According to the National Institute of Mental Health (NIMH; 2003), 29,350 people died as a result of suicide in 2000. It has also been estimated that 1 of every 60 Americans has experienced the loss of a loved one due to suicide, and it follows that many more personally know someone who committed suicide. Although there is no annual national data on the number of attempted suicides, it has been reported that there are an estimated 8-25 attempted suicides to 1 completion.
The evaluation and management of suicidal risk is a source of great stress for most mental health practitioners (Corey, Corey, and Callanan, 1993). Because the question is not “if”, rather “when” will a counselor deal with a suicidal client? awareness and training in suicide assessment and intervention is paramount.
As a counselor-in-training it is important to begin training in suicidology. This module is designed to begin to facilitate awareness of the information and processes of suicide assessment and intervention. Much of the information presented is applicable to a variety of populations. There is a great deal of information on suicide assessment and intervention as it relates to specific client populations. It is recommended that counselors engage in on-going training in issues related to working with clients who are suicidal.
If you are a counselor-in-training concerned about a client in your care, it is highly recommended that you seek consultation with a supervisor or instructor.
Nonmaleficence is the ethical principle addressing the counselor’s responsibility to “do no harm” including the removal of present harm and the prevention of future harm (Gladding, 2004). Of course, “harm” can be defined in a variety of ways.
For counselors, confidentiality is a foundational ethical standard. Confidentiality is the ethical duty to fulfill the promise that client information received during therapy will not be disclosed without authorization. As such, it follows that breaching confidentiality can result in “harm” to the counseling relationship and subsequently the client. Confidentiality is addressed in Section B of the Ethical Standards of the American Counseling Association Section B.1.a speaks to respect for client privacy. “Confidentiality becomes a legal as well as an ethical concern if it is broken, whether intentionally or not” (Gladding, 2004).
Because confidentiality is such a critical issue within counseling, exceptions to confidentiality must also be heavily considered. What if not breaking confidentiality leads to “harm”? Section B.1.c. outlines the exceptions to confidentiality including the fact that confidentiality does not apply “when disclosure is required to prevent clear and imminent danger to the client….” This exemption was written with the suicidal client in mind, clarifying that counselors have a duty to protect client from harm and that this supersedes the harm that may happen due to a breach of confidentiality.
The complexities surrounding confidentiality are brought to the forefront when dealing with a suicidal – or potentially suicidal – client. Any decision to breach confidentiality should be made with careful consideration. The difficulty in making a decision, even in cases of suicide risk, lays in assessing “clear and imminent danger.”
“Determining that a client is at risk of committing suicide leads to actions that can be exceptionally disruptive to the client’s life. Just as counselors can be accused of malpractice for neglecting to take action to prevent harm when a client is determined to be suicidal, counselors also can be accused of wrongdoing if they overreact and precipitously take actions that violate a client’s privacy or freedom when there is no basis for doing so” (Remley & Herlihy, 2001).
Negligence results from some type of wrongful action committed by one person, which results in “injury” to another person. As a general legal principle, a court must find the following four to be true:
With regard to the first issue, counselors have a duty to take steps to prevent client suicide. “Counselors have established themselves as mental health professionals, and the law imposes on counselors practicing in all settings the responsibility of knowing how to accurately determine a client’s risk for suicide” (Remley & Herlihy, 2001). It is not required that counselors always be correct in making their assessments of suicide risk, but they need to operate from an informed position and “fulfill their professional obligations to a client in a manner comparable to what other reasonable counselors operating in a similar situation would have done” (Remley & Herlihy, 2001).
The following are considered reasonable duty for counselors in terms of suicide prevention (Remley & Herlihy, 2001):
Brems (2000) summarized the following questions related to negligence:
Freemouw, Perczel, & Ellis (1990) note, “Any therapist, regardless of how competent, successful, and skilled, may lose a client through suicide. What will distinguish this therapist from another who was clearly negligent, careless, and indifferent to her or his client’s suicidal state is the presence of a well-documented, thorough client record” (P. 10).
The issue of confidentiality for minor clients is complex. While counselors are encouraged to maintain the confidentiality of minors in the same way as adults, legally, parent’s rights to information about their children override the counselor ethical obligation of confidentiality in most cases. This is due, in part, to the fact that minors are not seen as competent to give “informed consent” and therefore this power belongs to parents.
For counselors working with minor clients (including, but not limited to, school counselors), it is recommended that you become familiar with ethical and legal issues related to counseling children and adolescents.
With regard to suicide prevention and intervention, it is typically best practice to make parents/guardians aware of suicide risk for their children. Technically, the professional counselor’s legal liability ends when parents have been notified that their child is at risk for suicide and prevention actions have been recommended (Remley & Sparkman, 1993).
However, considerations as to whether this is in the ultimate best interest of the child remain fundamental (for instance, if the child sites his/her relationship with parents as a factor in the decision to attempt suicide). In addition, counselors have an obligation to follow up with a child, if parents or other significant others fail to act on prevention recommendations. In the vast majority of cases, it will be necessary to inform parents of the child’s risk for suicide. How effectively this is done takes forethought and intention. Proactively taking similar steps with minor clients that you would take with adults (informed consent, involving them in as much decision-making as possible, following up and supporting parents/guardians) are important steps in this process.
Regardless of where you work as a counselor, you are likely to provide services to someone who, at minimum, is expressing suicidal thoughts.
The following are statistics related to suicide in the United States from the Center for Disease Control: National Center for Injury Prevention and Control:
Regarding suicide attempts the following are estimates:
In addition to the prevalence of suicide attempts and suicide deaths, another reason to undergo study and training in suicidology as a counselor is to be able to differentiate from fact and common myths regarding suicide. “In fact, the argument has been made that dispelling myths about suicide is the single most important step in the societal prevention of suicide.” (Brems, 2000, p. 162).
What is possible, in working to prevent suicide attempts, is to recognize common crises and “warning signs” that may precipitate a suicide attempt. We then can make an effort to reach out to these people at risk.
Being aware of the risk factors and commonly associated variables of suicide is the first step in being able to assess for suicide risk and lethality on which interventions are subsequently based. There are a variety of risk factors associated with suicide, from immediate issues to long-term predictors. Keep in mind that there are also protective factors that also need to be considered in assessment.
Risk and lethality are related to the presence, intensity, and number of factors. While many of these factors may appear to be of a general nature, it is the clustering of these factors that contributes to the person’s mood, belief system, and coping ability that may lead to the risk of suicide. Additional risk factors for children are also presented.
Three or more of these behaviors lasting for an extended period of time (e.g., 1 month) would signal a need for assessment:
Any one of these behaviors on their own would indicate a need for assessment:
In assessment, it is also important to look for protective or inhibitory factors as well as warning signs. Protective factors are those that when activated or discussed, may actually inhibit the client from raking action to commit suicide.
Of course, there are exceptions to these factors that may make them risk factors. For instance, in some cultures suicide may be endorsed as a means of protest or redemption. In addition, although the commitment to care for and see children grow may be an inhibitory factor, it may become a risk factor if the client perceives the children would be better off without the client.
Counselors also need to be alert to client denial and the lack of complete truthfulness in discussing these factors. Brems (2000) suggests that while protective factors need to be explored carefully, they should also be approached with some skepticism.
***Counselors-in-training are highly encouraged to seek consultation with supervisors or instructors if there is immediate concern regarding a client.
Although there is much information to gather, there are no shortcuts to suicide assessment. Risk assessment requires directness, intentional questioning, and careful listening. The essential skills and conditions of counseling (empathy, reflections, restatements, attending, active listening, etc.) are important in suicide assessments and intervention. Information that is gathered during assessment should be documented.
There are recommendations that counselors conduct suicide risk assessments on all clients presenting for therapy (Laux, 2002). It is common practice that suicide ideation is assessed through intake forms and intake interviews
Specifically, clients presenting with depression or depressive symptoms or in states of crisis should be questioned for suicidal ideation. If using depression inventories, special attention should be given to questions related to suicidal thoughts (such as question 9 on the Beck Depression Inventory).
As the client tells his/her story, the counselor should be listening (and looking) for the presence of risk factors and protective factors. As the number of risk factors increases particularly in the absence of protective factors, suicide risk increases and should be questioned.
As a counselor attends to the client, language that reflects feelings of hopelessness and despair should be noticed and explored. For instance, it is paramount to ask for elaboration on statements such as “I can’t go on anymore.” “I want to end it all.” “I wish I were dead.” “This is hopeless, I don’t see any way out of this situation.”
In truth the first intervention for suicide is the assessment, in other words assessment begins the process of suicide intervention.
The point is to assess for risk AND leverage (information that can be used to intervene).
Either as part of an intake assessment, or based on information you have gathered indicating that a suicide assessment is in order, the starting point is:
If the answer is anything but a confident “No”, then assessment should proceed.
Even in cases when a client answers by saying “No”, continued exploration and discussion of what the client has said or presented that may be related to suicidal ideation is warranted.
For example: “When?” “How often?” “What happened?” “What was going on in your life at the time?” If attempts were made, then exploration of method and rescuer should be explored. If the client indicates having thoughts or having made attempts in the past, even if there is no current ideation, past experiences should be thoroughly explored. If the client does not answer questions about suicide, the answers are vague, or if the client conveys that he/she has entertained thoughts of suicide then…
Even if answers to these questions continue to be vague or seem to be more intermittent, ideas of how the person might commit suicide need to be explored.
Examples: “How have you thought of killing yourself?” “When would you carry out the plan?” “Do you have a date and time?” “Where would you be?” “Who would you want to find you?”
Examples: “If you were to commit suicide, how would you do it?” “Do you have the pills?” “Where are they?” “What type of pills would you take?” “What type of gun?” “Where would you get the gun?” “Do you have bullets?” “Where is the gun? The bullets?” “Do you have a rope/cord?” The previous questions have related specifically to suicide ideation. In addition, questions that assess for risk and protective factors are explored. All of this information aids in determining risk and subsequent interventions.
Various instruments have also been used assessing for suicide risk. These include assessments such as the Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974) and the Beck Depression Inventory (Beck & Steer, 1987) and the BDI-II (Beck, Steer, & Brown, 1996) that were not specifically designed to measure suicide ideation, but what is measured correlates with suicide ideation and can therefore be helpful.
In addition, there have been instruments developed specifically to assess for suicide ideation. These instruments include:
Some of the above instruments have also been validated for use with adolescent or college populations. In addition, there are instruments that have been specifically developed for these populations.
The use of suicide assessment instruments can be helpful, but should not replace the assessment interview. There are also times (due to the emotional and cognitive state of the client) when administration of a test would not be prudent.
*For a discussion on suicide assessment instruments, see Brems, 2000 and Westefeld, Range, Rogers, Maples, Bromley, and Alcorn, 2000).
This section focuses on level of risk as determined by the presence and combination of risk and protective factors and subsequent intervention information. In determining risk and interventions, it is important to consult knowledgeable colleagues.
***Counselors-in-training are highly encouraged to seek consultation with supervisors or instructors if there is immediate concern regarding a client.
Although there is much information to gather, there are no shortcuts to suicide assessment. Knowledge of risk factors and protective factors is essential in assessment of suicide risk. None of the warning signs (risk factors), if found in isolation, should cause you to be concerned, however the combination of several signs should prompt you to take several steps.
Part of decision-making involves evaluating whether protective factors outweigh risk factors or vice versa (Brems, 2000). As part of this evaluation it is also imperative that the counselor consider whether this balance is stable or if it may change in the future. For instance, if a mother has a strong protective factor related to being there to raise her daughter, but the daughter is 17 and about to graduate from high school and leave for college, the balance may then shift.
Risk may be judged by considering the following factors (Brems, 2000):
In addition, the following issues could also be considered (Brems, 2000):
In general, LOW risk would indicate the presence of ideation or passing thoughts without a plan and means, etc. MODERATE risk would indicate a serious consideration of harm, ideas of a plan and means, no access, the existence of some support, some risk factors present. HIGH risk would indicate the details in the plan, the greater degree of lethality and strength of intent combined with presence of risk factors and absence of support.
| Indicator | Low Risk | Moderate Risk | High Risk |
|---|---|---|---|
| Method | Undecided | Decided | Decided |
| Means | Not present | Easy access | In possession |
| Time and Place | Not chosen | Tentative | Definitely chosen |
| Lethality | Low | Moderate | High |
| Preparation | None made | Some planning | Steps taken |
| Prior attempts | No | Yes | Yes |
| Indicator | Low Risk | Moderate Risk | High Risk |
|---|---|---|---|
| Trigger (or trauma) | None or mild | 1 or moderate stress | Several or severe traumas |
| Indicator | Low Risk | Moderate Risk | High Risk |
|---|---|---|---|
| Diagnosis | No diagnosis | 1 diagnosis | Multiple diagnosis |
| Severity | None | Moderate | Severe |
| Discharge | More than 12 mts | More than 3 less then 12 mts. | Within 3 months |
| Substance Use | None | History of use – intermittent use | Currently using |
| Physical illness and pain | Mild or none | Chronic or moderate | Chronic or Severe |
| Loss | No or unimportant loss | One loss | Multiple losses |
| Family suicide history | No member | One member | Multiple members or close member or recent |
| Indicator | Low Risk | Moderate Risk | High Risk |
|---|---|---|---|
| Hopelessness | Mild | Moderate | Severe |
| Impulsivity | Low | Moderate | High |
| Perception of current emotional state | Will pass or be able to work through | Unsure if it will pass | Inescapable and intolerable |
| Problem-solving skills | Generally good | Adequate | Impaired |
| Future plans | Yes | Unclear | No |
| Indicator | Low Risk | Moderate Risk | High Risk |
|---|---|---|---|
| Number available and identifiable | Adequate resources | Limited resources | No resources |
| Willingness to use | Willing to access | Limited willingness | Unwilling |
| Connection with others | Regular social contacts | Some social contact | Isolated and withdrawn |
This grid provides an example of how to organize the information you collect in your assessment. There is no substitute for your clinical judgment that is based on experience, best practice, and consultation with other professionals.
Dealing with suicidal clients becomes a management issue first, not a therapy issue. The most important step is keeping the client from hurting him/herself or someone else. The legal guidelines state: If there is clear and imminent danger of a person harming him/herself and/or others, the counselor must take reasonable personal action or inform responsible authorities. Consultation with other professionals must be used where possible. At times it may be difficult to assess “clear and imminent,” however, it tends to be better to err on the side of caution rather than risk negligence.
In many cases, the counselor can work with a client, distress can be decreased, and mutually agreed upon action can be taken. Of course, the counselor cannot rule out the necessity for directive action. If a client is suicidal, the counselor needs to operate from a crisis intervention (LINK TO CRISIS SITE) approach. Meaning that the counselor becomes more active, directive and problem solving oriented, while continuing to demonstrate respect for the client.
Important skills, attitudes and behaviors when working with clients in crisis or with suicidal ideation:
In general, the approach to working with suicidal clients is to move from least restrictive and client empowering to highly restrictive. For example, moving from an outpatient confidential intervention, to outpatient management that involves others (in cases with children and adolescents – caregivers should be told of potential for suicide), to voluntary and finally involuntary treatment if other options did not work (Brems, 2000).
| Action | Example | Goal |
|---|---|---|
| Make psychological contact | Invite client to talk; Listen for what happened and clients perceptions; Use restatements and reflections to convey understanding and support | Client to feel accepted, heard and understood; reduction of intensity of emotions |
| Assessment | See Procedures for Assessment | Determine client needs, risk, protective factors; Learn about what is important to client |
| Identify the message | What will committing suicide do for you? What problem will it solve? | Determine what the client is attempting to communicate or the problem that will be solved |
| Define and impose goals | We need to come up with some things we can do that will help you… | Move into problem-solving |
| Expand client’s view of problem and situation |
|
Increase choice options; Reduce tunnel vision; Improve reality testing |
| Build on strengths | Point out client’s ability to tolerate pain Point out client’s coping abilities |
Improves cognitive functioning and improves reality testing |
| Support client problems solving | Separate thought from action Reinforce expressions of affect Consider consequences of action |
Engages client in active problem solving |
| Safety Contract | “As part of our work, I would like for us to develop a no-harm contract…” “It is important to involve the client as much as possible” |
Client pact not to commit suicide while in treatment |
| Remove Means |
|
Reduces potential for impulsive act |
| Engage social support |
|
|
| Increase sessions/contacts |
|
Provide consistent support during period of greatest need |
| Voluntary hospitalization |
|
Prevention in high risk situations |
| Involuntary hospitalization |
|
Prevention in high risk situations when client is “uncooperative” |
Remember to document assessment, decision-making, and intervention information.
In addition to suicide assessment and interventions with clients, professional counselors engage in prevention and postvention strategies.
Suicide prevention takes many forms. Curriculum-based prevention or education programs include in-service training modules to teachers and teaching staff, or in-class programs for students. These programs focus on providing information about warning signs, myths related to suicide, and steps for helping a person to get help. The intent is to inform people most likely to be in daily contact with someone who is suicidal so that behaviors and “cries for help” can be recognized.
Another approach is “inoculations” in which non-clinical populations are given interventions designed to lower suicide risk and, in affect, increase reasons for living and potential protective factors. Another way to view this is to build resiliency factors and remediate behaviors associated with risk factors. For information on Suicide Prevention see:
Postvention includes procedures to alleviate the distress of suicidally bereaved individuals, reduce the risk of imitative suicidal behavior, and promote the healthy recovery of the affected community. Postvention can also take many forms depending on the situation in which the suicide takes place. Schools and colleges may include postvention strategies in overall crisis plans. Individual and group counseling may be offered for survivors (people affected by the suicide of an individual). For information on Suicide Postvention see:
School counselors have a legal duty to protect students if they foresee or should have foreseen that the student was potentially dangerous to himself or herself. It is impossible to predict suicide – school counselors are expected to exercise reasonable care (take precautions) to protect students from foreseeable harm.
Understand the myths of suicide, warning signs, and how to respond: On-going training; Consult and follow district and school plans; Consult with peers and experts when possible
Involve everyone in this process:
Informed consent with students is important – let them know up front when you have to break confidentiality. Be developmentally appropriate. Talk with and listen to the student. Be direct and empathic. Lethality assessment. Assessment content and goals are similar to adult assessment, but use developmentally appropriate language (be concrete).
Communicate with mental health personnel working with the child (Release of Information needed). Continue to offer support and understanding. Possibly work with student on coping skills, expression of feelings, problem-solving skills, etc.
Plan for these situations to occur. Teach faculty, administration, and students to refer. Relationships are crucial. Don’t do this alone! Create a plan that involves others.
