Tag Archives: Suicide

Coping with the loss of a supervisee to suicide

By Keith Myers September 11, 2023

two white flowers with black ribbon lying beside a lit tea candle

Marharyta M/Shutterstock.com

Four years ago, I awoke to an email from my supervisee. She thanked me for being a great supervisor, and I thought, “Oh good, she’s going to find another supervisor for a diverse perspective.” But then I quickly realized that this wasn’t a typical exchange. In the next few lines, she said she was ending her life. The tone was resolute and final.

When I read those words, everything stopped. My vision blurred. It felt like I had entered a dark portal that was transporting me into an empty, dark abyss; the portal disappeared behind me, removing any chance I had of getting out. I was stuck, floating almost outside my body. I was in shock.

Moments after the loss

The word supervisee feels so formal and professional, almost sterile. It falls short in describing my connection to this person I had lost. We had spent over 100 hours of supervisory time together during the three years I had been her supervisor. That’s a lot of time. Our relationship was primarily professional, but she had attended my dissertation defense and met my wife, so the professional sometimes merged with the personal.

In the moments after reading the supervisee’s email, my mind started to race with thoughts: Is this real? When did she send the email? Is she alive? Maybe she tried and failed. Is she in pain? How did I miss this? Why would she do this? I have her address; I’m going over there. I should call her.

There is something in our spirit that wants to deny the reality of a deep and sudden loss.
In the email, she thanked me for my supervision, my encouragement and mentoring, and she encouraged me to “fight the good fight.” My first thought was, “Easy for you to say.” But then I realized that it hadn’t been easy for her.

During supervision, she talked about being recently diagnosed with a mental illness and how challenging it was for her and how she didn’t want to keep living like that. I wanted to let her know she wasn’t alone, so I shared that I had witnessed how difficult it could be because I knew someone who had the same mental illness.

I also wanted to tell her that one of my close family members currently struggles with this mental illness, but I didn’t. Sometimes I wonder if disclosing that would have made a difference — not the difference of her dying or living but helped her feel less alone. But maybe that is just the natural feeling we get after loss where we think we could have done something more.

Advice for coping with suicide loss

I have lost several clients to suicide, but I have always been able to differentiate myself from my clients and their decisions and struggles, even ones that result in them ending their lives. I tell my counseling students, “Attach to the person. Detach from their outcomes.”

But the loss of my supervisee was different. It was unfathomable. Because I had been her supervisor, I felt a greater sense of responsibility to her, and this caused me to reflect more on how I could have done things differently. I think it’s natural to evaluate your role when things go wrong. With time and consultation with a mentor, I realized that I had done everything I could. But some of the weight of this loss still remains with me today.

Classes don’t prepare us to cope with client losses, much less the loss of a supervisee. So, I doubt anyone has received training on how to cope with this unless it has been by a mentor who has experienced something similar. Loss by suicide is something we should talk more about — for ourselves as humans and clinicians.

Losing my supervisee to suicide taught me a few things about grief and loss. Although my experience is unique to me, I hope that by sharing what helped during this difficult time, I can help other supervisors and counselors who may experience the loss of a colleague or client at some point in their careers.

Let yourself feel — without judgment. I realized early on that I needed to allow myself space and freedom to feel a host of emotions, such as sadness, hurt, anger, betrayal, guilt and empathy. I never thought this would happen to one of my supervisees, so allowing myself to experience these emotions without judgment helped me process what I was feeling.

We also have to remember that we need to embrace and process these feelings before we act or attempt to find a new purpose. After the memorial service, I sat in my car and thought about what I would do differently because of her death. But my emotional part spoke up and said, “You need to wait. You need to feel your grief before you discover some grand new purpose.” I am grateful I listened to that voice inside me. Allowing yourself to feel before thinking and doing is a healthy response to a shocking loss.

Seek support from others. In my 20-year career as a mental health counselor and 13 years as a counselor educator, I have realized that we do not talk enough about how therapists can cope when a client dies by suicide. So, when it happens, counselors often find there is little professional or peer support. I realize the loss of a supervisee is uncommon; anecdotally, I asked 12 supervisors who had a cumulative 290 years of supervisory experience, and none could recall ever losing a supervisee through suicide. Trust me, you would more than recall if it happened to you. It is forever etched in my heart and soul.

Many counselors receive supervision at the agencies or hospitals where they work. However, since I am an independently licensed counselor in private practice, I was not receiving weekly supervision when my supervisee died. I was just doing monthly consultation. But I knew that I needed more than a monthly check-in during this time, so I asked a colleague who is a trauma-trained supervisor to be my regular, weekly supervisor for the next several months. I knew it was important to have additional and consistent professional support through this season of my life. The supervisor knew about my loss and was always mindful of ways in which I might have been projecting my grief onto my clients or any traumatic countertransference I may have been experiencing. The supervisor was comfortable addressing and exploring these concerns with me if they arose.

I advise colleagues to join a suicide support group. I know that support groups can feel daunting for some, and there may be an issue where the therapist knows the clinician leading the group or has clients in the group. You could also talk to a friend who is a suicide survivor or reach out to your support systems or another mental health professional. Lean on the people who love and support you.

Begin or revisit individual therapy. In addition to supervision, it’s important to be in therapy when coping with suicide loss. I hadn’t seen my therapist in several months, but it helped me find relief and validation for how I was feeling. After I told her what had happened, she looked at me with a blank stare and said, “I never.” Those two simple words resonated with me and affirmed how I felt in that moment. I never thought it would happen either.

Counseling provided me with a safe space to express the unfathomable. It also served as an additional source of support and gave me insight and awareness I would not have had if I were only in supervision. My therapist helped me explore the helper part of myself, which provided perspective around this loss.

Change your perspective. Metaphors, sayings and stories can help us find meaning during difficult or confusing times and help us gain new perspective. For example, the metaphor “Grief is a stone you carry in your pocket” reminds me that grief is always with us, even in times when we don’t realize it is present. It also illustrates how sometimes grief is smooth and contains wonderful memories, but other times, it has sharp edges that can prick you.

After my supervisee died, I resonated with the saying, “What is grief if not love persisting?” This quote allowed me to see how my grief also illustrated how much I cared for this person. If I hadn’t cared, I wouldn’t have felt it so deeply.

Books can also be a great source of comfort. A colleague and friend suggested I read Albert Hsu’s Grieving a Suicide: A Loved One’s Search for Comfort, Answers, and Hope. I’m thankful for this recommendation because it helped me further process my grief and provided helpful examples from a survivor’s faith-based perspective — something that is important to me. Hsu explained that sometimes suicide survivors view their lives through the lens of the death: Everything becomes what happened before or what happened after the loss. On a spiritual level, that is my truth.

An ongoing process

In the months after my supervisee’s death, I found myself obsessively reading her email over and over again. It was like I felt obligated or compelled to memorize it. Maybe I thought that memorizing it would help me not forget her. I wish I could say that I don’t feel compelled to read it now four years later, but I still do. Every year on the anniversary of her death, I find myself reading it again. My therapist recently asked if part of me is still searching for something in her last words. I don’t know the answer to this question yet because I’m still processing through the loss. Grief is an ongoing process after all.

I hope that none of you will ever face a loss like this. But if you do, know that you’re not alone. Give yourself space to grieve and care for the person you lost and rely on the support of others while you try to find comfort and make meaning of the unfathomable.


Helpful resources

  • Grieving a Suicide: A Loved One’s Search for Comfort, Answers, and Hope by Albert Hsu, 2017
  • Myths About Suicide by Thomas Joiner, 2011
  • “Supporting survivors of suicide loss” by Dana M. Cea, Counseling Today, 2019
  • Why People Die by Suicide by Thomas Joiner, 2007


Keith Myers has worked in clinical mental health for almost 21 years and is the founding clinic director of Ellie Mental Health in Marietta, Georgia. He received his doctorate in counselor education and supervision from Mercer University. He is a licensed professional counselor, approved clinical supervisor and an adjunct professor with both Mercer University and Richmont Graduate University. Much of his research focuses on traumatic stress and military issues, which resulted in his first book, Counseling Veterans: A Practical Guide. He works with veterans, first responders, couples and trauma therapists who are experiencing secondary traumatic stress.

Counseling Today reviews unsolicited articles written by American Counseling Association members. Learn more about our writing guidelines and submission process at ct.counseling.org/author-guidelines.

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 culturally responsive approach to suicide assessment

By Lisa R. Rhodes September 6, 2023

A woman sits on a couch looking worried with hands covering mouth and nose. Across from her is a woman with a notepad and a pen.

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Although the overall suicide rate in the United States has been decreasing in the past few years, death by suicide among people in marginalized groups has been increasing at an alarming rate. According to data by the Centers for Disease Control and Prevention (CDC), American Indian and Alaska Native people had the highest suicide rate increase from 2018 to 2021 at 26%. Although the second highest suicide rate was among non-Hispanic white people, this was the only group to show an overall decline by 4%.

Other marginalized groups, particularly among youth and men, indicate areas of concern for mental health professionals. According to the CDC, suicide rates among Black youth age 10 to 24 increased 37% from 2018 to 2021, and the suicide rate among Hispanic men increased by 5.7% from 2019 to 2020, while the suicide rate among non-Hispanic white men decreased by 3.1%. Among Asian American and Pacific Islander communities, suicide was the leading cause of death for people ages 10 to 19 in 2020.

Heather Dahl-Jacinto, an assistant professor and counseling program coordinator in the Department of Counselor Education, School Psychology and Human Services at the University of Nevada, Las Vegas, says while clinicians should not generalize about the experiences of marginalized groups, researchers have found that there is an association between historical and racialized trauma and suicide risk.

“For those with marginalized intersectional identities (such as race/ethnicity, sexual orientation, social class, gender identity), there is an increased pattern of suicide risk in individuals,” she explains. “Understanding the intersectional identities of our clients and their own lived experience is vital to our work with clients.”

Socioeconomic factors associated with suicide

The COVID-19 pandemic and social injustices may have contributed to the rise in suicide rates in the past few years, especially among marginalized groups. Karlos Lyons, a licensed professional counselor (LPC) at Davis Counseling Center PLLC in Dallas, says during the pandemic the Black community struggled to come to terms with social isolation, loss of loved ones, ongoing health disparities and the racial unrest that spread worldwide in the wake of the murder of George Floyd.

Ana Sierra, an LPC in Washington, D.C., says many of her Latinx immigrant clients, who work as essential workers, were among the first to get sick with COVID-19. She notes these clients suffered because they lacked access to health care and lost their jobs when they got sick, which forced many of them to lose stable housing.

“Latinx men have a particularly hard time because in their gender role, seeking help or talking about their worries with others is a sign of weakness,” notes Sierra, founder and executive director at Ana Sierra Counseling/Consejeria PLLC, an all-Latinx, bilingual (English/Spanish) and bicultural group practice. When Latino men, who are viewed as the head of their household, cannot fulfill their responsibilities to their families they don’t feel validated and can be hit by intense feelings of uselessness, she explains.

“In the Asian community, we have experienced an increased risk of suicide among Asian Americans due to systemic factors during the pandemic,” says Wales Khoo, a licensed mental health counselor in New York and the clinical director at the Chinese American Sunshine House, a nonprofit that provides mental health services for the Chinese community. “These factors include economic hardship, financial insecurity, racism, discrimination, hate crimes and limited access to health care.”

In addition, immigrant youth may face significant pressure from their families and communities to excel academically, Khoo says, which can lead to mental health issues such as stress, anxiety and depression. This pressure is particularly intense for first-generation immigrants who “may feel their success or failure reflects on their family’s reputation,” he adds.

“Many Asian American youths also experience acculturation stress as they navigate the challenges of living in a culture that is different from their parents’ or their family’s culture,” Khoo says. “Conflict between generations or between cultural values can contribute to feelings of isolation, depression and suicidal ideation.”

Research shows systemic socioeconomic factors — specifically racism, discrimination and adverse childhood experiences — directly affect suicide rates among people of color, notes Dahl-Jacinto, whose research areas include suicide prevention and assessment and social justice issues in professional practice. In addition, these factors can prevent marginalized clients from seeking mental health services as they seek to thrive in a society that presents persistent obstacles.

The counselors interviewed for this article recommend counselors be open to learn about a client’s lived experience, which will help people from marginalized communities feel safe enough to trust the therapeutic process and make it easier for counselors to thoroughly assess for suicide risk.

Cultural responsiveness requires counselors of all backgrounds “to gain an understanding of the client’s worldview and experiences in concert with the client,” says Danica G. Hays, a professor of counselor education and educational psychology and the dean of the College of Education at the University of Nevada, Las Vegas. And this includes validating any experiences of oppression and disempowerment that clients may report. “Those experiences are real and can exacerbate any mental health issues a client may be facing,” she stresses.

Building rapport

Recent clinical research about suicide risk assessment and intervention shows that focusing on the counselor-client relationship and cultivating trust and rapport can go a long way when dealing with a difficult topic such as suicide, Dahl-Jacinto says. She stresses the importance of not making assumptions about a client’s personal identity; instead, she advises counselors to use the strategy of broaching in session to create a safe space that allows clients to feel comfortable sharing their story.

“When working with communities that are traditionally marginalized, making sure that the counselor is intentionally acknowledging these concerns is essential to building rapport,” she explains.

Suicide risks are multifaceted, notes Lyons, who specializes in treating Black adolescents age 12 to 18. Some young Black men, for example, may struggle with hypermasculine ideals that “dictate to them not to feel or process their emotions because they are boys,” he says, noting that these clients often report having trouble connecting with others and dealing with feelings of worthlessness.

Lyons says it’s important to help these young men find others who can serve as healthy role models. “Once a young man has a positive, corrective, emotional experience with another male role model, whether it be a father, uncle, friend or even a peer, typically their mental health outcomes improve,” he explains. “They now have a safe place where they can go for validation and approval.”

Counselors need to model unconditional positive regard for their clients to build rapport with them, Lyons adds.

“When broaching the topic of suicidal ideation, look for the root cause of ideation, rather than the symptoms,” he advises. “I like to use Abraham Maslow’s hierarchy of needs to assess what needs are not being met that may have led to mental health distress.” Lyons says many adolescents have experiences in school such as poor school performance, bullying, a lack of friendships and isolation, which may lead to them becoming more suicidal.

Lyons also uses age-appropriate games as a therapeutic tool to encourage dialogue with his clients. For example, he sometimes asks clients to play the Ungame, a noncompetitive board game that requires players to answer lighthearted or serious questions as they roll the dice and move around the board. “It fosters organic dialogue between the therapist and client, and it facilitates really healthy conversations that can lead to some extremely helpful therapeutic content,” he notes.

Lyons, who is a Black man, says that simply “showing up as a Black man” can often help him gain his clients’ trust. For many Black youth, working with a clinician who looks like them and lets them know they are the expert on their own lives often helps them feel comfortable to “share their own truth,” he says.

The majority of Sierra’s clients have immigrated to the United States, and she says they often do not understand how the country’s mental health system works. She uses psychoeducation to explain what therapy is, how it can help, the difference between having suicidal thoughts and a suicide plan, and the stigma of mental illness and suicide. She says the clinicians at her practice also discuss any fears clients may have about being treated for suicidal behavior and their immigration status. For example, immigrant clients are less likely to seek treatment because they fear it will affect their chances of becoming documented in the future or they fear being deported, she says.

The therapists at Khoo’s clinic also adopt a culturally sensitive approach that acknowledges and respects clients’ cultural background and values. Because suicide is frequently regarded as a taboo subject in the Asian community, he and his colleagues, who treat primarily Asian American and immigrant clients, address the Asian community’s apprehension and worries about suicide by creating a safe and comfortable atmosphere, as well as encouraging family engagement, which are important elements that aid in healing.

Demonstrating a genuine acceptance of a client’s struggles with oppression helps to build rapport and trust, says Hays, author of the recent ACA book Assessment in Counseling: Procedures and Practices (seventh edition). Counselors are then able to “define the broad spectrum of what suicidality is and note the relevant statistics based on the client’s cultural makeup.”

It’s also important to help clients see that many other people face suicidality and that through treatment, clients have access to resources that can help them to heal, she adds.

Evidence-based assessment tools

Dahl-Jacinto and Hays acknowledge that while no suicide risk assessment tool is free from cultural bias or is completely culturally responsive, there are some evidence-based, standardized suicide risk assessment tools that can be used to evaluate a variety of clients. The counselors interviewed for this article recommend the following assessment tools:

  • The Columbia-Suicide Severity Rating Scale helps physicians, mental health clinicians and other health care professionals assess suicide risk using a series of simple, plain-language questions. The Columbia Lighthouse Project, which distributes the scale, provides free training.
  • The Collaborative Assessment and Management of Suicidality is an assessment and intervention framework where the client plays an active role in identifying and addressing the drivers of suicide risk.
  • The Ask Suicide-Screening Questions assessment, produced by the National Institute of Mental Health, can be used for both adults and youth of all ages and provides four brief, direct questions to identify suicide risk. This assessment is also available in Spanish.
  • The Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 are self-administered assessment tools that assess the severity of depression and anxiety, respectively. Sierra recommends clinicians use the Patient Health Questionnaire-9 to learn more about a client’s symptoms and any suicidal thoughts and feelings they may be experiencing.

Because of the link between trauma and suicidality, Hays also recommends counselors conduct a trauma assessment. She suggests clinicians use the Adverse Childhood Experience Questionnaire for Adults or the Clinical Ethnographic Narrative Interview.

The counselors interviewed for this article advise clinicians to make suicide risk assessment a part of the intake process. Providing a comprehensive psychosocial evaluation allows practitioners to explore a client’s personal and family history, their social support network and other environmental factors, Khoo says, which helps clinicians gain a full picture of a client’s mental state and well-being, not just the symptoms they present in session. The evaluation can also give counselors insight into a client’s cultural traditions, spiritual beliefs and value systems, which can be useful in the assessment process and creating treatment and safety plans, he adds.

Protective cultural factors

A client’s cultural traditions and spiritual beliefs are important to consider when assessing suicide risk and are also an essential part of building a strong therapeutic alliance. Dahl-Jacinto says when counselors are working with clients who are experiencing suicidality, they want to make sure they have a good idea of potential protective factors in the client’s life, including ones from their cultural traditions or spiritual beliefs.

“I like to use the building blocks metaphor that we use in suicide research — each protective factor we can identify acts as a building block that builds a wall around our client, protecting them from harm,” Dahl-Jacinto explains.

Khoo says in some Asian communities, cultural traditions, religion and spiritual beliefs play a significant role in people’s lives. “Many Asian cultures have unique beliefs and practices around mental health and suicide, and incorporating these into the treatment process can help build rapport, enhance treatment engagement and increase the client’s sense of hope and resilience,” he notes. For example, therapists at Khoo’s practice might use storytelling, art or music to facilitate a dialogue and help clients connect with their cultural heritage, which can help them build a sense of pride and identity.

Sierra says the clinicians at her practice normalize talking about suicide and make counseling a safe and welcoming space for clients — one that is similar to how clients might seek guidance from pastors, folk healers and others in their community. “A therapist,” she stresses, “is one more helper in their circle.”


Suicide risk and prevention resources


Lisa R. Rhodes is a senior writer at Counseling Today. Contact her at lrhodes@counseling.org.

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.

Finding hope after surviving suicide

By Lisa R. Rhodes September 27, 2022


Rick Strait, a licensed professional counselor (LPC) in Southeast, Missouri, tried to take his life on his 20th birthday. It was July 18, 1993, and Strait, then a lance corporal in the Marine Corps, spent the morning at the beach with his wife and son.

“That [trip] was kinda my goodbye to her and my son,” Strait says. “She didn’t know what I was thinking.”

When the family returned home, Strait attempted to take his own life by suicide, but his wife interrupted him. After seeing how distraught his wife was from the experience, Strait made the decision to never try to take his life again. “And I never did,” he says. “I honored that.” 

Strait, the substance use division director and suicide prevention coordinator at the Community Counseling Center in Cape Girardeau, Missouri, says the combination of the death of his younger brother in a car accident only a few months earlier that year and ongoing family struggles became too difficult for him to handle. 

“I didn’t know how to move forward,” Strait says, noting that the pain and sadness he felt about his brother’s death was so deep that he didn’t know how to communicate his feelings to family or friends. “I did not want to talk to my parents about it because they were also struggling. I didn’t want to become a burden, so I kept it to myself.”

Strait says he also questioned his purpose in life and felt the weight of survivor’s guilt.

“I thought, ‘Why did he die and I’m still here?’” Strait recalls. “I took a lot of responsibility for my brother’s death, even though I had nothing to do with it. I was [living] in another state. I still felt I should have been there for my little brother.”

Strait remained silent about the attempt on his life for more than 20 years. He says shame and embarrassment kept him from seeking psychotherapy. But in 2016, he told his parents and his children and started treatment.

“Most people, they really don’t want to die; they just want the pain to end,” Strait adds. 

According to the counselors interviewed for this article, applying cognitive behavior therapy (CBT) and strengths-based therapeutic approaches can help suicide attempt survivors learn the skills to cope with the complexities of life and find hope for the future. (The term “suicide attempt survivor” refers to a person who has attempted suicide and lived, whereas the term “suicide loss survivor” refers to a person who has lost someone who died by suicide.)

Strait says that with the right support and professional help, suicide attempt survivors “can get through” the aftermath of a suicide crisis.

Safety first

Suicide prevention and reducing the rate of suicide have been important goals for many mental health organizations for decades. Although suicide is a leading cause of death in the United States, with 45,979 suicides in 2020, according to the Centers for Disease Control and Prevention (CDC), the number of people who think about or attempt suicide is even higher. The CDC reported that in 2020, an estimated 12.2 million Americans seriously thought about suicide, 3.2 million planned a suicide attempt and 1.2 million attempted suicide.

According to the 2018 article “Suicide risk and mental disorders” published in the International Journal of Environmental Research and Public Health, most suicides are related to psychiatric disease, with depression, substance use disorders and psychosis being the most relevant risk factors. The article also notes, however, that most people with mental health disorders will not die by suicide. 

Tammi Ginsberg, a licensed clinical professional counselor with a private practice in Woodsboro, Maryland, says suicide attempt survivors are usually referred to counseling after being taken to the emergency room following the crisis and undergoing a psychiatric evaluation. A psychiatric evaluation is often necessary to determine if there’s an underlying mental health issue that needs to be addressed, she explains. Suicide attempt survivors may also meet with a therapist and case manager at the hospital to determine if inpatient or outpatient care is required and what community resources for therapeutic treatment are available.

The counselors interviewed for this article say the immediate short-term goals of therapy are to establish a relationship based on trust and to ensure the client’s safety by creating a safety/crisis plan. Meeting these clients “where they are” in their recovery journey and bringing empathy to the therapeutic relationship are effective ways to establish trust, says Trish Torzala, an LPC at Stress Management & Mental Health Clinics in their Waukesha, Wisconsin, office. 

Strait, who is also a part-time adjunct faculty member at the Zero Suicide Institute in Waltham, Massachusetts, and a board member of United Suicide Survivors International, advises counselors to be genuine and to treat clients with respect. He says it is also important to affirm them for sharing their suicidal thoughts or the circumstances surrounding the attempt.

“It takes a lot of bravery and vulnerability to share something so intimate,” he says.

Ginsberg, president of the Maryland chapter of the American Foundation for Suicide Prevention, recommends counselors practice “active listening” — listening without interruption, judgment, opinions or solutions — with clients. This type of listening gives clients the space to “let you know what’s really going on,” she says. 

“A lot of times, [these clients] just want somebody to listen to them. They don’t want you to tell them how to fix it. They don’t want you to tell them that everything is going to be OK,” Ginsberg continues. “They don’t want you to tell them all they have to live for. They just want you to listen.”

And by being an active listener, counselors can help decrease the chance of clients making another attempt because “they feel heard, they feel seen, they feel normalized and they don’t feel alone,” she adds.

In regard to creating a safety/crisis plan, Strait and other counselors interviewed recommend the Stanley-Brown Safety Planning Intervention, developed by psychologists Barbara Stanley and Gregory Brown. Counselors and clients can use this tool collaboratively in session to create an intervention plan aimed at reducing the client’s risk for suicide. A safety/crisis plan is particularly important for suicide attempt survivors because, according to the Harvard T.H. Chan School of Public Health, a “history of suicide attempt is one of the strongest risk factors for suicide.” 

The Stanley-Brown Safety Planning Intervention includes having clients identify possible warning signs for suicide, proposed coping strategies, people they can contact for help during a crisis, professionals contacts or organizations that can provide care and support, and guidelines to keep them safe (for example, the removal of firearms from a client’s home).

Dealing with the distress 

After counselors establish trust and work with clients to create a safety/crisis plan, they can then help their clients examine the unique factors that may have led to the suicide attempt. A family history of suicide, mental health disorders or substance use disorders can contribute to the reasons why people try to end their lives. However, according to the counselors interviewed for this article, these factors can often be combined with a painful or significant life event, either past or present, that seems insurmountable. 

These life events could include, for example, the breakup of a relationship or marriage, financial or legal problems, childhood trauma or other forms of unresolved trauma, or the death of a loved one. The weight of this psychological angst often results in questions about the meaning of life and the rumination of negative thoughts and feelings, which, the counselors interviewed for this article say, can linger in the aftermath of a suicide attempt. 

Támara Hill, an LPC and owner of Anchored Child & Family Counseling in Monroeville, Pennsylvania, says many suicide attempt survivors go through existential anxiety and feel uncomfortable in their lives. Some suicide attempt survivors, for example, say they can’t find their purpose or meaning in life or that they can’t see their own personal value or worth. “They sink under their own negative thoughts about life and themselves,” she notes. 

Torzala, who specializes in suicide prevention, has found that some clients express feelings of shame and anger for surviving an attempt. Their survival makes them feel like a failure, she says. When discussing their suicide attempt, some clients have told her, “I tried this and it didn’t work. What’s wrong with me?” or “I can’t even get that right.”

Ginsberg, who has counseled suicide attempt survivors and their families for 15 years, says she has heard similar comments from clients. Some have told her, “I’m disappointed that I’m still here.” 

Clients also express feelings of hopelessness and negative beliefs about the self after a suicide attempt, says John Sommers-Flanagan, a professor of counseling at the University of Montana. For example, clients may say, “I’m a bad person. I’m worthless. No one will ever love me.”

In addition, suicide attempt survivors may have difficulties solving problems in general and problems related to their suicidal impulses in particular, Sommers-Flanagan notes. “They have trouble believing that there are any solutions or alternatives that will make them feel better,” he says. 

The emotional distress that these clients experience both before and after a suicide attempt can feel so immense that they often feel defeated and trapped, explains Sommers-Flanagan, a member of the American Counseling Association. 

Clients often struggle to see any options beyond their crisis and only want to escape the unbearable pain, Torzala adds, and the only option they can see is to end their lives.

Addressing negative thoughts 

According to Hill and Torzala, suicide attempt survivors often struggle with cognitive distortions and emotional dysregulation. Ginsberg says suicide attempt survivors can also carry unresolved wounds from childhood trauma that impact their mental health. These counselors use  CBT techniques to help clients process negative thoughts, gain insight into their emotions and come to terms with childhood wounds.

Hill, author of Understanding and Helping Suicidal Teens: Therapeutic Strategies for Parents and Teachers From a Trauma Therapist, once used the CBT triangle to help a female client understand the connection between the thoughts, feelings and emotions that led to her suicide attempt. The goal was to help the client process and reframe her thoughts and feelings to develop healthier behaviors. 

Hill asked the client to journal the thoughts and feelings she had leading up to her suicide attempt. She then reviewed the journal in session with the client and pointed out the client’s negative self-talk and explained the cognitive process — the connections between her thoughts and feelings — that led to her suicidal behavior. 

Hill, who is also a board-certified trauma therapist, provides an example of this cognitive process. Someone may engage in negative self-talk such as “I’m never going to be loved,” “I’m never going to be good enough” or “I’m a failure in life.” This talk, she says, may then lead to suicidal thoughts (e.g., “I’m never going to make it,” “I’m never going to be happy,” “I might as well kill myself”) and negative emotions and feelings (e.g., feeling lonely, depressed or despair). And these thoughts and feelings may result in a suicide attempt. 

After explaining this cognitive process, Hill worked with the female client in session to draw the CBT triangle and added the client’s thoughts, feelings and behaviors using the client’s cognitive process as a guide.

Once Hill’s client was able to see and understand her own cognitive process, they talked about what coping skills the client could develop to prevent her from making another attempt. For example, she could talk to a trusted friend or loved one or schedule a session with her therapist when she noticed she was engaging in negative self-talk. She could also attend a support group with others who share similar lived experiences or participate in a fun activity with a family member to lift her emotions. 

Hill also used the CBT triangle exercise to help the client develop a detailed safety/crisis plan that included the triggers and warning signs that could lead her to suicidal ideation and the supportive people and actions that could help her avoid causing further harm to herself or others. 

Torzala, who is trained in trauma-informed therapy and eye movement desensitization and reprocessing, often uses journaling and mood tracking to help clients better understand their emotions and recognize that feelings and emotions, especially negative ones, can be temporary. She asks clients to monitor and track their moods over the course of a few weeks and record how they are feeling two or three times a day at any time they choose. In session, Torzala helps clients explore their emotions and feelings to see if they felt a particular way at a certain time of the day and if something was going on in their life that could have triggered the emotional response. 

When clients are suffering from depression or a low mood, they can have a limited mindset that skews their perception of life and may lead them to believe that their negative thoughts and feelings will last forever, Torzala notes. But this exercise, she says, helps clients identify how they are feeling and recognize that a thought or feeling can be temporary. 

For example, after experiencing negative feelings or emotions earlier in the week, a client may say, “Yesterday, I was actually feeling OK and I had the motivation to take a shower and go to the store.” The recognition of a changed emotion, Torzala notes, can help clients realize that thoughts and emotions are fluid and can fluctuate and that their intensity can and will pass. 

The limited mindset that many of these clients have can be deceiving, Torzala continues, and can lead them to feel that suicide is the only option they have at that time to escape whatever pain they are feeling.

“What their mindset is leading them to is something so final,” she says. But clients can learn that what they are experiencing will eventually pass. 

Ginsberg, who has received suicide education and training through the American Foundation for Suicide Prevention, uses a journal exercise to help clients work through unresolved childhood trauma and help them feel empowered.

The unresolved childhood trauma they often carry leads to a lifetime of feeling insecure, irrelevant and not good enough, Ginsberg says. This affects clients’ self-esteem and self-worth, which could escalate into a mental health disorder and/or crisis, and, ultimately, a suicide attempt. 

In the journal exercise, Ginsberg asks clients to visualize a time when they felt unsafe, threatened, unloved, unappreciated or unseen as child. She then asks clients to write that child a letter and tell them something their adult self would like that child to know. The client, for example, could express love for the child or a willingness to protect them. They could also let the child know that now they are safe and whatever was threatening them in the past is no longer relevant, she says. 

“Through journaling, the hope is that the client will understand that the young child did what they needed to do to survive and that they didn’t have the power to stop the abuse,” Ginsberg explains.

Clients can feel empowered when they realize that they are no longer that child and they are no longer a victim, she adds, and as an adult, they now have a choice and can work toward healthy alternatives rather than attempting to take their life to resolve childhood and other life wounds. 

A strengths-based approach 

Sommers-Flanagan advises counselors to use a strengths-based approach to treat clients who have survived a suicide attempt. “We’ve traditionally pathologized suicidality and previous attempts and doing so tends to cultivate shame,” he says. “Instead, strengths-based approaches view suicidality as a normal response to very painful and difficult life situations.”  

Sommers-Flanagan, along with Rita Sommers-Flanagan, co-authored the ACA book Suicide Assessment and Treatment Planning: A Strengths-Based Approach, which outlines a seven-dimension model that allows clinicians to integrate solution-focused and strengths-based strategies into clinical interactions and treatment planning. They elaborate on this model in the Counseling Today article “Taking a strengths-based approach to suicide assessment and treatment” (published in the July 2021 issue). “Our approach doesn’t replace traditional approaches but complements or supplements them,” Sommers-Flanagan notes.

He also stresses that it’s important for clinicians to recognize that it will be challenging for clients to develop and practice strengths-based techniques. “What’s really important is to be alongside clients in their pain and encourage and support them to try these hard things that will, in some cases, feel unnatural for them because it involves them trying to be positive when they’re feeling so negative,” he says.

It’s helpful to let clients know that focusing on a strengths and resources approach takes time, Sommers-Flanagan adds. Letting clients know they will be supported in the process can help them move at their own pace and comfort level. 

The following strengths-based techniques, Sommers-Flanagan says, can be useful for clients before and after a suicide attempt. 

Normalize suicidal ideation and suicidal behavior. Counselors who work to normalize suicidal ideation and behavior can help clients see that suicidal thoughts and behaviors are a normal part of the human experience and that they happen because of acute pain, helplessness and distress. 

“Many, many people have suicidal thoughts, and frequently people who are having suicidal thoughts view suicide as a possible solution to their pain and distress,” Sommers-Flanagan says. “They feel they didn’t have any other options that would make the pain and distress go away.” 

He recommends counselors normalize suicidality so clients don’t feel labeled or judged and are more willing to speak openly and honestly about their lived experience. 

Express gratitude to others. Counselors can invite clients to establish a gratitude practice. They can suggest clients write a note to someone to express their gratitude or give that person a call, Sommers-Flanagan says. And if clients do not want to write or reach out to anyone, then counselors can ask them to sit and reflect on how it might feel to express meaningful gratitude. Gratitude practice is based on positive psychology principles and often works best when practiced once or twice a week, he adds. 

Engage in intentional acts of kindness. Sommers-Flanagan says the suicidal distress clients often feel can be so overwhelming that it is all they can see in their lives. Counselors can help clients refocus their attention by inviting them to engage in small acts of kindness toward others. He suggests counselors discuss these acts with clients in session and have them monitor whether their kind actions resulted in positive thoughts, feelings or experiences. 

Develop a mindfulness meditation practice. Counselors can discuss how mindfulness has been shown to prevent depressive relapses or the worsening of depressive symptoms, and then invite clients to develop their own meditation practice. Again, for clients who have survived a suicide attempt, developing a mindfulness practice may be difficult, Sommers-Flanagan notes, so whenever counselors prompt clients to integrate positive practices into their lives, empathy and encouragement are essential.

Focus on three good things. It is common for these clients — and other people — to ruminate over depressive thoughts at the end of the day and worry about what tomorrow will bring, Sommers-Flanagan says. To address depressive reviews of the day and anticipatory anxiety for tomorrow, clinicians can ask clients to name three good things that happened to them during the day and have them reflect on why those good happened to them before they go to bed. This activity helps clients begin a habit of positive thinking, he says, and they may learn to recognize how they create positive experiences in their life, rather than lamenting about any negativity. 

Supporting family members

The family members of suicide attempt survivors can also struggle in the aftermath of a suicide attempt. The counselors interviewed for this article agree that family members are often in shock and can experience feelings of guilt, shame, embarrassment and anger after their loved one’s suicide attempt.

Hill says the event often leaves families scrambling to understand the reason(s) behind why their loved one tried to take their own life. Family members may also be despondent over the fact that their loved thought of fatally harming themselves, she notes. And they may feel guilty and wonder what went wrong in the family to cause the attempt or why they couldn’t prevent it from happening.

After a suicide attempt, some family members become fearful that their loved one will make another attempt, says Ginsberg, who is a suicide loss survivor, so they may begin to obsessively monitor the person’s behavior. In fact, she says she’s had several family members of clients say, “I can’t leave them alone.” She recalls one client whose family member slept outside their bedroom door each night to listen for any signals of distress.

Sommers-Flanagan says cultural factors can affect how individuals and families respond to a suicide attempt. Some family members will shut down socially and isolate themselves from others because they feel ashamed and embarrassed. And families may respond by keeping the attempt to themselves because grieving outside of the family unit is not culturally acceptable.

The counselors interviewed for this article all agree that family members need support for their own mental health needs and clinicians should work with families to ensure they take advantage of mental health services.

“They [family members] are at a higher risk for having a mental health crisis themselves [because of] the stress that it puts on a family,” Ginsberg says. “They need somewhere safe to talk about their struggles without making [their loved one] feel guilty.” 

Ginsberg uses CBT techniques when working with family members of suicide attempt survivors to help them process their feelings and emotions. In one exercise, she asks family members to imagine the worst thing that could happen in relation to their loved one’s struggles. Ginsberg provides an example of a possible exchange that could occur between a counselor and the family member during this exercise. The counselor can start the conversation by asking: 

What is the worst thing that can happen? 

My loved one will take their life.

What will be the consequences of the worst thing that can happen?

I will be devastated and it will impact the rest of my life.

How have you coped in the past? What can you do to cope better this time?

My loved one has been struggling for a long time now. I have had to deal with fear and anxiety around their possible suicide attempt. It has caused me to be depressed and on edge all the time. I need to practice self-care. If I’m not in a stable mental place, then I will have a difficult time being present for them.

What is more likely to happen?

Because my loved one has a great support system and mental health services, it is likely they will not make another attempt and they will begin to heal.

So is it worth living in a place of fear all the time?

The reality is that I will still feel some fear, but I know that I’m doing everything in my power to help my loved one. I can only control my own actions and emotions and must surrender to those things that are out of my purview.

Ginsberg says the real fear many family members have is that if their loved one died by suicide, they wouldn’t be able to survive it or that they couldn’t live with themselves. So she uses this worst-case scenario exercise to help family members understand that if the worst thing did happen, they could handle it and that it’s no one’s fault. The exercise also helps family members recognize their own strengths in the midst of a crisis and shows them that they can develop the coping skills they need to move forward in life.

The counselors interviewed for this article agree that clinicians can use psychoeducation to educate families about suicidal ideation, mental health disorders, and the triggers and warning signs that can lead someone to a suicide attempt. They can also refer family members to support groups for suicide loss survivors and/or mental health organizations that can provide additional community resources.

The counselors also stress the importance of helping families realize that their loved one is in critical need of support from both the family and mental health professionals. They suggest counselors encourage family members to participate in creating their loved one’s safety/crisis plan and to keep a copy of the plan, along with the counselor and the client. 

Families need to remember that “the true victim” is the person who attempted suicide, Hill says. Suicide attempt survivors “don’t ever think, ‘How can I hurt my family?’ They just want the pain to stop,” she notes. 

And it is the responsibility of the counselor, with help from the family, to focus on the needs of the client, Hill adds.

Torzala, who is a suicide loss survivor, says family members can significantly help a suicide attempt survivor heal through empathy while understanding and validating their emotional struggle. She also states that family members should recognize their own emotions after a suicide attempt because this can be a traumatic experience for them as well. 

The need for proper training

When Strait decided to seek treatment regarding his own suicide attempt, he did not have a good experience with mental health professionals because they were not adequately trained to treat people with suicidal ideation.

 “I had a psychiatrist tell me that I had a good family [and that] everything would be OK, so I shouldn’t be sad,” Strait recalls. And “I had a counselor who told me they didn’t think I needed to talk about it [because] it had been years since my attempt.”

Some counselors, Strait says, are not comfortable talking about suicide because of the stigma that surrounds the topic. (See below for more on the stigma associated with suicide.) He says it is important for counselors not to panic or overreact when a client discusses their suicidal thoughts and negative feelings. 

Torzala has experienced the unfortunate fallout from counselors who were not prepared to treat these clients. “In the past, I’ve had clients who were fearful to disclose their suicidal ideation because of the past actions of former therapists,” she says. “After they disclosed suicidal ideation, the therapist contacted family members or authorities, and sometimes the client was sent to inpatient involuntarily. Suicidal ideation can be common with certain mental health disorders, and it’s important to normalize that with the client in order to openly discuss it. This is where suicide prevention happens.”

Torzala recommends clinicians work through their own fears and misconceptions about suicide so that they can feel comfortable discussing the difficult aspects of suicidal ideation with their clients.

Ginsberg also advises clinicians to seek out training opportunities with mental health organizations and continuing education programs to ensure that they have the skills necessary to help suicide attempt survivors and their families rebuild their lives. And if possible, counseling students can take suicide education courses in graduate school, Strait adds.

In 2016, Strait finally found a counselor who made him feel comfortable to begin treatment. The two worked together to reframe his cognitive distortions using CBT.

“The biggest thing is that he [the counselor] was comfortable talking about [suicide] and made it OK for me to talk about it,” Strait says. “I felt no judgment, no pity. I did feel compassion. He met me where I was at on the journey and helped me move forward.”



Resources on suicide prevention


The stigma of suicide 

Historically, suicide has been linked to tragic mental illness and has been considered to be criminal behavior, notes John Sommers-Flanagan, a professor of counseling at the University of Montana. This negative historical perspective has led to stigma surrounding suicide.

“Suicide has often been categorized as something only ‘weak’ or ‘emotionally vulnerable’ people do,” says Támara Hill, a licensed professional counselor (LPC) and owner of Anchored Child & Family Counseling in Monroeville, Pennsylvania. “I have had some clients call it ‘selfish’ or ‘cowardly,’ when the reality is that the person just wants their pain to stop — or the client is seeking some control over their own life.”

Chris Sandwell, an LPC and director of accreditation, training and certification with the American Association of Suicidology (AAS), says stigma comes from a lack of understanding or fear, which might explain why people don’t know how to support, understand or help a person in a suicidal crisis.

“The counseling profession can help provide a place where people can talk openly and honestly about their suicidal thoughts, provide alternatives to calling the police and threatening hospitalization and provide true collaboration with people who are [considering] suicide,” Sandwell argues.

In 2014, AAS designated a membership category for suicide attempt survivors to “create a seat at the table for suicide attempt survivors and people with lived experience of suicide,” Sandwell explains. Today, she says about 15% of AAS members are people who identify as having a lived experience of suicide, including attempt and loss survivors, and about 34% of AAS members are clinicians.

Rick Strait, an LPC and the substance use division director and suicide prevention coordinator at the Community Counseling Center in Cape Girardeau, Missouri, says he has experienced stigma from colleagues and other mental health professionals because of his own suicide attempt. 

When Strait first sought treatment to process his past suicide attempt, he says a friend, who is also a counselor, told him that he should never tell anyone about his suicide attempt because prospective clients would not want to work with him.

“When I first started sharing my story, I had professionals give feedback that maybe I shouldn’t be in this field or [that] I shouldn’t share my lived experience,” Strait says. “Ironically, almost every time I share my experience with professionals or do a training with professionals, I have a least one professional reach out to me and share their struggles, past or present.”

Strait says some of his colleagues have expressed fears about getting help for their past attempts or suicidal thoughts because of how it may impact their career. And others have shared about family members and how their struggles with suicidal ideation have affected them. 

Tammi Ginsberg, a licensed clinical professional counselor with a private practice in Woodsboro, Maryland, says suicide attempt survivors are stigmatized for the same reason that people with other mental illnesses are also stigmatized. “Quite frankly, it comes from a place of ignorance,” she says. “Making a suicide attempt is a serious symptom of a mental health condition, just like having a heart attack is a symptom of a serious cardiac issue. It’s just not seen the same way.” 

Counselors must take on the challenge of advocating for better mental health treatment and normalizing diseases of the mind, Ginsberg argues, and the counseling profession must insist that prospective counselors who are interested in working with this population get ample training.



Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.


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

Preventing veteran suicide

By Justina Wong September 9, 2022

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

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

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

What to know about veterans and suicide

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

Photo by Sgt. Agustín Montañez/defense.gov

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

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

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

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

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

Screening for triggers

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

Potential triggers could include the following:

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

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

Nontraditional ways to help veterans

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

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

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

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

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

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

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

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

Counselors must take action

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

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

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



Related reading, from the Counseling Today archives:

Suicide prevention strategies with the military-affiliated population

Advice for counselors who want to work with military clients



Justina Wong

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





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

Suicide attempt survivors: How counselors can help with disclosures

By Joan M. Flynn April 15, 2022

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

— sample disclosure script


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

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

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



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

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

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

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

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


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

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


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

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

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


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

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

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

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

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

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


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

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

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

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

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


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

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

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

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


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

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


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

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




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Scripting a disclosure: Conversation starters

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

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

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



Practice take-aways for counselors

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



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


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