Suicide and Intersectionality

 

Emily St. Amant: 

Hello and welcome to the Voice of Counseling from the American Counseling Association. I'm Emily St. Amant, and joining me today is Janel Cubbage, who is here to talk about suicide and intersectionality for counselors.

Emily St. Amant: 

Before we begin, we want to offer a disclaimer that this episode will contain discussions about suicide. And if you or a loved one are experiencing thoughts about suicide, please call the new National Crisis Hotline at 988 to get immediate support.

Emily St. Amant: 

For more information about counseling individuals at risk of suicide, check out the ACA book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach by John and Rita Sommers-Flanagan, which can be found on our website at counseling.org in the 'publication' section.

Emily St. Amant: Janel Cubbage is currently the Strategic Partnerships and Equity Program Manager at the John Hopkins Center for Gun Violence Solutions.

Emily St. Amant: She began her career working with adjudicated youth and transitioned to working as a suicidologist. She's managed prevention programs for the military, served as the Director of Suicide Prevention at Maryland's Behavioral Health Administration, and she's shared Maryland's Governor's Commission on Suicide Prevention.

Emily St. Amant: Janel works as a licensed trauma therapist specializing in providing therapy for minoritized communities.

Emily St. Amant: Janel holds a Master's of Science in clinical mental health counseling from McDaniel College and is a recent fellow of the Bloomberg American Health Initiative.

Emily St. Amant: She earned her master's in public health at the John Hopkins School of Public Health in 2022.

Emily St. Amant: Thank you so much for joining us today, Janel. How are you?

Janel Cubbage: I'm good. Thank you so much for having me. I'm really excited for this conversation.

Emily St. Amant: Yeah, we really are too.

Emily St. Amant: So a lot of us counselors, one of the main reasons we wanted to focus on this topic in particular is a lot of us don't feel very comfortable or prepared when it comes to knowing how to work with a client who may be at risk of suicide. And based on your experiences working in the field, maybe you can speak to why that is.

Janel Cubbage: I think there's a couple reasons, one of which goes back to our training programs.

Janel Cubbage: I think that, unfortunately, suicide is often taught in our legal and ethical classes, as it should be because it is a legal and ethical issue, but it's first and foremost a clinical one, and I don't think that a lot of programs necessarily focus on the clinical aspect.

Janel Cubbage: Suicide risk assessment and management could be an entire course in and of itself. And I think sometimes it gets addressed maybe in assessment in how to do risk assessment, but there are really important steps to take after the assessment to help your client stay safe and also do some clinical decision making around what level of care they need in that moment, because not every person with suicidal ideation needs to go to the hospital.

Janel Cubbage: But I think the emphasis on suicide as a legal and ethical issue is probably what drives a lot of that anxiety: fear of being sued or doing the wrong thing. So unfortunately, I think that's what drives it. And then not receiving the proper training and attention to how to properly assess and make decisions to keep your client safe.

Emily St. Amant: Okay, so it goes back to maybe people not getting as much information as they need to on the front end, which kind of has an impact down the road. And we kind of just hope that along the way, maybe the employer or a supervisor of a location treatment setting will provide that education to the person, but maybe that doesn't always happen.

Emily St. Amant: And so I think a lot of people, if they don't have the education that really prepared them, I think it makes sense to be a little nervous, right?

Janel Cubbage: Hmm-mm. Yeah, you want to feel prepared.

Emily St. Amant:

Right.

Janel Cubbage:

And I will say, as someone who works in the suicide prevention field, I consider myself a suicidologist, even if you have training and experience doing this, I wouldn't necessarily say that that takes the anxiety away. I think that anxiety is a very natural feeling. Someone told you that they're having thoughts of ending their life; that's big, that's emotional. And not just for the person who's having the thoughts of suicide, but for you as a counselor too.

Janel Cubbage:

So I think it's important to acknowledge that and know that, even if you do receive training, even if you do feel prepared, that doesn't mean that you are not going to feel anxious when the time comes.

Emily St. Amant: Okay, yeah, that makes sense, because I think that it's that feeling that this person matters and this is a very critical situation here. And so being able to identify how we're feeling and manage that in the moment and know that it's okay to feel that way, I think that that might help people feel a lot better. Like it's okay to be anxious, it's okay to be a little nervous, because I think that says maybe people really care about doing the right thing too.

Emily St. Amant:

Can you speak to you why it's so important for all counselors to know; not just screen for assess, but maybe address suicide risk, whether they're working as a therapist or a school counselor even? Why is it so important for all of us to be aware of?

Janel Cubbage:

Suicide doesn't discriminate. It affects us across the lifespan, it affects us across all demographics. It's present in all of the settings that counselors would be in. And it's much more common than people realize.

Janel Cubbage:

So some of the estimates that we have suggest that at any point, about one in 20 people are thinking about suicide. So 5% of the population.

Janel Cubbage:

So that's probably much higher than most people realize. And so the likelihood is that, throughout your career, you're likely to encounter someone who is having thoughts of suicide.

Janel Cubbage:

If you don't, great, but it's better to have the skills and know what to do in the event that you do encounter it. And if you have the skills and you don't end up needing them, then at least you were prepared and you did your due diligence.

Emily St. Amant:

Absolutely.

Emily St. Amant:

So one in 20; that's a lot of people that will experience these kind of things. So it makes sense to sort of have universal precautions or universal education about these things.

Emily St. Amant:

And if we're not going through it ourselves with our clients, maybe someone's supervising someone who is, and supervisors need to know how to support their supervisees.

Janel Cubbage:

Exactly. When we think about our clinical reach, it's beyond our own caseload. So trainees that we're supervising could encounter it. That expands the pool of clients that we're touching, right?

Janel Cubbage:

But even people in our personal life that might be experiencing that. There's so much overlap at times with our profession and our personal life. It's inevitable because we're working with the human condition. So it can also just be helpful in those aspects.

Janel Cubbage:

And even outside of your counselor hat, you never know who you're going to encounter.

Janel Cubbage:

One story that really sticks with me through all of my work that I've done in the field is the story of Kevin Hines who made a suicide attempt on the Golden Gate Bridge and survived miraculously, and he now is an advocate in suicide prevention. He goes around and tells his story.

Janel Cubbage:

And he tells the story of the day that he made a suicide attempt; that he made a pact with himself that if one person asked if he was okay, he wouldn't attempt suicide.

Janel Cubbage:

And so he rode the bus to the bridge. He was crying; the bus driver told him to hurry up and get off the bus. He was standing by the bridge and crying; two different people walked up and asked him to take their picture. No one asked him if he was okay.

Janel Cubbage:

So I think it's just a powerful demonstration of being aware, knowing what to do, but also we may encounter this outside of our clinical roles.

Emily St. Amant:

Yeah, absolutely. And I think that speaks to why education for everybody is important and why a focus on suicide prevention at the national level, we'll get into that in a minute, it just hammers home why that's so important for us to all be aware.

Emily St. Amant:

When it comes to maybe the intersection of suicide risk and people that are a member of a community or people that hold membership in a marginalized identity, especially for people that hold more than one, their risk probably goes up for various things because they're experiencing more and different types of marginalization and oppression.

Emily St. Amant:

So can you talk about those people that experience that and how it connects with suicide risk?

Janel Cubbage:

Yeah.

Janel Cubbage:

So I think it's important to remember that all of our identities are constantly interacting with one another. So we never have just one identity that is occurring in a vacuum, and we don't have the luxury of just putting other identities on the table or picking them back up or whatever the case is.

Janel Cubbage:

So when I go out in the world, people see me as Black. That's one identity that I have. They also see me as a woman. So my two identities, my gender and my race, are constantly intersecting. That's why we call it intersectionality.

Janel Cubbage:

And that oppression, or privilege, depending on your identities, can compound. And so when people hold more than one minoritized identity, we have to be aware of the risks that are associated with that.

Janel Cubbage:

Many of them are similar, in that they can create a sense of othering.

Janel Cubbage:

So threatening someone's sense of belonging and acceptance and social connections, which are really important in terms of protection from suicide; experiencing discrimination.

Janel Cubbage:

There's research out that suggests that experiencing everyday racial discrimination is a painful and provocative event that can facilitate someone acquiring the capability for suicide.

Janel Cubbage:

So those risks on top of historical oppression, the research that we have on intergenerational trauma and how that can be inherited on the genetic level, but also through social mechanisms, is really important to keep in mind.

Emily St. Amant:

Suicide risk and marginalization, intersectionality, kind of like how that increases someone ... Basically, those are all risk factors, and it increases those risk factors.

Janel Cubbage:

Yeah.

Janel Cubbage:

So I actually finished my MPH this May, and I wrote my capstone on the intersection of racism and suicide risk.

Janel Cubbage:

So I think that interpersonal racism, I think that's an easy connection for people to make, of experiencing interpersonal racism and how that could lead to someone having thoughts of suicide.

Janel Cubbage:

I really focused on structural and institutional racism and how that creates factors and components of the interpersonal theory of suicide to drive suicide risk.

Janel Cubbage:

So it's important not to just think about the interpersonal experiences that your minoritized client may be dealing with. It goes beyond the microaggressions and everyday discrimination or exclusion and ostracizing from certain groups. There are also very real structural barriers that your client is facing that have an impact on suicide risk, like access to care; and if they're able to access care, are they receiving the same quality of care?

Janel Cubbage:

There are enough studies to show us that they may not be. And access to care and having a caring support team is a protective factor for suicide. So that might be denied to your client based on their minoritized identity.

Emily St. Amant:

Yeah.

Emily St. Amant:

So I think a lot of those systems, you know, housing, having that sense of belonging, there's so many other factors that play into someone's risk of suicide and so many things that are more of a societal community level where interventions are needed. Because if someone has housing insecurity, that just puts everything more escalated, more quickly.

Emily St. Amant:

And we hear about the various approaches and levels of impact for suicide prevention, and a lot of us counselors, we focus, which I personally love, that focus on that one person; that you know how to show up for that person, you know how to see them, hear them, identify what they need.

Emily St. Amant:

But I think it's also important to see that macro level too, right?

Emily St. Amant:

So can you tell us maybe more about what the public health or maybe the more macro approach to suicide prevention is and what it looks like?

Janel Cubbage:

Sure.

Janel Cubbage:

So a macro level approach could be policy.

Janel Cubbage:

So addressing policy for access to lethal means like firearms. We know that mandatory waiting periods, permit to purchase, child access protection laws, extreme risk laws are associated with reductions in suicide in states where those policies exist and are implemented.

Janel Cubbage:

I also think policy that addresses more upstream risk factors, like a livable wage, marriage equality, access to reproductive healthcare and abortion, housing security are really important and unfortunately not always prioritized, because a lot of our field focuses on the intervention of when someone is at risk and already having thoughts of suicide.

Janel Cubbage:

So a macro level hopefully has a more upstream approach to addressing some of those factors to prevent someone from even experiencing thoughts of suicide.

Janel Cubbage:

Stigma. Campaigns could be at a macro level. Although it can be really hard to implement wide scale messaging campaigns like that, and cultural attitudes take a really long time to change.

Janel Cubbage:

One macro level initiative around suicide prevention is with media reporting. There are certain components within media reporting on suicides that have been associated with increases in suicide deaths and attempts.

Janel Cubbage:

So after Robin Williams died by suicide, the US experienced an unexpected increase in suicide for the three months following his death. And after Kate Spade and Anthony Bourdain died by suicide, there was a significant increase in calls to the National Suicide Prevention Lifeline.

Janel Cubbage:

All of those cases involved reporting on their suicide deaths, and unfortunately, the method by which they died. I believe some of them published contents of suicide notes and things of that nature. And those are factors that are associated with increases in suicide.

Janel Cubbage:

So one macro level approach is working with the media in safer reporting on suicide.

Janel Cubbage:

And one way as counselors we can do that is, when we're contacted to do interviews with the media, ensuring that they know that there are actually guidelines that exist that are really helpful that let them know what to do, what to avoid, to make sure that they're safely reporting, and also make sure that we are safely reporting when we're talking about suicide and that we are not providing information that could be harmful to someone who's vulnerable.

Emily St. Amant:

Yeah. So I think it's really important for us to have that background understanding.

Emily St. Amant:

And there's a lot of social contagion factors that come into play with suicide specifically. So I think that that speaks to why we need to get more education training about the individual level, but also the public health interventions and such. So there is that connection between upstream, downstream; they play into each other, for sure.

Emily St. Amant:

So when counselors are working with people, maybe families groups or in their communities, when it comes to working with our clients, what do we need to be aware of when it comes to the public health perspectives, but also the systemic and interpersonal experiences of being marginalized or being oppressed? What are some things that we need to keep in mind?

Janel Cubbage:

So one is that ... Our therapy office is just that. Our therapy office, there is a whole world that is impacting our clients outside of it. So we may feel like we just work on the individual level, but there's so much more that we can do in terms of advocacy and trying to change systems that we know are contributing to the harm and traumatization of our clients.

Janel Cubbage:

I personally specialize in treating trauma, and so it's hard for me to ... When I'm sitting with clients and hearing their stories and how they've been harmed, it makes me really angry at the systems that have failed them or have harmed them, and that in part drives my advocacy work to try to make a better world and a world worth living in.

Janel Cubbage:

I think that in suicide prevention, a lot of times you hear people talking about keeping people alive and having a life worth living. And those things are important, but we need to be looking at why people want to leave the world and trying to change those things. And as counselors, we do have a role and an ethical responsibility to advocate for social justice, and suicide prevention is very much a social justice issue.

Emily St. Amant:

Yeah, I think that that is a hundred percent true.

Emily St. Amant:

I think that unless you've experienced it yourself, you know, being a therapist, working with people who are coming up against one barrier after another, the client's frustrated, the client is impacted in their mental health, their physical health even, but it's frustrating, it's very frustrating to want to help this person, but they also have all this other stuff going on in their life. If it's a lack of transportation to get to their job or to get to one thing or another, it's just ... You see these barriers. And I think that a lot of us ... They play into each other because it's our ethical imperative, but it's also, once you've experienced that in the therapy room, you see how important it is. You see how big of a difference the outside world, like you said, impacts people and their lives.

Emily St. Amant:

So what are some other things that counselors need to be aware of or keep in mind when working with clients that are more vulnerable, or just in general when it comes to gaining competency to work with suicide?

Emily St. Amant:

Or maybe someone wants to specialize in treating suicide. What are some things counselors need to know?

Janel Cubbage:

If you want to specialize in suicide, look up organizations like the American Association of Suicidology. They have a lot of trainings for clinicians specifically, as does ... I believe it's the Suicide Prevention Resource Center. They both have two very similar trainings. AAS has Recognizing and Responding to Suicide Risk, and then there's also Assessing and Managing Suicide Risk. So those will be good places to start.

Janel Cubbage:

There are also trainings on counseling on access to lethal means, or CALM training, and that will help give you the skills to talk to clients about reducing their access to lethal means, which is very important.

Janel Cubbage:

If you look up Barbara Stanley's Safety Plan, it's free and available in the public domain, as is the Columbia Suicide Severity Rating Scale, or the C-SSRS. And the C-SSRS website has many different versions of the scale as well as different webinars and trainings on how to use the tool.

Janel Cubbage:

So those will be good places to start.

Janel Cubbage:

And looking for continuing education opportunities in your area. Some states have even taken the step to mandate that some continuing education hours be focused on suicide prevention.

Janel Cubbage:

And maybe even thinking about contacting your local crisis center. They may be doing trainings for the community that you could benefit from attending.

Janel Cubbage:

Another one that's not necessarily geared towards clinicians but can benefit clinicians is ASIST, or Applied Suicide Intervention Safety Training ... ? It's been a while since I've taught ASIST, but it's A-S-I-S-T. It's by LivingWorks and it's a two day workshop that teaches people suicide intervention skills; how to safety plan, how to hear someone, and actually really sit and be with them and get past that panic of, "Oh my gosh, I have to tell them why they need to live."

Janel Cubbage:

And I also think it's helpful to contextualize our role in this. Our clients have agency. It's my role to help support them to get the care that they need and stay safe. I think a lot of times we get in our heads that, "Oh my gosh, I have to save this person's life." And we do have responsibilities to help keep them safe, but I'm trying to make the-

Emily St. Amant:

It's like a partnership. It's a partnership with a client.

Janel Cubbage:

It's collaborative. Yeah.

Emily St. Amant:

Yeah.

Janel Cubbage:

And ... Yeah, I'm trying to describe the difference between that lifesaver superhero kind of role that comes out.

Emily St. Amant:

Yeah, it's not all on us. It's a partnership. We can kind of say, "Hey, there's the path. I'm going to walk it with you." Right? It's not all on us. It's you and the client doing it together.

Janel Cubbage:

Hmm-mm.

Emily St. Amant:

Yeah.

Janel Cubbage:

Exactly. It is collaborative.

Janel Cubbage:

And I think that's so important when you are working with someone at risk, because many people may be concerned about being involuntarily hospitalized or having their agency taken away from them, and it's really important to walk with them and show them what's available to them to help them stay safe.

Emily St. Amant:

Yeah. And we're always leading from behind. We're not leading the charge. And I think that so many ...

Emily St. Amant:

I love evidence-based practice as much as anybody, I like knowing what works and what helps, but at the end of the day, if we could just say, "Here, do this", or whatever, if that worked, we probably wouldn't even need jobs as counselors.

Emily St. Amant:

But our role is to really meet people where they are, give them the tools, and help them figure out what works for them. And at the end of the day, it's their life and they know what's best for them. And it's not all on us.

Emily St. Amant:

It's so much pressure, I think, put on us sometimes, or we put on ourselves, or it's put on us by maybe employers, what have you, but it's not all on us. Right?

Janel Cubbage:

Yeah. And I think that anxiety drives that response of, "I am now 100% responsible." And like you said, that's not the case.

Janel Cubbage:

And I would actually challenge people to think of how paternalistic that can be. Because our clients are resourceful, they're smart, they know what's best in their life, they have insight to what works for them, and presenting them with the resources that are available to them and walking with them is what we should do.

Emily St. Amant:

And I think when we're working with clients and families, a lot of them are maybe just as frustrated or more frustrated than us with the systems or the barriers that they're encountering. So what do you do with that when a client experiences those things and maybe seems interested in trying to do something about those things?

Janel Cubbage:

Be with them and validate that.

Janel Cubbage:

And I think it can be really encouraging to be in tune when you see that a client wants to get involved in making change in these systems to empower them to do so. Encourage them to get involved in advocacy or with a community organization that maybe addresses the issues that they're trying to address, and letting them know that that's possible.

Janel Cubbage:

I think that a lot of our advocacy processes or even civic processes aren't always the most accessible, or people may not know where to look or that you can go and testify at a bill hearing or submit written testimony. So I think we have to know how to advocate and how to get involved, and then when we notice that yearning in our own clients, making sure that we're prepared to empower them to do that.

Emily St. Amant:

Yeah, I think that's super important, because being able to do something about something that ... I think helplessness is a really, really big risk factor for suicide, right? Feeling helpless, feeling like there's no other option. But advocacy can be a way to help people feel more empowered, and a byproduct of that is reducing their risk of suicide.

Emily St. Amant:

So that's an important thing that we need to be prepared to do with our clients. That is an excellent point.

Emily St. Amant:

Thank you so much for joining us today, Janel. Can you tell our listeners maybe how to find you if they're interested in learning more?

Janel Cubbage:

Sure. You can find me on Twitter at Janel Cubbage. J-A-N-E-L C-U-B-B-A-G-E. You can also find me on TikTok and Instagram at the tattooed counselor.

Emily St. Amant:

Awesome. Thank you so much for joining us today, Janel. And thanks to our listeners for listening in.

Janel Cubbage:

Thanks for having me.

Emily St. Amant:

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Emily St. Amant:

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Emily St. Amant:

Thanks again for joining us, and we hope everybody has a great rest of your day.

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