Suicide: An Overview

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Suicide : An Overview
John S. Westefeld, Lillian M. Range, James R. Rogers, Michael R. Maples, Jamie L. Bromley and John Alcorn The Counseling Psychologist 2000 28: 445 DOI: 10.1177/0011000000284002 The online version of this article can be found at: http://tcp.sagepub.com/content/28/4/445
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MAJOR CONTRIBUTION
Suicide:
An Overview
John S. Westefeld
The University of Iowa
Lillian M. Range
University of Southern Mississippi
James R. Rogers
University of Akron
Michael R. Maples
The University of Iowa
Jamie L. Bromley
University of Akron
John Alcorn
University of Southern Mississippi
Suicide is a major mental health problem in the United States and an issue that significantly impacts the mental health treatment community. Although the suicide rate remains relatively stable, the discipline of counseling psychology has broadened in scope and work settings have diversified. Thus, counseling psychology trainees are increasingly exposed to suicidal clients. Despite this reality, research suggests that comprehensive, systematic training in suicidology in counseling psychology programs rarely occurs. One reason for this state of affairs may be that the suicide literature is spread across a variety of disciplines, making it difficult for educators and practitioners to stay informed about the knowledge base in suicidology. The purpose of this contribution, therefore, is to provide counseling psychology educators and practitioners with an overview of the field of suicidology as it applies to the training and practice of counseling psychology.
Since the creation of the Center for the Study of Suicide Prevention in the 1960s by the National Institute of Mental Health (NIMH) (Resnik & Hathorne, 1973), the prevention of suicide has been a major focus of national public health policy in the United States. For example, Priority Area 6 of
Westefeld et al. / SUICIDE THE COUNSELING PSYCHOLOGIST / July 2000 The authors wish to express their sincere appreciation to Patricia Frazier, Deb Liddell, Mary Miller Lewis, Patricia Martin, and three anonymous reviewers for their contributions to this article. Address correspondence to John S. Westefeld, Psychological and Quantitative Foundations, 361 Lindquist Center, University of Iowa, Iowa City, IA 52242-1529; e-mail: johnwestefeld@uiowa.edu.
THE COUNSELING PSYCHOLOGIST, Vol. 28 No. 4, July 2000 445-510 2000 by the Division of Counseling Psychology.
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THE COUNSELING PSYCHOLOGIST / July 2000
Healthy People 2000 (U.S. Department of Health & Human Services, 1990) identified a reduction in the total number of suicides and a reduction in the incidence of injury resulting from suicide attempts among adolescents as year 2000 mental health objectives. Currently, work is evolving on the development of the National Strategy for Suicide Prevention as a component of Healthy People 2010 (A National Strategy for Suicide Prevention, 19981999). Reducing the prevalence of suicide remains the overarching goal of this developing plan. Despite these efforts, the rate of suicide has remained relatively stable and far too high. From 1993 to 1996, the national rate of suicide (number of suicides per 100,000 individuals) has fluctuated from a high of 12.06 in 1993 to a low of 11.65 in 1996 (NIMH, 1999). The actual number of reported deaths from suicide in 1996 was 30,903 (NIMH, 1999). This figure translates into approximately 84 suicides per day, or 1 every 17 minutes, and makes suicide the 9th leading cause of death overall. Suicide is the 3rd leading cause of death among people between the ages of 15 and 24 and the 14th for individuals 65 and older. Furthermore, each suicide is estimated to impact at least six other people intimately. Since 1971, 1 of every 59 Americans has become a survivor of suicide (i.e., emotionally related in some way to a person who committed suicide). Finally, the number of survivors in the United States grows by approximately 186,000 each year (American Association of Suicidology [AAS], 1998). Thus, suicide is unquestionably a major mental health problem in society today and a phenomenon that can cause unbearable pain for survivors.
THE ROLE OF THE COUNSELING PSYCHOLOGIST From its early identification as a specialty to promote educational, vocational, and personal adjustment (Whiteley, 1984, p. 8), the applied science of counseling psychology has developed as a discipline embedded in the national system of mental health service providers. For example, two classic studies found counseling psychologists to be involved in personal adjustment counseling and long-term psychotherapy and to view themselves in the roles of both clinical practitioner and consultant in a variety of areas (Fitzgerald & Osipow, 1986; Watkins, Lopez, Campbell, & Himmell, 1986). Though not abandoning the traditional counseling psychology focus (e.g., areas such as vocational psychology and life skills development), the field of counseling psychology has evolved over the past two decades as a primary care specialty, whether in university counseling centers, independent practice, or offcampus organized health care settings.
Westefeld et al. / SUICIDE
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At the most recent major national counseling psychology conference, the Georgia Conference held in Atlanta, attendees delineated a variety of potential and actual practice settings for counseling psychologists, including university counseling centers, business and industry, schools, medical settings, the Veterans Administration, and community mental health centers (Kagan et al., 1988). Attendees also stressed that the roles of counseling psychology were expanding, that trainees should be encouraged to enter a variety of settings, and that counseling psychology as a profession has a responsibility to address current societal issues, saying that we need to consider means by which we can improve social conditions (Kagan et al., 1988, p. 364). The topic of suicide is clearly one such critical social issue in all these employment settings. Counseling psychology practitioners see clients with a wide range of presenting problems and psychological issues. Depression and suicidal ideation are commonplace and are often intertwined in a complex pattern of concerns about school, finances/jobs, and interpersonal relationships. In support of this characterization, approximately 97% of psychology traineesincluding those trained in counseling psychologyreported working with suicidal individuals in treatment, 29% reported having at least one client who attempted suicide, and 11% reported having a client commit suicide (Kleespies, Penk, & Forsyth, 1993). Consequently, training in suicide assessment, intervention, and postvention should be an essential component of doctoral training in counseling psychology (American Psychological Association [APA], Board of Professional Affairs, Committee on Professional Standards, 1987; Bongar & Harmatz, 1991; Kleespies, 1998b). Furthermore, although some students may receive training in treating suicidal individuals during their graduate education, many do not. In one survey, only 55% of trainees reported having some training in this area and the instruction was minimal (Kleespies et al., 1993). Suicide is clearly relevant to all areas where counseling psychologists might find themselves working, but few report that they have the training they need to address this critical issue. Because counseling psychologists are likely to work with suicidal individuals at some point in their careers, they need access to current information on suicide risk assessment; intervention, prevention, and postvention; and an understanding of risk factors in special populations that may be particularly susceptible to suicide. Also, trainees and training programs in counseling psychology need this information. As a function of its multidisciplinary nature, the relevant literature in suicidology is spread across a wide variety of professional literatures including medicine, psychiatry, nursing, psychology, and sociology. The purpose of this major contribution, therefore, is to provide an overview of the field of suicidology as it relates to counseling psychology. The general organization of the contribution will be as follows: (a) major theoretical models of suicidal
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behavior; (b) empirically identified suicide risk factors; (c) suicide risk assessment issues; (d) intervention, prevention, and postvention models; (e) training and supervision issues; (f) current and emerging controversies in suicidology; and (g) future foci in suicidology and the role of the counseling psychologist. The Werth and Holdwick contribution (2000 [this issue]) addresses rational suicide/hastened death, a major and highly controversial issue in contemporary suicidology.
THEORETICAL MODELS OF SUICIDE Predominant theoretical models of suicide are multidisciplinary in nature. The predominant models (Blumenthal & Kupfer, 1986; Jacobs, Brewer, & Klein-Benham, 1999; Shneidman, 1987; Stillion, McDowell, & May, 1989) all consider the biological, psychosocial, and environmental factors that may impact suicidal behavior. Also, they represent a form of post hoc theorizing (Pedhazur & Schmelkin, 1991) as opposed to theoretical models that have been used to guide research in suicidology. Of these four models, only Shneidmans cubic model was developed from a predominantly psychological perspective. Overlap Model The Overlap Model (Blumenthal & Kupfer, 1986) is graphically depicted in Venn diagram form with five overlapping circles. The five areas or domains include (a) the psychosocial milieu (primarily viewed in the context of social support), (b) biological vulnerability (e.g., early biological development and later aging), (c) psychiatric disorders (specifically, affective and conduct disorders, schizophrenia, and organic mental disorders), (d) personality factors such as hostility, impulsivity, and depression, and (e) family history and genetics. Theoretically, the intersection of these five overlapping circles represents high risk for suicide. Three Element Model The Three Element Model (Jacobs et al., 1999) includes predisposing factors, potentiating factors, and suicidal threshold. Predisposing factors include affective disorders, alcoholism, and schizophrenia. Potentiating factors include family history and the broad social milieu, personality disorders (especially borderline, antisocial, and narcissistic personality disorders), life stressors (including severe physical illnesses), and access to means of committing suicide (in particular, firearms). These various characteristics may
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combine in idiosyncratic ways to move individuals to and across a theoretical suicidal threshold and toward suicidal behavior. Suicide Trajectory Model The Suicide Trajectory Model (Stillion et al., 1989) is an interactive multidimensional model that, in addition to considering the domains discussed by Blumenthal and Kupfer (1986) and Jacobs et al. (1999), includes a focus on triggering or final straw events in the presence of specific thoughts about suicide. Biological, psychological, cognitive, and environmental risk factors interact to bring a person to the brink of suicide. Biological risk factors include a genetic predisposition to depression and being a man. Psychological risk factors include depression, hopelessness, helplessness, low selfesteem, and poor coping skills. Relevant cognitive factors include cognitive rigidity and various cognitive distortions. Environmental risk factors include negative family experiences and other negative life events, loss, and the presence of firearms and other methods of suicide. Various combinations of the risk factors in conjunction with thoughts of suicide as a viable behavioral option and the presence of a triggering event may result in suicide. Cubic Model The Cubic Model (Shneidman, 1987), an attempt to develop an overarching psychological model of suicide, is a cube made up of 125 cubelets. The cube has three planes: press, pain, and perturbation. Pressevents done to the individual to which he or she reacts (Shneidman, 1987, p. 174)can range from positive to negative, but it is the negative experience of press that moves one to suicide. Negative presses can come in many forms such as humiliation, rejection, and failure, but it is the interpretation of those events as catastrophic that is most important. Painpsychological pain resulting from thwarted psychological needs (Shneidman, 1987, p. 174)can range from little or no pain to intolerable psychological pain. Additionally, psychological needs for autonomy, achievement, recognition, succor, and an avoidance of shame, humiliation, and pain are those most relevant to suicide for the individual. Perturbationa state of being upsetmay result from any number of sources, but the associated cognitive and perceptual constriction holds the most relevance for suicide (Shneidman, 1987). That is, as individuals become increasingly upset, they move into dichotomous thinking, tunnel vision, in which they view suicide as the only solution to the subjective experience of pain and press. An individuals status on each of these three factors or components could conceptually be rated on a 1 to 5 scale with 5 being the maximum intensity of press, pain, or perturbation (Shneidman, 1987). A rat-
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ing of 5 on all of the factors would place the individual at maximal risk for suicide. A rating of 5-5-5 accompanied with motivation toward egression (i.e., departure from distress) creates a situation of high probability for suicide. These models were developed as organizing frameworks for the empirically identified correlates of suicide and suicidal behavior. Although they serve a descriptive function, they have not been used in any a priori fashion as a way to guide research in suicidology (Rogers, in press). Indeed, rather than being theoretically driven, contemporary research in suicidology has maintained the pragmatic focus of identifying correlates of suicide and using those correlates as factors in assessment and prediction. Thus, the identified suicide risk factors have been determined empirically rather than theoretically.
EMPIRICALLY IDENTIFIED SUICIDE RISK FACTORS To achieve the goals of assessment, prediction, and prevention, much suicide research has focused on identifying individual correlates of suicide and suicidal behavior. The predominant methodology has been to compare suicidal and nonsuicidal individuals. The underlying assumption is that comparisons of groups of suicidal and nonsuicidal persons can provide critical insights that might not be apparent on an individual level. Some researchers assert that suicidality is best represented as a continuum ranging from having never thought about suicide to contemplating suicide to attempting suicide to committing suicide (i.e., Lester, 1996). Others assert that individuals who attempt suicide are distinctly different from people who merely consider suicide, both of whom are different from those who never even consider suicide (Linehan, 1986). The empirically identified risk factors in the first part of the following section, therefore, were obtained from comparisons of suicidal and nonsuicidal groups or from analyses assessing individuals across the suicide continuum. Note that age, gender, ethnic, and sexual orientation subgroups may share the general risk factors, but they also have specific statistically based risk factors. Personality, Cognitive, Environmental, Alcohol/Drug Use, Behavioral, and Physical Illness Factors Suicidality is associated with many psychological problems. Suicidality correlates relatively highly with a number of disorders, including depression (Black & Winokur, 1986; Evans & Farberow, 1988); schizophrenia and other disorders involving psychosis (Gilliland & James, 1993); personality disorders (Duberstein & Conwell, 1997; Kullgren, Tengstroem, & Grann, 1998),
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particularly borderline personality disorder (Duberstein & Conwell, 1997), even without using the repeated suicide attempts that are part of the criteria for this diagnosis (Linehan, 1987b); neuroticism (Beautrais, Joyce, & Mulder, 1999); and panic disorders (Bongar, 1991).
PERSONALITY
In terms of affect, suicidal individuals are relatively more depressed (Harrington, Fudge, Rutter, Pickles, & Hill, 1990) and anxious (Chance, Kaslow, & Baldwin, 1994) than their nonsuicidal peers. Temperamentally, they are more unpleasant, submissive, and particularly more arousable than their nonsuicidal peers (Mehrabian & Weinstein, 1985). Compared with others, suicidal individuals also have reduced ability to regulate their affect (MacLeod, Williams, & Linehan, 1992).
COGNITIONS
In terms of cognitions, suicidal individuals are relatively more hopeless (e.g., Cole, 1989), more perfectionistic (e.g., Blatt, 1995), and more irrational in their beliefs (Woods, Silverman, Gentilini, Cunningham, & Grieger, 1991) than their nonsuicidal peers. Suicidal individuals have relatively weaker reasons for living (e.g., Linehan, Goodstein, Nielsen, & Chiles, 1983; Westefeld, Cardin, & Deaton, 1992). They have a more external locus of control (Beautrais et al., 1999). Their attitudes toward life and death are different: They are less attracted to life and more repulsed by it, and at the same time they are less repulsed by death and more attracted to it (Cotton & Range, 1993, 1996). They tend to be less skillful at generating alternative solutions and anticipating negative consequences (Schotte & Clum, 1987); they are more likely to come up with inappropriate solutions to problems (Kehrer & Linehan, 1996). They display over-general retrieval of autobiographical memories and reduced ability to remember specific positive experiences (MacLeod et al., 1992). They are less future oriented than nonsuicidal individuals (MacLeod et al., 1992). Thus, their ineffective belief systems and weak problem-solving skills mean that suicidal individuals lack the personal resources they need when they experience strong negative feelings. Hopelessness and helplessness are two cognitive/affective states that are often present in suicidal clients. The feeling that things will never change and that there is nothing that can be done about it can be overwhelmingly distressing. Hopelessness is a particularly bad sign, is a better predictor of suicidal risk than depression (Weishaar & Beck, 1992), and is one of the best long-term predictors of eventual suicide (Beck, Steer, Kovacs, & Garrison, 1985). Interested readers should see Beck, Rush, Shaw, and Emery (1979);
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Bongar (1991); and Shneidman (1985) for further discussion regarding the relationships between hopelessness, helplessness, and suicide. In addition to negative feelings, therefore, suicidal individuals have beliefs that are irrational, hopeless, and not life affirming.
ENVIRONMENTAL STRESS
Suicidal individuals often carry environmental burdens greater than their nonsuicidal peers. They are more likely than nonsuicidal individuals to have physical and sexual abuse histories (e.g., Bendixen, Muus, & Schei, 1994); discordant family environments (Asarnow, 1992); recent turnover in interpersonal relationships (Paykel, Prusoff, & Myers, 1975); insufficient social support (DAttilio, Campbell, Lubold, Jacobson, & Richard, 1992); and stressful overwhelming life events or chronic severe stress (Yufit & Bongar, 1992). Absence of social support is especially relevant in terms of predicting suicidality (e.g., Hart, Williams, & Davidson, 1988; Lyons, 1985). Increased social support for the suicidal person reduces the likelihood of suicide and increases the likelihood of obtaining social support after an attempted suicide (Maris, 1992). In a time of crisis, the suicidal person who is socially isolated often fails to make people aware of his or her suicidal ideation or plan. Thus, in addition to having fewer resources to defuse a crisis, the socially isolated person is also less likely to be rescued from a suicidal crisis (Maris, 1992).
ALCOHOL AND DRUGS
Alcohol and drugs exacerbate the problem of suicide. Suicidal individuals report more drug and alcohol use than their nonsuicidal peers (Nielsen, Stenager, & Brahe, 1993). The lifetime risk of suicide for alcoholics in the United States and other Western countries is 60 to 220 times higher than the lifetime risk of suicide in the general population (Murphy & Wetzel, 1990). Moreover, comorbidity of alcoholism and depression increases suicide risk (Clark & Fawcett, 1992), perhaps because these agents exacerbate personality and cognitive problems and add to the environmental stressors (e.g., Valliant & Blumenthal, 1990). Alternatively, alcohol can impair cognitive functioning (Rogers, 1992). Using alcohol to relieve depression, anxiety, and fear often creates more depression and psychological distress, an effect labeled alcohol myopia (Steele & Josephs, 1990). Alcohol myopia involves narrowed or impaired perception that interferes with inferential thought and makes one the captive of an impoverished version of reality in which the breadth, depth, and time line of our understanding is constrained (Steele & Josephs, 1990, p. 923). Thus, the link between alcohol use and suicide goes
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beyond the pharmacological and interpersonal effects (Flavin, Franklin, & Francis, 1990). Rather, its association may additionally be a function of its capacity to restrict attention to immediate situations, inhibit the ability to solve current problems, and to limit hope for the future (Rogers, 1992, p. 541). Alcohol and substance use and abuse exacerbate other environmental problems and lessen the ability to cope.
BEHAVIORS
In addition to personality issues, negative emotions, cognitive distortions, and drug and alcohol involvement, some specific behaviors are associated with suicide. A past history of suicide attempt(s) is a danger sign for eventually committing suicide (Nordstroem, Asberg, Aberg-Wistedt, & Nordin, 1995). High lethality in previous attempts correlates with increased current risk level (Suokas & Loennqvist, 1991). In addition, the more recent the past attempt, the higher the current risk (Bongar, 1991). Finally, the opportunity for rescue is also of importancefewer opportunities for rescue are associated with higher risk. Verbal communication of intent is also critical. Intent is the individuals desire to die and expectation that death would result from action (Moscicki, 1999). One of the best predictors of suicide is how the client answers the following question: Have you been feeling so badly lately that you have thought about harming yourself? (Lester, 1992; Wolk-Wasserman, 1986; Wrobleski & McIntosh, 1986). Most clients will answer this question honestly, although the ambiguity of the answer (i.e., I dont know, or Not right now) is often a problem (Maris, 1992). Although the relation of ideation to action is not isomorphic, sometimes the best predictor of suicide is simply to ask people whether they are thinking about killing themselves (Maris, 1992, p. 11). Thus, an expression of verbal intent in response to a direct question can alert the intervening counseling psychologist to any plan, method, and potential time of occurrence of possible suicide behavior. However, the absence or denial of intent in response to a direct question regarding suicide may mask true suicidal intent (Shea, 1998). Therefore, counseling psychologists should be cautious in relying on verbal communication alone.
PHYSICAL ILLNESS
Across age groups, but particularly among the elderly, physical illnesses also correlate with suicidal risk (Draper, 1996; Duggan, Sham, Lee, & Murray, 1991; Runeson, Eklund, & Wasserman, 1996), particularly chronic physical illnesses and/or illnesses involving chronic pain (Hitchcock, Ferrell, & McCaffery, 1994). Specific physical illnesses associated with increased sui-
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cide risk include epilepsy, malignant neoplasms, gastrointestinal problems, musculoskeletal disorders (Maris, Berman, Maltsberger, & Yufit, 1992), history of migraine headaches (Breslau & Davis, 1993), and HIV (Marzuk et al., 1988).
SUMMARY
Suicidal individuals, compared with their nonsuicidal peers, have personalities that are more disturbed; affect that is more depressed and anxious; cognitions that are more negative; environments that are more adverse; and patterns of substance use and abuse that will depress them, lower their inhibitions, and impair their judgment. They suffer from hopelessness and helplessness, depression, anxiety disorders, and schizophrenia and are lonely, isolated, and physically ill to a greater extent than nonsuicidal individuals. They have histories of previous suicidal behaviors that increase their risk for future suicide and further distinguish them from their nonsuicidal peers. They will probably communicate to others that they are suicidal. Group Factors Groups of people of different ages, genders, ethnic backgrounds, and sexual orientations face some unique situations and risks for suicide. Therefore, counseling psychologists need to be aware of various subgroup (age, gender, race, sexual orientation) risk factors for suicide in addition to the general risk factors.
AGE
Age groups differ in their rates of suicide. Adolescents and adults older than the age of 65 are two groups that have significantly higher suicide rates as compared with the general population. Suicide is the third leading cause of death for adolescents (Goldman & Beardslee, 1999), but diminishes in the list of causes of death among the elderly because, although the risk for suicide increases with age (Moscicki, 1999), other causes of death also increase as people age. Adolescents. Among children and adolescents, suicide rates have risen in the past two decades. For adolescents (ages 15 to 24), the suicide rate was 12.2 per 100,000 in 1996; for children ages 10 to 14, the rate was 1.6 per 100,000. These rates made suicide in 1996 the third leading cause of death for young people between the ages of 15 and 24. Furthermore, there are an estimated 8 to 25 attempted suicides to 1 completion, with the ratio even higher
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in women and youth (NIMH, 1999). Although this section primarily discusses adolescents, children share many of the same risk factors. Suicide risk factors unique to adolescents can be divided into four categories, including demographic, psychosocial, psychiatric/medical, and miscellaneous (Jacobs et al., 1999). Demographically, married adolescents commit suicide more than unmarried adolescents. Psychosocially, suicide risk factors include being pregnant and unwed, experiencing parental absence and abuse, and having academic problems. Psychiatrically, suicide risk factors include attention deficit hyperactivity disorder, epilepsy, conduct disorders, impulsivity, explosiveness, disciplinary crisis, and humiliation (Jacobs et al., 1999). In terms of miscellaneous factors for individual adolescents, exposure to suicide and presence of firearms in the home are risk factors (Jacobs et al., 1999). Reasons for the higher suicide rate among youth include increased rates of alcohol abuse and depression; increased access to lethal methods, particularly firearms; and changes in family structure and practices such as divorce, mobility, and de-emphasis on religion (Goldman & Beardslee, 1999). Cultural factors may exacerbate or ameliorate individual factors in contributing to an adolescents suicide. Elderly. Suicide risk increases with age. The elderly have the highest suicide rates of all age groups (NIMH, 1999). Though rates for persons 65 and older dropped between 1940 and 1980, there was a 36% increase from 1980 to 1992 (Steffens & Blazer, 1999). This increase did not affect older adults between the ages of 65 and 74. Rather, there were increases of 11% for adults 75 to 79, 35% for adults 80 to 84, and 15% for adults 85 and older (Steffens & Blazer, 1999). Elderly European American men older than the age of 85 had the highest prevalence of completed suicides among age and ethnic groups, with a rate of 65.3 per 100,000 (NIMH, 1999). It is particularly risky to be an elderly, isolated, European American man with a history of past attempts and drug or alcohol abuse. Reasons for the high suicide rate among the elderly include physical illness, functional disability, chronic pain, and dependency on others for care (Steffens & Blazer, 1999). Suicidal elderly individuals experience increased hopelessness, loss of pleasure or interest in life, and cycling from a depressed mood to a feeling of well-being. Furthermore, these individuals have an acting-out coping style as opposed to being able to express personal distress (Steffens & Blazer, 1999). By contrast, factors such as living alone, financial problems, and death or illness in the family have been inconsistent in predicting suicidal behavior in the elderly (Steffens & Blazer, 1999). Compared with younger individuals, the old openly communicate their suicidal intent less frequently, use more violent and lethal means, and less often attempt sui-
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cide as a means of gaining attention or as a cry for help (Osgood & Thielman, 1990). Elderly individuals are less ambivalent about their own suicide than adolescents. The high rates of suicide in both adolescents and older adults speak to unique and specific concerns and problems facing these age groups. Identifying specific risk factors can be a convoluted task, but by increasing the understanding of the complex interactions and contributing factors that lead a person to attempt or commit suicide, counseling psychologists will be better equipped to help suicidal adolescents and elderly individuals.
GENDER
Gender differences exist in suicide rates. Men commit suicide 4.5 times as often as women (NIMH, 1999). However, women in most Western countries have a higher incidence of suicidal ideation and attempts than do men (Canetto, 1997; Canetto & Sakinofsky, 1998). Two possible explanations for these gender differences have been espoused, though there are inconclusive data to support either notion. First, it is possible that suicide attempts and ideation in men are underreported and that fatal suicidal behavior in women is misreported as accidents or deaths from undeterminable causes instead of suicides. Second, biological or sociocultural factors may actually result in the observed gender differences. For example, there are differences in how American men and women perceive suicide in general and how people in general perceive suicidal behavior in men and women: American families are more likely to hide a womans suicide than a mans, perhaps out of fear that the suicide will cast aspersion upon the woman (Kushner, 1985). Furthermore, a womans nonfatal suicide attempt is more likely to be seen as an acceptable cry for help (Langhinrichsen-Rohling, Sanders, Crane, & Monson, 1998), whereas similar behavior in a man is seen as weak and inappropriate given societal norms for men (Canetto & Sakinofsky, 1998). Thus, social norms may mitigate against nonfatal suicide attempts for men or provide some level of permission for nonfatal suicidal behavior for women, or both. Men and women display differences in help-seeking behavior that could contribute to the differences in suicide rates. Men who kill themselves usually do not consult a mental health professional beforehand (Shneidman, 1985). Relatedly, men are more uncomfortable than women being around a person they know to be suicidal (Dahlen & Canetto, 1996). Mens problems in coping with their own emotionality may lead to marked psychological distress with no source of comfort (Rabinowitz & Cochran, 1994). This unease is a concern in correctly identifying suicidal ideation and risk for self-harm among men, especially when these men are seen by male physicians, psy-
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chologists, and researchers, or when their intent is noticed (and disregarded) by male peers (Canetto & Sakinofsky, 1998). Cultural norms not only impact suicide and reporting of suicide, but help seeking in general. Culture may interact with gender relevant norms to impact suicide (Canetto, 1997; Canetto & Sakinofsky, 1998). One example is societys expectation regarding personal accomplishment. When a man is unable to meet culture-bound expectations regarding achievement, his self-esteem and sense of meaning in life may suffer. This phenomenon is likened to the warrior ethos that exists in some cultures, such as the American Plains Indians and some Asian cultures (Andriolo, 1998). The sense of honor that comes from accomplishment can extend beyond the individual to the family. When a man fails, he can deal with the disgrace to the individual and the family by suicide. In such cases, the suicide is expected; cultural ceremonies exist that even glorify the suicide (Andriolo, 1998). Such good suicides were by their very nature restricted to cultural warriors, usually men. Any suicidal act by a woman was bad, considered to be deviant. Thus, some women and men in specific cultural groups (discussed in more detail in the next section) who attempt or succeed in suicide may do so because of their perceived inability to accomplish culturally defined gender-specific norms. Furthermore, culture can impact whether and which kind of suicidal behavior is viewed as permissible (Canetto & Lester, 1995).
ETHNICITY
Ethnic background makes a difference in suicide rates. Cultures undergoing major periods of change have higher suicide rates than more stable cultures (Jilek-Aall, 1988), but change is not the complete explanation. Countries such as the United States, Japan, and Sweden that are highly competitive and goal directed have appreciably higher rates of suicide than countries such as Norway, which has been characterized as less competitive and less goal directed (Jilek-Aall, 1988). Culture may interact with other variables in increasing or reducing suicide risk. There is, of course, considerable difficulty in formulating a global approach to counseling suicidal individuals that encompasses all cultures. Each culture has its own particular stresses that can influence either a persons suicidality or the manner in which it needs to be addressed. In the following sections, some aspects of the four largest raciocultural groups in the United States (African Americans, Hispanic Americans, Asian Americans, and Native Americans) are reviewed to illustrate these issues. Note that distinguishing between groups of people is important in gaining an overview of broad categorical differences. However, there are many more differences within ethnic groups than differences between groups (Range et al., 1999).
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Obviously, membership in any group is not a definitive clue about suicide risk. Individuals may be suicidal regardless of their ethnic background. African Americans. African Americans have a suicide rate lower than European Americans. In 1996, the suicide rate was 6.46 per 100,000 compared to 11.65 per 100,000 for all groups (NIMH, 1999) and lower than most other ethnic groups (Gibbs, 1997). Though underreporting of suicide among African Americans may occur (Phillips & Ruth, 1993), with suicides perhaps being misinterpreted as accidents or homicides, the differences are too great to be the result of underreporting alone. Sex differences in suicide exist among African Americans. African American men have higher rates of suicide (11.44 per 100,000) than African American women (1.95 per 100,000). This sex difference in rates is comparable to European Americans even though European Americans have higher levels of suicide overall (NIMH, 1999). Furthermore, although African American women attempt suicide as often as European American women and even more than European American men, and although they frequently experience high levels of stress and psychological problems, their level of completed suicide is the lowest of all major ethnic/gender groups in the United States (Nisbet, 1996). This ethnic difference is interesting given the history of poverty and discrimination that African Americans as a cultural group have faced (Gibbs, 1997). Age differences in suicide also exist among African Americans. Innercity African American adolescent men are at greater risk of suicide than individuals of other ages (Maris, 1992). The peak ages for suicide among African American men in general are 20 to 24 years old (NIMH, 1999). Age and gender differences in suicide rates among African Americans are somewhat distinct from the majority culture. Experts assert that the reasons for the overall lower rates of suicide among African Americans include a history of resilience and life-affirmation in the African American culture (Billingsley, 1992); a belief that suicide is unacceptable no matter what the life circumstance (Early & Akers, 1993); a strong system of family and community support (Gibbs, 1997); heavy reliance on the extended family, especially family elders (Gibbs, 1997); and participation in a church or religious community (Early, 1992). There is empirical support for some of these assertions. For example, African Americans have stronger reasons for living than European Americans (Ellis & Range, 1991). Marriage is a protective factor for some African American women (Nisbet, 1996), though it appears to protect European American women against suicide even more (Nisbet, 1996; Stack, 1996). Though the mechanism is not entirely clear, the African American culture appears to provide some protective buffers against suicide as compared with the dominant culture.
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Hispanic Americans. Hispanic Americans, likely to be the largest ethnic minority group in the United States in the next century (Portes & Rumbaut, 1990), have a lower suicide rate than non-Hispanics (9.2 per 100,000 compared to 19.2 per 100,000). Suicide is reported as most prevalent among Hispanic Americans between the ages of 15 and 24 (Earls, Escobar, & Manson, 1990). Hispanic Americans may experience high levels of stress as a result of their minority status, even though they have a lower suicide rate than non-Hispanics. High stress levels result from difficulty with the English language, poverty, low levels of education, unemployment, poor housing conditions, low social and political status, and living with prejudice (Leong, Wagner, & Tata, 1995). In addition, Hispanic Americans as a group tend to underutilize mental health services (Leong et al., 1995), perhaps because such services lack relevance to them, are financially out of reach to them, are discouraged to them, or because they have alternative resources within the Hispanic American community. Culture may contribute to this lower than expected rate of suicide for Hispanic Americans in several ways. First, Hispanic Americans have a relatively high level of reliance on family, extended family, and friends, so that individuals have a well-developed social network. Second, Hispanic Americans typically have a high trust in religion, which includes the belief that suicide is unacceptable no matter what the circumstances. Third, Hispanic Americans have an emphasis on fatalismo, the belief that divine providence rather than personal control regulates the world, so the individual must strive to accept lifes circumstances rather than railing against them (Range et al., 1999). As is true for African Americans, cultural buffers may contribute to the lower than expected suicide rate among Hispanic Americans. Asian Americans. Asian Americans in the 1980 to 1990 decade were a fast growing group in the United States (Asia Central, 1997). They too have a lower suicide rate than the majority culture and have sometimes been overlooked in the study of suicide (Shiang et al., 1997). Furthermore, although the overall rate is low, suicide risk in this group rises steadily with age. A cultural force that may impact the suicide rate is the de-emphasis on the individual as opposed to the group, with a corresponding emphasis on interdependence or interconnectedness (Shiang et al., 1997). Thus, suicide is viewed as disrespectful or harmful to the entire group, as selfish, as inappropriately passionate, and/or as shameful to the family. When suicide occurs, it may be tied to acculturative stress. For example, acculturative stress may occur when an Asian woman comes to live with her family in the United States and discovers that the elderly are not revered or venerated as much as they were in Asia. Acculturative stress may also occur among men who come to America
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without their families and feel isolated and removed from their culture (Baker, 1994). Native Americans. Overall, Native Americans have suicide rates 1.6 to 4.2 times the national average (Echohawk, 1997). However, among the diverse Native American culture, there are more than 300 federally recognized tribes who are represented in 278 reservations (Earls et al., 1990), and the tribes vary widely in suicide rates. One possible explanation for the overall high suicide rate is the high rate of alcohol abuse among some Native American youth (LaFromboise & Bigfoot, 1988). In addition, culturally related risk factors, such as the breakdown of social cohesion and pressures against acculturation by tribal elders, may partially explain this high rate. Furthermore, the personal identities of some Native Americans, especially the young, have been somewhat ambiguous (LaFromboise & Bigfoot, 1988). Some young Native Americans have little understanding of their tribal traditions and those who choose to leave the reservation leave behind their sense of identity. In rejecting their native identities, attempting to acculturate into the majority culture, and being unable to find total acceptance among the majority, an identity crisis occurs for some. Though it is unclear whether acculturative stress raises the risk of suicidality or exacerbates preexisting stress and problems, Native American tribes with a stronger sense of cultural cohesion have lower suicide rates than other tribes (Lester, 1997b). In any minority culture, unsuccessful acculturation could result in increased stress, depression, and suicide (Hovey & King, 1997). Several factors that could mediate successful acculturation include a supportive community of ones own culture present within the new culture, a tolerance for diversity by the majority culture, the minority persons knowledge of and comfort with the majority culture, the reasons behind the persons migration or attempts to acculturate, and the individuals coping skills, self-esteem, and other aspects of psychological health (Williams & Berry, 1991). Acculturative stress, which can occur when individuals attempt to fit into cultures outside their own, results in an increased risk for suicide (Lester, 1997b).
SEXUAL ORIENTATION
Overall, the literature investigating the relationship between sexual orientation and suicide suggests that gay and lesbian individuals may be at a greater risk for suicidal behaviors than heterosexual individuals (e.g., Garofalo, Wolf, Wissow, Woods, & Goodman, 1998; Gibson, 1989; McBee & Rogers, 1997; Remafedi, Farrow, & Deisher, 1993; Remafedi, French, Story,
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Resnick, & Blum, 1998). For example, Gibson (1989) suggested that gay and lesbian adolescents were 2 to 3 times as likely to commit suicide than heterosexual adolescents. Similarly, Remafedi et al. (1993) reported that one third of their gay and bisexual adolescent sample had made a suicide attempt with more than half of the attempters reporting multiple suicide attempts. In a more recent population-based study using 1987 data, Remafedi et al. (1998) reported that 28.1% of male adolescent and 20.5% of female adolescent homosexuals and bisexuals had attempted suicide. Finally, Schneider, Farberow, and Kruks (1989) indicated that sexual orientation was a factor in contemplating or attempting suicide in three fourths of the cases they studied, and Guyer, Lescocher, Gallagher, Hausman, and Azzara (1989) concluded that sexual orientation is a greater predictor of a decision to commit suicide than either ethnicity or socioeconomic status. Although this literature has been interpreted as providing strong evidence of a link between sexual orientation and suicidal behavior (e.g., Gibson, 1989; Remafedi et al., 1998), others have argued for a more tentative interpretation (e.g., McBee & Rogers, 1997; Moscicki, 1999). For example, Moscicki (1999) has suggested that there is no unbiased evidence that clearly implicates sexual orientation as an independent risk factor for completed or attempted suicide outside the context of mental or addictive disorders (p. 48). Similarly, Faulkner and Cranston (1998) have highlighted typical limitations in the research on sexual orientation and suicide as including small and convenience-based samples, self-selection, and the absence of appropriate comparison groups. Although it may be premature to conclude that sexual orientation in and of itself is an independent risk factor for suicidal behavior, research in this area has identified a number of factors that seem to place some gay and lesbian individuals at a higher risk. According to McBee and Rogers (1997), many of the suicide risk factors for gay men and lesbian women overlap with those for heterosexuals, although these factors may take a somewhat different form. For example, substance abuse, which is linked to attempted and completed suicide in general (Rogers, 1992), is 3 times more prevalent among gay and lesbian adolescents than in the general population (Gibson, 1989). Possible reasons include using alcohol/drugs to cope with the hatred, physical abuse, fear, and isolation experienced by some gay men/lesbian women and using gay bars as socially acceptable places to meet others (McBee & Rogers, 1997). Similarly, family dysfunction, including paternal alcohol abuse and physical abuse, may be another predisposing factor for gay and lesbian suicide (Schneider et al., 1989). Identity confusion is also a significant contributing factor to the risk of suicide for gay men and lesbian women (McBee & Rogers, 1997). The stress of coming out (Schneider, Taylor, Hammen,
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Kenneny, & Dudley, 1991) exacerbates the typical stresses related to adolescent development (Rotherman-Borus, Hunter, & Rosario, 1994). In addition, the younger the age at which a gay man or lesbian woman becomes aware of his or her sexual orientation, the higher the risk for suicide (Gibson, 1989). Thus, alcohol abuse, family dysfunction, identity confusion, and the stress of coming outrather than sexual orientation per semay be contributing to the suspected relationship between sexual orientation and suicidal behavior. In addition, disrupted social ties also contribute to suicide risk for gay men and lesbian women in Western society (McBee & Rogers, 1997), with the risk becoming greater with increased disruptions in social networks (Saunders & Valente, 1987). This disruption may involve parents rejection of the gay or lesbian individual, loss of support from family and friends, and increased verbal and physical abuse from others (Gibson, 1989). The disruption may lead to low status and limited social integration of gay men and lesbian women (Saunders & Valente, 1987). Additionally, since gay and/or lesbian relationships are not socially condoned or accepted by some, gay and lesbian individuals who experience a termination in an intimate relationship may have less social support than heterosexuals (Saunders & Valente, 1987). Finally, the social inequity faced by gay and lesbian individuals may increase risk of suicidal behavior (McBee & Rogers, 1997). Examples of social inequity include denial of access to social benefits, lack of police protection equal to that of heterosexuals, lack of job security, withholding of the same rights as married heterosexuals, religious condemnation, physical victimization, and low status due to the stigma associated with AIDS (McBee & Rogers, 1997). Disrupted social ties may increase stress and diminish the coping resources of gay, lesbian, and bisexual individuals. Demographic Factors There are a variety of miscellaneous demographic factors that may relate to suicidal risk, and these will now be briefly discussed. Demographic factors associated with increased suicidal risk include being unemployed (Norstrom, 1995), being unmarried (Bongar, 1991) or being unpartnered (Mastekaasa, 1995). Suicide rates also seem to vary by geographical location, with the suicide rate higher in urban, metropolitan areas as compared to rural locations (Garrison, 1992). However, geographic differences in suicide rates may result from other factors such as inaccurate reports, accidental misidentification of death as indeterminate, and fewer autopsies being performed to determine cause of death in rural areas (Garrison, 1992). There is some evidence that suicide runs in families (Egeland & Sussex, 1985; Roy, Segal, Centerwall, & Robinette, 1990). For example, among Old
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Order Amish families in Pennsylvania, about 75% of 26 suicide victims clustered in four families (Egeland & Sussex, 1985). However, whether this association is due to modeling or a genetic link is uncertain (e.g., Platt, 1993; Rogers & Carney, 1994). Family history of psychopathology and/or suicidal behavior, disrupted family environments, negative parenting, and physical and sexual abuse within families correlate with an increased risk of suicidality (Moscicki, 1999). Whatever the mechanism, families are clearly the source of many shared vulnerabilities and stressors (Moscicki, 1999). Summary In summary, suicide risk clearly varies as a function of age, gender, ethnicity, sexual orientation, and demographics. In addition, for various subgroupings of individuals, risk factors common in the general population and those unique to the subgroup may both contribute to suicidal behavior. Although it is important for counseling psychologists to be aware of both the general and group-specific correlates of suicide, it is equally important to remember, again, that within-group differences are greater than betweengroup differences (Range et al., 1999). Thus, it is extremely difficult to generalize about the issue of suicide and the associated risk factors for subgroups. For example, the stress related to being a gay male or lesbian female may be formidable for some individuals and not for others. Nevertheless, an awareness of the general and unique suicide risk factors should serve as an initial guide for counseling psychologists to gain a better understanding of suicidal clients at the individual level. Furthermore, risk factors in isolation are rarely useful in predicting suicidal risk. What is crucial is a pattern or a clustering of clues.
Any suicidal outcome is a complex, multidomain, interactive effect of many biopsychosocial factors over fairly long times . . . [and] triggering or precipitating factors of suicide may be a gradual, nondramatic accumulation of many risk factors, not a dramatic, intense, single negative life event or stressor. (Maris et al., 1992, p. 669)
Many of these subgroup risk factors can co-occur. For example, a suicidal individual might be a Native American gay male who has a history of suicide in the family. However, none of these factors is a definite sign of suicide. Many suicidal individuals are heterosexual European Americans who have no history of suicide in the family. It is extremely important to re-emphasize that there are more within-group differences than between-group differences when examining group suicide
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rates. Though there are relationships between a variety of variables and suicide, causality is obviously not implied.
METHODOLOGICAL ISSUES Research examining suicidal and nonsuicidal groups has both advantages and disadvantages in terms of the quality of the data provided to counseling psychologists. A strength of this approach is that, rather than asking people hypothetical questions, actual suicidal and nonsuicidal people are studied. Furthermore, comparison studies can give important insights that might not be apparent on an individual level, thus leading to an understanding of specific risk factors. Also, prospective designs can be used, thus avoiding the potential of hindsight bias. Despite these advantages, group comparisons also have methodological weaknesses. First, definitions are often blurred. Researchers define suicidality in different ways, including people who have thought about suicide (e.g., Beck, Steer, & Brown, 1993); people who made a medically serious suicide attempt (e.g., Beautrais et al., 1999); or people who actually committed suicide (e.g., Fischer, Comstock, Monk, & Spencer, 1993). This blurring of definitions makes generalization and extrapolation difficult. Second, truly comparable groups are nonexistent. For example, a comparison group might be those hospitalized for nonsuicidal reasons, such as schizophrenia or drug abuse. Any comparison group will probably differ from the suicidal group along other dimensions in addition to suicidality (e.g., age and number of hospitalizations). Thus, differences between suicidal and comparison individuals may be due to factors other than the fact that one group is suicidal and the other is not, although it is possible to control for these. Third, comparing groups often means that information about individuals is obscured and group information may be inappropriately generalized to individuals. For example, a therapist might believe (erroneously) that a given woman client poses no risk for suicide because, in the United States, women as a group complete fewer suicides than men. Such an overgeneralization error might lead to mismanagement or mistreatment (e.g., Rogers, 1990). Both noncomparable control groups and the likelihood of inappropriate generalization are experimental criticisms from an objective, scientific point of view. A criticism of a group comparison approach comes from an existential framework. Historically, a natural science approach using controlled experiments is well suited to those problems in which a third-person perspective is desirable (Polkinghorne, 1992). It is less suited to the study of human experi-
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ence, in which what is desired is a first-person description of the meanings present in conscious awareness (Polkinghorne, 1992). In group comparisons, researchers often compare mean scores on specific testsobjective data that are easy to obtain. However, these scores fail to provide information about the personal meaning of the suicidal thought, plan, or action. One alternative to a comparison approach, the case-based design, is particularly recommended for studying suicide (Duberstein & Conwell, 1997). Such a design uses psychological autopsies, typically in-depth interviews of relatives and friends of the person who committed suicide. This design has the capacity to yield large, representative samples of completed suicides, potentially every suicide in a given community. Limitations include hindsight bias and informant bias (Duberstein & Conwell, 1997). Thus, the case-based design addresses some of the disadvantages of group comparisons but also has limitations. Counseling psychologists who use a comparison approach to studying suicide should be careful to use reliable, valid instruments designed for the specific population being studied. Although this point is a given, many projects have included idiosyncratic or single-item instruments, about which psychometric information is weak or unknown (Duberstein & Conwell, 1997). The assessment instruments currently available measure a range of suicidality characteristics (e.g., Dyck, 1991; Range & Knott, 1997) and are often designed for specific age groups, so instruments should be linked to the specific research question being asked. The existing research on the characteristics of those who attempt and commit suicide has been useful in describing risk factors that help shape the appropriate level of concern for any individual. Research on the psychological processes that are close causally and temporally to the suicidal behavior could refine this process even further (MacLeod et al., 1992). For example, research could focus on hopelessness and depression, and specific treatments that might ameliorate these affective variables known to be associated with suicide. As an ethical matter, it is important that studies of suicidal individuals have back-up plans in case research participants are actively suicidal, become upset, or need to talk to someone further. Such plans include referrals to mental health professionals and phone numbers for participants to call in case they have questions or concerns later. For children or participants otherwise unable to consent, such plans should include obtaining assent (children agree to participate) as well as consent (parents or guardians actively give permission for their children to participate), and informing parents and children of the possibility of violating anonymity if that possibility exists (e.g., Cotton &
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Range, 1993). Research with suicidal individuals, by necessity, entails precautions beyond those required in some other kinds of research. Suicide researchers should recognize that the generalizability of their findings is impacted by the populations they use, participation rates they obtain, and the form of data they collect. Explanations for limited participation rates are difficult to obtain because most researchers prefer to respect the privacy of those who refuse to participate. To address this problem, researchers should make extra efforts to enhance responding. For example, beyond the standard assurances, researchers should maintain personal contact with participants (e.g., Pennebaker, 1997) and involve them actively in the research process (e.g., Gergen, 1988). Recognizing that research is a collaborative venture between researcher and participant rather than something objectively administered to anonymous subjects might help to reduce low participation rates as well as produce information relevant to participants.
ASSESSMENT Hopes in the field of suicidology to develop strategies for predicting suicide have recently given way to the more realistic goal of suicide risk assessment (Maris, 1992). In fact, one might cynically conclude that only suicide predicts suicide (Maris, 1992, p. 3). To predict suicide implies an ability to foresee the behavior in some sense and, in terms of measurement issues, requires levels of measurement reliability, validity, sensitivity, and specificity well beyond that available with our current psychometric technology (see Maris et al., 1992, for a thorough discussion of these issues). Thus, predicting suicide has proven to be a formidable task given the low base rate of the behavior in the population and the current knowledge base in suicidology. By contrast, the goal of assessment sets a less precise expectation and implies estimation of potentials or probabilities for suicide, suicide attempts, or suicide ideas (Maris, 1992). Thus, assessment is a reasonable goal for counseling psychologists. Established Personality Measures Established personality measures that might be used in an initial screening, though not specifically addressing suicide, can also be used to assess suicide potential. Three such measures are the Minnesota Multiphasic Personality Inventory (MMPI), the Hopelessness Scale (HS), and the Beck Depression Inventory (BDI).
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MINNESOTA MULTIPHASIC PERSONALITY INVENTORY
The MMPI (Hathaway & McKinley, 1942) and MMPI-2 (Hathaway & McKinley, 1989)566 and 567 true-false questions, respectivelyare the most used objective measures of personality (Archer, Maruish, Imhof, & Piotrowski, 1991). A diversity of methodologies have assessed the MMPIs ability to predict suicide, including individual item analysis (e.g., Koss, Butcher, & Hoffman, 1976) and examination of specific scales and profiles (e.g., Waters, Sendbuehler, Kincel, Boodoosingh, & Marchenko, 1982; Watson, Klett, Walters, & Vassar, 1984). Though research is equivocal, those at most risk for suicide appear to be depressed individuals with deviant scores on the masculinity-femininity scale (Johnson, Lall, Bongar, & Nordlund, 1999). The MMPI is designed and better suited for measuring aspects of personality rather than suicidality.
HOPELESSNESS SCALE
The HS (Beck, Weissman, Lester, & Trexler, 1974)20 true-false questionshas more promise for suicide assessment. In two different studies (Beck et al., 1985; Beck, Brown, Berchick, Stewart, & Steer, 1990) hopelessness predicted eventual suicide. For example, the high-risk group identified by a cutoff score of 9 was 11 times more likely to commit suicide than the rest of the respondents in one study (Beck et al., 1990). The HS is highly internally consistent (alpha = .93), an important feature. Additionally, sensitivity for the HS has been reported as 91% for a 10-year follow-up of inpatients (Beck et al., 1985) and 94% for a 3-year follow-up of outpatients (Beck et al., 1990). Hopelessness is a predictor of suicide, and the HS is a good measure of hopelessness.
BECK DEPRESSION INVENTORY
The BDI (Beck & Steer, 1987) and BDI-II (Beck, Steer, & Brown, 1996)19 and 21 four-step alternatives, respectivelyare popular in both clinical practice and research. Evidence of the reliability of the BDI-II includes high internal consistency (alpha = .92 and .93), significant item-total correlations, and test-retest stability over a 1-week interval of .93 (Beck et al., 1996). Evidence of validity of the BDI-II includes significant correlations with the BDI, and correlations with measures of hopelessness, suicide ideation, and anxiety (Beck et al., 1996). Both the BDI and BDI-II are psychometrically sound. One particular item is useful in predicting suicidal risk (e.g., Beck et al., 1985; Westefeld, Scheel, & Maples, 1998). This hopelessness or pessimism
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item asks respondents how they have been feeling the past week. The four possible responses range from I am not particularly discouraged about the future to I feel that the future is hopeless and that things cannot improve. In a longitudinal study of 207 hospitalized patients who experienced suicidal ideation, this item significantly differentiated suicide attempters from completers at a 5- to 10-year follow-up (Beck et al., 1985). The BDI is a good clinical measure of depression, though in predicting suicide it overlaps to some degree with the HS. The MMPI, HS, and BDI may already be used in a clinical setting as measures of personality or depression, but might be used to address suicide as well. The instruments that follow are specifically related to suicide. Specific Suicide Questionnaires Several instruments are designed to measure specific aspects of suicide. In selecting a measure of suicide, counseling psychologists should consider the population or individual to be assessed (i.e., can the person complete the form, or does a professional need to ask the questions?), the amount of time available, and the specific questions of relevance (i.e., is the person thinking of suicide, or has the person made a suicide attempt in the past?).
SCALE FOR SUICIDE IDEATION
The Scale for Suicide Ideation (SSI) (Beck, Kovacs, & Weissman, 1979) consists of 19 stems (e.g., Wish to live) that an examiner reads along with the alternatives: 0 (moderate to strong), 1 (weak), or 2 (none). It has three factors: active suicidal desire, passive suicidal desire, and preparation. Total scores range from 0 to 38. Internal consistency is strong (alpha = .89; Beck et al., 1979) and interrater reliability is high; that is, when more than one person questions the suicidal individual, the raters scores match well (Beck et al., 1979; Clum & Yang, 1995). Evidence of validity includes significant correlations with the self-harm items of the BDI (Beck et al., 1979), discriminating suicidally hospitalized individuals from depressed outpatients (Beck et al., 1979), significant correlations in the expected directions with ratings of life, myself, and suicide (Beck et al., 1979), and positive correlations with daily self-monitoring of suicidal ideation (Clum & Curtin, 1993). However, in a 10-year prospective study, only the hopelessness scorenot the SSI scorepredicted eventual suicide (Beck et al., 1985). The SSI, administered by a professional, is a good instrument for clinical use or for research. The SSI has three useful modifications. The same format has been used to rate the patients suicide ideation at its worst point in their lives (SSI-W) (Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999). Evidence of reliability
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is moderately high internal consistency (alpha = .88). Evidence of validity is positive correlation with the SSI (Beck et al., 1999). Furthermore, patients who scored in the higher risk category for suicide ideation on the SSI-W had 14 times higher odds of committing suicide 4 years later than did patients who scored in the lower risk category (Beck et al., 1999). This finding means that counseling psychologists should assess the severity of past suicide ideation rather than rely solely on current ideas. Both the SSI and SSI-W are administered by a mental health professional and are very strong instruments. The Modified Scale for Suicide Ideation (SSI-M) (Miller, Norman, Bishop, & Dow, 1986)which can be completed by paraprofessionalsconsists of 18 items, 13 from the original SSI and 5 new ones. The SSI-M is highly internally consistent, with alphas from .87 (Clum & Yang, 1995) to .94 (Miller et al., 1986), item-total correlations from .41 to .83 (Miller et al., 1986), and stability over 2 weeks of .65 (Clum & Yang, 1995). Evidence of validity includes a high correlation with the suicide item from the BDI (.60; Miller et al., 1986), and significant correlations with the total BDI (.34; Miller et al., 1986), the Zung Depression Scale (.45, Clum & Yang, 1995), and the Beck Hopelessness Scale (.46; Clum & Yang, 1995). The SSI-M, administered by a paraprofessional, is also a good instrument. The Self-Rated Scale for Suicide Ideation (SSI-SR) (Beck, Steer, & Ranieri, 1988) can be completed on a computer or with paper and pencil. Its 19 items are similar to the SSI, and the scoring is the same. Internal consistency is strong (Beck et al., 1988), and item-total correlations are moderate to high (.56 to .92 for each item; Beck et al., 1988). Evidence of validity is its correlation of .90 with psychiatrists ratings, and of .94 and .90 with the SSI. Further evidence is its positive correlation with the BDI (Beck et al., 1988). Also, it discriminates between suicide attempters and nonattempters and has good short-term predictive validity (Rudd, Dahm, & Rajab, 1993). The SSI-SR is unique in that respondents typically score higher (i.e., more suicidal) on the computerized version than on the paper-and-pencil version (Beck et al., 1988), a conservative quality that might be desirable in a suicide assessment instrument. No longitudinal studies have been conducted to ascertain which version, if any, of the SSI has the most predictive validity. The clinician-administered SSI, the paraprofessional-administered SSI-M, and the self-administered SSI-SR are all strong instruments.
SUICIDAL IDEATION SCALE
The Suicidal Ideation Scale (SIS) (Rudd, 1989)a self-report instrument that focuses on suicidal ideashas 10 Likert items (e.g., I have been thinking of ways to kill myself) scored from 1 (never or none of the time) to 5
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(always or a great many times), depending on how respondents felt or behaved during the past year. Total scores can range from 10 to 50. The SIS has good internal consistency (Cronbach alpha = .86 and .90), as well as adequate item-total correlations (Rudd, 1989). Evidence of validity is its significant correlations with scales of depression and hopelessness. Also, suicide attempters scored higher than nonattempters (Rudd, 1989). Specifically targeted to college students, the SIS would be appropriate for use in a college counseling center.
SUICIDE BEHAVIORS QUESTIONNAIRE
The Suicide Behaviors Questionnaire (SBQ) (Cole, 1988; Linehan, 1981)originally a structured interview (Linehan, 1981)has been shortened to four questions (e.g., Have you ever thought about or attempted to kill yourself?) that are anchored differently (i.e., some questions are scored 1 to 3, and others, 1 to 6), reflecting how people actually responded in the original interview. Total scores can range from 5 to 19. Designed for adults, the SBQ is widely used and can be completed in less than 5 minutes. The SBQ has adequate internal consistency (alpha = .75 and .80 for clinical and nonclinical samples), and good test-retest correlations (.95 over 2 weeks; Cotton, Peters, & Range, 1995). Evidence of validity is its significant but moderate correlations with the Reasons for Living Inventory (RFL) and the SSI (Cotton et al., 1995). Advantages of the SBQ include its being straightforward, brief, and easy to complete. For suicidal individuals and counseling psychologists treating them, its face validity may be an advantage in that people can easily understand and respond to it, or a disadvantage in that it could be easily faked. Disadvantages also include the fact that it fails to ask about current suicidality and that it is scored differently on the different items.
REASONS FOR LIVING INVENTORY
The RFL (Linehan et al., 1983) is 48 reasons why persons would not kill themselves even if the thought were to cross their mind, with responses ranging from 1 to 6. When developed in the early 1980s, the RFL represented a new and unique way of thinking about the assessment of suicidal risk. Its positive approach reflects many of the fundamental philosophical views of counseling psychology. The factorially derived six factors are survival and coping beliefs, responsibility to family, child-related concerns, fear of suicide, fear of social disapproval, and moral objections (Linehan et al., 1983). The RFL is internally consistent, with alphas from .72 to .92 for each subscale (Linehan et al., 1983; Osman, Gifford et al., 1993), and strong item-total correlations
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(Osman, Gifford et al., 1993). There is good evidence of this instruments validity in that some of the subscales differentiate suicidal individuals from nonsuicidal individuals and ideators from attempters (Linehan et al., 1983). The RFL is a particularly useful instrument because individual items can be examined to determine key reasons for living for a specific client, and these reasons potentially can be used in psychotherapy. Furthermore, its positive wording could have an impact in and of itself. The reverse has been found for depression inventories, so that simply completing them leads to depression (Perlmuter, Noblin, & Hakami, 1983). Also, unlike the other inventories, the RFL has a theoretical base, built on the work of existential writers such as Victor Frankl (1959). One disadvantage of this instrument is that the 48 items are cumbersome for some populations such as inpatients or prisoners. Thus, in addition to representing a uniquely positive approach to assessment that is particularly relevant to counseling psychology because of the fields advocacy of client strength building, the RFL is psychometrically sound.
COLLEGE STUDENT REASONS FOR LIVING INVENTORY
The College Student Reasons for Living Inventory (CSRLI) (Westefeld et al., 1992; Westefeld, Badura, Kiel, & Scheel, 1996a, 1996b; Westefeld et al., 1998), which consists of 46 statements, was modeled after the RFL but developed specifically to assess college student risk for suicide. The CSRLI factors are survival and coping beliefs, college- and future-related concerns, responsibility to friends and family, moral objections, fear of suicide, and fear of social disapproval. The CSRLI has good internal consistency (Rogers & Hanlon, 1996; Westefeld et al., 1998). Evidence of validity is a significant negative correlation with the BDI and with self-reports of suicide risk (Westefeld et al., 1992, 1998). The CSRLI is specifically designed for college students, though the RFL has been validated on college students as well (Osman, Gregg, Osman, & Jones, 1992; Osman, Jones, & Osman, 1991). Either the CSRLI or the RFL would be particularly appropriate for a college counseling center.
BRIEF REASONS FOR LIVING INVENTORY
The Brief Reasons for Living Inventory (RFL-B) (Ivanoff, Jang, Smyth, & Linehan, 1994) is 12 of the original RFL items (2 items per subscale). The RFL-B is internally consistent when completed by college students (alpha = .80; Bryant & Range, 1997). Evidence of validity is significant correlations with the RFL, depression, hopelessness, and ability to predict SSI scores (Ivanoff et al., 1994). At times, respondents can complain or falter when completing the 48 items of the RFL or the 46 items of the CSRLI. College stu-
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dents are accustomed to this type of task, but others such as prison inmates or clinical inpatients can have difficulty. The RFL-B would be appropriate in such circumstances.
SUICIDE PROBABILITY SCALE
The Suicide Probability Scale (SPS) (Cull & Gill, 1982) contains 36 Likert items (e.g., I think of suicide) answered from 1 (none or a little of the time) to 4 (most or all of the time). Responses are totaled according to predetermined weighting to generate a total weighted score, a T score, and a suicide probability score. Also, its four clinical subscales are hopelessness, suicidal ideation, negative self-evaluation, and hostility, though a factor analysis of adolescents responses yielded only three factors (suicidal despair, angry frustration, and low self-efficacy; Tatman, Greene, & Karr, 1993). The SPS was designed as a clinical instrument to accompany an interview of adolescents older than the age of 14, though a majority of the normative sample was older than the age of 19 (Cull & Gill, 1982). Evidence of reliability includes adequate to strong overall internal consistency (.59 to .93; Cull & Gill, 1982; Tatman et al., 1993), good test-retest reliability (.92), and high split-half correlations (.93; Cull & Gill, 1982). Evidence of validity is the fact that the instrument differentiates between nonclinical children, psychiatric patient children, and suicide-attempting children (Cull & Gill, 1982), and that there are significant correlations with irrational beliefs (Woods et al., 1991). The T scores are a unique feature and an advantage. However, considering that it has different factor structures for adolescents than adults, it should be used with caution with adolescents until more research has been conducted (Tatman et al., 1993).
SUICIDAL IDEATION QUESTIONNAIRE
The Suicidal Ideation Questionnaire (SIQ) (Reynolds, 1987) is 15 to 30 Likert items (e.g., I thought it would be better if I were not alive) rated by respondents concerning their thoughts about suicide in the previous month. There are 30 items in the standard form, 15 in the junior high form, and 25 in the adult form. It is anchored on a 7-point scale from 0 (I never had this thought) to 6 (almost every day), so scores range from 0 to 180. Factor analysis has yielded three factors, a 25-item first factor accounting for 90% of the variance, and 3- and 2-item second and third factors (Reynolds, 1987). Reliability of the SIQ is strong, with high alphas (.90s) and strong item-total correlations (.72 to .76; Pinto, Whisman, & McCoy, 1997; Reynolds, 1987). Validity evidence includes its positive correlation with adolescent depression, adult depression, hopelessness, anxiety, and negative life events, and its neg-
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ative correlation with self-esteem (Reynolds, 1987). Furthermore, 4 items (thought of method, thought of death, would solve problems, and wished had nerve) discriminated between suicidal and nonsuicidal inpatients (Pinto et al., 1997). A total score of 20 is a good cutoff for suicide risk. Designed for clinical use as a screening tool, the SIQ has the unique advantage of having a junior high version. Because of its brevity and ease of administration, it appears to be useful clinically as a screening tool as well as a research instrument.
MULTIATTITUDE SUICIDE TENDENCY SCALE
The Multiattitude Suicide Tendency Scale (MAST) (Orbach et al., 1991) is 30 Likert items (e.g., I know people who have died and I believe that I will meet them when I die) rated on a 5-point scale from 1 (strongly agree) to 5 (strongly disagree). It has four theory-based factors: attraction to life, repulsion by life, attraction to death, and repulsion by death. Evidence of reliability is satisfactory internal consistency (.71 to .89) for the subscales (Orbach et al., 1991; Osman, Barrios, Grittmann, & Osman, 1993; Osman et al., 1994). Evidence of validity is that the four factors extracted by factor analysis correspond to the theoretical attitudes toward life and death (Orbach et al., 1991; Osman et al., 1994). Furthermore, psychiatric high school, nonsuicidal high school, and suicidal high school groups differed on the subscales (Osman et al., 1994). Also, some MAST subscales were correlated as expected with SBQ scores, SPS scales, and psychiatric symptoms (Osman et al., 1994). Advantages of the MAST are its theoretical base and the fact that it was designed specifically for adolescents. A disadvantage of the MAST is that its scales correlate with social desirability (Osman et al., 1994), suggesting that young peoples answers could be biased because they respond the way they think that they are supposed to respond. Many suicide instruments may have this same disadvantage, but their correlation with social desirability has yet to be reported.
FAIRY TALES TEST
The Fairy Tales Test (FT)also called the Life and Death Attitude Scale or the Suicidal Tendencies Test (Orbach, Feshbach, Carlson, Glaubman, & Gross, 1983)consists of two parallel sets of stories, with four stories in each set. Each story has an animal hero and delineates one of four attitudes: attraction to life, attraction to death, repulsion by life, and repulsion by death. For example, the attraction to life story is similar to Pinocchio, in that a wooden puppet yearns to be a live boy. The child says how much better off the animal would be by indicating with his or her hands a distance between any
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two lines on a multicolored 30-inch 1-inch ruler. Any 5-inch distance is 0.5 points, so scores range from 0 to 3. The procedure takes 15 to 25 minutes, and is particularly appropriate for children younger than age 10 (Orbach et al., 1983). Evidence indicates significant test-retest correlations for the four factors over 4 weeks (Orbach et al., 1983) and 6 to 8 weeks (Orbach, Feshbach, Carlson, & Ellenberg, 1984), with the weakest factor being attraction to death. Suicidal and normal children differed in the expected directions (Orbach et al., 1983; Orbach, Rosenheim, & Hary, 1987), as did suicidal, chronically ill, and normal children (Orbach et al., 1984). Advantages of the FT are its theoretical base (Orbach, Gross, & Glaubman, 1981); its projective nature, which may appeal to young children; and its unique focus on children younger than the age of 10.
SUICIDE STATUS FORM
The Suicide Status Form (SSF) (Jobes, Jacoby, Cimbolic, & Hustead, 1997) consists of six items scored on a 5-point Likert-type scale, and one yes/no question about agreeing to maintain safety. Designed to be completed by client and counselor, the SSF has three items based on Shneidmans cubic theory (1987), one item about hopelessness (Beck, 1986), one item derived from Neuringers (1974) empirical work on self-regard, and one global assessment. The items are quasi-independent and therefore not totaled. Evidence indicates low to moderate test-retest correlations (Jobes et al., 1997). Evidence of validity is that suicidal students scored higher than nonsuicidal students (Jobes et al., 1997). Counselor ratings of pain were higher than client ratings. The SSF is a promising new addition to the suicide assessment literature, and is particularly appropriate for college counseling centers. This is because it was developed in a counseling center; it has a theoretical as well as an experimental base; and it gives the counseling psychologist and client a chance to independently rate the same items, thus offering an innovative way of verifying perceptions of suicidality.
SUICIDE INTERVENTION RESPONSE INVENTORY
As opposed to assessing a potentially suicidal individual, the Suicide Intervention Response Inventory (SIRI) measures how mental health professionals might respond to a suicidal caller. The SIRI (Neimeyer & MacInnes, 1981) consists of 25 statements that a suicidal telephone caller might make, and two forced-choice alternatives, one of which is more facilitative than the other. For example, You were supposed to help me, but youve only made things worse, which has alternatives (a) Im sorry. I was only trying to
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help, or (b) You sound pretty angry. Responses are scored as right or wrong, so a maximum score is 25. A revision (SIRI-2) (Neimeyer & Bonnelle, 1997) requires respondents to evaluate each response (+3 = highly appropriate to 3 = highly inappropriate), and has weighted scoring so that good scores closely match experts responses. The SIRI-2 is more sensitive than the original SIRI in reflecting improvement in skills after a crisis intervention class for masters level counselors (Neimeyer & Bonnelle, 1997). Evidence of reliability of the SIRI is high test-retest correlations (.86) over 3 months (Neimeyer & MacInnes, 1981), and good internal consistency (.83; Cotton & Range, 1992, and .84; Neimeyer & MacInnes, 1981). Evidence of validity of the SIRI is that veterans score better than trainees or untrained students (Cotton & Range, 1992; Neimeyer & Diamond, 1983; Neimeyer & MacInnes, 1981). The same pattern is true for the SIRI-2 (Richards, 1999). Also, the SIRI is significantly correlated with the Counseling Skills Evaluation (Neimeyer & MacInnes, 1981), though neither converged with job interview-based ratings of counseling potential (Neimeyer & Oppenheimer, 1983). Furthermore, the SIRI is unrelated to opinions about the ethics of suicide (Neimeyer & Diamond, 1983), death anxiety (Neimeyer & Neimeyer, 1984), or abstract knowledge of suicide lethality factors (Inman, Bascue, Kahn, & Shaw, 1984). The SIRI and SIRI-2 are unique in focusing on how to handle a suicidal communication, so they might be particularly appropriate for measuring training progress in counseling psychology students. These instruments are designed to assess specific aspects of suicidality and have strong psychometric characteristics. They might be used singly or in combination to aid in the assessment of a suicidal individual. Summary Assessment of suicidal risk remains elusive, but there are a variety of correlates that seem useful in this regard. Relevant factors include hopelessness/helplessness, a history of certain psychiatric diagnoses, a previous attempt, substance use/abuse, isolation, certain demographic patterns, family history, and giving verbal intent. Some inventories that may already be included in an intake battery such as the HS and the BDI-II may be useful, but specific instruments such as the SSI (or its modified and self-report variations), SIS, SBQ, RFL (or its college student or brief variations), SPS, SIQ, MAST, FT, and SSF can provide specific information that might be helpful in assessing an individual or designing an intervention. Single clues in isolation, however, are rarely useful in predicting suicidal risk (Maris, Berman, Maltsberger, & Yufit, 1992). What is crucial is a thorough assessment of an individuals status with regard to a broad range of suicide risk indicators and
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an integration of that information with clinical observation to guide clinical judgment (Jobes, Berman, Maltsberger, & Yufit, 1995; Maris, 1992). Thus, comprehensive suicide risk assessment can be used to inform clinical judgment and subsequently guide the intervention, prevention, and postvention activities of the counseling psychologist working with suicidal individuals.
INTERVENTION, PREVENTION, AND POSTVENTION In view of the pervasiveness of suicidal ideation and action, and the breadth of professional settings where they may find themselves, intervention, prevention, and postvention are all activities within the purview of counseling psychologists. As used here, intervention will refer to actions with specific suicidal individuals. Prevention will refer to actions within a broader setting, such as a school or community, designed to reduce the suicide rate. Postvention will refer to actions taken after a suicide takes place. Intervention Intervention in a suicidal crisis actually begins with an assessment of risk. If a client is suicidal, a crisis-intervention approach is typically adopted (Callahan, 1998; Clark, 1998), though suicide risk is not always a crisis for the patient or an emergency for the clinician (Clark, 1998, p. 75). Crisis situations develop as a result of client difficulties related to meaning, coping, and support (Callahan, 1998). Thus, crisis intervention in the case of suicide entails evaluating a clients status in these three areas, assessing the need for hospitalization and/or medication, and making specific plans. Based upon the outcome of this process, the therapist may need to violate confidentiality if the person is acutely suicidal (or homicidal). Beyond the initial assessment and related crisis intervention responses, psychotherapy is often recommended. Though all suicide risk issues may not represent crises and emergency situations, all threats of self-harm should be taken seriously when intervening with a suicidal person (Clark, 1998). The counseling psychologist must make a quick decision about whether to let the client leave the office or be involuntarily hospitalized if risk appears imminent. Additionally, the issue of involuntary hospitalization raises the entire question of clients rights vis--vis committing suicide, an issue addressed by Werth and Holdwick (2000). In addition to overall crisis intervention and taking all threats seriously, there are some specific interventions that are often effective, and these are reviewed in the following section.
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CONTRACTS
One specific intervention for suicidal clients is contracting, an approach that, though favored by many experts (e.g., Bongar, 1991), is controversial (Miller, 1999). Contracting involves the clients making an agreement not to attempt suicide while in treatment. Typically, the contract includes a specific time component, such as a week, a day, or until the next appointment. There is a plan in place if the client realizes that he or she is unable to keep the contract or the appointment. Though there is little research evidence about the utility of contracts, most professionals believe that contracts have potential benefits and entail no harm (Bongar, 1991; Davidson & Range, in press; Pipes & Davenport, 1990). Contracts can come in a variety of forms. A written contract is recommended, one that is signed and kept by both parties. We recommend using contracts tailored to the specific individual, but caution counseling psychologists that contracts are not a guarantee against suicidal behavior; nor do they necessarily provide protection against malpractice claims.
IDENTIFYING THE MESSAGE
Another specific intervention is to identify the message, that is, what the client is attempting to communicate and/or what problem he or she is trying to solve through the suicidal behavior (Shneidman, 1987). Communicating suicidal intent and using suicide as a problem solving strategy are two common characteristics of suicidal individuals (Shneidman, 1987). Because suicidal actions are often cries for help, one major focus of therapy is assisting clients to learn alternative methods of asking for help and alternative problem solving strategies (Shneidman, 1987). Encouraging suicidal individuals to develop their problem solving skills is a reasonable goal for therapy. Research is needed that examines the most appropriate ways to accomplish this goal.
VENTILATION
Another intervention is allowing clients to ventilate, a tactic clearly tied to a crisis intervention strategy (e.g., Callahan, 1998). Ventilation can sometimes defuse the crisis situation enough to allow for other interventions such as contracting and problem solving. For this reason, we recommend that counseling psychologists allow some time for ventilation during a session before making a hospitalization decision. Experimental evidence indirectly supports this recommendation. In one study, encouraging college students to write about a traumatic event lessened health visits but made no change in their level of suicidal thinking (Kovac & Range, in press). However, the level
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of suicidal thinking was very low in the first place. Future research could explore the same tactic with individuals who are more suicidal or who are seeking treatment.
ENGAGING SOCIAL SUPPORT
Often, a critical intervention tactic is to engage the social support network. When a person is suicidal, counseling psychologists should ask detailed questions about family and friends. This process can help the suicidal person identify social support possibilities, an important aspect of crisis intervention (Callahan, 1998). Encouraging clients to make a list of individuals and agencies that can be contacted at different times throughout the day and night can provide a concrete reference for reaching out in the midst of a suicidal crisis. Frequent therapeutic contact with suicidal clients is also an important strategy during times of higher risk for suicidal behavior. Research is needed that explores ways to maximize the social support networks of suicidal individuals or encourages them to use their social support network more effectively.
MEDICATION
Because many suicidal people, though not all, are suffering from a major disorder of some kind, medication may be useful. Frequently, the person is depressed, so antidepressants are prescribed. However, giving drugs could be putting a potential weapon into the hands of the client. Thus, anyone who is being treated with medicine needs to be monitored closely. A collaborative relationship between the prescribing physician and the counseling psychologist is a necessity.
PSYCHOTHERAPY
In addition to short-term crisis intervention and some specific actions, psychotherapy is often the long-term intervention strategy of choice. Two prominent approaches to treating suicidal individuals are Dialectic Behavior Therapy (DBT) and Cognitive Behavior Therapy. Both can be effective, though evaluating effectiveness and efficacy is a concern. Dialectic Behavior Therapy. DBT involves behavioral, cognitive, and supportive therapies in individual and group format (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). The group format is psychoeducational, whereas individual therapy focuses on hierarchically arranged treatment targets, the first of which is the suicidal behavior (Linehan, 1987a). DBT integrates traditional, change-oriented behavioral analysis and therapy (skill
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training, problem solving, contingency management, exposure, etc.) with acceptance- and validation-based treatment strategies. Clients are taught four skills: interpersonal effectiveness, emotion regulation, distress tolerance, and mindfulness (Linehan, 1993). Overall, this approach blends a cognitive behavioral orientation with a humanistic recognition of the importance of the interpersonal relationship and interpersonal acceptance of the client. DBT is helpful in reducing suicidal thoughts and actions. Over a year of treatmentcompared with those who received treatment as usual (individual therapy, referrals, hospitalization as necessary) outpatients who received DBT had fewer and less severe suicide attempts, more likelihood of remaining in therapy, and fewer inpatient psychiatric days (Linehan et al., 1991). Also, DBT had a positive influence on other measures of adjustment. Women with borderline personality disorder who received DBT had less anger, and better interviewer-rated and self-rated social adjustment than a comparison treatment-as-usual group (Linehan, Tutek, Heard, & Armstrong, 1994). Dialectical techniques balancing acceptance and change are more effective than pure change or acceptance techniques in reducing suicidal behavior (Shearin & Linehan, 1992). Thus, DBT is a promising psychotherapeutic treatment approach for counseling psychologists who are working with suicidal individuals. Cognitive therapy. Cognitive approaches hold promise in treating suicide. In particular, the strategy of Aaron Beck has voluminous support (Beck, 1970, 1976, 1986). Becks model is built around the idea that critical cognitive distortions can occur when people experience problems; these cognitions can maintain and exacerbate difficulties. Cognitive distortions include arbitrary inference (concluding without evidence), overgeneralization, selective abstraction (not seeing the forest for the trees), personalization, dichotomous thinking, and magnification/ minimization. The key to effective psychotherapy is collaborative empiricism, in which the client and therapist test out a variety of beliefs by examining relevant data. Brief cognitive-behavioral interventions have been shown to be helpful for suicidal individuals. For example, flamboyant, self-harming patients assigned to manual assisted cognitive behavioral treatment had fewer suicidal acts than did those assigned to treatment as usual (Tyrer et al., 1999). In another study, a time-limited cognitive approach involving primarily outpatient, intensive, structured group treatment supplemented by occasional crisis intervention and/or hospitalization included problem-solving and social-competence training and targeted fundamental skills, in addition to improved social functioning and adaptive coping (Rudd et al., 1996). The format included approximately 9 hours per day at the treatment facility for a
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2-week period. This approach to treating suicidal individuals produced about the same benefits as treatment as usual (Rudd et al., 1996). Two important and effective long-term approaches for suicidal individuals are DBT and cognitive therapy. There is considerable overlap in the specific interventions used in either approach. The term cognitive therapy typically refers to briefthough sometimes quite intenseinterventions, whereas DBT often takes longer, usually 1 to 2 years. Counseling psychologists might use either approach, tailored to meet the needs of the individual client. Evaluating psychotherapy effectiveness. Although both the DBT and cognitive approaches produce positive results when applied to suicidal individuals (Clark, 1998), more outcome research is necessary in this area. Evaluating psychotherapy for suicidal individuals can involve either an efficacy model or an effectiveness model (Seligman, 1995). These models produce two distinctly different kinds of outcome studies. The efficacy model of evaluating psychotherapy typically involves prescreening participants to meet select criteria (such as a specific score on the SSI), often including a single diagnosis (such as depression but not borderline personality disorder), random assignment to a treatment or control group, manualized treatment for a fixed number of sessions, and welloperationalized outcomes rated blindly (e.g., a score on the SSI administered by someone blind as to treatment condition). The efficacy model is traditionally used in rigorous scientific experiments. However, though scientifically rigorous, efficacy studies often involve tremendous cost and expenditures of time. Furthermore, this experimental paradigm has drawbacks. First, efficacy studies fail to replicate what actually happens. In real-world psychotherapy, patients are not randomly assigned to treatment but rather choose their therapist based on referrals, word of mouth, or other criteria that might predict success (Seligman, 1995). Second, treatment is not manualized but rather is continuously adjusted by therapist and client based on progress. Third, rather than sticking to a specific, short timeline, treatment continues until it works, money runs out, or the therapist or patient gives up (Seligman, 1995). Fourth, psychotherapy patients, particularly suicidal ones, typically have multiple problems rather than a single diagnosis. Fifth, researchers who conduct these studies are usually theoretically and philosophically aligned with a particular approach. Thus, they may tailor their interventions and dependent measures to their approach, enhancing the chance of finding that it works best. Thus, efficacy model evaluations of psychotherapy are scientifically rigorous but fail to model what happens in real life. These experimental problems are particularly prominent with the issue of suicide because of its multidimensional and multidetermined nature.
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A different way to evaluate psychotherapy is an effectiveness model. In effectiveness studies, users are surveyed about the value of their psychotherapy. A recent study in Consumer Reports (Mental health, 1995) evaluated psychotherapy effectiveness. In this survey, middle-class respondents reported that psychotherapy helped them in terms of specific improvements, global improvement, and satisfaction. This study had several major strengths. First, the naturalistic study evaluated how treatment works as it is actually performed (Seligman, 1995). Second, a large base of persons completing the survey provided a more extensive sample of middle-class, educated Americans than would be available to most academic researchers. Third, this effectiveness model avoided the research bias typical of efficacy studies. With no advertisements or financial support other than subscriptions, Consumer Reports is relatively objective. This extensive effectiveness study had the advantages of objectivity and realism. The effectiveness approach also had drawbacks. Detailed questions about the psychotherapy experience were not askedthere is a limit to how many questions people will answer in any survey. In addition, self-report was the only type of outcome measurethere were no double-blind or single-blind raters. Further, all the questions were retrospective, and there were no control group(s) and no randomized assignment (Seligman, 1995). Finally, the Consumer Reports survey asked no specific questions about suicide, though some inferences about psychotherapy for suicidal individuals could certainly be made. One such inference is that reporting satisfaction and global/specific improvements implies that people would be less suicidal after therapy than before therapy. Also, the fact that most people found therapy helpful might counteract the hopelessness that often accompanies suicidal thoughts and behaviors. Efficacy and effectiveness model evaluations of psychotherapy give different information, and both have value. An effectiveness research project on psychotherapy for suicidal individuals has yet to be done. Such research would be a valuable objective for counseling psychologists, who might be particularly appropriate for this kind of research because of their scientist-practitioner training as well as their focus on dealing with real-world problems and solutions. The authors recommend that suicide researchers conduct traditional efficacy studies as well as effectiveness studies. Both approaches are valuable. Furthermore, some researchers could blend such approaches. Such a blend would necessitate a compromise between the traditional strict randomized studies and the more observational designs of effectiveness studies (Norquist, Lebowitz, & Hyman, 1999). Creativity in methods and statistical analytic procedures is needed (Norquist et al., 1999), and is an objective to which counseling psychologists should aspire. Such research might incorpo-
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rate multisite, research-oriented university counseling centers that treat people who think about suicide as well as people who have attempted suicide. The goal of these centers would not be to deliver an ivory tower level of intervention, but rather to deliver the usual, economical level of care to the suicidal individual as well as careful, reliable documentation of outcomes for well-defined populations (Klein & Smith, 1999). The goal of the research would be to explicate the processes that underlie successful therapy for a suicidal individual (MacLeod et al., 1992). An innovative attitude and serious environmental support would be needed to accomplish these objectives. In summary, intervention strategies for suicidal individuals include no-harm agreements, identifying the message underlying the suicidal actions, encouraging ventilation, engaging their social support network, using medicine as appropriate, and psychotherapy. Research is needed that explores the forms of psychotherapy best suited for suicidal individuals and how psychotherapy works in combination with medicine specifically for this population. Furthermore, research is needed on aspects of treatment such as specific problem-solving strategies, no-harm agreements, and guidelines for engaging social support networks. Prevention In addition to assessment and intervention, the issue of prevention has traditionally been a very important component of counseling psychology (e.g., Gelso & Fretz, 1992). Suicide prevention efforts take various forms, including suicide crisis centers or hot lines, educational programs, and suicide inoculation programs.
CRISIS CENTERS
Suicide crisis centers or hot lines are a major community-based prevention approach, although data on their effectiveness are mixed. In one metaanalysis, crisis centers had neither a positive nor a negative overall effect on community suicide rates (Dew, Bromet, Brent, & Greenhouse, 1987). In another analysis in the 1970s, communities with suicide prevention centers had fewer suicides than communities in general (Lester, 1993). In still another analysis, suicide hot lines were minimally effective in reducing suicidal behavior (Shaffer et al., 1990). The group most helped seems to be young European American women (Lester, 1993; Miller, Coombs, Leeper, & Barton, 1984). In a review of 14 studies examining the impact of suicide prevention centers on suicide rates (Lester, 1997a), 7 supported prevention efforts, 1 found that prevention increased the suicide rate, and 6 found no significant effects. Among the 7 studies with a significant decrease, the effects
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varied according to population and method of suicide prevention. One effective approach, such as that of the Los Angeles Suicide Prevention Center, is multidimensional in that it uses hotlines in conjunction with individual and group therapy, clinics, psychiatric consultation, and inpatient as well as outpatient treatment. Research in this area typically compares suicide rates in communities with suicide prevention centers (SPCs) to the overall rate, or compares suicide rates in communities with SPCs to those without SPCs. An advantage of this strategy is that it focuses on the bottom line: how many suicidal deaths actually occurred. However, by design these studies tend to be nonexperimental and therefore cannot address cause and effect. Furthermore, they fail to take into account the many other differences that exist between communities. Sociological comparisons of the suicide rates of communities with and without suicide crisis centers is a first step toward answering the question of what prevents suicide.
EDUCATION PROGRAMS
Curriculum-based prevention or education programs represent a relatively new, real-world approach to suicide prevention (Garland & Zigler, 1993). These programs can include in-service training modules to teachers and teaching staff, or in-class modules for students. They can target potentially suicidal students, or those most likely to interact with them. Teachers sometimes change their attitudes toward suicidal students after a brief educational module about suicide (Davidson & Range, 1999), but, at other times, modules have no impact (Davidson & Range, 1997). Principals view curriculum-based programs and in-service presentations to staff more favorably than student screening programs (Miller, Eckert, DuPaul, & White, 1999). Thus, teaching professionals are often but not always responsive to training modules. When presented to students (although not exclusively suicidal students), results are mixed. In one study, suicidal 9th graders reacted more negatively than nonsuicidal students did to 3- and 1.5-hour suicide prevention modules from a classroom teacher (Shaffer et al., 1990). However, this study was criticized for using a short-term program briefly inserted into students daily lives (Schmitt & Ellman, 1992). In another study, Native American 9th and 11th graders reacted positively to a culturally relevant life skills curriculum delivered in a required class. At posttest, life-skills students scored healthier than a no-intervention group on suicide probability and hopelessness (LaFromboise & Howard-Pitney, 1995). In another study, students who participated in a module about no-suicide contracting became significantly more likely than controls to recognize symptoms of suicide in others, intervene
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appropriately with peers, and arrange for professional follow-up with a peer who was suicidal. They were also less likely to consider suicide an acceptable option themselves. They maintained these improvements at 7-week follow up (Hennig, Crabtree, & Baum, 1998). Likewise, students who participated in a suicide modulemore than controlssaid that they would tell an adult about a suicidal peer at posttest (Kalafat & Gagliano, 1996). In a review of more than 300 prevention programs including suicide prevention programs, the most effective ones were based on a sound foundation of empirical knowledge (Price, Cowen, Lorion, & Ramos-McKay, 1989). Evaluating education modules provides important information about the impact of potential learning. A pretest and posttest design with an experimental and control group can show whether participants changed as a result of suicide prevention training and establish that these changes are more than what would be expected due to time alone. However, even though suicide education modules modify attitudes under certain conditions, attitude changes are not necessarily correlated with behavior. Also, modules typically have more impact on teachers than students, although even for students, some modules are effective. Furthermore, these modules often miss the most needy students who are comparatively (a) more likely to have attendance problems and (b) less responsive to intervention attempts. In addition, the test to establish that learning occurred is sometimes removed from real life. For example, student Jane Doe completes a suicide module and then passes a multiplechoice test in which she chooses the correct answer to a question about suicide always being taken seriously. However, when John Brown expresses preoccupation with death or gives away some prized possession, Jane Doe may fail to recognize that she should ask directly if John is suicidal. Evaluations of educational modules are a second step toward answering the question of what prevents suicide.
INOCULATIONS
Inoculations against suicide represent a proactive focus of prevention activity. In this strategy, nonclinical populations are typically given an intervention designed to lower their suicide risk and are compared with a control group who receive no intervention or a comparable but noninoculating intervention. For example, elderly Italian individuals given access to a Tele-health phone line had fewer suicides than the general population (De Leo, Carollo, & Buono, 1995). In another example, college students asked to remember positive childhood experiences (Ellis & Range, 1989) or repeat positive or negativebut not neutralcognitive statements (Turzo & Range, 1991) experi-
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enced some improvement in their reasons for living. Bolstering reasons for living would be helpful in the study of suicide and would use the skillsaffirming orientation typical of counseling psychology. Suicidal individuals would be particularly suitable for this type of study. Another promising inoculation is autobiographical writing, in which participants write about a personal, traumatic, profound event, typically one not widely discussed. Comparison groups typically write about innocuous topics such as what they ate at their last meal. Autobiographical writing lessens health center visits, helps college students maintain their grades (Pennebaker, Colder, & Sharp, 1990), lessens absenteeism for university employees (Francis & Pennebaker, 1992), and increases the likelihood of reemployment after being laid off from a professional-level job (Spera, Buhrfeind, & Pennebaker, 1994). Furthermore, autobiographical writing tends to reduce unique grief among individuals recently bereaved from suicide (Kovac & Range, 2000). Though some efforts have been made to research the question of whether prevention efforts are actually successful with suicidal individuals, this area seems weak in comparison to studies of the characteristics of suicidal individuals. Prevention researchparticularly studies that examine inoculation against suicideis recommended for counseling psychologists. Postvention Postvention includes procedures to alleviate the distress of suicidally bereaved individuals, reduce the risk of imitative suicidal behavior, and promote the healthy recovery of the affected community (Hazell, 1991). Postvention can take various forms, depending on the situation and context in which the suicide or suicide attempt takes place. For example, postvention could focus on students in a school where a suicide or suicide attempt occurred. Also, postvention could focus on a counselor or therapist whose client committed suicide, helping this individual to process feelings associated with the loss. Alternatively, postvention efforts could focus on the bereaved family and friends. Therapeutic strategies include helping survivors to process feelings of remorse and guilt and initiating steps that will permit them to engage in a healthy grieving process. A number of writers/ researchers have discussed the key principles involved in postvention (e.g., Bongar, 1991; Gilliland & James, 1993; Grossman et al., 1995; Hazell, 1991; Hazell & Lewin, 1993; Hewett, 1980; Lamb & Dunne-Maxim, 1987; Ness & Pfeffer, 1990). They emphasize several key points, which are described in the following sections.
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SPEED
First, speed is important. Postvention should begin quickly (Jobes, Berman, OCarroll, Eastgard, & Knickmeyer, 1996). Though people respond along different time dimensions (i.e., some are more readily able to deal with their feelings about suicide than are others), it is still important to respond within hours if possible. The postvention may extend over a brief or a long period of time. Some survivors are immediately ready to deal with their feelings, whereas for others it may be days, weeks, months, or even years before they are ready.
FLEXIBILITY
Second, flexibility is important. A number of opportunities for support should be provided, including responses to individuals, a group, or both. For example, if a member of a sorority commits suicide, the postvention personnel will probably need to spend time with individuals, small groups, and the entire sorority. In a school, support could include faculty-led rap sessions, designated staff whose doors are open for talking, and the general message that faculty members are available (Lamb & Dunne-Maxim, 1987). In one school setting, counseling focused on the students understanding of the events that led to the suicide, rumor control, and personal reactions, acknowledging that some students in the group may also feel suicidal and giving specific advice (Hazell & Lewin, 1993). Although there was no difference between counseled students and matched controls, methodological problems are severe in this kind of field research (Hazell & Lewin, 1993). Allowing for ventilation, providing some normalization (i.e., in these situations, persons often experience anger, fear, etc.), providing support, offering psychoeducation concerning post-traumatic stress disorder issues, and providing information for referral are also critical in postvention.
DISCOURAGE CONTAGION
Third, avoiding glamorizing or dramatizing the suicide is important because of the possibility of contagion. Suicidal contagion is typically studied by examining the suicide rate in a community after a suicide occurs, compared to before the suicide. Increasingly studied in the past 20 years, suicidal contagion has mixed empirical support. Some research shows a marked suicide contagion rate. For example, after four fictional movies about suicide were televised in metropolitan New York City in 1984 to 1985, the average number of suicide attempts and completions increased significantly (Gould & Shaffer, 1986). Also, after a twice-
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broadcast six-episode television film about suicide, the suicide rate increased for 15- through 29-year-old men, the group most similar to the suicidal person in age and gender (Schmidtke & Haefner, 1988). Similarly, after televised news stories about suicide, the suicide rate increased (Phillips & Carstensen, 1986). This research evidence shows an increase in the suicide rate after a suicide is announced or shown. However, other evidence is mixed or shows no suicidal contagion. For example, after a television movie about suicide in California and Pennsylvania, there was no increase in suicide (Phillips & Paight, 1987). Likewise, after a television soap opera suicide, there was no significant change in the suicide rate (Kessler & Stipp, 1984). In another analysis, contagion increased if the suicide was an entertainer or a political celebrity, but not if the person was an artist, villain, or a member of the economically elite (Stack, 1987). Thus, research evidence about suicidal contagion is equivocal. Examining the suicide rate after a suicide is publicized gives a unique community-wide or nationwide perspective on what occurs. Thus, this type of research can reveal trends not apparent on a local level. However, it also fails to reveal information about any one individual. For example, did the person who committed suicide actually watch the television story about the suicide (Eisenberg, 1986)? An alternative way to explore suicidal contagion is an analog design in which participants read or watch a story about suicide (or a control incident), then estimate their own or someone elses suicidal behavior. Studies using analog experimental designs also yield inconsistent information about suicide. On one hand, college students believed that a teen they watched on television who knew about a suicide in the community was more likely to commit suicide than the same teen who did not know about a community suicide (Range, Goggin, & Steed, 1988). College students furthermore thought that they themselves would also be vulnerable in the same circumstances (Range et al., 1988). In a similar vein, high school students who read a newspaper story about a distressed adolescent who knew someone who either committed suicide or sought therapy believed that contagion would occur in both circumstances (Gibson & Range, 1991). This type of design ensured that teens actually watched or read about the suicide and produced results suggestive of suicidal contagion. However, other analog research shows no evidence of contagion. For example, high school students who viewed a video of a distressed teen and then read a summary containing an embedded sentence about a suicide or plane crash in the community, or no embedded sentence, expected no suicidal contagion (Steede & Range, 1989). College students viewed others as more likely to copy someone who committed suicide but viewed themselves as more likely to copy someone who sought therapy (Higgins & Range, 1998).
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Thus, contagion analog studies suggest that people view others as somewhat vulnerable to suicidal contagion but view themselves as vulnerable sometimes and immune at other times, depending on exactly how the question is worded. Analog studies of suicidal contagion correct for a flaw in studies of national rates because they ensure that people actually learn of a suicide, either by watching it on television or reading about it in a newspaper-like story. However, they are flawed in that they are unrealistic. Reading about a suicide in the newspaper or hearing about it on television is probably a less common way of learning about suicide than simply being told about it. Furthermore, laboratory analog studies of suicidal contagion are hypothetical in that they ask respondents how they expect themselves or others to react, and people may be inaccurate about how they would respond to news about a suicide. Several suggestions for reducing contagion have been offered. For example, physical memorials on school grounds are not recommended because of the possibility that they would mystify the event (Lamb & Dunne-Maxim, 1987). A recommended alternative is some type of activity such as a fund drive for a worthy cause (Lamb & Dunne-Maxim, 1987). Furthermore, the specifics of how a suicide is reported may encourage or discourage contagion. For a celebrity who commits suicide (such as musician Kurt Cobain), it is important to distinguish between the talented person and the drug abuser who ultimately killed himself (Jobes et al., 1996). Simplistic, repetitive, sensationalistic news coverage probably encourages suicide, and how-to descriptions are not recommended (Jobes et al., 1996).
ADVANCE PLANNING
Fourth, advance planning for postvention is very important. Having a specific protocol in place can be very helpful for officials facing a crisis. A coordinated team approach is typically needed for a school system (Mackesy-Amiti, Fendrich, Libby, Goldenberg, & Grossman, 1996). A vitally important aspect of advance planning is how to handle the media. A curt no comment is usually a poor response (Jobes et al., 1996). Instead, having one specific person designated to handle the media can be useful (Jobes et al., 1996). Furthermore, the media can be useful as a way of promoting crisis centers as a place to get help during times of distress and despair (Jobes et al., 1996). Having a good intervention plan results in increased telephone calls to a crisis center but decreased actual suicidal deaths (Jobes et al., 1996). Thus, advance planning has empirical as well as intuitive support.
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MULTIPRONGED EFFORTS
Fifth, multipronged efforts are necessary. Having staff identify those in need of postvention is not enough (Hazell & Lewin, 1993). School staff may be unaware of persons beyond the obvious grieving friendship group who could also be at considerable risk. On the other hand, inviting students to self-select for postvention counseling fails to address the problem of high-risk students who are unwilling to identify themselves as being in need. Therefore, some experts recommend a brief but systematic screening of all students for the presence of risk factors for suicide (Hazell & Lewin, 1993). Secondary school principals are not particularly in favor of self-report screening, however, perhaps because of misperception that it would promote suicidality or because of inadequate treatment resources (Miller et al., 1999). Multipronged efforts should include a variety of ways of identifying those in need of help and a variety of avenues and people to provide the help.
RESOURCES
Sixth, it is important to note that excellent postvention resources are available. The AASs (1990) guidelines for postvention in schools are an excellent resource and are recommended for counseling psychologists who work in the schools. In addition, AAS maintains numerous materials on this topic as well as many others in the area of suicide and maintains a directory of survivor groups, which can be of great value in the postvention process.
SUMMARY
The primary goals in responding to a suicide include helping all involved to understand grieving and begin to grieve, preventing additional suicides, and providing referrals (AAS, 1990). Specific aspects of postvention include coordinating community linkages, managing the actual crisis, disseminating information, providing debriefing counseling (group and individual), dealing with memorials/funerals, and responding to the media. It is important to plan in advance; use a team approach; provide a wide variety of modes of counseling such as individual, small group, large group, immediate, and delayed to all impacted; and follow-up. Furthermore, because responses to a suicide are heterogeneous, all involved must remain flexible and be responsive to a wide diversity of reactions (AAS, 1990). The issues of intervention, prevention, and postvention with suicidal individuals represent complex and understudied areas. In addition, the complexities related to the assessment of risk for suicide and the lack of welldeveloped theoretical approaches for conceptualizing suicidal clients increase
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methodological problems. Given the ambiguities in the field of suicidology, the seriousness of suicidal behavior for both the individual and those close to him or her, and the likelihood of encountering suicidal individuals in a counseling psychology career, it is important to include a focus on suicide assessment, intervention, prevention, and postvention in counseling psychology training programs.
TRAINING Training in dealing with suicidal individuals should begin early in the training program and should continue throughout internship and postdoctoral experiences. Training can be provided through both formal and informal means. As a minimum, training should include at least one didactic course with content in both suicide and death (Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989). Supplementary offerings such as workshops, discussion groups, and/or experiential exercises, optimally led by a multidisciplinary team, could be added to help trainees feel comfortable around suicidal persons as well as the general topic of death (Chemtob et al., 1989). Such educational experiences reduce anxiety about working with death-related issues (Benoliel, 1988). Training components include supervision, practical experiences, systematic protocols, operationalized definitions of crises/emergencies, strategies to minimize litigation, and ethical issues.
SUPERVISION
Training must include appropriate supervision when the issue is suicide. A mentor model of supervision (Kranz, 1985) primarily focuses on the supervisor/intern relationship but could be applied to training programs and training clinics. First, in this model, supervisor and trainee are paired so that the trainee has an opportunity to observe the experienced therapist with the suicidal individual. Second, the trainee gradually assumes more responsibility, a process designed to reduce the anxiety for the intern/student. Third, the supervisor and trainee thoroughly review suicidal clients, and the supervisor gradually encourages the intern/student to make independent clinical judgments (Kranz, 1985). A gradual approach in supervision should enable the counseling psychology student to learn the requisite skills in dealing with suicidal individuals.
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PRACTICAL EXPERIENCES
Practical experiences are essential in training students how to handle a suicidal crisis. Practica, externships, and internships provide obvious settings for helping students to develop confidence in handling suicidal crises. In addition, seminars, case conferences, assigned readings, and special workshops can be integrated with the day-to-day management of cases to broaden the general competency level of students (Ellis & Dickey, 1998). Combined with individualized supervision, these kinds of practical experiences can be very helpful to trainees.
PROTOCOL
A clearly delineated protocol for assessing suicidal potential and/or implementing interventions should be provided for the guidance of staff and trainees. Such a protocol might include steps to be followed in addressing the needs of the client and ensuring that supervisory personnel and administrators are appropriately informed of potential risk. Treatment of the client would minimally include an assessment of potential for carrying through on a suicidal act, helping the client identify alternative means of resolving the crisis, and completing a no-suicide agreement. Additional agency procedures include (a) notifying the immediate supervisor, the clinical director, and the training director; (b) filing a formal incident report; (c) providing supervision and support for trainees as they address the emotional impact of the crisis; (d) conducting a meeting to critique the clinical intervention; and (e) making a report to a Morbidity and Mortalitytype review panel (Ellis & Dickey, 1998). Self-help support groups, peer support, and supervisors sharing personal experience about suicidal clients have been helpful and therapeutic for trainees (Berman, 1995; Jones, 1987; Kolodny, Binder, Bronstein, & Friend, 1979). Training, therefore, should start early and continue late, include a variety of formats but necessarily include supervision, and have formal as well as informal aspects.
STANDARDIZED OPERATIONAL DEFINITIONS
In dealing with suicidal individuals, standardized operational definitions may be helpful to trainees and other staff members as they attempt to consistently make good clinical judgments (Kleespies, 1998a). An emergency is a serious, acute situation requiring immediate treatment (Munizza et al., 1993, p. 7). A crisis is a serious disruption of the individuals baseline level
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of functioning, such that his or her usual coping mechanisms are inadequate to restore equilibrium (Callahan, 1994, p. 10). Thus, not all crises are emergencies, but emergencies usually arise when the client is in a crisis (Kleespies, 1998a). Another helpful distinction for counseling psychology training programs is the difference between being able to identify suicidal risk factors and being able to respond effectively and therapeutically to the suicidal client (Bongar, Lomax, & Harmatz, 1992). These two domains are separate areas of clinical competence, and students in counseling psychology programs need to learn both skills to effectively intervene with a suicidal individual.
MINIMIZING LITIGATION
Regardless of the effectiveness of the intervention, litigation is a possibility when a client attempts or commits suicide. A clients suicide is one of the leading causes of malpractice litigation for mental health professionals (VandeCreek & Knapp, 1989). Not surprisingly, those involved are often concerned that information communicated in a postvention procedure might be subpoenaed in a malpractice trial (Ellis & Dickey, 1998). Such concerns may be unwarranted because they may be manifestations of a natural tendency to use avoidance or denial as a means of coping with an emotionally difficult issue (Ellis & Dickey, 1998). Regardless, the issue of litigation can exacerbate an experience that is at best draining and at worst debilitating. Fear of legal action could prompt experienced counseling psychologists as well as trainees to avoid suicidal clients (Clark, 1998). This fear can be detrimental to clients in need of services (Clark, 1998). The best course is to provide good care, make the best decisions possible, and document these activities to the best of ones ability (Clark, 1998, p. 92). Also, suicide assessments should be performed on all new clients, consultation should be used as appropriate, all documentation regarding suicidal clients should be clear and legible, and any clinical decisions should be fully documented with the rationale for the decisions made by the psychologist (Clark, 1998). Training in the use of such procedures would be useful for trainees and reduce legal fears that could prevent students from treating clients who are suicidal.
ETHICAL TRAINING
Training in ethical issues in managing suicidal crises also is critical. In addition to the potential need of violating confidentiality if a person is imminently harmful to himself or herself (or to another person), there is the issue of competency. As with all clients, APA guidelines on competency apply to
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working with suicidal personsthat is, work with such persons only if one has adequate training (Berman & Cohen-Sandler, 1983; Bongar & Harmatz, 1989). Counseling psychologists need go beyond acceptable levels of competence and give a suicidal person optimal care (Berman & Cohen-Sandler, 1982). Ethical and legal issues are relevant to all clients but are particularly relevant to suicidal individuals. Counseling psychology programs are doing a disservice to students if they fail to provide adequate training in the area of suicide prevention, intervention, and postvention. The emotional impact of losing a client to suicide has a long-term impact on the career of a new professional (Kleespies, Smith, & Becker, 1990). Trainees are less experienced, less secure in their roles, and more shocked by suicide threats, gestures, attempts, or completions than are professionals (Kleespies, Niles, Mori, & Deleppo, 1998). Furthermore, trainees may experience the potential interference of personal beliefs in treatment of the suicidal individual, may misunderstand the ramifications of legal and ethical issues regarding attempted or completed suicide, or have other problems in dealing with suicidal clients. Training in suicide work should not be left to happenstance and can best be addressed through a well-organized, coherent training component that is integrated within the counseling psychology core. An example would be a required course in crisis management, a documented protocol for handling suicidal clients, systematic and wellsupervised practical experience in handling suicidal clients, and an outlined review panel in the event that a client commits suicide. Such a model offers the best possibilities for producing well-informed, highly competent counseling psychologists. This could be done both by training programs as well as practice sites.
CONTROVERSIES AND FUTURE DIRECTIONS The area of suicidality has ongoing controversies, including the effectiveness of suicide prevention via preferred method restriction (especially firearms); the lack of consensual definitions of suicide and attempted suicide (e.g., Ellis, 1988); the need for theoretical grounding in suicide research and the application of nonlinear models to suicide; and issues of rational suicide, physician-assisted suicide, and other forms of hastened death falling under the general right to die rubric. These controversial areas represent guides for future directions in suicidology.
SUICIDE PREVENTION VIA PREFERRED METHOD RESTRICTION
The issue of the effectiveness of suicide prevention efforts has been and continues to be controversial in suicidology (e.g., Auerbach & Kilmann,
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1977; Dew et al., 1987; Lester, 1998). Outcome research typically focuses on the two predominant forms of suicide prevention, prevention center/crisis intervention programs and psychiatric/psychological treatments. Most outcome studies (though not all) suggest that these methods are largely ineffective in reducing the incidence of suicide (Lester, 1998). Despite this equivocal support, most suicide prevention resources continue to flow in this direction. Given this general lack of empirical support, some experts suggest that it may be time to add a new approach to the prevention armamentarium: restricting access to preferred methods (Lester, 1998). This new approach is grounded in research showing that restricting access to firearms (e.g., Lester & Murrell, 1980) and detoxifying natural gas (i.e., reducing the levels of toxins in natural gas to reduce its lethality; Kreitman, 1976) correlates with a drop in suicide rates. A controversial aspect of implementing such a restriction is its impact on access to firearms. Despite the fact that the majority of suicides (National Institute of Mental Health, 1999) are firearm related, the constitutionally guaranteed right to bear arms continues to ensure relatively easy access to firearms in the United States. Similarly, restricting access to jumping as a method of suicide raises the possibility of fencing in national landmarks such as the Golden Gate Bridge and the Bay Bridge in San Francisco, historically popular sites for suicide (Lester, 1998). Though a restriction-of-methods approach holds promise if the larger social issues can be addressed, additional research is needed focusing on the decision-making processes of suicidal individuals and what factors influence their choice of method. Likewise, research is needed that examines the potential for switching to an alternative method if ones first choice for committing suicide is unavailable.
OPERATIONAL DEFINITIONS
Another area of controversy in contemporary suicidology relates to the definitions used for suicide and suicidal behaviors. One issue is the potential underreporting of completed suicides in the national death statistics because of the lack of uniform application of operational classification criteria (Moscicki, 1999). Another issue is whether individuals who complete suicide and individuals who attempt suicide represent a homogeneous group (Ellis, 1988), and even whether suicide attempters can be considered as homogeneous (Arensman & Kerkhof, 1996) These questions are much more than academic because much of what we think we know about suicide in terms of risk factors and interventions is based on generalizations across these global groupings. If individuals who commit suicide and individuals who attempt suicide are qualitatively different from each other, then factors that may be useful in identifying them and
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intervening may, likewise, be different. Similarly, if there are various meaningful subgroupings of suicide attempters, then research will need to identify risk factors and interventions separately for these groups. Perhaps the lack of demonstrated effectiveness of assessment and prevention efforts is related to faulty assumptions regarding the homogeneity of suicidal individuals. Concerted research efforts attempting to clarify these important issues will be needed in the future.
THEORY-GROUNDED RESEARCH
An emerging controversial issue in the field of suicide is related to the role of theory in research. Current research on suicide is hampered by a general lack of theoretical grounding and an overreliance on linear modeling (Lester, 1994; Rogers, in press; Rogers, 1995; Rogers & McGuirk, 1998). With the creation of the Center for the Study of Suicide Prevention by the NIMH (Resnik & Hathorne, 1973), the study of suicide in the United States took on a clearly pragmatic focus. That is, the short-term goal became to identify risk and protective factors for suicide and suicidal behaviors, toward the long-term goal of reducing the incidence and prevalence of those behaviors. As a result, much of the research was conducted from an atheoretical perspective. This absence of theoretical grounding may be playing a role in the inability of the field to impact the suicide rate and gain a better understanding of suicidal individuals in general. Consequently, many researchers (e.g., Lester, 1998; Rogers, in press) call for increased attention to theory development and application of solid scientific procedures to test these theories. Along these lines, the field of suicidology could benefit from the application of the various nonlinear dynamic systems models such as chaos, self-organized criticality, and catastrophe modeling (Masterpasqua & Perna, 1997; Rogers, 1995). Common across these models is a focus on understanding the behavior of dynamic interactive systems as a holistic process rather than concentrating on prediction through reductionistic approaches. According to Casti (1994), nonlinear dynamic systems models are an outgrowth of systems research indicating that randomness and determinism often coexist, that the whole cannot always be understood by reducing it to simpler parts, that instability is commonplace, and that change is frequently abrupt and discontinuous (p. 42). This description of systems behavior might easily be applied to human behavior and especially to human behavior as it applies to suicide (Rogers & McGuirk, 1998). Thus, these models might be applied to suicidology in a similar fashion as they have been applied to other areas of psychology such as development, psychotherapy, and disorder in general (Masterpasqua & Perna, 1997). The application of these system-based mod-
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els should result in the development of more comprehensive formulations of suicidal behavior and lead to a better understanding of suicidal individuals (Lester, 1994). Despite these suggestions and movement in related fields to attempt to understand phenomena from dynamic systems perspectives, little progress has been made thus far with respect to this call.
RATIONAL SUICIDE
Undoubtedly, the most controversial issue facing suicidology is that of rational and physician-assisted suicide, and for this reason, this issue is treated as a separate article following this review (see Werth & Holdwick, 2000). Contemporary discussions of the role of the counseling psychologist vis--vis rational suicide (Rogers & Britton, 1994; Werth, 1992) are particularly relevant to counseling psychologists who work with chronically or terminally ill clients, but are also a concern in a broader social context. Of late, social policy activity has increased around the issues of rational and physician-assisted suicide, and some professional organizations, such as APA (1997), have made systematic responses. Controversy in this area is related to the question of whether a decision to end ones life can be considered rational, how rationality might be assessed, and what role counseling psychologists might reasonably play in helping clients who are struggling with these important issues. Werth and Holdwick (2000) present a thorough discussion of this important and complex area of growing concern for the mental health profession in general and counseling psychology in particular. Clearly, there are a variety of areas in suicidology that are controversial yet have relevant directions for the future of the field. Counseling psychologists, by virtue of their scientist-practitioner orientation, are in a position to substantially impact this field of study and practice through systematic attempts to understand and resolve these controversies.
A FINAL NOTE Counseling psychologists of the future will increasingly confront a broader array of mental health problems than in the past, as the population in settings such as university counseling centers diversifies and as the practice of counseling psychology expands. Across settings such as schools, medical sites, the veterans administration, and community mental health centers, counseling psychologists will encounter clients with suicidal thoughts and behaviors. Thus, counseling psychologists need to be grounded in theories of
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suicidality, knowledgeable about risk factors, and able to competently screen for suicidality through intake assessments using instruments such as the HS, the SSI, the SBQ, and the RFL. They need to be able to design and administer interventions, preventions, and postventions that take into account the knowledge base that exists and be good scientists in furthering this knowledge base. For all these reasons, the authors reiterate their call that training in suicidology be a core requirement of all counseling psychology training programs. Unfortunately, we are not there yet. There currently seems to be widespread inattention to preparing trainees for this mental health challenge (Kleespies et al., 1993). Academic programs expect that most training will occur during internship supervision (Ellis & Dickey, 1998). Thus, counseling supervisors who may not have the appropriate levels of training are, nevertheless, expected to train students in this important area. We hope that this major contribution will help create an awareness of the need for systematic training related to working with suicidal issues as a component of core training in counseling psychology. Also, we hope that this contribution can serve as a resource for a general grounding in suicidology as it relates to both the science and practice of counseling psychology.
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