Tag Archives: Suicide

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.

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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: 

 

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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.

Taking a strengths-based approach to suicide assessment and treatment

By John Sommers-Flanagan and Rita Sommers-Flanagan July 7, 2021

When the word “suicide” comes up during counseling sessions, it usually triggers clinician anxiety. You might begin having thoughts such as, “What should I ask next? How can I best evaluate my client’s suicide risk? Should I do a formal suicide assessment, or should I be less direct?” In addition, you might worry about possible hospitalization and how to make the session therapeutic while also assessing risk. 

Suicide-related scenarios are stressful and emotionally activating for all mental health, school and health care professionals. Counselors are no exception. But counselors bring a different orientation into the room. As a discipline, counseling is less steeped in the medical model, more oriented toward wellness, and more relational throughout the assessment and intervention processes. In this article, we explore how professional counselors can meet practice standards for suicide assessment and treatment while also embracing a holistic, strengths-based and wellness orientation.

GoodStudio/Shutterstock.com

Moving beyond traditional views of suicide

Suicide and suicidality have long been linked to negative judgments. Sometimes suicide — or even thinking about suicide — has been characterized as sinful or immoral. In many societies, suicide was historically deigned illegal, and it remains so in some countries today. In the past, suicidality was nearly always pathologized, and that largely remains the case now. Defining suicide and suicidal thoughts as immoral or illegal or as an illness is an alienating and judgmental social construction that makes people less likely to openly discuss these thoughts and feelings. Most people experiencing suicidality already feel bad about themselves; socially sanctioned negative judgments can cause further harm.

Our position is that suicide is neither a moral failure nor evidence of so-called mental illness. Instead, consistent with a strengths-based perspective, we believe suicidal ideation is a normal variation on human experience. Suicidal ideation usually stems from difficult environmental circumstances, social disconnection or excruciating emotional pain. Improving life circumstances, enhancing social connection and reducing emotional pain are usually the best means for reducing the frequency and intensity of suicidal thoughts and feelings. 

Practitioners trained in the medical model tend to diagnose people who are suicidal with some variant of depressive disorder and provide treatments that target suicidality. Sometimes treatments are applied without patient consent. Health care providers are usually considered authority figures who know what’s best for their patients. 

In contrast to the medical model, a strengths-based perspective includes several empowering assumptions:

  • When painful psychological distress escalates, strengths-based counselors view the emergence of suicidal ideation as a normal and natural human response. Suicidal ideation is a reaction to life circumstances and may represent a method for coping with relentless psychological pain. 
  • Because suicidal ideation is viewed as a normal response to psychological pain, client disclosures of suicidality are framed as expressions of distress, rather than evidence of illness. Consequently, if clients disclose suicidality, counselors don’t react with fear and judgment, but instead welcome suicide-related disclosures. Strengths-based counselors recognize that when clients openly share suicidal thoughts, they are showing trust, thus creating opportunities for interpersonal and emotional connection.
  • Many people who are suicidal want to preserve their right to die by suicide. If they feel judged by health care or school professionals and coerced to receive treatment, they may shut down and resist. Instead of insisting that clients and students “need treatment,” strengths-based counselors recognize that clients are the best experts on their own lived experiences. Strengths-based counselors provide empathic, collaborative assessment and treatment when clients and students are suicidal.
  • Instead of relying on mental health diagnoses or asking symptom-based questions from a standard form such as the Patient Health Questionnaire-9, strengths-based counselors weave in assessment questions and observations pertaining to client strengths, hope and coping resources. Using principles of solution-focused counseling and positive psychology, strengths-based counselors balance symptom questions with wellness-oriented content.

We believe the preceding assumptions can be woven into counseling in ways that improve traditional suicide assessment and treatment approaches. In fact, over the past two decades, evidence-based treatments for suicide, such as collaborative assessment and management of suicide, have increasingly emphasized empathy, normalization of suicidality and counselor-client collaboration. An objectivist philosophy and medical attitude is no longer required to work with clients or students who are suicidal. Newer approaches, including the strengths-based approach discussed here, flow from postmodern, social constructionist philosophy in which conversation and collaboration are fundamental to decreasing distress and increasing hope.

A holistic approach

When clients disclose suicidal ideation, it’s not unusual for counselors to overfocus on assessment. In reaction to suicidality, counselors may begin asking too many closed questions about the presence or absence of suicide risk and protective factors. This shift away from an empathic focus on what’s hurting and toward analytic assessment protocols is unwarranted for two primary reasons. First, based on a meta-analysis of 50 years of risk and protective factors studies, a research group from Vanderbilt, Harvard and Columbia universities concluded that no factors provide much statistical advantage over chance suicide predictions. In other words, even if mental health or school professionals conduct an extensive assessment of client risk and protective factors, that assessment is unlikely to offer clinical or predictive value. Second, focusing too much on suicide risk assessment usually detracts from important relationship-building interactions that are necessary for positive counseling outcomes. 

Instead of overemphasizing risk factor assessment, counselors should identify client distress and respond empathically. Recognizing and responding supportively to emotional pain and distress will help individualize your understanding of the client’s unique risk and protective factors. From a practical perspective, rather than using a generic risk factor checklist, counselors are better off directly asking clients questions such as, “What’s happening that makes you feel suicidal?” and “What one thing, if it changed, would take away your suicidal feelings?” 

Additionally, as strengths-based practitioners, we should be scanning for, identifying and providing clients feedback on their unique positive qualities. Statements such as “Thank you so much for being brave enough to tell me about your suicidal thoughts” communicate acceptance and a reflection of client strengths. Although counselors may work in settings that use traditional suicide risk assessment protocols, they can still complement that procedure with a more holistic, positive and interpersonally supportive assessment and treatment planning process. 

To help counselors tend to the whole person — instead of overfocusing on suicidality — we recommend using a dimensional assessment and treatment model. Our particular dimensional model tracks and organizes client distress into seven categories. Here, we describe each dimension, offer examples of how distress manifests differently within each dimension, and identify evidence-based or theoretically robust interventions that address dimension-specific distress.

The emotional dimension: Clients who are suicidal often experience agonizing sadness, anxiety, guilt, shame, anger and other painful emotions. Other times, clients feel numb or emotionally drained. Focusing on and showing empathy for core emotional distress or numbness is foundational to working with these clients. Clients also may experience emotional dysregulation. Interventions to address emotional issues in counseling include traditional cognitive behavioral therapies for depression and anxiety, existential exploration of the meaning of emotions, and dialectical behavior therapy to aid clients in emotional regulation skill development.

The cognitive dimension: Humans often react to emotional pain with maladaptive cognitions that further increase their distress. Hopelessness, problem-solving impairments and core negative beliefs are linked to suicide. Depending upon each client’s unique cognitive symptoms and distress, strengths-based counselors will begin by responding with empathy and then, if needed, work with hopelessness in the here and now as it emerges in session. Counselors may also initiate problem-solving strategies, emphasize solution-focused exceptions and teach clients how to notice, track and modify maladaptive thoughts.

The interpersonal dimension: Substantial research points to social and interpersonal difficulties as factors that drive people toward suicide. Common interpersonal themes that trigger suicidal distress include social disconnection, interpersonal grief and loss, social skills deficits, and repetitive dysfunctional relationship patterns. Interventions in the interpersonal dimension include couple or family counseling, grief counseling, social skills training, and other strategies for enhancing social and romantic relationships.

The physical dimension: Physical symptoms trigger and exacerbate suicidal states. Common physical symptoms linked to suicide include agitation/arousal, physical illness, physical symptoms related to trauma, and insomnia. Using a strengths-based model, counselors can collaboratively develop treatment plans that directly address physical symptoms. Specific interventions include physical exercise, evidence-based trauma treatments, and cognitive behavior therapy for insomnia.

The cultural-spiritual dimension: Cultural practices and beliefs alleviate or contribute to client distress and suicidality. Religion, spirituality and a sense of purpose or meaning (or a lack thereof) powerfully mediate suicidality. Specific cultural-spiritual themes that trigger distress include disconnection from a community, higher power or faith system. A sense of meaninglessness or acculturative distress may also be present. Strengths-oriented counselors explore the cultural-spiritual and existential issues present in clients’ lives and develop individualized approaches to addressing these deeply personal sources of distress and potential sources of support or relief.

The behavioral dimension: Clients and students sometimes engage in specific behaviors that increase suicide risk. These may include alcohol/drug use, impulsivity and repeated self-injury. Having easy access to guns or other lethal means is another factor that increases risk. Helping clients recognize destructive behavior patterns, develop alternative coping behaviors and decrease their access to lethal means can be central to a holistic treatment plan. Additionally, collaborative safety planning is an evidence-based suicide intervention that focuses on positive coping behaviors. 

The contextual dimension: Many larger contextual, environmental or situational factors contribute to distress in the other six dimensions and thus heighten suicidality. These factors include poverty, neighborhood or relationship safety, racism, sexual harassment and unemployment. Helping clients recognize and change contextual life factors — if they have control over those factors — can be very empowering. Clients also need support coping with uncontrollable stressors. Developing an action plan and discerning when to use mindful acceptance may be an important part of the counseling process. Advocacy can be particularly useful for supporting clients as they face systemic barriers and oppression. 

Suicide competencies

Regardless of theoretical orientation or professional discipline, mental health and school professionals must meet or exceed foundational competency standards. In this article, we recommend integrating strengths-based principles, holistic assessment and treatment planning, and wellness activities into your work with individuals who are suicidal. Our recommendation isn’t intended to completely replace traditional suicide-related practices, but rather to add strengths-based skills and holistic case formulation to your counseling repertoire. 

When adding a strengths-based perspective into one’s counseling repertoire, counselors should remain cognizant of the usual and customary professional standards for working with suicide. The American Counseling Association’s current ethics code doesn’t provide specific guidance for suicide assessment and treatment. However, suicide-related competencies are available in the professional literature. For example, Robert Cramer of the University of North Carolina Charlotte distilled 10 essential suicide competencies from several different health care and mental health publications, including guidelines from the American Association of Suicidology. 

Cramer’s 10 suicide competencies are listed below, along with short statements describing how strengths-based counselors can address each competency.

1) Be aware of and manage your attitude and reactions to suicide. Strengths-based counselors strive for individual, cultural, interpersonal and spiritual self-awareness. Self-care also helps counselors stay balanced in their emotional responses to clients who are suicidal. 

2) Develop and maintain a collaborative, empathic stance with clients. Strengths-based counselors are relational, collaborative and empathic, while also consistently orienting toward clients’ strengths and resources.  

3) Know and elicit evidence-based risk and protective factors. Strengths-based counselors understand how to individualize risk and protective factors to fit each client’s unique risk and protective dynamics. 

4) Focus on the current plan and intent of suicidal ideation. Strengths-based counselors not only explore client plans and intentions but also actively engage in conversations about alternatives to suicide plans and ask clients about individual factors that reduce intent.

5) Determine the level of risk. Strengths-based counselors engage clients to obtain information about self-perceived risk and collaborate with clients to better understand factors that increase or decrease individual risk.

6) Develop and enact a collaborative evidence-based treatment plan. Strengths-based counselors engage clients in establishing an individualized safety plan that includes positive coping behaviors and collaboratively develop holistic treatment plans that address emotional, cognitive, interpersonal, cultural-spiritual, physical, behavioral and contextual life dimensions.

7) Notify and involve other people. Strengths-based counselors recognize the core importance of interpersonal connection to suicide prevention and involve significant others for safety and treatment purposes.

8) Document risk assessment, the treatment plan and the rationale for clinical decisions. Strengths-based counselors follow accepted practices for documenting their assessment, treatment and decision-making protocols.

9) Know the law concerning suicide. Strengths-based counselors are aware of local and national ethical and legal considerations when working with clients who are suicidal.

10) Engage in debriefing and self-care. Strengths-based counselors regularly consult with colleagues and supervisors and engage in suicide postvention as needed.

The strengths-based approach in action

Liam was a 20-year-old cisgender, heterosexual male with a biracial (white and Latino) cultural identity. At the time of the referral, Liam had just started a vocational training program in the diesel mechanics trade through a local community college. He was referred to counseling by his trade instructor. About a week previously, Liam had experienced a relationship breakup. Subsequently, he punched a wall while in class (breaking one of his fingers), talked about killing himself, threatened his former girlfriend’s new boyfriend, and impulsively walked off the job at his internship placement. 

Liam started his first session by bragging about punching the wall. He stated, “I don’t need counseling. I know how to take care of myself.” 

Rather than countering Liam’s opening comments, the counselor maintained a positive and accepting stance, saying, “You might be right. Counseling isn’t for everyone. You look like you’re quite good at taking care of yourself.” 

Liam shrugged and asked, “What am I supposed to talk about in here anyway?” 

Many clients who are feeling suicidal immediately begin talking about their distress. Others, like Liam, deny suicidality. When clients lead with distress, the counselor’s first task is to empathically explore the distress and highlight unique factors in the client’s life that trigger suicidal thoughts and impulses. In contrast, with Liam, the counselor mirrored Liam’s opening attitude, accepted Liam’s explanation and explicitly focused on Liam’s strengths: his employment goals, his initiative to start vocational training immediately after graduating high school, his ability to care deeply for others (such as his ex-girlfriend), and his pride at being physically fit. 

After about 15 minutes, the conversation shifted to how Liam made decisions in his life. Instead of questioning Liam’s judgment, the counselor continued a positive focus, saying, “As I think about your situation, in some ways, hitting the wall was a good idea. It’s definitely better than hitting a person.” The counselor then added, “I don’t blame you for being pissed off about breaking up. Nobody likes a breakup.” 

The counselor asked Liam to tell the story of his relationship and the events leading to the breakup. Liam was able to talk about his sense of betrayal and loneliness and his underlying worries that he’d never accomplish anything in life. He admitted to occasional thoughts of “doing something stupid, like offing myself.” He agreed to continue with counseling, mostly because it would look good to his vocational training instructor. Before the session ended, the counselor explained that counselors always need to do a thing called “a safety plan.” During safety planning, Liam admitted to owning two firearms, and even though he “didn’t need to,” he agreed to store his guns at his mom’s house for the next month. 

After the first session, the counselor documented the assessment, the intervention and Liam’s treatment plan. The counselor’s documentation included problems and strengths, organized with the holistic dimensional model:

1) Emotional: Liam experienced acute emotional distress and emerging suicidal ideation related to a relationship breakup. Although he minimized his distress, Liam was also able to articulate feelings of betrayal and loneliness. 

2) Cognitive: Liam felt hopeless about finding another girlfriend. He was somewhat evasive when asked about suicidal ideation. Eventually, he acknowledged thinking about it and that if he ever decided to die (which he said he “wouldn’t”), he would shoot himself. Liam was able to participate in problem-solving during the session.

3) Interpersonal: Although Liam was distressed about the breakup of his romantic relationship, he agreed to consult with his counselor about relationships during future sessions. He collaboratively brainstormed positive and supportive people to contact in case he began feeling lonely or suicidal. Liam reported a positive relationship with his mother. 

4) Physical: Liam reported difficulty sleeping. He said, “I’ve been drinking more than I need to.” During safety planning, Liam agreed to specific steps for dealing with his insomnia and alcohol consumption. Liam was in good physical shape and was invested in his physical well-being.

5) Cultural-spiritual: Liam said that “it won’t hurt me any” to attend church with his mom on Sundays. He reported a good relationship with his mother. He said that going to church with her was something she enjoyed and something he felt good about.

6) Behavioral: Liam contributed to writing up his safety plan. He agreed to follow the plan and take good care of himself over the coming week. Liam identified specific behavioral alternatives to drinking alcohol and suicidal actions. He agreed to store his firearms at his mother’s home.

7) Contextual: Other than high unemployment rates in his community, Liam didn’t report problems in the contextual dimension. He said that he currently had an apartment and believed he had a good employment future.

Concluding comments

A holistic, strengths-based and wellness-oriented model for working with clients and students who are suicidal is a good fit for the counseling profession. In tandem with knowledge and expertise in traditional suicide assessment and treatments, the strengths-based model provides a foundation for suicide assessment and treatment planning. A detailed description of the strengths-based model is available in our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach, which was published earlier this year by ACA.

 

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John Sommers-Flanagan is professor of counseling at the University of Montana with over 100 professional publications, including Suicide Assessment and Treatment Planning, Clinical Interviewing and seven other books co-authored with Rita Sommers-Flanagan. Contact him at john.sf@mso.umt.edu or through his blog, which also offers free counseling-related resources, at johnsommersflanagan.com.

Rita Sommers-Flanagan is professor emerita of counseling at the University of Montana. Since retiring, Rita has shifted her interests toward suicide prevention, positive psychology, creative writing and passive solar design. She blogs at godcomesby.com/author/ritasf13 and can be contacted at rita.sf@mso.umt.edu.


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

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

The need for standardization in suicide risk assessment

By Gregory K. Moffatt April 14, 2020

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

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

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

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

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

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

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

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

Looking back

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

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

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

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

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

Risk assessment tools

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

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

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

How do we know our assessments are effective?

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

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

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

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

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

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

What we risk

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

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

A standard approach

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

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

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

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

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

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

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

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

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

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

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

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

Assessment of Abigail

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

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

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

Conclusions

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

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

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

 

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

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

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

When the caring is too much

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

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

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

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

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

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

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

What veterinarians are saying about mental health

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

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

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

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

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

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

Suggestions for all helpers

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

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

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

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

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

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

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

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

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

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

Conclusions

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

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

Resources

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

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

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

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

 

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

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

 

Letters to the editor:  ct@counseling.org

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

 

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