I’ve been doing some thinking about ACA Conference 2016 and the possibility of presenting a poster discussion. It has struck me that our graduate programs still lack a standardized, required course in suicide assessment, intervention, and legalities/ethical considerations for involuntary hospitalization.
If we think about the goals of counseling, a client’s death is clearly the absolute worst possible outcome. It seems a glaring deficiency in our gatekeeping process that neophyte counselors aren’t required to study theory and technique on the assessment, counsel, and ethical management of a client presenting with suicidal ideation and behavior.
This quickly became the subject of a paper I was asked to write for my ethics class, and may form the basis of my poster discussion next year. The paper is reproduced below.
Every spring, thousands of new counseling graduate students leave the classrooms of their graduating institutions and set foot into the field of mental health work. Armed with their theory of choice and a genuine desire to help those in need, neophyte counselors often feel prepared to meet a wide variety of client needs, but there is one client that many fear eventually encountering – the suicidal client.
Few situations can make the hair on an inexperienced counselor’s neck stand up like a disclosure of suicidal ideation. As we try to keep our composure externally, internally we begin to scramble. “What are best practice guidelines here? How serious is this threat? Does this individual have a plan, and the means to execute that plan? Have they tried this before? Should I get my supervisor in here? Can I let them leave my office today or do they need to be sent for psychiatric evaluation? How will I keep my case notes on this session?” And of course, most vexing of all, “Can I save this person?”
According to the American Foundation for Suicide Prevention there were 41,149 recorded deaths by suicide in 2013, making it the 10th leading cause of death for Americans, just behind cancer and heart disease (Facts and Figures, 2013). Suicide is closely linked with many DSM-V diagnoses, most notably major depressive disorder. We learn about these disorders and often see suicidal ideation as common symptomology, but rarely are we specifically instructed about how to work with such clients in a way that maximizes their chance for successful recovery and protects us legally from malpractice allegation should treatment fail for the client.
A Brief Snapshot of Graduate School Training
According to a study on psychology graduate training and exposure to suicide published in 2014, “over 75% of trainees had received education on suicide during graduate school; however, few students reported receiving clinical supervision on this topic,” (Mackelprang, J. L., Karle, J., Reihl, K. M., & Cash, R., 2014).
These findings are surprising on two levels. First, while ¾ of the students surveyed did receive education on suicide, an entire ¼ did not. Furthermore, almost none of the students from either group reported receiving career supervision on counseling the suicidal client. Internship and early work experience under supervision is the perfect time to hone skills that may not have been perfected in school, and yet students are reporting that one of the most serious situations of all is being glossed over.
Also of interest is that the article vaguely describes “in class training on suicide prevention or intervention.” reader is unaware what such classroom training covers. Are students learning assessment instruments, or merely helpful tips and tricks? Do they understand intervention strategies and theory, or merely the protocol for questioning a suicidal client? It is disheartening that the study does not clarify, and altogether likely that the curriculum varies significantly across the assessed programs.
Furthermore, classes within “psychology” programs don’t always overlap with counseling programs. To learn more about how risk assessment is taught within the counseling field specifically, examination of another study entitled “Confrontation or Avoidance–What is Taught on Counsellor Training Courses” is necessary.
This study was conducted in 2004 took a look at 49 accredited counselor education programs in the UK and assessed how thoroughly the profession’s students were being educated on suicide risk assessment and intervention. The findings revealed a substantial gap between the student’s desire for risk assessment skills, and the availability of them at many programs.
“Given that 95.8% of informants believed that a specific consideration of [suicide and self-harm] risk was an essential component of a counselor training curriculum,” the study explains, “the fact that 47.8% of courses either did not include or had not considered the necessity to include in their skills development an opportunity for trainees to practice risk assessment strategies is worthy of further consideration,” (Reeves, A., Wheeler, S., & Bowl, R., 2004, p. 9).
The author’s analysis is understatement, to say the least. Nearly half of the participating graduate programs neglected to offer their students suicide and self-harm risk assessment before sending them into the field. We know that relying on supervision to do this training is a risky gamble, given the findings of the Mackelprang, Karle, Reihl, & Cash (2014) study discussed above. So the question persists – where are neophyte counselors supposed to get this training if half the schools aren’t offering it, and many clinical supervisors don’t touch it?
Suicide Prevention Education: A Fractured Curriculum
Food for thought for educators – Studies indicate that students who are fortunate enough to receiving some specialized training in suicide assessment and prevention strategies do in fact feel more confident working with at-risk clients in a clinical setting. Researchers in counselor education have conducted experiments to pinpoint effective curriculum and approaches to use, and two such studies are discussed below.
A study entitled “Teaching Suicide Risk Assessment to Counselor Education Students” performed an experiment to measure the practical value of a specially designed suicide assessment instructional video on counseling students’ clinical acumen (Juhnke, G. A., 1994). The structured, 55-minute, self-instructional videotape was designed for training entry-level counselors, and covers three factors identified by the author as vital to suicide risk assessment – the face-to-face clinical interview, empirical evaluation, and consultation.
Experimenters split a total of 59 Master’s level counseling students into three groups. The first group received the video training, the second group received a classroom lecture on suicide risk assessment, and the third group – the control – received no special training at all. The study found that, “The [students] receiving the videotaped training were significantly better at identifying suicide risk and at proposing adequate clinical intervention than were the [students] in the other two groups.” The study’s conclusion states that, “The potential for use of similar instructional videotaped methods related to crisis intervention…seems nearly limitless,” and encourages educators to develop similar videos or acquire the one used in the study for their programs (Juhnke, G. A., 1994).
A second study on measured suicide knowledge and prevention practices of 73 counselors and 165 teachers after participation in a statewide training program in suicide prevention using the “Question, Persuade, and Refer” program. These trainees were measured against a control group that did not undergo the training. The study reveals that, “Follow-up surveys conducted…4.7 months after training indicated that trainees demonstrated greater knowledge of suicide risk factors and reported making more no-harm contracts than did controls.” Clearly, an organized approach to assessment and intervention helped these counselors make more informed decisions to help their at-risk clients. The authors felt that their findings “support the value of gatekeeper training for both counselors and teachers and substantiate the important role of counselors in suicide prevention,” (Reis, C., & Cornell, D., 2008).
Is this “Question, Persuade, and Refer” program the best system for student instruction? What about the idea of disseminating and showing training videos like the one discussed in the Juhnke study? Other institutes (most notably the Beck Institute) offer suicide risk, intervention, and counseling training materials as well. How are educators to decide which is most helpful, and who should be responsible for creating and standardizing this training across our field?
Unfortunately, there does not currently exist a unified curriculum utilized by the entire profession and endorsed for teaching these skills to counseling students. Instead, what we have are various different perspectives from professionals and organizations with their own views on the subject. Two particularly intriguing and forward-thinking perspectives that seek to expand our thinking on traditional techniques are discussed below. Perhaps future training will take these ideas into account should a standard curriculum be designed.
New Perspectives: Counselor Attitudes on Suicide and Prevention
Many believe (and research indicates) that it is nearly impossible to predict if a client is actually “suicidal” or not. I (C.C.) spoke on the phone to one of counseling’s biggest champions of suicide assessment and intervention reform, Eric Beeson, to a get a better understanding of how counselors are taught to engage clients struggling with suicidal thoughts. “I don’t believe it is helpful to assess how “suicidal” a client is, because there is no such way to accurately gauge this,” he tells me, “I try to determine how at risk they are for dying.” Lest the reader write this off as a semantic distinction, Beeson believes that viewing a client as suicidal conjures up many feelings we have about the act of taking one’s life (that it is shameful, for the week, verboten, acceptable in certain circumstances, etc.) and existential ideas about death itself (that it takes us to a better place, that it is terrifying, etc.). He claims that these ideas can enormous influence how well we attend to an at-risk client and accurately assess and serve their unique needs.
Beeson, a Licensed Professional Clinical Counselor and counselor educator at Walden University, was discussed in the May 2015 issue of Counseling Today for his view that the personal attitudes a counselor holds about suicide has implications for how they handle clients for whom suicide is an option (Meyers, L., 2015). These attitudes, as described in his dissertation Death and Suicide: An Exploration of Attitudes among Counseling Students are the acceptance of suicide, condemnation of suicide, and preventability of suicide (Beeson, Eric T., 2014).
Beeson encourages counselors to examine their own ideas about suicide and dying. His piece in Counseling Today explains that his trainings with students are structured to get them thinking about the possibility that everyone – yes even the students themselves – could possibly consider dying by suicide under the right circumstances. “I don’t know what it’s like for… any person to walk in their shoes, and who am I to say they’re walking in their shoes wrong?” Beeson asks. “Who’s to say that if I wasn’t in a similar situation, that my shoes might get a little uncomfortable? And if they become more uncomfortable than I’d like to bear and I cant find a new pair of shoes, then who’s to say I might not take those shoes off?”
The article notes that there is still quite a bit of stigma surrounding suicide and the victims it claims. “People who have died by suicide or attempted suicide are typically viewed as weak. “This represents an empathy gap,” Beeson reminds us, “one that counselors need to close.”
Beeson’s trainings on empathy and suicide attitudes are aimed at helping counseling students do exactly that. In this way, he hopes that counselors can hear client stories without judgment, and use the counseling session as a time to explore all options, including suicide.
New Perspectives: Thomas Joiner’s Interpersonal-Psychological Theory
Another leading pioneer in suicide research is the great academic Thomas Joiner, who has spearheaded a new theory on the suicidal mind known as the Interpersonal-Psychological Theory of Suicidal Behavior. In his paper, “Why People Die By Suicide: Further Development and Tests of the Interpersonal-Psychological Theory of Suicidal Behavior”, Joiner and his team challenge the common notion that hopelessness and sadness will eventuate in suicidal ideation (Joiner Jr., Thomas E.; Silva, Caroline Shaver, Phillip R. (Ed); Mikulincer, Mario (Ed), 2012). Instead, Joiner declares, “the fundamental constituents of suicidal ideation – as distinct from suicidal behavior – are the perceptions that one is alienated from others and that one is simultaneously a burden on others.” He clarifies further, explaining that “these two perceptions, “I am hopelessly alienated” and “My death will be worth more than my life to others,” according to the theory, characterize the suicidal mind,” (p. 2).
Counseling students are often taught to ask clients if they know how they’d like to die, if they have a plan, and whether that plan is feasible. All good advice, but perhaps future students being trained in assessment should also be instructed to listen for talk of the social alienation and burdensomeness to others that Joiner discusses.
Death by suicide is far more rare than the relatively common suicidal ideation one encounters in clinical populations. His theory seeks to understand the difference between thinking and acting; in other words why some people with suicidal ideation actually do die from suicide, while the majority do not. The theory’s answer involves a critical cognitive component, wherein the client who is truly at risk for dying has broken through a mental barrier that is evolutionarily coded into the core of ourselves – our life-preservation instinct. “Death is inherently fearsome and daunting and it thus takes considerable resolve, intent, and fearlessness to enact,” Joiner explains. “This does not make it laudable, but it does make it difficult,” (p. 2).
For any professional counselor, young or old, new or experienced, a client contemplating suicide is an alarming moment, and represents one of the most challenging clinical situations to assess. Requiring simultaneous use of empathy, keen judgment, theory, and the assistance of a clinical assessment, the call of hospitalization vs. letting the client walk is never an easy one to make.
It is incumbent upon us as a profession to consider all of the research and great thinking that has been done on this topic to create a standardized, ethically informed, evidence-based training program that could be required for all graduate students to be educated under. My proposal of such a class would combine the following into a required graduate school course on the subject:
- Traditional Training on the Suicidal Mind: Students would learn the standard method of assessing the client’s risk of dying by suicide through lecture on the suicidal mind, and the assessment of a client’s plan (specifics of the plan, feasibility of the plan, prior attempts, etc.).
- Beck Hopelessness/Suicide Intent Scale: All counselors ought to be taught a standard method or system of assessing suicide intent with a trusted instrument, and the Beck scales are some of the professions best. Students in this class would gain hands on experience using these instruments in practice role-plays.
- Thomas Joiner’s Interpersonal-Psychological Theory: In addition to the traditional knowledge of the suicidal mind, students in this theoretical class should also have as required reading Thomas Joiner’s book, “Why People Die By Suicide.” This will help them incorporate emerging research from Joiner on the factors of social isolation and burdensomeness to others into their standard assessment.
- Eric Beeson’s attitude assessment: If Beeson is correct in his research (and it would seem nearly inarguable that he is), counselors would do well to assess their own attitudes about suicide. Students could complete reflection papers exploring their own attitudes, and open discussions about these ideas in class.
- Ethical and Legal Considerations: Finally, students need to be instructed on proper note keeping, ethical, and legal considerations involved in disclosure, confidentiality, and involuntary psychiatric evaluation.
Without such a class, we as a profession take serious risks with our competency, and in these particular risks can have unacceptable – and indeed deadly – consequences.
Facts and Figures. (2013). Retrieved July 26, 2015, from https://www.afsp.org/understanding-suicide/facts-and-figuresMackelprang,
L., Karle, J., Reihl, K. M., & Cash, R. (2014). Suicide intervention skills: Graduate training and exposure to suicide among psychology trainees. Training And Education In Professional Psychology, 8(2), 136-142. doi:10.1037/tep0000050
Reeves, A., Wheeler, S., & Bowl, R. (2004). Assessing risk: Confrontation or avoidance–What is taught on counsellor training courses. British Journal Of Guidance & Counselling, 32(2), 235-247. doi:10.1080/03069880410001697288
Reis, C., & Cornell, D. (2008). An evaluation of suicide gatekeeper training for school counselors and teachers. Professional School Counseling, 11(6), 386-394. doi:10.5330/PSC.n.2010-11.386
Juhnke, G. A. (1994). Teaching suicide risk assessment to counselor education students. Counselor Education And Supervision, 34(1), 52-57. doi:10.1002/j.1556-6978.1994.tb00310.x
Meyers, L. (2015). Fresh thinking on old issues. Counseling Today, Volume 57/Number 11. American Counseling Association Publication.
Beeson, Eric T., (2014). Death and Suicide: An Exploration of Attitudes among Counseling Students, Department of Counseling and Higher Education and The Patton College of Education.
Joiner Jr., Thomas E.; Silva, Caroline Shaver, Phillip R. (Ed); Mikulincer, Mario (Ed), (2012). Why people die by suicide: Further development and tests of the interpersonal-psychological theory of suicidal behavior. Meaning, mortality, and choice: The social psychology of existential concerns. , (pp. 325-336). Washington, DC, US: American Psychological Association, xvii, 438 pp. http://dx.doi.org/10.1037/13748-018