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A suicide crisis intervention model with 25 practical strategies for implementation.

Suicidal clients are a difficult and challenging population in counseling. This article contains 25 practical, hands-on strategies for mental health counselors to assist in their interactions with suicidal clients. The strategies are situated within a seven-step model for crisis intervention that is specifically tailored to suicidal clients.

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Suicidal clients are some of the most difficult and challenging for mental health counselors. Almost all practicing counselors will encounter a suicidal client during their careers, and most, as many as 71% in one study, will work with an individual who has made a suicide attempt (Rogers, Gueulette, Abbey-Hines, Carney, & Werth, 2001). Nearly one-quarter (23%) of professional counselors have experienced a client suicide (McAdams & Foster, 2000). Mental health professionals who experience a client suicide describe it as "the most profoundly disturbing event of their professional careers" (Hendin, Lipschitz, Maltsberger, Haas, & Wynecoop, 2000, p. 2022).

Much has been written about the assessment of suicide risk (e.g., Granello, in press; Jacobs & Brewer, 2006; Westefeld et al., 2000), and careful risk assessment is clearly the cornerstone of treatment. There also is information available about how to make decisions about appropriate care and meaningful treatment plans (e.g., Slaby, 1998; King, Kovan, London, & Bongar, 1999; Rudd, Joiner, Jobes, & King, 1999). However, there is far less information available about how best to interact with and manage suicidal clients when the risk of suicide is high. There are strategies and techniques for working effectively with suicidal clients, but there is not much practical information on how to manage them. This article provides 25 such strategies.

In general, clinical interventions with suicidal clients take a two-tiered approach. The first, the focus of this article, is short-term stabilization. There are very specific acute management and crisis intervention strategies to keep clients alive and invested in counseling long enough to move to the core problems underlying suicidality. The goal of the first tier of intervention is to prevent death or injury and restore the client to a state of equilibrium.

The second tier of intervention addresses the client's underlying psychological vulnerability, mental disorders, stressors, and risk factors. This tier is ultimately based in the entire field of mental health counseling, with interventions as varied and unique as the clients with whom they are applied. However, only after clients are stabilized using strategies to address the first tier of the approach can the ongoing work of counseling begin (Berman & Jobes, 1997).

Working with clients in suicidal crisis can include many types of care, including inpatient, short- and long-term outpatient, day treatment, and emergency intervention. Models and algorithms are available to help clinicians determine which are appropriate. Though these models vary, they generally include information on (a) conducting meaningful assessments; (b) developing treatment plans; (c) determining levels of care; (d) engaging in psychiatric evaluations for medications; (e) increasing access to treatment; (f) developing risk management plans; (g) managing clinician liability; and (h) assessing outcomes. (For more information on determining levels of care, see: Bongar et al., 1998; Kleespies, Deleppo, Gallagher, & Niles, 1999.)

WORKING WITH CLIENTS IN SUICIDAL CRISIS

There is a belief widely held by suicidologists that most suicidal individuals do not wish to die but simply cannot imagine continuing to live in their current state of psychological turmoil (Granello & Granello, 2007). In fact, suicidal crises are typically the result of a temporary, reversible, and ambivalent state (Stillion & McDowell, 1996), and interventions with suicidal clients are based on the premise that, successfully navigated, the suicidal crisis need not be fatal.

The goals of immediate intervention with suicidal clients are based on models of crisis intervention (e.g., Aguilera, 1998; Greenstone & Leviton, 2002; James & Gilliland, 2001), with specific strategies that are unique to this population. In general, an expanded version of Roberts's 2000 crisis intervention model is recommended (Granello & Granello, 2007). This model has crisis theory as its theoretical foundation and suicidology research and practice to ground the intervention strategies offered within each step. Thus, the seven-step model offers counselors an overall strategy in their work with suicidal clients, and most counselors who have worked in crisis intervention will recognize the approach.

The specific strategies offered within each step are meant to help counselors operationalize the interventions suggested by the model. For example, many crisis intervention models suggest that counselors work to "restore hope" in their clients, but few offer concrete suggestions for how to do this. The 25 practical strategies offered here are intended to help counselors implement a crisis intervention approach with suicidal clients. The expanded model, with several strategies for implementing each step, is outlined in Table 1.

In what follows, each stage of the model is discussed, followed by practical tips and intervention strategies. The strategies are broad enough to apply to many different types of clients in many different settings. However, they are intended only as a guide; the needs of individual clients may vary significantly. For example, developmental, multicultural, or cognitive limitations of clients may shape implementation of the strategies. These steps do not replace existing models and algorithms for suicide assessment and intervention. They are intended to provide strategies to help implement traditional guidelines.

Further, although some of the strategies offered use basic counseling skills as their foundation, others are more advanced. Beginning counselors (or counselors new to work with suicidal clients) may find that they need to practice these skills under supervision or observe more advanced counselors as they implement the strategies with clients before they feel competent to use them on their own. As always, counselors are encouraged to seek supervision, consultation, collaboration, and advanced training as they work with suicidal clients.

Step One: Assess Lethality

The first and most important step in working with suicidal persons is accurate assessment. Although assessment may occur slowly, with more information becoming apparent as clients tell their stories, a general understanding of level of lethality is central for guiding the process. For this, suicide risk assessment protocols are used (American Psychiatric Association, 2003; Rush, First, & Blacker, 2008). An individual in suicide emergency, for example, has a clear intent to die at the first opportunity (Sommers-Flanagan & Sommers-Flanagan, 1995). As a general stipulation, counselors should approach all situations of suicide risk as a potential suicide emergency until they obtain enough information to be convinced otherwise (Kleespies et al., 1999).

Ensure immediate safety. Individuals in acute suicidal crisis should never be left alone, not even to get another person to help or make a phone call. Suicide can happen quickly. And counselors should never transport a highly suicidal person in their cars, as the person might jump out in transit or grab the wheel and cause an accident (Sommers-Flanagan & Sommers-Flanagan, 1999).

Have and use suicide emergency plans. All counselors who work with highrisk clients should have a planned set of steps to determine actions and decisions at each point during an emergency. If any client exhibits behaviors that could quickly result in serious injury or death or who has sufficiently impaired judgment to be a potential harm to self, counselors must invoke the ethical imperative of duty to protect (Werth & Rogers, 2005). The first step is containment. What will the counselor do if an agitated client attempts to leave the building? What resources are available? How can other professionals within the agency be alerted that help is needed? (For more information on drafting suicide emergency plans, see Kleespies et al., 1999.)

Step Two: Establish Rapport

One of the most significant factors in assessing suicide risk and determining the prognosis for success of interventions is the therapeutic relationship (Bongar, 2002). Suicidal adolescents stated (Paulson and Everall, 2003) that the quality of the therapeutic relationship was one of the most helpful aspects of treatment. Lack of such a relationship has been found to have a negative impact on outcomes for clients in suicidal crises (Maltzberger, 1986). Basic counseling skills and the Rogerian core conditions help convey a genuine, caring, and nonjudgmental therapeutic stance (Chiles & Strosahl, 2005).

Stay with the client. Because the therapeutic relationship is central to client safety and positive outcomes, counselors who have even a minimal therapeutic relationship with a suicidal client should attempt to stay with the client during the entire risk assessment phase. Handing the client off to another clinician for a risk assessment is seldom useful, as the client may deny suicidal intent to an unknown clinician. The referring counselor should be involved in all aspects of the comprehensive risk assessment, the initial treatment plan, and if necessary hospital intake: Counselors should optimally be present, or at the very least initiate dialogue with the hospital staff about the client. Counselors who do not pass along important information to the clinicians assuming responsibility for a client in crisis may be held legally liable (Granello & Granello, 2007).

Manage countertransference. Suicidal clients are likely to elicit strong countertransferential emotions in counselors, including fear, anxiety, anger, helplessness, defensiveness, overprotectiveness, or resignation (Bongar, 1991). Counselors may overreact to any mention of suicide and impose overly restrictive controls. The opposite risk, which can be much more serious, occurs when counselors deny the level of threat and underreact by not imposing sufficient controls. Either situation, when arising from the emotional reactions of the counselor rather than the needs of the client, is dangerous.

Using a sample of 35 therapists who had worked with at least one suicidal client, Richards (2000) found several common themes in countertransferential reactions. They spoke of feeling angry or frustrated with the client, and many felt overwhelmed by the intensity of their feelings. Others began to question their own competence and wondered whether the client would be better off with another counselor. They reported using many strategies to help manage these reactions. Among the most helpful were seeking more clinical supervision, engaging in consultation, seeking support from professional colleagues, and using their own therapy to process these difficult emotions.

Normalize the topic. When interacting with people in suicidal crisis, it is easy to become flustered or anxious. Suicidal persons may present as unlikable, angry, or agitated, which can increase the counselor's anxiety (Lagges & Dunn, 2003). The goal with a suicidal client is to remain calm while expressing empathy for the desperation that led the client to consider suicide. Normalizing the topic can help clients feel safe. Although suicidal behaviors should never be framed as normal, it is important to normalize that thoughts of suicide are relatively common. For example, more than 1 in 5 adults and 1 in 3 adolescents report having seriously considered suicide (Harris Interactive, 2003).

However, it is also important to help clients recognize that they do not have to follow through on these thoughts. Counselors should make it clear that it is acceptable to talk openly and honestly about suicide: talking about suicidal thoughts and behaviors in a therapeutic setting can reduce suicide risk (Chiles & Strosahl, 2005). It is also important to normalize the guilt and shame that often accompany admissions of suicidal thoughts. For example, counselors might say "When people are feeling this upset, they sometimes think about suicide..." or "I know this is hard to talk about, so just go slow, take your time, and use whatever words you are most comfortable using to express your suicidal thoughts and feelings." Counselors must "deal with [their] clients' thoughts and feelings in a matter-of-fact manner; this suggests to them that [the counselor has] dealt with such issues previously and it reassures them, to some degree, that their experiences are not all that unusual" (Sommers-Flanagan and Sommers-Flanagan, 1999, p. 262). A sense of normalcy and calm will allow clients to explore suicidal ideation in the safety of a strong therapeutic relationship.

Convey calm through short declarative sentences and downspeak. Many of the counseling skills that are common to all crisis interventions are appropriate for these clients as well. For example, it is important to speak slowly and calmly, in short declarative sentences. Downspeak, where the pitch of the voice drops at the end of sentences, results in declarative statements. This contrasts with upspeak, which implies a question through a raised tone at the end of sentences, connoting uncertainty and tentativeness (Bradford, 1997). Downspeak, short sentences, and a slow pace communicate safety, control, and calm.

Move from an authoritative to a collaborative approach. In traditional counseling approaches, there is an inherent hierarchy with counselor as expert and client as patient. The more directive approaches that are common to crisis intervention may inadvertently exacerbate this dichotomy. Although conveying a sense of competency that can be calming to clients, the counselor need not be the expert who has all the answers. Rather, Jobes (2006) recommends a collaborative approach in which counselor and client work together. In other words, the client is the expert about his or her own experience and is engaged as an active collaborator in care. Small changes, such as rearranging the seating so counselor and clinician sit side by side during assessment and intervention, send a different message to the client about who is in charge.

Completing suicide assessment ratings with rather than about the client is another small change that carries a big message. Jobes (2006) suggests comments such as "The answer to your struggle lies within you--together we will find those answers and we will work as treatment partners to figure out how to make your life viable and thereby find better alternatives to coping than suicide" (p. 41). Another possible approach is: "I want you to consider taking a therapeutic road trip with me. On this trip you will be the driver, and I will be the navigator. I have taken this trip many times before, I know the roads well, and I have excellent maps ... but the journey is always unique to the driver" (p. 68).

Support the decision to seek help. Counselors can build rapport by reassuring clients that it was a good idea for them to seek help. Even clients who have submitted to care involuntarily can be praised for anything they do to facilitate it. Praise should not ring hollow but should be rooted in a deep, genuine belief that seeking or participating in help was and is a good decision.

Step Three: Listen to the Story

As many as 70% of individuals who died by suicide communicated their intent to someone else in the week before their death, and the percentage may be as high as 85% for adolescents and young adults (U.S. Department of Health & Human Services, 2001). Yet most suicidal statements are met with less than helpful responses, usually silence, ridicule, or judgment (Suicide Prevention Resource Center, 2005). Allowing clients to tell their stories and fully explore what led to their suicide risk is itself therapeutic (Yalom, 1975). Williams and Morgan (1994) noted that the skilled clinician will recognize "the immense value of reaching out and listening to resolve a suicidal crisis, no matter how complex and apparently insoluble the individual's problems might seem" (p. 16).

Listen, understand, validate (LUV). LUV is a useful mnemonic (Echterling, Presbury, & McKee, 2005). Using this model, counselors listen to the client's story, convey deep understanding of the meaning behind the suicidal intent, and validate the client's intense psychological pain. This distinction of what to validate is important. Counselors should not validate suicide as an option but should instead validate that the client believes suicide is the only option. For example, a counselor might say, "I hear that you feel overwhelmed by the situation, and I understand that from where you sit, you cannot see a way out of this other than suicide. It is clear to me that you are in such tremendous psychological pain that you feel you simply cannot face another day." It is important, however, not to end the discussion in this negative and hopeless place. Essential factors in continuing this conversation are discussed under Step Five.

Slow things down. The ambivalence that surrounds suicide is a double-edged sword. It creates an opportunity for counselors to intervene, but living in a state of ambivalence also creates great anxiety that can pressure the client to make a choice to lower the anxiety. This is why some people who have decided to die can appear calm and serene. They have removed the anxiety of ambivalence. Because of anxiety, clients may talk faster as they discuss suicide plans with rapid and pressured speech as they rush to tell their stories. Counselors should allow plenty of time, reassure clients that they want to hear, and use nonverbal communication to convey a sense of calm. For example, a counselor might say, "It's okay. You don't have to rush through your story. I will listen. Take a deep breath and tell me what you want me to hear." The counselor may take several deep breaths with the client, invoking the body's natural relaxation response, to slow the process.

Create a therapeutic window. This strategy is used to buy the counselor time for crisis stabilization. Suicidal clients can feel as though the crisis is taking over, and they are overwhelmed by the pressure to quickly succumb to suicide. Counselors in turn often feel pressured to come up with immediate solutions when clients talk about imminent suicide plans. Helping clients to put distance between themselves and suicide conveys the message that if suicide truly is the only solution to this crisis, it will still be available to the client later on; it does not have to happen right now.

The good news is that suicidal emergencies are self-limiting. Very few individuals can maintain a state of acute crisis for more than 24-48 hours without going into an adaptive period of emotional exhaustion (Chiles & Strosahl, 2005). That means that buying some time can help move clients through the suicidal crisis. For example, a counselor might say, "You told me that you are thinking of jumping off the top of the parking garage this weekend when everyone is away and the parking garage is empty. I'm wondering why it has to be this weekend. We can certainly both agree that the parking garage will be there next month, right? And if we can agree to put off any more preparations for the suicide until then, it gives us some time to see if we can't come up with some other solutions."

Using Jobes's analogy (2006) of the therapeutic road trip (see Step Two), the counselor might say:
   Because I know you suffer deeply, I am only asking that you travel
   with me for a specific period of time, a minimum of 4 weeks to a
   maximum of 3 months. [At that point] we can decide together whether
   we should continue our travels or perhaps part ways so that you can
   drive on your own or perhaps travel with a different navigator (p.
   68).


The hope, of course, is that when the client is given time to slow down, consider other options, and find hope, the crisis will pass. Clearly if the crisis is still in place as the new deadline approaches, other interventions, perhaps including hospitalization, must be put in place. Yet the client has everything to gain, and very little to lose, by postponing suicide and giving treatment a chance. Although not a long-term solution, creation of a therapeutic window gives the client time to work with the counselor to find other solutions.

Categorize the problems. Suicidal clients have both distal and proximal problems and risk factors. Some client problems and psychological vulnerabilities (e.g., mood disorders, personality disorders, history of attempts) are far beyond the scope of the first tier of crisis intervention. Other problems, however, can be more easily addressed. As counselors listen to client stories, prioritizing the problems into those that can be addressed early and those that must wait for more long-term counseling can be particularly useful. This allows counselors to help clients have a few quick successes, bolstering their belief that at least some of their problems can be managed and increasing their sense of self-efficacy. Sometimes, when clients list their problems, they all seem to take on the same magnitude, even though some are actually quite easily solved.

For example, a client may say "... and I have no friends, and no one cares if I live or die, and I used to go to church and see people, but I don't even go there anymore." The counselor may wish to ask about church. Is attending church something the client could agree to for the coming weekend? Counselor and client might set a goal for attending a service, though only if this is something the client believes he or she can accomplish, lest not doing so be perceived as another failure. Though it does not solve the larger problems of social isolation, it is one small step that can help reframe the client's ability to solve problems. Of course, this does not mean that counselors should immediately problem-solve for their clients--that be very unhelpful and alienating. Rather, it means selecting one or two small problems that can quickly be addressed and working with the client to build some early successes.

Identify the message. There are as many reasons for suicide as there are suicidal individuals. However, many suicides have an underlying message, and a completed suicide may indicate that the message was not received (Portes, Sandhu, & Daya, 2002). Uncovering the message is critical because it will determine, in large part, the foundation of the intervention. Although there are many explanations for what brings a person to the brink of death, most can be grouped into three major categories: communication, control, or avoidance.

For some individuals, suicide threats and attempts are a way to communicate to others just how unbearable their psychological pain has become (Nock & Kessler, 2006); as conventional methods of communication become less effective, the threats and behaviors increase (Bonnar & McGee, 1977). For others, suicide is a way to control one's own fate, control the actions of others through suicide attempts or threats, or seize control when the world seems chaotic and unsafe (Rogers, 2003). Finally, for some who face the intense (and, in their perception, unalterable) pain of a current situation or the anticipated pain of a future event (e.g., living alone after the death of a spouse, facing legal or financial hardship), suicide is perceived as a way to avoid this fate (Shneidman, 1981). Understanding the meaning of the suicide for the client can be extremely helpful in shaping appropriate interventions.

Step Four: Manage the Feelings

People in suicidal crisis often feel overwhelmed by emotion. Because ambiguity is so often part of the crisis (not wanting to die but wanting the pain to end), it is not unusual for many different emotions to occur simultaneously. Among the common themes that have been identified (Shneidman, 1981) are (a) acute perturbation or an exacerbation of the already-troubled state of mind; (b) increased negative emotions, such as self-loathing, guilt, or shame; (c) cognitive restriction, or the inability to engage in problem-solving; and (d) focused attention on the thought of suicide as a way to end emotional pain.

Encourage emotional ventilation. Allowing individuals to experience and express their emotions in a safe place to someone else without fear of being judged can help suicidal clients to manage their feelings. Clients may say: "I'm afraid if I let the tears start, they'd never stop" or "I'm so angry it feels like my head might explode." Of course, tears do stop and heads do not explode. The goal is to allow clients to say those words aloud and fully experience their feelings. Note that the goal is not emotional escalation. Statements by the counselor such as "I know it feels overwhelming--this is a safe place for you to talk about these things" can be particularly helpful. Emotional expression is a form of self-disclosure that has been linked to reduced suicidal intent (Apter, Horesh, Gothelf, Graffi, & Lepkifker, 2001). There is even some evidence that emotional ventilation can defuse a suicidal crisis enough to allow for other interventions, such as contracting and problem solving (Westefeld et al., 2000). Although emotional ventilation is typically not sufficient, it appears to be critical to managing a suicidal crisis.

Acknowledge the psychache. Edwin Shneidman, the father of suicidology, coined the term "psychache" for the extreme psychological pain of the suicidal person (2005). Chiles and Strosahl (2005) assert that underlying a suicidal crisis is "emotional or physical pain that [the person believes] is intolerable, inescapable, and interminable" (p. 63). Counselors must acknowledge that emotional desperation and unbearable affect if they are to provide effective support. Anything the client might perceive as disconfirming this pain can lead to escalation. If the pain is not acknowledged, clients might think, "You don't understand how bad I really feel. Let me show you." Setting an emotional tone for the counseling session that acknowledges the psychache can help clients move toward more collaborative problem-solving.

Teach tolerance of negative emotions. Through emotional ventilation and acknowledgement of the psychache, counselors send an important message: the goal of this tier of intervention is not to get rid of all disturbing thoughts or feelings, but to teach the client to "make room for them and do what needs to be done to get on with life" (Chiles & Strosahl, 2005, p. 117). There is no reason to wait until all negative emotions have lifted before change can occur. In fact, moving forward with behavior changes in the presence of negative emotions reinforces for clients that they are resilient and can learn to tolerate negative emotions.

Step Five: Explore Alternatives

There is much evidence that people in suicidal crisis have diminished problem-solving skills. During a crisis, clients engage in selective abstraction, using a set of filters to make negative generalizations about the world and themselves (Granello & Granello, 2007). People who are suicidal often fail to recognize the reasons they have for living or possible alternatives to their current situation. Exploring alternatives is not the same as providing advice or answers.

Exploring alternatives is critical, but it is also critical that it not be done too soon. In other words, if a counselor moves a client too quickly to this stage, before a relationship is fully established, before the client has a chance to tell his or her story or express emotions, the client may feel minimized and rushed and not be ready to engage in problem-solving. Timing is important.

Minimize the power struggle. Clients have the power to kill themselves. Denying that reality is futile. In almost any exploration of alternatives, the counselor's comments can move an individual who is ambivalent about suicide to its defense. For example, if the counselor were to say, "I wish you wouldn't kill yourself," the client would be almost forced to say, "But here are the reasons why I should." If the counselor says, "Let's see if we can think of some alternatives," the client will inevitably say, "I've thought of everything, there is no answer except suicide." In other words, given the dynamics of conversation, once one person takes a stance on one side of the issue (against suicide), the ambivalent person may be forced to take the other side (in favor of it). Thus, a person who is uncertain about suicide is moved to a position of defending it.

Fortunately, a simple linguistic strategy can be used to help generate alternatives: The counselor says, "I understand that suicide is an option that is open to you. I do not agree that it is the best possible outcome. However, I understand that of all the options available to you, suicide is one. Therefore, let's leave suicide on the table and call it Plan A. It's on the table. Now, let's try to come up with a Plan 13 or a Plan C." If the client begins to defend suicide, the counselor says, "I agree. It's an option. It's already on the table as Plan A. Now we're working on Plan B." The point is that a client who no longer has to defend suicide is free to work with the counselor to find other alternatives. A simple linguistic shift moves counselor and client from opposite sides of the problem to working collaboratively on the same side, and suicide becomes the "other."

Establish a problem-solving framework. Counselors can help clients reframe the suicidal crisis by making clear the connections between failed problem-solving and suicidal thoughts and behaviors. Past attempts to solve the problems have clearly met with limited success, and improving problem-solving skills must now become the focus. Clients see suicide as a solution (though not a very good one), not a problem; moving the discussion back to the problem helps them step back to see the larger picture. Effective problem-solving includes (a) identifying a problem; (b) identifying alternative solutions or strategies; (c) evaluating the likely outcome of the alternatives; (d) selecting a specific problem-solving technique and formulating a plan; and (e) implementing the strategy and evaluating its effectiveness (Chiles & Strosahl, 2005).

Here the basic tenets of motivational interviewing, helping clients identify the discrepancy between how they want to live and how they are living to motivate behavior change, may be useful (Miller & Rollnick, 2002). For some clients, strategies from solution-focused therapy may be appropriate (Guterman, 2006). It is typically not helpful to pass judgment on whether the client has truly engaged in real efforts at problem-solving. Giving advice or problem-solving for the client is equally unhelpful.

Engage social support, as appropriate. People who are suicidal are often lonely or isolated and have lost or never had the ability to engage all of their supports. When someone expresses danger to self, normal limits of confidentiality may no longer apply (AMHCA, 2000). The ethical imperative is to engage any professional or personal assistance that can help keep the client alive. It can be useful to reframe this for the client from "breaking confidentiality" (a term that emphasizes a broken therapeutic relationship) to "adding layers of support" (a term that enhances caring and connection). Clients should be encouraged to make lists of support people and fully explore their social support networks for possible assistance.

It is important that counselors not make assumptions about the support network. Some family members might provide excellent support; others might exacerbate the situation. Clients can be encouraged to consider who might be available at different times. Is there a neighbor who can offer support in the evenings? Is there someone at work if feelings escalate there? Is there a clergy member who can help? These individuals should be apprised of the need for assistance, asked if they are willing to participate, and given information to help them promote client safety. Linking the client to social support networks (e.g., grief groups, Alcoholics Anonymous, religious groups) may also help.

Restore hope. Often, the core of suicidality is hopelessness (Shneidman, 1981). Finding ways to restore hope is critical to all interventions with suicidal clients and is a goal both in the immediate intervention stage and as a necessary byproduct of longer-term counseling (Ellis, 2001). Jobes (2006) noted that counselors should be "vendors of hope" to clients (p. 50). Methods for restoring hope will depend on the therapeutic and theoretical stance of the counselor, but it is vital not to appear to be minimizing the crisis. A suicidal person may perceive a counselor who presents as too hopeful as inauthentic, unempathetic, or glib (Granello & Granello, 2007). Statements like "you have so much to live for" or "she's not worth it" can challenge clients to defend their decisions to die (McDonald, Pelling, & Granello, 2009). Messages that help instill hope might be: "I understand that you are feeling hopeless right now. I have to tell you that from where I sit, I do not believe the situation is hopeless" or "I am hopeful that there is a way out other than suicide. I believe that if we work through this together, we'll figure it out" or "I'm willing to stay with you as we work through the problem together." They convey a sense of calm and optimism without minimizing the client's problem.

Another simple strategy is for the counselor to become the "holder of hope." The counselor might say, "I understand that you don't have hope right now. That's okay. I want you to know that I have enough hope for both of us. In fact, I will become your 'holder of hope.' When you are ready, you let me know, and I will give your hope back to you." This strategy does not force the client to pretend to feel hopeful and, paradoxically, the relief of not having to pretend can actually increase hope. Making an abstraction like hope into something concrete and tangible can be particularly useful. Using hand motions to "reach out and grab" hope, and to "put it in your drawer for safekeeping" can be quietly reassuring. In fact, it is not uncommon for clients in a later session to carry through the analogy by saying, "I am ready to get my hope back now." Counselors can "reach back into the drawer" to return the hope, a symbolic gesture that can have great significance for the client.

Help the client to envision possibilities and build resilience. Fortify reasons for living. When suicidal individuals are ambivalent, there are at least some reasons why they want to stay alive. If the general goal is to try to understand the totality of the person's view of suicide, the goal in this strategy is to reinforce the positive side of ambivalence. Counselors can think to themselves, "If there were an unequivocal desire to commit suicide, this person would probably already be dead. My job is to find the spark of life that brought the person here and reinforce it" (Chiles & Strosahl, 2005, p. 29). Counselors can reinforce counseling itself as a mechanism for hope. When clients agree to an action plan (Step Six), they are agreeing to engage in the possibility of a future. That represents hope.

Step Six: Use Behavioral Strategies

There is clearly a continuum of risk for people in suicidal crisis, and a comprehensive suicide risk assessment will help determine the level of risk and the necessary level of care. Development of a treatment protocol is beyond the scope of this article (see Bongar, 2002, for a comprehensive discussion of suicide risk assessment, determination of levels of care, and treatment planning). What is important at this step in the process is that a comprehensive plan is prepared and implemented. For example, if there is to be ongoing risk assessment, how often and by whom will this be done? Is there a need for a psychiatric evaluation to help treat an underlying mental disorder? If the treatment is to be done in an outpatient setting, should the number of treatment sessions be increased? All these questions and more must be addressed in a comprehensive action plan.

Draft a short-term, positive action plan. One piece of the comprehensive plan is a short-term behavioral management plan that client and counselor put together collaboratively. This plan addresses what actions need to be taken in the next few days to help the client move toward problem resolution and away from suicide. A good plan is concrete, detailed, and within the client's ability to complete (Chiles & Strosahl, 2005). Its goal is to create small steps that can have a great impact on the client's quality of life, rather than trying to make major changes. It is critical that the steps in the plan be do-able for the client, lest inability to complete the action plan become one more failure. Two key questions are (1) "If you were able to do X in the next few days, would you see that as a sign of progress?" and (2) "Do you think X is something that you can actually do in the next few days, given the way you are feeling?" (Chiles & Strosahl, 2005, p. 181). Typical goals might be to decrease social isolation, increase positive events, engage in an activity with a high likelihood of success, increase physical activity, increase relaxation or self-care behaviors, and to engage in coping strategies that worked previously.

Coping cards, often used with clients with anxiety, might be useful. Clients make and carry index cards with step-by-step processes for specific coping strategies, such as deep breathing. If a distressing situation arises, the client goes through the steps. With a short-term positive action plan, the first follow-up session is typically conducted within 1-3 days after the initial intervention, perhaps even by a telephone check-up (Chiles & Strosahl, 2005).

Use a safety plan. Many counselors and mental health agencies use no-suicide contracts to elicit promises that clients will not engage in suicidal behavior for a specified period. However, there is no evidence that they actually reduce suicide attempts, and no-suicide contracts do not guarantee client safety. In fact, they may lead the counselor into a false sense of security. In one study, 41% of clinicians had a client complete suicide or make a serious attempt after entering into a no-suicide contract (Kroll, 2000). Anecdotal reports also suggest that contracts may increase the counselor's legal liability (Granello & Granello, 2007). Although there is no evidence that no-suicide contracts are therapeutically harmful, nor is there evidence that they are helpful. What is clear is that such contracts, if they are used at all, are most useful where there is a strong therapeutic alliance (Davis, William, & Hays, 2002). Mental health counselors who use no-suicide contracts should do so with the full understanding of their limitations, and with no illusions that they ensure client safety.

Safety (risk management) plans help clients know what to do when they have suicidal ideation or an increase in suicidal risk. They are essentially relapse prevention plans that give clients an early warning system and a clear response plan. Chiles and Strosahl (2005) caution that clients should be told that there is a potential for recurrence of suicidal thinking, and a safety plan gives them the skills they need to confront the potential of relapse. Clients should think about warning signs of increasing suicidal potential (e.g., social withdrawal, self-preoccupation, low acceptance of feelings) and specific strategies they believe would be effective in combating these early warnings.

Safety plans should be in writing and typically include names and contact numbers of support persons the individual has agreed to call, if needed. Most plans specify an individualized process that counselor and client develop together: a. If I start to feel anxious, I will take a walk. b. If that doesn't help calm me, I will call my friend X at [phone number], c. My next step is XXX). Some counselors put in their own emergency contact information, but at the very least the plan should have community contacts, such as local emergency mental health counseling and the number and location of the nearest emergency room. The safety plan should include a reminder that calling 911 is an option if the individual believes he or she is imminently suicidal and has no other safety mechanisms to call on. Clients can be asked to imagine obstacles that might get in the way of implementing the safety plan and together the counselor and client can rehearse strategies for overcoming those obstacles (Chiles & Stroshal, 2005). A safety plan is essential for all potentially suicidal persons who are not being seen in inpatient settings.

Step Seven: Follow-up

The type of follow-up needed will depend on the degree of risk. In general, all clients at increased risk for suicide require aggressive and frequent follow-up (Macdonald et al., 2009). During a suicidal crisis, clients at low to moderate risk benefit most from (a) intensive follow-up, including case management, telephone contacts, and possibly home visits; (b) a clear safety plan in case the risk escalates; and (c) short-term cognitive-behavioral therapy to improve problem-solving and reduce suicidal ideation (although this has not been seen to be as effective for long-term risk reduction) (Rudd et al., 1999).

Use the concept of funneling to ensure quality follow-up care. A single person must assume responsibility for follow-up care, coordinating treatment, and monitoring ongoing risk assessment. Funneling is the act of building case management protocols that return the client and all information about that client to a single point of contact (Chiles & Strosahl, 2005). That may be the mental health counselor, a crisis interventionist, case manager, or other mental health professional. Releases must be obtained so that all treating professionals can share all information. This is particularly important when working with suicidal clients because different treatment professionals may have very different ideas about how to work with them, leaving the client confused and bewildered.

Done appropriately, funneling helps prevent disputes or misunderstandings between multiple treatment providers, reduces inconsistent or contradictory responses to suicidal behaviors, and minimizes the client's potential for confusion about the treatment regimen. The person who is the identified point of contact should have (1) a clear approach to the problem that is articulated in the treatment plan; (2) a concrete, operationalized statement of what role each treatment provider should play; and (3) a method for frequent, specific feed-back about how the plan is working and any modifications that are necessary to ensure positive outcomes (Chiles & Strosahl, 2005). This plan should specify what to do or who to contact if the identified point of contact is unavailable.

Assess the intervention for future learning and enhanced care. After working with a client in a suicidal crisis, there is great opportunity for the counselor to assess the intervention strategies employed and make modifications for the future. For example, was the agency emergency suicide plan sufficient? If not, now is the time to update it. Were there open feedback loops among all treating professionals? Were all steps in the intervention directed by the best interests of the client? Does the counselor need to strengthen relationships with emergency room personnel or residential treatment staff to ensure a more smooth transition of suicidal clients in future? A candid post-assessment can give counselors important insights into how to better intervene with future suicidal clients.

CONCLUSION

As many as 30% of people in the general public have at some point in their lives had suicidal thoughts, and 20% have seriously considered suicide (Harris, 2003). Thus, it is imperative that mental health counselors have the skills and knowledge to manage suicidal clients as they work through assessment and intervention protocols. The 25 practical strategies given here are intended to help counselors craft specific approaches to operationalizing general suicide intervention guidelines. These are concrete and usable strategies for one of the most difficult populations to manage in counseling. Clearly, the strategies are intended not as an exhaustive approach to intervening with suicidal clients but to provide counselors with practical methods for engaging in the very difficult work of intervention with suicidal clients.

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Darcy Haag Granello is affiliated with The Ohio State University. Correspondence concerning this article should be addressed to Darcy Haag Granello, Ph.D., LPCC, Counselor Education, 448 PAES Building, 305 W. 17th Avenue, Columbus, Ohio 43210. E-mail: granello.1@osu.edu.
Table 1. A 7-Step Model with 25 Practical Strategies for Working with
Suicidal Clients

Step One: Assess lethality
    1. Ensure immediate safety
    2. Employ existing suicide emergency plans
Step Two: Establish rapport
    3. Stay with the client
    4. Manage countertransference
    5. Normalize the topic
    6. Convey calm through short declarative sentences and downspeak
    7. Move from an authoritative to a collaborative approach
    8. Support decision for help-seeking
Step Three: Listen to the story
    9. Listen, understand, and validate
    10. Slow things down
    11. Create a therapeutic window
    12. Categorize the problems
    13. Identity the message
Step Four: Manage the feelings
    14. Encourage emotional ventilation
    15. Acknowledge the psychache
    16. Teach tolerance of negative emotions
Step Five: Explore alternatives
    17. Minimize the power struggle
    18. Establish a problem-solving framework
    19. Engage social support
    20. Restore hope
    21. Help the client to envision possibilities and develop
        resilience
Step Six: Use behavioral strategies
    22. Draft a short-term, positive action plan
    23. Use a safety plan rather than a no-suicide contract
Step Seven: Follow up
    24. Use the concept of funneling to ensure quality follow-up care
    25. Assess the intervention for future learning and enhanced care
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Author:Granello, Darcy Haag
Publication:Journal of Mental Health Counseling
Geographic Code:1USA
Date:Jul 1, 2010
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