Think about the case of Jonna. According to chapter 2 (ATTACHED), counselors do not have magic words or tricks to use when someone is experiencing intense grief. We do, however, have the po

Chapter 2

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and sudden deaths can be felt with such impact and can trigger feelings of intense loneliness, disconnection, and panic. It is during those times that even words of comfort can feel empty. We all experience grave losses in different ways, and such factors as the nature of the loss, our relationship to the loss, our internal resources, and the resources around us affect our survival.

The Association for Creativity in Counseling is a division within the American Counseling Association focused on using internal and external creative resources as well as the shared creativity of the counselor and client in counseling practice (Duffey, 2005; Duffey, Haberstroh, & Trepal, 2016). Creativity in counseling (CIC), as a model, is defined as “a shared counseling process involving growth-promoting shifts that occur from an intentional focus on the therapeutic relationship and the inherent human creative capacity to affect change” (Duffey, Haberstroh, & Trepal, 2016, p. 448).

According to CIC, creativity is as integral to counseling practice as the therapeutic relationship. The relationship helps us feel connected and know we matter in the midst of such chaos, and it sustains us as we try to understand, come to terms with, and adapt to unanticipated life changes. Our shared creativity fosters compassion and creates space for the process to unfold. Even in those moments when we cannot begin to connect with the concept of creativity, our creative forces are at work.

Joanna came to counseling following the death of her only son, months before he was to graduate from college. Losing her beloved boy was the greatest crisis ever experienced by her family. Amidst the chaos and consolations that came in its aftermath, to hear her tell it, all she could do was put one foot in front of the other and remember to carry a bottle of water with her because “water is good for you.”

Joanna was in shock following the accident and for many months afterward. She sought counseling because she did not know what else to do and wanted to do something. On the first visit, she entered the office, sat on the couch, gave a faint smile, and sighed. There began what came to be one of my (Thelma’s) most pow- erful experiences in counseling, and Joanna became one of my greatest teachers.

Joanna grieved her son and her life every day. She also allowed herself the space, without judgment, to just be. She spent considerable time alone, which was helpful to her, at the same time that she found solace in some close relationships. She attended counseling every week for months and would bring in heart-shaped artifacts that she would find along her path. Sometimes she would see a heart- shaped carving in a door and would take a picture of the door. These served as signs, or reminders, to her that there is much more to life than we know. Joanna’s faith sustained her, and it was in faith that she most connected with her creativity.

Working with people in grief, or those undergoing crisis and loss, is deeply humbling. As counselors, we do not have the magic words that can make things better. We do not have the most brilliant interventions that can change the course of a person’s life after loss. What we do have, however, is the human connection and compassion that can foster a sense of hope and the training that can help us be present and connected with the unimaginable pain that people suffer. Moreover, it is in relationship that we can find the creative strength to move forward.

There are times when our traumatic experiences can leave us feeling immobi- lized. We may find ourselves thinking and feeling in debilitating ways. In Joanna’s case, her creativity, faith, and relationships helped her move past these obstacles. Not all people are so fortunate. Others succumb to their grief, sadness, and loss,

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and they do not find their way home. These are tragic realities. As counselors, we bring our authenticity, training, and hope to our work and relationships, and we co-create a space where our clients can, to the best of their capacities, connect with their own.

Empathy and Responsiveness as Creativity

RCT is not technique driven, yet it does offer guidelines for working with trauma, and it helps both counselor and client make sense of what are often confusing dynamics. For example, RCT proposes the need for responsiveness rather than re- activity (Jordan & Hartling, 2002). Being responsive is not akin to complete spon- taneity, or what RCT refers to as amygdala authenticity, on the part of the counselor (Jordan, 2018). This method is not what RCT suggests. Borrowing from the brain health literature, we know that amygdala reactivity will inevitably occur at times on the part of the counselor, but it is to be worked with, not let loose (Kindsvatter, Russotti, & Tansey, 2019). Thus, the counselor engages respectfully and honors both the client’s yearning for connection and the need for protective strategies of disconnection.

Empathic Failures

There are times when empathic failures will occur. In these times, it is important that the counselor let the client know that she earnestly wants to understand the client better and suggests they take a look at the disconnection that occurred. There are also times the counselor simply notices the client’s need to pull away and does not comment, prod, or analyze it. Sometimes the counselor simply “stays with” the client at an emotional distance that feels safe to the client. If necessary, calming or grounding approaches might be suggested to help the client with her reactivity. When safety is reestablished, the counselor might decide to make a gentle inquiry about the process, or she might decide to simply allow the comfort level in the room to settle in and engage around less-charged topics.

There are times when counselors are off track or do not follow the client’s lead. In these cases, counselors can apologize and acknowledge the situation. More im- portant than the counselor’s need to feel effective or like a “good helper” is the need for the client to see that she is being listened to and taken seriously and that her healing supersedes all else. In addition, counselors need to practice steady presence and be on the lookout for their emergence of ego, investment in being right, or retreat into theory. To the extent that the counselor is invested in building or maintaining an image of “the good counselor” or “empathic listener,” he or she will not be available for real relationship.

Reworking Disconnections

When, however, the counselor is present in healing moments, the brain’s parasympathetic and sympathetic systems rebalance (Banks, 2015). “Good vagal tone” (Porges, 2011), which allows a person to find comfort and growth in relationships, is reestablished. The pain of exclusion is lessened as the client feels joined-with (Banks, 2015). In RCT therapy, the underlying neural patterns that are the result of trauma and chronic disconnection begin to shift. Together,

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My wife, Amanda, who is an amazing writer (and an amazing person), told me that my experience reads as “flowery, and verbose . . . more like a suspense novel than a genuine tale of struggling to help those grappling with depression.” And she is absolutely right, because that’s exactly how that moment felt for me—being my first time. I was worried that my skills were lacking, an experience common for those new to this field (Douglas & Wachter Morris, 2015).

Unless you have specific training in suicide assessment and intervention, you are most likely going to have one class or one chapter of a textbook—if you are lucky—and that will not feel like enough when you are sitting across from your first client who is living with suicidal ideation. This chapter will be a primer for you, and my hope is that through this chapter you will increase your comfort with the topic of suicide and gain tools to pull from.

Understanding Those Living With Suicidal Thoughts and Behaviors

It is evident that those who engage in suicidal behavior are suffering emotionally, psychologically, or physically (Gramaglia et al., 2016). To understand the individ- ual’s unique pain, the counselor appreciates the client’s perception with full em- pathy. Edwin S. Shneidman, the father of contemporary suicidology, believed that “the author of suicide is pain” (Shneidman, 1998, p. 246), and he introduced the idea of those engaging in suicidal behavior as experiencing psychache. Psychache is the aching psychological pain that can take over the mind (Shneidman, 1999). Shneid- man (1999) suggested that suicidal behavior occurs when an individual deems their psychache to be intolerable and begins to see death as an active option to be rid of their pain. Indeed, those living with suicidal ideation are struggling to find connec- tion and hope. Riethmayer (2004), in her discussion on trauma, stated:

Trauma’s initial impact brings four very powerful messages to a trauma survivor and the community. It tells the survivor that the world is no longer safe, kind, predictable, and trustworthy. Each of these has been taken away, or at the very least has been violated and/or damaged through the traumatic experience. (p. 219)

Individuals living with suicidal behavior experience a sense of the world as unsafe, unkind, unpredictable, and untrustworthy (National Suicide Prevention Lifeline, 2017a). In a suicide assessment and intervention, a counselor remembers that this per- spective is likely how their client is experiencing the world, and the counselor should actively look for hope and stability as they move toward a treatment decision.

Myths

The word “suicide” feels heavy for many. This feeling may be due to the taboo na- ture of the act, personal and societal moral and philosophical views, or simply the fear of not knowing what to do after a client states, “I want to die.” Society and cul- ture have a large impact on the narrative of suicide. In addition, the act of suicide is so personal that those affected by it may create their own narrative about it (Amer- ican Association of Suicidology [AAS], 2014). As a result, several myths abound (Moskos, Achilles, & Gray, 2004; World Health Organization [WHO], 2014). The WHO (2014) published six common myths in a report on suicide:

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1. “Once someone is suicidal, he or she will always remain suicidal” (p. 69). According to the WHO report, this assumption is not the case: “Heightened suicide risk is often short-term and situation-specific” (p. 69). Although it is true that those with suicidal ideation may reexperience suicidal ideation, these thoughts need not be permanent, and individuals with previous ideations and attempts can continue their life with- out existing in this state.

2. “Talking about suicide is a bad idea and can be interpreted as encouragement” (p. 94). The WHO report suggests that because of social and cultural stigma around suicide, it becomes difficult for those who are living with suicidal ideation to know who to reach out to. Encouraging an individual to share may introduce the option to reflect on and reexamine their decision. This approach can lead to the prevention of an attempted suicide.

3. “Only people with mental disorders are suicidal” (p. 77). Although “suicidal behav- ior indicates deep unhappiness” (p. 77), it does not always indicate the comorbidity of a mental health disorder.

4. “Most suicides happen suddenly without warning” (p. 41). As indicated by the WHO report, most suicides are preceded by warning signs and symptoms. Knowing what to look for can make you a protective factor for a person contem- plating suicide.

5. “Someone who is suicidal is determined to die” (p. 64). The WHO report suggests that most suicidal people are “often ambivalent about living or dying” (p. 64). There are also occasions of impulsivity, but those individuals may still hold uncertainty.

6. “People who talk about suicide do not mean to do it” (p. 21). The WHO report sug- gests that “a significant number of people contemplating suicide are experiencing anxiety, depression and hopelessness and may feel that there is no other option” (p. 21). Most likely, those people who are speaking about suicide are looking for some- one to talk to and are reaching out for assistance.

Additional mental health advocacy organizations, such as the AAS, have also cre- ated materials to dispel suicide myths.

Suicide Nomenclature

To further our understanding of the individual living with suicidal behavior, we turn to the terms we use to talk about suicide. Having a common language sup- ports continuity of care within the helping profession and across disciplines. Many agree that how suicidal behavior is labeled is essential (Hoff, Hallisey, & Hoff, 2009; National Suicide Prevention Lifeline, 2017a; WHO, 2014); however, there have been difficulties adopting universal nomenclature.

Next, you will find the most widely accepted terminology as well as language that is no longer used. The accepted and defined terms are suicidal behavior, sui- cide, suicidal ideation, suicide plan, suicide attempt, and suicide survivor. Al- though there are other more specific terms connected to assessment, such as levels of lethality (which are covered later), these terms are essential for documentation and for communicating about suicide with other professionals.

Recommended Terms The following are recommended terms to use when describing the range of con- cepts related to suicide.

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