Client suicide is one of the greatest fears of all counselors. Suicide prevention is a difficult and commonly avoided area of counseling. Client confidentiality is of utmost importance, but when a client indicates that he or she may be suicidal, counselors have a duty to report this to family members and authorities. Contrary to common belief, there are several effective suicide treatments for adolescents and adults. Using these techniques, first counselors must help clients out of the actively suicidal state, and then they must help the client develop the skills needed to create and uphold lives worth living (Meyers, 2017).
Clients may be asked to sign a No-Suicide contract or a Commitment to Treatment contract. These can be helpful in certain instances, but if the counselor-client relationship is strained or new, clients can feel as though they are being made to sign the contract to shift moral blame away from the therapist in the event of a tragedy, although the contract is in no way legally binding. Suicide is the third leading cause of death among 15 to 24 year-olds (Canady, 2017). Seventy-one percent of psychotherapists report having at least one client who has attempted suicide, and twenty-eight percent of psychotherapists report having had at least one client die by suicide (Firestone, 2018). It is an unfortunately common event that most practitioners will experience in their careers.
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For most counselors, an ethical dilemma is apparent when they encounter a confounding situation in which they feel hindered in their decision making because there appears to be conflict between or inconsistency among the ethical standards, the situation is so compounded that the ethical codes offer unhelpful guidance, there appears to be a discrepancy between ethical and legal standards, or there appears to be a conflict between the moral principles that underlie most ethical codes. If the correct route to take in a counselling situation is unclear, the ACA’s ethical decision-making model may need to be employed (Forester-Miller & Davis, 2018). When making an ethical clinical decision it is essential to consider both personal bias (ACA, 2014, A.4.b) and level of professional competence (ACA, 2014, C.2.a)
A 30-year-old client named John decides to speak to a counselor because he has been feeling down. His thirtieth birthday was a month ago, and since then he has been overwhelmed with the feeling that he is not where he expected to be at this point in his life. He married young and has been divorced for five years. He is estranged from his parents and he does not have any siblings. He did not complete college and complains about his unrewarding and tiresome job. He lives alone and struggles to find a healthy balance for his life, saying that he usually only works, comes home, drinks, and watches TV before falling into a restless sleep, repeating the cycle weekly. He mentions that he enjoyed hunting, but he can no longer find the will to do even what he enjoys. He does not explicitly mention thoughts of suicide, but he shows many of the warning signs. He states that he feels as though his current life is pointless and unimportant.
John shows signs of isolation and feelings of worthlessness. He has not expressed true a desire to improve his life, only that there may be a problem, putting him in the contemplation stage of change. He has taken the first step of attending counseling, but he does not seem as though he will continue attending counseling long-term. His love of hunting indicates that he has access to firearms. Studies have shown that when there are no firearms in a household, there are fewer suicide deaths. John lives in a rural area, where it has been shown that suicide attempts are more often successful than in urban areas (Westefeld, Gann, Lustgarten, and Yeates, 2016). John also has a high rate of alcohol consumption which is a factor in 50% of suicides (Firestone, 2018).
The mind of a suicidal person is working against itself. A part of the client wants to live, while another part is self-destructive. All suicides have elements of both planning and of spontaneity. Therefore, therapists must act quickly and precisely if suicidal thoughts are suspected or stated. There are many thought patterns common in suicidal clients including self-hatred, hopelessness, isolation and pushing away loved ones, feeling like a misfit, and feeling like a burden. There are also many common behaviors like past suicide attempt(s), sleeplessness, anxiety and agitation, rage outbursts and low problem tolerance, risky behavior, alcohol use, sudden positive shift in mood, and any direct talk of suicide related behavior (Firestone, 2018). The stakeholders and main decision-makers in this situation should be a collaborative effort between the client and the counselor. If the counselor is still unsure of what to do or feels that the client is being untruthful or flawed in his assessment of himself, the counselor can talk with other counselors for a second or third opinion on the plan of action.
John should be encouraged to continue counseling. The counselor does not want to hurt John’s already weakened sense of pride by suggesting that he may be suicidal, but neither does she want to avoid a life-threatening possibility. John does not have family who could be alerted or friends nearby. The only people who could offer him support are his co-workers. It would be a breach in confidentiality to alert them, however (Ethical, 2018). The counselor fears that John is not expressing his suicidal thoughts for fear of the consequences laid out in the informed consent agreement. John is in a high risk demographic group because he is male, white, and unmarried, but this is also an extremely high false positive group (Fowler, 2012).
If a client is thought to be suicidal, the best course of action is to ask the client directly, difficult as this may be. John should be asked to sign a commitment to treatment agreement. This could encourage him to take the counseling process seriously and could assist in his symptom improvement. John appears to be suffering from depression. He could be referred to a doctor for an antidepressant. He should be encouraged to exercise, eat well, and drink less alcohol; all mood and energy boosters. Exercise could help improve his quality of sleep.
If he had family nearby, they might be able to assist in removing the guns from John’s home and providing him with support. John has been asked to put his firearms in a remote location that he does not have immediate access to, but John has denied the request, citing his need for protection in the event of a burglary although he lives in a very safe area of the country. This is also an indicator that he is unreasonably paranoid, a warning sign for suicide. The only other option is to alert authorities, but this could make John turn away from counseling completely and send him deeper into his depression (Westefeld et al., 2016).
In the first session with John, a relatively high-risk client, I would assess his current suicide risk. Next I would communicate my intent to understand more about his life and what makes living difficult for him. Lastly, I would ask John if he would be willing to negotiate treatment options and make a plan for managing his well-being, immediate risk removal, and symptom improvement. Suicidal states are often triggered by unbearably painful emotions associated with feeling abandoned, alone, alienated, and disconnected, all of which John is experiencing. In those most vulnerable to suicide, the capacity to think clearly and flexibly collapses, and suicide emerges as a means of escaping unbearable pain. Treatments that focus on restoring the capacity to reflect on strong emotions, and to weather affective storms are emerging as highly effective in reducing the occurrence of suicide-related behaviors. Techniques aimed at improving tolerance for, and improved modulation of, intense affect include radical acceptance, mindfulness acceptance, insight-oriented interpretation, and mentalizing, to name a few. In my practice I use all elements to fit the needs of the patients but rely heavily on enhancing the patient’s curiosity about their emotions because suicidal patients like Esther are nearly phobic of negative emotions.
The most accurate predictor of suicide is past suicide attempts (. John has denied ever attempting suicide before.
Clients presenting for treatment with active suicidal ideation and intent must be assessed for risk. As a new counselor or counselor in training, I would probably conduct a formal suicide interview. Fowler (2012) says it is best to communicate interest in the clients’ suffering and to invite them to speak openly about their struggles. Counselors should work to understand the client’s reasoning for wanting death and aim to create a sufficient empathic reply to their internal pain in the form of marked mirroring.
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