Even among counselors and therapists, suicide is not an easily discussed – or understood - topic. Accurately identifying and diagnosing suicidal individuals continues to challenge the most experienced of counselors. After a patient commits suicide, the emotional toll can be intense, causing feelings of blame and regret.
Despite large numbers of empirically based research studies on how to treat a number of mental health disorders, studies on suicide haven’t been as prolific. Knowing how to address suicidal ideation and suicide attempts often has been less science and more intuition.
Yet mental health experts and public health organizations cite both statistics and research studies showing the malevolent effects of suicide on today’s culture. Both the National Institute of Mental Health (NIMH) and the Substance Abuse and Mental Health Services Administration (SAMHSA) call it today’s leading under-recognized public health crisis.
Eric Broderick, acting administrator of SAMHSA and assistant surgeon general, testified in 2009 before a senate committee that Americans are unaware of suicide’s toll and global impact.
“Suicides account for up to 49.1 percent of all violent deaths worldwide, making suicide the leading cause of violent deaths, outnumbering homicide. In the United States, suicide claims approximately 32,000 lives each year. When faced with the fact that the annual number of suicides in our country now outnumbers homicides by three to two, the relevance and urgency of our work becomes clear,” he stated.
Increasing rates of suicide, especially among certain groups of individuals over the past decade, have motivated both public and private organizations to increase funding for more research-informed suicide studies. (see article on Old-Age Suicide.) An increased awareness of the problem has placed a greater emphasis on the need for better-trained and more knowledgeable suicide counselors.
Realistically, all counselors and therapists must now consider themselves suicide counselors. Because they treat a wide range of mental health disorders, including the most common conditions associated with suicide, all counselors and therapists must stay current with research taking place today on how to treat suicidal individuals.
Additionally some counselors dedicate their careers to working almost entirely with suicidal individuals and their families. These counselors work specifically in inpatient or outpatient mental health settings, or become trained suicide crisis counselors who work in suicide call centers, or for online organizations that seek to provide 24-hour crisis suicide assistance.
Whatever title a counselor or therapist uses, whether it’s suicide counselor, mental health counselor, or psychotherapist, knowing the therapeutic interventions and treatments for suicide is essential.
Cognitive Behavioral Therapy
A large body of empirically based studies exist on cognitive behavioral therapy (CBT), a type of therapeutic intervention that focuses on changing dysfunctional thoughts. The therapist and patient work together to uncover and understand these thoughts and underlying assumptions supporting these thoughts.
In other words, CBT isn’t as much concerned with what is happening to individuals, but how individuals interpret what is happening. These interpretations are ultimately what contribute to dysfunctional behaviors.
Therapists uncover problematic thoughts by constructing a series of questions, questions that lead patients to arrive at logical conclusions. This is also called Socratic questioning or dialogue because it promotes learning through the questioning process.
Originally developed by Aaron Beck, a Philadelphia psychiatrist, CBT was first used to treat depression – the leading cause of suicide – but has since expanded to almost all other mental health disorders and issues.
The therapy is brief, about 16 sessions, active, directive, and problem-oriented. However, because suicide most often involves more than one disorder or issue - a perfect storm of intense conditions, risk factors, and stressful life situations - therapists treating suicidal individuals often combine CBT with other forms of therapy.
Dialectical Behavior Therapy
Current research taking place today on effective suicide therapy involves a combination of CBT with dialectical behavior therapy, or DBT. Developed by Marsha Linehan at the University of Washington, DBT stresses patients balancing an acceptance of themselves and their worlds as they currently exist, while simultaneously working on the necessary changes to correct problematic thoughts and behaviors.
Linehan first used DBT to treat borderline personality disorder, but other researchers and therapists are using it to treat a number of other conditions, especially those that involve self-injurious behaviors.
Linehan stresses the importance of validating the patient’s current distress, as well as the importance of the therapist-patient relationship – a major digression from the typical CBT form of treatment.
“My emphasis on the therapeutic relationship as crucial to progress in DBT comes primarily from my work in interventions with suicidal individuals,” Linehan states in her book “Cognitive-Behavioral Treatment of Borderline Personality Disorder.”
“At times, this relationship is the only thing that keeps them alive.”
Balancing change and acceptance is a complex process, and might take longer than interventions based exclusively on CBT. This type of intervention might also include the group therapies.
Other Therapy Combinations
Group-based therapy is also appropriate when treating suicidal ideation in adolescents. Adolescents with depressive disorder and a history or suicidal behavior are at an extremely high risk for completed suicide attempts. For more information see Adolescence Developmental Psychology.
Despite this fact, the field lacks empirically based studies on individual psychotherapies for adolescents. Currently, research is taking place trying to find the right combination of CBT and DBT for teens, and the efficacy of family-based therapies such as multisystemic family therapy, and other forms of teen group therapies.
In addition, health care experts and practitioners cite the need for more proven therapies – CBT, DBT or any other approaches – that are effectively applied in emergency rooms. Doctors and nurses need training on how to psychologically treat and handle patients who have attempted suicide, as well as information on how to counsel significant others and family members.
The dire need for more suicide research, and counselors knowledgeable about and willing to apply the findings from science-based studies, and train others on these therapies, translates into a challenging, yet gratifying mental health career.
This simultaneous need for more suicide counselors and researchers opens up several opportunities for those desiring to make a difference by trying to save lives. Learn more about career as a mental health counselor, or request information from psychology schools to get started on acquiring the required educational qualifications.
Risk Factors for Suicide and Suicidal Behaviors*
The following risk factors are considered permanent and non-modifiable. If patients present with any of these factors, they’re at an increased risk for suicide over the course of their lifetimes:
- Past suicide attempts, especially more than once
- Past thoughts of suicide or suicide ideation
- A history of inflicting injuries to oneself
- A family history of suicide; violence; parental substance abuse; parental psychiatric hospitalization; divorce
- Past trauma or abuse – physical or sexual
- A history of violent behaviors, and/or impulsive and reckless behaviors
- Itinerant or mobile lifestyle
- Psychiatric hospitalization(s)
- White, American Indian, male, older Age, separation, divorce, widowhood (demographic factors)
The following suicidal risk factors are considered predisposing and potentially modifiable:
- The following mental health disorders: mood disorder (includes depression and bipolar disorder); anxiety disorder; schizophrenia; substance abuse; eating disorders; body dysmorphic disorder; conduct disorder; personality disorder
- A combination of one or more mental health disorders
- Physical illnesses especially those involving chronic pain
- Traumatic Brain Injury
- Poor self-esteem/high self-hate
- Tolerant or accepting toward concept of suicide
- Exposure to suicide
- A family rejecting or lacking acceptance of sexual orientation
- Perfectionism (especially when combined with depression)
The following suicidal risk factors are acute, meaning if patients exhibit any of these factors, there is an increased risk for near-term suicide:
- Recent suicide attempt
- Recently discharged from psychiatric hospital
- Threatening, planning or preparing for suicide (communicating these thoughts or suicidal ideation)
- Psychological pain in response to loss, humiliation, rejection – any acute distress
- Anger, rage and seeking revenge; aggressive behavior
- Anxiety, panic agitation, insomnia; continuing nightmares; paranoia; severe confusion; hallucinations urging suicide; desperation; hopelessness; intense loneliness; self-hate; dramatic mood swings
- Excessive or increased use of alcohol and/or drugs
- Current self-injurious behaviors
- Diagnosis of a terminal medical illness
- Extremely impulsive or reckless behavior, especially if out of character
- Feeling completely trapped, that no other way of living exists – poor problem solving
- Recently divorced or separated with intense anger, rage, or victimization (demographics)
- Perception of being a burden
- Dismissive or negative attitude toward receiving help
- Feelings that life has no meaning, purposelessness
If patients are vulnerable to suicide, a heightened period of risk should be acknowledged with any of the following triggering stimuli:
- Current or recent experience with another’s suicide (friend, acquaintance, celebrity, etc.)
- Financial difficulties, job loss, legal problems, feelings of rejection or abandonment
- Humiliation, despair, loss of face or status, shame
* Source: American Association of Suicidology