clients disclose suicidality, conflicts between clinician goals and client goals arise (AAS, 2010). Clients who present with suicidal ideation or impulses are often expressing a desire to die; in contrast, your professional goal is to help clients stay alive. This inherent conflict makes it difficult to establish collaborative relationships (Jobes, 2016).
Clients know their pain and the nature of their suffering. If clinicians do not honor client perspectives, clients can refuse to open up; they can slide the deadbolt to their inner thoughts and feelings and block clinicians from gathering information. A collaborative attitude requires respecting client perspectives. That often means honoring your clients’ desire to keep suicide as an option to life. Pushing against clients’ rights to die by suicide may activate psychological reactance or resistance and end up pushing them toward, rather than away from, suicide (Brehm & Brehm, 1981; J. Sommers-Flanagan & Shaw, 2017). A collaborative relationship is central to all contemporary and evidence-based approaches to suicide assessment and management (Bryan & Rudd, 2018; Jobes, 2016; Wenzel et al., 2009).
Regardless of your clients’ problems, empathy is a robust predictor of positive counseling outcomes (Elliott et al., 2018). Maintaining empathy with clients who are suicidal can mean that counselors accept and try to understand intense emotional pain. Unremitting hopelessness is common (e.g., “Nothing will ever help me feel better”). If clinicians pivot away from emotional pain and hopelessness and bring up solutions too quickly, clients may feel isolated, misunderstood, or judged. It can be uncomfortable to continue paraphrasing and resonating with your client’s emotional pain, especially when your goal is to nudge your client toward a safety plan or hospitalization.
Although working with suicidality requires a specific knowledge base and skill set, many basic counseling skills transfer. Skills for working collaboratively, showing empathy and positive regard, and using problem-solving form the foundation for effective suicide assessment and treatment (Michel & Jobes, 2010). Continuing to develop your general counseling skills, obtaining specific suicide-relevant workshop training, and studying from resources like this book will help you establish competency.
Competency 3: Know and Elicit Evidence-Based Risk and Protective Factors
Cramer and colleagues (2013) wrote, “One of the clinician’s primary objectives in conducting a suicide risk assessment is to elicit risk and protective factors from the client” (p. 6). As we discuss in greater detail later, this competency is problematic for at least three reasons. First, in an extensive meta-analysis covering 50 years of research, the authors concluded, “All risk (and protective factors) [for suicidal thoughts and behavior] are weak and inaccurate. This general pattern has not changed over the past 50 years” (Franklin et al., 2017, p. 217). In other words, there is no clear formula of risk and protective factors that accurately predict suicide.
Second, the number of potential risk and protective factors of which counselors should be aware is overwhelming. Granello (2010b) reported 75-plus factors, we have a list of 25 (J. Sommers-Flanagan & Sommers-Flanagan, 2017), and even Cramer and colleagues (2013) lamented, “It would be impossible for clinicians to be familiar with every risk factor” (p. 6). Jobes (2016) referred to suicidology as “a field that has been remarkably obsessed with delineating countless suicide ‘risk factors’ (that do little for clinically understanding acute risk)” (p. 17).
Third, prominent suicide researchers have concluded that efforts to categorize client risk are ill advised (McHugh et al., 2019; Nielssen et al., 2017). For example, even the most commonly identified symptom of suicide, suicidal ideation, is a poor predictor of suicide in clinical settings; this is because suicidal ideation occurs at a very high frequency, but death by suicide occurs at a very low frequency. In one study, 80% of patients who died by suicide denied having suicidal thoughts when asked directly by a general medical practitioner (McHugh et al., 2019). Even the oft-cited risk factor of a previous suicide attempt has only a small statistical relationship to death by suicide. In a review of 17 studies examining 64 unique suicide prediction models, Belsher and colleagues (2019) reported, “These models would result in high false-positive rates and considerable false-negative rates if implemented in isolation” (p. 642).
To summarize, this suicide competency includes a deep dialectic. Clinicians absolutely must be aware of suicide risk factors, warning signs, and protective factors. Granello (2010b) recommended that counselors keep a list of relevant risk factors and warning signs on their desks. However, as Belsher et al. (2019) noted, risk and protective factors and warning signs—or any checklist or instrument—should not be used in isolation; an overemphasis on checklists impedes development of the therapeutic relationship, and the statistical reality is that suicide is not predictable and risk categorization is typically inaccurate. This competency can be boiled down to four parts, some of which form a dialectic:
1 Competent practitioners should have knowledge of evidence-based suicide risk and protective factors.
2 Competent practitioners are aware that evidence-based suicide risk and protective factors may not confer useful information during a clinical interview.
3 Instead of relying on checklists of suicide risk and protective factors, competent practitioners collaboratively identify and explore client distress and then track client distress back to individualized factors that increase risk and enhance protection.
4 Competent practitioners use skills to collaboratively develop safety plans that address each client’s unique risk and protective profile.
Although risk and protective factors do not provide an equation that tells clinicians what to do, knowing and addressing each unique individual’s particular risks and strengths remains an important competency (Granello, 2010b).
Competency 4: Focus on Current Plan and Intent of Suicidal Ideation
Asking directly about suicide and collaboratively exploring suicidal ideation, suicide planning, and suicidal intent are essential to competent suicide assessment. However, as noted for the previous competency, when asked about suicide, many clients or patients who will go on to die by suicide deny suicidal ideation (McHugh et al., 2019). Simply asking directly about suicide is not enough. Competent practitioners have clinical skills for asking about suicidality in ways that make it easier for clients to be open and honest.
Several important tasks are linked to this competency (and described in Chapter 3). These tasks include the following:
1 Use effective listening skills to show empathy and develop rapport.
2 Use sophisticated clinical interviewing skills to discuss suicidality with clients in ways that make it easier for them to disclose suicidal thoughts.
3 Collaboratively explore the frequency, intensity, duration, and termination of suicidal ideation.
4 Identify what distracts clients from a preoccupation with suicide and other ways to decrease the frequency, intensity, and duration of suicidal ideation.
5 Be able to use subjective suicide rating scales with clients.
6 Ask directly—using a collaborative style—about client plans, suicide methods, previous attempts, and behaviors related to suicide preparations.
Competency 5: Determine the Level of Risk
As discussed previously, accurately determining client suicide risk is probably impossible.
