Counseling for Suicide: Client Perspectives

Despite comprehensive prevention and awareness programs, suicide continues to be the 11th leading cause of death among Americans (McIntosh, 1991, 1999) and 5th leading cause of death among Canadians (Health and Welfare Canada, 1994). Of even greater concern is the drastic increase in the rate of suicide for youths over the past 20 years (Health and Welfare Canada, 1994; Sakinofsky & Leenaars, 1997). Due to the prevalence of attempted and completed suicides, it is not surprising that suicide is the most frequent crisis situation encountered by mental health professionals (Bongar, 1992). Because suicidal individuals often communicate their thoughts to someone, the therapeutic approach taken by a counselor is of tremendous importance. To be effective in reducing suicidal behavior and ideation, an extensive understanding of the dynamics of the therapeutic process is necessary. As a result of the strong substantiating research that supports the efficacy of all psychotherapy approaches (Bergin & Garfield, 1994; Lambert, 1992), the question arises as to what constitutes effective treatment components. Among the factors contributing to therapeutic efficacy with clients, in general, that have been identified by researchers thus far are the therapeutic relationship (alliance), client motivation, client distress, and in-session emotional intensity (Beutler, 1999; Greenberg & Watson, 1998; Lambert & Bergin, 1994). Although these findings apply to clients, in general, much remains to be done to specify what works best with specific client populations (e.g., clients who pose a suicide risk). Although, typically, it has been the counselor's or investigator's point of view that has informed our understanding of this therapeutic process, the client's perspective is increasingly being recognized as essential in understanding the therapeutic process and efficacy of treatment (Heppner, Rosenberg, & Hedgespeth, 1992; Lietaer, 1992; Wilcox-Matthew, Ottens, & Minor, 1997). In addition, numerous researchers (Bachelor, 1991; Elliott & James, 1989; Gershefski, Arnkoff, Glass, & Elkin, 1996; Orlinsky, Grawe, & Parks, 1994) have recognized the importance of understanding the client's perception of the treatment process because it often differs from the counselor's perception. This expanding body of research provides a compelling argument for a more collaborative client-counselor relationship that respects and understands the client's frame of reference. Despite the growing evidence that suggests a need to incorporate the client perspective as a key element in the therapeutic process, the majority of the research literature on suicidal individuals has been focused on risk assessment, prediction, and crisis management strategies (Bongar, 1992; Firestone, 1997; Maltsberger & Goldblatt, 1996; Maris, Berman, Silverman, & Bongar, 2000). Although some research suggests that cognitive-behavioral strategies are helpful in altering patterns of thinking in suicidal individuals (Freeman & Reinecke, 1993; Hughes & Neimeyer, 1990), increasingly the relational aspects of counseling are being considered key components in treating suicidality (Eddins & Jobes, 1994; Jobes, 2000; Lineham, 1997). ERRORS OF TREATMENT The literature notes certain errors in treatment, which include failure to develop an understanding of the individual (Kreiger, 1978), therapist anxiety about death (Birtchnell, 1983; Hendin, 1981), and therapist difficulty in dealing with anger and hostility (Pope & Tabachnick, 1993). A critical and potentially dangerous error of treatment reported in the literature is the failure to assess the clients' access to emotional support (Maltsberger & Buie, 1989). Treatment errors, either by omission or commission, can provide counselors with an additional understanding of counseling suicidal individuals. Firestone (1997) identified the failure to prevent suicide as occurring in the absence of adequate risk assessment and preventive measures when events could have been foreseen. …