W When the word “suicide” appears during counseling sessions, it usually triggers the clinician's fear. You might start to have thoughts like, “What should I ask next? How can I best assess my clients' suicide risk? Should I conduct a formal suicide assessment or should I be less direct? ”In addition, you may be concerned about a possible hospitalization and how to treat the session while assessing the risk.
Suicide-related scenarios are stressful and emotionally activating for all mental health, school and health care professionals. Consultants are no exception. But consultants bring a different orientation into the room. As a discipline, counseling is less shaped by the medical model, more geared towards well-being and more relationship-oriented during the assessment and intervention processes. In this article, we examine how professional counselors can meet practice standards for the assessment and treatment of suicide while taking a holistic, strength-based, and wellness orientation into account.
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Go beyond traditional views of suicide
Suicide and suicidality have long been associated with negative judgments. Sometimes suicide – or even thinking about suicide – has been labeled sinful or immoral. In many societies, suicide has historically been considered illegal, and in some countries it is still today. In the past, suicidality was almost always pathologized, and it is largely the case today. Defining suicide and thoughts of suicide as immoral, illegal, or illness is an alienating and judgmental social construction that makes people less likely to openly discuss these thoughts and feelings. Most people who experience suicidality already feel guilty. Socially sanctioned negative judgments can cause further damage.
Our position is that suicide is neither a moral failure nor evidence of a so-called mental illness. Instead, we believe that thoughts of suicide, consistent with a strengths-based perspective, are a normal variation on the human experience. Thoughts of suicide usually result from adverse environmental conditions, social separation, or excruciating emotional pain. Improving living conditions, improving social bonding, and reducing emotional pain are usually the best ways to reduce the frequency and intensity of suicidal thoughts and feelings.
Doctors trained in the medical model tend to diagnose people at risk of suicide with a variant of a depressive disorder and offer treatments aimed at suicidality. Sometimes treatments are performed without the patient's consent. Health care providers are generally considered to be persons of authority who know what is best for their patients.
In contrast to the medical model, a strengths-based perspective contains several empowering assumptions:
When a painful psychological distress escalates, strength-oriented counselors consider the occurrence of suicidal ideation as a normal and natural human reaction. Thoughts of suicide are a reaction to living conditions and can represent a method for coping with relentless psychological pain.
Since thoughts of suicide are viewed as a normal response to psychological pain, the revelations of thoughts of suicide are framed by clients as expressions of suffering rather than signs of illness. As a result, when clients reveal suicidality, counselors do not react with fear and judgment, but instead welcome suicide-related disclosures. Strengths-based counselors recognize that clients show trust when they openly share suicidal thoughts, thus creating opportunities for interpersonal and emotional connections.
Many people at risk of suicide want to protect their right to commit suicide. If they feel judged by health care professionals or school officials and feel compelled to seek treatment, they can shut down and resist. Rather than insisting that clients and students “need treatment”, strengths-based counselors recognize that clients are the best experts on their own lived experiences. Strength-based counselors offer empathic, cooperative assessment and treatment when clients and students are at risk of suicide.
Rather than relying on mental health diagnoses or asking symptom-based questions from a standard form such as Patient Health Questionnaire-9, strengths-based counselors weave in questions and observations related to the client's strengths, hopes, and coping resources. According to the principles of solution-oriented counseling and positive psychology, the strength-oriented counselors balance symptom questions with wellness-oriented content.
We believe that the above assumptions can be incorporated into counseling in a way that improves traditional suicide assessment and treatment approaches. Indeed, over the past two decades, evidence-based treatments of suicide, such as joint assessment and management of suicides, have increasingly emphasized empathy, normalization of suicidality, and collaboration between counselors and clients. An objectivistic philosophy and medical attitude is no longer required to work with clients or students who are suicidal. Newer approaches, including the strengths-based approach discussed here, stem from postmodern, social constructivist philosophy, in which conversation and collaboration are fundamental to reducing need and increasing hope.
A holistic approach
When clients reveal suicidal ideation, it is not uncommon for counselors to focus too much on the assessment. In response to suicidality, counselors may ask too many closed questions about the presence or absence of suicide risk and protective factors. This shift from an empathic focus on what hurts to analytical assessment protocols is unjustified for two main reasons. First, based on a meta-analysis of 50 years of studies of risk and protective factors, a research group at Vanderbilt, Harvard, and Columbia Universities concluded that none of the factors offer a large statistical advantage over random suicide prediction. In other words, even if a mental health professional or school does a comprehensive assessment of the client's risk and protective factors, that assessment is unlikely to have any clinical or predictive value. Second, too much concentration on the assessment of the risk of suicide usually impairs important relationship-building interactions that are necessary for positive counseling results.
Instead of overemphasizing the risk factor assessment, counselors should recognize the client's stress and react empathically. Recognizing and providing supportive responses to emotional pain and stress can individualize your understanding of the client's unique risk and protective factors. From a practical point of view, it is better for counselors to ask the client questions directly rather than using a general checklist of risk factors such as, “What happens to make you feel suicidal?” And “What if it changed To take your suicidal feelings? "
Additionally, as strengths-based practitioners, we should look for customers, identify them and give them feedback on their unique positive attributes. Statements such as “Thank you very much for having the courage to tell me about your suicidal thoughts” convey acceptance and a reflection of the client's strengths. Although counselors can work in facilities that use traditional suicide risk assessment protocols, they can still complement this process with a more holistic, positive, and interpersonal supportive assessment and treatment planning process.
To help counselors focus on the whole person – instead of focusing too much on suicidality – we recommend using a dimensional assessment and treatment model. Our special dimensional model tracks and classifies clients' suffering into seven categories. Here we describe each dimension, offer examples of how distress manifests itself differently within each dimension, and identify evidence-based or theoretically robust interventions that deal with dimension-specific distress.
The emotional dimension: Clients at risk of suicide often experience agonizing sadness, fear, guilt, shame, anger and other painful emotions. At other times, clients feel numb or emotionally drained. Concentrating on and showing empathy for core emotional complaints or numbness is the basis for working with these clients. Clients can also experience emotional dysregulation. Interventions to address emotional problems in counseling include traditional cognitive behavioral therapies for depression and anxiety, existential research into the meaning of emotions, and dialectical behavioral therapy to help clients develop emotional regulation skills.
The cognitive dimension: People often react to emotional pain with maladjusted cognitions, which further intensify their suffering. Hopelessness, impairment in problem-solving, and basic negative beliefs are all linked to suicide. Depending on each client's unique cognitive symptoms and ailments, strengths-based counselors will respond with empathy and then, if necessary, work with hopelessness in the here and now as it arises in the session. Counselors can also initiate problem-solving strategies, highlight solution-oriented exceptions, and teach clients how to notice, track, and modify inappropriate thoughts.
The interpersonal dimension: Extensive research indicates social and interpersonal difficulties as factors that drive people to suicide. Common interpersonal issues that trigger suicidal stress include social separation, interpersonal grief and loss, deficits in social skills, and repetitive dysfunctional relationship patterns. Interventions in the interpersonal dimension include couple or family counseling, grief counseling, social skills training, and other strategies to improve social and romantic relationships.
The physical dimension: Physical symptoms trigger suicidal states and intensify them. Common physical symptoms related to suicide include arousal / arousal, physical illness, physical symptoms related to trauma, and insomnia. Using a strengths-based model, counselors can work together to develop treatment plans that address physical symptoms directly. Specific interventions include physical activity, evidence-based trauma treatments, and cognitive behavioral therapy for insomnia.
The cultural-spiritual dimension: Cultural practices and convictions alleviate or contribute to the suffering and suicidal tendencies of the clients. Religion, spirituality and meaningfulness or meaningfulness (or lack thereof) strongly convey suicidality. Specific cultural-spiritual issues that trigger hardship are separation from a community, a higher power, or a belief system. A sense of futility or acculturative distress may also be present. Strengths-oriented counselors explore the cultural, spiritual and existential issues in clients' lives and develop individual approaches to address these deeply personal sources of suffering and potential sources of support or relief.
The behavioral dimension: clients and students sometimes show specific behaviors that increase the risk of suicide. This can include alcohol / drug use, impulsiveness, and repeated self-harm. Easy access to guns or other deadly means is another factor that increases the risk. Helping patients identify destructive behavior patterns, develop alternative coping strategies, and reduce their access to lethal agents can be central to a holistic treatment plan. In addition, collaborative safety planning is an evidence-based suicide intervention that focuses on positive coping behavior.
The context dimension: Many larger context, environmental or situation factors contribute to distress in the other six dimensions and thus increase suicidality. These factors include poverty, neighborhood or relationship security, racism, sexual harassment, and unemployment. Helping clients identify and change contextual life factors – when in control of those factors – can be very encouraging. Clients also need support in coping with uncontrollable stressors. Developing an action plan and deciding when to use mindful acceptance can be an important part of the counseling process. Advocacy can be particularly useful to support clients who are faced with systemic barriers and oppression.
Suicide skills
Regardless of theoretical orientation or professional discipline, psychiatry and school professionals must meet or exceed basic competence standards. In this article, we recommend incorporating strengths-based principles, holistic assessment and treatment planning, and wellness activities into your work with suicidal individuals. Our recommendation is not intended to completely replace traditional suicide-related practices, but to expand your counseling repertoire to include strength-based competencies and holistic case formulation.
When introducing a strengths-based perspective into the counseling repertoire, counselors should be aware of the usual and customary professional standards for working with suicide. The current American Counseling Association Code of Ethics does not provide specific guidelines for the assessment and management of suicide. However, suicide-related skills are available in the literature. For example, Robert Cramer of the University of North Carolina Charlotte identified 10 essential suicide skills from several different health care and mental health publications, including guidelines from the American Association of Suicidology.
Cramer's 10 suicidal skills are listed below, along with brief statements describing how strengths-based counselors can address each skill.
1) Be aware of and control your attitudes and reactions to suicide. Strength-based counselors strive for individual, cultural, interpersonal and spiritual self-awareness. Self-care also helps counselors stay balanced in their emotional responses to suicidal clients.
2) Develop and maintain a collaborative, empathic attitude towards clients. Strength-based consultants are relationship-oriented, cooperative and empathetic, but also consistently orientate themselves towards the strengths and resources of the clients.
3) Know and determine evidence-based risk and protective factors. Strength-based consultants understand how to individualize risk and protection factors in order to adapt them to the unique risk and protection dynamics of each client.
4) Focus on the current plan and intent of the suicidal ideation. Strength-based counselors not only explore clients' plans and intentions, but also actively engage in discussions about alternatives to suicide plans and ask clients about individual factors that reduce intent.
5) Determine the level of risk. Strength-based counselors encourage clients to obtain information about self-perceived risk and work with clients to better understand factors that increase or decrease individual risk.
6) Develop and implement a collaborative, evidence-based treatment plan. Strength-based advisors commission clients with the creation of an individualized safety plan that includes positive coping behavior, and together they develop holistic treatment plans that address emotional, cognitive, interpersonal, cultural-spiritual, physical, behavioral and context-related dimensions of life.
7) Notify and involve other people. Strengths-based counselors recognize the central importance of interpersonal connection for suicide prevention and involve important others for safety and treatment purposes.
8) Document the risk assessment, treatment plan and rationale for clinical decisions. Strength-based counselors follow accepted practices to document their assessment, treatment, and decision logs.
9) Know the suicide law. Strengths based counselors are aware of local and national ethical and legal considerations when working with suicidal clients.
10) Participate in the debriefing and self-care. Strength-oriented counselors consult regularly with colleagues and superiors and, if necessary, take part in suicide postventions.
The strengths-based approach in action
Liam was a 20 year old cisgender, straight man with a biracial (white and Latin American) cultural identity. At the time of the transfer, Liam had just started training as a diesel mechanic at a local community college. He was referred to advice by his trade teacher. Liam had experienced a breakup about a week earlier. Then he hit a wall in class (he broke his finger), talked about suicide, threatened his former girlfriend's new boyfriend and impulsively quit his internship.
Liam started his first session by bragging about banging on the wall. He said, “I don't need any advice. I know how to take care of myself. "
Instead of counteracting Liam's opening comments, the advisor maintained a positive and accepting attitude, saying, “You might be right. Advice is not for everyone. You look like you could take good care of yourself. "
Liam shrugged his shoulders and asked: "What should I talk about here?"
Many clients who feel suicidal immediately start talking about their plight. Others, like Liam, deny suicidality. When leading distressed clients, the counselor's first job is to empathize with the distress and highlight unique factors in the client's life that trigger suicidal thoughts and impulses. In contrast, the counselor at Liam reflected Liam's open-minded attitude, accepted Liam's explanation, and focused specifically on Liam's strengths: his professional goals, his initiative to start vocational training immediately after graduating from high school, his ability to care deeply for others ( z ex-girlfriend) and his pride in being physically fit.
After about 15 minutes the conversation shifted to how Liam made decisions in his life. Rather than questioning Liam's judgment, the counselor continued to focus positively, saying, “When I think about your situation, it was in some ways a good idea to bump into the wall. It is definitely better than hitting a person. ”The counselor then added,“ I don't blame you for being pissed off for parting. Nobody likes separations. "
The counselor asked Liam to tell the story of his relationship and the events that led to the separation. Liam could talk about his feelings of betrayal and loneliness, and his underlying worries that he would never achieve anything in life. He admitted that he occasionally thought of "doing something stupid like insulting myself". He agreed to continue with the counseling, mostly because it would look good for his vocational training teacher. Before the end of the session, the consultant explained that consultants must always carry out a so-called "safety plan". During security planning, Liam admitted having two firearms, and although he "didn't have to," agreed to keep his guns in his mother's house for the next month.
After the first session, the counselor documented Liam's assessment, intervention and treatment plan. The consultant's documentation included problems and strengths, organized using the holistic dimensional model:
1) Emotional: Liam experienced acute emotional stress and emerging suicidal thoughts in connection with a relationship breakdown. While minimizing his grief, Liam was also able to articulate feelings of betrayal and loneliness.
2) Cognitive: Liam felt hopeless to find another girlfriend. He was a little evasive when asked about suicidal thoughts. Eventually he admitted to thinking about it and that if he ever decided to die he would shoot himself (which he said he wouldn't). Liam was able to participate in the problem solving during the session.
3) Interpersonal: Although Liam was desperate about the breakup of his love affair, he agreed to consult with his advisor about relationships in future meetings. He worked together to brainstorm positive and supportive people to contact if he was feeling lonely or suicidal. Liam reported a positive relationship with his mother.
4) Physically: Liam reported sleeping disorders. He said, "I drank more than I need." During the safety planning, Liam agreed to certain steps to deal with his insomnia and alcohol consumption. Liam was in good physical shape and invested in his physical well-being.
5) Cultural-spiritual: Liam said that “it doesn't hurt me” to go to church with his mother on Sundays. He reported having a good relationship with his mother. He said that she would like to go to church with her and that he was comfortable with it.
6) Behavior: Liam helped create his security plan. He agreed to follow the plan and take good care of himself for the coming week. Liam identified specific behavioral alternatives to alcohol consumption and suicidal acts. He agreed to store his firearms with his mother.
7) Contextual: Apart from high unemployment rates in his community, Liam did not report any problems in the context dimension. He said that he currently owned an apartment and believed that he had a good future career.
Final comments
A holistic, strength-based and wellness-oriented model for working with suicidal clients and students fits well with the consulting profession. Together with the knowledge and expertise in traditional suicide assessment and treatment, the strengths-based model provides a basis for suicide assessment and treatment planning. For a detailed description of the strengths-based model, see our book Suicide Assessment and Treatment Planning: A Strengths-Based Approach, published by ACA earlier this year.
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John Sommers-Flanagan is Professor of Counseling at the University of Montana with over 100 publications including Suicide Assessment and Treatment Planning, Clinical Interviewing and seven other books co-authored with Rita Sommers-Flanagan. Contact him at [email protected] or through his blog, which also offers free counseling resources, at johnsommersflanagan.com.
Rita Sommers-Flanagan is Professor Emeritus of Counseling at the University of Montana. Since retiring, Rita has shifted her interests towards suicide prevention, positive psychology, creative writing, and passive solar design. She blogs at godcomesby.com/author/ritasf13 and can be contacted at [email protected].
Counseling Today reviews unsolicited articles written by members of the American Counseling Association. For writing guidelines and tips for accepting an article for publication, visit ct.counseling.org/feedback.[19459004
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Opinions and statements in articles appearing on CT Online should not be construed as the opinions of the editors or guidelines of the American Counseling Association.
