Working with Clients at Risk of Suicide

Emily St. Amant:

Welcome to the Voice of Counseling from the American Counseling Association. I'm Emily St. Amant with the ACA. Today's guest is Derek Lee, and he's joining us for a special episode for Suicide Prevention Month.

Before we begin, we want to offer disclaimer that this episode will contain discussions about suicide. If you or a loved one are experiencing thoughts about suicide, please call the new national crisis hotline at 988 to get immediate support.

Derek is the founder of the Hope Institute and Perrysburg Counseling Services, where he serves as CEO and sees clients on a limited basis. Derek also teaches at Texas Tech University Health Sciences Campus in the Clinical Mental Health Counseling Program. And he's completing his PhD at the Ohio State University in Counselor Education and Supervision.

His research interests includes suicidal behaviors and training clinicians to work with individuals struggling with suicide. Derek is trained in the collaborative assessment in management of suicidality, and was the first clinician to earn the Cam Certified status. Thank you so much for joining us today, Derek. How are you?

Dr. Derek Lee:

I'm doing very well. Thank you.

Emily St. Amant:

So let's just jump right into it here. How did you develop a passion for, and a specialty in working with clients at risk of suicide?

Dr. Derek Lee:

Unlike a lot of people in the field, I don't have this great backstory. Suicide had touched my life as a child. I lost an aunt and I heard the occasional story, but it was kind of shrouded mystery. And it wasn't something that I planned on going into, but I took a job with a local organization called Rescue Incorporated. And Rescue was the local center for suicidal crisis.

And in working there, it was a good experience. But one of the things that I've found very frustrating was that it was very hard to get kids, specifically adolescents, after care. You'd call around and a lot of people wouldn't take adolescents, and almost nobody wanted to take adolescent children.

And that made me kind of go into outpatient therapy, working with that population. Because one of the things I found is that this population was so eager to get better. They wanted the help. They wanted to get better. If you give them a path, they would take it, but there weren't people giving them those opportunities. So it was really just one of those moments in time that I'm very thankful for, but it was just kind of meant to be.

Emily St. Amant:

Okay. So not something you set out to, but because of your experience, happened a job or opportunity came around and you saw firsthand what the need was. And like you said, I think a lot of us in the field have seen, there are not enough providers to go around.

But then again, providers who are willing to work with children and teens, and especially youth that are at risk of suicide as well. I think that it's really hard to find somebody to take care of those individuals. So sounds like that natural experience that you had really led you to want to learn more and to get into it more.

Dr. Derek Lee:

Absolutely.

Emily St. Amant:

And I think that taking a step back from in our training as counselors. And we don't get a lot of really specialized training in working with suicide or treating suicide. And I think unfortunately, a lot of us hold onto maybe some myths or misunderstandings about suicide.

So what are some of those things that maybe we need to unlearn? Even for us counselors, for us to really know how to think about and work with people at risk of suicide?

Dr. Derek Lee:

You're absolutely right. I think one of the most misunderstood myths is that they're difficult to work with. They're really not. As a site supervisor for practicum internship students, I've dealt with many universities that don't want students working with suicidal patients initially. And to me, I'll talk to the university because to me that's just a travesty. If we're not willing to do that, we're actually neglecting our client base.

And I don't think we should be scared of working with suicidal clients as long as we're trained to work with them. And that's something that every one of my practicum students actually goes through CAMS training within the first month of coming to our facility. So they are prepared, they've been educated, they know what they're doing moving forward, and they get active supervision on it.

I think something very closely tied also has to do with the liability. People think there's this high level of liability in working with suicidal individuals. And the liability really comes from not following evidence-based practices and not documenting and not actually having measurements. So if you're using an evidence based practice and you have measures, it's actually very difficult to sue a counselor who's doing things correctly, even if you have a poor outcome.

I think the third piece that's important to identify too, is that there's a belief out there that hospitals stabilize patients. And as somebody who worked in a hospital setting, we don't. We have the ability to monitor them 24 hours a day to make sure that they're not doing risky activities. Hospitals also are able to do immediate med changes, or I should say immediate being within 24 hours. But the reality is most people leave the hospital at a higher risk of suicide than they went in. That's what the research tells us.

Emily St. Amant:

Oh, wow. I think that's really hard to hear, is we think that we're helping people, we're getting them this very intensive level of care and treatment. And then when they leave, like you said, they're at maybe more risk than they were when they got there. That's tough to hear.

Dr. Derek Lee:

I think what you just said is really important because we equate going to the hospital with treatment, but very rarely is the hospital actually providing treatment. They're providing, you've got three shifts of people coming through to make sure you can keep eyes on them, even at 3:00 and 4:00 o'clock in the morning. But there's very little treatment going on.

Emily St. Amant:

Right. So it just seems like that would make it even more important for more people to be able to work with a client service of suicide who do need treatment, who do need that ongoing support. And you mentioned CAMS care. So that's one of the ways that people are trained to work with clients. Can you tell us more about that? What that is?

Dr. Derek Lee:

Yes. CAMS is the Collaborative Assessment and Management of Suicidality. It was created about 30 years ago by Dr. David Jobes. Who I should also mention, he was actually a mentee of Marsha Linehan who developed dialectical behavioral therapy. So there's a very strong tie between the two in looking at things like a reasons for living inventory and instilling hope.

And I think one of the great things about CAMS is that it's actually a model that you can follow. You can be trained in it and you can follow it. It's a very economical model, especially for students who want to get trained. But it gives you an actual pathway to treatment, not just how to manage a session. But a treatment to take somebody from a suicidal episode to deescalation, to actually resolving the suicidal issue. And I think that's critical.

Emily St. Amant:

Absolutely. To be able to assess, follow them through, intervene, know you're helping, et cetera. And that's one way for people to learn more about how to work with clients and support them. What are some other things that counselors can do to sharpen their skills, to learn more about what you said, those evidence based practices?

Dr. Derek Lee:

So currently SAMSA identifies four evidence based practices. And I think two of the best are CAMS and then Brief Cognitive Behavioral Therapy. And what I like about both of them is that CAMS, you can typically stabilize somebody in roughly six sessions or six weeks. BCBT is about 12 weeks, but they both have a very quick stabilization program. Versus I'm actually a DBT therapist as well.

And I love DBT but DBT in itself is a much larger process and can take a little bit longer for stabilization. So these are much more acute. And the other great thing about these, is that they're very applicable for people who don't necessarily have severe underlying mental health issues.

The SAMSA data shows that almost 40% of individuals who struggle with a suicidal crisis over the course of a year, don't actually have an underlying issue or need ongoing therapy. So by using some of these brief methods, it allows us to give good treatment, but also allows people to not get latched into a system that's already overburdened.

Emily St. Amant:

Yeah, absolutely. Because I think it's giving people the right care when they need it, really makes a lot of difference. And I think that you just spoke to something that maybe people that are experiencing suicidal crisis of some kind, maybe they get misdiagnosed or they get mis-routed in some way, somehow.

So I think that being able to expand out those services. And for those of us who do encounter the client, we know how to help them. We know what to do. Because that's such an opportunity and you want to strike while the iron's hot, so to speak.

Dr. Derek Lee:

Absolutely.

Emily St. Amant:

Because if you don't, the risks, the stakes are pretty high in a lot of clinical situations, but especially this one, right?

Dr. Derek Lee:

Absolutely.

Emily St. Amant:

Yeah.

Dr. Derek Lee:

And I mentioned a couple trainings. There's also the American Association of Suicidality or Suicidology. And the American Foundation for Suicide Prevention. They both have fantastic websites with really robust resources that people can explore. And a lot of the resources are free.

Emily St. Amant:

That's a good call out. And I think that we just kind of talked about this a little bit, but why isn't it so important for counselors to have ongoing training in suicide risk? Why is maybe a one and done CE training or course, why is that not enough?

Dr. Derek Lee:

Well for a number of reasons, the first being data changes over time. And especially in this arena, it hasn't been studied extensively. I mean, it's kind of shocking how little we've studied it over the last 30 years.

But one of the things that we found is just 15 years ago, no harm contracts or safety contracts were very common. And there are still very appropriate safety planning contracts that are done. But a lot of the traditional methods are actually not good methods to use now.

Something just last week I had somebody talk to me who's not used to working with suicidal clients. And they said, "Well, we talked about it and I asked them if they could promise me to stay safe until we met again." And that alone is actually not a good practice because it can strain the therapeutic relationship. It can create guilt when the person is struggling with ideation. And actually sometimes they're less likely to reach out because they don't want to disappoint the therapist.

And even though it's a very natural thing to do in our heads, when it comes to research, it's not. So we need to be able to stay up to date, because I'm going to guess 50% of the research we knew 15 years ago is not applicable, or we have completely different outlooks on it today.

Emily St. Amant:

Oh wow. Wow. So I think a lot of that training that we get is to help us counteract our intuition, what feels right? Maybe we're trying to help our client in that situation by saying, "Please don't hurt yourself until I see you again." But I think that, like you said, with the research shows something different. Often what is effective is counterintuitive, right?

Dr. Derek Lee:

Absolutely. Yeah. I mean counselors that do that, mean well. I mean it's not meant to be a shot because we all have that. I can tell you myself, I had that instinct early on before I trained and before I knew better. We're trying to help people. We're thinking that we're leveraging that relationship, when actually we're potentially damaging it.

Emily St. Amant:

Yeah, absolutely. So in your work with your clients, what were some of the things that you've seen be most helpful for them as they're working towards finding recovery from experiencing suicidal ideations? What are some things that just in general, your clients have found helpful as far as interventions practices?

Dr. Derek Lee:

I would say two of the things that are most integral in helping them get better are the installation of hope and helping them focus on reasons for living. What they're going through at that point is extremely painful. And when we think about suicide as an option, it's really about escapism.

They're trying to escape this overwhelming pain they're in and they've lost sight of hope. They've lost sight of why they want to live. So that hope is such a big factor. But when we talk about hard skills, I think two of the really powerful things can be mindfulness and distraction techniques.

Because again, they're relying on suicide as a way to escape. And sometimes we can utilize mindfulness or those distraction techniques for that same escape. It's a much more shorter duration, which is what we want. But it's those moments, when you've been in excruciating mental agony for days or weeks, just a few minutes of peace can go a long way.

Emily St. Amant:

I think it's so important to know that there's the suicide risk curve and doing some education about, we know this too shall pass, not to sound too cliche there. But to provide some education about how people's risk can increase, but then it will decrease.

You're not always going to feel this way. And then finding whatever sources of hope, things to look forward to in the future. Having hope for their future self is a really, really important thing for us to work on with our clients.

Dr. Derek Lee:

Absolutely.

Emily St. Amant:

So as far as for counselors who maybe are interested in specializing in the treatment of suicidality, if they want to have a specific focus in that, where would they even start?

Dr. Derek Lee:

That's a great question because most people don't know where to start and it's something, unfortunately our graduate schools are not great at training on yet. And again, that's not meant to be a negative thing towards graduate schools. They have so many things that they've got to train in such a short period of time.

But to me, suicide is a very important thing to focus on. I would say start with an evidence based model and I do like the brief models like CAMS or Brief Cognitive Behavioral Therapy because they're relatively quick training, but they also give you actual skills to get from A to Z, versus just some interventions. They also help build confidence. So you're actually going towards mastery versus just having a few techniques in your pocket.

The other thing I think is really important is actually getting supervision. And this is something that people talk about time and investment. But when we're talking about these skills and saving lives, literally saving lives, I think getting supervision from somebody that both knows the model and works with the population is invaluable.

Emily St. Amant:

Yeah, absolutely. So get the right training, get the right experience, but then also get the right supervision.

Dr. Derek Lee:

And it doesn't have to be terribly expensive. I believe as a clinician, you can do a full CAMS training for like $350. And I'm not saying that's cheap, but compared to some of the models out there where they're charging 1000s, it's definitely affordable.

Emily St. Amant:

That's all, I think really helpful information for our counselor listeners. And this episode is for Suicide Prevention Month. So speaking to some of the more broader ways we talk about suicide, maybe portray suicide in the news or in the media. Why is it so important to get that right? And to do that safely for everyone? Not just for counselors, but for if someone's going to write a news article or post online about it, what are some things people need to keep in mind?

Dr. Derek Lee:

I think one of the things that's really important about being accurate, is that it helps people. People who are struggling with suicide are going to be more relatable to it if it's accurate. If it feels genuine, they're going to be relatable, and that there's going to be a sense that there is help there.

I think part of the problem we have is just the opposite. Quite often, it's romanticized in media and the truth is there's nothing romantic about suicide. Suicide's about pain and the act of completing is about the transfer of pain. But what we have to have people understand is that there are actual solutions to the pain, and suicide isn't really one of them.

Emily St. Amant:

Right. So being genuine that you're just starting from a place that you really care. Maybe speaking naturally, not copying and pasting a message. That's a nice gesture, but something that's more personal, something that's more personalized and genuine goes further. It's received better, right?

Dr. Derek Lee:

Absolutely. Well, again, we're talking about people who are in extreme pain and they don't want to hear a cliche. They don't want to see a meme, they want connection.

Emily St. Amant:

Right. And I think that we've seen the numbers, we've seen the reports, and I think this is something that we all need to be prepared to talk to our friends and family about. Not just our clients, for the counselor listeners, but I think everybody needs to start to be more comfortable with talking about suicide.

And learning to do things like asking directly, "Are you having thoughts of suicide?" Not beating around the bush. Not being indirect and saying things like, "Are you thinking about hurting yourself?" We really need to be direct. I think that's one thing that people can do to make sure they're prepared if someone in their life is experiencing a crisis. That maybe if someone doesn't know anything else about this, what are some things that just anybody can do to get prepared for someone in their life experiencing a suicidal crisis?

Dr. Derek Lee:

I think you just hit on one of the most important things, is actually asking the question. Not beating around the bush. And what I find with adolescents is they're very comfortable talking about it. It's their parents that aren't. A lot of parents are worried that we're going to plant the seed. We're going to make them start considering it. That's really not what the research shows us. If they're thinking about it, they're thinking about it.

So if we ask the question though, it gives them permission, it removes shame. It starts to downplay that stigma. And I think that also ties into when we talk about hope, people are so scared to breach the topic of suicide because it seems so big and scary and heavy. But the truth is I found a lot of joy in working with individuals with suicidal ideation. Because when they come back, it's such a big triumph.

Most of our people who struggle with ideation, or even attempt, will be okay in the end. And that is a tremendous, tremendous bounce back for them. That's something that they can celebrate. And I don't think a lot of people understand the joy that's found in overcoming suicidal ideation.

Emily St. Amant:

Yeah, absolutely. So once people go through this and then get to the other side of it, they can start to live a full life and get back to experiencing their life and finding meaning and purpose and joy and connection and all of those things. But you can't do that unless you actually acknowledge reality, what's going on right now first.

Dr. Derek Lee:

Absolutely.

Emily St. Amant:

So yeah, I think just having ...

Dr. Derek Lee:

Well, it's kind of that old saying, they're just kicking the can down the road. It's not actually going anywhere. For individuals dealing with suicidal ideation, quite often it's not going to disappear with time. It'll shift and change, but for a lot of people out there, it's just going to get pushed down the road.

But if we deal with it, we can actually get through it relatively quickly. And when I say relatively quickly, I opened a center that Dr. Jobes is heavily involved in. And what we're finding is that we're able to get rid of ideation, to really stabilize adults in six weeks, and adolescents in 5.2. And there's a percentage of those individuals that don't need ongoing therapy. So they're able to actually just return to life. And to me, that's amazing.

Emily St. Amant:

It really is. It really is. Thank you so much for joining us today, Derek. This has been an incredible conversation, an important conversation, and I'm so glad that we were able to have you on to talk about these really important topics.

Is there anything you want to share with the audience to wrap up? Where they can find you on socials? Or how they can get in touch with you?

Dr. Derek Lee:

I'm really not much of a tech guy, but our office is Perrysburg Counseling.com. You can also find me at The Hope Institute.net, which is our crisis stabilization facility. And my emails are on both of those websites. So I try to be pretty accessible. But thank you so much for having me.

Emily St. Amant:

Yeah. Thank you so much. Thank you again for joining us. And before we go, we wanted to let you know about a few other cool things we have going on here at the ACA. We are very excited to announce that we've released a series of videos about the 988 crisis hotline. And this can be found at Counseling.org. Select continuing education, product catalog, to learn more.

We are also very, very, very excited about our new virtual conference experience. And that's going to be October 17th through the 21st. And we are going to be featuring education sessions, networking opportunities, and some keynote speakers. Sessions will be available on demand until December 31st. So you don't want to miss out on that.

Or those who attend live, you'll get to participate in live networking events with your peers and participate in live Q and As with some of our featured session presenters. So we look forward to seeing you there.

Be sure to subscribe to the Voice of Counseling on Apple Podcast and Google Play. And be sure to follow us on social media to hear even more updates about all the things going on with the ACA. Thank you again so much for joining us. And we hope you have a great day.

Speaker 3:

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