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“Counseling is both a science and an art, but that’s really true when it comes to [preventing] suicide,” says Julia Whisenhunt, a licensed professional counselor (LPC). “There’s a lot of solid research out there on the topic, but figuring out the complex constellation of suicide warning signs in a specific individual is an art. It’s based on science, but it’s also an art.”

Recognizing suicidal ideation in clients and meeting their unique needs comes not only from being trained and up to date on suicide prevention and response, but also from a measure of professional intuition, says Whisenhunt, an associate professor and director of the doctoral program in professional counseling and supervision at the University of West Georgia (UWG). Suicide is a complex issue, and counselors must do their utmost to ensure client safety and maintain client trust while asking tough questions that probe people’s lowest moments.

Above all, suicide is a topic that counselors should not tiptoe around or be fearful of, stresses Whisenhunt, a member of the American Counseling Association. Practitioners bear a responsibility to screen for suicidal ideation and to address the topic with sensitivity.

“Most people aren’t necessarily going to directly reach out and ask for help. [They] will communicate distress in other ways, and it’s a matter of whether we’re paying attention,” says Whisenhunt, who routinely conducts suicide prevention workshops and trainings on the UWG campus and surrounding community. “As humans, we tend not to see it. We can’t imagine the people in our lives would think about it [dying by suicide]. If you’re not trained in suicide prevention, you might know something’s off but not fully understand what it is and what the warning signs are. That’s the importance of training — so you can make that connection and know how to support them.”

No population untouched

According to the Centers for Disease Control and Prevention (CDC), suicide is the 10th-leading cause of death in the United States. For many age groups, however, it ranks much higher. Consider:

• Suicide is the second-leading cause of death among those in the 10-14, 15-24 and 25-34 age groups.
• Suicide is the fourth-leading cause of death among those in the 35-44 and 45-54 age groups.
• Suicide is the eighth-leading cause of death among those ages 55-64.

In 2017, the most recent year for which CDC statistics are available, more than 47,000 Americans died by suicide — an average of 129 people each day. These numbers reflect a 33% increase in rates of suicide over the past 18 years, according to the CDC. America’s age-adjusted suicide rate rose from 10.5 deaths per 100,000 people to 14 deaths per 100,000 people between 1999 and 2017.

Statistics are even more dire for certain populations, including military veterans. The U.S. Department of Veterans Affairs (VA) reports that there were more than 6,000 veteran suicides each year from 2008 to 2016. In 2016, the suicide rate among veterans was 1.5 times higher than the rate among the civilian/nonveteran population. According to the VA, an average of 20 veterans die by suicide daily.

Issues related to suicide have grabbed headlines in recent years, not only as news outlets have reported on statistics and trends, but also as notable figures such as Robin Williams, Kate Spade and Anthony Bourdain have died by suicide.

With rates of suicide increasing across geographic regions and almost all ethnic groups, people may reach the conclusion that suicide prevention programming isn’t working or isn’t worth the effort. That simply isn’t true, stresses Jenny L. Cureton, an assistant professor of counselor education and supervision at Kent State University. People often cite outreach programs, crisis hotlines and even signs on bridges as things that interrupted them on their path toward suicide, she says. The National Suicide Prevention Lifeline answered 2.2 million calls in 2018 and a total of 12 million calls in the first 12 years after it was established in 2005.

“When we believe that we can cope and that people care about us, when we have hope and reasons to be here, we can more easily choose life. Great prevention efforts target these goals, and laypersons and professionals alike can target them too, every day,” says Cureton, a member of ACA.

“For the most part, as a society, we understand [now] that talking about suicide doesn’t cause suicide,” Cureton says. “But what we might not understand as a profession is that empathizing with a client’s reasons for wanting to die is not the same as agreeing with them.”

“Empathy and trust are a huge factor in suicide work. Empathizing with a client’s situation is not [the same as] endorsing their suicidal thoughts,” she continues. “You have to balance the client’s reality while acknowledging all the facets of it. Take the time to be with them in the scary, angering and sad places where suicide usually resides. And then say, ‘When you escape this place, even for one moment, what do you find there? What’s a moment that you thought would be the end and it wasn’t? Who was there for you? Can you imagine something shifting even the slightest bit? What does that hope look like?’”

Using empathy to acknowledge a client’s pain helps counselors better understand what the client is experiencing and can inform their work together in counseling to help the person stay safe going forward. “I want to see the world from their eyes so I can help them have the world they want for themselves,” Cureton says. This also demonstrates “that I care about them staying here. I care about them having a life that is so worth living that they live it.”

Exploring risk

Assessing for suicide risk is a vital procedure that should be undertaken with every client. However, forging a bond with the client ought to be the first step that professional counselors take before launching into detailed assessment questions, says Kristin Bruns, an LPC who is an assistant professor in the Department of Counseling, School Psychology and Educational Leadership at Youngstown State University.

Practitioners should also endeavor to understand the client’s full situation before intervening. Bruns acknowledges that this may require counselors to overcome an instinct to take action immediately, especially when clients express thoughts and feelings about killing themselves. But what clients need most in that moment is a practitioner who will listen, Bruns says, not one who reacts or recoils.

“Don’t jump in to assist too soon because the client may shut down,” says Bruns, an ACA member who presented a daylong learning institute on suicide assessment, treatment and safety planning at the ACA 2019 Conference & Expo in New Orleans. “[Demonstrating] empathy and being able to sit with [the client’s] discomfort is critical for counselors to do. … Fully listen to the client’s story to feel what they’re carrying. We have to be human in the [counseling] room. Work against the alarm bells going off in your head.”

When it’s time to move into the questioning phase with clients, Bruns recommends that counselors use an evidence-based suicide risk assessment tool and then stick with it. Practitioners shouldn’t go off of memory, even if they have used the same tool for years, she cautions. Numerous evidence-based suicide assessment and treatment tools are available. Bruns suggests that clinical counselors simply choose one that is a good fit for their style and client population.

As the client is answering questions, counselors can probe for detail, such as how long the client has been experiencing suicidal thoughts and what might have led to those thoughts in the first place, such as a life change or personal loss, Bruns says. It’s also important to ask if those thoughts are constantly present with the client or are more fleeting in nature.

“Don’t tiptoe around the issue,” Bruns says. “Starting with clear language from the beginning makes it easier: ‘Do you want to kill yourself? Have you ever thought about how you would die [by suicide]? Do you have a plan? What would it look like?’ Open and clear communication is important. It’s also an opportunity to educate [the client] on the brain and how it doesn’t make rational decisions in a crisis.”

Bruns says that when asking such questions, counselors should remain sensitive to the client’s needs and presenting issue. “We have questions that we know we need to ask, but at the same time, pay attention to the client and don’t overwhelm them. Put yourself in their shoes. If they’re struggling, be thoughtful about how many questions you’re asking … [and] your volume and type of questions,” Bruns says.

Certain clients might be particularly wary of disclosing suicidal thoughts because they fear the revelation could affect their athletic or job status (e.g., college or professional athletes, law enforcement personnel, military personnel). Counselors should ensure that they fully explain the limits of client-counselor confidentiality during the informed consent process but also reassure clients that they won’t be institutionalized or “taken away” — like in the movies or television dramas — for acknowledging that they have or have had suicidal thoughts, Bruns says.

“Don’t buzz through conversations about confidentiality,” she says. “Explain that there’s a continuum [of suicidal ideation]. Just by telling me that you’ve thought about suicide doesn’t mean that you’ll be hospitalized. ... If there’s any kind of hesitancy [from the client], don’t just barrel through with questions. Pause and reassess, and pick up on why they’re uncomfortable.”

Suicide prevention literature lists dozens of risk factors sorted by environmental and other factors, including feeling hopeless or helpless; experiencing a stressful life event such as divorce or financial trouble; experiencing prolonged stress from bullying, unemployment or other issues; having a family history of suicide; and experiencing a death by suicide of a family member or close personal acquaintance. (Find detailed lists of suicide warning signs and risk factors at the websites of the American Foundation for Suicide Prevention, afsp.org, and the National Suicide Prevention Lifeline, suicidepreventionlifeline.org.)

Clients who have a suicide attempt in their past are at higher risk for another suicide attempt. Co-occurring issues that put clients at higher risk of suicide include depression, bipolar disorder, a substance use disorder, and other mental illnesses that are untreated or are not being properly managed, Bruns notes.

Probing for details of past suicide attempts can help inform counselors’ understanding of an individual’s current suicide risk, Whisenhunt adds. She recommends asking if prior attempts were planned or impulsive, what means the person used to carry out the attempts, and whether the attempts were intentionally or unintentionally interrupted. “Ask about their thoughts and feelings preceding, during and following [the attempt],” she says. “When it didn’t work, did they feel anger or relief?”

Access to lethal means, such as firearms or drugs, also puts a client at higher risk of suicide. Firearms were involved in slightly more than 50% of nationwide suicide deaths in 2017, according to the CDC. The VA reports that 69.4% of veteran suicide deaths in 2016 involved a firearm.

Firearms can be a polarizing issue, but as part of suicide assessment, professional counselors should not hesitate to ask clients if they have access to firearms, Bruns says. These discussions are an opportunity to talk about brain science and how the human brain doesn’t operate rationally in a crisis, she says. Even if clients say they would never touch a gun, they may make an irrational decision if, during a moment of crisis, firearms are easily accessible or are not secured, Bruns points out.

Whisenhunt discourages counselors from asking clients to rate their suicide risk on a scale of zero to 10 during assessment. “[Clients] can’t rate their own [suicide] risk for a number of reasons. Things may change at any given moment. Life is fluid,” says Whisenhunt, who presented a session on suicide prevention at the ACA 2019 Conference & Expo.

Clinical counselors are more likely to understand the full picture of a client’s suicidal ideation if they also screen for depression, anxiety, impulsivity, major life changes (such as job loss or divorce), past trauma, addiction or substance use disorders, other co-occurring issues, and whether the client has a solid support system, Whisenhunt says. “There’s a huge relationship between interpersonal stress and relationship issues and suicide. We need to look at the whole person, not just the suicidal thoughts,” she says.

Counselors must also resist the urge to try to pin a client’s suicidality to a single cause or reason, Bruns adds. Risk factors often come from multiple areas of life, she points out. “Don’t be too narrow-minded in [the] assessment process. Don’t think that there’s one single cause. … Suicide is complex in nature, and too often it gets oversimplified,” Bruns says.

Safety planning

Once a client’s suicidal ideation is recognized and explored through assessment, the next step is for counselors to design a safety plan with the client, Bruns says. She emphasizes that it is critical to create this safety plan in the same session in which suicidal ideation is identified. Counselors should also make sure that the client takes a copy of the plan home.

Safety planning templates are available online (for example, see the Suicide Prevention Resource Center website at sprc.org) and can serve as an evidence-based starting point, Bruns notes. In addition to including the names and phone numbers of friends, family members and professionals whom the client can contact if in crisis (plus contact information for a 24/7 hotline), the plan lists individualized warning signs that a crisis might be developing, protective factors, and coping strategies to fall back on when things start to escalate. Safety planning is considered a best practice and is preferred over the “no suicide contract” method that counselors sometimes used with clients in years past, Bruns notes.

“This is of paramount importance. [Safety planning] gives them coping skills but also a way to reach out for more help,” Bruns says. “It’s an empowering approach. [Clients] are able to identify their triggers on their own. If they’re able to get to step two and go for a run or use a breathing technique to minimize their suicidal thoughts, it’s empowering to realize that they did that on their own. Or, if that didn’t help, they are empowered to take the next steps” and seek help from someone listed on the plan.

Counselors should also be careful to check in with these clients regularly to ensure that their safety plans are still applicable and working. As Bruns notes, clients’ personal emergency contacts may change over time, as might their triggers and coping mechanisms.

Protective factors

Assessment and a counselor’s “focus on the why” are important parts of suicide work with clients. But equally important, Cureton contends, is exploration of clients’ protective factors. Each client will have a combination of things that can bolster and carry them through low moments. Not identifying or asking about these factors does a disservice to the client, Cureton argues.

“If we don’t explore both risks and what has protected them and kept them alive, we are really missing the whole person,” she says. “Only focusing on lessening risk factors is only half the picture — less than half. For those who have a suicide attempt [in their past], they are still here, and there was something that carried them through. To not explore that, address that, is missing something.”

Cureton urges practitioners to listen carefully when clients talk about their low points or past suicide attempts in counseling. The client might use language such as “I don’t know how I got through that moment.” Counselors should use that as an opportunity to help clients talk through and focus on the elements, large and small, that interrupted them on their path to suicide, she says.

Suicide prevention is both a professional and a personal area of passion for Cureton, who lost her grandfather to suicide when she was in middle school. Cureton co-authored an article with Matthew Fink on suicide protective factors in the July issue of the Journal of Counseling & Development.

Cureton and Fink developed a mnemonic, SHORES, for mental health practitioners to use when identifying and discussing protective factors with clients:

• S: Skills and strategies to cope (emotional regulation, adaptive thinking and engaging in interests)
• H: Hope (including goals for the future and ways to meet those goals)
• O: Objections (moral or cultural objections)
• R: Reasons to live and Restricted means (motives for staying alive, such as responsibility to family or children, and reducing access to firearms, poisons, medications and other means of suicide)
• E: Engaged care (receiving care and finding a meaningful connection with a counselor, physician or other medical or helping professional)
• S: Support (supportive social environments and relationships, including family and caregivers)

Support can also include professional and career connections, political or activist groupings, and other nonfamilial relationships, Cureton adds. She says counselors should explore support systems even with those clients who appear to have a large number of friends. Clients can often feel alienated from friends who have moved or had life changes, such as getting married or having children, she notes.

Cureton acknowledges that the second point, hope, can sometimes seem nebulous. So, in addition to engaging clients in goal-setting and thinking of the future, Cureton directs them to visualize what their version of hope looks like. In session, she sometimes cups her hands together and holds them out to the client, asking the client to describe what, for them, makes up the “ball of hope” she holds in her hands.

Cureton then asks where the client would like to keep this hope. She and the client visualize taking the hope from her hands and “storing” it in the client’s purse, pocket or heart. With younger clients, it can be effective to create a “hope jar” in session or to have them design a room in a video game where they keep their hope, Cureton adds.

Counselors should aim to prompt discussions that help clients envision that circumstances can change for the better in their lives, Cureton says. She suggests asking clients to think of a time when they did have hope and then exploring that answer in more depth together. Alternately, she might ask a client, “Do you dream of a time when you will be self-sufficient and connected?” or “What’s one goal we could set, even if it’s something small?”

“It’s looking into the future and imagining something slightly different,” she explains.

Regardless of how it’s done, exploring protective factors brings a positive narrative and a focus on resilience to a tough topic with dark connotations, Cureton says.

Similarly, Whisenhunt looks for ways to incorporate positive themes into suicide prevention work. She adds a measure of lightheartedness to some of the programs she organizes by calling them “suicide prevention fairs.” With the help of graduate counseling student volunteers, she sets up a series of tables. Participants earn badges as they stop at each table and complete a puzzle or activity to learn about an aspect of suicide prevention. Once they collect all the badges from the fair, participants are eligible for a prize.

“It might sound odd, but you would not believe how many people we get involved. It makes [the topic] more approachable, and people respond,” Whisenhunt says.

When it comes to suicide prevention, positivity and patience can attract interest to a tough subject, she adds. “Know that we might be passionate about it, but it might take the layperson a little while to warm up to talking about it,” she says. “If you’re passionate about something, it comes across. The more I enjoy doing suicide prevention work, the more people enjoy being part of that. I don’t invalidate suicide loss, but I explain that I’m not talking about death and dying. I’m talking about how to save lives. It’s empowering — focusing on hope and the fact that we can do something.”

A delicate subject

Cureton acknowledges that introducing the topic of suicide and suicidal ideation in session can be “prickly.” She prefaces her questions to clients by allowing that it is a touchy subject — but one that is important to deal with.

“I say, ‘You may assume that even if we talk about it, I’ll respond in a negative way, be shocked at what you’re sharing or brush it off because I’m uncomfortable. But none of these things will be true. I’m used to talking about it, and it needs to be covered.’”

When it comes to suicide, counselors need to think both in terms of the individual and systemically, Cureton says. The subject may be even more uncomfortable for clients who come from a culture or religious background that shames or stigmatizes suicide, viewing it as a personal failing or sin. Cureton lets these clients know that it is her responsibility as a professional counselor to learn about their culture and how suicide might be perceived within it.

“If I’ve done that work, it should be easier for me to say … ‘I know that this is an uncomfortable topic to talk about for everyone, but especially in your culture. I know that it might be harder for you to talk about it in here than [it is] for me.’”

She also works with these clients to identify someone from their cultural group with whom they might feel comfortable talking about suicidal thoughts — for example, a pastor or elder perhaps. As a counselor, Cureton says, “I can’t be the only person they talk about this with. It’s important to have someone in their cultural group.”

On the flip side, cultural factors can also influence how counselors view the issue of suicide and clients struggling with suicidal ideation, Bruns notes. As with all issues, it is important for practitioners to put their own attitudes and beliefs aside and to respond to clients with empathy and without judgment, she says.

Elizabeth Hodges Shilling is an LPC and licensed clinical addictions specialist who works as part of a counseling team in the trauma center at Wake Forest Baptist Health Medical Center in Winston-Salem, North Carolina. She also urges counselors to drop any assumptions they may harbor about suicide, especially in connection to client demographics.

“One of the things that is not frequently talked about is [suicide and] older adults. We do see a fair number of [older] individuals who are struggling with both suicidal ideation and substance abuse. We find that older adults at times, in fact, have a greater risk of completing suicide and dying by suicide,” says Shilling, an ACA member. “Frequently, people make assumptions about death with older people or assume that it was an accident or natural [cause]. Keep your assumptions about people in check, especially when it comes to who’s at risk. … It’s not doing that person any good to assume.”

Whisenhunt agrees and stresses that counselors need to have conversations about suicide with their clients that are free of judgment or expectation. “Just talking about suicidal thoughts and distress can be helpful [for the client]. A lot of people feel a lot of shame about these feelings,” Whisenhunt says. “Be open to talking about suicide without getting nervous and inadvertently shutting down the conversation.”

The long term

Is a client who has experienced suicidal ideation ever not at risk? Bruns recommends checking in with clients periodically, even if they seem to be long past their lowest point. She tells clients that she would rather annoy them with repeated questions about suicide risk than somehow not ensure that they are still safe or not offer them the space to continue talking about it.

Bruns also urges practitioners to be mindful of a client’s triggers and to use clinical intuition to broach the subject, if needed. For example, perhaps a client previously experienced suicidal ideation after a painful break-up with a partner, and now the client is dating again or facing relationship struggles.

At the same time, counselors shouldn’t assume that because a client experienced suicidal ideation in the past that he or she will continue to have suicidal thoughts, Whisenhunt says. Life is fluid, and risk factors may increase, decrease or sometimes change altogether.

“Whatever was contributing in the past might have resolved, but maybe not. For me, a best practice is to screen with all clients at intake and then periodically screen throughout treatment,” Whisenhunt says. “It’s our responsibility to communicate that we can talk about this. We are not afraid of talking about [suicidal ideation], if you need it.”

The silver lining

Cureton acknowledges that suicide prevention work is challenging and can induce fear, even for those who specialize in it or have years of experience. However, as rates of suicide continue to increase across the U.S., counselors have the much-needed skills to address and destigmatize the issue with each client who sits in front of them.

“The unfortunate reality is that suicide is everywhere. It has the potential to be present in any person we are working with, at any point in their life,” Cureton says. “The positive side to this is that anyone can play a role in addressing that — career counselors, school counselors, all practitioners. … The great thing is that we can all do something about this. It’s a misnomer that suicide work is only for certain types of practitioners, such as addictions or clinical mental health counselors. It’s important for all of us to say, hey, we can do something about this.”

 

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Call for help

The National Suicide Prevention Lifeline offers free and confidential support around the clock, seven days a week, at 800-273-8255 or via chat at suicidepreventionlifeline.org.

Calls are routed to the nearest location in the Lifeline network of more than 150 crisis centers across the U.S. Help is offered in Spanish at 888-628-9454 and for callers who are deaf or have partial hearing loss at 800-799-4889.

The Lifeline website also has information on best practices for mental health practitioners, downloadable brochures and other resources.

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For more information on suicide prevention, access ACA’s webpage of resources at counseling.org/knowledge-center/mental-health-resources/suicide-prevention-resources.

CT Online also offers a variety of past articles on the topic, including:

• “Fighting suicide: The importance of hope” by David Kaplan
• “Raising awareness of suicide risk” by Jerrod Brown and Tony Salvatore
• “Facing the specter of client suicide” by Laurie Meyers

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Suicide, substance abuse and medical trauma

Counseling Today interviewed members of a team of professional counselors embedded in a trauma center in a busy hospital facility in North Carolina. Read more about their work and their insights on the intersection of suicidality and substance abuse in an online exclusive, “Suicide, substance abuse and medical trauma."

****   ACA participates in federal suicide screening panel

Carrie Wachter Morris, an associate professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, represented the American Counseling Association in June at an event titled “Building Robust Systems for Suicide Screening and Treatment Pathways for Youth in Pediatric Settings.”

Organized by the federal Substance Abuse and Mental Health Services Administration, the event’s goal was to inform and shape a guide to suicide screening in pediatric primary care settings. Wachter Morris was the only professional counselor on the event’s expert panel. The audience was primarily composed of medical doctors but also included nurses, social workers and others.

“We talked about a range of things over the two days that we met, including screening instruments, clinic flow, the role of other medical and nonmedical personnel, financing and sustainability,” Wachter Morris says. “Much of what we talked about included the need to really support primary care providers in the process of assessment and referral of youth who are contemplating suicide. … Discussion centered around the importance of appropriate referral and [how] immediately placing a youth who discussed suicidal ideation in an inpatient placement was likely to be counterproductive, unless it was necessary to maintain that individual’s immediate physical safety.”

“This is really where counselors can make a huge difference,” Wachter Morris says. “We can engage with the medical professionals in our community so that they know the resources that we have to support children, adolescents and their families when they are struggling. So many of the [physicians] at the table expressed frustration at not knowing where to connect youths who are in need of support and lacking the time and expertise to intervene on their own. Particularly when coupling this with the industry standard that pediatricians should spend approximately 10 minutes with each patient, it’s easy to see how suicide screening and treatment has not been well-integrated into primary care visits. I spent a good bit of my time educating the medical providers at the table about what counselors are able to do and what a strong support we can be for them. … I also helped advocate for the needs of all our children and adolescents, including the specific needs and risks of those in minoritized communities, and particularly those who identify as LGBTQI+. We had an engaging dialogue about how to promote openness and reduce the likelihood that a youth might feel further silenced.”

Wachter Morris says she came away with an appreciation for the potential for collaboration between professional counselors and pediatricians on suicide prevention.

“Professional counselors have the power to support individuals who are experiencing crisis and trauma, wrestling with mental health issues or experiencing challenging transitions. As a field, we are dedicated to helping people not only survive but also thrive. We have training that pediatricians and family medical providers don’t,” Wachter Morris says. “That was something that really struck me. I’d always thought that because they had rounds in psychiatry that [physicians] had a strong working knowledge of mental health issues and suicide. But that was clearly an assumption of mine that isn’t necessarily reality for every medical provider.

“There are some who are exceedingly skilled, but there are also those who may not ask suicide screening questions for fear of what to do if a child or adolescent answers that they are thinking about suicide. Counselors can be a group that pediatricians’ offices can connect with when they have a child or adolescent who is struggling, not just with suicidal thoughts, but with other challenges that are outside that physician’s scope of practice.”

— Bethany Bray

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Contact the counselors interviewed for this article:

• Kristin Bruns: kbruns@ysu.edu
• Jenny L. Cureton: jcureton@kent.edu
• Carrie Wachter Morris: cawmorris@uncg.edu
• Elizabeth Hodges Shilling: ehshilli@wakehealth.edu
• Julia Whisenhunt: jwhisenh@westga.edu

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

Letters to the editor: ct@counseling.org

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