preceding list is skeletal. Depending on your setting and needs, to fill in the content, you might elaborate on your rationale for treatment, including describing how and why the treatment you are providing is a good match for your client’s unique problems and symptoms. Specifically, you could (a) highlight immediate or prominent risk factors (including suicide triggers) and how you are addressing them, (b) describe how you plan to draw out or activate protective factors to reduce suicidality, and (c) include immediate and longer term interventions you are taking to reduce suicide risk. Using direct quotes or paraphrases from your client that support your evaluation and decision-making is recommended. You can also include mental status observations of physical and nonverbal behaviors, such as lack of eye contact, sighs, or poor hygiene.
Competency 9: Know the Law Concerning Suicide
The laws concerning suicide are simple and complex. The simple part follows court rulings on the duty to protect clients from knowable dangers from self and others (Tarasoff v. Regents of the University of California, 1976). The duty to protect is a legal mandate.
In addition to knowing federal guidelines regarding suicide and the law, you also need to know laws and statutes in your specific locality. Jobes and O’Connor (2009) wrote, “All states . . . have explicit expectations of a duty to protect . . . when [clients] pose an imminent danger to self” (p. 165). The state in which you practice has legal statutes covering the involuntary civil commitment process and standards of care for working with clients or minors who are suicidal. Consulting with experienced professionals in your region (and/or seeking training) can help you understand the practical steps you need to cover in your locality.
If you are employed by an agency or school, you will need to know its suicide policy. When you join a new agency or school, read the institution’s suicide-related policies and procedures and discuss them with a senior clinician or administrative staff before you even begin seeing clients or students. If your agency or school does not have suicide-related policies and procedures, work with your administration to adopt a temporary working model from a similar agency, and establish a task force to create a more permanent model. You never know when the next client or student will be suicidal. On the first week of his first job, one of our graduates had to manage a student who was actively suicidal. He called and said, “Wow! You guys weren’t kidding when you said to know how to handle things before you even open the door!” (see Wheeler & Bertram, 2019, for more information on legal issues in counseling).
Competency 10: Engage in Debriefing and Self-Care
Feeling responsible for life-and-death situations is overwhelming (Cramer et al., 2013). As in the opening case of Kevin, when clients make suicide attempts or die by suicide, practitioners often experience an avalanche of guilt, preoccupation with possible mistakes, and feelings of incompetence. Even though such feelings are natural, they are still extremely difficult. As noted in Chapter 1, self-care is always important for mental health and school professionals, but when suicide is the issue, self-care is especially critical (Binkley & Leibert, 2015).
Debriefings of some sort are important whenever you conduct a suicide assessment. Debriefings may involve you taking the lead and reporting exactly how you handled a particular assessment or intervention. They can also include your supervisor (or classmates or colleagues) asking specific questions. Common debriefing questions include the following:
1 What clinical observations increased your concerns about suicide?
2 What clinical observations decreased your concerns about suicide?
3 What risk and protective factors did you notice through observation? What risk and protective factors did you ask about?
4 How did you directly ask your client about suicide? What was your client’s response?
5 What was the quality of your therapeutic relationship or connection?
6 Did you trust that what your client told you was truthful? If so, what made you trust your client? If not, what made you reluctant to trust your client?
7 Did you gather information about the frequency, intensity, duration, and termination of your client’s suicidal ideation? What was your client’s response to these questions?
8 Did you ask about previous attempts? What was your client’s response?
9 Did you ask about suicide plans? What was your client’s response?
10 What were your client’s reasons for living and reasons for dying?
11 Did you initiate a safety planning intervention? If so, what was your client’s response?
12 What was your impression regarding your client’s willingness to engage in ongoing counseling?
Suicide-Related Ethical Issues
Imagine you are working as a school professional. Three high school students suddenly pop into your office. They take turns speaking, saying things like the following:
“Serena is talking about suicide.”
“She posted a creepy thing about death on Instagram that’s freaking us out.”
“We think you should talk with her.”
“She’s been drinking way too much. We’re totally scared.”
This case scenario highlights the complexities associated with decision-making around suicidality. Many questions arise. Should you summon Serena from class and meet with her? Serena is 16 years old; does that mean you have a responsibility to contact her parents? What is the school district’s policy on suicide risk assessment? If Serena admits to suicidal ideation but assures you she will not act on her thoughts, what discretion do you have as to whether or not you contact her parents? If Serena denies suicidal ideation and says her friends are being silly and stupid, do you have any duty to protect? At a minimum, cases like Serena’s reveal the importance of knowing your school’s (or agency’s) suicide assessment and disposition protocol (including whom to contact first). Here we cover ethical considerations specific to suicidality and related emergent or dangerous clinical concerns.
Is Serena Suicidal?
School counselors and school mental health professionals gain information about students in many different ways. In an ideal world, Serena would approach you, acknowledge suicidal ideation, and ask for help; you would responsibly follow your district’s policy for informing your school administrator, contacting the parents, providing referral information, and staying in touch with Serena via your school’s suicide-related case management protocol. Unfortunately, the opposite process may unfold. You may hear about Serena’s suicidality through her friends or via a teacher. Serena may never approach you and may not be honest with you about her suicidal ideation. To complicate matters further, your district policy may be enigmatic or excessively detailed, Serena’s parents may be unreachable or overreactive, referral resources may be nonexistent, and you may not have a case management protocol for students who are suicidal.
In an article in the American School Counselor Association’s magazine (ASCA School Counselor), Carolyn Stone (2018) described school counselors’ responsibilities for reporting suicidal
