As most of you know, I recently published an article in Psychotherapy Networker on my long-term experience of coping with the death of a client by suicide. In response to the article, I’ve gotten many supportive responses, some of which included additional published resources on coping with client death by suicide.
This blog post has two parts. First, I’m promoting the Networker article again to get it more widely shared as one resource for counselors and psychotherapists who have lost a client. Below, is an excerpt from the article. . . followed by a link. Please share with friends and colleagues as you see fit.
Second, at the end of this post I’m including additional resource articles that several people have shared with me over the past two weeks.
Here’s the excerpt . . .
The Prevention Myth
I’d worked with Ethan for about 20 sessions. Stocky, socially awkward, and intellectually gifted, he often avoided telling me much of anything, but his unhappiness was palpable. He didn’t fit in with classmates or connect with teachers. Ethan felt like a misfit at home and out of place at school. Nearly always, he experienced the grinding pain of being different, regardless of the context.
But aren’t we all different? Don’t we all suffer grinding pain, at least sometimes? What pushed Ethan to suicide when so many others, with equally difficult life situations and psychodynamics, stay alive?
One truth that reassures me now, and I wish I’d grasped back in the 1990s, is that empirical research generally affirms that suicide is unpredictable. This reality runs counter to much of what we hear from well-meaning suicide-prevention professionals. You may have heard the conventional wisdom: “Suicide is 100 percent preventable!” and, “If you educate yourself about risk factors and warning signs, and ask people directly about suicidal thoughts or plans, you can save lives.”
Although there’s some empirical evidence for these statements (i.e., sometimes suicide is preventable, and sometimes you can save lives), the general idea that knowledge of suicide risk, protective factors, and warning signs will equip clinicians to predict individual suicides is an illusion. In a 2017 large-scale meta-analysis covering 50 years of research on risk and protective factors, Joseph Franklin of Vanderbilt University and nine other prominent suicide researchers conducted an exhaustive analysis of 3,428 empirical studies. They found very little support for risk or protective factors as suicide predictors. In one of many of their sobering conclusions, they wrote, “It may be tempting to interpret some of the small differences across outcomes as having meaningful implications, . . . however, we note here that all risk factors were weak in magnitude and that any differences across outcomes . . . are not likely to be meaningful.”
Franklin and his collaborators were articulating the unpleasant conclusion that we have no good science-based tools for accurately predicting suicide. I hope this changes, but at the moment, I find comfort in the scientific validation of my personal experience. For years, I’ve held onto another suicide quotation for solace. In 1995, renowned suicidologist Robert Litman wrote, “When I am asked why one depressed and suicidal patient dies by suicide while nine other equally depressed and equally suicidal patients do not, I answer, ‘I don’t know.’”
Here are the additional resources people have shared with me:
Ellis, T. E., & Patel, A. B. (2012). Client suicide: what now?. Cognitive and Behavioral Practice, 19(2), 277-287.
Jorgensen, M. F., Bender, S., & McCutchen, A. (2021) “I’m haunted by it:” Experiences of licensed counselors who had a client die by suicide. Journal of Counselor Leadership and Advocacy. DOI: 10.1080/2326716X.2021.1916790
Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-in-training who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37(5), 547-557.
Ting, L., Jacobson, J. M., & Sanders, S. (2008). Available supports and coping behaviors of mental health social workers following fatal and nonfatal client suicidal behavior. Social work, 53(3), 211-221.
As always, thanks for reading, and have a great day!
Yesterday, Rita posted a free rooster to give away on a local Facebook page. She was surprised that no one claimed him. I waxed empathic, “I don’t understand,” I said, “people always want free things. Getting a free rooster would make the right person very happy.”
We’ve been studying happiness, but not the smiley sort of happiness. We’re into Aristotelian eudaimonic happiness (of course we are). You know, the sort of happiness you experience from living your life in ways that honor others and consistent with your deep values. That just might involve high-quality daily interactions with a free rooster. Think about it.
I was so puzzled by not having our rooster snapped up for immediate adoption that I took to the streets. Really, it was just one street. We’re living in Absarokee for the summer; there are streets, but not very many, and I only spent time on one street.
I cleverly wove the rooster opportunity into my banking business. With only two employees left in the bank on a late Friday afternoon, I asked with great cheer, “Would either of you like a free rooster?” They both quickly said “No thanks,” but I got my transaction processed in record time.
Rita was still in the grocery store (we were dividing and conquering our errands). I marched in, offered to carry her beer, and announced, “Hey. Anybody want a free rooster?” The cashiers avoided eye contact. The bagger started talking about his pigs; they made him happy. He didn’t need a rooster. I guess that proves it’s possible to have too much happiness.
Despite repeated rejections, I’m still convinced that our rooster could bring free happiness to someone. In fact, I think our failed transactions are evidence that happiness is in the eye of the beholder. When I was a teenager, our neighbors got a rooster. We woke up every morning to fantasies of murdering the neighbor’s rooster. I started plotting a late-night abduction. After all, roosters are the mother of opportunity. [I know that’s a wrong and terrible butchering of the saying “necessity is the mother of invention,” and I know that butchering must be the wrong word here, but I’m typing fast and consequently it’s impossible for me to suppress or repress my aggression and mother issues when free associating at this pace. Freud would be happy. But then Freud had his own peculiar tastes regarding what made him happy, which is, of course my point.
The famous Peanuts cartoonist, Charles Shulz, wrote a book titled, “Happiness is a warm puppy.” Although warm puppies likely bring happiness for many people, they’re certainly not the recipe for happiness for everyone. If I recall correctly, for Linus, happiness was a warm blanket.
And I can’t stop myself from thinking that, perhaps, for some lucky person out there . . .
. . . happiness is a warm, free, pet rooster.
If you’re that person, contact me, because right now, for me, happiness is giving away a free pet rooster.
In this post I’m sharing a link to an article I just had published in Psychotherapy Networker. Although I had hoped it would be the Networker’s “lead article,” instead, they put Shankar Vedantam first? And then a bunch of other people, like David Burns and Martha Manning? Seriously? All jokes aside, the truth is, I’m humbled to be included.
The article—titled “The Myth of Infallibility”—is about my immediate and ongoing emotional reactions to the loss of a client to suicide. I hope the article provides useful information and emotional support for counselors and psychotherapists who have experienced—or will experience—a similar loss.
You can use the following link to bypass the paywall and read the article for free.
Thanks for reading this. Please share the link if you feel so moved. One of my counseling colleagues shared it with all her students, which seemed great to me, mostly because IMHO, we don’t talk much or get formal training on how to cope when or if we have a client who dies by suicide.
Today, I’m especially grateful for all the people in my life who have supported me in one way or another, over so many years.
Critical Race Theory (CRT) has been in the news lately, especially in Montana. As it turns out, several Montana public officials (you know who you are) appear frightened by CRT. Their response to the idea (not the reality) of CRT being taught anywhere or anytime is to try to ban it, as in make it illegal. It’s like a modern Montana-style prohibition (“Don’t you go out and get caught with a bottle of CRT or we’ll be taking you on down to see the sheriff!”).
All jokes aside (well, not all), I have a couple brief comments and a question.
I’m struck that, in the 21st century, anyone is using the old tried and failed strategies of banning ideas and burning books. Alcohol prohibition seemed rather unsuccessful. . . and we don’t need to know what happened with Romeo and Juliet to understand that, that which is forbidden, takes on a certain sex appeal.
My other main thought is that, just in case anyone was sleeping through science class, Critical Race Theory is a . . . (wait for it) . . . a theory! As with all theories, it’s not a perfect explanation of anything. It’s a working model, a set of ideas, with maybe a few scientific hypotheses. The right response to CRT isn’t to outlaw it—because if CRT is outlawed, then only outlaws will understand CRT. Instead, CRT is great food for thought, discussion, and public and private discourse. Rather than make it illegal, we should be discussing, evaluating, and critiquing its usefulness and validity, rather than acting like studying the presence of systemic racism in American history is blasphemy. If you contemplate the issue, the answer is “Yes, of course” there has been, from the beginning, systemic racism in the U.S. (think Columbus, slavery, Indian Boarding Schools, etc.). However, the fact that systemic racism is an historic and contemporary reality doesn’t make every jot and tittle of CRT true; but certainly it suggests we take it seriously. If not, we risk tempting our children with forbidden fruit or teaching them to be afraid of new ways of thinking. Either way, banning or illegalizing or running like scared rabbits away from CRT does a disservice to our state, our country, and our children.
My question is whether I should write an Op-Ed piece on this topic. If you think so, let me know. If you think not, tell me I should let it go.
Most of the time I take irrational pride in my emails. I work very hard to eliminate typos and grammatical problems. I also work very hard to give my emails just the right touch of snark and hilarity.
My goal is to send literary emails. I keep waiting for someone to publish them. Something like the Freud-Jung letters. But alas, no one has offered, and so, once again, I have to be the responsible party and do the right thing and publish them here.
My emails are in italics; the introduction to each email is not in italics.
To an academic friend from Xavier University who wrote to me to share one of his student’s complaints about the fact that we said something positive about Paul-Michel Foucault in our Counseling and Psychotherapy Theories textbook:
Anyhow, I guess I’ll be cancelling Foucault in the future. I checked online, and the dude was a bad sexual predator creep. If it seems appropriate, offer my apologies to your student. It’s tough to stay up on all the idiotic creeps out there. When I read about them, I can’t figure out where they found the time to act out on all their stupid sexual perversions. Well, obviously, that’s not the only question I have . . .
2. To a former student who had the audacity to suggest she could beat me at games like Charades/Pictionary/Balderdash/Cards Against Humanity:
As someone who is a trained observer of human insecurities, I think you should know that when someone (like, let’s say, you) writes something like “You telling me you’ve never lost those games means nothing. . .” it’s a clear indication that whatever that person (like, let’s say, you) is writing about “means something.” You may be familiar with the protesting too much line from William S. . . . and he may have, indeed, been speaking of thou-est defense mechanisms.
If I cry during our upcoming competition, it will be from glee and not mushrooms or your game-playing domination fantasies.
Is the idea of using your corpse as a scarecrow an unusual idea? I’ve been away from human contact for so long that I’m not sure of what’s normal and what’s not and therefore take no personal responsibility for the normality of whatever I’m writing.
3. To the same former student (see above) who for some reason wrote to me about being open to being taxidermied after death and placed as a “greeter” on our porch:
You’re always so full of good ideas that I’m not sure what I can add. Back in the 20th century, we had a life-sized Jean Luc Picard cardboard cut-out that we kept on our porch to greet visitors. Should I outlive you, I’d be honored to keep your taxidermy self in our garden. Right now, Rita is writing about mushroom-based caskets as an alternative that results in quick biodegradation. We could put your likeness in a mushroom patch and then you might melt into the ground.
I probably should stop with all my good ideas now.
4. To an attorney who’s helping me with the details of a legal contract:
I’m glad to hear we’re outside the boundaries of HIPAA. One of my life goals is to pretty much always stay outside the boundaries of HIPAA. That’s why, when I ask people for their vaccination status, I also tell them I won’t be billing their insurance😊.
5. To a former student and professional counselor:
No one other than you would ever think to begin an email message with a statement about unmanned robot lawnmowers. I’d ask you about what you’re reading in your spare time, but I’m worried for what I might hear.
6. To my fellow faculty, when I forward them information I received from our national accrediting body:
I haven’t looked at this myself, but it seemed like I should pass it on.
7. To my Fall, 2021 Research class:
Hello Prospective Researchers,
It’s June, and anyone with any sense is thinking about the COUN 545 Research class right about now. Haha. Not really. I’m just procrastinating on other things.
I’m writing because I had emailed a few of you before saying that I would likely NOT be teaching the Research class . . . however . . . the excellent, very good news is that I WILL BE teaching the Research class. The plan is for us to be live, in-person, and following whatever health guidelines the University has in place for fall semester. I know, the good news just won’t stop.
I just wanted to clarify what’s happening and dispel any rumors and let you know in advance that we’ll be having the best research class experience ever.
More stuff will come your way (like a syllabus) in late July or early August. Until then, you should start systematically collecting data wherever you go and whatever you’re doing (sorry, more research jokes there, no need to do that).
Seriously, until then, you should have a fantastic summertime.
That’s all for now. And you all should have a fantastic June weekend!
Rita and I have been watching way too many bad detective shows. You know the format, someone gets abducted, then the hero or detective or agent tells the frightened parent or spouse or sibling, “We’ll get her back, I promise.”
The words “I promise” are accompanied by intense eye contact and complete—albeit unfounded—confidence.
IMHO, these scenes represent a very poor use of the words, “I promise.” How can you promise something over which you don’t have complete control? For example, I can promise never to leave the toilet seat up again, but I can’t promise to rescue someone who just got abducted by aliens. What the writers/actors really mean to say is something like, “By golly, I’ll do my best to rescue your son from the jaws of that shark, but I don’t really have control over all the variables here, and so, although I wish I could guarantee a positive outcome, I can’t.”
Now you see why no one is asking me to become a screenwriter.
My point is that I’m about to make several promises to the members of the Association for Humanistic Counseling, and I want everyone reading this to know that I take promise making very seriously. I’m a careful and contemplative promise-maker. . . and I promise to do my best to fulfill the following promises during my online keynote speech this coming Friday, June 4, from 1-2pm (EDT).
Wait, one other sidetrack, before I share my list of promises.
My speech is titled, “Growth through Struggle: Embracing Sparkling Moments and Strengths, while Avoiding Avoidance and Denial.”
Now you can see why no one is asking me to come up with titles for their keynote speeches.
In the description of my speech, I included the following statement (which is sort of like a promise): “Join John Sommers-Flanagan in this keynote presentation, for a review of five positive strategies counselors can use for lightening their burdens, while simultaneously embracing deep existential challenges.” The problem here is that the five positive strategies I’ll be sharing come from the so-called “happiness” literature, and when talking about happiness with people who are fully in touch with their existential angst and nihilism, it’s advisable to offer a few caveats.
And so here come the caveats (aka promises):
I promise not to use reductionistic pop-psych pretend brain science terminology like the “amygdala hijack,” partly because if we really imagine an amygdala hijack, then we have to conjure up miniature D.B. Cooper character to conduct the hijacking, and those of us who embrace the humanist label tend to be rather disinclined to attribute our behavior to imaginary entities that live in our brains.
When talking about evidence-based happiness interventions, for obvious reasons, I promise to never use the phrase, “Happiness Hack.”
Throughout the keynote, I’ll never use the term “Mental illness” unless I’m explaining to everyone why I never use the term “Mental illness.”
Because I like to use a little Carl Rogers terminology here and there, I may spontaneously weave the term “organismic” into my speech. I’m sharing this in advance because, at that moment when I’m speaking to hundreds of people via Zoom and feeling nervous, there’s always the possibility that Sigmund Freud will pop into my brain, double-crossing Rogers, and taking over my unconscious. This could cause me to misspeak, and say “orgasmic” instead of “organismic.” Keep in mind that if you think you hear the word “orgasmic” during my keynote, I promise, what I really meant was “organismic” in the Rogerian sense of the word.
I promise to stretch myself, my self-awareness, and my understanding of the whole of existential humanism by refusing to boil down any part of human existence into the presence or absence of specific hormones or neurotransmitters like oxytocin, serotonin, and dopamine.
I won’t engage in reductionistic and sexist discourse by using rhyming words, like “fight or flight,” to describe complex, multidimensional human behavioral choices.
Overall, I promise to do my best to talk about how to use happiness interventions to help cope with the immense struggles many of us have been experiencing, without pretending that any of us can easily discover a secret, magic, or miraculous solution to human suffering.
If you’re interested in tuning into this keynote speech, during which I do not say the word “orgasmic,” yes, there’s still time. You can register and experience to whole slate of amazing, live, online presentations brought to you by the fabulous Association for Humanistic Counseling and their cool and fantastic President, Victoria Kress, by clicking here: https://www.humanisticcounseling.org/ahc-conference Then, just scroll down until you see, “Register for the Conference.”
I just realized that mindfulness meditation is all about nonjudgmental acceptance of the experience of failing at mindfulness meditation. Mindfulness meditation always involves failure, therefore it requires nonjudgmental acceptance.
We fail at mindfulness because we are always more or less distracted; we cannot achieve perfect mindfulness.
Practice does not make perfect; practice makes practice.
If the goal of mindfulness is to practice, then we cannot fail, unless we fail to practice.
But if we practice nonjudgmental acceptance, failing to practice is neither failure nor victory.
All this brings us back around the circle to never failing, but just being.
What if I owned a company and paid all my employees to conduct an intervention study on a drug my company profits from? After completing the study, I pay a journal about ten thousand British pounds to publish the results. That’s not to say the study wouldn’t have been published anyway, but the payment allows for publication on “open access,” which is quicker and gets me immediate media buzz.
My drug intervention targets a longstanding human and societal problem—post-traumatic stress disorder (PTSD). Of course, everyone with a soul wants to help people who have been physically or sexually assaulted or exposed to horrendous natural or military-related trauma. In the study, I compare the efficacy of my drug (plus counseling) with an inactive placebo (plus counseling). The results show that my drug is significantly more effective than an inactive placebo. The study is published. I get great media attention, with two New York Times (NYT) articles, one of which dubs my drug as one of the “hottest new therapeutics since Prozac.”
In real life, there’s hardly anything I love much more than a cracker-jack scientific study. And, in real life, my thought experiment is a process that’s typical for large pharmaceutical companies. My problem with these studies is that they use the cover of science to market a financial investment. Having financially motivated individuals conduct research, analyze the results, and report their implications spoils the science.
Over the past month or so, my thought experiment scenario has played out with psilocybin and MDMA (aka ecstasy) in the treatment of PTSD. The company—actually a non-profit—is the Multidisciplinary Association for Psychedelic Studies (MAPS). They funded an elaborate research project, titled, “MDMA-assisted therapy for severe PTSD: A randomized, double-blind, placebo-controlled phase 3 study” through private donations. That may sound innocent, but Andrew Jacobs of the NYT described MAPS as, “a multimillion dollar research and advocacy empire that employs 130 neuroscientists, pharmacologists and regulatory specialists working to lay the groundwork for the coming psychedelics revolution.” Well, that’s not your average non-profit.
To be honest, I’m not terribly opposed to careful experimentation of psychedelics for treating PTSD. I suspect psychedelics will be no worse (and no better) than other pharmaceutic-produced drugs used to treat PTSD. What I do oppose, is dressing up marketing as science. Sadly, this pseudo-scientific approach has been used and perfected by pharmaceutical companies for decades. I’m familiar with promotional pieces impersonating science mostly from the literature on antidepressants for treating depression in youth. I can summarize the results of those studies simply: Mostly antidepressants don’t work for treating depression in youth. Although some individual children and adolescents will experience benefits from antidepressants, separating the true, medication-based benefits from placebo responses is virtually impossible.
My best guess from reading medication studies for 30 years (and recent psychedelic research) is that the psychedelic drug results will end up about the same as antidepressants for youth. Why? Because placebo.
Placebos can, and usually do, produce powerful therapeutic responses. I’ll describe the details in a later blog-post. For now, I just want to say that in the MDMA study, the researchers, despite reasonable efforts, were unable to keep study participants “blind” from whether they were taking MDMA vs. placebo. Unsurprisingly, 95.7% of patients in the MDMA group accurately guessed that they were in the MDMA group and 84.1% of patients in the placebo group accurately guessed they were only receiving inactive placebos. Essentially, the patients knew what they were getting, and consequently, attributing a positive therapeutic response to MDMA (rather than an MDMA-induced placebo effect) is speculation. . . not science.
In his NYT article (May 9, 2021), Jacobs wrote, “Psilocybin and MDMA are poised to be the hottest new therapeutics since Prozac.” Alternatively, he might have written, “Psilocybin and MDMA are damn good placebos.” Even further, he also could have written, “The best therapeutics for PTSD are and always will be exercise, culturally meaningful and socially-connected processes like sweat lodge therapy, being outdoors, group support, and counseling or psychotherapy with a trusted and competent practitioner.” Had he been interested in prevention, rather than treatment, he would have written, “The even better solution to PTSD involves investing in peace over war, preventing sexual assault, and addressing poverty.”
Unfortunately, my revision of what Jacobs wrote won’t make anyone much money . . . and so you won’t see it published anywhere now or ever—other than right here on this beautiful (and free) blog—which is why you should pass it on.
These days mostly we tend to orient toward the culturally specific, and that’s a good thing. Much of intersectionality, cultural competency, and cultural humility is all about drilling down into unique and valuable cultural and individual perspectives.
But these are also the days of Both-And.
In contrast to cultural specificity, some theorists—I’m thinking of William Glasser right now—were more known for their emphasis on cultural universality. Glasser contended that his five basic human needs were culturally universal; those needs included: Survival, belonging, power (recognition), freedom, and fun.
Although Glasser’s ideas may (or may not) have universal punch, he’s a white guy, and pushing universality from positions of white privilege are, at this particular point in history, worth questioning. That’s why I was happy to find an indigenous voice emphasizing universal ideas.
I came across a quotation from a Lakota elder, James Clairmont; he was discussing the concept of resilience, from his particular linguistic perspective:
The closest translation of “resilience” is a sacred word that means “resistance” . . . resisting bad thoughts, bad behaviors. We accept what life gives us, good and bad, as gifts from the Creator. We try to get through hard times, stressful times, with a good heart. The gift [of adversity] is the lesson we learn from overcoming it.
Clairmont’s description of “the sacred word that means resilience” are strikingly similar to several contemporary ideas in counseling and psychotherapy practice.
“Resisting bad thoughts, bad behaviors” is closely linked to CBT
“We accept what life gives us, good and bad, as gifts from the Creator” fits well with mindfulness
“We try to get through hard times, stressful times, with a good heart” is consistent with optimism concepts in positive psychology
“The gift [of adversity] is the lesson we learn from overcoming it” and this is a great paraphrase of Bandura’s feedback and feed-forward ideas
In these days of cultural specificity, it makes sense to work from both perspectives. We need to recognize and value our unique differences, while simultaneously noticing our similarities and areas of convergence. Clairmont’s perspectives on resilience make me want to learn more about Lakota ideas, both how they’re similar and different from my own cultural and educational experiences.
Earlier today I had a 90-minute Zoom meeting with the staff from Bridgercare of Bozeman, Montana. Bridgercare is a medical clinic focusing on sexual and reproductive health. Our meeting’s purpose was to provide staff with training on how to integrate a strengths-based approach to suicide assessment and treatment into their usual patient care.
It’s probably no big surprise to hear this, but even through Zoom, the Bridgercare staff was fabulous. They’re clearly dedicated to the safety and wellbeing of their patients. I enjoyed meeting them and wish I could have been there live and in-person (but, having gotten my second vaccine shot today, more live and in-person events are in my future!).
One member of the medical staff asked if I had material on how to enhance the safety planning process with patients. After fumbling the question for a while, I remembered that I included a safety planning case example in Chapter 8 of our suicide book. I’ve included the excerpt below. Although the case is written in my voice, as you read through, think about how you might put it into your voice.
This case description illustrates a positive working relationship and outcome. Just to make sure you know that I’m not too Pollyannaish about suicide-related work, the whole book also includes cases and situations with less positive scenarios and outcomes.
Below, the counselor is discussing a safety plan with a 21-year-old cisgender female college senior named Kayla. Kayla was attending a large state university and living off campus in a small apartment. In this case, Kayla was social distancing in compliance with state stay-at-home orders; the session was conducted remotely, via an online video-based HIPAA-compliant platform (e.g., Doxy.me, SimplePractice, etc.).
The Opening and Unique Suicide Warning Signs
Counselor: Kayla, I’m putting your name on the top of this form [holds form up to camera]. It’s called a safety planning form. Some very smart people made up this form to help people stay safe. There are six questions. We’re supposed to fill it out together. If you hate it when we’re done, we can toss it in the trash. Okay?
Kayla: Okay. That’s possible.
Counselor: That would be fine. Here’s the first question. I’m just going to read them to you. Then you answer, I’ll write down your answers, and then we talk about your answer. What are the signs, in yourself or in your environment that will be a warning that tells you that you need to do something to keep yourself safe?
Kayla: I just like feel a wave of sadness and defeat. Like my life means nothing. Like I’m a damaged, bad person who should die.
Counselor: Okay. A wave of sadness and defeat. How will you know that wave has come? What do you feel in your body or think in your brain?
Kayla: I feel a physical ache. I think about being abused. I think horrible thoughts.
Counselor: I’m writing down, “Wave of sadness and defeat, and physical ache, and thoughts of being damaged, bad, and abused.” Those are all signs that you should follow this safety plan.
Kayla: Also, being home alone at night.
In this initial exchange the counselor empowers Kayla to reject the plan if she wants to. Offering to let Kayla reject the plan probably makes it more likely for her to take ownership of the plan. If Kayla ends up rejecting the plan, that information becomes part of the overall assessment and guides treatment decision-making.
Kayla immediately engages in the process. Specifically, her trauma-based thoughts of being damaged and bad could be fruitful therapeutic grist for cognitive processing therapy or EMDR, both of which address trauma and focus on beliefs about the self. However, when using the SPI, it’s best to stay focused on the SPI, and save the deeper therapeutic content for later. The counselor could (and should) have said, “For now, we’re working on this plan. But later on, if you want, we can start working on your feelings of being damaged and bad.”
Personal Coping Strategies
Counselor: What can you do in the moment to cope with suicidal thoughts and feelings?
Kayla: Look. I could cut myself to feel better, but nobody wants me to do that.
Counselor: I’m sure it’s true that people don’t want you cutting. I also think it’s true that people would rather have you cut yourself than kill yourself. If cutting keeps you alive, we should put it in the plan, at least for now.
Kayla: I think it should be there then.
Counselor: Okay. So, cutting goes on here as a method for calming or soothing yourself. Have I got that right?
Kayla: Yeah. It calms me down when I’m upset.
Counselor: What else could calm you down or distract you from suicidal thoughts?
Kayla: I could listen to music or call a friend.
Counselor: Great. I’m writing those ideas into the plan right now.
Brainstorming coping responses is similar to other processes discussed in chapter 5 (problem-solving and alternatives to suicide). One key principle is to accept all responses before evaluating them later. In the preceding interaction, the counselor accepts that cutting might be a viable (even if not preferred) short-term coping strategy, and then continues to nudge Kayla to generate additional coping ideas. Although cutting isn’t addressed in this case example, after developing the safety plan, therapeutic conversations about cutting and alternatives to cutting, should become a part of ongoing counseling (see Kress et al., 2008; Stargell et al., 2017).
Social Contacts and Settings
Counselor: I’m wondering about those times when you’re alone. Who could you be with to stay safe? Even if it’s only for you to distract yourself?
Kayla: I have a friend named Monroe. He’s crazy. He’s always happy. Sometimes he annoys me, but he’s a good distraction.
Counselor: Monroe sounds like a great distraction. He’s in the plan. Are you able to see him in person, or would you do Facetime or a Zoom call.
Kayla: He lives in the apartment building and we could meet up outside.
Counselor: That sounds great. Who else?
Kayla: I can always call my parents, but when I do, I feel like failure. I’m an adult.
Counselor: If you’re feeling suicidal, would your parents want you to call?
Counselor: Okay then. Let’s put your parents down. We can talk more later about how calling them might make you feel.
The counselor does a good job of getting Kayla to be specific about how she could connect with Monroe. Overall, Kayla doesn’t have an extensive social support network. Expanding that network will likely become an important goal for counseling.
People Whom I Can Ask Help
Counselor: This question is similar to the last one, but a little different. Instead of people who are distracting, now I’m wondering who you can turn to if you’re in crisis?
Kayla: Monroe wouldn’t be the right person for that.
Counselor: Not Monroe. But who would be right for that?
Kayla: My parents, I guess. And my aunt, Sarah. She’s always been there for me. I could call her if I need to. And my grandma.
Counselor: Good. That’s four. Your mom, your dad, your aunt Sarah, and your grandma. Are they around here, or would you call or text them?
Kayla: My parents and aunt live close by, but we’d probably just Facetime because they’re older I don’t want them to get COVID. My grandma lives in Minnesota.
While generating lists, it’s useful to draw clients into being even more specific than illustrated in this exchange. For example, as Kayla identifies people to call, getting specific about texting or calling, where the person might be, and what to do if there’s no answer, is good practice. Role playing a call or text can be useful, because rehearsing behaviors make them more likely to occur.
Mental Health Professionals or Agencies to Contact
Counselor: How about professionals or agencies that you can call if you’re in a crisis?
Kayla: I don’t have anyone.
Counselor: Wait. You need to put me here. I should be on the list. I can be available for short calls Sunday through Thursday evenings up until 9pm.
Counselor: And there’s 9-1-1, right? You can always call 9-1-1. In an emergency, that’s what you do. There’s also a new suicide hotline number, 9-8-8. I’m going to write that number down too. You don’t have to call any number, but it’s good to have them just in case you do want to call for professional help during a crisis. The other thing to remember about calling hotlines is that you may get someone you don’t like or don’t connect with. If that happens, keep trying, but also, jot down a few notes so you can tell me about it.
In the preceding exchange, the counselor offers to be a limited option. Whether you provide a personal contact number is up to you. Whatever you do, spell it out in your informed consent and have boundaries around the times when communications with you are acceptable. Because calling hotlines may or may not feel helpful, empowering Kayla to critique her hotline experience and then report it to the counselor might increase her willingness to call.
How Can I Make My Environment Safe?
Counselor: This last question has to do with how you can make your environment safe. We’ve talked about various things, like how you can cope and who you can call. Now we need to talk about whether there’s anything dangerous in your home, anything that could be used to kill yourself if you were suddenly suicidal.
Kayla: Yeah. Well I bought a hand-gun last year. That’s how I would do it.
Counselor: Right. Thanks for telling me about the gun. Can I just tell you what I’m thinking right now?
Counselor: With guns and suicide, there are two good options. One is for you to give it to someone for now, until you’re feeling better. The other is for you to safely store the gun or get a trigger lock. I’m just being totally honest with you about this. The reason we should get your gun locked up or given to your parents or someone else, is because most of the time, people are intensely suicidal for only 5 or 10 or maybe 30 minutes. During that intense time, people can do things they later regret. Most people who make a suicide attempt don’t make another attempt. It’s usually a one-time thing. My main goal is for you to be safe.
Kayla: But I’m not planning to use the gun or anything.
Counselor: Right. That’s great. But let’s say your Aunt Sarah was suicidal and she had a gun, would you be willing to keep it for her if it made her safer?
Kayla: Of course I would.
Counselor: So, whether it’s you or your Aunt Sarah, we want to make sure suicide doesn’t happen because of one terrible moment.
The preceding is an example of psychoeducation around suicidality and safety planning. If you have a good rapport and connection with your client, the psychoeducation is likely to be well-received. If your rapport and connection is less good, then you’ll either need to work on the relationship, or take a more directive and authoritative role to promote your client’s safety.
Counselor: All right. I’ve written down your ideas for the safety plan. Now, I’m going to scan it and send it to you through our secure portal. As we’ve already discussed, we’re going to make a bigger plan for your counseling. But in the meantime, we need to keep you safe so we can do the counseling. Right now, you’ve got this safety plan you can use, and we can revise it if we need to. Okay?
Counselor: Kayla, thank you very much for working with me on this safety plan. I think we made a good plan together.
Kayla: Me too. I guess I won’t throw it in the trash.