Tag Archives: Suicide

Thriving, not just surviving: Un milagro de Dios

By Kelly M. Whaling July 18, 2016

“Catalina” (pseudonym used to protect the identity of the individual being interviewed) is not your typical medical student. Young, Dominicana and the first generation of her family born in washing machinesthe United States, she shoves her clothes into a washing machine in her apartment complex. Graciously, she answers questions about an epidemic in the Latina community: adolescent suicide.

According to the Centers for Disease Control and Prevention (CDC), in 2013, the United States saw one suicide every 13 minutes. A study conducted by Danice K. Eaton et al. in 2011 found that Latina adolescents attempt suicide at even higher rates than other gender and ethnic groups, with 14 percent of Latinas attempting suicide in a given year. This stands in stark contrast to attempts made by white adolescents (7.7 percent). A 2011 report by the CDC uncovered similar rates, with 20 percent of Latina adolescents reporting a plan to commit suicide and 11.1 percent attempting suicide.

Catalina tells me, “It’s just the nature of being an adolescent, wanting to fit in and being different in all of these ways. I’m not American enough, and I’m not Latina enough. It’s like trying to be one thing or the other, while being neither.”

This is not the first time that perceived differences, peer victimization and sociocultural factors have been linked to hardships in the Latina community. Furthermore, these hardships have been linked to increasingly common suicidal behavior in Latinas. In 2014, Andrea Romero, Lisa Edwards, Sheri Bauman and Marissa Ritter stated that levels of suicidality in the Latina adolescent community were epidemic. When reviewing the statistics, it’s truly a miracle of God (un milagro de Dios) that Catalina is alive — and not just alive, but thriving. Thriving with an education level that reaches far beyond her bachelor’s degree and with pride in her heart when she discusses the adversities that she faced growing up.

While navigating middle school and high school, Catalina contended with homelessness, poverty, the incarceration of a parent, the suicidality of a parent and her feelings of missing family members who had remained in the Dominican Republic. “I felt like my whole life, my way of coping with the bull—- was to put on this extremely tough exterior,” she tells me. “I don’t like to show weakness. It was adaptive because I had to be strong for my family.”

Painting a picture of what strength for her family looked like, and perhaps hinting at familismo as a protective factor against suicidality, Catalina laughs and says, “I feel like that was a lot of my issues growing up — this constant need to be tough and in control and be strong for my family. If people f—– with my sister, I would tell them I’d rip their face off. When I think back, I’m like, ‘Whoa, I was f—— insane.’”

All things considered, it doesn’t sound that “insane” to me. Given Catalina’s circumstances, it sounds adaptive. This was her coping mechanism to deal not only with family problems and problems faced by most adolescents, but also with struggles unique to being a Latina.

In a 2012 study paper, Allyson Nolle, Lauren Gulbas, Jill Kuhlberg and Luis Zayas suggested that a model of risk factors for suicidality in adolescent Latinas includes factors such as familismo, the adolescent’s own emotional vulnerability, acculturative stress, conflicts between the dominant culture and the culture of the family, immigration stress, socioeconomic status and gender roles.

Another possible factor that increases suicide rates in this population: Latina/os are less likely than other ethnic groups to seek mental health care. In 1999, William Vega, Bohdan Kolody, Sergio Aguilar-Gaxiola and Ralph Catalano found that less than 20 percent of U.S.-born Latinos searched for mental health services. That number decreased to 9 percent when specifically considering whether an individual sought care in a mental health care setting as opposed to general practice. Other barriers to receiving services for Latina/os include insurance issues, transportation and stigma.

Thriving, rather than just surviving, indicates that through adversity, individuals are able to better themselves, grow from their experiences and develop adaptively. Although there are unique cultural factors that contribute to Latina adolescent suicidality, there are also unique factors that contribute to Latina thriving, as evidenced in the success of Catalina.

Given that Latina teens are at risk for many mental health challenges, how do they cope? How can we maximize upon this coping? Catalina attributes her own personal thriving over suicidality to an optimistic outlook of her future, including the assumption that she could go to college; familismo, including the sense that she could not take her life because her family needed her; and an acceptance of her cultural identity.

Regarding her cultural identity, Catalina shared, “I don’t have to be either this or that. If I like being or having certain things that, yes, confirm stereotypes, then f— it. That’s just the way it is. I like to shake my ass, and I like salsa and hoop [earrings] and red lipstick. I can get a little hood, but I can also go to college.”

Currently, the National Center for Education Statistics estimates that 15 percent of all undergraduates in the United States are Latinas, a number that rises sharply when looking at regions with high concentrations of Latina/o populations. As suggested through Catalina’s narrative and current social science statistics, there are unique factors that create hardships and mental health issues for Latina adolescents at a disproportionate rate. It is of the utmost importance that counselors focus on culturally relevant, fair and sensitive practices when working with Latinas, especially given their historical rates of college enrollment and barriers to college retention. Thus, those who work with Latina adolescents in any capacity should use culturally relevant coping mechanisms not only to buffer the influence of the hardships that Latinas face, but to encourage thriving among this client population.

Many scholars, including Zayas in 2005, have issued calls for more research to be conducted on Latina suicidality. With levels of suicide in this population rising disproportionately, we must utilize the participants as experts. Future research must be conducted from a communitarian psychology or liberation psychology framework, in which the individuals participating in studies have an active role in the research process. This results in an emancipatory experience for participants and a broader sense of the true and lived experiences of adolescent Latinas facing issues of depression and suicidality.

In addition, it is suggested that participants be invited back to take part in outreach workshops in the community as promotoras (lay community members who receive training in conducting workshops on special topics). This approach engenders more community trust and engagement, and it also increases self-esteem for the promotoras who are survivors of suicide.

In conclusion, it is important to note that whereas a significant amount of research exists on the deficits that can cause Latina adolescents to attempt suicide, a balanced amount of research is needed on the strengths that promote thriving, not just surviving in this community.




Kelly M. Whaling is a counseling psychology doctoral student in the Department of Counseling, Clinical and School Psychology at the University of California, Santa Barbara. Contact her at kwhaling@education.ucsb.edu.




‘We must do more’: Counselors have part to play in stemming U.S. suicide increase

By Bethany Bray May 19, 2016

After more than a decade of almost constant decline, the rate of suicide deaths in the United States has increased 24 percent over the past 15 years. In fact, the country’s rate of suicide is at its highest point since 1986, according to data released recently by the U.S. Centers for Disease Control and Prevention (CDC).

Between 1999 and 2014, rates of suicide death increased for both males and females for all ages between 10 and 74. The highest rates of increase occurred between 2006 and 2014, according to the CDC.

In 2014, the age-adjusted suicide rate for males (20.7 for every 100,000 population) was more than three times that for females (5.8).

In the male population, suicide rates are most prevalent among those 75 and older. For females, suicide rates are highest for those in the 45-64 age range, which was also the case in 1999. But the greatest rate of increase for suicides took place among females ages 10-14. Although the total number of suicides among that population was comparatively small (150 in 2014), it represented a threefold increase between 1999 and 2014.


Counseling Today contacted Doreen Marshall of the American Foundation for Suicide Prevention (AFSP) to discuss these statistics and what professional counselors can do to help bring an end to this concerning trend.

Marshall, vice president of programs for AFSP, holds a doctorate in counseling psychology. Prior to joining AFSP, Marshall served as associate dean of counseling at Argosy University.


Doreen Marshall, vice president of programs for the American Foundation for Suicide Prevention

Doreen Marshall, vice president of programs for the American Foundation for Suicide Prevention

As someone who has worked in suicide prevention for many years, what is your reaction to these statistics?

We have known that the numbers have been on the rise, although it is sobering to see this increase over time, particularly in light of our ongoing efforts to prevent suicide. It is important to recognize that while other causes of death — such as those from HIV/AIDS, heart disease and breast cancer — have decreased over this time period, the suicide rate continues to rise. The data presented in this report is just one cross section of what we need to get a full picture of the suicide rates across America. We know that suicide prevention efforts that are concentrated and strategic can be successful. We have seen that targeted efforts can reduce suicide rates, and many of these can be expanded for wider impact and more lives saved. As a nation, we need to invest our time and resources in such prevention efforts, as well as in research to better understand the problem of suicide.


There is a lot of data packed into this report. What are some of the main takeaways you would want to point out to professional counselors?

We must do more to prevent suicide in our local communities, and this is where counselors can have a key role, both in terms of providing treatment to those who need it [and in] educating the public about suicide risk. All counselors need to be knowledgeable about the factors that contribute to suicide risk.

Suicide is a complex phenomenon, and assessment also needs to consider risk factors in the context of the individual who is being assessed. Suicide risk increases when several life stressors and health factors converge at the same time. For example, 85 to 90 percent of those who die by suicide had a mental health condition, whether diagnosed or not, at the time of their death, so we know that the detection and proper treatment of mental health conditions can plan an important role in suicide prevention. Other factors that should be assessed include a person’s past history of suicide attempts or behaviors, access to lethal means, past history of child abuse or trauma, present substance use and current life stressors.


What do you want professional counselors to know about this situation? What should they keep in mind and be aware of?

In short, suicide is on the rise in the U.S. In terms of trying to explain the increase, suicide experts consider a few possible contributions. One thing we know for sure is that a large contributing factor is untreated mental health conditions. Another factor is the economic downturn and job losses that occurred during that same period of time, resulting in increasing stress. There may also be a cohort

effect for the baby-boomer generation, in which suicide rates and other problems like substance use problems and other health conditions, and higher rates of life problems like divorce, have unfortunately followed this demographic population from their earlier stages of life. Despite these considerations, it is hard to know all of the factors that may have contributed to the increase. But we do know that the suicide rate is higher now than in the past.


From your perspective, is there anything counselors could or should be doing differently in their work with clients in light of this data?

Many of us may not have had extensive training in suicide prevention as part of our graduate work, so it is important to seek more information and training on how to effectively counsel someone who is experiencing suicidal thoughts or has engaged in a suicide attempt. Given the numbers, it is very likely that we will encounter someone who is suicidal or who has been affected by a suicide death in the course of our counseling work, so all counselors need to improve their knowledge and skills in this area.


What advice would you give to counselors who work with populations that showed a sharp increase in suicide deaths — for example, girls ages 10-14, Native Americans, middle-aged adults?

It is important to keep this report, and the increases noted, in context. While suicide does happen in young girls, it is fairly rare compared to the suicide rates in middle-aged and older adults. While the rise is of concern, it was based on an exceedingly low base rate in 1999 of 0.5 per 100,000. It was a total of 50 girls in 1999 and 150 in 2014 across the United States. The overall numbers of suicide deaths in girls ages 10-14 remain low.

In the U.S., most of the persons who die by suicide are middle-aged and older adults, and terms of race/ethnicity are Native Americans, Alaskan Natives and Caucasians.

That said, I think counselors should be aware that there is no one age, race or ethnicity that is immune from suicide, and risk should be assessed across all demographics and ages. In children and adolescents in particular, early detection and adequate treatment of mental health conditions such as depression, bipolar disorder and anxiety can go a long way in helping to reduce their lifetime suicide risk.


What would you want school counselors, in particular, to know and keep in mind?

School counselors should encourage their schools to have a policy for responding to suicide in students. They should also encourage regular training of school personnel to know the risk factors and warning signs of suicide as well as how to refer a student for further assessment if they encounter a student who is suicidal. School counselors often play an important role when a student is suicidal, so it is important that they expand their knowledge in this area as well.


From your perspective, how can counselors play a part in combating these statistics and preventing suicides?

First, I would encourage counselors to familiarize themselves with risk factors and warning signs for suicide, as well as seek additional professional training in evidence-based interventions for those at risk for suicide, such as cognitive behavior therapy for suicide prevention (CBT-SP), dialectical behavior therapy (DBT) and collaborative assessment and management of suicide (CAMS), among others.0001-245393381

At the minimum, all counselors should build their skills in assessing for suicide and assess their clients regularly. They should also learn about ways to effectively help their clients to manage their suicidal feelings between sessions, such as by using safety planning as a brief intervention. Counselors and other clinicians have an obligation to familiarize themselves with how to best work with those who are suicidal in a way that is compassionate, responsive and effective.

I think one of the biggest barriers to prevention is that people, including counselors, are sometimes afraid to ask their clients directly about suicide. Asking about suicide does not increase an individual’s risk for suicide. More likely, asking them conveys that you are paying attention to the difficulties they are experiencing and are willing to take steps to help them. It is important that we, as counselors, use our knowledge of suicide risk and of mental health conditions to work to educate the general public about suicide prevention.

I would also encourage counselors to get involved with local and national advocacy efforts that support suicide prevention efforts. More information about advocacy and how to get involved in suicide prevention can be found at our website at afsp.org.




Graphic via the U.S. Centers for Disease Control and Prevention

Graphic via the U.S. Centers for Disease Control and Prevention



Read more


Find out more and view and the CDC’s breakdown of data at http://1.usa.gov/1qG5IZf


Via NPR, “Suicide rates climb in U.S., especially among adolescent girls” http://n.pr/1Vqxlm9


For more insights on this topic, see Counseling Today’s cover story, “Facing the specter of client suicide


Did you know the Substance Abuse and Mental Health Services Administration (SAMHSA) has created a smartphone app with suicide prevention tools and resources for practitioners? Find out more here.




Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

The tangible effects of invisible illness

By Cathy L. Pederson and Greta Hochstetler Mayer April 26, 2016

A variety of invisible illnesses can greatly impact both the physical and mental health of individuals. Some of these illnesses are debilitating, preventing participation in the normal activities of daily living. Examples include chronic fatigue syndrome/myalgic encephalomyelitis, Ehlers–Danlos syndrome, fibromyalgia, lupus, Lyme disease, multiple sclerosis, myasthenia gravis, postural orthostatic tachycardia syndrome (POTS), regional complex pain syndrome and Sjogren’s syndrome.

These disorders disproportionately affect women and are not well understood by the health care Branding-Images_invisibleestablishment or the general community. Lack of understanding can lead to feelings of alienation and hopelessness for those suffering from these disorders.

Such was the case for Natalie (case study used with permission). Seemingly overnight, she transformed from a vivacious teenager at the top of her eighth-grade class to being virtually bedridden with fatigue, dizziness and chest pain. She visited a series of doctors in search of relief. A few months later, at age 15, Natalie’s life changed forever when she was diagnosed with POTS and Ehlers–Danlos syndrome, neither of which is curable or easily managed medically.

POTS is a disorder of the autonomic nervous system in which blood pressure, heart rate, blood vessel and pupil diameter, peristaltic movements of the digestive tract and body temperature are affected. Natalie’s Ehlers–Danlos syndrome caused additional pain — her connective tissues were weak and her joints would easily dislocate. During her freshman year of high school, Natalie was bound to a wheelchair. But as a sophomore, her dizziness and other symptoms were better controlled, so she went roller-skating with friends. She broke her wrist and injured her neck that evening, and her fall triggered debilitating migraines.

Although not widely studied, rates of suicide are believed to be higher in people with chronic or terminal illness. It is unclear if physical illness alone leads to risk of suicide or whether having an illness increases the chances of developing depression or hopelessness, which then increases suicide risk.

Painful, chronic illnesses and illnesses that interfere with a person’s everyday functioning are believed to be risk factors for suicide, especially among older adults. Some illnesses associated with increased suicide risk are AIDS, certain forms of cancer, Huntington’s disease and multiple sclerosis.

Risk of suicide is often linked with co-occurring mood, anxiety and substance use disorders in this population. However, people with invisible illnesses may not necessarily be clinically depressed or anxious; instead they may feel hopeless about their prognosis, experience real and anticipated future losses, and suffer from chronic pain — all of which are potent risk factors for suicide. The basic science of these individuals’ physical condition is not well understood, which makes developing medications to treat them difficult. Most treatments are aimed at individual symptoms rather than the root cause of the problem.

It takes Natalie three times more energy than normal just to stand because of her POTS. Even making minor movements around the house and engaging in daily routines, including eating meals and showering, can be exhausting for her and increase her symptoms. Her quality of life is similar to those with congestive heart failure or chronic obstructive pulmonary disease.

At 16, Natalie endured weeklong hospitalizations for headaches and other POTS symptoms. Medications didn’t offer relief. An honor student, Natalie missed more than 70 days of school during the last half of her sophomore year. She was no better by the end of her junior year and eventually dropped out of high school. She was behind in her work and struggled to complete projects and tests that would have been easy for her when she was healthy. “It was heartbreaking,” said Natalie’s mother about seeing her daughter transform from high achiever to high school dropout.

Natalie’s family had done everything right. They took her to see physicians, followed all prescribed treatment regimens, put her in counseling and supported her through her illness. Unfortunately, medical help was evasive and mental health care was marginal. Over time, Natalie’s friends drifted away. She couldn’t be physically active, participate in community events or hold a job. Eventually, she confronted insidious suicidal thoughts.

Working with those who are chronically ill

Many chronic illnesses are not terminal conditions, but they can severely impact a person’s quality of life for decades. For example, imagine that you have POTS. You feel lightheaded every time that you stand, and you faint several times per day. You experience neuropathic pain that feels like bees stinging your arms and legs. Hot flashes arrive without warning, and you begin to sweat. Despite possessing above-average intelligence, you have difficulty concentrating and analyzing problems. Simply taking a shower drains your energy, and it doesn’t replenish itself. Your physical isolation and illness create feelings of being misunderstood and not belonging.

These feelings only increase when you finally venture out of the house. People congratulate you on your “recovery.” Friends tell you how good you look. Distant relatives offer advice about how to get better. Even worse, you are bullied, called a faker or are the target of other derogatory comments. Your boss suggests that you would feel better if you only ate right and exercised. Even your spouse says, “Just get over it!”

Counselors should not fall into these traps when working with these clients. For someone who is chronically ill, even hearing “you look good” might be equivalent to “I don’t believe that you are really sick.” Normal niceties take on special meaning and ring hollow for those with chronic illnesses.

For most people, a doctor’s visit will result in control of their illness and restoration of their health. This isn’t true for many individuals suffering from chronic, invisible illnesses. Not only are they grieving their loss of health because of their physical condition but, often, they also feel dismissed and even traumatized by their health care practitioners.

Many with chronic illness feel ignored or abandoned by doctors and nurses. Some individuals have even been told to stop fainting or to bring down their heart rate, as if they are making choices meant to curry attention. Many physicians aren’t educated about these debilitating illnesses, and specialists in these fields often have waiting lists that are years long. Imagine how such repeated, negative experiences might erode hope for recovery and lead to suicidal thinking. What is a patient to do? In the case of those with POTS, the incidence of mental illness is the same as is found in the general population. The seemingly paranoid behavior these individuals demonstrate related to their health can be the result of medical mistreatment and neglect, and it is often justified and understandable.

Sadly, invisible illness can put even the strongest relationships in jeopardy. As days turn to months and years, the constancy of chronic illness can wear on marriages, friendships and family relationships. Missed holidays, birthdays and other social events leave loved ones feeling betrayed and wondering if the person who is chronically ill could make more of an effort to be present. Friends and family members often doubt whether their loved one is sick. Some acquaintances become confrontational with the person who is chronically ill, whereas others turn passive-aggressive. Because a person’s hair doesn’t fall out with chronic fatigue syndrome, no skin lesions appear with multiple sclerosis and no significant weight loss takes place with fibromyalgia, it is easy to forget the internal battles being waged every day by those with chronic illness.

Counseling professionals are well-positioned to address the fallout of living with chronic illness. Counseling can provide something that those with chronic illness who are feeling suicidal desperately need but are often missing — a safe place where they can be heard, validated and comforted. Most important, counselors are particularly skilled at uncovering suicide risk, advocating for underserved populations and providing clinical management of complex cases.

In Natalie’s case, she was depressed from grieving her loss of physicality, friends and school. She had found some relief through the use of an antidepressant and went to counseling regularly. In the midst of a flare, her physician switched Natalie to Prozac, which she had taken previously, without considering the fact that it might increase suicidal ideation in teenagers. Natalie never mentioned the suicidal thoughts to her family or doctor. Shortly after titrating to 30 milligrams, the 17-year-old attempted suicide.

Consider physical illness part of the problem

Many people with debilitating and invisible chronic illnesses are told that it is all in their heads. As a counselor, you may be the first person who truly listens and tries to understand what is happening in the individual’s life. Don’t be afraid to suggest that someone who has especially dry mouth and eyes (Sjogren’s syndrome), fainting episodes and difficulty thinking (POTS), debilitating fatigue that can’t be attributed to known causes (chronic fatigue syndrome/myalgia encephalomyelitis, POTS, fibromyalgia, lupus) or chronic pain (complex regional pain syndrome, fibromyalgia, POTS) should get a thorough checkup with a good physician.

Consider working collaboratively with these physicians as a multidisciplinary team. Recommend someone who is a knowledgeable problem-solver to investigate underlying physical causes for the person’s anxiety or depression. In addition, assess regularly for suicide risk, especially during transitions in levels of care, and take all warning signs and risk factors seriously. Labeling a person’s symptoms as part of a recognized disorder will often be a great relief to the person psychologically.

Physical limitations and their effect on counseling

As a result of chronic illness, routine activities can cause debilitating fatigue. Standing, walking, showering, riding in the car and even attempting to focus on a conversation can quickly exhaust those with chronic illness. As their fatigue increases, brain fog also tends to increase.

As counselors, it is important to understand and recognize the effort it takes for these clients to walk through your office door. Offering small encouragements will reinforce the proactive effort they have taken to maintain their mental health and improve their quality of life.

Also note that many people with invisible illness are particularly sensitive to light, noises and smells. This is particularly true when they are flaring. Simple gestures such as closing the blinds or turning off fluorescent lights may help them conserve their energy for their work with you. Similarly, avoiding the use of candles, strong scents or incense can be helpful.

Differentiating the physical from the psychological

When working with clients who are chronically ill, differentiating their physical issues from their psychological issues can be difficult. Consulting with knowledgeable health care specialists is essential. Taking the time to learn about a client’s chronic illness can greatly increase empathy, provide authentic understanding and help in guiding the person to proper medical care.

Counselors should be aware that the coping skills people use to deal with symptoms of chronic illness can look like warning signs for depression or suicide. For example, coping skills to manage many invisible illnesses, such as staying in bed and avoiding the shower, may be unrelated to depression or risk of suicide.

In addition, dysregulation of the autonomic nervous system causes surges of norepinephrine that can lead to insomnia, anxiety or panic attacks. A person’s lack of appetite can be related to gastroparesis (paralysis of the stomach) or other digestive motility issues. Debilitating fatigue and difficulty focusing/concentrating are also common problems connected to many invisible illnesses.

At the same time, it is important to remember that individuals with chronic illnesses that involve functional impairment and chronic pain are at greater risk for suicide, so warning signs such as suicidal thoughts and threats, previous suicide attempts and hopelessness must be taken seriously. In Natalie’s case, she had confided her suicidal thoughts to her counselor. Unfortunately, her parents and doctors were unaware of the extent of Natalie’s overwhelming emotional pain until she attempted suicide.

Follow-up care after hospitalization is critical

Pursuing inpatient hospitalization for people at serious risk of suicide can be a life-saving step. However, the current health care environment poses challenges to accessing timely, quality care when needed, even for those at imminent risk for suicide. Inpatient stays are difficult to secure, and lengths of stay are minimal at best.

Individuals often transition from an inpatient level of care to outpatient settings before their stabilization, and this is not easy for individuals with chronic illness or their families. In addition, being hospitalized for mental health problems can be further stigmatizing and demoralizing for the person with chronic illness.

The period immediately following hospital discharge is particularly dangerous for people at risk for suicide. Counselors operating from a multidisciplinary framework can mitigate this risk (with permission of the person with chronic illness) by coordinating care with hospital staff, medical specialists and key family members.

Providing continuity of care also helps with stabilization, engagement and retention in aftercare. Long-term counseling is necessary to strengthen the person’s reasons for living and to uncover the problematic situations and underlying psychological vulnerabilities that led to the suicidal crisis.

“After 12 inpatient days and nine partial hospitalization days, I’m starting to feel confident that she is on the road to recovery,” Natalie’s mother reported. Natalie’s medications were changed, and she passed the GED test in lieu of her high school diploma. She is now on the road toward college. We hope that sharing her story can help to prevent suicide attempts in other young adults with chronic illness.




Cathy L. Pederson holds a doctorate in physiology and neurobiology. She is a professor of biology at Wittenberg University and founder of Standing Up to POTS (standinguptopots.org). Contact her at cpederson@wittenberg.edu.

Greta Hochstetler Mayer holds a doctorate in counselor education and is a licensed professional counselor. She is the CEO and initiated suicide prevention coalitions for the Mental Health & Recovery Board of Clark, Greene and Madison Counties in Ohio. Contact her at greta@mhrb.org.

Letters to the editor: ct@counseling.org


Facing the specter of client suicide

By Laurie Meyers October 19, 2015

In counseling, the therapeutic bond is essential. What happens when that bond is severed by a client’s suicide? “Many laypersons do not realize how closely counselors connect with their clients,” says Daniel Weigel, a professional counselor who lost a client to suicide just a few weeks after receiving his license. “Of course we set clear professional boundaries, but I had known this young lady for just over a year. Her loss was very painful for me, both personally and professionally.”

(Note: Details of counselors’ case stories have been altered to protect client privacy.)

The possibility of having a client die by suicide is a specter that hovers in the background for many counseling professionals. It is perhaps the crisis situation that clinicians most fear facing. Even so, client suicide is a subject often laden with shame, guilt, denial and many other difficult emotions — emotions that counselors excel at helping others handle but would much rather not face in themselves, say researchers and practitioners who have lost clients to suicide.

It would be unfair to say that counselors who have difficulty processing a client’s suicide are just plant_brick_brandingpracticing avoidance, however. Practitioners’ careers revolve around taking care of others. So when a client dies by suicide and practitioners are asked how they are holding up, their natural inclination may be to protest that the suicide isn’t about them but rather the client and the client’s family.

“Frankly, I was not sure I had the right to grieve her loss at the time because I was much more focused on taking care of others,” acknowledges Weigel, an American Counseling Association member who is now a professor of counseling and the practicum and internship coordinator at Southeastern Oklahoma State University. “I was, however, struggling with a great deal of sadness that had caught me off guard.”

Practitioners may also attempt to process a client’s suicide in solitude because they’re unsure of where to turn and fear possible judgment from colleagues. Unfortunately, say counselors who have experienced a client’s suicide, that fear of censure and avoidance on the part of colleagues and supervisors is not necessarily unfounded.

“I think there’s this quiet stigma for people who have had clients suicide,” says Ford Brooks, a practitioner and addictions specialist who lost a client to suicide about five years ago. “Others are saying, ‘I’m glad it’s not me’ or ‘There’s something you didn’t do.’ There is probably an underground group of counselors that this has happened to who just haven’t talked about it.”

This lack of peer support compounds what is already a personal and professional trauma, which is why those who have gone through a client’s suicide say that the counseling profession as a whole needs to develop a greater understanding of these incidents and their aftermath.

According to the Centers for Disease Control and Prevention (CDC), more than 41,000 people in the United States died by suicide in 2013, the most recent year for which statistics are available. That same year, almost 500,000 people in the United States were treated in emergency rooms for self-inflicted injuries. The CDC cautions that these numbers underestimate the overall threat of suicide to public health because many people who have suicidal thoughts or make suicide attempts never seek health or mental health services.

As noted by an April 2000 Journal of Mental Health Counseling study (“Client Suicide: Its Frequency and Impact on Counselors”), little research has been published about how frequently counselors lose clients to suicide or the personal and professional effects of those losses on counselors. The study’s authors, Charles R. McAdams III and Victoria A. Foster, reporting the results of a national survey in which 376 professional counselors participated, found that approximately 24 percent of counselors had lost clients to suicide. Among the counselors who had gone through that experience, approximately one-fifth were student counselors.

When asked about the effect of the client suicide on their lives, survey respondents reported feelings of anger and guilt and a lack of self-confidence. The respondents also reported having significant intrusive and avoidant thoughts about their clients’ suicides. The authors reported that student counselors experienced more severe and persistent reactions than did licensed practitioners.

McAdams and Foster also pointed out in their article that client suicide is a common crisis faced by mental health practitioners. Therefore, the authors asserted that training in coping with client suicide should be a routine part of counselor education programs.

Indeed, Weigel notes that nothing in his counselor education or supervision experience had prepared him for the possibility of losing a client to suicide. He believes that preemptive training would have helped him absorb and process the shock he subsequently experienced. At the same time, he — along with the other individuals interviewed for this article — says that nothing can truly prepare a counselor for the death of a client by suicide.

The client is ultimately in charge

E. Christine Moll, a licensed mental health counselor and private practitioner in Buffalo, New York, had been seeing her client, a man in his early 60s, twice a week for about five weeks when he died by suicide.

She notes that the client’s life had been in a significant state of upheaval. As he worked with Moll, the client realized that he had been experiencing recurring episodes of depression throughout his life. Some of his family members had a history of depression, but the client had never been diagnosed himself. The client had very recently retired and was still struggling to figure out that next stage of his life, says Moll, an ACA member who is a past president of the Association for Adult Development and Aging. In some ways, the client’s world was falling apart. His home was in a state of disrepair, and he had virtually no money to have it fixed. The client also felt inept because he didn’t view himself as handy, saying he couldn’t take care of even simple repairs that he saw other men doing, Moll says.

From the start, Moll was fully cognizant of the man’s significant level of distress. “As soon I met the man, I met with the psychiatrist [a clinician with whom Moll frequently consulted] and said, ‘I need supervision,’” she remembers. “Through it all, I was seeking guidance.”

Moll suggested that her client also see the psychiatrist and perhaps take medication if warranted, but the man refused, saying he was currently taking an herbal supplement. Moll researched herbal supplements to gain a better understanding of the self-help methods the man was using and his frame of mind.

She was also attentive to the possibility of suicide. The client had expressed some suicidal thoughts in their early sessions, but these thoughts were vague, and the man stated he had no present plans to kill himself. Still, each week Moll used a suicidal “barometer” to assess intent. When Moll saw the man the week that he died, he didn’t express any active thoughts of suicide, she says. In fact, he was making future plans. In the weeks prior, the client had decided to ask his sons — who were more adept at home improvement — to come in from out of town to help him make the necessary repairs, she recalls. The last time that Moll saw her client, he said he was looking forward to seeing his sons and to other plans that were five or six weeks in the future.

But then Moll received a call from the client’s wife saying that her husband and his car were missing. The man had exited their house, leaving his wallet and driver’s license behind on the table. A search was undertaken, and the client’s car was found in a state park where some tourists had seen an individual go over a barrier to the park’s waterfall. The tourists assumed the man had fallen, but evidence indicated he had jumped, Moll says.

When Moll went through the complete case with the consulting psychiatrist, he assured her that she had done everything by the book. For a time, she continued to meet with the psychiatrist for both formal sessions and informal talks. Moll also reached out to the client’s family in sympathy. As they went over the events preceding the man’s suicide together, Moll says it became clear that neither she nor the family held any missing information or insight that would have indicated the client might take his own life.

In the aftermath of the client’s suicide, Moll says that prayer was an important part of her healing process. She adds that her recovery was a gradual process that transpired in part through tackling everyday tasks and obligations. “It’s not that we forget but that life continues,” Moll says when asked how counselors persevere through a client’s suicide. “Our families need us. Our clients need us.”

As she recovered, Moll, who is also an associate professor and chair of the Department of Counseling and Human Services at Canisius College in Buffalo, came to the realization that many factors in clients’ lives were simply out of her hands.

“Even if we do everything by the textbook, we have no control over [whether] our clients make irreversible choices,” she says.

Eric Beeson, a licensed professional counselor (LPC) and lecturer at the University of North Carolina–Greensboro, has also grown to accept that a client dying by suicide is ultimately out of a counselor’s hands. Early in his career while working in a hospital behavioral unit, Beeson and his colleagues used all the clinical and legal tools at their disposal but couldn’t stop a patient intent on dying by suicide.

The patient was determined to leave the hospital’s behavioral unit despite the objections of the clinical team and the unit’s medical director. The patient’s son was concerned that his parent would attempt suicide if released and signed a petition to commit his parent for further care. However, the county’s mental health court determined there was no legal justification for holding the patient. The patient was released and died by suicide later that day.

“At that point, my colleagues and I were really angry and found ourselves blaming the court,” recounts Beeson, a member of ACA. However, the hardest part of the case was seeing how devastated the patient’s son was, Beeson says. The son had worked incredibly hard to get his parent the necessary help and wanted desperately for the parent to be well so they could be together.

The debriefing process Beeson and the rest of the clinical staff engaged in helped them move through their anger and grief, Beeson says. The unit’s medical director used the debriefing to help the staff understand that, despite what they might want, clients ultimately have the right to choose to die by suicide.

“It really does challenge our own God complex,” says Beeson, who now studies and lectures on suicide (see “Fresh thinking on old issues” in the May issue of Counseling Today to read about Beeson’s 2015 ACA Conference session on counselors’ attitudes toward suicide). He contends that it is not helpful for counselors to hold themselves responsible for their clients’ choices. All counselors can do is dedicate themselves to providing the best and most ethical care possible, he says.

Overwhelming pain

“I don’t blame myself, but for a long time I seriously wondered if I should,” says Julie Bates-Maves, a former addictions counselor who lost a client to suicide seven years ago. “Even now as I think about it, I’m racking my brain for unspoken clues, [but] I still come up with nothing.”

Bates-Maves’ client was in his early 30s and suffered from chronic pain after breaking his neck and back during a fall at his construction job. He had developed an addiction to his pain medication, and once that was no longer being prescribed to him, he turned to heroin and crack as a way to manage his pain. The man was in treatment for his addiction and was seeing Bates-Maves as part of his methadone maintenance treatment. She had been treating him for about nine months when he died by suicide.

“About seven months before [the suicide] happened, he had expressed suicidal ideation, and we worked through this over the course of a few months,” explains Bates-Maves, a member of ACA. “He had not expressed suicidal ideation in more than three months at the time of his death. On the contrary, he consistently used future talk and spoke about his hopes for his future children and impending marriage. He was also on the verge of settling his workers’ compensation claim — a payout that would have exceeded a million dollars. He had also stopped using heroin altogether and significantly reduced his crack use.”

The suicide happened when Bates-Maves was still a beginning counselor. She sometimes wonders if things would have turned out differently if she had possessed more experience at the time.

“With my current knowledge and additional experience, I’d like to think that I would have been more cautious as his depression lifted and he regained energy. I like to think that I would have caught on to something so that he’d still be here,” says Bates-Maves, who is now a counselor educator at the University of Wisconsin–Stout.

However, she wasn’t alone in not seeing any signs that the man was contemplating suicide. Bates-Maves’ supervisor and the client’s group counseling facilitator were just as shocked at what transpired. All three went over their clinical notes and discussed the case at length but still couldn’t find anything to suggest that they could have done anything that might have led to a different outcome.

Bates-Maves and the client’s group facilitator sought healing by attending the man’s funeral. “We sat in the back and didn’t speak to anyone,” Bates-Maves recalls. “We had never met his family in person, so no one knew who we were. For us, it was an important step in our grieving process to say goodbye. I vividly remember the happy pictures placed around the room and was thankful that [the client] had such a good support system at home. He deserved that.”

“After the funeral,” she continues, “I remember feeling more settled with the fact that he was gone and that no matter how many times I thought about what I maybe had missed, it wouldn’t bring him back. I had to move forward and keep his memory inside me as a constant reminder that more often than not, pain is not what it seems. People don’t have to appear sad to be hopeless, don’t have to appear depressed to be suicidal and don’t have to appear to be in pieces to take their life.”

Spiraling out of control

There was no question that Weigel’s client — a woman in her early 20s — was gravely troubled. She presented with signs of being in the prodromal phase of schizophrenia, which would later lead to a psychotic break. When the client came to the community mental health center where Weigel was working, she was struggling not only with a descent into psychosis but also a significant heroin abuse problem. The young woman had also started to experiment with other drugs, recalls Weigel, who is trained in the treatment of co-occurring disorders.

Weigel recognized that the client was spiraling into psychosis and sought assistance from the agency’s clinical director, psychologist and staff psychiatrist in hopes of preventing the woman’s first psychotic episode. However, several factors complicated the team’s efforts, he says. The woman actually had strong family support, but she lived alone and had isolated herself socially. Aside from her family, her interpersonal interactions were mainly limited to drug dealers.

Weigel and the treatment team launched an intensive effort to address the woman’s substance abuse problem while trying to stabilize her. The client went through detoxification twice, but neither time could Weigel secure the intensive level of care she needed to continue treating her heroin abuse after she was released from the hospital. Inevitably, this led to relapse.

In addition, the woman had started engaging in what Weigel describes as “graphic and bizarre” self-mutilating behaviors. But once again, getting the level of help the client needed proved nearly impossible.

“On one occasion, her family paid for her to receive inpatient care,” Weigel remembers. “She was uninsured, and inpatient, indigent mental health services were unavailable. Thus, her parents went into debt paying for inpatient mental health care for as long as they could before she was transitioned back to outpatient care. … I stayed in close communication with the hospital, where she showed optimistic improvement, but despite a carefully planned transition to outpatient counseling and psychiatric care, a [heroin] relapse quickly followed her discharge. Unfortunately, it also led to the discontinuation of medications that may very likely have prevented her first psychotic episode.”

The young woman began engaging in life-threatening self-injurious behaviors and was involuntarily hospitalized. “Again she showed improvement, and we [the treatment team] transitioned her care as precisely as possible upon release,” Weigel says, “but heroin quickly drew her in again.”

Not long after her release from the second hospital, the woman took her own life. Weigel, devastated by his client’s death, found few resources to help him cope in the event’s immediate aftermath.

“I was working in a very rural setting, as I have my entire career,” he explains. “Thus, options like support groups and personal counseling … were really not a viable option for me due to my geographic isolation. I tried to find books or journal articles addressing the effects of suicide on counselors and coping mechanisms, but at the time there was a real shortage of information for counselors coping with such a loss.”

Weigel decided to take some leave time to try and regain his focus. He also went over the client’s case with colleagues. “When a tragedy like this happened at the agency in which I worked, an interdisciplinary team critically examined what happened and what could be learned from it — a psychological autopsy of sorts,” Weigel explains. “My colleagues were very supportive. They realized I had done virtually all I could to help this young woman, which I now believe to be true. Unfortunately, my evaluation of myself at the time was much more critical. It took time for me to heal and regain my confidence.”

Today, Weigel uses those “lessons learned” to help prepare his counselor education students at Southeastern Oklahoma State. Each semester he reviews suicide prevention and intervention skills with the students. He also tells them about the young woman’s story, while maintaining her anonymity.

“I do it to help prepare them for what I consider one of the toughest aspects of our work as counselors but also to help them prepare for the likelihood that they will experience a client suicide during their careers or even during their internship experiences,” he explains.

“We also have a frank discussion regarding self-blame, burnout and the terrible but real possibility of being accused of malpractice in such a situation,” he continues. “This is always a possibility, and the fears it brings, in conjunction with the deep sadness that counselors experience, make for a highly volatile internal dialogue. Debriefing and talking with colleagues is critical.”

A counselor’s worst nightmare

Brooks, who is also a counselor educator at Shippensburg University in Pennsylvania, knows all about the real possibility of being accused of malpractice. When one of his clients died by suicide about five years ago, her family sued Brooks and the school that employed him. He had been practicing for more than 25 years when the crisis unfolded.

The client was a high school senior at a private school where Brooks was counseling part time as an independent contractor. The transition from adolescent to young adult can be an inherently unstable time for many individuals, and the prospect of transitioning out of high school can add to those feelings of instability, Brooks notes. In addition, this particular client had already experienced a significant amount of instability in her life since adolescence. Brooks and the client were just starting to talk through some of her troubles when their work came to an abrupt end — after about seven or eight sessions — because she was dismissed from the school campus (although she was given the opportunity to finish her courses independently and graduate). The student’s parents picked her up, Brooks says, and the next day, she took her own life by jumping off a bridge.

The young woman’s death was a total shock, Brooks says, but he barely had time to process it because her family almost immediately filed suit against the school, the director of the school and Brooks himself. The family claimed that the school and Brooks should have foreseen their daughter’s suicide and should have committed her for treatment involuntarily, he says.

“I don’t know what [the law] is in other states, but here [in Pennsylvania], unless someone says to you directly, ‘I’m going to kill myself,’ you can’t issue a temporary detention order for that person. You just can’t,” he says.

One of the things that pained Brooks about the lawsuit — aside, of course, from being partially blamed for his client’s death — was that during the legal process, the young woman’s privacy was completely violated. “Although the client was not at all interested in her family knowing anything about her therapy, because they took over the postmortem rights [to her record] … they were able to go through every single document that any therapist had ever created,” he says. “They got all the notes — including doctors notes — and could see everything she said, and that’s the exact opposite of what she wanted to have happen.”

In the aftermath of his client’s suicide, Brooks immediately sought counseling and treatment, including medication, and went to peers for support. But he also needed to address the pending legal case. He promptly retained a lawyer and contacted his liability insurance company to prepare for what would be a long and drawn out process. The case dragged on for roughly three and a half years. If he had been the sole defendant, Brooks says, he may have been able to reach a settlement with the family in less time, but because he was part of a larger group, he had to go along with whatever negotiations the other parties wanted to engage in.

As the legal case plodded along, Brooks notes sadly, the primary emotion he was processing was anxiety about its outcome. “It became more about the case than really grieving this person who had a pretty difficult life,” he recounts. “It wasn’t until it was all over that I could really process this feeling of having lost a client.” In the end, all of the involved parties agreed to a financial settlement.

In Brooks’ words, the suicide and subsequent lawsuit “enveloped” his professional life. Before his client’s death, Brooks was providing outside supervision, but he ceased doing that almost immediately. He also stopped practicing and hasn’t seen a client since.

“I like counseling, and I was doing this because I like helping other people,” he says, “but no good turn goes unpunished, so I am much more wary of putting myself out there [as a practitioner], sadly.”

In addition, the lawsuit has heightened his sensitivity to the possibility of vicarious liability in his role as a supervisor at the university and altered how he teaches, he notes.

“I am a real live nightmare that every counselor would want to avoid,” Brooks says. Brooks tries to help his students understand what it is like being sued as a counselor, while also presenting himself as an example of a helping professional who has gone through the legal grinder and survived.

Although the legal case often made Brooks angry, he says he tried not to give in to that feeling. “It didn’t really do me any good to be angry, so I was trying … to be really forgiving. My faith system is to pray for the family and their loss and what they’re going through and not get into ‘woe is me’ and ‘poor little old me,’” he says. “At times I slipped into it, but I tried not to, and that seemed to help.”

Brooks acknowledges that counselors are sometimes bad at taking care of themselves properly in the face of their job demands, but he also says that concepts such as “wellness” are inadequate for living through and bouncing back from a client’s suicide, at least in his personal experience. “There is no such thing as wellness [in these cases]. It’s survival and getting out of bed,” he says. “There was nothing well about it. I just did what I could.”

However, Brooks adds that throughout his ordeal, he did maintain certain activities, such as running, that had helped him cope with stress in the past.

Brooks also believes that some kind of nationwide network of clinicians who have gone through client suicide should be established. The network could serve as a supportive place to which these practitioners could turn to talk with others who have an understanding of what they are going through, he says.

Knowledge out of tragedy

Bates-Maves says she will never be completely at peace with losing her client to suicide, but the incident did help her arrive at some important realizations.

“What’s left with me is his memory and an even greater respect for suicidal thoughts and people courageous enough to express them out loud. They are never to be dismissed, forgotten or ignored,” she says emphatically. “It both scares and saddens me when I hear any practitioner or student say, ‘They [the client] are just doing it for attention.’ My response is always, ‘Yes, they are. And you know what? That matters. Attend to them, care for them, and don’t add to their pain by telling them their words are meaningless.’”

“Counselor educators need to do a better job of making that point, in my opinion,” she continues. “I’ve heard suicidal threats brushed off or ignored or blamed away far too often. It needs to stop, and clients need to be taken seriously. It will never hurt to be curious and to have a conversation to further explore intent and emotional state. But it could kill if we don’t take the time.”

Weigel urges his students — and all beginning counselors — to trust their instincts. “If counselors allow themselves to use their internal instincts as part of the suicide assessment process, I have found that they are much more likely to invite their clients to discuss this topic as early as possible and perhaps even save a life by asking the necessary questions the moment their instincts tell them to act,” he says. “This is the ‘art’ component of suicide assessment, which accompanies a formal assessment. It has been my experience that many highly skilled counselors struggle with allowing themselves to follow their gut instincts and [thus] risk missing windows of opportunities or getting lost in mnemonic devices or other interventions that come less naturally.”

“There is so much stigma around the actual possibility of death that I think even counselors brush off the seriousness of it at times,” adds Bates-Maves. “Fear is powerful, and yet we cannot be too scared to ask, check in and persist in those efforts.”

“Someone’s life could truly be at stake,” she continues, “and I’d rather have a scary conversation about death than wonder if I missed something or could have done something. … That’s a scary place too, and it is one that doesn’t really have an end point. I’ll always carry those thoughts with me to some degree.”




Additional resources

The American Counseling Association offers the following resources that speak to the topic of suicide assessment and treatment and the legal issues surrounding client suicide. All resources are available on the ACA website at counseling.org.


  • The Counselor and the Law: A Guide to Legal and Ethical Practice, seventh edition, by Anne Marie “Nancy” Wheeler & Burt Bertram
  • Harm to Others: The Assessment and Treatment of Dangerousness by Brian Van Brunt
  • Clinical Supervision in the Helping Professions: A Practical Guide, second edition, by Gerald Corey, Robert Haynes, Patrice Moulton & Michelle Muratori


  • Suicide Assessment and Prevention, presented by John S. Westefeld

Webinars and podcasts

Practice Brief




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org


Fresh thinking on old issues

By Laurie Meyers April 23, 2015

Trauma, suicide and bullying are not new topics for most counselors, who at some point in their careers have likely worked with clients on each of these issues. However, as research and practice Paint-Splatter_Brandingcontinue to progress, some counselors are using emerging approaches or perspectives to tackle these problems.

At the American Counseling Association’s 2015 Conference & Expo in Orlando, Florida, Counseling Today attended several sessions that presented some of these fresh approaches. We then caught up with three presenters after their sessions to get a more in-depth look at their ideas so we could share them with readers.

Complex PTSD

As far back as the ancient Egyptians, the chronicles of war have noted trauma-induced psychological symptoms. Samuel Pepys wrote about them in the wake of the Great Fire of London. Historians think that the author Charles Dickens may have experienced them after a horrific train accident. We now know these symptoms as indicative of posttraumatic stress disorder (PTSD), but until relatively recently, the cause of trauma-induced behavioral changes was thought to be purely internal and was sometimes even referred to as cowardice.

Trauma-induced psychological symptoms were not officially labeled as a disorder until 1952, in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which identified it as “gross distress reaction.” However, in 1968, as the memory of World War I and World War II faded, the diagnosis was dropped from the DSM. It wasn’t until scores of Vietnam veterans returned with severe psychological trauma that researchers began a deeper examination of the condition and its causes. The term PTSD officially entered the lexicon in 1980 with publication of the DSM-III. Defined, in essence, as a common set of symptoms brought on by extremely traumatic events such as combat, natural disasters, accidental disasters or personal catastrophes, PTSD has more recently gained greater recognition, both in mental health circles and the public eye, because of the struggles of veterans returning from the wars in Iraq and Afghanistan.

At the same time, many mental health experts have come to believe that another, more common, form of trauma exists that is often misdiagnosed as PTSD. Referred to as complex trauma or complex PTSD, this type of trauma is caused by repeated exposure to abuse or other traumatic events over time.

Despite the urging of many trauma experts, complex trauma was not included in the DSM-5. However, the disorder is very real and distinct from the current definition of PTSD, asserts Cynthia Miller, an ACA member who presented on “Recognizing and treating complex PTSD” at the ACA 2015 Conference.

Complex PTSD is typically the result of cumulative trauma and abuse that started in childhood. Miller’s interest in complex PTSD was first piqued when she was counseling women in the corrections system, where many of her clients — and many of the incarcerated women in general — had histories of trauma and childhood abuse.

“I got interested [in complex PTSD] in my work with the prison population, but even in my community work, I saw that histories of trauma were way more common than we realized and also at the root of so many things that we were treating,” she says.

Clients with trauma histories are often misdiagnosed not only with single-incident PTSD but also with borderline personality disorder, bipolar disorder or major depression, Miller says. These disorders — along with alcohol and substance abuse — can accompany complex trauma, but counselors need to understand that the trauma colors everything the client is experiencing, explains Miller, a licensed professional counselor with a private practice in Charlottesville, Virginia. At the same time, treating complex trauma by immediately turning to protocols for PTSD, such as eye movement desensitization and reprocessing (EMDR), prolonged exposure therapy and cognitive processing therapy, is not going to work as well and may actually result in retraumatizing the client, she says. Methods such as EMDR may be helpful for some clients later in the treatment process, Miller says, but only after they have been through an initial stabilization process.

“One of the most common mistaken impressions [when treating trauma] is that someone who has been through trauma needs to talk about and process it,” explains Miller, who is also an assistant professor of counseling at South University in Richmond. By doing this, she says, “counselors are trying to help clients, but they [may] open up trauma that neither the counselor nor the client is ready to deal with. When dealing with complex trauma, the first thing you need to do is to help them live in the present, not the past.”

Although PTSD and complex trauma share certain symptoms, they also feature significant differences — differences that are crucial for counselors to understand, Miller says.

PTSD is typically caused by a single or time-limited event. Its symptoms include intrusive thoughts, avoidance behaviors, negative alterations in mood and cognition, and alterations in arousal and reactivity.

Complex trauma, on the other hand, is caused by long-term traumatic experiences such as child abuse, intimate partner violence, community violence (including living in a society at war), experiences as a refugee or displaced person, trafficking and forced servitude, chronic illness and disability necessitating invasive treatment, and bullying. Symptoms may partially mirror those for PTSD but also feature additional severe problems such as:

  • Difficulty regulating emotions
  • Disturbances in attention and consciousness
  • Affect dysregulation
  • Altered self-perception, including feelings of guilt and worthlessness
  • Difficulty interacting with other people
  • Chronic dysphoria or dissociation
  • Engaging in self-destructive behavior
  • Difficulty with self-soothing

People who are experiencing complex trauma do not have the emotional skills necessary to address the issues they’re facing, so before moving forward, a counselor must first help the client to stabilize, Miller says. Stabilization begins with establishing a sense of safety, including addressing the client’s most basic needs.

“You really almost have to go through Maslow’s hierarchy with [these clients] to find out if food, clothing and shelter are concerns,” Miller says. “If so, how can you help the client address it? Because it’s hard for someone to build skills if they don’t have a place to sleep.”

After the client’s basic needs have been addressed, the counselor should help the individual establish a sense of safety with “self,” Miller explains. This requires the counselor to probe for self-injurious behavior, suicidal behaviors or urges, risky sexual and other behaviors, and attendance to the health and integrity of the body. Assessing for self-protective behavior is also important, Miller continues. For example, is the client locking his or her house or bedroom door at night? Does he or she go running alone at night in crime-ridden areas? Safety with others is also important, she notes. For instance, is the client in a relationship in which he or she is being abused or exploited?

The third element of safety — without which the counselor cannot help the client with the first two — is feeling safe in therapy, Miller emphasizes. The client must feel that he or she is in control of what is going on.

“There must be a mutually designed treatment plan, informed consent throughout and the promise that the therapist is not going to do anything that the client doesn’t want to do or push them into doing something that they don’t want to do,” Miller says.

As the counselor and client address safety skills together, they should also work on other stabilization elements, such as reducing the acuity of trauma symptoms, Miller says. Symptom reduction involves developing coping skills and may or may not include medication, she adds.

Miller has found that dialectical behavior therapy (DBT) is particularly effective when teaching clients emotional coping skills. DBT helps clients learn that their symptoms are not their fault but rather a natural reaction to what has happened to them. This helps remove the attendant stigma and the clients’ sense that something is really wrong with them, Miller explains.

Because complex trauma causes dissociation, dysphoria, physical agitation and cognitive distortions, grounding skills — both physical and mental — are essential for reconnecting clients with themselves and their surroundings, Miller says. For instance, when a client’s nervous system is overloaded or aroused, his or her cognition is disrupted. To help these clients ground and re-engage, Miller directs them to say their ABCs backward, name the 50 states and state capitals, or name the different makes of automobiles.

To counteract physical disruption and the dissociation that sometimes accompanies it, Miller teaches clients grounding methods that engage the senses, such as touching physical items that have texture, describing what they see in their immediate physical surroundings or listening to soothing music. She also suggests physical stretching and movement, even if it’s just having clients stomp their feet while sitting down, or the sensory experience of running warm or cool water over their hands.

Miller also uses other soothing strategies such as safe place imagery with clients who have complex PTSD. Clients imagine a place, real or imaginary, where they feel safe, and Miller asks them to put themselves there by describing what they see, hear, feel, smell and taste.

Another soothing visualization technique involves picturing a nurturing and protective figure who has made the client feel cared for. Miller says this might be a relative, a friend, a pet or even a fictional or spiritual figure, just as long as the client can envision this figure during a time of need.

Clients with complex trauma also struggle with intrusive thoughts, so Miller asks them to visualize a container — whether it is a box, a safe, a vault, a dumpster or a tractor trailer — that is big enough to hold all of the things that disturb them. “It has to be as real as possible, and they have to be able to ‘lock’ it,” she says. Miller directs clients to visualize the container, set it aside and then walk away. “When they walk away, I have them walk to their visualized safe place,” she says.

Clients who are struggling with complex trauma also need to learn to relate to themselves and to others in different ways, Miller says. DBT can help in this area by teaching clients skills for managing intense emotions and interpersonal relationships. These skills include distress tolerance, emotional regulation, mindfulness and greater interpersonal effectiveness.

After clients are stabilized and feel safe, counselors can help them to integrate their traumatic memories so that the clients are no longer controlled by these memories, Miller says. She emphasizes that the aim of integration is to resolve the traumatic symptoms without retraumatizing the client.

Miller cautions that counselors should proceed carefully, helping the client to re-evaluate the meaning of the trauma and having the client demonstrate the ability to remember experiences while still remaining physically, emotionally and psychologically intact. The re-evaluation may involve an organized recounting of events using methods such as prolonged exposure therapy, cognitive processing therapy, narrative exposure therapy, traumatic incident reduction, EMDR and art therapy, she says.

After successfully stabilizing and integrating traumatic memories, the client and counselor can then work on enhancing the client’s relationships and planning for the future, Miller says.

Miller reiterates that complex trauma is more common than most helping professionals might realize, so she recommends that counselors screen for it routinely. “Counselors should be prepared. … Clients are not necessarily going to tell them [about their trauma] right away,” she says. Even if clients do bring up traumatic experiences on their own, it’s unlikely that they will reveal everything to a counselor initially, so counselors need to create a safe space and be patient, Miller says.

Miller adds that if a counselor suspects a client is experiencing complex trauma, the counselor should ask about it — but carefully. “Ask behaviorally,” she says. “Don’t ask clients if they were physically or sexually abused. Instead, ask them if anyone has ever punched, slapped, kicked or touched [them] in a way that [they] didn’t like or want.” Initially, clients struggling with complex trauma may not recognize or be willing to identify these behaviors as abuse, Miller says.

Because the trauma focus in counselor education is typically on PTSD and not complex trauma, Miller urges counselors to seek further training through continuing education and conferences. “It’s one of those things that you can’t afford not to know about and not know how to treat because, whatever work you do, you’re going to see it,” she says.

Understanding and assessing clients who are suicidal

It’s a counselor’s worst fear: a client who dies by suicide. Yet, as any counselor knows, there is no research that can definitively tell practitioners how to prevent suicide. But what if prevention starts with acceptance rather than assessment? What if connecting with a client who is suicidal requires accepting and understanding that there are circumstances under which many people might consider suicide? These are the questions that ACA member Eric Beeson explored in his conference session, “How do I know if someone is suicidal? A discussion of suicide theory, attitudes and interventions.”

Beeson, a licensed professional counselor and lecturer at the University of North Carolina-Greensboro, thinks that accepting the validity of such feelings is key to understanding why a client believes suicide is the answer. When faced with a client expressing suicidal thoughts, many mental health professionals instead focus on immediately shutting those thoughts down, he says. Although acknowledging there are certain cases that require emergency treatment such as hospitalization, Beeson says an immediate focus on preventing suicide may actually alienate the client and hinder treatment. He believes that approach is often based in the mental health professional’s fear — not only of losing a client but also of having to deal with and consider the subject of suicide. To understand and, hopefully, redirect a client’s suicidal urges, counselors must first examine their own attitudes, he asserts.

Beeson started asking such questions early in his counseling career during a four-year stint at a hospital, where dealing with death and the aftermath of suicide attempts was a regular occurrence. “Watching the way some of the staff interacted with people after a suicide attempt, some of the judgments I saw, got me curious about people’s attitudes toward suicide and then, eventually, how … that attitude influences practice,” he says.

With more than 41,000 reported suicides in the United States in 2014, these are urgent questions to answer. Beeson, a contributing faculty member at Walden University, began his presentation by asking attendees to consider the following questions as a way to examine their own attitudes about suicide and people who die by suicide.

  • How can I tell if my client is suicidal?
  • Why do people attempt or die by suicide?
  • Is suicide a singular event or a process?
  • Can suicide be rational and/or permitted?
  • What is my role when working with someone experiencing suicidal behaviors?
  • Am I capable of suicide?
  • Even though you would prefer another way to die, painful circumstances in life might lead to suicidal ideation. How do you estimate the probability that you sooner or later will die by suicide?

a) I am sure I never will die by suicide.

b) I hope I will never die by suicide, but I am not absolutely sure.

c) Under certain circumstances, I consider suicide as a possibility.

d) I consider suicide as a possibility for the future.

n  What suicide attitudes do you think are most helpful to counseling practice?

a)  More/less acceptance of suicide

b)  More/less condemnation of suicide

c)  More/less belief in the preventability of suicide

Beeson notes that even within the mental health field, the stigma and avoidance surrounding suicide remains strong. People who have died by suicide or attempted suicide are typically viewed as weak. This represents an empathy gap — one that counselors need to close, Beeson asserts. So, he challenges counselors to ask themselves about their personal suicide potential.

During his session, Beeson used humor to demonstrate circumstances that might cause a person to consider suicide as a viable option. In a clip from the old TV sitcom Cheers, four characters — Sam, Woody, Norm and Cliff — are preparing to sky-dive. But when the time comes to jump, they’re all petrified, realizing that they could die. Suddenly, skydiving doesn’t seem like such a good idea. However, for various reasons — to prove something, to not look like a coward, because everyone else is doing it — they each eventually jump. Cliff is the last and the most hesitant. Seemingly nothing will make him jump. But then the plane starts to sputter and the pilot says it’s going to go down. Cliff decides to take his chances — to, in essence, take control of how he will die — and jump.

Beeson asked the audience to think about which character they identified with. What might motivate them to get out of that plane? Beeson says he does this to help counselors recognize that under certain circumstances, anyone might consider dying by suicide. In turn, that helps them better understand why a client might consider suicide a viable — or even the only viable — option.

Beeson notes this is not just theoretical for him. During his time working with clients who were suicidal, he found that the more he focused on prevention, the less effective he was. However, once he started focusing on acknowledging the client’s struggle and the resilience it had taken to come this far, he was better able to take that resilience and direct it toward other methods of coping.

“I don’t know what it’s like for … any person to walk in their shoes, and who am I to say that they’re walking in their shoes wrong?” Beeson asks. “Who’s to say if I wasn’t in a similar situation, that my shoes might get a little uncomfortable? … And [if they] become more uncomfortable than I’d like to bear and I can’t find a new pair of shoes, then who’s to say that I might not take those shoes off?”

“I don’t believe that people just want to kill themselves,” he says. “It’s just that last-ditch effort to attain something that seems unattainable.”

Beeson believes counselors need to view suicidal intent on a continuum. “Suicidal is a misleading term. There’s no research to suggest that there’s any way to truly decide when someone is or is not — quote, unquote — ‘suicidal,’” Beeson says.

The better question, he asserts, is how likely is someone to die. Dying is painful and goes against the natural human instinct to preserve life. Beeson explains that research by psychologist and suicide expert Thomas Joiner posits that suicide requires overcoming that instinct and becoming capable of killing oneself. When that capability is combined with circumstances that seem intolerable, the risk of suicide is very high, Beeson explains.

Some people, such as those in high-risk, high-intensity jobs, including police officers, firefighters and emergency services personnel, already have a greater risk of death because they are regularly exposed to and habituated to it, Beeson contends. In addition, people in these jobs are routinely exposed to others’ experiences of pain. This engenders a certain comfort level with pain that also increases the person’s likelihood of dying, Beeson says.

But working in one of these high-intensity professions is not the only way that people habituate themselves to pain and the risk of death. Nonsuicidal self-injury, prior suicide attempts, intravenous drug use and prostitution have all been linked to suicidal behavior, Beeson says.

He adds that research by Joiner and others has shown that suicidal risk factors fall under three main categories.


  • Mental disorders — particularly mood disorders, schizophrenia, anxiety disorders and certain personality disorders
  • Alcohol and other substance use disorders
  • A sense of hopelessness
  • Impulsive or aggressive tendencies
  • History of trauma or abuse
  • Some major physical illnesses
  • Previous suicide attempt
  • Family history of suicide



  • Job or financial loss
  • Relational or social loss
  • Easy access to lethal means
  • Local clusters of suicide that have a contagious influence



  • Lack of social support and sense of isolation
  • Stigma associated with help-seeking behavior
  • Barriers to accessing health care, especially mental health and substance abuse treatment
  • Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma)
  • Exposure to suicide, including through the media, and the influence of others who have died by suicide

Beeson says counselors should evaluate clients for these risk factors and also look for the following warning signs.

Talk: The client talks about killing himself or herself, having no reason to live, being a burden to others, feeling trapped, having no hope or being in unbearable pain.

Behavior: New or increased episodic behavior, especially if related to a painful event, loss or change; increased use of alcohol or drugs; looking for a way to kill themselves, such as searching online for materials or means; acting recklessly; withdrawing from activities; isolating from family and friends; sleeping too much or too little; visiting or calling people to say goodbye; giving away prized possessions; and displaying aggression.

Mood: Displaying depression, anxiety, rage, irritability, humiliation or sudden calmness.

Beeson also explained that there are five levels of risk for suicide:

Nonexistent: No or few risk factors, no previous attempts and no suicidal behaviors.

Mild: A previous attempt but no other risk factors, or no previous attempts but demonstrating short-term, mild suicidal behaviors.

Moderate: A previous attempt with other notable risk factors, or no previous attempts but exhibiting ambivalent plans or preparation, suicidal desire or two other notable risk factors.

Severe: Previous attempt with two or more notable risk factors, or no previous attempts but having moderate or severe symptoms of resolved plans and preparation.

Extreme: Previous attempts with severe symptoms of resolved plans and preparations, or no previous attempts with severe symptoms of resolved plans and preparations and two or more other risk factors.

If a counselor has a client who is displaying suicidal risk factors, the first step is to ensure immediate safety, which in some cases may require hospitalization. Otherwise, the counselor and client can work to develop emergency plans that the client can follow if he or she is feeling suicidal, Beeson says.

It’s also important for counselors to establish a rapport with these clients and listen to their stories without judgment, he emphasizes. Counselors should then help clients manage their feelings by acknowledging their pain and encouraging them to use the session as a time to consider all options, including suicide, Beeson says.

Another critical factor is to guide clients in exploring alternatives to suicide by helping them envision future possibilities. Beeson says counselors should emphasize future plans by asking questions such as: How are you going to stay alive in the next week? Will you be back to see me next week? He adds that helpful behavioral strategies include drawing up a short-term positive action plan and using safety or wellness plans.

Beeson gives presentations on suicide frequently because he feels the topic is so important. “I just want to foster tough conversations about what we believe about suicide and the implications for practice,” he says. “I want people to live. That’s my goal. But I also believe in autonomy and the client’s right to choose. I think as we acknowledge that autonomy, we are better able to connect with people. I just think that one of the best ways to promote those types of interventions is to address what it is that we believe so that we can promote life-giving conversations. Then maybe we can promote that hope that the unattainable might just be attainable in some other direction.”

A playful approach to bullying prevention

Bullying prevention often focuses on punitive measures. The bully is identified, chastised and punished — with little or no consideration given to why the bullying occurred in the first place, says ACA member Ruth Ouzts Moore. And if counselors, teachers and other educators don’t address the underlying reasons, the likelihood of preventing bullying over the long term is low, she adds.

But how can counselors and educators learn the real reasons for bullying? Those who bully and those who are bullied often are too ashamed, scared or just plain angry to talk honestly about what is driving the bullying, Moore notes. That’s why she has come to believe that play, not punishment, is the best way to address and reduce bullying.

As a licensed professional counselor, counselor educator and part-time school counselor in the Savannah, Georgia, area, Moore has implemented this creative approach with young students and found it to be very effective. She described her experiences in a session at the ACA 2015 Conference.

Moore, an ACA member, began her presentation by clarifying the definition and different types of bullying. At its root, she said, bullying is an intentional, abusive act or attempt to inflict injury or discomfort on another person. She further explained that bullying can take the form of physical, verbal, relational or cyber abuse.

Bullying is fueled by the imbalance of power between the person doing the bullying and the person being bullied. Moore, a core faculty member in the mental health counseling graduate program at Walden University, noted that research suggests targets of bullying are at a disadvantage in this power differential for various reasons, which include:

  • Being perceived as different or weak and defenseless
  • Experiencing depression, anxiety or low self-esteem
  • Being less popular
  • Being perceived as annoying or attention seeking

Bullies, on the other hand, are generally students who are easily angered or frustrated, have family issues or are overly concerned with popularity.

For the targets of bullying, the gap between them and their tormentors must seem huge, but Moore notes that the bully and the bullied usually have similar backgrounds. For instance, children who come from abusive or violent backgrounds, grow up in neglectful environments in which there is little parental involvement or are caught in the middle of a high-conflict divorce face a higher likelihood of being bullied and bullying others, she says.

Bullying has serious and long-lasting effects on both the bully and the bullied, Moore points out. These effects include anxiety, low self-esteem, depression, suicidality, fear, mistrust, truancy, academic decline and nonsuicidal self-injury. In addition, the bully and the bullied are not the only ones affected. Bystanders, teachers, parents and siblings also suffer the consequences, directly or indirectly, she says.

Counselors face myriad challenges with both populations when working to address the issue, Moore says. Research has found that those who bully:

  • Often minimize or deny their aggressive acts and behaviors
  • Can be reluctant or resistant to disclose sensitive issues such as family violence or emotional problems that may be at the root of the bullying
  • Are sometimes repeating behavior that is intergenerational
  • Are often handled punitively and therefore may be distrustful of counselors

Similarly, research has found that those who are targets of bullying:

  • Often won’t tell anyone they are being bullied
  • May present in counseling with other issues such as depression, anxiety or school avoidance that may complicate or obscure the bullying issue
  • May have difficulty verbalizing their feelings
  • May not want to disclose bullying because they are ashamed and humiliated
  • May not disclose family problems that are at the root of or complicating the bullying

In her private practice, Moore has worked extensively with adolescents who bully or who have been bullied. She recently took on a school counseling position that allows her to address bullying with prekindergarten-age children through eighth-graders, both from a group and individual perspective. She notes that early education and intervention are the most effective means of preventing bullying.

Moore was hired specifically to address bullying at a private school that was having serious problems. Her goal was to help prevent bullying through identifying the sources of the problem, providing education and implementing active classroom strategies.

Moore presents weekly classroom sessions in which she combines educational sessions and activities in the form of games. She says the students enjoy the activities because they’re fun and provide a break from classroom work. The games also give Moore an opportunity to observe the classroom and identify the children who act out. She will often follow up by providing individual therapy to the most disruptive children.

Her activities focus on neutralizing bullying by increasing self-esteem and developing anger management skills. The self-esteem building activities include things such as a written quiz with 10 questions: 1) What’s good about you? 2) What’s good about you? 3) What’s good about you? And so on, with the same question repeated 10 times.

“It makes them laugh,” Moore says. “Kids often get stuck and can’t think about what’s good, so we’ll talk about how it’s hard to say good things about yourself because people will think you’re bragging, but it’s really important.”

In another game, Moore hands out Riesens caramels when students tell her the reasons or “Riesens” they like themselves.

During her presentation at the ACA Conference, Moore handed out balloons to audience members to demonstrate another activity she conducts for anger management. She asks the students to blow into the balloons to represent how stressful their day has been. The balloons end up being anywhere from just a tiny bit full to completely blown up.

“We talk about how amazing it is [to see] how quickly the balloons can fill up,” Moore says. She then goes on to talk with the students about how to moderate anger.

Another activity, “Bullying Bingo,” has helped students learn about the different types of bullying. Moore has also led students in activities to strengthen their sense of collaboration, such as by working together to build a peanut butter sandwich without looking at one another.

The activities seem to be having an effect. In the two years since Moore started working at the school, it has witnessed a huge decline in incidents of bullying.

Moore credits the creative approach for the results. She believes it works because the approach is nonthreatening, allows kids to express things they have trouble verbalizing and helps to build their confidence. On top of that, the activities are fun.

Moore encourages counselors to explore the creative approach when addressing issues of bullying. She also urges counselors who want to learn more to join the Association for Creativity in Counseling, a division of ACA for which Moore currently serves as secretary.

“Be open to new approaches,” she concludes.




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org