Behavioral Dimension
Although Alina denies suicidal intent, she may be engaging in behaviors that increase her vulnerability to suicide. Within the behavioral dimension, assessing Alina’s substance use and previous overdose is essential. In addition, making sure Alina does not have easy access to firearms or other lethal means is essential and can be addressed in a collaborative safety plan.
Contextual Dimension
Gathering information about Alina’s living conditions and her unemployment situation is important. Helping Alina identify community supports, identify financial resources, and understand the potential role of discrimination in her life may help decrease distress and provide a sense of direction.
Concluding Comments
We would love to offer a clear and easy formula for preventing all suicides, but we cannot; no one can. Suicide rates are on the rise, and suicide is neither 100% predictable nor 100% preventable. Regardless of these discouraging realities, people struggling with suicidal thoughts and impulses need the best care available. Providing the best care requires professionals who are comfortable and skilled when working with client suicidality.
Facing the daunting professional task of providing suicide assessment and treatment services may leave you feeling overwhelmed. Feeling overwhelmed—including having self-doubt and anxiety—is part of a normal developmental process linked to learning about suicide assessment and treatment. As you progress through these chapters, your knowledge and skills will grow and your feelings of being overwhelmed will shrink.
Practitioner Guidance and Key Points to Remember
Over the course of your professional life, you are likely to have many people who are suicidal on your caseload. As you face the stress that these situations evoke, you will benefit from developing personal and professional self-care strategies. In this chapter, we recommended the following:
Stop reading (take breaks from suicide content as needed).
Recognize the hazards inherent to working with people who are suicidal.
Intentionally focus on positive and rewarding life experiences.
Use a variety of self-care strategies.
Accept your distress and engage in self-soothing behaviors.
In addition to developing self-care strategies, you also need to manage your attitudes toward suicide, including your personal values. Ethical bracketing—or setting aside your personal values to focus on your clients—is one method of preventing your personal values and attitudes from negatively affecting clients. We recommend using Kocet and Herlihy’s (2014) five-step counselor values-based conflict model to facilitate ethical bracketing.
Currently, the functional model for treating suicidality has the strongest evidence base. The functional model is used to identify psychopathological processes that underlie suicidal thoughts and behaviors and target them in treatment. Similar to the functional model, our suicide assessment and treatment model targets suicidal thoughts and behaviors within the context of the individual’s history and present circumstances. However, the model used in this book is a wellness-oriented, strengths-based, and holistic model that views suicidality through the lens of seven dimensions of human functioning:
Emotional
Cognitive
Interpersonal
Physical
Cultural-Spiritual
Behavioral
Contextual
The seven-dimension model is a foundation for focusing on the whole person—including personal strengths—as you develop treatment plans for clients who are suicidal. Counselors and other professionals who are working with clients contemplating suicide are encouraged to gently and collaboratively explore the questions “Where does it hurt?” “How can I be of help?” and “Where are you strong?”
Chapter 2
Competence and Ethics
Imagine you are working with Kevin, a 21-year-old college student. Kevin identifies as a White cisgender heterosexual male. He is mandated to see you for five sessions after receiving a campus citation for using alcohol in his dorm. During your first three sessions, he strikes you as affable, engaging, and relatively well adjusted. He is physically fit, gets good grades, and does not seem depressed. Kevin acknowledges that his father had problems with alcohol; he openly admits to guilt over his own use. During the second session, Kevin expresses an interest in cutting back on drinking, partly because of his father’s problems and partly because his girlfriend thinks he drinks too much. Then, after his third session, out of the blue, you get a call from his girlfriend. She tells you she is breaking up with Kevin, and he is threatening suicide. She says, “Kevin needs to see you right away,” and asks you to call him. Tragically, before you make contact, Kevin places the barrel of a gun in his mouth, pulls the trigger, and dies by suicide.
In the swirling aftermath of Kevin’s suicide, you are emotionally devastated. You keep replaying session vignettes in your mind, wondering, “How could this have happened?” and “What did I miss?” Your confidence is shaken. You are questioning your professional competence.
Understanding Suicide Competence
Suicide competence refers to what clinicians need to know and do to provide professional services to clients at risk for suicide. In a general sense, suicide competencies encompass three parts of a symphony that includes many different notes, movements, and melodies. Like all competency models (Cramer et al., 2013), these three parts include the following:
Self-awareness and attitudes. This includes developing greater awareness of your own attitudes toward suicide and how your attitudes, beliefs, and personal values might play out in specific clinical scenarios. Exploring your attitudes toward suicide helps you cope with personal and emotional reactions while maintaining a therapeutic relationship and implementing state-of-the-art suicide assessment and treatment planning procedures.
Knowledge acquisition. Foundational knowledge includes information on effective assessment and treatment and an understanding of ethical and legal standards. Having greater foundational knowledge of suicide helps increase your confidence and frees you to experience and express compassion for clients struggling with suicidality.
Skill development. This refers to learning and practicing specific skills and strategies, including (a) comfortably asking about suicide; (b) empathically interacting with clients who are experiencing depression, hopelessness, and irritability; (c) engaging in collaborative assessment; (d) developing collaborative treatment and safety plans; (e) implementing specific interventions; and (f) documenting clinical decision-making.
At the beginning and throughout the symphony of suicide-related self-awareness, knowledge, and skill acquisition, there is a steady drumbeat of ethical and legal standards in the background. This drumbeat will sometimes distract you; other times it will provoke anxiety. On good days, local and national practice standards will guide your work with clients who are suicidal. Practice standards include knowledge of ethical decision-making models, breaching confidentiality, documentation, and much more.
Within the counselor education discipline, there is little guidance