Suicide attempt survivors: How counselors can help with disclosures

April 15, 2022

By Joan M. Flynn

As suicide rates have risen to the 12th-leading cause of death in the United States, the number of suicide attempts has risen as well to an estimated 1.2 million in 2020, according to the American Foundation for Suicide Prevention.

Because suicide attempt survivors are at higher risk for both fatal and nonfatal suicide attempts, disclosure of past attempts is an important aspect of their mental health treatment. Yet research published in the American Counseling Association’s April 2022 Journal of Counseling & Development (JCD) indicates that many survivors choose not to disclose to their counselor, or they may choose to disclose to others in ways that increase their own social risks.

CT Online interviewed Lindsay Sheehan, a licensed clinical and rehabilitation counselor and lead author of the JCD study, to find out more about how counselors can better assist clients who may be thinking of suicide, have made a past attempt or are considering disclosing this aspect of their life to others.

What is most important for counselors to understand about how suicide attempt survivors make disclosure decisions, and why are such disclosures important in counseling?

People who have survived a suicide attempt are more at risk for ideation and future suicide attempts, so disclosure of a past attempt opens the conversation for talking about it in future times of need. It is much easier for a counselor to provide support if they know the client’s history, such as the circumstances of a past attempt, before there is another crisis situation. Counselors, friends and family members can be proactive in supporting the person’s mental health, knowing what to do and discussing with the person how they want to be supported in the event of a future crisis and what they don’t want to happen.

Often, a suicide attempt is an important part of someone’s life journey and even their identity, but seldom is it considered acceptable or is talking about it encouraged. Counselors should keep in mind that talking about suicide makes one very vulnerable — counselors need practice to be comfortable talking openly about suicide, and they need to make sure they are conveying to the client that they are comfortable with it.

Becoming comfortable talking about suicide involves the counselor first reflecting on their own thoughts, attitudes and potential biases around suicide. For example, is suicide preventable? Should clinicians use every means necessary to save a person’s life?

Common misconceptions about people who attempt suicide or who have suicidal thoughts are that they are attention-seeking, selfish, manipulative, weak, damaged, unpredictable, irrational, dangerous or immoral. Another common misconception is that asking someone if they are having thoughts of suicide will make them even more distressed. Language such as “tried to commit suicide” implies that suicide is a criminal act — similarly, the term “failed attempt” is insensitive. Counselors should understand how stigma can impact their client’s life. They should help explore how the client might experience overt prejudice and discrimination related to their suicide attempt/mental health or how they might internalize the stigma, resulting in shame, depression and lowered self-esteem. When clients recognize stigma as a problem residing in society rather than themselves, this may lessen its impact.

Why might a client not disclose a past suicide attempt to the counselor?

Many suicide attempt survivors have been exposed to coercive situations in health care, such as hospitalizations, welfare checks, interventions, restraints, incarcerations and institutionalizations, in which they felt a loss of control over their own lives and were traumatized. Many live in fear of that happening again. They may be concerned that a counselor will overreact, that the counselor will treat them differently after the disclosure or that the counselor will say that they are not qualified to work with them, especially if they disclose current ideation. Clients may detect subtle signs of discomfort from counselors around the topic of suicide and feel like counselors are overly concerned about liability rather than about helping them.

When and how should counselors initiate discussions about past suicide attempts?

I believe the topic should be broached with every client; counselors should not assume that any of their clients have or haven’t had a suicide attempt or thoughts of suicide. A counselor’s initiation of the topic communicates that the counselor is comfortable talking about suicide. Counselors should also initiate conversation regularly about suicidal ideation. Suicidal ideation is relatively common, but many people do not feel comfortable talking about it even with a counselor, so it is important to provide an opening for that discussion often. If the client says they’ve never experienced ideation or aren’t experiencing it right now, the counselor can let them know that if they ever do so in the future, the counselor is open to helping them work through it.

The counselor should be explicit and transparent about the protocol for addressing suicide, such as through a professional disclosure statement that includes a detailed description of how they will respond to disclosures related to suicide. Counselors might also wish to outline their previous experience, philosophies and techniques related to counseling clients with suicidal ideation on their website or disclosure statement.

How can a counselor help in guiding the client’s disclosures to others? What factors would a counselor consider in helping to create a disclosure strategy or plan?

Counselors can help clients consider the pros and cons of disclosing using motivational interviewing techniques, recognizing that there are many situations, such as at work, where it might be particularly risky to disclose. Individuals who are currently experiencing distress or ideation might have reasons or motivations for disclosing that center around gaining support, while others might wish to disclose so they can help other people or strengthen relationships.

Counselors can help clients recognize that disclosure is nuanced — the person they disclose to, the timing of the disclosure, method of disclosure, content of disclosure, can all be considered. Disclosure can be a selective and gradual process in which clients might share a small part of their mental health story with a selected person, and then decide whether to share further and more broadly. Some clients might tend to over-disclose, which can make others uncomfortable and reduce social support.

Clients can practice disclosure scripts (see sidebar below) with their counselors to become more comfortable and strategic about their disclosure. If clients have a disclosure-related goal in mind, they can tailor the disclosure to maximize benefits and reduce risks.

Counselors can help clients discern whether they are ready to disclose and how they might cope if a disclosure does not go as hoped or planned. Although talking about suicide reduces shame and helps people process their thoughts and feelings, it can also be anxiety-provoking and bring up difficult memories, thoughts and feelings. Clients may need help discerning which people/environments might be more supportive of disclosures.

Even when a disclosure goes “well,” it can have unintended consequences. For example, someone who engages in suicide advocacy work and then tells their story publicly may experience an extremely warm and positive response but become overwhelmed and have difficulty setting boundaries — at the expense of their own mental health — if peers come to them for help, support or resources. Counselors can help clients think through some of these unintended consequences as well.

Your JCD article mentions disclosures clients may make online or on social media. Are there any special considerations for such disclosures?

I actually recently submitted a paper to another journal that goes into more detail about benefits and risks of online disclosures. In short, perceived advantages of online disclosure are the anonymity it can provide, depending on the forum you are using, so people can disclose without being subject to stigma, coercive treatments or active rescues.

People often struggle most with suicidal ideation at night when they are alone and their support people, both professional and nonprofessional, are unavailable. The online world provides opportunities to connect with many people at all times of the day and night. Online support is also relevant for people with disabilities or other isolating situations that make getting support or interaction difficult. Some survivors talk about how having a large audience to share their story with is empowering and makes it possible to reach and impact others to save lives.

Disadvantages related to disclosure on social media include that it could be upsetting or triggering for others, especially if there are graphic descriptions of suicide methods. Of course, there is always the risk of trolling and online bullying in response to a disclosure, as well as having others not take the person who is disclosing seriously and perceiving them as attention-getting. Finally, there are obvious communication barriers in online communication such as the lack of body language, communication possibly not being in real time, and an inability to provide direct help in a crisis situation.

There are some folks in Australia who have done more work in this area and specifically focusing on young people (see https://www.orygen.org.au/chatsafe).

What “errors” or missteps should a counselor avoid in the discussion of disclosures?

Counselors may not realize how common it is for clients to have chronic suicidal ideation, including every day for years, but not have a plan or intent and to never talk about it.

Talking about suicide can be difficult for both the counselor and the client, and much like trauma work, counselors should be prepared for and have supervision around this.

Counselors should be prepared to engage in safety planning with their clients and have a safety plan template.

What should be included in safety planning or in a safety plan template? For example, do you mean a “road map” that the person agrees to follow if they are thinking about attempting suicide, stating who they will call, what they will say and where they will go to not be alone? Or a preemptive plan that might involve locking away medications or firearms outside of the home to reduce being able to complete suicide impulsively?

Yes, exactly as you describe. The safety plan is a road map and might include warning signs/triggers, coping strategies, reasons for living, specific plans for who to call or where to go, including professional and nonprofessional support, crisis line/emergency information, and self-restriction of lethal means. There are also apps that people can use for safety planning.

Lastly, how did the idea for this research come about?

I was doing research on the stigma surrounding suicide, and during interviews and focus groups, people talked about disclosure dilemmas and about not being comfortable talking about suicide with their therapists or counselors. I was fortunate to receive some funding to conduct the research on stigma and disclosure, so that was also very important.