1. Suicide Counselling
I. Introduction
A friend when sent me this:
1. The common purpose of suicide is to seek a solution;
2. The common goal of suicide is the cessation of consciousness;
3. The common stimulus in suicide is intolerable psychological pain;
4. The common stressor in suicide is frustrated psychological needs;
5. The common emotion in suicide is hopelessness -- helplessness;
6. The common cognitive state in suicide is ambivalence;
7. The common perceptual state in suicide is constriction;
8. The common action in suicide is egression;
9. The common interpersonal act in suicide is the communication of intention;
10. The common consistency in suicide is with lifelong coping patterns.
I thought he had captured the essence of the predicaments of suicidal victims. To enter into
mind of the suicide victim is the essential step in suicide counselling. The perceived
insurmountable problems block the victim from perceiving anything better other than death;
at least s/he feels s/he is free to decide on that, as Sartre had said. Anything better, well there
may be some possibilities, all the possibilities are not exhausted – Samuel Beckett’s Estrogen
tells Valdimir when the latter wants to end his life in the tragicomedy Waiting for Godot.
Perhaps opening up the possibilities is that is required for the suicidal victim. The
possibilities open two aspects of suicide counselling – immediate: preventing immediate
suicide; and the remote to enable and strengthening to cope with the life’s muddles. But
before investigating into that let us see again what leads a person to suicide.
II. Causes of Suicide in India

2. Suicide rate in India is higher compared to the Western world (World Health
Organization, 2001). Western data suggest a very high prevalence of mental illness in those
who commit suicide. The Indian experience, on the other hand, suggests that most suicides
are impulsive and related to stress. Recent studies using verbal autopsy data have shown that
suicide is often related to socioeconomic circumstances, interpersonal, social, and cultural
conflicts (Prasad et al., 2006).
Psychological autopsies have also supported the conclusion that suicide is associated
with interpersonal conflicts, marital discord, alcoholism, financial problems, and
unemployment (Gururaj, Isaac, Subbakrishna,& Ranjani, 2004), and with adverse economic
circumstances among farmers (Sainath, 2007). Older Indian studies, while documenting the
association between suicide and psychopathology, have also highlighted the association with
adverse life events (Vijayakumar & Rajkumar, 1999).
Qualitative data suggest that many in the general population view suicide as an option
when faced with apparently insoluble personal difficulties and misfortune (Manoranjitham et
al., 2007). Having said that people with mental illness committing suicide though exist in
India, but their numbers are smaller compared to the secondary causes (K.S. Jacob, (2008)
The prevention of suicide in India and the developing world, Crisis; Vol. 29(2):102–106). All
the citations above are as cited by this author).
Thus the problem of suicide counsellors in India is more demanding and calls for
multi-factorial approach. It is within the frame work of economic, social and psychological
issues that a counsellor has to fulfil the task of counselling the prospective suicide victims.
This task is more challenging since many of these factors are beyond the control of the
counsellors even though the immediate danger of suicide may be postponed. The more
enduring prevention is that is difficult. Nevertheless, these factors need to be understood and

3. kept in mind to create empathic response to the client and to establish therapeutic relationship
which is the crux of suicide counselling.
II. Suicide Counselling Approaches
II.1. General Considerations
Because suicidal individuals often communicate their thoughts to someone, the
therapeutic approach taken by the counsellor is of great importance. To be effective in
reducing suicidal behaviour and ideation, an extensive understanding of the dynamics of the
therapeutic process is necessary. The question is what constitutes effective treatment
components? Among the therapeutic factors contributing to counselling efficacy with the
clients, in general, that have been identified by researchers thus far are the a) therapeutic
alliance or relationship, b) client motivation, c) client distress and in-session emotional
intensity and d) Giving importance to client’s perspective (B. Paulson & E. Worth (2002),
Journal of Counselling & Development: 80, 86).
Be aware
Before we discuss this further a word of caution to the prospective counsellors. It is
also important for a counsellor to be aware of his/her own weaknesses when counselling a
client with suicidal ideation. In fact, the WHO’s manual for Prevention of Suicide states that
the counselling suicidal clients is an “occupation hazard” since difficulty they meet in
counselling such clients (http://whqlibdoc.who.int/publications/pdf).
Paulson and Worth summarising studies point out these aspects to consider before
entering to the counselling the suicidal clients
1. The counsellour need to understand his or her own anxiety about death.
of the individual, therapist anxiety about death, the therapist’s difficulty in dealing
with anger and hostility and failure of the counsellor to assess the clients’ access to emotional
support” (87). Apart from these the legal complications that arise in the event of the worst

4. may also intimidate the counsellors. These factors need to be addressed and dealt with
appropriately before a counsellor enters into this service.
II.2. Preventive Steps
One of the steps that the professional counsellors as well as all the concerned may
undertake is to take the preventive steps. WHO’s manual outlines the following as the
preventive factors that may address this grave issue:
a) support from family, friends, relatives and acquaintances,
b) strengthening religious and cultural beliefs about preciousness and dignity of life and the
value of suffering, life etc
c) community involvement,
d) Satisfying social relations,
e) social integration through e.g., employment, constructive use of leisure time etc., and f)
access to mental health services and sources (3).
A counsellor may explore these possibilities for the client to strengthen the clients.
II.3. Assessment
It is important for the effectiveness of counselling that he/she assesses the suicidal
client for an effective intervention and prevention activities. Primary goal of suicide
assessment is to provide information for prevention and counselling. Assessment
subsequently guides clinical judgement counselling intervention, prevention and postvention.
An effective assessment should contain the following:
- A review of relevant risk factors;
- any history of suicidal behaviours
- unchangeable biological, psychosocial, mental, situational or medical conditions;
- The extent of current suicidal symptoms including the degree of hopelessness;

5. - Precipitant stressors;
- Level of impulsivity and personal control;
- Other mitigating information; and
- Protective factors
Suicide assessment requires an evaluation of the behaviour and risk factors, the
underlying diagnosis of mental disorder and a determination of the risk for death. Once the
assessment is completed it is important to rate the overall suicide risk in terms of severity,
perhaps on a continuum from nonexistent to extreme suicide risk.
II.4. Immediate Intervention
Very often a counsellor is faced with a situation where the client is on the verge of
committing suicide. At this juncture the primary task of the counsellor is to avert the
immediate danger. Capuzzi & Gross (2000. I don’t want to live, VA: ACA, 319-352) give the
following points to be kept in mind at the immediate intervention to prevent suicide:
 Be calm and supportive;
 Be nonjudgemental;
 Encourage self-disclosure
 Acknowledge suicide as a choice, but not “normalize” suicide as a choice;
 Actively listen and positively reinforce self-care;
 Keep the counselling process focussed in the here and now of the client
 Avoid in-depth counselling until the crisis abates
 Call upon others to help assess the potential for self harm;
 Ask questions about lethality;
 Remove lethal means
 Make effective crisis management decision.

6. Since the trust and confidence in the counsellor paramount so that the client opens
him/herself to the counsellor his/her intentions, during the suicide management, it is
important for the counsellor not to express personal moral, religious, or philosophical
perspectives since these could contribute to a block in communication and alienate the
suicidal individual. Potential helpful resources, both personal and community, need to be
processed with individual. This can include family, friends, clergy, faith healers and other
sources of support. It also is important to not make promises regarding confidentiality about
the individual’s suicidal intentions.
It is also important that the client feels understood by the counsellor and that the
counsellor is with him/her in that moment of crisis in the life of the client. The counsellor
staying in the here-and-now of the client helps his to reframe his/her situation and thinking so
as to dawn in him the rays of hope for the better tomorrow.
The counsellor should also know that the averting of the crisis is all important in the
emergency, for this he/she need to take collaboration from all the sources like clergy, faith
healers, immediate neighbours, friends, social workers, physicians etc. Consequently, a good
network of the people involved in humanitarian works, mental health professionals and other
interested parties.
The counsellor also should keep in mind often the clients deny their intention of
suicide. Consequently any denial should be taken cautiously. This is more so when the
immediate crisis is averted and aftercare services begin.
II.5. Long term interventions
Once immediate crisis is averted, a counsellor cannot rest secure that client will not
take recourse to suicide in the future. In fact, it has been reported that sixty percent of the
client’s with suicidal tendency attempt suicide again. Consequently intensive follow-up and
after care including case management, continued telephone contacts and support and in some

7. case home visits are essential. Premature termination of counselling and inadequate response
to treatment can have an unfavourable prognosis for eventual suicide.
II.6. Therapeutic Interventions
It has been found the cognitive behavioural therapy is one of the most useful therapies
in addressing the issues of suicidal clients. According Meichenbaum the following are the
therapeutic tasks based CBT approach to counselling the clients with suicidal ideation or
attempts:
1. Conduct ongoing risk assessments, including motivational and functional analyses.
Collaboratively generate a safety plan.
2. Develop and maintain a collaborative therapeutic alliance with the suicidal patient and
significant others.
3. Target suicidal behaviours and cognitive vulnerabilities explicitly. (Research indicates that
treatments designed to reduce depression do not necessarily correlate with a reduction of
suicidal behaviour.
4. Conduct psycho-educational sessions, collaborative goal-setting and treatment
interventions that teach and nurture coping strategies such as distress tolerance, emotional
regulation, problem-solving and interpersonal skills on how to develop and maintain
“healthy” social supports.
5. Address issues of comorbid disorders and provide integrative psychotherapeutic
interventions.
6. Help the suicidal patient develop a life worth living and help change hopelessness into
hopefulness.
7. Include relapse prevention trials where suicidal patients can rehearse, both in and out of the
therapeutic session, how to handle potential stressful events and internal and external triggers
for suicidal ideation and suicidal behaviours.

8. 8. Help health care providers deal with the stress of working with suicidal patients. Address
issues of vicarious traumatisation. (see Meichenbaum's handout on www.melissainstitute.org;
mypage.iusb.edu/~jmcintos/basicinfo.htm).
In therapy in practice, some of the most important considerations are the following:
1.Establish therapeutic alliance: The first and most critical task in working with suicidal
patients is the ability to develop and maintain a good therapeutic alliance which can act as an
excellent safe-guarding protective factor. Therapeutic alliance implies:
1. Be attentive, remain calm and provide the patient with a private, non-threatening and
supportive environment to discuss experienced difficulties. Do not express anger,
exasperation, or hostile passivity. Be forthright and confident in manner and speech to
provide the patient with a stable source of support at a time of crisis.
2. Have the patient tell his/her "story," at his/her own pace. Conduct a behavioural chain
analysis of events of the proximal factors that triggered the suicide attempt.
3. Use Motivational Interviewing procedures. The four principles of Motivational
Interviewing are: Expressing Empathy; Developing Discrepancy between the patient's
present behaviours and values; Rolling with Resistance as the therapist strives to
understand and respect both sides of the ambivalence from the patient's perspective.
The therapist can empathize with the needs that give rise to suicidal ideation, without
approving suicidal behaviours. Finally, the therapist can Support the patient's Self-
efficacy by acting as a guide or consultant, suggesting possible ways to proceed.
2. Psycho education: Following matters may be covered in the psycho-education:
 Conduct assessment procedures. Provide feedback from the assessment and use the
Case Conceptualization Model to help the patient and significant others better
understand risk and protective factors.

9.  Educate the patient and significant others about the disorders and the cognitive model
of depression and suicide and the proposed treatment plan.
 Help the patient and significant others to appreciate the role of warning signs and the
role of setting factors that may potentiate suicide attempts (e.g., discontinuance of
medication, sleep deprivation, substance abuse behaviors, manic episodes,
disengagement and social withdrawal behaviors).
 Use self-monitoring, Clock metaphor, downward spiral explanation,
 Develop a safety plan on ways that the patient can solicit help.
 Provide bibliotherapy for both the patient and significant other.
3. Nurture Hope: Following may be used for nurturing hope:
 Engage in collaborative goal-setting (Hope has been equated with goal-directed
thinking).
 Focus on concrete attainable goals.
 Help the patient appreciate the progress that has been made.
 Employ an Anti-suicide kit. Explore "Reasons for Living."
 Introduce the patient to coping models.
 Involve significant others and adjunctive interventions.
 Assess and build on "strengths."
 Use Time Lines.--One can trace collaboratively with the suicidal patient and
significant others. Following may be the time line:
Time Line 1- traces from birth to the present, the list of stressors
and interventions
Time Line 2- traces evidence of individual, familial and
cultural resilience and strengths
Time Line 3- engages the suicidal patient in collaborative

10. goal-setting. This time line begins in the present
and extends into the future
 Use Future Time Imaging Procedures
 Encourage the patient to reconnect with supportive and prosocial significant others
and reengage in life tasks and undertake unfinished life projects.
 Convey that psychotherapy is concerned with "life-promotion" and not just suicide-
prevention. It is designed to help patients develop a life worth living
4. TEACH COPING SKILLS
 Help the patient develop internal and external compensatory strategies.
 Address the patient's impulsiveness and nurture emotion-regulation and distress
tolerance skills.
 Engage in problem-solving and communication training with a focus on the problems
that triggered the most recent suicidal attempt.
 Conduct cognitive therapy of depression.
 Increase the patient's adaptive use of social supports and develop ways to broaden
social support network.
 Build in Behavioral Activation and Activity Scheduling.
 Use cognitive behavior skills training procedures (e.g., Self-instructional training,
Stress inoculation training).
 Use mindfulness and acceptance treatment strategies, willingness to experience
thoughts, feelings and situations fully, in a non-judgmental fashion.
 Use cognitive rehabilitation procedures (e.g., memory and attentional pictorial
reminders and supports) in order to build in self-efficacy trials for suicidal patients
with Traumatic Brain Injuries and other such patients as ways to apply CBT
procedures with TBI patients).

11.  Help foster positive, supportive, "cognitive prosthetic" social environments.
 Increase the patient's use of and compliance with adjunctive services to be
conducted in an integrated fashion (e.g., use of medication).
Apart from the above, issues of comorbid disorders, and relapse prevention
procedures are also to be taken care. The latter includes: Help the suicidal patient to decrease
cognitive constriction and rigidity by learning how to engage in problem-solving in order to
consider a wider range of possible options. Help the patient to chart a possible new course,
accepting less-than-perfect solutions. Have the patient and significant others recognize how
far he/she has come-- taking credit for improvement. Need to help the patient develop
Reasons for Living and reclaim a life that is worth living. Have life-affirming experiences.
Use relapse prevention tasks. Have patients visualize themselves in a future suicidal crisis.
Use guided visual imagery of employing their coping skills in dealing with the events leading
up to suicidal crisis and ways to handle suicidal urges.Help the patient make good choices in
response to “bad feelings.” Such imagery rehearsal procedures can be used as relapse
prevention tasks involving past and potential stressful scenarios that might trigger suicidal
ideation and suicidal behavior in a kind of stress inoculation fashion (see Meichenbaum,
2007). Successful accomplishment of such tasks can be used to determine whether gradual
termination of treatment is required or whether further treatment is warranted. In this fashion,
the length of the treatment is performance-based, rather than arbitrarily set ahead of time.
(The last subtitle data are adopted from
http://www.melissainstitute.org/documents/35_Years_Suicidal_Patients.pdf)