Strait says, noting that the pain and sadness he felt about his brother’s death was so deep that he didn’t know how to communicate his feelings to family or friends. “I did not want to talk to my parents about it because they were also struggling. I didn’t want to become a burden, so I kept it to myself.”
Strait says he also questioned his purpose in life and felt the weight of survivor’s guilt.
“I thought, ‘Why did he die and I’m still here?’” Strait recalls. “I took a lot of responsibility for my brother’s death, even though I had nothing to do with it. I was [living] in another state. I still felt I should have been there for my little brother.”
Strait remained silent about the attempt on his life for more than 20 years. He says shame and embarrassment kept him from seeking psychotherapy. But in 2016, he told his parents and his children and started treatment.
“Most people, they really don’t want to die; they just want the pain to end,” Strait adds.
According to the counselors interviewed for this article, applying cognitive behavior therapy (CBT) and strengths-based therapeutic approaches can help suicide attempt survivors learn the skills to cope with the complexities of life and find hope for the future. (The term “suicide attempt survivor” refers to a person who has attempted suicide and lived, whereas the term “suicide loss survivor” refers to a person who has lost someone who died by suicide.)
Strait says that with the right support and professional help, suicide attempt survivors “can get through” the aftermath of a suicide crisis.
Safety first
Suicide prevention and reducing the rate of suicide have been important goals for many mental health organizations for decades. Although suicide is a leading cause of death in the United States, with 45,979 suicides in 2020, according to the Centers for Disease Control and Prevention (CDC), the number of people who think about or attempt suicide is even higher. The CDC reported that in 2020, an estimated 12.2 million Americans seriously thought about suicide, 3.2 million planned a suicide attempt and 1.2 million attempted suicide.
According to the 2018 article “Suicide risk and mental disorders” published in the International Journal of Environmental Research and Public Health, most suicides are related to psychiatric disease, with depression, substance use disorders and psychosis being the most relevant risk factors. The article also notes, however, that most people with mental health disorders will not die by suicide.
Tammi Ginsberg, a licensed clinical professional counselor with a private practice in Woodsboro, Maryland, says suicide attempt survivors are usually referred to counseling after being taken to the emergency room following the crisis and undergoing a psychiatric evaluation. A psychiatric evaluation is often necessary to determine if there’s an underlying mental health issue that needs to be addressed, she explains. Suicide attempt survivors may also meet with a therapist and case manager at the hospital to determine if inpatient or outpatient care is required and what community resources for therapeutic treatment are available.
The counselors interviewed for this article say the immediate short-term goals of therapy are to establish a relationship based on trust and to ensure the client’s safety by creating a safety/crisis plan. Meeting these clients “where they are” in their recovery journey and bringing empathy to the therapeutic relationship are effective ways to establish trust, says Trish Torzala, an LPC at Stress Management & Mental Health Clinics in their Waukesha, Wisconsin, office.
Strait, who is also a part-time adjunct faculty member at the Zero Suicide Institute in Waltham, Massachusetts, and a board member of United Suicide Survivors International, advises counselors to be genuine and to treat clients with respect. He says it is also important to affirm them for sharing their suicidal thoughts or the circumstances surrounding the attempt.
“It takes a lot of bravery and vulnerability to share something so intimate,” he says.
Ginsberg, president of the Maryland chapter of the American Foundation for Suicide Prevention, recommends counselors practice “active listening” — listening without interruption, judgment, opinions or solutions — with clients. This type of listening gives clients the space to “let you know what’s really going on,” she says.
“A lot of times, [these clients] just want somebody to listen to them. They don’t want you to tell them how to fix it. They don’t want you to tell them that everything is going to be OK,” Ginsberg continues. “They don’t want you to tell them all they have to live for. They just want you to listen.”
And by being an active listener, counselors can help decrease the chance of clients making another attempt because “they feel heard, they feel seen, they feel normalized and they don’t feel alone,” she adds.
In regard to creating a safety/crisis plan, Strait and other counselors interviewed recommend the Stanley-Brown Safety Planning Intervention, developed by psychologists Barbara Stanley and Gregory Brown. Counselors and clients can use this tool collaboratively in session to create an intervention plan aimed at reducing the client’s risk for suicide. A safety/crisis plan is particularly important for suicide attempt survivors because, according to the Harvard T.H. Chan School of Public Health, a “history of suicide attempt is one of the strongest risk factors for suicide.”
The Stanley-Brown Safety Planning Intervention includes having clients identify possible warning signs for suicide, proposed coping strategies, people they can contact for help during a crisis, professionals contacts or organizations that can provide care and support, and guidelines to keep them safe (for example, the removal of firearms from a client’s home).
Dealing with the distress
After counselors establish trust and work with clients to create a safety/crisis plan, they can then help their clients examine the unique factors that may have led to the suicide attempt. A family history of suicide, mental health disorders or substance use disorders can contribute to the reasons why people try to end their lives. However, according to the counselors interviewed for this article, these factors can often be combined with a painful or significant life event, either past or present, that seems insurmountable.
These life events could include, for example, the breakup of a relationship or marriage, financial or legal problems, childhood trauma or other forms of unresolved trauma, or the death of a loved one. The weight of this psychological angst often results in questions about the meaning of life and the rumination of negative thoughts and feelings, which, the counselors interviewed for this article say, can linger in the aftermath of a suicide attempt.
Támara Hill, an LPC and owner of Anchored Child & Family Counseling in Monroeville, Pennsylvania, says many suicide attempt survivors go through existential anxiety and feel uncomfortable in their lives. Some suicide attempt survivors, for example, say they can’t find their purpose or meaning in life or that they can’t see their own personal value or worth. “They sink under their own negative thoughts about life and themselves,” she notes.
Torzala, who specializes in suicide prevention, has found that some clients express feelings of shame and anger for surviving an attempt. Their survival makes them feel like a failure, she says. When discussing their suicide attempt, some clients have told her, “I tried this and it didn’t work. What’s wrong with me?” or “I can’t even get that right.”
Ginsberg, who has counseled suicide attempt survivors and their families for 15 years, says she has heard similar comments from clients. Some have told her, “I’m disappointed that I’m still here.”
Clients also express feelings of hopelessness and negative beliefs about the self after a suicide attempt, says John Sommers-Flanagan, a professor of counseling at the University of Montana. For example, clients may say, “I’m a bad person. I’m worthless. No one will ever love me.”
In addition, suicide attempt survivors may have difficulties solving problems in general and problems related to their suicidal impulses in particular, Sommers-Flanagan notes. “They have trouble believing that there are any solutions or alternatives that will make them feel better,” he says.
The emotional distress that these clients experience both before and after a suicide attempt can feel so immense that they often feel defeated and trapped, explains Sommers-Flanagan, a member of the American Counseling Association.
Clients often struggle to see any options beyond their crisis and only want to escape the unbearable pain, Torzala adds, and the only option they can see is to end their lives.
Addressing negative thoughts
According to Hill and Torzala, suicide attempt survivors often struggle with cognitive distortions and emotional dysregulation. Ginsberg says suicide attempt survivors can also carry unresolved wounds from childhood trauma that impact their mental health. These counselors use CBT techniques to help clients process negative thoughts, gain insight into their emotions and come to terms with childhood wounds.
Hill, author of Understanding and Helping Suicidal Teens: Therapeutic Strategies for Parents and Teachers From a Trauma Therapist, once used the CBT triangle to help a female client understand the connection between the thoughts, feelings and emotions that led to her suicide attempt. The goal was to help the client process and reframe her thoughts and feelings to develop healthier behaviors.
Hill asked the client to journal the thoughts and feelings she had leading up to her suicide attempt. She then reviewed the journal in session with the client and pointed out the client’s negative self-talk and explained the cognitive process — the connections between her thoughts and feelings — that led to her suicidal behavior.
Hill, who is also a board-certified trauma therapist, provides an example of this cognitive process. Someone may engage in negative self-talk such as “I’m never going to be loved,” “I’m never going to be good enough” or “I’m a failure in life.” This talk, she says, may then lead to suicidal thoughts (e.g., “I’m never going to make it,” “I’m never going to be happy,” “I might as well kill myself”) and negative emotions and feelings (e.g., feeling lonely, depressed or despair). And these thoughts and feelings may result in a suicide attempt.
After explaining this cognitive process, Hill worked with the female client in session to draw the CBT triangle and added the client’s thoughts, feelings and behaviors using the client’s cognitive process as a guide.
Once Hill’s client was able to see and understand her own cognitive process, they talked about what coping skills the client could develop to prevent her from making another attempt. For example, she could talk to a trusted friend or loved one or schedule a session with her therapist when she noticed she was engaging in negative self-talk. She could also attend a support group with others who share similar lived experiences or participate in a fun activity with a family member to lift her emotions.
Hill also used the CBT triangle exercise to help the client develop a detailed safety/crisis plan that included the triggers and warning signs that could lead her to suicidal ideation and the supportive people and actions that could help her avoid causing further harm to herself or others.
Torzala, who is trained in trauma-informed therapy and eye movement desensitization and reprocessing, often uses journaling and mood tracking to help clients better understand their emotions and recognize that feelings and emotions, especially negative ones, can be temporary. She asks clients to monitor and track their moods over the course of a few weeks and record how they are feeling two or three times a day at any time they choose. In session, Torzala helps clients explore their emotions and feelings to see if they felt a particular way at a certain time of the day and if something was going on in their life that could have triggered the emotional response.
When clients are suffering from depression or a low mood, they can have a limited mindset that skews their perception of life and may lead them to believe that their negative thoughts and feelings will last forever, Torzala notes. But this exercise, she says, helps clients identify how they are feeling and recognize that a thought or feeling can be temporary.
For example, after experiencing negative feelings or emotions earlier in the week, a client may say, “Yesterday, I was actually feeling OK and I had the motivation to take a shower and go to the store.” The recognition of a changed emotion, Torzala notes, can help clients realize that thoughts and emotions are fluid and can fluctuate and that their intensity can and will pass.
The limited mindset that many of these clients have can be deceiving, Torzala continues, and can lead them to feel that suicide is the only option they have at that time to escape whatever pain they are feeling.
“What their mindset is leading them to is something so final,” she says. But clients can learn that what they are experiencing will eventually pass.
Ginsberg, who has received suicide education and training through the American Foundation for Suicide Prevention, uses a journal exercise to help clients work through unresolved childhood trauma and help them feel empowered.
The unresolved childhood trauma they often carry leads to a lifetime of feeling insecure, irrelevant and not good enough, Ginsberg says. This affects clients’ self-esteem and self-worth, which could escalate into a mental health disorder and/or crisis, and, ultimately, a suicide attempt.
In the journal exercise, Ginsberg asks clients to visualize a time when they felt unsafe, threatened, unloved, unappreciated or unseen as child. She then asks clients to write that child a letter and tell them something their adult self would like that child to know. The client, for example, could express love for the child or a willingness to protect them. They could also let the child know that now they are safe and whatever was threatening them in the past is no longer relevant, she says.
“Through journaling, the hope is that the client will understand that the young child did what they needed to do to survive and that they didn’t have the power to stop the abuse,” Ginsberg explains.
Clients can feel empowered when they realize that they are no longer that child and they are no longer a victim, she adds, and as an adult, they now have a choice and can work toward healthy alternatives rather than attempting to take their life to resolve childhood and other life wounds.
A strengths-based approach
Sommers-Flanagan advises counselors to use a strengths-based approach to treat clients who have survived a suicide attempt. “We’ve traditionally pathologized suicidality and previous attempts and doing so tends to cultivate shame,” he says. “Instead, strengths-based approaches view suicidality as a normal response to very painful and difficult life situations.”
Sommers-Flanagan, along with Rita Sommers-Flanagan, co-authored the ACA book Suicide Assessment and Treatment Planning: A Strengths-Based Approach, which outlines a seven-dimension model that allows clinicians to integrate solution-focused and strengths-based strategies into clinical interactions and treatment planning. They elaborate on this model in the Counseling Today article “Taking a strengths-based approach to suicide assessment and treatment” (published in the July 2021 issue). “Our approach doesn’t replace traditional approaches but complements or supplements them,” Sommers-Flanagan notes.
He also stresses that it’s important for clinicians to recognize that it will be challenging for clients to develop and practice strengths-based techniques. “What’s really important is to be alongside clients in their pain and encourage and support them to try these hard things that will, in some cases, feel unnatural for them because it involves them trying to be positive when they’re feeling so negative,” he says.
It’s helpful to let clients know that focusing on a strengths and resources approach takes time, Sommers-Flanagan adds. Letting clients know they will be supported in the process can help them move at their own pace and comfort level.
The following strengths-based techniques, Sommers-Flanagan says, can be useful for clients before and after a suicide attempt.
Normalize suicidal ideation and suicidal behavior. Counselors who work to normalize suicidal ideation and behavior can help clients see that suicidal thoughts and behaviors are a normal part of the human experience and that they happen because of acute pain, helplessness and distress.
“Many, many people have suicidal thoughts, and frequently people who are having suicidal thoughts view suicide as a possible solution to their pain and distress,” Sommers-Flanagan says. “They feel they didn’t have any other options that would make the pain and distress go away.”
He recommends counselors normalize suicidality so clients don’t feel labeled or judged and are more willing to speak openly and honestly about their lived experience.
Express gratitude to others. Counselors can invite clients to establish a gratitude practice. They can suggest clients write a note to someone to express their gratitude or give that person a call, Sommers-Flanagan says. And if clients do not want to write or reach out to anyone, then counselors can ask them to sit and reflect on how it might feel to express meaningful gratitude. Gratitude practice is based on positive psychology principles and often works best when practiced once or twice a week, he adds.
Engage in intentional acts of kindness. Sommers-Flanagan says the suicidal distress clients often feel can be so overwhelming that it is all they can see in their lives. Counselors can help clients refocus their attention by inviting them to engage in small acts of kindness toward others. He suggests counselors discuss these acts with clients in session and have them monitor whether their kind actions resulted in positive thoughts, feelings or experiences.
Develop a mindfulness meditation practice. Counselors can discuss how mindfulness has been shown to prevent depressive relapses or the worsening of depressive symptoms, and then invite clients to develop their own meditation practice. Again, for clients who have survived a suicide attempt, developing a mindfulness practice may be difficult, Sommers-Flanagan notes, so whenever counselors prompt clients to integrate positive practices into their lives, empathy and encouragement are essential.
Focus on three good things. It is common for these clients — and other people — to ruminate over depressive thoughts at the end of the day and worry about what tomorrow will bring, Sommers-Flanagan says. To address depressive reviews of the day and anticipatory anxiety for tomorrow, clinicians can ask clients to name three good things that happened to them during the day and have them reflect on why those good happened to them before they go to bed. This activity helps clients begin a habit of positive thinking, he says, and they may learn to recognize how they create positive experiences in their life, rather than lamenting about any negativity.
Supporting family members
The family members of suicide attempt survivors can also struggle in the aftermath of a suicide attempt. The counselors interviewed for this article agree that family members are often in shock and can experience feelings of guilt, shame, embarrassment and anger after their loved one’s suicide attempt.
Hill says the event often leaves families scrambling to understand the reason(s) behind why their loved one tried to take their own life. Family members may also be despondent over the fact that their loved thought of fatally harming themselves, she notes. And they may feel guilty and wonder what went wrong in the family to cause the attempt or why they couldn’t prevent it from happening.
After a suicide attempt, some family members become fearful that their loved one will make another attempt, says Ginsberg, who is a suicide loss survivor, so they may begin to obsessively monitor the person’s behavior. In fact, she says she’s had several family members of clients say, “I can’t leave them alone.” She recalls one client whose family member slept outside their bedroom door each night to listen for any signals of distress.
Sommers-Flanagan says cultural factors can affect how individuals and families respond to a suicide attempt. Some family members will shut down socially and isolate themselves from others because they feel ashamed and embarrassed. And families may respond by keeping the attempt to themselves because grieving outside of the family unit is not culturally acceptable.
The counselors interviewed for this article all agree that family members need support for their own mental health needs and clinicians should work with families to ensure they take advantage of mental health services.
“They [family members] are at a higher risk for having a mental health crisis themselves [because of] the stress that it puts on a family,” Ginsberg says. “They need somewhere safe to talk about their struggles without making [their loved one] feel guilty.”
Ginsberg uses CBT techniques when working with family members of suicide attempt survivors to help them process their feelings and emotions. In one exercise, she asks family members to imagine the worst thing that could happen in relation to their loved one’s struggles. Ginsberg provides an example of a possible exchange that could occur between a counselor and the family member during this exercise. The counselor can start the conversation by asking:
What is the worst thing that can happen?
My loved one will take their life.
What will be the consequences of the worst thing that can happen?
I will be devastated and it will impact the rest of my life.
How have you coped in the past? What can you do to cope better this time?
My loved one has been struggling for a long time now. I have had to deal with fear and anxiety around their possible suicide attempt. It has caused me to be depressed and on edge all the time. I need to practice self-care. If I’m not in a stable mental place, then I will have a difficult time being present for them.
What is more likely to happen?
Because my loved one has a great support system and mental health services, it is likely they will not make another attempt and they will begin to heal.
So is it worth living in a place of fear all the time?
The reality is that I will still feel some fear, but I know that I’m doing everything in my power to help my loved one. I can only control my own actions and emotions and must surrender to those things that are out of my purview.
Ginsberg says the real fear many family members have is that if their loved one died by suicide, they wouldn’t be able to survive it or that they couldn’t live with themselves. So she uses this worst-case scenario exercise to help family members understand that if the worst thing did happen, they could handle it and that it’s no one’s fault. The exercise also helps family members recognize their own strengths in the midst of a crisis and shows them that they can develop the coping skills they need to move forward in life.
The counselors interviewed for this article agree that clinicians can use psychoeducation to educate families about suicidal ideation, mental health disorders, and the triggers and warning signs that can lead someone to a suicide attempt. They can also refer family members to support groups for suicide loss survivors and/or mental health organizations that can provide additional community resources.
The counselors also stress the importance of helping families realize that their loved one is in critical need of support from both the family and mental health professionals. They suggest counselors encourage family members to participate in creating their loved one’s safety/crisis plan and to keep a copy of the plan, along with the counselor and the client.
Families need to remember that “the true victim” is the person who attempted suicide, Hill says. Suicide attempt survivors “don’t ever think, ‘How can I hurt my family?’ They just want the pain to stop,” she notes.
And it is the responsibility of the counselor, with help from the family, to focus on the needs of the client, Hill adds.
Torzala, who is a suicide loss survivor, says family members can significantly help a suicide attempt survivor heal through empathy while understanding and validating their emotional struggle. She also states that family members should recognize their own emotions after a suicide attempt because this can be a traumatic experience for them as well.
The need for proper training
When Strait decided to seek treatment regarding his own suicide attempt, he did not have a good experience with mental health professionals because they were not adequately trained to treat people with suicidal ideation.
“I had a psychiatrist tell me that I had a good family [and that] everything would be OK, so I shouldn’t be sad,” Strait recalls. And “I had a counselor who told me they didn’t think I needed to talk about it [because] it had been years since my attempt.”
Some counselors, Strait says, are not comfortable talking about suicide because of the stigma that surrounds the topic. (See below for more on the stigma associated with suicide.) He says it is important for counselors not to panic or overreact when a client discusses their suicidal thoughts and negative feelings.
Torzala has experienced the unfortunate fallout from counselors who were not prepared to treat these clients. “In the past, I’ve had clients who were fearful to disclose their suicidal ideation because of the past actions of former therapists,” she says. “After they disclosed suicidal ideation, the therapist contacted family members or authorities, and sometimes the client was sent to inpatient involuntarily. Suicidal ideation can be common with certain mental health disorders, and it’s important to normalize that with the client in order to openly discuss it. This is where suicide prevention happens.”
Torzala recommends clinicians work through their own fears and misconceptions about suicide so that they can feel comfortable discussing the difficult aspects of suicidal ideation with their clients.
Ginsberg also advises clinicians to seek out training opportunities with mental health organizations and continuing education programs to ensure that they have the skills necessary to help suicide attempt survivors and their families rebuild their lives. And if possible, counseling students can take suicide education courses in graduate school, Strait adds.
In 2016, Strait finally found a counselor who made him feel comfortable to begin treatment. The two worked together to reframe his cognitive distortions using CBT.
“The biggest thing is that he [the counselor] was comfortable talking about [suicide] and made it OK for me to talk about it,” Strait says. “I felt no judgment, no pity. I did feel compassion. He met me where I was at on the journey and helped me move forward.”
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Resources on suicide prevention
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The stigma of suicide
Historically, suicide has been linked to tragic mental illness and has been considered to be criminal behavior, notes John Sommers-Flanagan, a professor of counseling at the University of Montana. This negative historical perspective has led to stigma surrounding suicide.
“Suicide has often been categorized as something only ‘weak’ or ‘emotionally vulnerable’ people do,” says Támara Hill, a licensed professional counselor (LPC) and owner of Anchored Child & Family Counseling in Monroeville, Pennsylvania. “I have had some clients call it ‘selfish’ or ‘cowardly,’ when the reality is that the person just wants their pain to stop — or the client is seeking some control over their own life.”
Chris Sandwell, an LPC and director of accreditation, training and certification with the American Association of Suicidology (AAS), says stigma comes from a lack of understanding or fear, which might explain why people don’t know how to support, understand or help a person in a suicidal crisis.
“The counseling profession can help provide a place where people can talk openly and honestly about their suicidal thoughts, provide alternatives to calling the police and threatening hospitalization and provide true collaboration with people who are [considering] suicide,” Sandwell argues.
In 2014, AAS designated a membership category for suicide attempt survivors to “create a seat at the table for suicide attempt survivors and people with lived experience of suicide,” Sandwell explains. Today, she says about 15% of AAS members are people who identify as having a lived experience of suicide, including attempt and loss survivors, and about 34% of AAS members are clinicians.
Rick Strait, an LPC and the substance use division director and suicide prevention coordinator at the Community Counseling Center in Cape Girardeau, Missouri, says he has experienced stigma from colleagues and other mental health professionals because of his own suicide attempt.
When Strait first sought treatment to process his past suicide attempt, he says a friend, who is also a counselor, told him that he should never tell anyone about his suicide attempt because prospective clients would not want to work with him.
“When I first started sharing my story, I had professionals give feedback that maybe I shouldn’t be in this field or [that] I shouldn’t share my lived experience,” Strait says. “Ironically, almost every time I share my experience with professionals or do a training with professionals, I have a least one professional reach out to me and share their struggles, past or present.”
Strait says some of his colleagues have expressed fears about getting help for their past attempts or suicidal thoughts because of how it may impact their career. And others have shared about family members and how their struggles with suicidal ideation have affected them.
Tammi Ginsberg, a licensed clinical professional counselor with a private practice in Woodsboro, Maryland, says suicide attempt survivors are stigmatized for the same reason that people with other mental illnesses are also stigmatized. “Quite frankly, it comes from a place of ignorance,” she says. “Making a suicide attempt is a serious symptom of a mental health condition, just like having a heart attack is a symptom of a serious cardiac issue. It’s just not seen the same way.”
Counselors must take on the challenge of advocating for better mental health treatment and normalizing diseases of the mind, Ginsberg argues, and the counseling profession must insist that prospective counselors who are interested in working with this population get ample training.
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Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@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.
