10 Most Common Err.docx

10 Most Common Errors in Suicide Assessment/Intervention
Robert Neimeyer & Angela Pfeiffer
1. Avoidance of Strong Feelings – Diverting discussions away
from powerful, intense
emotion and toward a more abstract or intellectualized
exchange. These responses keep
interactions on a purely cognitive level and prevent exploration
of the more profound
feelings of distress, which may hold the key to successful

treatment. Do not retreat to
professionalism, advice-giving, or passivity when faced with
intense depression, grief, or
fear.
• Do not analyze and ask why they feel that way.
• USE empathy! “With all the hurt you’ve been
experiencing it must be impossible
to hold those tears in.”
• Tears and sobbing are often met with silence of tangential
issues instead of
putting into words what the client is mutely expressing: “With
all the pain you’re
feeling, it must be impossible to hold those tears in.”
• “I don’t think anyone really cares whether I live or die.”
Helpers often shift to
discussing why/asking questions as opposed to reflecting
emotional content.
2. Superficial Reassurance – trivial responses to clients’
expressions of acute distress and
hopelessness can do more harm than good. Rather than
reassuring clients, these responses
risk alienating them and deepening their feelings of being
isolated in their distress.
• Attempts to emphasize more positive or optimistic aspects
of the situation: “But
you’re so young and have so much to live for!”
• Premature offering of a prepackaged meaning for the
client’s difficulties: “Well
life works in mysterious ways. Maybe this is life’s way of

challenging you.”
• Directly contradicting the client’s protest of anguish:
“Things can’t be all that
bad.”
3. Professionalism – Insulating or protecting by distancing and
detaching from the brutal,
exhausting realities of clients’ lives by seeking refuge in the
comfortable boundaries of role
definition. The exaggerated air of objectivity/disinterest implies
a hierarchical relationship,
which may disempower the client. Although intended to put a
person at ease, this can come
across as disinterest or hierarchical. Empathy is a more
facilitative response.
• “My thoughts are so awful I could never tell anyone” is
often met with, “You can
tell me. I’m a professional” as opposed to the riskier, empathic
reply.
4. Inadequate Assessment of Suicidal Intent – Implicit negation
of suicide threat by
responding to indirect and direct expressions of risk with
avoidance or reassurance rather
than a prompt assessment of the level of intent, planning, and
lethality. Most common
among physicians and master’s level counselors – due to time
pressures, personal theories
or discomfort with intense feelings.
• What they’ve been thinking, For how long, Specific
plans/means, Previous
attempts

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• “There’s nowhere left to turn” and “I’d be better off dead”
should be met with
“You sound so miserable. Are you thinking of killing yourself?”
5. Failure to Identify the Precipitating Event – Pinpointing the
specific occurrence that
prompted the client’s decision to seek help can identify and
prioritize issues in a way that
more quickly restores a client’s sense of balance and
equilibrium and facilitates action
planning. This should be an extension of basic empathic

concern. Ask about recent key
incidents or life events; can help move toward necessary action
steps.
• It sounds like everything collapsed when your brother
died 3 years ago, but what
has happened recently makes you feel even worse, that dying is
the only way
out?
• To the life-threatening client who complains at length that
“life has been
worthless” since the death of his wife, the counselor might
respond, “Sounds like
your world fell apart when your wife died...What has happened
recently to make
things worse, to make you think dying is the only way out?”
6. Passivity – 25% of counselors and helpers took a passive
clinical stance. Failure to join
with a client’s distress and taking a nonparticipatory role, even
when the client clearly
required higher levels of helper involvement. Early stages of
suicide interventions need to
be active, engaging, empathic, with the helper structuring the
intervention.
• Go on, I’m here to listen; Call back some other time when
you can talk more
easily
• Client stammers, voice breaks, and silence ensues: “Go
on. I’m here to listen” vs.
reflecting the client’s distress, “It must be very hard for you to
talk about what’s
bothering you.”

• [Over telephone] “It’s hard to talk here, with all these
people.” could be met
with “Would it help if I asked questions.” or a paraphrase. “Call
back some other
time when you can talk more easily” could terminate the
connection at a
potentially dangerous moment, with no clear plan for follow-up.
Try “I
understand it’s really awkward for you to talk right now, but
I’m really worried
about you. Will you promise to call us back?” (variation on a
pact when suicide is
not discussed).
7. Advice Giving – Overly simplistic, rarely effective, and tends
to convince the client that
the counselor does not appreciate the gravity of the situation
nor understand the actual or
psychological constraints that prevent the client from following
the advice. Action plans are
worked out collaboratively, after the particulars of a client’s
situation have been explored
and assessed. concrete action ideas are good, after trust has
been established. Action plans
should come from the client’s tentative ideas, rather than from
the authoritative advice of
the helper.
• Remember, focus on the positive; Try not to worry about
it; Just ignore the
person who is bothering you.
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• “Considering all you have going for you, things can’t be
that bad”, “Try not to
worry about it”, “Look on the bright side”, and “Try to focus on
the positive
aspects of your situation” are patronizing and ineffective.
• “What would be one or two small steps you could take in
the next few days to
start to deal with this problem?” arouses less resistance and may
reveal
interventions not envisioned by the counselor.
8. Stereotypic Response – Making unwarranted assumptions
about the client’s personality,

pathology, or predicament. Interventionists should focus on
clients’ individuality and unique
emotional experience without trying to fit them into a typology
of client problems. Helpers
should focus on the individuality of each person; don’t use
shortcuts.
• She’s a borderline, attention getting female
• [Male sobbing] “I try so hard to keep from crying.” The
response, “Do you think
it’s so hard for you to cry because you’re a man?” is based on a
stereotypic
assumption and misses the opportunity for reflection of
feelings.
9. Defensiveness - Often arises when an angry or rejecting
client directly or indirectly
rebuffs attempts to help. Reacting personally as opposed to
therapeutically erodes
whatever level of trust might be established. Join with the
client’s concern through
empathy. The key is not to respond in an automatic, self-
protective manner.
Anger/rejection is common during intense crisis – avoid power
plays or sarcasm; maintain a
caring stance.
• Responding to, “How could you ever help me? Have you
ever wanted to kill
yourself?” with “Sure. But I’ve always found healthier ways to
resolve my
problem” is condescending. The empathic reply is, “Sounds like
you’re afraid I
won’t be able to understand and help you.”

• Outright rejection of client’s feelings: Responding to, “I
can’t talk to anybody.
Everyone is against me.” with “That isn’t true. There are
probably lots of people
who care about you.”
• “You don’t really care about me anyway.” can be
responded to with a genuine
expression of concern, “I think your death would be a terrible
waste.”
10. Insufficient Directness – In dangerous, unpredictable
situations, counselors must be
attentive to the urgency. Emphasize the importance of continued
interaction, or at a
minimum, secure a verbal no-suicide contract. Effective crisis
intervention often requires
directive crisis management, particularly in terms of creating
distance between a distressed,
impulsive client and means of self-injury. At minimum, a verbal
‘no suicide’ contract should
be obtained.
• If you keep feeling suicidal, remember you can call back,
vs. OK, we have an
appointment set up for you, you have my phone # for tonight,
and I’ll stop by the
school to see how it’s going tomorrow
• More than 1/3 responded to caller’s bid to end the call
with “OK, but if you keep
feeling suicidal, remember you can always call back” instead of
parting.
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• “I have a gun pointed to my head, and I’m going to pull
the trigger if you don’t
help me” was met with a weak reflection of “you seem to be
somewhat upset”
as opposed to securing sufficient control for continued
interaction, “I want you
to put down the gun so we can talk.”
10 Most Common Errors During a Suicide Intervention.
Retrieved
from
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How to Accurately Assess and Help a Client
Program Transcript
SUE BANKS: At this time, Dr. Slater and I want to discuss
some issues that we
think are important to consider when we're dealing with clients
who present with
serious issues like suicidality. So, Dr. Slater, why don't you tell
me a little bit
about your practice, and why you became interested in this topic
of suicide?
MICHELLE SLATER: Well, I got started in my first semester of
graduate school.
And my instructor was the director of the local crisis center, so
I went through the
training there. And, honestly, I was hooked on it from then. So
there was an
extensive training program, and we trained to answer the 24-
hour suicide hotline.

As I worked my way into the center, over the years I became
part of the outreach
team in the community-- responding in person to suicidal
clients, doing death
notifications with local law enforcement, and following up in
the community after
a completed suicide death. And then I ended my stint there as a
trainer-- kind of
training new phone volunteers and practicum students and crisis
response.
SUE BANKS: That's interesting. My background is a little bit
different. I work with
the chronically mentally ill individuals-- SPMI. And so I went
through the ASIST
training. I don't know if you're familiar with that.
MICHELLE SLATER: Oh, yeah.
SUE BANKS: So my training and background came through
learning how to work
with and assess individuals who came in for standard treatment
and services.
And so the ASIST model was really effective for me. I learned
quite a bit using
that model. Now, you mentioned that you learned then through
the suicide
hotline, and your work with clients currently consists of--
MICHELLE SLATER: Currently, I have a private practice
office location, and I
see suicidal clients more in acute crisis-- not really dealing as
much with
chronically suicidal or with severe mental health issues. So
fairly frequently, I get

the opportunity to work with a client who's just hit a crisis point
in their life-- a rock
bottom-- struggling with some feelings of hopelessness and
depression-- and
working through that is commonplace. We teach our students,
obviously, that
nobody escapes the need to have to deal with clients in crisis.
You can't really
predict exactly when or what that will look like, which is why
it's so important to
have exposure to how to assess and how to deal with suicidal
clients.
SUE BANKS: And so what would you say your approach to
assessing your
clients in suiciding your clients?
MICHELLE SLATER: Having started my mental health career
working with high-
risk and suicidal clients, it seems to be such a natural part of
what I do. And I
© 2018 Laureate Education, Inc. 1

think the first thing that jumps out when I think about what my
approach is like I'm
listening for the hallmarks of suicide. So emotionally, that's
hopelessness,
despair, ambivalence. People want to live, but they don't know
how.
And so that's part of, I think, when I'm assessing lethality-- I'm
hearing
hopelessness. A lot of students are afraid we're planting those
ideas. It's a
reflection. So I'm hearing that, and then saying back, you're
feeling helpless. If a
client responds to that in the affirmative, then I'm going to go
ahead and put out
there-- you're thinking of killing yourself.
And that's really hard for students to get used to the idea of--
there's a boldness
and a confidence to doing that. I think it's a good time to, sort
of, add-- I've never
had clients be mad at me for doing that. That that is, at least,
demonstrates a
willingness to go there.

And early on the hotline, I can remember saying that with a
client who seemed
very hopeless and crying. And so when I had said that, there
was silence, and
then she kind of chuckled a little and said, oh, my gosh. I must
sound terrible.
And it gave us an opportunity to say, you sound like you're in a
really bad space.
And so it didn't turn out that she was actively lethal or
considering it, but what a
great conversation and a great opportunity to assess it. Even if
it's not
necessarily heading in that direction.
SUE BANKS: When I think about my approach, I tend to be
very narrative
focused. So it's important for me to allow the client an
opportunity to tell the story
as much as they're able to. Because I don't know how much of
an opportunity
they've had in the past, to just-- to talk about what they're
experiencing. So I try
to just go with them and allow them to tell as much of their
story as I can. And as
I'm listening for their story, then I'm assessing the risk, the
opportunities to plan.
And so from there, I'm able to determine-- or just, kind of, like
process with them
where they are in their plan. To the point that, again, once I am
satisfied that the
risks are present, then I do just initially ask, do you want to kill
yourself, or are
you thinking about suicide, to see how they will respond.

MICHELLE SLATER: One thing that I have happen quite a bit
is the struggle with
people who are having suicidal thoughts or feeling really
trapped or hopeless but
not actively wanting to kill themselves. And as that comes up in
assessment, I
think has been really helpful for me over the years to kind of
present to clients
this continuum. We're all on the same health and wellness
continuum. It's very
easy for-- particularly, beginning counselors and counselors in
training-- to
inadvertently have an us and them, so those people that struggle
with feeling
hopeless or those people who are suicidal.
As opposed to that's us-- what would it take on any given day,
when you are here
at this end, feeling healthy and well, and on this end, giving up
hope. And that

any given time, we could be sliding on that continuum. So I
have found it really
powerful to present that to clients in a way that helps normalize
it. And that allows
me then to assess do you want to die, or is it just that you're
having a hard time
figuring out how to live?
SUE BANKS: Yes.
MICHELLE SLATER: And I get a lot more, in my practice now,
I get a lot more
clients that will say, no, I don't want to die. It's just none of this
makes sense. I
cannot figure out how to cope with this pain. And that that's a
real nuanced part
of an assessment that I don't I don't think you always get that in
the textbook
about asking the questions.
SUE BANKS: Exactly and separating depression or assessing

for depression
and suicide because sometimes the hopelessness can display as
signs of
depression. But, yet, you pinpoint that depression, however, you
don't go a step
further to assess and continue forward with suicidality. And
that's really important
as well.
MICHELLE SLATER: Yes.
SUE BANKS: That continuum.
MICHELLE SLATER: And I think to what you said about
letting them tell their
stories, a lot of mistakes that I have seen over the years in
training students and
phone volunteers to assess, it's that it turns into an interview--
an interrogation.
So you're thinking about killing yourself-- when, how-- all the
questions that you
learn how to do but don't quite learn exactly that how of it, the
nuanced way.
That's that art and science and a balance when you're learning to
be a counselor
and letting them tell their story. Then finding out another piece
of that puzzle and
a very natural, you're thinking about killing yourself? Yes, and
tell me more,
instead of getting triggered and scared of what the client said,
sitting back.
SUE BANKS: And as we're talking, I often think about the
interplay, or the
change between transference and countertransference, when

you're talking
about, do we hear, get the sense that there are some suicidal
ideations going on.
And then we go into interrogation mode, and start to question,
answer process.
And how much does transference and countertransference really
impact the
whole process that is occurring?
Sometimes, it's-- I have to be careful not to allow my own views
or thoughts
about how a client presents in practice with me, and really miss
what's going on,
or what their story is, or what they're communicating to me
because I've already
framed them based on their appearance, or based on how they
present-- some
of the stereotypes. Oftentimes, as well, I have to be mindful of
how clients frame

me and their view of me because it really does impact and affect
how much they
will share with me, or how willing they are to really disclose
their story, or what
they're dealing with.
MICHELLE SLATER: People are therapy wise. We go over the
limits of
confidentiality-- what you see in movies, what you know that
there can be
consequences if you are honest. And a lot of times, beginning
counselors are
real concerned about that. And our clients are hypervigilant
about that. And I do
think being able to really explain to clients that, so something
like that continuum
of where they are on that.
Also being aware of how we're triggered, and how we're
reacting, and being able
to express genuine concern for clients that help me-- like help
me understand
how you're going to stay safe. That being able to speak to that
part of them that

does want to live. Certainly, we don't want to underreact, and
we don't want to
overreact. And I think to your point, really, it's about that
moment of connection
and staying in the fray with them.
SUE BANKS: Yes.
MICHELLE SLATER: Being in that session can be scary and
uncomfortable for
both parties.
SUE BANKS: Yes and maintaining the boundaries or having the
clear boundaries
without verbalizing what those boundaries are. It's very
important because,
again, the safety of the client is what's-- the main focus from
the therapist's
perspective, the counselor's perspective. But at the same time,
you want the
client to feel comfortable enough to really express and to open
up and talk about
what they're struggling with.
MICHELLE SLATER: And how do we do that? How do we--
that, again, our
preoccupation with the safety concerns that a suicidal client
presents with can
really be a barrier to the advanced empathy, to the depths that
we need to be
able to connect. It's that well theory of we have to be willing to
get into the well
with our clients.
SUE BANKS: Absolutely. You call it getting into the well. I
call it going around the

bin. I use the analogy of the three-legged race, and walking,
running that three-
legged race with that client and not dragging the client-- staying
with them. And
at that-- in that case, you are able to, again, communicate the
safety concerns
that you have as a counselor, and then offer them an opportunity
to share more
in-depth what they're experiencing, and get the help that they
need because
that's what they're really there for.
MICHELLE SLATER: Yeah, and I think really that's the
primary concern for a lot
of our students from beginning counselors-- am I going to be
able to handle it?

Am I going to be able to-- whether it's your legs strapped
together in a three-
legged race-- or am I going to be able to go into this dark, deep
well where it
feels scary and painful?
Am I going to-- not only can I go in, but am I going to be able
to get out? Or
what's going to happen to me if I join into that type of pain?
And you had
mentioned boundaries. We talk so much in this program about
self-care,
confidence, experience, training. All of those things, I think,
help us know that
we're not alone in it. That we have what it takes to engage that
level of intensity
and be OK.
But your client is struggling in that well, and I like to remind
my students that this
is part of what we've signed up for. Not to join in with
someone's distress when
it's convenient for us, but when they show up, we show up, and
meet them there.
It does no good to stand at the edge of the well and yell down,
you're going to be
fine.

Or I sometimes in my mind think-- I'm a very visual person-- of
this idea of when
people are drowning, and the Coast Guard is rescuing them, so
they lower a
basket down, and they come with them, and they secure the
person in the
basket. They don't just lower it down on top of them.
SUE BANKS: It's a process, and reminding students that there
is a process to
assessing risk-- suicide risk. There's a process in everything that
we do, or
method to everything that we do. But at the same time, we are
to be human. I
think sometimes we get so-- or it's an opportunity for students
to become so
theoretical or so focused on the process and the steps and what
you do, that
they forget the human part in being with the client as you go
through that. The
more human you are, the more you respond to what is actually
happening in the
client's experience, then it makes the process or the steps that
you have to take
through suicidality, or whatever the other risk is more personal,
more relatable.
MICHELLE SLATER: Authenticity is critical. A lot of times, I
think, beginning
counselors trying to pretend that they're not freaking out about
this person is
really in despair. And I'm looking down, and realize I have to
go into the well. But
to be able to say-- and I, over the years in very genuine
moments, I can think of a

couple of different situations with clients that were in intense
pain, where I have
just naturally, my hand just goes to my heart.
It sounds unbearable. I can't even imagine how you're carrying
that type of pain. I
don't know if that response is in a textbook somewhere, but I
know that in the
moment, that's my honest reaction to what they've shared. And
being able to say,
I don't have all the answers. The scariest clients for me have
asked very directly,
give me a reason to live. When I share that with students in
training situations,
you can see the look on their face. Oh my gosh, if a client ever
asks me that, it
sounds like, what would you do in that situation?

SUE BANKS: So what do you have to say, or what are your
thoughts about
vicarious trauma and clients who have attempted suicide?
MICHELLE SLATER: For me, boundaries, of course, self-care,
compartmentalizing-- some of that is essential. But also, I have
a way a of
viewing-- people have said over the years, how could you do
that kind of work, or
how could you respond to a completed suicide and not just be
devastated? Or
how do you not take that home with you?
And I think, honestly for me, it's the way that I look at it. I see
it as a growth.
Crisis is danger and opportunity. And I see a lot of pain. But I
also see a lot of
people overcoming and coping and surviving and growing. And
reminders of that
give me perspective. I can't save anyone.
SUE BANKS: Yes.
MICHELLE SLATER: That's not my job, but I'm walking
alongside of you in your
pain. I do a disservice to my clients if I try to carry that for
them. They don't get

stronger.
SUE BANKS: Absolutely.
MICHELLE SLATER: And so perspective really helps me to be
aware of what's
mine to carry and what's theirs? And that it's patronizing to
assume that they
need me to save them or take care of them or to care-- I'm
empowering them. So
knowing my role and my limits, I think, is really the most
important part of how I'm
able to, at the end of the day, I know.
And I'm asking myself that if I were to see this on the news,
what would I have
wanted to do differently? Is there anything I would have wanted
to say or do?
And to the best of my ability, I finish my day, I finish my
session, not having
regrets about things that I could've, would've, should've said or
done. And that
would really be my advice to any counselors that are working
with high-risk
clients.
Just know that in that moment, you're pushing yourself to do the
uncomfortable
things, to ask the questions that need to be asked, and that
you're willing to risk.
And that that leaves me feeling satisfied at the end of what I've
done.
SUE BANKS: Yeah, I agree. I agree with the boundaries--
understanding your
role as a counselor and not believing that you are there to solve

any of the client
problems or to be that fairy who fixes it all.
MICHELLE SLATER: The nature of crisis really is that there
are no easy fixes.
And for beginning and counselors in training, I think that's
really the tricky part.
There's still a tendency to want to solve the problem. And there
isn't an easy

answer. The only way is to connect. And so in the absence of
that, if you're doing
the best you can to connect, then you've done all you need to
do-- all you can do.
With the clients that I referenced, they are asking, looking for a
reason to live.
The answer then is I would if I could. But what can I do for
you? I can sit through
this with you. I can journey alongside you, and I can help you
try to find the hope
that's going to keep you going. And I would think that really a
part of being able to
cope with this type of intense work is knowing what you can do.
SUE BANKS: Yeah, I think that sometimes students--
especially beginning
students-- really seek for something to do. They feel like they
have to be doing
something.
MICHELLE SLATER: They're not doing enough.
SUE BANKS: As opposed to being. I focus on just being--
being with, being
there, being human. And that, oftentimes, is what gets clients
through crisis, as
opposed to doing something.
MICHELLE SLATER: Absolutely.
SUE BANKS: So in that, I think that there are no steps, finite
steps, that we can

suggest to say-- do this and this is the outcome. But to be
mindful, again, what
the role is, what their boundaries are. Having the approach, how
do you address
certain things? There are approaches and steps to take. And just
being mindful
of that and then being-- being with.
MICHELLE SLATER: That's great, great advice. And just even
talking with you
about it, you realize it emphasizes the importance of
consultation, peer support,
of connecting with people who understand what you're going
through. So there
are opportunities to a long day, you vent with family or friends,
or it's really, it was
just a hard day, or it was a difficult client.
But really it is important to have your own network too of-- I
have fabulous
counselor that are friends and our colleagues at Walden are an
amazing source
of support. Even in private practice, I have people that I can
call up if I need to
process. And that's with regular clients, and then I have people
who specialize in
crisis work and have the same background.
And diversifying that, and making sure that you have a good
support system of
people who understand you. Sometimes, I don't want to talk
about it at all. So I've
got those friends too, and just crafting a good network, I think,
is so important.
SUE BANKS: When I have clients who present with suicide, I

tend to always
conference those-- just in case there's something that I missed.
Or that there's
some precaution that I should take, or something that I should
think about the
next time that I meet with them, or in the next situation beyond
when they leave

my office. So just having the network to discuss and to
conference cases is what
is important.
MICHELLE SLATER: And the value is twofold. You get to
learn from your
experiences if needed, and then just debriefing.
SUE BANKS: Yes.
MICHELLE SLATER: In my crisis work, I do a lot of
debriefings in response to
crisis in the community. And I never underestimate the power of
bringing people
together and just letting them, like you said, tell their stories,
share what
impacted them, and we need to do that as counselors too.
SUE BANKS: Yes.
MICHELLE SLATER: Tackle that continuum. Sometimes
helping professionals
are guilty of-- we're on a different category as well. We're
supposed to be able to
handle this. And I do think that is it gets to a, speaks to a fear,
that a lot of
students may have as well. That they're going to get out there,
and be on their
own not-- overwhelmed and not able to cope with it. And I
mean, we have to
work to build that network. And we have to allow ourselves to
be vulnerable to
access support.
SUE BANKS: So we have a few more minutes left, and I do
want to know what

are your thoughts about suicide contracts?
MICHELLE SLATER: Well, I do not use a written contract. I
think it's critical to get
some verbal agreement. There's research out there that confirms
getting clients
to agree to a plan, a safety plan, does impact their safety. And,
again, that plays
to the ambivalence.
They want to live, and so they follow through with the plan
because it gives them
a sense of security-- something to count on. And I can't tell you
how many times
in my work at the Crisis Center, I've been working the phone
lines and had
someone call back in and just say, I'm calling because I said I
would or I agreed.
Sometimes, they're even annoyed.
And, yet, this sort of drive to want to stay alive compels them
to do what they've
agreed to do. So, I mean, I think it's absolutely critical. I'm glad
that there has
been a move away from written contracts in a lot of places. It
doesn't seem to
work for me, in terms of the relationship nature of what I'm
doing with my clients.
If I ask you to do something and you say yes, then I'm not going
to have you sign
it. I'm going to believe you would do it. And so that the spirit of
it feels very
important to me and how you communicate that to your client.

SUE BANKS: I-- my experience is a little different. I tend to
work with more of the
public agencies, so suicide contracts are almost mandated that
you have some
type of written contract or agreement for between you and the
client, for the most
part. Just to verify that you have documentation and addressed
the-- and assess
the suicidality and had some kind of documentation. So for the
most part, I think,

in my experience, the contracts are used as that last
documentation or
verification that you, the counselor, has addressed.
MICHELLE SLATER: That brings up a really good point about
you knowing your
agency's policy--
SUE BANKS: Yes.
MICHELLE SLATER: --on safety-- whatever that might be. If
it's homicidal or
suicidal-- whatever risk factors are involved, you're going to
have a policy and
procedure in place. And as we were talking earlier about
consulting, that's
mandated in some places.
In my work in the corporate world, there was a mandatory
consultation process in
place. Where if that has happened, and you've assessed the
validity, you're
required to then notify-- at the time, I was the clinical director.
The team has to
notify, so that that keeps you from not feeling isolated in that.
And, certainly, with
a written contract, the agency is at risk then having
documentation that is critical.
So knowing your policy, I have to document in private practice.
And we did, we
kept notes at the Crisis Center as well. That I'm documenting
that I've done it
somewhere it should be documented and you should know what
the policy is
where you're working. And that's critical because again, you're

not functioning in
isolation. Even if you're in private practice, there's notes that
are being taken and
some accountability. And I think that's a great reminder for
students-- know
what's expected of you.
SUE BANKS: Yes, you have to follow the policies of the
agency that you work.
And, oftentimes, like I said, the contract is that client signature
acknowledging
that they are aware that they've been assessed, and that this is a
concern. And
so moving forward, I'd like to kind of wrap up with the last
question of, what
advice would you give to students who are worried about not
being able to
effectively assist suicide in a client?
MICHELLE SLATER: I think we've touched on a couple of the
kind of tips for
managing it in terms of trusting yourself and confidence. But
really, this is one
class that students are taking, and there are lots of great
trainings, great
organizations out there for students that I think are going to be
working with
population, where they may experience this more than others.

Agencies would definitely benefit from participating in
additional trainings. And
research is out there to suggest that the practice builds
confidence. Learning,
reading builds knowledge, but really the difference is can you
do it when it
matters? And so getting more training is good-- support, things
that we've talked
about.
But I also think maybe not giving it so much power. It's the
same skills that you're
using to connect with a client. It's just a different scenario. It's
a different intensity

level, and maybe students allow themselves to blow that up
bigger. If you know
how to be with a client, you know how to be with a client in
distress.
You know how to be with a client in crisis, and you know how
to be with a client
who is suicidal. And just remembering that because confidence
is huge. Trust
yourself. That's primarily the advice I would give, and get help
when you don't or
can't.
SUE BANKS: Absolutely. I agree with that. Oftentimes, we
want to be reactive as
opposed to proactive. And so there are ways that you can be
proactive with
every client-- whether they are presenting with suicide or not--
and having that
process that when a client presents with suicide, what are steps
that you are
naturally going to take with that client?
Either they be, if you are in private practice, then you develop
those prior to you
seeing clients. If you're in a public agency, then know the
protocols and the
procedures of addressing, and how you address a client who
presents with
suicide ideation and following those steps. And not only that,
aside from the
training, sometimes you may work with-- or students may work
with clients
infrequently, who present with suicidal ideation. And so that
when it does appear,
you're like, OK, I forgot. What do I do? Those annual trainings

and refresher
courses that you can take on how to assess suicide clients and
how to work with
suicide clients will keep you mindful of the steps it takes, and
how to address
clients when they do present.
And then, finally, for me, is supervision. Either you're in
private practice, you
should have a supervisor or someone you can call if you feel
stuck and don't
know what to do. You can be genuine. I'm sorry. I'm going to
need some help
with this. This is a little bit out of my comfort, and seek that
supervision. If you're
in an agency and the supervisor's down the hall, just break for a
moment and
show that you are human and seek help.
MICHELLE SLATER: That's funny. I was thinking, again, it
comes up with
authenticity. I'm a bit of a truth pusher, and to be able to just
say to your client,
this is-- it's overwhelming.
SUE BANKS: Yes, it can be.

MICHELLE SLATER: I need for you to partner with me, and
we'll create a safety
plan together. It's very difficult to invest in our clients if they're
not willing to invest
in themselves. And so to try to create that balance together. And
in 20 years of
doing this work, one of the things that stands out for me is I
have not had a client
involuntarily hospitalized.
Now, many times, I have had them have someone come pick
them up, and they
have self-- they have taken themselves for help. And I think that
really speaks to
my process is very collaborative in nature. We do have the

power and the ability
to ensure that they get treatment. But what we do with that
power is really
important.
And there have been moments where I've said to clients, like, I
need you to work
with me because I'm concerned about you, and I don't feel
comfortable letting
you leave. So here's our options. So we can do this. We could
do this.
There's a lot of different plans. With my kids, I say it's the easy
way or the hard
way. So it's some sort of version of that that we're presenting to
our clients.
There are options.
SUE BANKS: There are.
MICHELLE SLATER: And in crisis, it's helpful to have
someone who is clear and
calm and able to present those. And clients, again, they want to
live if you tap
into that. I have found more times than not that they are willing
to self-refer, or
check themselves in, or to get the assessment on their own. So,
again, you can
work that out some with your clients of shutting down and
feeling like you have to
handle it, fix it yourself.
SUE BANKS: So we've had an extensive discussion about this
topic of suicide.
And I want to thank you, Dr. Slater, for sharing your thoughts
and your views and

your experiences today. I'm also hopeful that you've gained
quite a bit from our
discussion, and thanking you for allowing us to share with you
our experiences in
working with clients who present with suicidal issues. I'm really
hopeful that you
are able to use this information as you move forward in your
training as future
counselors.
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___________________________________________
___________________________________________
"Facilitative Response Activity"
*
Program Transcript
*
Sue is 43 years old; she has come to a local clinic seeking help.
She is feeling sad and not sure why or the
cause of her sadness. She is meeting with Michelle, who is
conducting a suicide assessment and

intervention.
As you observe the interaction between Sue and Michelle, you
will be asked to select between two
options on what Michelle should say next. You will receive
feedback on the selection that you made.
Choose wisely, because the better you interact with Sue, the
better her suicide assessment and
intervention.
Client Paperwork:
• Name: Sue
• Age: 43-years-old
• Gender: Female
• Status: Married
• Husband Ken, works as a lawyer in a local law firm.
Husband noted that he didn't know why his
wife appeared sad all of the time and recommended that she
visit the clinic as a possible
solution.
• Client has two children, ages 10 and 12.
• Client was a human resource representative for a large
company before leaving her position to
start a family.
1 Michelle and Sue Interaction
MICHELLE: So, Ms. Johnson, do you understand the
confidentiality that we've just finished discussing?
SUE: Yes.

MICHELLE: Are there any questions you'd like to ask me
before we get started?
SUE: No, no questions.
MICHELLE: Would it be all right if I called you Sue?
SUE: Yes, that's fine.
MICHELLE: Thanks. So, Sue, tell me a little bit about what
brought you into the clinic today.
___________________________________________
___________________________________________

___________________________________________
___________________________________________
___________________________________________
*
Program Transcript
*
SUE: I'm not really sure where to start. My husband's a
successful lawyer. We're financially set. He
spends lots of time with me. The kids are doing well. They have
lots of activities at school and with their
friends. I should be happy, but I'm not. I feel lonely and sad all
the time. It's like nothing matters
anymore.
1 of 10 How would you respond? Choose A or B
*
Choose A:
*
So even though it seems like there are a lot of things that are
going well for you, your life still feels
*

meaningless and empty. You're having a hard time feeling good
about it.
*
Choose B:
*
You know Sue, being a wife and a mom can sometimes feel like
a thankless job. Sounds like, even
*
though you have a lot of things to be grateful for, you're
struggling and could use some help figuring out
*
how to focus on the more positive aspects of your life.
*
SUE: I just can't take it anymore. Nothing I do ever works out. I
think everybody would be better off
without me. And so, I just think I'm going to just end it all.
*
Choose A:
*
The pain you're feeling is so unbearable. You don't see any
other way out. You're feeling helpless.
*
Choose B:
*
You know, things aren't always as bad as they seem. It sounds
like you have a lot to live for. And I'm sure
*
a lot of people would be sad if you were gone.

*
SUE: Well, my thoughts have been so terrible, I couldn't tell
anyone what I've been thinking.
___________________________________________
___________________________________________
___________________________________________

___________________________________________
*
Program Transcript
*
Choose A:
*
You know, you can talk to me, Sue. I am-- I've been trained to
be objective about these kinds of things,
*
and I'm here to listen.
*
Choose B:
*
Your thoughts are so frightening to you that you imagine other
people would be shocked to know that
*
you're thinking such disturbing things.
*
SUE: I really feel like I'm going to do something to myself, like
I might hurt myself or something, like I
want to put an end to all the misery once and for all.

*
Choose A:
*
Sue, it sounds like you're having some really scary thoughts.
And I'd like to hear more about what's
*
really bothering you.
*
Choose B:
*
It must be terrifying to feel so hopeless and alone. Are you
thinking about killing yourself?
*
SUE: I've wrestled with it for over a year without involving my
family. I don't see the point in telling them
now. I don't want to put them through that. So, I just want to
just give up.
*
Choose A:
*
Sue, you've been carrying the weight of this secret, this pain,
for over a year now. And I'm wondering
*
what happened recently that's caused you to feel so hopeless?
*

Choose B:
*
Protecting your family from the pain that you're experiencing is
very important to you. I'm wondering
*
what you think your family would want.
*
___________________________________________
___________________________________________
___________________________________________
___________________________________________

___________________________________________
*
Program Transcript
*
SUE: I don't know how to say it. Every time I think about it and
want to talk about it, I try, but I just go
numb, and can't talk about it.
*
Choose A:
*
You're devastated by the weight of what you're dealing with and
detaching from that pain. It's been the
*
only way that you've been able to get by.
*
Choose B:
*
You can tell me, Sue. I'm here to listen. I know it's hard, but
you're doing a great job.

*
SUE: I've done good staying positive and taking care of myself
and doing everything that I'm supposed to
do. But I don't know how much longer I can keep doing this. It's
just too hard. And so, I just don't think I
can do it anymore.
*
Choose A:
*
You know, it's exhausting. I can hear that. I can see that. It
sounds like you have a really supportive
*
family. And I'm sure they would want to help you. You've got to
find a way to tell them.
*
Choose B:
*
It's exhausting, carrying it on your own for so long. I'm
wondering, what's one thing that you could think
*
of that might help you get the support that you really need?
*
SUE: I cry all the time. I can't keep it together. I feel so weak. I
don't want to need anybody and rely on
anybody and put anybody through any of this. And I just can't
do it anymore.

___________________________________________
___________________________________________
___________________________________________
___________________________________________

*
Program Transcript
*
*
Choose A:
*
You put so much pressure on yourself. The pain and the hurt,
it's overwhelming. And it must be
*
impossible to hold all that pain inside.
*
Choose B:
*
You know, it's hard to talk about your problems and to reach out
for help. And there are a lot of stigmas
*
about what that says about us, and that reaching out for help
makes us weak, or that struggling with
*
mental health issues makes us crazy. And I'm wondering, do you
carry shame about needing help from
someone?
*
SUE: What are you? Are you a doctor or something? How are
you going to tell me about the pain and
the misery that I've experienced? I'm sure your life has been

perfect, and you've never experienced any
kind of pain or hurt that I've been feeling. How can you even
help me? You don't even know anything
about what I'm going through. Have you ever tried to kill
yourself before?
*
Choose A:
*
You know, I have been through difficult times too, and
struggles. And I believe that everybody's pain
*
matters. You're not really giving me a chance to help you. We
all struggle. And there are healthy and
*
unhealthy ways to cope. People find different answers to their
pain and look for different solutions.
*
Choose B:
*
You're afraid to trust me, afraid I won't be able to understand.
You're taking a risk sharing your pain.
*
And it makes you feel vulnerable and uncertain, and wondering
if it's even going to make a difference.
*
SUE: It's been good coming in to talk to you. I feel a lot better,
but I still feel like I just put a Band-Aid on
an open wound. I'm still raw and I still don't really know what
to do. I don't know what's going to

happen on the next bad day that I have. What do I do then? Still
not sure.
___________________________________________
*
Program Transcript
*
*
Choose A:

*
It's hard for you to imagine a future where you'd be free from
this pain and despair that's weighed on
*
you for so long. You took a huge risk coming in today, Sue, and
it was very courageous for you to share
*
your pain with me. I know that that wasn't easy.
*
And, you know, I wish that you could leave today not feeling
that pain again. But it's a process that we
*
can work through together. I hope that you've begun to have
some hope that your future might be free
*
from all this that's weighing you down.
*
It does concern me that you were considering suicide. And it's
important that you have a plan in place to
*
keep you safe. I'm wondering if you would consider calling the
1-800 suicide hotline if you were thinking
*
of hurting yourself.
*
Choose B:
*
I'm glad you're feeling better, Sue. You took a big step coming
in today. But progress takes time. And
*
you've been struggling with this for a long time. It's going to
take time for us to work on that together.
*

Well if you're feeling like hurting yourself, you can always call
and make an appointment. And in the
meantime, I hope you'll stay positive and continue to do the best
you can trying to cope until we get a
*
chance to meet again.
*

Suicide Assessment and Safety Planning
Program Transcript
FEMALE SPEAKER: So, Robert, did you understand the
confidentiality I just
presented?
ROBERT: Yeah. Yeah. I got it. It's fine.
FEMALE SPEAKER: Do you have any questions before we get
started?
ROBERT: No, no. I mean, that was pretty clear.
FEMALE SPEAKER: OK. So why don't you tell me a little bit
about your
background growing up?
ROBERT: Background. Well, growing up was-- I mean, it was--
what do people
do? We grow up, right? It wasn't-- it was tough. My dad, he was
really tough on
me. I was the oldest. Little sister. So she didn't see much of
what happened.
And eventually what happened was, we left. They were never
married, so my
mom didn't feel a commitment to stay. They had me. That didn't
keep them
together, so we left. Went to stay with some cousins in Virginia.
Norfolk.
FEMALE SPEAKER: So your dad was abusive?

ROBERT: Very, I would say. I mean, I would get-- there was
this one Christmas
where I opened up a packet. And all I think was to open up the
package, right?
And he was like, did you give me the finger? I'm like-- I'm like
a kid, right? And
I'm like, this isn't even-- I knew as a child that it didn't make
any sense, right?
He's like, how would I give a-- I didn't even know what a finger
was. I mean. It
was just scary to live in the house.
So you would just get beat for nothing. And my mom would
stop it. She would
come in time to try to stop him from spanking me. So she did
what she-- she did
the best she could. Everybody did the best they could with what
they had at the
time. So--
FEMALE SPEAKER: Yeah. So it says on your intake form that
you were in the
military. Can you tell me a little bit more about your experience
in service?
ROBERT: Yeah. Well, we didn't have any money and I knew
that they would pay
for schooling. So I was always taking things apart and putting
them back
together. So I went into combat engineering. We would build
things and blow
things up. That was always fun.

Now, I like to know how people think, so my backup was like
psy-ops, which is--
people hear psy-ops. They think, oh, crazy strange stuff. But it's
not crazy
strange. It's just how people think. The methodologies and
modalities of how
people make decisions. So combat engineers was first, psy-ops
was second.
I grew up near Norfolk. And I don't know if you ever been to
the area, but it's
nothing but jets all the time, right? So I never wanted to fly, but

I think that's what
pushed me towards the military. So I chose the Army and
enlisted when I was
18. Went on from there.
FEMALE SPEAKER: And when you enlisted, where did you
head from there?
What were your experiences?
ROBERT: I had two tours. The first one was Afghanistan, the
second was Iraq.
And the second one is where I ended my career and left.
FEMALE SPEAKER: I can see as you're talking about that that
it's painful. I'm
wondering if you'd be willing to talk to me a little bit about
that.
ROBERT: What would you like to know?
FEMALE SPEAKER: I guess I'm most interested in what you
experienced there.
It's part of who you are sitting in front of me today. And I'd like
to understand
what that experience was like for you.
ROBERT: [CLEARS THROAT] OK. Yeah. We can. So headed
back to base. Not
far away, like five clicks. There was debris on the road in front
of us. It wasn't
enough that it looked like it was intentionally placed, but I
knew that it didn't
belong there. We could not sit there because, of course, they
could come on our
six, have us trapped. So what we did was we reversed about 50
feet, made a k-

point turn.
And when we made the k-point turn, that was when we hit the
IED. And the way
the vehicle slipped back onto its left side. I was pinned down.
My mother says--
[LAUGHS BRIEFLY] she always talks about how she would
pray for me and
stuff, but-- so not everybody that day was protected, though.
FEMALE SPEAKER: Yeah. And you carry that pain with you.
ROBERT: Yeah. I would say so. Ramirez-- and he was having a
baby girl. I don't
know why I-- I was allowed to live, you know? That's-- I mean,
it's not fair.
FEMALE SPEAKER: Yeah.
ROBERT: But I don't make the rules, so--

FEMALE SPEAKER: Yeah. But you ask yourself that. Why?
Why him? Why
them? Why not me?
ROBERT: I do. I mean, I do. I-- what makes me deserving? You
know? It sounds
cliche when people say survivor's guilt. I mean, it's-- I'm not
guilty, it just doesn't
make-- what if I was sitting on the right-hand side, you know?
It's little decisions
like that that makes you think about what you do and don't do.
FEMALE SPEAKER: Yeah. And does it matter at all? Sounds
like it's left you with
a lot of confusion and questions, and now what?
ROBERT: [LAUGHS BRIEFLY] Exactly. I mean, like, now
what?
FEMALE SPEAKER: You were protected and it sounds like
you're struggling
even to understand why or what you're supposed to do with this
life that you got
saved.

ROBERT: Yes, ma'am.
FEMALE SPEAKER: So, I'm sorry. I'm sorry to hear about that
experience for
you. And I can't imagine what it's been like to cope with that.
And can you tell me
a little bit about what it's been like since you came home? After
you had
discharged?
ROBERT: [EXHALES] Not the same. [EXHALES]
FEMALE SPEAKER: Yeah. How could that be?
ROBERT: I have no freaking idea how that could be. My joy is
there. John is fine.
You know? I mean, I missed his birth, but he's good. Tess is
great. She works at
the hospital. She's what keeps us going because where we're at
is rural, so
there's not a lot to do. It's farms, it's this-- it's-- she'll always
have a job. I mean,
nurses can go anywhere. Backwoods, they'll be fine.
Me, like I said, with the combat engineering, I'm good with my
hands, right? With
the psy-ops, that's like marketing. Big city, New York stuff, so-
- we're not in the
big city, we're not in New York, work is hard to come by. I just
had a online sites
Craigslist list to try to find stuff to do.
And we fight a lot because she-- I mean, she didn't sign up to be
the
breadwinner. That's my job. I'm the man. I'm supposed to do
that, so--

FEMALE SPEAKER: Yeah. And it sounds like you're having a
hard time finding
your place.
ROBERT: It's tough. I mean, I get to see John all the time

because I'm the
babysitter, but I'm not supposed to be the babysitter, you know?
I was supposed
to be out there and doing, so--
FEMALE SPEAKER: Yeah. It's creating a lot of tension at
home?
ROBERT: We go at it. [LAUGHS] We do go at it. It gets
intense. The other day, it
was about, like, nothing, you know? She said something, I said
something, he's
crying, and then it just blew up into a whole bunch of nothing.
And it was like all
this red flash, right? And then I blanked out for a second. Not
blanked out like on
the floor. Just like I wasn't me and like I just saw-- I just saw
my hand like moving
towards her and I was like, I-- I can't do that. It's-- you know?
FEMALE SPEAKER: Like it was happening outside of you. And
that's not the
person--
ROBERT: No.
FEMALE SPEAKER: you want to be, that you know yourself to
be.
ROBERT: No, no. That's totally-- that's totally out of character
for me. That's not--
FEMALE SPEAKER: What else is different since you've gotten
back?
ROBERT: No friends. Nothing happening. No hanging out. I

mean, it's TV. I
would never even start video games because I know my
addictions. [LAUGHS]
You know? Just trying to find stuff to do. Trying to find work.
FEMALE SPEAKER: Pretty isolated.
ROBERT: That's a very good word. Isolated. And she comes
home and she
doesn't want to talk because she's had a tough day. I don't want
to talk. So she'll
eat, I'll eat downstairs. She'll go to bed and then she would be
like (IMITATING
FEMALE VOICE) can you go to bed? And then I'm like, I'm
coming to bed, but--
I'll go to bed but I'll get back out of bed because I can't sleep,
right?
So then, what will happen next is-- let's open a beer. It's beer,
beer, beer, beer.
And just-- you know, six, eight. Even numbers is good, right?
So a 12 pack, you
know? Just--
FEMALE SPEAKER: Whatever it takes to be able to get to
sleep. Shut it off.
ROBERT: Shut it off. Yeah. That's a good way to put it.
FEMALE SPEAKER: That's causing problems at home.

ROBERT: Oh, definitely. Because, I mean, how can you pay for
beer when you
don't have work, right? [LAUGHS] So it's like a cycle, you
know? Trying to break
the cycle.
FEMALE SPEAKER: Yeah. So, tell me, Robert, I'm getting this
picture of some of
the trauma that you've gone through and what you've
experienced since you
were discharged. What specifically caused you to seek help

today?
ROBERT: I almost hit my wife.
FEMALE SPEAKER: It scared you.
ROBERT: It scared the hell out of me. That's not me. Like, I
know that's not me.
So that's not me.
FEMALE SPEAKER: What else is not you? Are there other
things that you're
concerned about? Sounds like there's a lot of things you've said
a couple of
times that are out of character for you.
ROBERT: But-- I mean, why-- my thing is, why-- I'm sorry. I'm
just thinking about
the confidentiality thing. What I share between you and I, right?
FEMALE SPEAKER: Everything that you share in here is
confidential unless
you're talking about hurting yourself or someone else, then we
would have to
have another conversation. Is there's something that you're
afraid to share, that
you're afraid you can't talk about with me?
ROBERT: It's not that I'm afraid to talk about it, it's just--
sometimes I feel like
why even keep going on, you know? Like, why-- I guess it goes
back to that
whole protection thing. Like, why was I protected? Why was I
spared? Maybe it
would just be better for everybody, you know-- Tess will always
have work. John

will always be OK. We have a family that will take care of
them, you know? Like,
if I'm the problem, well, you do the math, right? You solve the
problem. So if I
wasn't around, it would be-- maybe it would be better for
everybody. You know?
FEMALE SPEAKER: If you took yourself out of the equation.
ROBERT: Yes, ma'am. I mean, I have a gun. I would-- I'm not
saying I'm going to
walk around and do anything crazy, I'm not just-- I'm not saying
that, but I'm just
saying, why?
FEMALE SPEAKER: Because you're having a hard time
understanding why
you're here and why it's all worth it. Or thinking that it's not.
ROBERT: Is it even worth it?
FEMALE SPEAKER: Yeah.
ROBERT: That's question, right?

FEMALE SPEAKER: Sounds like you really are struggling with
that. Trying to
answer that question.
ROBERT: Yes, ma'am.

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