Suicidal clients are a difficult and challenging population in counseling. This article contains 25 practical, hands-on strategies for mental health counselors to assist in their interactions with suicidal clients. The strategies are situated within a seven-step model for crisis intervention that is specifically tailored to suicidal clients.
Suicidal clients are some of the most difficult and challenging for mental health counselors. Almost all practicing counselors will encounter a suicidal client during their careers, and most, as many as 71% in one study, will work with an individual who has made a suicide attempt (Rogers, Gueulette, Abbey-Hines, Carney, & Werth, 2001). Nearly one-quarter (23%) of professional counselors have experienced a client suicide (McAdams & Foster, 2000). Mental health professionals who experience a client suicide describe it as "the most profoundly disturbing event of their professional careers" (Hendin, Lipschitz, Maltsberger, Haas, & Wynecoop, 2000, p. 2022).
Much has been written about the assessment of suicide risk (e.g., Granello, in press; Jacobs & Brewer, 2006; Westefeld et al., 2000), and careful risk assessment is clearly the cornerstone of treatment. There also is information available about how to make decisions about appropriate care and meaningful treatment plans (e.g., Slaby, 1998; King, Kovan, London, & Bongar, 1999; Rudd, Joiner, Jobes, & King, 1999). However, there is far less information available about how best to interact with and manage suicidal clients when the risk of suicide is high. There are strategies and techniques for working effectively with suicidal clients, but there is not much practical information on how to manage them. This article provides 25 such strategies.
In general, clinical interventions with suicidal clients take a two-tiered approach. The first, the focus of this article, is short-term stabilization. There are very specific acute management and crisis intervention strategies to keep clients alive and invested in counseling long enough to move to the core problems underlying suicidality. The goal of the first tier of intervention is to prevent death or injury and restore the client to a state of equilibrium.
The second tier of intervention addresses the client's underlying psychological vulnerability, mental disorders, stressors, and risk factors. This tier is ultimately based in the entire field of mental health counseling, with interventions as varied and unique as the clients with whom they are applied. However, only after clients are stabilized using strategies to address the first tier of the approach can the ongoing work of counseling begin (Berman & Jobes, 1997).
Working with clients in suicidal crisis can include many types of care, including inpatient, short- and long-term outpatient, day treatment, and emergency intervention. Models and algorithms are available to help clinicians determine which are appropriate. Though these models vary, they generally include information on (a) conducting meaningful assessments; (b) developing treatment plans; (c) determining levels of care; (d) engaging in psychiatric evaluations for medications; (e) increasing access to treatment; (f) developing risk management plans; (g) managing clinician liability; and (h) assessing outcomes. (For more information on determining levels of care, see: Bongar et al., 1998; Kleespies, Deleppo, Gallagher, & Niles, 1999.)
WORKING WITH CLIENTS IN SUICIDAL CRISIS
There is a belief widely held by suicidologists that most suicidal individuals do not wish to die but simply cannot imagine continuing to live in their current state of psychological turmoil (Granello & Granello, 2007). In fact, suicidal crises are typically the result of a temporary, reversible, and ambivalent state (Stillion & McDowell, 1996), and interventions with suicidal clients are based on the premise that, successfully navigated, the suicidal crisis need not be fatal.
The goals of immediate intervention with suicidal clients are based on models of crisis intervention (e.g., Aguilera, 1998; Greenstone & Leviton, 2002; James & Gilliland, 2001), with specific strategies that are unique to this population. In general, an expanded version of Roberts's 2000 crisis intervention model is recommended (Granello & Granello, 2007). This model has crisis theory as its theoretical foundation and suicidology research and practice to ground the intervention strategies offered within each step. Thus, the seven-step model offers counselors an overall strategy in their work with suicidal clients, and most counselors who have worked in crisis intervention will recognize the approach.
The specific strategies offered within each step are meant to help counselors operationalize the interventions suggested by the model. For example, many crisis intervention models suggest that counselors work to "restore hope" in their clients, but few offer concrete suggestions for how to do this. The 25 practical strategies offered here are intended to help counselors implement a crisis intervention approach with suicidal clients. The expanded model, with several strategies for implementing each step, is outlined in Table 1.
In what follows, each stage of the model is discussed, followed by practical tips and intervention strategies. The strategies are broad enough to apply to many different types of clients in many different settings. However, they are intended only as a guide; the needs of individual clients may vary significantly. For example, developmental, multicultural, or cognitive limitations of clients may shape implementation of the strategies. These steps do not replace existing models and algorithms for suicide assessment and intervention. They are intended to provide strategies to help implement traditional guidelines.
Further, although some of the strategies offered use basic counseling skills as their foundation, others are more advanced. Beginning counselors (or counselors new to work with suicidal clients) may find that they need to practice these skills under supervision or observe more advanced counselors as they implement the strategies with clients before they feel competent to use them on their own. As always, counselors are encouraged to seek supervision, consultation, collaboration, and advanced training as they work with suicidal clients.
Step One: Assess Lethality
The first and most important step in working with suicidal persons is accurate assessment. Although assessment may occur slowly, with more information becoming apparent as clients tell their stories, a general understanding of level of lethality is central for guiding the process. For this, suicide risk assessment protocols are used (American Psychiatric Association, 2003; Rush, First, & Blacker, 2008). An individual in suicide emergency, for example, has a clear intent to die at the first opportunity (Sommers-Flanagan & Sommers-Flanagan, 1995). As a general stipulation, counselors should approach all situations of suicide risk as a potential suicide emergency until they obtain enough information to be convinced otherwise (Kleespies et al., 1999).
Ensure immediate safety. Individuals in acute suicidal crisis should never be left alone, not even to get another person to help or make a phone call. Suicide can happen quickly. And counselors should never transport a highly suicidal person in their cars, as the person might jump out in transit or grab the wheel and cause an accident (Sommers-Flanagan & Sommers-Flanagan, 1999).
Have and use suicide emergency plans. All counselors who work with highrisk clients should have a planned set of steps to determine actions and decisions at each point during an emergency. If any client exhibits behaviors that could quickly result in serious injury or death or who has sufficiently impaired judgment to be a potential harm to self, counselors must invoke the ethical imperative of duty to protect (Werth & Rogers, 2005). The first step is containment. What will the counselor do if an agitated client attempts to leave the building? What resources are available? How can other professionals within the agency be alerted that help is needed? (For …