Collaboration and a Self-Help Orientation in Therapy with Suicidal Clients

Working with suicidal clients historically has placed a heavy burden of responsibility on the therapist for a successful outcome. This orientation generally has left clinicians feeling stressed and in need of controlling their clients' behavior; clients, in turn, often have developed unrealistic expectations of therapy or resistance of the therapist's interventions. In this context, the chance for a potentially valuable collaboration between client and therapist is often lost. This paper builds on previous work that has introduced the notion of a collaborative working relationship with suicidal clients. It is argued that the therapeutic process ideally should not only utilize the therapist's knowledge and skills in treating suicidal clients, but also cultivate self-efficacy by encouraging the client to adopt a self-help orientation to therapy. Several general principles of a collaborative/self-help orientation to working with suicidal clients are discussed and a variety of specific therapeutic strategies consistent with this orientation are described.     

Nonbinary-Affirming Psychological Interventions

Nonbinary individuals experience unique stressors and stigma compared to binary transgender individuals. Given the many social systems that operate on a binary gender system, nonbinary individuals frequently experience microaggressions, discrimination, and harassment and suffer from high rates of negative mental health outcomes as a result. The unique stressors that nonbinary individuals face warrant specific clinical considerations for working with this population. Yet, limited published clinical guidance exists on working with nonbinary clients. This article uses minority stress theory to understand the unique stressors and mental health risks that nonbinary individuals face, a cultural competency framework to describe affirming practices, and ecological theory to contextualize how mental health providers can intervene and support nonbinary individuals. Concrete micro-, mezzo-, and macro-level interventions are provided for clinicians to enact to support the well-being of nonbinary clients including affirming the client’s experience of gender, taking a stance of openness and flexibility, and advocating for inclusive policies and practices.     

Counseling for Suicide: Client Perspectives

The purpose of this study was to describe key therapeutic processes that facilitated overcoming suicidal ideation and behaviors in previously suicidal clients. A research method called “concept‐mapping” was used to develop an understanding of what was helpful in counseling. Thirty‐five (9 male, 26 female) previously suicidal clients (M = 38 years) performed card sorts on 65 statements derived from qualitative interviews of 9 (2 male, 7 female) previously suicidal individuals (M = 42 years). Participants identified 3 therapeutic processes that contributed to overcoming their suicidal thoughts and behaviors: (a) validating relationships, (b) working with emotions, and (c) developing a new identity.     

The experiences of person-centred counsellors working with suicidal clients online through the medium of text

ABSTRACT

In this study, we attempt to provide an understanding of the experiences of four UK-based person-centred counsellors working with suicidal clients online using text-based therapies and the impact of their clients’ suicidal ideation upon their “way of being”. The counsellors were selected purposively; each was working as a person-centred counsellor online, was encountering suicidal ideation in their clients, and was a member of a professional organisation. A narrative approach was taken, using unstructured interviews and a stanza format of representation. We found that participants had developed a way of being online that may be distinct from their in-person practice. Challenges included being more directive, lacking physical presence, lacking confidence in assessing risk and questions about empathic understanding. Working online with risk raises specific challenges for person-centred practitioners in line with what is indicated in the little relevant research currently already available.     

Graduate training and the treatment of suicidal clients: the students' perspective

Existing literature suggests that graduate programs may not provide adequate training in working with suicidal clients. Therefore, we surveyed 238 predoctoral psychology interns and assessed the prevalence of clients engaging in suicidal behaviors and the amount of formal training in managing suicidal clients received. Results showed approximately 5% of participants indicated a client suicide and 99% indicated they had treated at least one suicidal client during their graduate training. In contrast, results demonstrated only 50% of the participants reported attending programs where formal training was offered. These findings suggest a continued need for increased formal training in managing suicidal clients in graduate psychology programs.     

Safety Planning Within Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is a contextual behavioral psychotherapy that helps clients build meaningful lives in the service of their own chosen values, rather than specifically focusing on symptom reduction or prevention of destructive behaviors. However, empowering ACT clients to navigate suicidal crises effectively is vital to ensuring the opportunity to build a life they will choose to live. Suicide safety planning is a widely used empirically supported approach to prepare clients to survive suicidal crises, and can be effectively incorporated into ACT. In this paper, we offer a contextual behavioral conceptualization of suicide as an extreme attempt to solve the problem of painful thoughts, emotions, and sensations, and provide an example of how this conceptualization and the necessity of safety planning can be introduced to clients. Use of chain analysis of suicidal behavior is introduced as a tool to inform the suicide safety plan. We describe how ACT processes can enhance safety plans and, in turn, create safety plans that will serve as means to develop skills associated with efficacious/effective ACT interventions. Finally, we discuss the ongoing evaluation and revision of the safety plan from an ACT framework.     

‘What meaning does somebody's death have,what meaning does somebody's life have?’ Psychotherapists’ stories of their work with suicidal clients

Working with suicidal clients is perceived to be demanding and anxiety provoking for psychotherapists. This investigation explores what it is like for psychotherapists who work with suicidal clients, particularly as within the prevailing culture there is an increasing focus on strategies aimed at suicide prevention. Five themes were identified through narrative analysis, with support systems such as supervision and peer support being seen as vital in surviving working with suicidal clients. However, there is also ambivalence about involving other professionals, such as mental health services, as there is a sense that to do so may be anti-therapeutic and unhelpful to the client. Overall, what emerges from this study is that it is important to challenge the prevailing culture in which a medical discourse is dominant, in order to find a different way of talking about suicide and despair.     

Styles of Suicide Intervention: Professionals' Responses and Clients' Preferences

As the rates of suicide in America continue to rise, suicide recently has been declared to be a national public health concern. The crisis intervention model, which has dominated the treatment of suicidal individuals in America since the 1950s, is currently believed to be the most effective model for suicide intervention. This study examined this belief by taking a more complex look at professionals' responses to suicidal clients both by investigating the existence of different ways in which professionals interpret the crisis intervention model. In one interpretation (the "fight" response), the professional takes power and agency away from the client and does what is perceived to be "best" for the client. An alternate interpretation, the "ideal" response, allows for a respectful engagement with the client. Professionals also can act contrary to the model (i.e., the "flight" response). In addition, based on the humanistic notion that clients are the experts of their own experience and that their voices are a very valuable part of evaluating the treatment process, this study investigated which response style clients report to be most helpful and most desired. The results suggest that while the typical response of mental health professionals to suicidal clients is most characteristic of the "fight" response style, clients overwhelmingly report that the contrasting "ideal" response style is most helpful. The findings are discussed along with implications for practice, research, and training.     

Follow‐up with Callers to the National Suicide Prevention Lifeline: Evaluation of Callers’ Perceptions of Care

Continuity of care for suicidal individuals engaged with a variety of health and mental health care systems has become a national priority, and crisis hotlines are increasingly playing a part in the risk management and continuum of care for these individuals. The current study evaluated a national initiative to have crisis centers in the National Suicide Prevention Lifeline network provide follow‐up care to suicidal callers. Data were obtained from 550 callers followed by 41 crisis counselors from 6 centers. Two main data sources provided the information for the current study: a self‐report counselor questionnaire on the follow‐up activities completed on each clinical follow‐up call and a telephone interview with follow‐up clients, providing data on their perceptions of the follow‐up intervention's effectiveness. The majority of interviewed follow‐up clients reported that the intervention stopped them from killing themselves (79.6%) and kept them safe (90.6%). Counselor activities, such as discussing distractors, social contacts to call for help, and reasons for dying, and individual factors, such as baseline suicide risk, were associated with callers’ perceptions of the impact of the intervention on their suicide risk. Our findings provide evidence that follow‐up calls to suicidal individuals can reduce the perceived risk of future suicidal behavior.     

Mindfulness in the Treatment of Suicidal Individuals

Suicidal behavior is exhibited by a diverse population of individuals and spans many diagnostic categories. In order to develop effective prevention and treatment programs, it is important to identify transdiagnostic processes that impact the many pathways to suicidality, are amenable to intervention, and affect clinical outcomes when modified. A growing body of data suggests that experiential avoidance, or the tendency to escape or avoid unwanted psychological experiences, even when such efforts cause harm, may represent one such universal process. This article reviews theory and evidence that support mindfulness and psychological acceptance as a means to target experiential avoidance in suicidal clients and thereby reduce the risk of suicide. The article also provides two case examples of the application of mindfulness to suicidality and discusses how mindfulness may help clinicians in managing the stress associated with treating suicidal clients.     

“One Size Fits All”: An Existential-Constructivist Perspective on the Crisis Intervention Approach with Suicidal Individuals

The empirical data on the relationship between suicide and suicide attempts are interpreted as suggesting that the contemporary assessment and intervention approaches to suicidal individuals are, by and large, ineffective. In support of our argument, we focus on the crisis intervention model as one example and suggest that the crisis intervention approach to responding to suicidal individuals is at best, ineffective and, at worst, can be viewed as exacerbating suicidal risk through its distancing, marginalizing, and stigmatizing effects. Additionally, we hypothesize that the mechanics of the crisis intervention model contribute to the societal message that a meaning and contextual-based discussion of suicidality is taboo and that this message tends to continue into more long-term psychotherapeutic approaches. Along these lines, we present an alternative to the crisis intervention model grounded in an existential-constructivist theory of suicidal behavior and the principles of therapeutic and feminist assessment philosophies as an heuristic intended to stimulate the development of new and innovative approaches to working with suicidal individuals.     

The 5th Annual psyche awards: celebrating excellence in scholarship

The Psyche Awards were developed to recognize the best journal articles published during the previous year. Each award confronts a specific topic within the field of mental health care, identifying articles that integrate the science and practice of psychology. For the current awards, 161 journals were screened, and 223 relevant articles were identified. The papers were then narrowed down to 46 papers distributed across 11 award categories. A panel of four expert judges read each article and rated all papers for their contribution to the field. The current award categories highlight some of the best articles published during 2021, capturing important information about psychological assessment, treatment of depression, working with suicidal clients, technology-assisted psychotherapy, the impact of Covid-19 on mental health, lessons from a review of history, recent innovations in the field, and strategies to expand the integration of science and practice.

     

Counsellors' experiences of working with suicidal clients: An exploratory study

Counselling is increasingly available in a wide variety of contexts, including mental health and psychiatric services. As a consequence, counsellors increasingly work with clients who present with suicidal ideation, expressing either suicidal thought and/or intent in the counselling session. This paper describes an exploratory study that examined the experience of counsellors when working with suicidal clients. The paper considers counsellors' behavioural, cognitive and emotional responses to such suicidal expression, both on a personal and professional level. The research employed semi‐structured interviews. A constant comparative method was used in analysing the transcribed interview text. Results suggest that counsellors experience a range of responses when their clients express suicidal thought, including fear, anxiety, anger and professional impotence. The interviewees also expressed self‐doubts about their professional competence. In addition, they identified the threat of litigation for negligent practice and the lack of confidence in appropriate risk assessment approaches as significant causes for concern. The implications for further research, and practice, are discussed.     

Impairment in risk-sensitive decision-making in older suicide attempters with depression

Suicidal behavior is a potentially lethal complication of late-life depression. In younger adults, suicide has been linked to abnormal decision-making ability. Given that there are substantial age-related decreases in decision-making ability, and that older adults experience environmental stressors that require effective decision-making, we reasoned that impaired decision-making may be particularly relevant to suicidal behavior in the elderly. We thus compared performance on a probabilistic decision-making task that does not involve working memory ("Cambridge Gamble Task") in four groups of older adults: (1) individuals with major depression and a history of suicide attempt (n = 25), (2) individuals with major depression with active suicidal ideation but no suicide attempt (n = 13), (3) individuals with major depression without suicidality (n = 35), and (4) nondepressed control subjects (n = 22). There was a significant effect of group on quality of decision-making, whereby the suicide attempters exhibited poorer ability to choose the likely outcome, compared with the nonsuicidal depressed and nondepressed comparison subjects. There were no group differences in betting behavior. The suicide attempters differed in several aspects of social problem-solving on a self-report scale. Quality of decision-making was negatively correlated with the score on the impulsive/careless problem-solving subscale. These data suggest that older suicide attempters have a deficit in risk-sensitive decision-making, extending observations in younger adults. More specifically, older suicide attempters seem to neglect outcome probability and make poor choices. These impairments may precipitate and perpetuate suicidal crisis in depressed elders. Identification of decision-making impairment in suicidal elders may help with designing effective interventions.     

Working With the Suicidal Client Who Also Abuses Substances

Substance use disorders and suicidal thoughts and behaviors commonly co-occur in adolescent and adult psychiatric populations and are often functionally interrelated. Although the evidence base for treatment of this population is sparse, integrated cognitive behavioral treatment (CBT) protocols, or those that rely heavily on CBT techniques, hold promise. In this paper, we provide an overview of the evidence-based literature for interventions that target suicidal behavior and substance use disorders with adults and adolescents. We then discuss the manner in which these behaviors may be functionally interrelated and offer a conceptual framework (S-O-R-C) to guide case conceptualization and treatment planning for clients with co-occurring suicidality and substance use disorders. Next, we provide a case example of a client with suicidal behavior and an alcohol use disorder and demonstrate how to apply an integrated CBT treatment protocol to this case. This case example is followed by a more general discussion about the potential advantages of integrated CBT protocols for suicidality and substance use disorders, guidelines for prioritizing treatment targets and skill selection for each individual client, and other important treatment considerations. We conclude with recommendations for future research in this area.     

Treating the Capability for Suicide: A Vital and Understudied Frontier in Suicide Prevention

Current efforts at suicide prevention center largely on reducing suicidal desire among individuals hospitalized for suicidality or being treated for related psychopathology. Such efforts have yielded evidence‐based treatments, and yet the national suicide rate has continued to climb. We propose that this disconnect is heavily influenced by an unmet need to consider population‐level interventions aimed at reducing the capability for suicide. Drawing on lessons learned from other public health phenomena that have seen drastic declines in frequency in recent decades (HIV, lung cancer, motor vehicle accidents), we propose that current suicidality treatment efforts trail current suicidality theories in their lack of focus on the extent to which individuals thinking about suicide are capable of transitioning from ideation to attempt. We summarize extant evidence for specific capability‐centered approaches (e.g., means safety) and propose other options for improving our ability to address this largely overlooked variable. We also note that population‐level approaches in this regard would represent an important opportunity to decrease risk in individuals who either lack access to evidence‐based care or underreport suicidal ideation, as a reduced capability for suicide would theoretically diminish the potency of suicidal desire and, in this sense, lower the odds of a transition from ideation to attempt.     

Chaos Theory as a Model for Life Transitions Counseling: Nonlinear Dynamics and Life's Changes

Chaos theory is presented for counselors working with clients experiencing life transitions. It is proposed as a model that considers disorder, unpredictability, and lack of control as normal parts of transition processes. Nonlinear constructs from physics are adapted for use in counseling. The model provides a method clients can use to reconstruct their own alternative life narratives, a framework in which life stories are understood, and a means to facilitate cocreation of adaptive interventions.     

When REBT Goes Difficult: Applying ABC-DEF to Personality Disorders

ABC-DEF framework is at the core of rational emotive behavior therapy. It is a highly flexible framework and has proven to be applicable to many emotional disorders. We cannot take for granted, however, that this framework can be used successfully with all clients, particularly with those suffering from severe disorders or personality disorders. In fact, the difficulties of these clients in recognizing, naming and reflecting upon states of mind, their dysregulated emotions and self-defeating behavior, and their difficulty in establishing a strong working alliance with a therapist may hamper the correct implementation of the ABC-DEF framework and the disputing of their irrational beliefs. This paper aims to describe in detail the challenges that clients with personality disorders may pose during treatment and offer possible technical suggestions, derived from either REBT or non-REBT literature, that can help REBT and CBT practitioners adapting their interventions to resistant clients.     

A Multilevel Approach for Reducing Mental Health and Substance Use Disparities Affecting Bisexual Individuals

Despite bisexual individuals being at increased risk for mental health and substance use problems, clinicians’ ability to provide affirmative and competent care to bisexual clients is limited by their lack of bisexual-specific training. To address this common gap in training, this article provides a brief review of bisexual health disparities and the factors that influence them. Then, we describe a multi-level approach for improving the health and well-being of bisexual individuals. This approach addresses factors that influence health at the micro-level (e.g., strategies that clinicians can use to help bisexual clients cope with stigma-related stressors), mezzo-level (e.g., adaptations to clinical environments and training programs that promote bisexual-affirmative care), and macro-level (e.g., advocating for political change and implementing strategies to reduce prejudice against bisexual individuals at the population-level). Specifically, we describe how clinicians can adapt evidence-based interventions to tailor them to the needs of their bisexual clients. Additionally, we discuss the need for bisexual-affirmative clinical training and provide recommendations for how clinical training can be adapted to prepare clinicians to work effectively with bisexual clients. Finally, we describe how population-level interventions can be used to reduce prejudice against bisexual individuals in order to reduce bisexual health disparities. Given the striking health disparities affecting bisexual individuals, there is a critical need to develop, test, and disseminate interventions to improve the health of this population and to prepare clinicians to provide bisexual-affirmative care.