Academic journal article
By Granello, Darcy Haag
Journal of Mental Health Counseling , Vol. 32, No. 3
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. …