Client suicide is one of the greatest fears of all counselors, and suicide prevention is a difficult and commonly avoided area of counseling. Suicide rates in the United States have steadily increased from 10.4 per 100,000 in 2000, to 13.4 per 100,000 in 2014. This is a 27.6 percent increase over 15 years. If this trend continues, the occurrence of suicide will be one issue that most counselors will unfortunately have to face at some point in their practice. There are many legal, moral, and ethical difficulties surrounding the topic that could ruin a career if not properly dealt with (Sommers-Flanagan and Shaw, 2017).
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. Next they encourage and teach the client to develop the skills needed to create and uphold fulfilling, rewarding, and enjoyable lives (Meyers, 2017). In this paper I will explore an ethical dilemma involving suicide and highlight some of the areas of greatest difficulty in the event of a client death.
For most counselors, an ethical dilemma is apparent when they encounter a confounding situation in which they feel hindered in their decision-making due to various factors. There may appear to be conflict between, or inconsistency among, the ethical standards. The situation could be so compounded that the ethical codes offer unhelpful guidance. A discrepancy between ethical and legal standards could materialize, or there may seem 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). How is a counselor to proceed if a client has many symptoms of depression and suicidal ideation and fits into one of the most likely demographic categories for a suicide, but denies all thoughts of suicide?
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, who emotionally abused him for all of his childhood, 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 excessive amounts of alcohol, and watches TV before falling into a restless sleep, repeating the cycle weekly. He mentions that he enjoyed hunting, but can no longer find the will to do even what he enjoys. He does not explicitly mention thoughts of suicide, but shows many of the warning signs. He states that he feels as though his current life is pointless and unimportant. After the third session, John commits suicide using one of the guns in his home.
John showed signs of isolation and feelings of worthlessness. He had not expressed a true desire to improve his life, only that he recognized that there may be a problem, putting him in the contemplation stage of change. He had taken the first step of attending counseling, but he did not seem as though he would continue attending counseling long-term, stating on the third session that he did not think counseling was going to be as effective as he had hoped.
His expression of 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 lived 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 had a high rate of alcohol consumption which is a factor in fifty percent 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 stated in counseling. 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 after the first two sessions, the counselor should talk with other counselors for a second or third opinion on the plan of action (ACA, A.1.c, 2014).
John should be heavily 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 friends nearby or family that could be alerted. 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). In one study, job/financial problems were found to be an issue in 22.5 percent of the suicide cases analyzed (Schiff et al., 2015). 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. However, this is also an extremely high false positive group (Fowler, 2012). John was also emotionally abused during his childhood. This puts him at a higher risk for psychopathology. He has trouble forming trusting relationships, as clearly evidenced by his relationship with his counselor. John, like many emotional abuse survivors, finds it difficult to form secure attachments and has trouble forming and maintaining interpersonal relationships. This also puts him at a heightened risk for suicide (Allbaugh et al., 2018).
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.
As difficult as it may be, if a client is presenting symptoms of depression and suicidal ideation, the best course of action is to ask the client directly if he is or is not considering suicide as an option. 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. 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. John appears to be suffering from depression. He could be referred to a doctor for an antidepressant, but there is limited evidence that medications have substantial impact on suicidal ideation and self-harm behaviors (Jobes, 2017).
If he had family nearby, they might have been able to assist in removing the guns from John’s home and provide him with emotional support. John was asked by the counselor after the second session to put his firearms in a remote location that he does not have immediate access to. John 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 perhaps unreasonably paranoid, which is a warning sign for suicide. The only other option would have been to alert authorities, but if John was not suicidal, this could have made John turn away from counseling completely and send him deeper into his depression (Westefeld et al., 2016). Remember that he also did not express any suicidal ideation, making it a breach of confidentiality to alert anyone at that point.
In the first session with John, a relatively high-risk client, the counselor should assess his current suicide risk. Next, she should communicate her intent to understand more about his life and what makes living difficult for him. Lastly, she should ask John if he would be willing to negotiate treatment options and devise 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. John is experiencing all of these feelings. In those most vulnerable to suicide, the capacity to think clearly and flexibly collapses, and suicide emerges as a means of evading intolerable affliction. 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 forbearance for, and improved regulation of, intense affect include radical acceptance, mindfulness acceptance, insight-oriented interpretation, and mentalizing, to name a few. It is beneficial to use all elements to fit the needs of the client, but it is also advised to rely heavily on raising the patient’s curiosity and awareness of their emotions because suicidal clients are often phobic of negative or conflicting emotions. The most accurate predictor of suicide is past suicide attempts (Fowler, 2013). John has denied ever attempting suicide before.
Clients presenting for treatment with active suicidal ideation and intent must be assessed for risk. A new counselor or counselor-in-training should 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. John’s risk assessment came back as negative, so it was the counselor’s decision to not have John placed on suicide watch based on his results and the expert opinion of the counselor (ACA, E.2.c., 2014).
Over the past 20 years there has been a shift in how psychoanalysts assess potentially suicidal clients. We now realize that, unfortunately, suicide risk factors mean little for prediction and prevention efforts. A positive aspect of the developments in suicide-related theory is the move away from the medical model. There is increased emphasis on the initial and ongoing clinical encounter, including use of comprehensive suicide assessment interviewing protocols and use of increasingly nuanced methods for clinicians to directly question patients about suicidal ideation. There are also methods for monitoring suicidal ideation and risk over time (Sommers-Flanagan and Shaw, 2017).
The assessment of suicide risk usually rests on the admission from the client of suicidal ideation, either voluntarily communicated, reported by the patient’s significant others, or confirmed by skilled clinician examination. Most of the more commonly used screening tools for suicide risk, such as the the Ask Suicide?Screening Questions and the PHQ9 rely heavily on the self?report of suicidal ideation. Even expressed suicidal ideation is only a weak predictor of suicide, however (Berman, 2018).
I think many counselors in this situation would feel the need to do something for John. He has many risk factors and many would say that it is obvious that he was suicidal, but he would not admit to suicidal ideation or planning. This puts the counselor between a metaphorical rock and a hard place. There is unfortunately nothing the counselor could have physically done to stop John. Justice and autonomy allow John to keep his firearms. Universality is apparent because any client would have to be treated in the same manner as John. Beneficence of the counselor toward John means that she has the client’s best interest in mind and she trusts him to tell the truth, even though in this example he did not. Publicity stops the counselor from alerting John’s coworkers, the only possibility of people to provide emotional support in his life, of her concern.
For counselors and counselors in training, client death is a difficult event to move past. The only thing we can do is be as prepared as possible if the event should occur. According to Veilleux and Bilsky (2016), training in suicide prevention does not prepare trainees or training programs for the cataclysm that a suicide can ensue. Suicide postvention procedures exist in other fields to help those affected, but mental health clinicians are forced to adhere to the ethical mandate of confidentiality. Therefore, therapist survivors are not free to openly grieve with others who knew the deceased. In combination, the feelings of responsibility related to the client’s mental health and the ramifications of breaching confidentiality can leave the counselor with an often great burden that must be endured in solidarity.
Understanding legal and ethical problems related to suicidality is important knowledge to have when counseling suicidal clients. Mental health care providers should grasp state laws pertaining to suicide, recognize legal challenges that are painstaking to defend against as a result of poor or incomplete documentation, and ensure the safety of client records and rights to privacy and confidentiality following the Health Insurance Portability and Accountability Act of 1996 that went into effect April 15, 2003 (Cramer, Johnson, McLaughlin, Rausch, & Conroy, 2013).
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