Tag Archives: Suicide

The need for standardization in suicide risk assessment

By Gregory K. Moffatt April 14, 2020

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

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

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

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

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

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

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

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

Looking back

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

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

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

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

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

Risk assessment tools

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

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

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

How do we know our assessments are effective?

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

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

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

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

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

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

What we risk

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

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

A standard approach

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

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

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

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

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

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

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

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

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

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

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

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

Assessment of Abigail

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

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

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

Conclusions

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

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

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

 

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

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

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

When the caring is too much

By Christine Sacco-Bene and Fay Roseman January 13, 2020

With the proliferation of research and information focusing on human-animal interactions, counselors are more aware of opportunities to incorporate animal-assisted interventions as part of their clients’ treatment. However, there is a population of clients who have been overlooked in this equation until recently — veterinarians. In fact, the mental health of these professionals is an emerging area of research and mental health treatment. We (the authors of this article) have also seen the pressures of this field firsthand with our family members and friends who are veterinarians and veterinary students. The sheer level of stress and strain they experience on a day-to-day basis has a significant impact on their work and personal lives.

For that reason, this article focuses not on animal-assisted interventions or the benefit of animals in their humans’ lives but rather on the increasing need of mental health attention to the helpers who take care of our pets and service animals. Note that although the information presented here may be applicable to others who work to care for animals, we are focusing specifically on veterinarians and veterinary students in this article.

We depend on veterinarians to be kind, compassionate and attentive to their patients and their patients’ owners. Because of the multifaceted nature of veterinary service, the occupational stress of these interactions and the inherent professional isolation of the field can result in a number of mental health challenges, including compassion fatigue, burnout, depression and anxiety. Veterinarians face some of the same challenges that other health care professionals face, including working with a large number of stressed clients (people and animals), long hours, and limited financial resources. However, they also have the added pressures of meeting the difficult requests and expectations of pet owners, making the best decisions given difficult situations, and dealing with unwanted or sick animals.

In the Centers for Disease Control and Prevention report “Prevalence of Risk Factors for Suicide Among Veterinarians — United States, 2014,” Randall Nett and colleagues chronicled that veterinarians were found to experience serious psychological distress at a rate higher than the general U.S. adult population. Their survey of over 10,000 veterinarians in the United States further detailed that more than 1 in 6 veterinarians have experienced suicidal ideation. Belinda Platt and colleagues, in their study “Suicidal Behaviour and Psychosocial Problems in Veterinary Surgeons: A Systematic Review,” noted that these challenges have also contributed to the increasing rate of death by suicide among veterinarians. This information draws attention to the need for further consideration and development of support and assistance strategies for this community of helpers.

While neither of us has worked directly with this population, we do have a personal interest in this area. Christine has a close friend who is currently in her final year of veterinary medical training. The financial stress related to the cost of being in this professional program and uncertainty about how she will be able to pay off her college loans after graduation have caused her and her family significant worry. Even more startling are the stories about the strains the veterinary program puts on its students related to schedule, physical and mental demands, money, travel, etc. Christine’s friend has shared accounts of her peers breaking down in tears on a regular basis (sometimes several times a day), not sleeping or eating properly, pushing themselves to do more practice, and maintaining late night and early morning study times, sometimes alone and sometimes in groups, to prove themselves worthy to their faculty. The demands leave little (if any) time to engage in self-care, which seems to be affecting their current mental well-being and may be setting a precedent that will affect their mental health as they progress through their careers.

Fay’s daughter is a veterinarian who became interested in the high rate of suicide among veterinarians while she was in school for veterinary medicine. She explored the potential connection between compassion fatigue and suicidality and shared her work with Fay. After Fay’s daughter graduated and entered into veterinary work, she experienced the loss of colleagues to death by suicide. Our mutual concern about the high rate of death by suicide among veterinarians and the stigma felt by numerous veterinarians about seeking mental health counseling has prompted us to raise awareness of this issue with other counseling professionals. 

What veterinarians are saying about mental health

Some of the mental health issues that veterinarians face are similar to those faced by the general population. However, international studies, particularly in Europe and Australia, report more significant mental health concerns within the veterinary profession when compared with the general population or with other health care professionals. The 2012 article “Suicidality in the Veterinary Profession: Interview Study of Veterinarians With a History of Suicidal Ideation or Behavior,” by Platt and colleagues, indicates that specific challenges of workplace relationships, career concerns, patient issues, unreasonable work hours/work volume, and responsibilities related to clinical practice management are all contributing factors to veterinarians’ mental health issues. Research also notes that student debt and ethical dilemmas, most notably around issues of animal care and euthanasia, generate the highest levels of stress for this population. In a 2018 article for JAVMAnews (Journal of the American Veterinary Medical Association), R. Scott Nolen noted that veterinarians show a higher rate of psychological distress and have slightly lower degrees of well-being than does the general population. The seriousness of this dilemma is more significant when considering that 25% of veterinarians have considered suicide at some point in their lives and 1.6% have attempted suicide.

In their review of the practice of veterinary social work, Elizabeth Strand and colleagues found evidence suggesting that veterinarians may experience stress, anxiety and depression as early as their first year of study. High-achieving students are often drawn to veterinary medicine, and among this group, failure is not an option. Veterinary school is demanding and requires a great deal of time and energy from students, beginning with the acceptance process and continuing through clinical practical experiences. Rates of depression, self-harm, and suicidal ideation increase during the clinical year when students are completing medical rotations in various specialties of veterinary medicine. The rigor of each rotation and the requirement of completing multiple rotations, which can be located either near or far from home, present other challenges for managing stress and the life skills of students. Although the social support offered by family, friends, and veterinary faculty was found to be beneficial to these students, we believe the specialized training of mental health practitioners might improve outcomes for veterinary students during their course of study.

The debt acquired through the course of study can become a significant contributing factor to the stress levels experienced by veterinarians at the beginning of their careers. A review of the 2019 cost of veterinary medicine programs throughout the United States indicates that a four-year residential program can range from $168,000 to $329,000, whereas a nonresidential program can cost between $223,000 and $460,000. The median debt carried by veterinary school graduates ranges from $96,000 to $329,000. Given the significant cost of a four-year veterinary degree, it is easy to identify another reason for increased stress, anxiety and depression among this population.

The function of a veterinarian is not only to provide top-quality medical care to animals and to maintain a relationship with pet owners but also to do so in a compassionate manner, even when it creates significant stress for the veterinarian. Many veterinary professionals become overwhelmed when they need to offer emotional support and comfort to patients’ owners because they are not adequately equipped to handle the owners’ emotional responses. This is especially true when having to convey messages about a patient’s illness or death.

In her article “Moral Stress the Top Trigger in Veterinarians’ Compassion Fatigue,” Susan Kahler noted that giving bad news, managing adverse events, interacting with difficult clients, working in teams, and balancing work and home life create diminished levels of wellness for veterinarians. This work cannot be done in isolation, and the support staff in a veterinary hospital is a key component to the relationship between veterinarian, pet and pet owner. People trust that veterinarians will interact sympathetically with them, but managing these multiple relationships, in addition to providing ethical and professional care and respecting the dignity of the patient and patient’s owner, can be a challenge. This is especially relevant when considering that veterinarians encounter difficult issues — including cases of trauma, illness, abuse, terminal illness and death — on a regular, sometimes daily, basis.

Another identified contributing factor to the mental health issues of veterinarians is the ongoing pressure inherent in the daily operation of a clinical practice. In addition to the stress of managing the business side of the clinical practice (billing, inventory, equipment, payroll, legal, etc.), veterinarians are now dealing more frequently with “emotional blackmail,” which involves attempts to guilt these professionals for charging for their services. Just as we have seen in other industries, consumers of veterinary services are increasingly turning to social media to complain about products and service. In “Media’s Emotional Blackmail Is Killing Veterinarians,” Dr. Sarah Boston, a veterinary surgical oncologist, explained, “There are several results of this irresponsible reporting. The obvious one is the direct damage to the veterinary hospital and staff. There is also the widespread damage it does to all veterinary professionals when they receive the message that what we do is not valuable and should not cost money, and that we are terrible people who are only in it for the money.”

Suggestions for all helpers

Until recently, wellness and mental health self-care were not included in the curricula of veterinary training programs. Because veterinarians tend to be empathetic and nurturing, they focus their efforts on caring for and promoting the health and well-being of animals and routinely put the needs of patients and patients’ owners above their own. In her article on moral stress, Kahler explained that moral stress is unique in that the typical stress management techniques are useless and may even contribute further to mental health challenges. She encourages these professionals to redefine their work ethic to include self-care.

Self-care is really a moral imperative for all professionals in the helping fields, including veterinarians. Helping professionals have a moral obligation not just to facilitate patient care but also to take care of themselves. In collaboration with university training programs, mental health care professionals and counselor educators can help start this process by integrating self-care, stress management skills, and education about mental health issues and substance abuse into veterinary school courses. The College of Veterinary Medicine and the College of Social Work at the University of Tennessee created a collaborative partnership in which focus is given to animal-human interactions, including the issues of compassion fatigue and conflict management.

University counseling centers can also be invited to have greater presence during professional development seminars with veterinary students. This can help erode the stigma of students and professionals seeking mental health care when it is needed. The colleges of veterinary medicine at both Ohio State University and Colorado State University have taken proactive positions in providing resources and education to their students about mental health and self-care.

In addition to reaching out to veterinary programs to capture the attention of students, professional counselors might consider reaching out directly to veterinary professionals. The integration of tools to manage school-work-life balance should be incorporated at both the student and professional levels.

Moral stress and its associated challenges — compassion fatigue, burnout, depression and anxiety — can feel insurmountable to manage. Veterinarians are generally problem-solvers, analytical thinkers and high achievers. They tend to be task oriented and strive toward order. These characteristics certainly help veterinarians to be good at their jobs, but they do little to help these professionals remain good “in” their jobs. Although veterinarians are empathetic toward their patients, some may lean toward low self-awareness and struggle with understanding or dealing with their own emotions. Incorporating opportunities to promote emotional intelligence during veterinary programs and professional development trainings can help these professionals to become more aware of their emotions and the emotions of others, which in turn facilitates better management of themselves and their relationships with colleagues, staff members and patients’ owners.

Mental health professionals can assist veterinarians with increasing awareness of their emotional reactivity and help them take a more proactive approach to self-understanding and emotion regulation. Daniel Goleman popularized the psychological theory of emotional intelligence and its five components: self-awareness, self-regulation, internal motivation, empathy, and social skills. These components can easily be assimilated into training and wellness interventions. Emotional intelligence enhances the individual’s ability to reroute their thinking, allowing them to move away from their initial emotional response to situations (including avoidance) and toward more action-based reasoning.

Many times, veterinarians with a history of suicidal thoughts or behaviors do not talk about or share their experiences with anyone because they feel guilty or ashamed. Their silence may also be attributed to a fear that reaching out will affect their job, or simply to a feeling that they do not have time to seek help. Providing a space for group work, whether in person or virtually,  allows veterinarians to develop support networks. Kahler explains that group time presents veterinarians with a setting to talk about and debrief their experiences and memories together in an open, safe forum. When this group interaction occurs, the group members start making sense of their situations and learn that they are not isolated in their experiences.

One of the major stress factors for this group of professionals is their reported lack of time. Especially for those with busy schedules or those who work in rural areas, telemental health services may be a particularly attractive option.

In addition, bibliotherapy is a brief adjunct intervention that is helpful with a variety of psychological problems. It can be a resource for veterinary professionals with busy schedules or for those who work in locations far from traditional mental health offices. Bibliotherapy is used to increase clients’ understanding about what they are experiencing, and it promotes agency in their treatment. In their systematic review of the use of bibliotherapy in the treatment of depression, Maria Rosaria Gualano and colleagues explain that there is a self-help element to bibliotherapy. It teaches, through the reading of specific material, a number of strategies designed to regulate negative emotions and explains how to practice them in daily life. Bibliotherapy interventions are best used in conjunction with counseling. They can be used between counseling sessions to enhance clients’ commitment to working toward health and well-being.

Finally, mental health professionals can help by providing education, maintaining open opportunities for collaboration, and advocating with the veterinary field to promote well-being and reduce stigma around mental health issues and counseling.

Conclusions

The suicide rate among veterinary professionals is higher than that of other professional fields due to the unique responsibilities of veterinarians. Veterinarians, like other helping professionals, are at risk of giving too much of themselves to their patients and their patients’ families, their staffs, and their businesses and leaving little time for themselves because of their natural qualities of compassion, empathy and caring. A variety of stressors, starting during veterinarians’ programs of study, can lead to mental health issues over time.

On the basis of what we have learned, we believe that providing access to counselors and other mental health professionals could help veterinary students become more proactive in managing some of the emotional challenges they may face as they move through their programs of study. In addition, counselors working with veterinarians in the community can help these clients identify any unhealthy coping methods and provide opportunities for promoting resiliency and wellness. This may require offering strategies that extend beyond the counseling office because of the veterinary profession’s time demands.

Resources

Various resources are available to counselors working with these gifted healers and for veterinarians themselves.

The American Veterinary Medical Association (AVMA) lists several articles and resources for its members and for those who work as veterinarians. Among the areas highlighted under AVMA’s professional development dropdown menu at avma.org are well-being and peer assistance.

The University of Tennessee veterinary social work program provides referrals and resources to people in veterinary practice. The university’s S.A.V.E (Suicide Awareness in Veterinary Education) mental health education program, which was created to honor a colleague’s last wishes, has served as a model for mental health education in veterinary schools across the country (see vetsocialwork.utk.edu and vetmed.tennessee.edu/SAVE).

The National Suicide Hotline (suicidepreventionlifeline.org) provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, seven days a week.

 

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Christine Sacco-Bene is a licensed professional counselor and licensed mental health professional. She is an associate clinical professor in the Rehabilitation Counseling Department at the University of South Carolina. Over her 15 years as an educator, she has been an advocate for students and professionals in the field of counseling (and in all helping professions) to engage in self-care activities to support their mental well-being and professional growth. Contact her at christine.sacco-bene@uscmed.sc.edu.

Fay Roseman is an associate professor in the counseling program in the Adrian Dominican School of Education at Barry University in Florida, where she also served as the coordinator for practicum and internship. As a practitioner certified in the Myers-Briggs Type Indicator, she teaches career development and other courses in the master’s and doctoral programs. Contact her at froseman@barry.edu

 

Letters to the editor:  ct@counseling.org

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

 

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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.

Supporting survivors of suicide loss

By Dana M. Cea October 29, 2019

Each year, more than 40,000 people die from suicide in the United States, making suicide the 10th-leading cause of death in our nation. Worldwide, more than 800,000 people are lost to suicide annually. These are devastatingly high numbers. But an even larger number encompasses the people who have been impacted by a loved one’s death from suicide. They are known as survivors of suicide loss.

In 1973, psychologist and suicidologist Edwin S. Shneidman — who founded the American Association of Suicidology (AAS) — estimated that for every suicide death, there were six survivors affected. Thirty-eight years later, research by psychologist Alan L. Berman — at that time the executive director of AAS — determined there were anywhere from five to 80 or more survivors of suicide loss for each suicide death. That year, 2011, was the same year my dad died from suicide.

The response to my dad’s death made Berman’s research findings seem like a significant underestimation. Hundreds of people showed up for my dad’s funeral and contacted our family after his death. A 2018 article published by the American Association of Suicidology found the number of people impacted by one suicide death to be around 135 people. Thus, approximately 6 million people in the United States are affected by suicide loss each year.

 

Survivor day

After I found out my dad had died from suicide, I called my previous college therapist. Even though I had not seen her in more than a year, she called me back. She listened, she validated, she empathized — all of the things you hope a therapist would do. She also told me about a day specifically to support survivors of suicide loss: International Survivors of Suicide Day (Survivor Day for short). In 1999, Sen. Harry Reid, who had lost his father to suicide, introduced a resolution to create an annual day for survivors of suicide loss to come together for healing and support. Congress designated the Saturday before Thanksgiving as Survivor Day.

The American Foundation for Suicide Prevention (AFSP) supports hundreds of Survivor Day events around the world. Each year, AFSP creates a documentary of the stories of suicide loss survivors that is shown at Survivor Day events. Both the documentaries and the events focus on healing, surviving and thriving. Survivor Day events offer survivors of suicide loss a safe space to “find connection, understanding and hope through their shared experience.” Past documentaries can be viewed on AFSP’s website.

Since 2012, I have assisted in hosting a local Survivor Day each year. This year, I am hosting the event in Greenville, North Carolina, at East Carolina University’s Navigate Counseling Clinic, part of the Department of Addictions and Rehabilitation Studies, where I am pursuing my doctorate. At past events, I have witnessed survivors talking about their loved one’s death from suicide for the first time — sometimes years or decades after their loss. I have heard survivors share their experiences of shame, guilt, anger and grief. I have also heard stories about funny, kind, caring, smart, artistic and achieving loved ones who have been lost to suicide. I have experienced connections that may not have been found anywhere else.

 

Support groups

In 2011, Survivor Day fell on the same day as my dad’s funeral, and in a sense, we held our own impromptu Survivor Day event. Without the actual designation or documentary, hundreds of people came together as survivors of the suicide loss of my dad. After I went back to Tennessee, where I was living at the time, I began individual therapy with a local provider. I remember feeling that she did not “get it”  — the “it” being all that comes with the loss of a loved one to suicide. However, she gave me information about the Tennessee Suicide Prevention Network, which was hosting a support group for survivors of suicide loss in my area. That support group is where I found others who did get it.

The support group members did not blame each other for their loved one’s death. They did not make comments such as “I hope God forgives your dad”; “You should have known this was going to happen”; “Your dad is in a better place now”; “I do not know how I could keep living if I were you”; “Why didn’t you stop him?”; “That was so selfish of him to do that to you”; or any of the other insensitive remarks that survivors of suicide loss so often hear.

Some of the group members had people in their lives who no longer talked to them or who actively avoided them. Yet the support group members continued to show up for each other. When group members tried to talk with other people about their pain or how their loved one had died, the conversations often shut down immediately. Yet the support group members encouraged one another to share and express their emotions.

Losing someone to suicide is very different from losing someone to another cause of death. And sometimes, finding someone who understands your loss requires finding someone who has also lost someone to suicide.

 

Postvention

Postvention is the work done to support survivors of suicide loss. In my master’s counseling program, we learned some about suicide prevention, yet suicide postvention was hardly mentioned. Although suicide prevention and intervention training can be inadequate in some counseling programs, suicide postvention training is often nonexistent. So, how can we as mental health professionals help clients who have lost a loved one to suicide?

First, we can be trained to provide services specifically tailored for survivors of suicide loss. AFSP’s website has a list of clinicians trained in suicide bereavement. These clinicians have been through a daylong training workshop that includes information about what being a survivor of suicide loss means, the impact the loss has on survivors’ mental health and well-being, and common themes survivors may experience in their bereavement. Clinicians also learn clinical techniques that can help survivors work through their bereavement and piece their lives back together. AFSP provides training for professionals interested in becoming suicide bereavement clinicians.

AFSP also provides training for clinicians who want to lead or facilitate support groups for survivors of suicide loss. There are two different versions of the training: one for facilitating adult support groups and another for child and teen groups. Each program lasts two days and includes lectures, interactive discussions, and role-playing.

Clinicians who are not interested in leading a group can still give clients a list of AFSP-curated support groups for survivors of suicide loss.

Hosting a Survivor Day in your area is another powerful way of helping suicide survivors, some of whom may be more comfortable with a one-day event rather than regularly attending a support group. The Out of the Darkness Community Walk is another one-day event. These walks, which take place in numerous locations nationwide, are not specifically for survivors of suicide loss. Their purpose is to raise awareness — and funds — to help prevent suicide. These walks are also where many survivors of suicide loss find support for the first time. Each walk is sponsored by a local chapter of AFSP, and being connected to those chapters can give clinicians access to resources to help themselves and clients.

 

Other resources

When I called to set up therapy after my dad died from suicide, I was told the wait was several weeks. During that time, I leaned on the support of family, friends and co-workers. I wish I had known about some of the resources available to recent survivors of suicide loss.

Healing Conversations is an AFSP program that connects recent survivors of suicide loss to volunteers who are also survivors and have been through a training and vetting process. Healing Conversations, formerly known as the Survivor Outreach Program, offers that connection to people without the pressure of therapy, groups or events. Survivors simply submit a form through the AFSP website, and a coordinator connects the survivor and a volunteer for an in-person visit, phone call, or video call.

AFSP’s I’ve Lost Someone page contains a variety of helpful tools, including practical information for immediately after a loss, resources to help loss survivors find support, and self-care recommendations. Schools, colleges and workplace managers can also access postvention toolkits. Survivors can use the page to identify ways to honor loved ones lost to suicide through digital and physical memory quilts, memorial funds, and Out of the Darkness walks.

AFSP is not the only organization that provides helpful resources and information. The Suicide Prevention Resource Center (SPRC) offers a variety of suicide prevention resources, training programs and toolkits, including “Suicide Prevention Competencies for Faith Leaders.” SPRC’s website also has sections devoted to postvention and supporting survivors of suicide loss.

The Tragedy Assistance Program for Survivors (TAPS) offers “compassionate care to all those grieving the loss of a loved one who died while serving in our Armed Forces or as a result of his or her service.”

The U.S. Department of Veterans Affairs (VA) has suicide prevention coordinators at each VA medical center nationwide. They can help active-duty members and veterans get counseling and needed services. The suicide prevention coordinators are also incredible resources for families, loved ones and communities.

 

Talking about suicide

The phrase “commit suicide” can be one of the worst things that a survivor of suicide loss hears. Where did this phrase come from? For hundreds of years, attempting or dying from suicide was an actual crime in Britain. Punishments may have included denial of a funeral, burial alone without a marker, desecration of the body, and confiscation of the person’s property. States such as Maryland and Virginia, despite having developed their own laws, continue to recognize this law. The phrase “commit suicide” reinforces the suggestion of suicide as a crime.

Two other phrases that come across as icky, for lack of a more scientific term, are “completed suicide” and “successful suicide,” as if death were the preferred outcome of an attempt. Advocates for suicide prevention and postvention encourage the use of “died by suicide.” While I see this as a much-preferred phrase, I take the phrase one step further and use “died from suicide.” I have never heard anyone say someone “died by” a heart attack, an accident, cancer, or any other disease. People commonly say that someone “died from” whatever the cause of death was. Therefore, I prefer “died from suicide.”

Other advocates prefer to say that someone “died from a mental illness” rather than from suicide. Although I can see the intention behind this phrasing, the reality is that not everyone who dies from suicide has a mental health condition. In 2018, the Centers for Disease Control (CDC), after examining suicide statistics in 27 states from 1999-2016, released a report showing that more than 50% of people who died from suicide did not have a diagnosed mental health condition at the time of their death. Reading and quoting these statistics can make the conversation confusing, and the bottom line is that there are tens of thousands of people dying from suicide each year who do not have a mental illness.

Regardless of your current or future involvement in supporting survivors, I ask one thing of each of you reading this: Please be aware of how you talk or joke about suicide. Both AFSP and SPRC have guidelines for talking about suicide: Speaking Out About Suicide and Suicide Reporting Recommendations.

 

Suicide’s impact on counselors

As mental health professionals, we are not immune to being impacted by losses from suicide. While I am not going to delve into our legal responsibilities, I will touch on our ethical responsibilities. If we lose someone to suicide, we may be affected by our grief more than we realize, and this can take a personal toll and negatively affect our work with clients. I encourage us as mental health professionals to take care of ourselves, to seek support, and to take off as much time as needed so that we can live up to the ethical responsibilities we have to provide competent care.

I also implore mental health professionals to bracket their values that may be harmful when discussing death from suicide with clients. If someone comes to me and says that they will not attempt suicide because that would be a sin, I will use that as a protective factor with the person. However, I would not tell someone that attempting or dying from suicide is a sin. The reality is that many religions and places of worship no longer view suicide as a sin and have come to realize the part that mental health and life situations play in deaths from suicide.

If you do decide to offer services specifically to survivors of suicide loss, or if some of your clients are or become survivors of suicide loss, please consider seeking training, consultation and supervision. Survivors of suicide loss are at higher risk of having thoughts of suicide due to their exposure to suicide compounded with their grief. Grief journeys can be difficult enough without the additional layers that come with a suicide loss. Gaining additional expertise in counseling survivors of suicide loss through training, consultation and supervision can make all the difference in the care you provide to clients.

 

Conclusion

As we continue to raise awareness and work to prevent suicide, we can expand our efforts to assist those who have been affected by suicide. Please join me in supporting survivors of suicide loss by being aware of and using available resources, encouraging postvention efforts, talking about suicide safely, and taking care of ourselves so that we can continue to provide effective mental health services.

 

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Dana M. Cea, pronouns she/her or they/them, is a volunteer for the National Alliance on Mental Illness and the American Foundation for Suicide Prevention, a mental health professional, a survivor of suicide loss, and a current doctoral student at East Carolina University. She focuses her research on mental health and suicide, the LGBTQ+ community, youth, and autism spectrum disorder. Dana lives with mental health disorders, her spouse, and their three dogs. Contact her at danamcea.com.

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

Suicide prevention strategies with the military-affiliated population

By Duane France and Juliana Hallows

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

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

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

Using a public health approach

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Maximizing protective factors

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

Connectedness

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

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

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

Economic stability

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

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

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

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

Education and awareness

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

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

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

Minimizing risk factors

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

Access to care

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

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

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

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

Lethal means safety

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

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

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

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

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

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

Postvention

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

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

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

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

Suicide prevention is everyone’s job

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

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

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

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

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

 

Letters to the editor: ct@counseling.org

 

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

 

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

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.