The COVID-19 pandemic has pushed many counselors into the practice of telehealth, for the first time in their careers. Navigating new technology, attending differently to nonverbal communication, and dealing with periodic disruptions can distract counselors from the evidence-based practices for providing care to suicidal clients. Dealing with quarantine and social distancing situations, along with the financial and economic impacts of the COVID-19 pandemic, has increased depressive and anxiety symptoms for many clients. When working with suicidal clients, it is particularly important to continue providing support, guidance, and encouragement and not allow the new telehealth environment to distract you from providing the minimum standard of care.
- Remember to Ask: Even as clients develop the ability to move away from their suicidal thinking and behaviors, it is important to establish that we are going to keep checking in with them on their suicidal thoughts. When you have established with your client that you will be checking with them regularly on the topic of suicide, remember to follow-through. Asking the client clearly and directly about suicide gives the client permission to discuss this topic, which may feel taboo to them, and establishes that you are a safe person with whom they can discuss their suicidal thoughts.
- Utilize a Standardized Suicide Risk Assessment Tool: Brief screeners like the PHQ-9 provide clients with an opportunity to express if they have had suicidal thoughts recently. If clients indicate they have suicidal thinking, follow-up by completing a suicide risk assessment tool such as the Columbia - Suicide Severity Rating Scale (C-SSRS). In telehealth settings, you can read the questions out loud and have your client respond verbally. Consider supplementing the use of a standardized tool with additional exploration of the client's suicide thinking including the frequency, duration, and intensity of the client's suicide thoughts, their reasons for dying and their reasons for living, and scaling around the client's intention to act on their suicidal thoughts. Remember, suicide risk assessment is about planning, not a prediction. As you identify areas of suicide risk, work with the client to plan ways to minimize or remedy those risk areas.
- Use the Safety Plan in your Ongoing Treatment: Development of a collaborative and individualized suicide safety plan with each suicidal client is considered the minimum standard of care. Remember that this safety plan is not a one-time task to develop with the client and then file way in the client's chart. Use the safety plan as a central aspect of your treatment with the client. How many times since the last session has the client had suicidal thoughts? When they did, did they utilize their safety plan? What steps on the plan provided them some relief? Which did not? Can the ineffective steps be replaced with something more effective?
- Supervision and Consultation: Edwin Shneidman positioned that mental health professionals should always be in consultation or supervision regarding clients who present with even a moderate amount of suicide risk. Providing ongoing care to suicidal clients can be highly emotional and stressful work for counselors. Make sure you have consultative or supervisory support from a professional who can objectively assess if you are following best practices for suicide prevention and intervention. Attend to the ACA Code of Ethics (B.7) regarding confidentiality in case consultation settings.
- Document Your Work: Do not let the move to the online setting cause you to forget to document your work in the client's file comprehensively. Each of the previous steps should be clearly documented in the client's file each time you complete the step. Treatment frameworks like the Collaborative Assessment and Management of Suicide (CAMS) and its Suicide Status Form (SSF) can assist clinicians with systematic documentation of suicide treatment but even without a tool like the SSF, make sure you document the client's suicide risk and how you are working with the client to reduce and remedy that risk each session.
The Colorado Counseling Association is developing continuing professional development training on evidence-based suicide prevention, intervention, and treatment for LPCs, LPCCs, and students. Check the CCA website regularly for updates on the availability of these pieces of training.
Dr. Gregg Elliott has been a Licensed Professional Counselor since 2003. Dr. Elliott provides group therapy part-time in a Denver-area inpatient hospital, and his clinical expertise and research interests are in working with suicidal clients. He has over 30 presentations and publications, and many focused on the topic of training counselors to work with suicidal clients. His most recent publications and current research have focused on inter-state licensure processes in the Rocky Mountain region, the training of counseling students on working with suicidal clients, the intersection of childhood trauma and suicidal ideation, and the experiences of grief and loss of adult adoptees.
Follow this link to learn more about Dr. Gregg Elliott.