Hallie might have felt indebted, guilty, or ashamed. She might have pulled back and minimized contact with Sharon, despite her needs for emotional support.
Hallie could have begun regularly orienting to Sharon for her material needs.
Either way, small boundary breaks can have big implications for counseling and the counseling relationship.
Here are a few basic boundaries we generally recommend:
Unless your school or agency requires it and provides appropriate liability coverage, do not transport agitated clients who may be suicidal or agree to ride with them in their cars.
Do not invite clients to join you at social events or places of worship.
Do not invite clients to your home.
Do not give your clients your private contact information.
Do not discuss your family members with clients.
In Case Vignette 2.2, Sharon’s school counseling load included 300 students. She could not provide the contact and care for each of them that she was temporarily extending to Hallie. Sharon knew her limits. She brought in the group home parents, had a safety plan in place, and was actively working with Hallie to transition her mental health care to an appropriate community resource.
When Suicide Happens
Having a client die by suicide is an outcome that all mental health professionals dread. Not only will client suicides trigger sadness, anger, guilt, shame, fear, and self-doubt, but sometimes suicides lead to lawsuits or legal inquiries. Other times, suicide survivors or family members will reach out to counselors for support. Whatever the details, the aftermath of a client death by suicide is painful and complex. Several postsuicide measures can help professionals cope with losing a client or student.
Consultation Groups
If your practice includes routinely working with clients who are suicidal, we recommend that you participate in an ongoing peer consultation or peer supervision group. Peer consultation serves two important purposes. Professionally speaking, you need someone to review your assessment and treatment protocols as well as your documentation. If there are gaps in your documentation or questionable professional choices, your colleagues can help you prepare to account for these and orient you toward better practices in the future. Modifying clinical records is illegal, but understanding potential problems can help you focus on how to deal with legal inquiries.
Peer consultation groups also provide professional connection for solace and understanding from friends and colleagues. Emotional support from colleagues who face similar challenges can be especially meaningful. Wellness Practice 2.1 includes a mood management strategy that you can use yourself or with your colleagues.
Wellness Practice 2.1 Happy Songs in Your Life
Music in general, and songs in particular, can trigger happiness, sadness, other emotions, and life memories. Sometimes emotional responses to music are all about the music. Other times emotional responses are about the personal associations or memories that the songs trigger. For example, when John listens to “Joy to the World” by Three Dog Night, he is transported back to positive memories of ninth-grade basketball. It is not unusual for people to turn to music to help regulate emotions or to heighten particular feelings.
For this wellness practice, experiment with the following, and then later consider engaging clients with this activity:
1 Select a song that triggers positive emotions for you.
2 Listen to the song twice in a row and just let the song do its work. You can do this with a friend or by yourself.
3 After you have listened twice and let the positive feelings come, respond to the following prompts:What emotion does the song bring up?What is your best guess (hypothesis) for why the song brings up that particular emotion?Do you usually intentionally listen to this song or just randomly wait for the song to pop into your life?Optional: Share the song with someone and tell that person why the song triggers positive emotions for you.
At the time of this writing, we have located several articles that illuminate issues that might emerge following a client death by suicide:
“Facing the Specter of Client Suicide” by Laurie Meyers (2015) in Counseling Today (https://ct.counseling.org/2015/10/facing-the-specter-of-client-suicide/)
“As a Therapist, How Should I Grieve After a Patient’s Suicide?” by Lucy Maddox (2018) on Mosaic (https://mosaicscience.com/story/therapist-how-should-i-grieve-after-patients-suicide/)
“Paradise Lost: When Clients Commit Suicide” by Marian Joyce (2013) on Psychotherapy.net (https://www.psychotherapy. net/article/client-suicide-article)
Many other articles are available that focus on how counselors can deal with client suicides. We recommend that you explore this important area and find resources that fit your needs.
Postvention
Postvention is an essential component of dealing with completed suicides. The term postvention was first coined by Edwin Shneid-man in 1968 at the inaugural gathering of AAS. In 2017, the Psychopathology Committee of the Group for the Advancement for Psychiatry defined and articulated the rationale for suicide postvention: “Postvention, or how clinicians manage the postsuicide aftermath, strengthens suicide prevention, destigmatizes the tragedy, operationalizes the confusing aftermath, and promotes caregiver recovery” (Erlich et al., 2017, p. 507).
Although research on postvention is limited, many different postvention protocols and strategies have been developed. For instance, a 234-page document titled Coming Together to Care is available for download at www.texassuicideprevention.org/wp-content/uploads/2013/06/TexasSuicidePrevention-2012Toolkit_8-31.pdf. This document is a postvention toolkit developed in Texas by a consortium of organizations dedicated to suicide prevention.
Postvention is an underdeveloped pillar of suicide prevention (Maple et al., 2019). This is partly because postvention effects are notoriously difficult to assess. Given that every suicide and community or school context is unique, identifying a control group for postvention efficacy research is impossible. In one review of 16 published studies of high research quality, the researchers concluded, “No protective effect of any postvention program could be determined for number of suicide deaths or suicide attempts” (Szumilas & Kutcher, 2011, p. 18). However, “contact with a counseling postvention for familial survivors of suicide generally helped reduce psychological distress in the short term” (p. 18).
Nationally and internationally, beliefs vary regarding how much attention to give a death by suicide. Famous or infamous deaths by suicide get substantial press coverage, and sometimes this raises awareness of the problem. However, the tone of the coverage is influential.