Tag Archives: Suicide

Finding hope after surviving suicide

By Lisa R. Rhodes September 27, 2022

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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

988 Suicide & Crisis Lifeline
American Foundation for Suicide Prevention (AFSP)
AFSP’s Talk Saves Lives program (afsp.org/talk-saves-lives)
AFSP’s More Than Sad program (afsp.org/more-than-sad)
AFSP’s Suicide Bereavement Clinician Training program (afsp.org/suicide-bereavement-clinician-training)
American Association of Suicidology (see their training and accreditation courses at suicidology.org/training-accreditation)
Zero Suicide Institute (see their toolkit at zerosuicide.edc.org/toolkit and collection of resources at zerosuicide.edc.org/resources)

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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.

Preventing veteran suicide

By Justina Wong September 9, 2022

In February, Russia invaded Ukraine and started a war that is still going on today. When President Zelensky asked foreign fighters to join Ukraine’s resistance against Russia, many American veterans answered the call. Although it’s a devastating war that has taken many innocent lives, it has given some veterans, especially those who are still struggling with the aftermath of the U.S. military’s withdrawal from Afghanistan, a renewed sense of purpose.

Having a sense of purpose and belonging and working toward a common goal can help veterans who are struggling with suicidal thoughts or ideations. According to the Centers for Disease Control and Prevention, in 2019 an average of 17.2 veterans died by suicide daily, and from 2001 to 2019, the suicide rate among veterans increased by almost 36%. In certain battalions, there have been more deaths from suicide than those killed in action during the wars in Iraq and Afghanistan.

With September being Suicide Prevention Awareness Month, it is important to remember that suicide affects the military and veteran communities year-round.

What to know about veterans and suicide

Suicide in the veteran community is different from suicide in the civilian community. Veterans have a higher suicide rate compared to civilians, and in my personal experience working with different nonprofit veteran organizations and being friends with veterans, I noticed that veteran suicides can sometimes be more impulsive than civilian suicides.

Photo by Sgt. Agustín Montañez/defense.gov

I also noticed that one of the biggest triggers for veteran suicides are other veteran suicides/deaths. In talking with veterans, I learned that some are more likely to think about and follow through with taking their own life when they hear about a close friend who died by suicide or died from a variety of reasons.

In my attempt to destigmatize suicide among veterans, I encourage all the veterans I speak with to be transparent and honest about their experiences. I have heard some harrowing stories.

One veteran told me about how his team leader in Iraq attempted to end his own life in front of his family members, and when he survived, he crawled into his bedroom and died in a second, fatal suicide attempt. The veteran who shared this with me could not fathom why the family did nothing to stop him, and he felt hopeless and helpless.

Another veteran told me about how a happy battalion reunion with his fellow veterans ended in tragedy when one of his friends who had been struggling with survivor’s guilt for many years died by suicide. After the reunion was over and they all went home, three more of his fellow veterans killed themselves and another died in a car accident. He said he felt hopeless because it didn’t seem as if anyone or anything could help stop veteran suicides.

The two most common statements I hear from veterans about suicide in the veteran community are that it never ends and that it’s not about if but when it will happen to them. Stories and statements such as these happen too often among veterans, but it doesn’t have to be that way.

Screening for triggers

One of the biggest lessons I learned through my nonprofit work with veterans is that clinicians need to understand what triggers veterans to attempt to take their own life and how to continuously screen for these triggers.

Potential triggers could include the following:

Being reminded of a similar place through smell, sound or sight
Having a history of mental health illness
Losing fellow veterans to suicides or other deaths such as drowning, car accidents or fires
Experiencing the death of family members who were pillars of support
Ending a romantic relationship through breakup, separation or divorce
Feeling hopeless, helpless and like nothing will ever take their pain away
Continuously seeking and being denied help
Facing financial, food or housing insecurities
Being exposed to continuous world tragedies such as pandemics, natural disasters and school shootings
Being in toxic environments where they are emotionally, mentally, physically or sexually abused

Veterans are special people because they signed up to do a job that most people are unwilling to do. Every human being has a breaking point, and it’s up to counselors to ensure that veterans don’t reach their breaking point or to help veterans navigate their lives if they do reach that point.

Nontraditional ways to help veterans

When veterans leave the military community, they often lose their sense of purpose. As I mentioned previously, some veterans found their sense of purpose again by helping Ukrainian refugees or helping train Ukraine’s military to fight Russia.

In my CT Online article “Addressing the Afghanistan humanitarian crisis,” published earlier this year, I referenced Ben (a pseudonym), a former Marine and a personal friend of mine. He worked as a military contractor for 15 years until the United States withdrew from Afghanistan, a withdrawal that caused Ben to struggle with moral injury.

When Russia invaded Ukraine, Ben decided to end his military contracting career to join a group of veterans who served in special operations units prior to leaving the military. Together they deployed to Poland and Ukraine to train individuals in Ukraine’s military and help evacuate Ukrainians who had difficulty leaving.

This new mission gave Ben a renewed sense of purpose, and his feelings of anger, hopelessness and worthlessness over the United States withdrawal from Afghanistan subsided. He also had the opportunity to go into Ukraine at the beginning of the invasion to help evacuate Ukrainians who had physical disabilities. He told me about how he and another veteran helped carry an older woman who was in a wheelchair to safety across the border to Poland. The woman’s son had died recently, and she was the sole caretaker for his four children, all of whom were under the age of 15.

Although carrying an older woman across the border may seem like a small act, her gratitude toward Ben ignited his passion for continued selfless service. It reminded him that he can still utilize what he learned in the military to help people. It was the moment that Ben realized he wasn’t hopeless or worthless. He had skills and a purpose. He went from helping Ukrainians evacuate to training Ukrainian women in hand-to-hand combat and combat triaging. I heard a great sense of pride in his voice as he described these events to me.

Ben’s decision to deal with his anger, hopelessness, worthlessness and suicidal thoughts by helping evacuate and train Ukrainians might not be a traditional form of therapy, but it worked for him just as much as traditional forms of therapy work with civilians.

Counseling veterans often requires a certain level of creativity, especially if traditional therapy is not working. Here are some nontraditional forms of therapy that may help veterans:

Engaging in activities that utilize a veteran’s military occupational specialty
Using adventure/outdoor forms of therapy, such as hiking, cycling, hunting, fishing, whitewater rafting, skiing, snowboarding or surfing
Volunteering with organizations that are built and led by veterans (e.g., Team Rubicon, The Mission Continues, Team RWB, Operation White Stork)
Attending unit/battalion reunions on a regular basis
Using cinematherapy
Incorporating creative arts, including drawing, painting, sculpting, glassblowing, coloring, music and writing
Utilizing an organized battle buddy system
Doing good deeds for others
Attending veteran retreats that are specifically built for veterans struggling with suicidal ideation
Engaging in religious or spiritual activities and rituals

Counselors must take action

The veteran population has always been a population that is underserved. During my fieldwork internship, I worked with veterans who waited months to get appointments with mental health professionals at their local Veteran Affairs clinics. Even veterans who expressed experiencing suicidal ideations were denied services and forced to wait. Most veterans will give up after being denied many times. Some veterans will assess their situation and decide that it is not as severe as other veterans’ problems and will not seek help so that their fellow veterans are serviced first.

As counselors, we must do better. As a community and world, we are better than this. It is up to counselors to uphold veterans’ human rights and advocate for them. This population will always be underserved unless we as a community of mental health professionals come together to serve those who have served us.

Counselors must take action. Veterans deserve to know that they are not alone.

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Related reading, from the Counseling Today archives:

“Suicide prevention strategies with the military-affiliated population”

“Advice for counselors who want to work with military clients”

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Justina Wong

Justina Wong is a second-year new professional currently earning hours toward licensure at a group private practice in California. She serves on the Military and Government Counseling Association’s board of directors and has worked with veterans in the nonprofit community for over 10 years. Justina is also a member of the American Counseling Association’s Human Rights Committee.

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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 attempt survivors: How counselors can help with disclosures

By Joan M. Flynn April 15, 2022

I haven’t shared this with many people, but last year, I was struggling and tried to take my life.

— sample disclosure script

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As suicide rates have risen to the 12th-leading cause of death in the United States, the number of suicide attempts has risen as well to an estimated 1.2 million in 2020, according to the American Foundation for Suicide Prevention.

Because suicide attempt survivors are at higher risk for both fatal and nonfatal suicide attempts, disclosure of past attempts is an important aspect of their mental health treatment. Yet research published in the American Counseling Association’s April 2022 Journal of Counseling & Development (JCD) indicates that many survivors choose not to disclose to their counselor, or they may choose to disclose to others in ways that increase their own social risks.

CT Online interviewed Lindsay Sheehan, a licensed clinical and rehabilitation counselor and lead author of the JCD study, to find out more about how counselors can better assist clients who may be thinking of suicide, have made a past attempt or are considering disclosing this aspect of their life to others.

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What is most important for counselors to understand about how suicide attempt survivors make disclosure decisions, and why are such disclosures important in counseling?

People who have survived a suicide attempt are more at risk for ideation and future suicide attempts, so disclosure of a past attempt opens the conversation for talking about it in future times of need. It is much easier for a counselor to provide support if they know the client’s history, such as the circumstances of a past attempt, before there is another crisis situation. Counselors, friends and family members can be proactive in supporting the person’s mental health, knowing what to do and discussing with the person how they want to be supported in the event of a future crisis and what they don’t want to happen.

Often, a suicide attempt is an important part of someone’s life journey and even their identity, but seldom is it considered acceptable or is talking about it encouraged. Counselors should keep in mind that talking about suicide makes one very vulnerable — counselors need practice to be comfortable talking openly about suicide, and they need to make sure they are conveying to the client that they are comfortable with it.

Becoming comfortable talking about suicide involves the counselor first reflecting on their own thoughts, attitudes and potential biases around suicide. For example, is suicide preventable? Should clinicians use every means necessary to save a person’s life?

Common misconceptions about people who attempt suicide or who have suicidal thoughts are that they are attention-seeking, selfish, manipulative, weak, damaged, unpredictable, irrational, dangerous or immoral. Another common misconception is that asking someone if they are having thoughts of suicide will make them even more distressed. Language such as “tried to commit suicide” implies that suicide is a criminal act — similarly, the term “failed attempt” is insensitive. Counselors should understand how stigma can impact their client’s life. They should help explore how the client might experience overt prejudice and discrimination related to their suicide attempt/mental health or how they might internalize the stigma, resulting in shame, depression and lowered self-esteem. When clients recognize stigma as a problem residing in society rather than themselves, this may lessen its impact.

Why might a client not disclose a past suicide attempt to the counselor?

Many suicide attempt survivors have been exposed to coercive situations in health care, such as hospitalizations, welfare checks, interventions, restraints, incarcerations and institutionalizations, in which they felt a loss of control over their own lives and were traumatized. Many live in fear of that happening again. They may be concerned that a counselor will overreact, that the counselor will treat them differently after the disclosure or that the counselor will say that they are not qualified to work with them, especially if they disclose current ideation. Clients may detect subtle signs of discomfort from counselors around the topic of suicide and feel like counselors are overly concerned about liability rather than about helping them.

When and how should counselors initiate discussions about past suicide attempts?

I believe the topic should be broached with every client; counselors should not assume that any of their clients have or haven’t had a suicide attempt or thoughts of suicide. A counselor’s initiation of the topic communicates that the counselor is comfortable talking about suicide. Counselors should also initiate conversation regularly about suicidal ideation. Suicidal ideation is relatively common, but many people do not feel comfortable talking about it even with a counselor, so it is important to provide an opening for that discussion often. If the client says they’ve never experienced ideation or aren’t experiencing it right now, the counselor can let them know that if they ever do so in the future, the counselor is open to helping them work through it.

The counselor should be explicit and transparent about the protocol for addressing suicide, such as through a professional disclosure statement that includes a detailed description of how they will respond to disclosures related to suicide. Counselors might also wish to outline their previous experience, philosophies and techniques related to counseling clients with suicidal ideation on their website or disclosure statement.

How can a counselor help in guiding the client’s disclosures to others? What factors would a counselor consider in helping to create a disclosure strategy or plan?

Counselors can help clients consider the pros and cons of disclosing using motivational interviewing techniques, recognizing that there are many situations, such as at work, where it might be particularly risky to disclose. Individuals who are currently experiencing distress or ideation might have reasons or motivations for disclosing that center around gaining support, while others might wish to disclose so they can help other people or strengthen relationships.

Counselors can help clients recognize that disclosure is nuanced — the person they disclose to, the timing of the disclosure, method of disclosure, content of disclosure, can all be considered. Disclosure can be a selective and gradual process in which clients might share a small part of their mental health story with a selected person, and then decide whether to share further and more broadly. Some clients might tend to over-disclose, which can make others uncomfortable and reduce social support.

Clients can practice disclosure scripts (see sidebar below) with their counselors to become more comfortable and strategic about their disclosure. If clients have a disclosure-related goal in mind, they can tailor the disclosure to maximize benefits and reduce risks.

Counselors can help clients discern whether they are ready to disclose and how they might cope if a disclosure does not go as hoped or planned. Although talking about suicide reduces shame and helps people process their thoughts and feelings, it can also be anxiety-provoking and bring up difficult memories, thoughts and feelings. Clients may need help discerning which people/environments might be more supportive of disclosures.

Even when a disclosure goes “well,” it can have unintended consequences. For example, someone who engages in suicide advocacy work and then tells their story publicly may experience an extremely warm and positive response but become overwhelmed and have difficulty setting boundaries — at the expense of their own mental health — if peers come to them for help, support or resources. Counselors can help clients think through some of these unintended consequences as well.

Your JCD article mentions disclosures clients may make online or on social media. Are there any special considerations for such disclosures?

I actually recently submitted a paper to another journal that goes into more detail about benefits and risks of online disclosures. In short, perceived advantages of online disclosure are the anonymity it can provide, depending on the forum you are using, so people can disclose without being subject to stigma, coercive treatments or active rescues.

People often struggle most with suicidal ideation at night when they are alone and their support people, both professional and nonprofessional, are unavailable. The online world provides opportunities to connect with many people at all times of the day and night. Online support is also relevant for people with disabilities or other isolating situations that make getting support or interaction difficult. Some survivors talk about how having a large audience to share their story with is empowering and makes it possible to reach and impact others to save lives.

Disadvantages related to disclosure on social media include that it could be upsetting or triggering for others, especially if there are graphic descriptions of suicide methods. Of course, there is always the risk of trolling and online bullying in response to a disclosure, as well as having others not take the person who is disclosing seriously and perceiving them as attention-getting. Finally, there are obvious communication barriers in online communication such as the lack of body language, communication possibly not being in real time, and an inability to provide direct help in a crisis situation.

There are some folks in Australia who have done more work in this area and specifically focusing on young people (see https://www.orygen.org.au/chatsafe).

What “errors” or missteps should a counselor avoid in the discussion of disclosures?

Counselors may not realize how common it is for clients to have chronic suicidal ideation, including every day for years, but not have a plan or intent and to never talk about it.

Talking about suicide can be difficult for both the counselor and the client, and much like trauma work, counselors should be prepared for and have supervision around this.

Counselors should be prepared to engage in safety planning with their clients and have a safety plan template.

What should be included in safety planning or in a safety plan template? For example, do you mean a “road map” that the person agrees to follow if they are thinking about attempting suicide, stating who they will call, what they will say and where they will go to not be alone? Or a preemptive plan that might involve locking away medications or firearms outside of the home to reduce being able to complete suicide impulsively?

Yes, exactly as you describe. The safety plan is a road map and might include warning signs/triggers, coping strategies, reasons for living, specific plans for who to call or where to go, including professional and nonprofessional support, crisis line/emergency information, and self-restriction of lethal means. There are also apps that people can use for safety planning.

Lastly, how did the idea for this research come about?

I was doing research on the stigma surrounding suicide, and during interviews and focus groups, people talked about disclosure dilemmas and about not being comfortable talking about suicide with their therapists or counselors. I was fortunate to receive some funding to conduct the research on stigma and disclosure, so that was also very important.

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ACA is proud to celebrate 100 years of publishing excellence with the Virtual Special Issue: JCD at 100 Volumes.

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Scripting a disclosure: Conversation starters

Lindsay Sheehan notes that disclosure can be a selective and gradual process. Some examples of disclosure “conversation starters” are:

“I haven’t shared this with many people, but last year, I was struggling and tried to take my life. I’m doing much better, especially these past couple months, but I really value our friendship and thought it was important for you to know.”
“You know, I do have a history of my own mental health struggles, including being suicidal. If you want to talk with someone who’s been there, let me know.”
“I’m reaching out because I haven’t been feeling well lately, mentally, and just wanted to see if you had some time today to have lunch and talk with me a bit.”

In addition, if a client is choosing to disclose online, in a book or in a formal talk, they may want to include more details and make their script more like a “story” they can tell, Sheehan suggests.

Pranch/Shutterstock.com

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Practice take-aways for counselors

Understand that although talking about suicide reduces shame, it can be anxiety-provoking and bring up difficult memories, thoughts and feelings for survivors.
To be more comfortable discussing suicide, first reflect on your own thoughts, attitudes and potential biases around it.
Help clients who wish to disclose outside of counseling to evaluate the pros and cons and to discern which people or environments are more likely to be supportive.
Offer to help the survivor practice a “disclosure script” to help them feel more comfortable and become more strategic about disclosing.
Engage in safety planning with survivors using a safety plan template.
Be explicit and transparent about the protocol you follow for addressing suicide, such as through a professional disclosure statement that includes a detailed description of how you will respond to disclosures related to suicide.

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Joan M. Flynn is a senior content editor at the American Counseling Association and a contributing editor to Counseling Today. Contact her at jflynn@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.

Suicidality among children and adolescents

By Laurie Meyers August 25, 2021

This past spring, Children’s Hospital Colorado declared a “state of emergency” in youth mental health. Over the course of the COVID-19 pandemic, the hospital system’s pediatric emergency rooms and inpatient units had become increasingly overrun with children and adolescents with serious mental illness, many of whom were actively suicidal.

“It has been devastating to see suicide become the leading cause of death for Colorado’s children,” the hospital’s CEO, Jena Hausmann, told journalists and reporters at a pediatric mental health media roundtable on May 25.

This mental health crisis is not confined to Colorado, however. Pediatric medical systems across the nation have reported a significant and sustained rise in mental health-related visits for children and adolescents that began in spring 2020. According to the June 18, 2021, issue of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, mental health-related emergency room visits among adolescents ages 12-17 increased 31% compared with the rate in 2019. In addition, the report found that in this age group, the mean weekly number of emergency room visits for suspected suicide attempts was 22.3% higher during summer 2020 and 39.1% higher during winter 2021 than during the corresponding periods in 2019. This increase was more pronounced in girls; during winter 2021, suspected suicide attempt visits to the emergency room were 50.6% higher among girls ages 12-17 than during the same period in 2019.

polya_olya/Shutterstock.com

A confluence of factors

Research indicates that mental health concerns and suicidality have been increasing in children and adolescents for years. The current crisis cannot be linked to any singular cause, but it is evident that the isolation and anxiety of the pandemic added an accelerant to an already burning flame.

Renee Turner, a licensed professional counselor (LPC) in San Antonio, points to several factors she believes have been detrimental to child and adolescent mental health. Although she declares she is not by any means anti-technology, Turner admits she is concerned about the influence of social media, which not only continues to feed cyberbullying — which, unlike “old-school” offline bullying, is inescapable and omnipresent — but also encourages children and adolescents to view the world through an artificial lens, she says. “Children don’t have the ability to sort out what is real, what’s true,” and many parents are not teaching them how to consume online content in context, explains Turner, a registered play therapist supervisor. Technology is all-consuming, and many parents do not monitor or restrict their children’s screen time.

For that matter, Turner notes, many adults struggle with their own screen addictions. She believes this contributes to another modern problem: attachment issues. The rise of dual-income families, in which parents work demanding hours or multiple jobs for financial reasons or because of career demands, makes it more difficult to find time for bonding, she asserts.

Turner also considers the pressure of living in such an achievement-oriented society another potential factor in the increase of suicidality among this population. “I see kids who are chronically overscheduled,” she notes. These young people are involved in myriad activities in consistently competitive environments in which achievement is conflated with self-worth, Turner points out. “It’s all [based on] their output, instead of them being valuable for just being them,” she says.

Turner, the director of Expressive Therapies Institute PLLC, has counseled middle school-age children who are already anxious about how they’re going to get into college. The demands on their time are such that they are staying up late into the night to get everything done, she says. What really stands out for Turner is that some of her clients who are in middle school and younger are self-harming and suicidal because they see no end to the treadmill they find themselves on. The COVID-19 pandemic further complicated the situation, she says, because children and adolescents struggled with online schooling even as parents tried to juggle working from home, taking care of the kids and helping with schoolwork.

Turner stresses that children and adolescents need to have areas of their lives that exist simply for enjoyment — not performance. “If everything is evaluated, everything becomes work,” she observes.

Sarah Zalewski, an LPC who specializes in child and adolescent counseling, was working as a school counselor in a Connecticut middle school at the beginning of the pandemic. She noticed that the coronavirus restrictions had a profound effect on her clients and on students. “The kids who were in virtual schooling and separated from their peers struggled way more than those in school,” she says. “That routine and the connection with their peers is almost like a distraction from the stuff that is going on in their heads.” Things that had been on a “low boil” suddenly flared up, she says.

Children and adolescents also seemed to struggle with the loss of familiar routines, Zalewski adds. Interestingly, she noticed that students who had been perennially overscheduled before the pandemic had a particularly hard time coping.

Catherine Tucker, a licensed mental health counselor in North Carolina and Indiana who specializes in trauma therapy for children, adolescents and adults, notes that early adolescence (approximately 11 to 14 years) is a particularly vulnerable time. “One of the normal developmental pieces [during early adolescence] is that every generation thinks they’ve invented all the normal problems, such as peer pressure, sex, bullying, dating. They feel like nobody older than them can possibly understand what is happening to them,” she says. As a result, adolescents often feel seen and understood by their peers but not by adults, especially their parents, notes Tucker, an American Counseling Association member and a licensed school counselor at the middle school level. This is a vital source of emotional validation that adolescents have been missing while separated from their peers, she points out.

Tucker also thinks that we’re underestimating the value of physical contact. “Just basic touch; it doesn’t have to be intimate. Just being near other people. The more we find out about neurobiology, the more we learn that things like eye contact, physical gestures and cues can help regulate the nervous system,” she says.

Marginalized populations are at an even greater risk for mental health issues and suicide, and the disproportionate toll of COVID-19 on Black, Indigenous and people of color communities has been an exacerbating factor. Brenda Cato, a professional school counselor who has experience with elementary, middle and high school students, says many of the students at her predominantly Black high school in Augusta, Georgia, saw school not as a social event but as an escape. Most of her clients come from impoverished homes where parents are working multiple jobs and utilities are skyrocketing. At school, these students get two meals a day. Cato believes not being able to get these meals during the pandemic played a significant role in students’ general inability to cope.

Working with parents

The counselors interviewed for this article contend that educating parents is a vital part of addressing the suicide crisis among children and adolescents. Learning the warning signs of suicide and knowing what to do if a child becomes suicidal is crucial for parents, but it all begins with establishing communication and a sense of trust and safety. “The most important thing is to be able to establish a safe … [environment] where your kid can come and talk to you,” Zalewski says.

She advises parents to schedule regular one-on-one time with their children. That might involve going out to eat ice cream together or playing games and talking, for example, but she emphasizes that the time should be spent without the parent being on their phone. It is important for children and adolescents to know that they have their parent’s full attention, she says. Zalewski also recommends having regular conversations in which the parent communicates that anything their child tells them in that time or space has no consequences.

Turner’s clients include overscheduled and single parents who often struggle with the idea that to truly be there for their children, they need more time — time that they don’t have. So, Turner emphasizes quality time to these parents. “It’s essentially meeting the child where they are,” she says. “Taking an interest in what the child is interested in and asking them about that, engaging in their world.” Turner suggests parents have “date nights” with their kids and schedule times when everyone shuts off their phones and puts them in a basket to create a distraction-free zone.

It can also be helpful to teach parents to establish “bursts” of listening time, Turner says. For example, when a parent is in the middle of something and a child is saying, “Mom, Mom, Mom,” the parent can reply, “OK, I have five minutes right now, so tell me what you need to tell me.”

Of course, parents may struggle with how to respond appropriately when they find out that their child is experiencing a mental health crisis, especially if the child says, “I don’t want to live anymore.” Zalewski reminds parents that it is important to first take a moment to listen to their child. She then advises parents to say something that lets their child know they are there for them. For example, “Thank you for telling me. That was a brave thing to tell me. Do you want to tell me more about that?”

Zalewski then helps her clients plan for the next steps. “It doesn’t need to be a heavy-handed thing,” she says. Parents can use language such as “We are going to collaboratively figure out what our next steps are. I don’t want you to feel that way, and I want to keep you safe.” The child and parents can then discuss options.

She adds that parents should ask one crucial question: “Are you able to keep yourself safe?” If the child isn’t sure, she advises parents to say, “I think maybe we need to go to the hospital and see if the counselor there can give us some ideas.” In many states, clients can call 211 to reach appropriate health agencies and even request that a mobile crisis unit come to the home to help establish a crisis plan, she adds.

But even children and adolescents who have trusting and open relationships with their parents don’t always speak up when they’re experiencing suicidal thoughts. So, counselors need to ensure that parents recognize the warning signs, which are similar to those in adults. “What’s scary is that adolescents can be so much more impulsive than adults, especially … kids who have poor impulse control generally,” Tucker acknowledges. “There are fewer warning signs and fewer opportunities for intervention.”

Tucker emphasizes the importance of educating parents about reducing children’s access to means of suicide, such as having unlocked firearms and medications in the home.

“The warning signs that I look for are not necessarily different than [those for] adults but are often written off as ‘teenage behavior,’” Zalewski says. For example, withdrawing may be either a warning sign or simply a wish to be alone. Parents should look for major changes in their child’s behavior in areas such as eating, sleeping and socializing, she says. Giving away prized possession is also a major red flag, she adds.

Zalewski stresses that parents should not dismiss a child’s statement of wanting to hurt or kill themselves. “So many parents have said, ‘I thought this was just them expressing themselves for attention.’ If this is your kid’s way of getting attention, you need to pay attention and find out why they are using those words,” she says.

Zalewski also urges parents to honor their intuition: “If you think there is a problem,” she says, “there probably is.”

Teachable moments

Cato faced a different kind of challenge when educating parents of students who had been identified as suicidal. “I was working in a predominantly Black elementary school, and a teacher sent a child to me who had been making suicidal comments,” she recalls. After assessing the student, Cato called the grandmother, who was the child’s guardian. The woman was irate and asked how many students in the school had been tested for suicide. Cato reassured the grandmother that the school didn’t test — it assessed. This taught Cato the importance of educating parents on suicide rates and the percentage of children who attempt or die by suicide.

Cato didn’t approach the situation with the student’s grandmother from the attitude of “your kid is suicidal, and you will get help.” As a parent herself, she knew that if she didn’t understand what was happening with her own child, she would want someone to walk her through it. So, Cato sat down with the grandmother and explained that her granddaughter wouldn’t necessarily be put on medication or need ongoing therapy. However, Cato recommended that the child be seen by an expert. She told the grandmother that the school just wanted to make sure the child was OK and that she wouldn’t harm herself. Cato also reassured her that her granddaughter would not be stigmatized or labeled as a “problem” student, nor would a note be put in her permanent record. “I think everything is about how you communicate with people,” Cato says. Besides, the grandmother’s concerns were understandable, she adds. Black students are commonly — and disproportionately — diagnosed with serious mental health issues, Cato says, adding that she has seen students of color sent to special education classes based solely on disciplinary issues.

After the student was medically cleared, Cato worked with the student to create a reentry plan that included regular check-ins. These were sometimes as simple as walking casually with the child and asking her to rate her day on a scale from 1 to 10.

Cato tries to turn all her interactions with students and parents into teachable moments. She provides them with pamphlets, resources and crisis hotline numbers, and every time she visits a classroom, she reminds students that the counselors and teachers are there for them. She says she tries to “help them to understand it is not abnormal to feel this way.” She purposely uses “we” when she speaks to students: “We’ve all gone through rough times; we all need help sometimes.”

Zalewski believes it is essential to also point out and honor the resilience strategies that children are already using. If listening to music helps a child or makes them feel better, then it is a good coping skill, she says. Discovering coping strategies helps build children’s confidence, she notes, and she informs parents of their children’s coping strategies too.

For that matter, Zalewski has found that her young clients often love to teach the strategies they have learned in session to their parents. In fact, to encourage clients to practice a skill outside of session, she recommends that they teach their parents how to correctly take a deep breath and explain what deep breathing does to the brain to calm the body. “Because then we’re helping parents regulate, [and] then we are co-regulating,” Zalewski says. “It can also really give a child a sense of self-efficacy that a lot of kids are lacking because kids are inherently powerless.”

She also works with clients on mindfulness, guided imagery, progressive relaxation, and identifying what physical activities they enjoy and why. For example, a child might like to play basketball in the driveway, but in Connecticut, snow often gets in the way. So, Zalewski helps them figure out the source of their enjoyment: Is it the physical energy they’re expending? Is it the repetition? They then come up with alternatives such as using weights in the basement. Zalewski is a firm proponent of anything that can get clients moving and (when possible) outside. “Nature is reparative for most humans,” she notes.

Tucker says that before the pandemic, children and adolescents were already experiencing stress related to a lack of connection, which she thinks could be associated with too much screen time. As children and adolescents begin to return to in-person activities, it is crucial to make sure they strike a healthy balance between screen time and social activities such as playing sports, working on art projects or simply hanging out together, she stresses. She also believes that the currently common practice of banishing recess in favor of test preparation or other extra classroom work has contributed to children’s anxiety levels. She argues that kids need a lot more time dedicated to free play and imagination.

Helping the helpers

Julia Whisenhunt, an LPC and certified professional counseling supervisor, specializes in studying and training others in suicide prevention. She always frames her workshops around suicide data to “help people understand that [suicide] isn’t uncommon.” Her goal isn’t to normalize the idea of suicide but rather to let people know that it happens and there is help.

“I know there’s an assumption that talking about suicide makes people suicidal, but the research doesn’t bear that out,” notes Whisenhunt, an ACA member who is an associate professor in the counseling department at the University of West Georgia (UWG). “I think it’s the opposite. I’m confident that trainings have saved lives and helped individuals. I know that. I’ve lived it. The suicidality is there — people are just struggling in silence.”

It is important when training people who are not mental health professionals to emphasize that their role is not to “save” an individual who is suicidal but rather to get them help, Whisenhunt adds.

Although Whisenhunt’s workshops are geared toward college staff (and students in positions of authority, such as resident associates), she is trained in Applied Suicide Intervention Skills Training (ASIST), which can be used to train staff in public school districts. ASIST is a 14-hour training created by the company LivingWorks that is grounded in research, Whisenhunt says. UWG’s counseling department does ASIST training with practicum students, and Whisenhunt says they report feeling much more confident once they have taken the course, even though they have already learned a good deal about suicide in their program.

One of the main components of ASIST is the “pathway for assisting life,” Whisenhunt explains. “They have a model for how to have a conversation about suicide with someone.” She tells practicum students that this is a model that summarizes everything they already know, but it presents the information in a format that is easy to keep at hand in a crisis.

The first part of the model is about connecting with suicide, she says. It has two main tasks: exploring indications of suicide risk and then spotting warning signs and naming them. Once warning signs are identified, trainees learn to act directly without beating around the bush, Whisenhunt says.

Whisenhunt and her follow trainers also instruct workshop participants on how to talk about suicide and what to do if someone is expressing suicidal thoughts. She warns participants not to ask, “Are you thinking of hurting yourself?” because that could mean many different things to the person. Instead, she encourages training participants to be direct and not be afraid to use the word “suicide.” For example, they could ask, “Are you thinking of killing yourself? Are you thinking of suicide?”

She also advises them not to ask leading questions. “If you ask, ‘You’re not thinking about suicide, are you?’ the person knows the answer you want them to give,” Whisenhunt explains. “If the person seems hesitant, trust your gut, talk a bit more, make them feel more comfortable, and circle back around.”

She also tells people to keep asking about suicide. Don’t just ask once and feel “relieved that you got that out of the way,” she insists. “If you felt like you needed to ask and the answer doesn’t feel right, ask again,” she says. “A lot of people don’t want to die — they just want the pain to end. Help them know there’s another way out.”

Counselors also need to be prepared to provide resources, Whisenhunt adds. She advises her trainees to keep hotline numbers in their phones and to carry suicide prevention cards in their wallets.

“When talking with an individual and hearing about their despair, chances are you are going to hear something that means that they don’t want to die. It’s often something like, ‘I don’t want to leave my dog,’” Whisenhunt says. “If you hear that little thing that says they don’t want to die, you don’t [want to] be manipulative, [but] you say, ‘I know that you’re in a lot of a pain, but it seems to me like you’re still thinking about living because you want to be there to take care of your dog.’ That’s the turning point — where they start to turn away from suicide and toward life.”

Counselors can then ask clients if they want to develop a plan to keep them safe for now, Whisenhunt continues. The use of the phrase “for now” is important, she stresses, because when people are in a suicidal crisis, talking about living for years and years is overwhelming to them. The safety plan should be for a matter of hours or days — just until the person can be connected with help, she explains.

The ASIST safety plan includes “safety guards” and “safety aids.” Whisenhunt says safety guards include protecting clients from risk factors such as a plan to die by suicide, problematic alcohol or drug use, prior suicidal behavior, or mental health concerns that might exacerbate risk. Counselors can help clients consider ways to mitigate these risks such as by reducing or eliminating drug use.

Guarding also involves being mindful and looking at previous suicide attempts for clues to keep the client safe, Whisenhunt adds. For example, the client might be impulsive, so part of keeping them safe involves having someone stay with them for a few days.

Safety aids are elements that help improve a person’s chances of staying safe, Whisenhunt explains. Counselors can help clients consider the strengths they already possess and the supports they need to build. “It’s strengths-based,” she says. “We try to help individuals see their strengths and resilience and see options to help them feel better.”

Being prepared

Counselors may be trained in suicide assessment and prevention, but putting that knowledge to use can still be a scary prospect, Zalewski acknowledges. For that reason, she stresses the importance of specialized training. If possible, she recommends that counselors find a local training opportunity with someone who can continue to serve as a resource for them afterward. She chose to work with a mobile crisis unit to learn more about helping those in suicidal crisis.

“There are a lot of modalities out there for suicide assessment,” Zalewski notes. “I would recommend not just picking one modality to learn. To be competent, you have to have a good understanding of what’s out there. Whatever you choose to work with has to mesh with you as a human. Explore what’s out there [and] learn several. … It’s well worth it, so when you are faced with some child who has decided they don’t really feel like living anymore, you’re not looking in your file cabinet or texting saying, ‘OMG.’”

Supervision is also essential, Zalewski stresses. “As counselors,” she says, “it’s easy to get to the point where you think, ‘I’ve been doing this for years, and I don’t need supervision.’” But that’s not the case. Sometimes, Zalewski says, she’s certain that she knows something, but supervision helps her realize that somewhere along the way, what she thought she knew got twisted.

Counselors also need to have their own sources of support when doing this difficult work. “If you’re working with children and adolescents who are suicidal, it is a heavy weight,” Zalewski acknowledges. “It is so easy to question yourself.” And if the all too imaginable happens and a client completes suicide, the counselor is going to need backup, she adds.

“Everyone in the end makes their own decisions,” she says. All that counselors can ultimately control is the level to which they provide clients with the best preventive tools, and “a good supervisor will help you assimilate that.”

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Laurie Meyers is senior writer at Counseling Today. Contact her at LMeyers@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.

Crisis counseling: A blend of safety and compassion

By Bethany Bray July 27, 2021

When crisis strikes, clients need a counselor who can listen and share their heartbreak without inserting themselves into the situation, says Amanda DiLorenzo-Garcia, an American Counseling Association member and mobile response coordinator for the Alachua County Crisis Center in Gainesville, Florida. She describes crisis counseling as a short-term intervention to an acute situation with a singular purpose: ensuring that the client is safe and feels seen and heard.

Clients need someone who is “willing to be there, be present and be uncomfortable,” she explains. “We can’t help to fix the situation; all we can do is help the client to withstand it, to survive it — and often that’s heartbreaking. It challenges our humanity. … We have to stretch ourselves to be able to hold space for the immense emotions of despair, grief, hopelessness and helplessness, and that can be really uncomfortable to do.”

Part of life

Crisis counseling is a specialty within the counseling profession, but it’s also a skill that all counselors need to master because crises will pop up in everyday life for clients in all settings.

Thelma Duffey and Shane Haberstroh, in the ACA-published book Introduction to Crisis and Trauma Counseling, explain that crisis “is often an immediate, unpredictable event that occurs in people’s lives — such as receiving a threatening medical diagnosis, experiencing a miscarriage or undergoing a divorce — that can overwhelm the ways that they naturally cope.”

Crisis can also occur when multiple stressors are present simultaneously in a client’s life and a seemingly small incident, such as losing their keys and getting locked out of the house, pushes them to “the end of their rope” and sends them into a tailspin, says Ruth Ouzts Moore, an associate professor in the Counselor Education Department at the Chicago School of Professional Psychology.

Shock, denial and disbelief are often the first emotions that clients experience in crisis situations, along with hopelessness and helplessness, says DiLorenzo-Garcia, who co-presented on “Breaking Through Barriers to Provide Effective Crisis Support” at ACA’s Virtual Conference Experience this past spring with Jessica L. Tinstman Jones and Amber Haley. A vast range of physical, mental, emotional and behavioral symptoms can indicate that a client is in crisis, she notes. (See list below.)

Moore defines crisis as the presence of a “risk of foreseeable harm” in a client’s life, either immediately or in the short term. The client may not automatically disclose this risk factor in counseling, however. Instead, their presenting concern can often be a “Band-Aid” or something more benign, she says, and it’s up to the counselor to “peel away the layers” to assess for risk. This can especially be the case with children, who may be referred to counseling for behavioral issues or because they’re falling behind at school. Sometimes, a crisis — such as abuse at home — may be the root cause of these struggles, notes Moore, an ACA member who specializes in working with children and adolescents who have experienced crisis and trauma.

Ali Martinez is a licensed marriage and family therapist and director of the Alachua County Crisis Center (where DiLorenzo-Garcia also works). In addition to mobile crisis response and in-person counseling services, the center operates a local 24/7 crisis hotline and responds to calls from their area of Florida to the National Suicide Prevention Lifeline. Most of the more than 45,000 calls the agency answers each year are from people who are feeling utterly alone as they face something that feels threatening to them, Martinez says. This includes losses that involve the death of a loved one as well as relational, financial and other losses.

“Most [callers] are not suicidal but are in some level of pain — experiencing something big that hasn’t been fully expressed, and they’re seeking space to do that,” Martinez explains. “They either are truly alone in what they are facing or feel alone in what they’re facing. They’re desperate for some sense of connection. They often know we can’t fix what’s happening — and that’s not usually what they’re seeking. …The struggle with crisis, what creates the danger and the true pain around a crisis, is the sense of how it disconnects us from people. The chaos, lack of control and strong emotions can make us feel alone. On the hotline, so often it’s trying to manage that chaos and find validation and connection — that what they’re feeling is a normal response to an abnormal situation. People often need someone outside their own world to let them know that what they’re feeling is OK and give them permission to express it.”

Crisis is self-defined

People can express their feeling of being in crisis very differently, but one common way that it manifests is tunnel vision, according to Martinez. In counseling, practitioners may hear a client who is experiencing a crisis speak with a narrowed scope or train of thought, returning to a singular experience or feeling over and over again.

Clients in crisis may feel like they’re drowning in emotions and that the issue that sent them into crisis is all-encompassing. Counselors may get the sense that their words are not getting through to the client because the client’s anger or despair is “filling the room,” Martinez says. Attending to the pain a client experiences during a crisis forces counselors to slow down their approach.

If counselors are “trying to get [the client] to look at the long term or take a bigger perspective and they can’t seem to do that and they keep coming back to that one painful thing, then we must change our approach and realize that this is the most important thing for them right now — and we have to listen for that,” Martinez says.

Above all, counselors must remember that “a crisis is defined by the person in it,” Martinez stresses. “For them, if it’s a crisis, it’s a crisis, and we have to honor that. Be aware that in that moment, we might have a much broader perspective on the possibilities [in the client’s life] and we might have good ideas about what could happen, but they may not be ready to hear it.” One of the most powerful things a counselor can say to a client in crisis is “tell me what this means to you,” she adds.

Martinez gives an example of a 12-year-old adolescent who is devastated after their first romantic relationship ends in heartbreak. As an adult, it would be easy for a counselor to tell the preteen client that this is the first of many heartbreaks life will bring. However, the client won’t be ready to focus on larger lessons about relationships and self until the counselor has helped them attend to their initial pain and despair over the breakup.

“For them, this is everything — feeling rejection and shame, sadness and despair. It doesn’t make it any less of a crisis experience for them,” Martinez says. “We [counselors] have to go in understanding it from their thinking.”

Josh Larson, a licensed professional counselor (LPC) in private practice in Denver, agrees that crisis must be self-defined by the client. He previously worked as a crisis clinician and operations and quality assurance specialist at Rocky Mountain Crisis Partners, a nonprofit organization that answers calls around the clock for several crisis hotlines, including the National Suicide Prevention Lifeline.

“We would always assure the caller that what they feel is a crisis, is a crisis. For one person, it could be that their cat got outside and they haven’t seen [the cat] for two hours and they’re feeling suicidal. For someone else, it’s something much bigger or more layered,” says Larson, an ACA member. “As a practitioner, even if what the client is telling us wouldn’t be a crisis for us, if they identify it as a crisis, then we need to treat it as such.”

Freedom to speak authentically

There is no shortage of crisis counseling models and assessment tools in the professional literature for practitioners to draw from in their work with clients. The counselors interviewed for this article did not recommend any one particular model or framework over another. They instead encouraged practitioners to research and select the counseling approach that works best for their style and client population.

No matter the model — or even if no model is used at all — a competent crisis counselor should shape a session into an arc that begins with rapport building and ends with connecting the person with resources. This last step ensures that the client has a safety plan (if needed) and is aware of options for follow-up care, such as local counseling services, walk-in crisis clinics and emergency hotline numbers. In the middle of this arc, at the core and heart of the therapeutic interaction, counselors create a nonjudgmental and empathetic space for the client to talk about their situation and share their burden.

The client does most of the talking in crisis counseling sessions, with the majority of the time spent simply “letting them tell their story,” DiLorenzo-Garcia explains.

Given that some clients may experience suicidal ideation during a crisis, an important part of this work is becoming well-versed in suicide assessment. DiLorenzo-Garcia and the other counselors interviewed for this article recommend that practitioners weave questions about a client’s safety, including those focused on suicide assessment benchmarks and protective factors, throughout the conversation.

In some situations, crisis counseling can offer clients the much-needed freedom to make strong statements without feeling judged or censored, Moore notes. This includes the freedom to talk about feelings such as anger or thoughts of harming oneself that can have shame or stigma attached to them.

This was the case for a 15-year-old client Moore once counseled who had turned to drinking, taking drugs and other risky behaviors to deal with turmoil at home, including feeling powerless when his father was abusive toward his mother. In session, the teen, referring back to an invective his father had directed at him, asserted, “I want to be an asshole.” Moore didn’t flinch at the client’s use of profanity. Instead, she responded, “You’re not an asshole.” When she repeated her statement, the teen began to cry, releasing emotions that had been pent-up.

“He had a deep, deep level of anger, resentment and betrayal that we needed to talk through. He found freedom in being able to say those things in a safe environment,” Moore recalls. “It was freeing that he could speak so strongly and hear his counselor repeat it back.”

Many of the crisis calls DiLorenzo-Garcia’s team responds to are in the public schools. Sometimes they respond because a student has called the county hotline themselves, but most often it’s because a school staff member (a school counselor, principal, school resource officer or administrator) has called to request their help.

In such cases, DiLorenzo-Garcia often begins a one-on-one session with a student by explaining the context of why the school asked her to come and speak with them. She assures the student that they are not in trouble and that she’s there because people are concerned about them. For example, she may say, “This is what I’ve heard from your school counselor, but I’m curious what your perspective is. What’s going on for you?”

“That’s the door opener. I reassure them, ‘I don’t want to make any assumptions about you. Your experience is your own, and I want to understand,’” says DiLorenzo-Garcia, a postdoctoral scholar at the University of Central Florida whose dissertation was on the loss and growth experience of mass shooting survivors and their families.

If the client’s experience includes thoughts of suicide, allowing them to talk through how they truly feel can help both the client and counselor realize how serious those thoughts are, DiLorenzo-Garcia adds. Sometimes a client has thoughts of suicide but doesn’t want to die, which can be accompanied by feelings of shame or isolation. If a client has a concrete plan to end their life, talking that through can help determine whether or how soon the client might act on that plan — and the necessity for follow-up care.

Assessing client needs

Larson notes that a majority of the callers during his time at Rocky Mountain Crisis Partners were not suicidal. However, some callers would say at the start of the call that they were not suicidal, but as the conversation went on and they began to unpack the depth of their emotions, it would become clear they were in fact experiencing suicidal ideation, he says.

This aspect of crisis counseling is why it’s imperative for counselors to be familiar with and proficient in suicide assessment. A counselor should be able to assess for preparatory behaviors, substance use problems, a client’s internal and external coping mechanisms, and other benchmarks to determine next steps, including safety planning or follow-up counseling, DiLorenzo-Garcia says.

Moore says it is important to be knowledgeable about assessing for not only suicidal ideation but also homicidal ideation when clients are in crisis. She acknowledges that asking questions about homicidal intent can be uncomfortable for practitioners. However, counselors must keep in mind that when in crisis, clients could have thoughts about harming others as well as themselves, she says.

“Be comfortable asking those difficult questions: ‘Are you having thoughts of killing yourself or harming anyone else?’ Don’t sugarcoat it,” says Moore, who presented the session “One Size Doesn’t Fit All: Creative Strategies for Counseling Diverse Families in Crisis” at ACA’s Virtual Conference Experience.

Larson points out that, along with active listening, validation of a client’s concerns and assurance of safety, de-escalation is a large part of crisis counseling. This can include mini versions of deep breathing and other grounding skills that clinicians might use in long-term counseling sessions with clients.

It can be helpful to match the person’s affect level, Larson says. For example, a counselor shouldn’t respond to a person who is hysterical with a flat, monotone voice. Instead, mirror them with a tone that is slightly calmer to gradually de-escalate the situation, he advises. Similarly, a crisis counselor shouldn’t respond to a client who is monotone or expressionless with a bright, bubbly demeanor. Instead, mirror their tone at a slightly more expressive level to gradually lift their affect, he says.

In crisis counseling, de-escalation and being presented with the opportunity to talk through what they are feeling will be enough for some clients, Larson continues. Others will be looking for help with problem-solving, such as conflict resolution or next steps to take after receiving a crushing health diagnosis. But Larson finds that clients in crisis are usually looking for one or the other, not both. Therefore, he advises counselors to be upfront and ask those in crisis, “What do you need? Do you want someone to listen or [someone to] help you problem-solve?”

“If you offer solutions to someone who is not wanting them, it can escalate them further into crisis,” Larson adds. Instead, he may tell clients, “I’m listening, and I’m willing to offer solutions if that’s what you’re looking for.”

In cases of suicidal ideation, DiLorenzo-Garcia finds it helpful to focus on the short term with clients. For example, she may say, “It’s a lot to ask you to live forever or live until next year, but right now, let’s talk about if you can live to tomorrow. What might that look like? Can you withstand the pain you’re going through just for tonight? What would it look like to survive and come back to school tomorrow?”

The counselors interviewed for this article emphasize that it is critical to arrange for follow-up support after crisis sessions but say that involving law enforcement to conduct welfare checks on a person in crisis should be done only as a last resort.

“Always follow up with a person who is in crisis, even if your session ends well and it sounds like things are going to work out,” DiLorenzo-Garcia stresses. Her agency contacts each client within three days after the initial crisis counseling session to make sure they are supported and doing well. In school settings, she also debriefs the adults involved in the student’s care (e.g., parents, school counselor) to ensure they are aware of the student’s needs and any next steps after a crisis counseling session.

Client safety

Meredith McNiel, an LPC who co-wrote the chapter “Crisis and Trauma Counseling With Couples and Families” in Introduction to Crisis and Trauma Counseling, notes that during crisis counseling, practitioners should focus on client safety through three lenses:

Feeling safe to express themselves fully in the crisis counseling session
Feeling safe at home and in the world outside of the counseling session
Feeling safe within their life, including protective factors and social connections

An important part of this focus, she says, is reminding clients (multiple times if needed) that the counseling session is a safe and confidential space to speak freely about what they are experiencing.

Clients may disclose dark and powerful thoughts, such as suicidal or homicidal ideation, during crisis counseling, and McNiel acknowledges that many counselors’ first instinct may be to refer these clients for more intensive care. However, practitioners need to push through this initial reaction to keep from breaking clients’ trust.

“If a counselor is worried or nervous or scared about handling a situation, the client will feel that,” McNiel says. “We need to be comfortable asking hard questions while keeping the client comfortable.” The counselor should allow the client to say what they need to in session and “hold that space” without trying to fix their situation, she stresses.

“In a suicide crisis session, many professionals might [automatically] think, ‘Where can we send you?’ and in my experience, that is an absolute last resort. If a client hears that they’re going to be hospitalized or referred out to someone they don’t know or trust, they can instantly lose trust with a counselor,” says McNiel, an ACA member with a private counseling practice in Austin, Texas. Instead, “allow the session to happen fully in the way the client needs to share or release and process, and go from there,” she advises. “I assure [the client] that if anything further needs to happen, we will decide that together. I will not take control of what’s going to happen. I remind them that they are in control of their circumstances.” (See more about the ethical guidelines regarding protecting clients from “serious and foreseeable harm” in Standard B.2.a. of the 2014 ACA Code of Ethics at counseling.org/ethics.)

Crisis counseling is “less clinical and more relational” than long-term counseling, explains McNiel, who was a crisis counselor at the University of Texas at San Antonio Academy for Crisis and Trauma Counseling during her LPC internship. Practitioners need to let clients share and talk through their experience “until it feels complete” — whatever that looks like for them.

To ensure that a client’s safety and comfort are the primary focus in crisis counseling, practitioners must be so familiar with assessment tools that they don’t need to read the questions off a piece of paper or computer screen, says McNiel, whose doctoral research was on college counseling work with students who were suicidal. “[Instead of] saying, ‘Hold on, I’m going to grab this checklist and ask you some questions’ … ask questions in a relational way and fill out the assessment afterward rather than stopping the flow of a session,” she says. Counselors should be “getting answers [from the client] through conversation rather than interrogation.”

For example, an assessment tool might prompt a counselor to ask the client, “Are you thinking about killing yourself?” Practitioners still need to ask direct questions about suicidal ideation, but couching those questions in a more conversational way aids in maintaining trust, McNiel notes. Alternatively, the counselor could say, “I can see and hear that you are really struggling with this situation. You’ve shared with me that you have thoughts about killing yourself, and that makes sense considering what you’ve been through. I’m wondering how close you are to doing that? How close are you to going home and following through [on those feelings]?”

“The difference [in phrasing it this way] is the compassion in the language surrounding those really heavy questions,” she notes.

At the conclusion of a crisis session, counselors should talk through next steps with the client, including addressing what the client would do if things became worse and a crisis resurfaced after the session, McNiel says. If the individual is a long-term client, she advises scheduling their next session and letting them know how and when to reach the counselor during nonbusiness hours, as well as providing crisis hotline numbers.

Martinez agrees that in crisis counseling, practitioners should resist the urge to “fix” the situation the client is facing. In addition, counselors should avoid viewing it as a linear cause and effect. This includes thinking of suicidal ideation in binary terms of yes or no.

“We have to think of suicide in a much broader continuum, a range of pain and despair,” Martinez says. “[Society’s] fear and the stigma around suicidality makes us think about it as an on-or-off switch, but it’s more complicated than that.”

By definition, crisis is chaotic and messy, and the goal of a crisis counseling session is to de-escalate and share that burden, rather than organize or reorder it. Martinez illustrates this with a metaphor of a jumbled pile of sticks on the ground. A counselor’s instinct might be to gather the sticks and assemble a neat structure for the client, she says. Instead, crisis counseling involves allowing the client to pick up the sticks, one by one, and assemble them however they need to — even if it’s just into another pile on the ground that, to an outsider, looks equally as messy. “That’s much more powerful than us trying to figure out where the sticks belong,” Martinez says.

If a counselor approaches a crisis counseling session with the goal of tracking a client’s story in context, the counselor will miss the client’s full range of emotions — and the chance to connect and help the client bear that pain, Martinez says. “We can get caught up in [feeling that] ‘I need to make sense of the story.’ But that’s our need, our desire. The client may not need that or be ready for that. … When they talk and are listened to, they often begin to make sense of it themselves.”

Take Care of Yourself

The counselors interviewed for this article agree that it is imperative for practitioners who engage in crisis counseling to take steps to avoid burnout. In addition to regular self-care, this can include ongoing supervision or consultation with colleagues as well as other methods to combat feelings of isolation and empathy fatigue that can easily overwhelm practitioners whose clients share such heavy and troubling topics.

Moore suggests counselors take steps to maintain a balanced caseload and stay aware of how stress and burnout manifest for them personally. “Doing trauma and crisis work is heavy stuff. It can be super rewarding but super draining,” Moore says. “We carry [clients’] trauma with us, so it’s important to take care of ourselves. … Sadly, we need more and more counselors to do crisis work, and if you don’t take care of yourself, that’s one less counselor to help people who need it.”

It’s also important to remember that sharing the burden of crisis with clients is a gift, Larson says. A crisis counselor may be the only person the client feels they can talk to during their lowest moments.

“It takes a lot of courage to pick up a phone and tell a stranger [a crisis counselor] that you want to die,” Larson says. “Always remember that it’s an honor and privilege to hear people’s hardest stuff — their deepest, darkest secrets.”

fran_kie/Shutterstock.com

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Contact the counselors interviewed in this article:

Amanda DiLorenzo-Garcia: amanda.dilorenzo@ucf.edu
Josh Larson: josh@emotional-nutrition.com
Ali Martinez: amartinez@alachuacounty.us
Meredith McNiel: dr.meredith@essencetherapyatx.com
Ruth Ouzts Moore: rouztsmoore@thechicagoschool.edu

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Crisis counseling via text message

People in distress send messages to the Crisis Text Line 24/7 looking for help and support. Its team of volunteers across the U.S. has had nearly six million chat conversations since the nonprofit organization was established in 2013.

How can aspects of crisis counseling be translated for use via text? Counseling Today talked with Ana Reyes, a licensed professional counselor and bilingual manager of clinical supervision at the Crisis Text Line, to find out more about the nuances of crisis counseling via text message. Read more in an online exclusive article here.

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