to work in counseling. Before the session ends, you and Alina develop a safety plan, you get a signed release of information form so you can communicate with her physician, and you make a request for her previous treatment records. As she leaves, you feel confident about her short-term safety and her commitment to treatment, but she is a client you will be sure to think about during the week.
As Alina’s counselor, you might feel uncomfortable because she has described several significant suicide risk factors. She has current suicidal ideation and a recent previous attempt. She feels socially isolated. Her family has not supported her sexual identity. She has symptoms of depression combined with high personal distress. All of these factors—and more—contribute to your concerns.
Cases like Alina’s naturally ignite self-doubt and anxiety in clinicians. But cases like Alina’s also hold great potential. If you connect with Alina, the two of you develop a therapeutic relationship, and she responds well to your work together, you might experience immense gratification. As a mental health professional, what could feel better than helping a distressed and struggling person through an extremely difficult time? For many of us, the chance to help people like Alina is exactly why we chose this challenging professional path.
Our goals for this book are to increase your self-awareness, knowledge, and skills for working effectively with clients who are suicidal. Whether you are working with a 16-year-old version of Alina in a school setting or a grieving 70-year-old who is considering whether life is worth living, we want to help you feel more prepared, comfortable, and competent to work with people who are suicidal.
In the 21st century, counseling professionals are more likely than ever to work with youth and adults who are suicidal (Binkley & Leibert, 2015; Lund et al., 2017). This is partly because the latest data available indicate that suicide rates in the United States have increased by 42% (from 10.0 deaths per 100,000 individuals in 1999 to 14.2 deaths per 100,000 individuals in 2018; American Foundation for Suicide Prevention, 2020). Although the relative per capita increase in suicide of 42% is troubling, the raw numbers are even worse. In 1999, an estimated 29,180 Americans died by suicide. In comparison, in 2018 (the latest year for which data are available), there were 48,344 deaths by suicide. This represents a 65.7% increase in the raw number of deaths by suicide over 19 years. Suicide is the 10th leading cause of death in the United States and the second leading cause of death among youth and young adults ages 10 to 34 years (Hedegaard et al., 2020).
Although we do not currently know how recent events like the coronavirus (COVID-19) pandemic or ongoing world events like climate change will affect suicide rates, most health professionals, suicidologists, and sociologists predict that social distancing, unemployment, and economic hardships will adversely affect mental health and contribute to further increases in suicidality, suicide attempts, and death by suicide (Bryan et al., 2020). The need for providers who can conduct suicide assessments and interventions will likely only increase in the coming years (Copelan, 2020).
Not only have suicide rates increased, but suicide attempts have also increased (to approximately 1.4 million in 2018; American Foundation for Suicide Prevention, 2020), and more clients and students than ever are talking about suicide. Many different cultural and sociological phenomena have combined to make it more likely that teenagers and young adults will use the word suicidal when describing their emotional pain or personal distress. Media productions like the feature film Thirteen (Levy-Hint et al., 2003), the Netflix television series 13 Reasons Why (Season 1 released in 2017; Incaprera, 2017), and the proliferation of publications and internet websites oriented toward self-mutilation and suicidality contribute to increased thoughts about suicide (e.g., Asher, 2007; see also Ybarra, 2015). All of these factors speak to a need to redouble our efforts to gather knowledge and develop skills for working with people struggling with suicidal thoughts and impulses.
Throughout this book, we emphasize that suicidality does not represent a deviant or pathological state. During difficult times it is not uncommon for people to consider suicide an option (J. Sommers-Flanagan, 2018a). Counseling can help clients reduce or eliminate suicidal thoughts and urges. However, although we believe deeply in suicide prevention, we also respect human autonomy and individuals’ right to die by suicide. Consequently, this book does not provide guidance for working with clients who have terminal illnesses and wish for compassionate assistance to end their lives. There may be some crossover, but along with Freedenthal (2018), we believe that those circumstances represent a distinctly different clinical domain.
Getting Ready
Despite rising rates, death by suicide is a rare event (about 14 to 15 deaths per 100,000 people in the United States in 2018; American Foundation for Suicide Prevention, 2020). However, early and often throughout your career, you are likely to see many students and mental health clients who struggle with suicidality (Binkley & Leibert, 2015; Roush et al., 2018). Being ready to respond competently and calmly to suicidal thoughts and impulses is essential. As Joiner (2005) wrote, “Suicide is an urgent issue—it kills people—but urgency need not entail panic” (p. 17). Becoming and remaining competent is your best antidote to panic.
Practical Realities
Often, as in the case of Alina, concerns about suicide emerge partway into a session, even though suicidality was not the primary reason for the referral or meeting. Other times suicidality will be the immediate issue demanding your focus. In still other scenarios, your client will not mention distress or suicide until near the end of the session, leaving you with very little time to deal with a very big issue.
As you develop competence for handling suicide scenarios, at a minimum, you have your own attitudes and values to examine; assessment skills to learn, practice, and memorize; professional and ethical responsibilities to manage; intervention strategies to consider; and many other competencies to acquire and fine-tune. No wonder this is a stressful domain for most counselors. If thinking about these responsibilities causes you anxiety, you are not alone. Most health and mental health care professionals rate suicide assessment, management, and treatment planning as one of their greatest stressors (Binkley & Leibert, 2015; Maris, 2019). When clients talk about suicide, it is natural to begin worrying about a range of issues, including potential hospitalization and your responsibilities for keeping clients and students alive.
Increased suicide rates have translated into increased demand for competent professional assessment and treatment services. Unfortunately, suicide assessment and treatment competencies have not been systematically integrated into the training curricula of students in counseling, psychology, social work, nursing, and psychiatry (Cramer et al., 2013; Granello, 2010a; Morris & Minton, 2012). This lack of systematic training in suicide assessment and treatment has relevance for you and your practice. Along with most of the mental health and health care workforce, you may feel uncertain about suicide assessments, unclear about how to develop suicide-specific treatment plans, and uninformed about research-supported interventions for clients and students who are suicidal.
Before reading further, take a moment to check in with yourself. You know that this is a book about suicide assessment and treatment planning, but even that obvious fact deserves reflection. Although we are taking a positive, wellness-oriented approach, content in the following pages and chapters can and will be activating. You will find yourself reacting to the material.
In many places, we write about suicide directly, using actual and constructed suicide cases as well as composite and hypothetical suicide scenarios (note that identifying information is removed or modified to protect confidentiality). Our purpose is to prepare you to work in counseling situations in which suicidality is a concern. We write about suicide in provocative ways for several reasons:
1 You never know whether or when your next client or student will be suicidal. We believe that you can and should be prepared to address suicide
