According to the World Health Organization, in the year 2000, approximately 100, 000 people died by suicide around the world. That averages out to be one death by suicide every 40 seconds.
If you are a mental health
professional who has been personally affected by someone’s death by suicide – a sibling, a parent, a friend, or relative, an acquaintance, or a client – you will likely find that you are in need of support. The American Association of Suicidology’s Clinician-Survivor Task Force is a terrific place to start. In addition to providing lots of information and research on related issues, they also host an old-fashioned email discussion list that is restricted to clinicians who are survivors.
If you know of other resources for clinicians who have experienced this unique type of loss – in their personal or professional lives – I hope you will share them with us here.
Tamara,
I was just thinking about this issue! I lost both brother and father to suicide and wondered if, as a therapist, I would be able to deal with suicidal clients. I can and do! I am a dialectical behavior therapist as well, and this is the treatment of choice for this clientele who also suffer from emotional dysregulation. I just presented at the NAMI conference and got a few referrals. I reflected on how I must be vigilant in assessing for suicidal ideation with these clients. Then I find this post from you! Awesome and thank you very much!
Good morning, Linda! I wonder how those losses inform the work you do with clients who consider suicide as an option . . . . And, if you have any advice you can give to those of us who have not yet been down that path.
So happy to hear that you were presenting at NAMI! That’s not only feeding your practice but also giving back to your community! Thank-you . . . for having the wisdom and the courage to share your journey with us!
Tamara,
You have found another of my Soapboxes. This is something I do trainings twice yearly (I do have a great PowerPoint) as it is essential to understand warning signs. There are multiple other staggering statistics.
75% of people in the United States have thought about suicide (as a potential option) at one point in their life. I had a plan to end my life when I was a teenager. A friend spoke to me (I do not remember what was said but the person speaking to me was enough for me to change my mind). Sharing that thinking about it is normal; making plans is unhealthy. I had a uncle kill himself as he could not face his future with his illness. I have had a client kill themself (I am being vague for client protection). I had to perform CPR on the person, cut them down, etc.. It was a very traumatic experience. It took crisis counseling and EMDR to remove the anxiety around similar situation. It took 8 years for me not to remember the anniversary date. It was tough but I vowed to educate others so that it can be minimized. In addition, I am much more careful and detailed about my initial assessment questions.
The plan to deal with it is to recognize that it is a painful experience. To label it anything else, minimizes the power of death and the impact on relationships. I tell future clinicians that it will happen and you will likely now know who. I work to help all work through pain. I used professional and non-professional counseling to help. I used training on the subject and worked to be an expert in it. I used my faith and spiritual support to help. I had great support from my company who planted a tree in memory. I had coworkers who checked with me often, especially around anniversary time.
Bryan, thank you for sharing your experience and your hard-fought wisdom. I agree . . . it is only a matter of time until all of us will encounter our own or another’s consideration of suicide. I appreciate you working to dispel the myth that thoughts of suicide are anomalies. I know your personal experiences and willingness to talk about your own journey must allow you to touch so many more lives that mere statistics.
I teach ASIST (Applied Suicide Intervention Skills Training). It’s one of only 2 or 3 few evidence-based intervention models. One of the facts that I know is that most people who consider killing themselves are more likely to talk to a friend or a family member or even a religious leader before they will talk to a therapist or a doctor or a first responder. That’s why it’s so important to get this information out to professionals and non-professionals alike.
Very true about the training. I speak about it on Facebook. I also speak with my 9 year old (soon to be 10 and “double digits”) about it as there are statistics of elementary students killing themselves. I know that she is empathetic and is able to share information she hears with teachers or her mom and dad. If we can identify the risk factors, then we can offer some great help. I went to a training several years ago from Jack Klott. He shared this so I’ll share.
There are four major protective factors related to suicide. These were discovered to be the factors elderly black women have as their suicide risk is very low (zero CDC deaths when the training was done). Sharing these with others is essential as well as to help foster these attitudes (what a message for election day).
Resiliency – try, try again. Keep trying until something works.
Hope – never ending, primarily religious, future thinking.
Radical Acceptance of Life – these are the cards that you were dealt, deal with it.
Social Affirmation – a strong social network.
Bryan, the fastest growing group for completed suicides in my county, Douglas County, Colorado – is children under 10 years of age. Your daughter is fortunate to have parents willing to have those conversations now.
And, what I know is that the one factor that all people who attempt suicide have in common . . . it’s that they feel isolated or alone. Thanks for sharing Jack’s protective factors!
Happy election night!
This is such an important topic. Thanks, for sharing such personal stories of courage and overcoming such powerful situations. I remember when I first started working as a counselor – I knew that statistically a lot of people considered suicide at one time or another, but I was surprised about how often such a discussion comes up in counseling sessions. The majority of the time, this leads to a discussion on coping mechanisms and how the clients are able to see that either the suicidal thoughts are in the past or they are able to mention other coping mechanisms that they can use in their current situation. I even created a business card that has a few crisis numbers that I give to every one of my clients. It has the agency’s phone number, the crisis numbers that we use regularly in our county, and a few national numbers. I end up having a lot of people give the card to people they know and ask me for another one.
I remember that suicide was something that was discussed in my college dorm, and I often reflect back on those experiences. I didn’t have a lot of formal training at that point in the beginning, but if the college health center was already closed, I was the best thing until something else could be done. I learned a lot about empathy during those discussions. It’s a very delicate balance.
Over time, a lot of my clients have learned not to use phrases casually, like “I just wanted to curl up into a ball and die” because they know that I’m going to ask more about it. Often times, before I finish the question they’ll say something like “no, no, I was just kidding… I was just upset and wanted to be left alone for a few minutes, really.”
On the flipside, I’ve also had people who respond to a question about that kind of statement who actually do mean something similar to what they say, and they have said “nobody has ever asked me that before… you mean you really want to know?” It can be very powerful experience to help someone talk through feelings like that when they are are able to talk about the possibility of having another options to make their life closer to their ideal.
Good morning, Lauren! Thanks for sharing some of the things that you have done to support your clients. Initiating discussions about suicide can be very scary for clients. There’s so many taboos related to death and dying and taking your own life. And, initiating those discussions can be scary for therapists, too.
I think what’s helpful to me is to remember that
– I want to be helpful and it’s always more helpful to initiate those conversations than to not;
– Most people want to escape their pain rather than kill themselves – sometimes they just don’t see all their options; and,
– I can help most people to find more options, get more support, and find other solutions . . . . However, what I can’t do is keep every person every time from choosing suicide.
Statistics show that most people think about suicide at some point in their lives. Given that one fact, it seems like this is one of the first things new therapists should learn and more seasoned therapists should keep abreast of. Therapists are best prepared to address suicide when they have taken the time to thoroughly work through their own beliefs and biases related to suicide and gotten training and skills to work with individuals who are thinking about suicide. And, good training on suicide intervention is going to build in time to let you do just that.
I’ve been a little busier than normal this week, so a little slower to comment. You’re right that most people just want to either escape pain or some other negative emotion. I remember remarking to a mother of a very young client that she seemed really overwhelmed. I was actually going to ask if she had thought about self harm or suicide, and before I even got there, she was disclosing that she had a very specific plan of what she wanted to do the night before.
I know that we are technically only supposed to treat our clients, but sometimes other people who present in our offices also need help, and if such a situation arises, not only do I have a responsibility to act, but I have a desire to try to help anyone in dire need, even if that involves getting them to the right place for the right treatment.
I’ve had situations similar to the above two or three times than I can recall. It starts with a basic empathetic statement about how it sounds like it has been a rough week or something, and turns into something that needs immediate attention. Immediately after such a situation (or in the next day or so), I find myself really thankful that I asked.
Lauren, you are so right. Thanks for expanding this conversation to be about more than “just” our clients!
We and our clients lose when we are fearful to speak about a subject, either because of taboo or our personal concerns. Direct talk about suicide is essential and welcome to our clients. When we are not afraid, they become less fearful and then can address the real issues as Tamara said.
Thanks for sharing this blog. I have had this personal experience with a client early in my career, before I was a therapist, as a mental health Case Manager . Even today I will think about this client. One of the things that I learned in this process is you can put all the necessary steps in place to prevent suicide but if I client has chosen this path they will find a way to follow through. I continue to ask myself if there were things that I could have done differently to prevent the sucide; when in reality I put all the necessary ethical steps in place and it still happened. Though I now this I still struggle with the fact that it happened. I am guessing this is true for all therapists.
True. If a client wants to die, then they will find a way and not share anything with other. My client took this approach despite several conversations with clinicians that day. I told no one of my plans when I was planning it. Despite our best efforts, some people are in so much pain that they must end it. That is not the way this world is supposed to be.
🙂 So glad you are still with us, Bryan! Thanks for normalizing something that is mythically thought to be exceptional. It is not. In fact, it is the individual who has never once thought of suicide that is the exception. (Wouldn’t it be interesting to see stats specific to mental health professionals who have considered suicide? Anyone know of such research?)
US suicide rates are around 10 per 100,000. Women are generally lower than men. Isolated populations are higher, such as Native Alaskans. Police, fire personnel are around 20 per 100,000. Doctors and dentists are also at that same level. Mental health workers, e.g. counselors, social workers, etc. are also at 20 per 100,000. Twice the national average. This is a good reference site (http://www.suicidology.org/web/guest/home). I suspect that research would be difficult in this area given IRB concerns (but very needed).
This site is helpful as well. (http://www.sprc.org).
Hi, Lyndsey. You are exactly right! You could only do what you knew to do. And, what I would add is that even if you had not done it all “perfectly” whatever that is . . . you tried. You did the best that you could do – and it sounds like you did everything you could have done – and it still wasn’t enough to save the life of that individual.
In the ASIST classes that I teach, we say “It takes a village to create a suicide-safer community.” No one – not even a highly trained, highly motivated, highly caring mental health Case Manager – can do it all alone.
The good news is that your tried. You did what you knew to do. I don’t know that we are ever supposed to get comfortable with someone killing himself; but what I do know is that by sharing your story today, you are helping to dispel the myth that losing clients to suicide happens only to “bad” therapists and that losing clients to suicide is “unbearable.” Thank you.
It’s sad. It’s frustrating. It’s often life-altering and practice-altering for a therapist . . . . But it happens more often than we would like to think . . . in spite of really great therapists (and really great family members, co-workers, and friends) and yet what I know is that we can bear it. We can learn what we need to learn, initiate the difficult conversations, make the “right” choices, . . . and do it again if we have to . . . again . . . and again . . . and again.
If you and anyone else reading this post have been there and are struggling after a loss by suicide, I hope you will check out the AAS Clinician-Survivor Task Force.
I think it’s also important to note that we have to trust what our clients are telling us. It’s true, sometimes we confront inconsistencies in what they have previously stated, but if we ask a client whether they are considering self harm or suicide and they say that they are not, it is our responsibility to document that we asked the question and provide telephone numbers in case they are needed and document that they agreed to call one of the crisis numbers before taking any action to harm themselves or others.
It is my hope that clients would be truthful and I try to create an environment that lends itself to comfort for being open and honest, I also recognize that not every client is truthful about everything.
We have to do the best we can with what we have or what we know.
Lauren, I think part of relationship-building with a client is trust. And, yes, I believe that is true even when working with clients who are in denial. If there isn’t any reciprocal trust going on, then there’s not much therapy going on.
Having said that, I think it’s important to acknowledge that when clients are giving you mixed messages, they are trusting us to make helpful decisions with those mixed messages, too. I’ve worked with clients who were alcoholic and I’ve worked with clients who cut on themselves, too. Sometimes giving mixed messages is the best clients can do and when that happens, it’s important to do the best we can with all that we know.
I agree, Tamara. A supervisor told me once that clients will tell us as much of the truth as they can (or choose to) at any given moment. The therapeutic relationship is a very important element for successful treatment (and a lot of research says that this is more telling than a counselor’s actual theoretical approach with a given client).
You are absolutely right that we are to do the best we can with all we know, whether it’s what is overtly being expressed or whether we are noticing things about their nonverbal behavior. Both are very important, but both are restricted to what we have been given access to. For example, if we notice that a client has cuts on his or her arms, for example, we can ask about them, but if they are cutting on their stomach, chances are very slim that we would know about it unless they mentioned it in another way.
Of course, it’s also important to look at major changes in mood for every client that are otherwise unexplained – whether they are positive or negative. Besides, if a client is really happy about something, what’s the harm in spending a portion of the session on that? I know that we have to work on something that is related to the treatment plan, but chances are that it is in some way related or perhaps an example of a really good coping mechanism for future use. Focusing on strengths can be very useful.
And since we’re on the subject of suicide, a very sudden positive swing may also be another warning sign, though I don’t usually look upon it that way unless there are other signals.
I generally work to trust what clients say. However, some clients are unaware of their own thought process. I work with very difficult clients so there are several who make suicidal comments with no obvious intent to die, but they really desire to die. One client attempted to use it to manipulate his way out of treatment (as previous providers panicked over the comments). We did not. I told him that he is actually closer to death and ending his life than he initially thought. After several months of treatment, he stated that he was closer to the brink than he thought and was afraid of his past comments and behaviors related to suicide. I had the advantage of lots of past history on his and used my insight (gut reaction) to his comments. This was after the death of my client so I was able to not panic about his comments but to see what he was really saying and feelings.
Generally, I trust clients but since I have clients who have severe neglect, abuse, and trauma (pure complex trauma) and are juveniles, many are not aware of their own feelings and thought process. I use what I know from their history and my gut feelings to do the right interventions at the right moment.
Bryan,I’ve seen this happen, too – where clients don’t realize what they are saying about life. It sounds like the death of your other client continues to inform your choices and your practice. That really is insight.