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How to Accurately Assess and Help a Client

How to Accurately Assess and Help a Client Program Transcript

SUE BANKS: At this time, Dr. Slater and I want to discuss some issues that we think are important to consider when we're dealing with clients who present with serious issues like suicidality. So, Dr. Slater, why don't you tell me a little bit about your practice, and why you became interested in this topic of suicide?

MICHELLE SLATER: Well, I got started in my first semester of graduate school. And my instructor was the director of the local crisis center, so I went through the training there. And, honestly, I was hooked on it from then. So there was an extensive training program, and we trained to answer the 24-hour suicide hotline.

As I worked my way into the center, over the years I became part of the outreach team in the community-- responding in person to suicidal clients, doing death notifications with local law enforcement, and following up in the community after a completed suicide death. And then I ended my stint there as a trainer-- kind of training new phone volunteers and practicum students and crisis response.

SUE BANKS: That's interesting. My background is a little bit different. I work with the chronically mentally ill individuals-- SPMI. And so I went through the ASIST training. I don't know if you're familiar with that.

MICHELLE SLATER: Oh, yeah.

SUE BANKS: So my training and background came through learning how to work with and assess individuals who came in for standard treatment and services. And so the ASIST model was really effective for me. I learned quite a bit using that model. Now, you mentioned that you learned then through the suicide hotline, and your work with clients currently consists of--

MICHELLE SLATER: Currently, I have a private practice office location, and I see suicidal clients more in acute crisis-- not really dealing as much with chronically suicidal or with severe mental health issues. So fairly frequently, I get the opportunity to work with a client who's just hit a crisis point in their life-- a rock bottom-- struggling with some feelings of hopelessness and depression-- and working through that is commonplace. We teach our students, obviously, that nobody escapes the need to have to deal with clients in crisis. You can't really predict exactly when or what that will look like, which is why it's so important to have exposure to how to assess and how to deal with suicidal clients.

SUE BANKS: And so what would you say your approach to assessing your clients in suiciding your clients?

MICHELLE SLATER: Having started my mental health career working with high- risk and suicidal clients, it seems to be such a natural part of what I do. And I

How to Accurately Assess and Help a Client

think the first thing that jumps out when I think about what my approach is like I'm listening for the hallmarks of suicide. So emotionally, that's hopelessness, despair, ambivalence. People want to live, but they don't know how.

And so that's part of, I think, when I'm assessing lethality-- I'm hearing hopelessness. A lot of students are afraid we're planting those ideas. It's a reflection. So I'm hearing that, and then saying back, you're feeling helpless. If a client responds to that in the affirmative, then I'm going to go ahead and put out there-- you're thinking of killing yourself.

And that's really hard for students to get used to the idea of-- there's a boldness and a confidence to doing that. I think it's a good time to, sort of, add-- I've never had clients be mad at me for doing that. That that is, at least, demonstrates a willingness to go there.

And early on the hotline, I can remember saying that with a client who seemed very hopeless and crying. And so when I had said that, there was silence, and then she kind of chuckled a little and said, oh, my gosh. I must sound terrible. And it gave us an opportunity to say, you sound like you're in a really bad space. And so it didn't turn out that she was actively lethal or considering it, but what a great conversation and a great opportunity to assess it. Even if it's not necessarily heading in that direction.

SUE BANKS: When I think about my approach, I tend to be very narrative focused. So it's important for me to allow the client an opportunity to tell the story as much as they're able to. Because I don't know how much of an opportunity they've had in the past, to just-- to talk about what they're experiencing. So I try to just go with them and allow them to tell as much of their story as I can. And as I'm listening for their story, then I'm assessing the risk, the opportunities to plan.

And so from there, I'm able to determine-- or just, kind of, like process with them where they are in their plan. To the point that, again, once I am satisfied that the risks are present, then I do just initially ask, do you want to kill yourself, or are you thinking about suicide, to see how they will respond.

MICHELLE SLATER: One thing that I have happen quite a bit is the struggle with people who are having suicidal thoughts or feeling really trapped or hopeless but not actively wanting to kill themselves. And as that comes up in assessment, I think has been really helpful for me over the years to kind of present to clients this continuum. We're all on the same health and wellness continuum. It's very easy for-- particularly, beginning counselors and counselors in training-- to inadvertently have an us and them, so those people that struggle with feeling hopeless or those people who are suicidal.

As opposed to that's us-- what would it take on any given day, when you are here at this end, feeling healthy and well, and on this end, giving up hope. And that

How to Accurately Assess and Help a Client

any given time, we could be sliding on that continuum. So I have found it really powerful to present that to clients in a way that helps normalize it. And that allows me then to assess do you want to die, or is it just that you're having a hard time figuring out how to live?

SUE BANKS: Yes.

MICHELLE SLATER: And I get a lot more, in my practice now, I get a lot more clients that will say, no, I don't want to die. It's just none of this makes sense. I cannot figure out how to cope with this pain. And that that's a real nuanced part of an assessment that I don't I don't think you always get that in the textbook about asking the questions.

SUE BANKS: Exactly and separating depression or assessing for depression and suicide because sometimes the hopelessness can display as signs of depression. But, yet, you pinpoint that depression, however, you don't go a step further to assess and continue forward with suicidality. And that's really important as well.

MICHELLE SLATER: Yes.

SUE BANKS: That continuum.

MICHELLE SLATER: And I think to what you said about letting them tell their stories, a lot of mistakes that I have seen over the years in training students and phone volunteers to assess, it's that it turns into an interview-- an interrogation. So you're thinking about killing yourself-- when, how-- all the questions that you learn how to do but don't quite learn exactly that how of it, the nuanced way.

That's that art and science and a balance when you're learning to be a counselor and letting them tell their story. Then finding out another piece of that puzzle and a very natural, you're thinking about killing yourself? Yes, and tell me more, instead of getting triggered and scared of what the client said, sitting back.

SUE BANKS: And as we're talking, I often think about the interplay, or the change between transference and countertransference, when you're talking about, do we hear, get the sense that there are some suicidal ideations going on. And then we go into interrogation mode, and start to question, answer process. And how much does transference and countertransference really impact the whole process that is occurring?

Sometimes, it's-- I have to be careful not to allow my own views or thoughts about how a client presents in practice with me, and really miss what's going on, or what their story is, or what they're communicating to me because I've already framed them based on their appearance, or based on how they present-- some of the stereotypes. Oftentimes, as well, I have to be mindful of how clients frame

How to Accurately Assess and Help a Client

me and their view of me because it really does impact and affect how much they will share with me, or how willing they are to really disclose their story, or what they're dealing with.

MICHELLE SLATER: People are therapy wise. We go over the limits of confidentiality-- what you see in movies, what you know that there can be consequences if you are honest. And a lot of times, beginning counselors are real concerned about that. And our clients are hypervigilant about that. And I do think being able to really explain to clients that, so something like that continuum of where they are on that.

Also being aware of how we're triggered, and how we're reacting, and being able to express genuine concern for clients that help me-- like help me understand how you're going to stay safe. That being able to speak to that part of them that does want to live. Certainly, we don't want to underreact, and we don't want to overreact. And I think to your point, really, it's about that moment of connection and staying in the fray with them.

SUE BANKS: Yes.

MICHELLE SLATER: Being in that session can be scary and uncomfortable for both parties.

SUE BANKS: Yes and maintaining the boundaries or having the clear boundaries without verbalizing what those boundaries are. It's very important because, again, the safety of the client is what's-- the main focus from the therapist's perspective, the counselor's perspective. But at the same time, you want the client to feel comfortable enough to really express and to open up and talk about what they're struggling with.

MICHELLE SLATER: And how do we do that? How do we-- that, again, our preoccupation with the safety concerns that a suicidal client presents with can really be a barrier to the advanced empathy, to the depths that we need to be able to connect. It's that well theory of we have to be willing to get into the well with our clients.

SUE BANKS: Absolutely. You call it getting into the well. I call it going around the bin. I use the analogy of the three-legged race, and walking, running that three- legged race with that client and not dragging the client-- staying with them. And at that-- in that case, you are able to, again, communicate the safety concerns that you have as a counselor, and then offer them an opportunity to share more in-depth what they're experiencing, and get the help that they need because that's what they're really there for.

MICHELLE SLATER: Yeah, and I think really that's the primary concern for a lot of our students from beginning counselors-- am I going to be able to handle it?

How to Accurately Assess and Help a Client

Am I going to be able to-- whether it's your legs strapped together in a three- legged race-- or am I going to be able to go into this dark, deep well where it feels scary and painful?

Am I going to-- not only can I go in, but am I going to be able to get out? Or what's going to happen to me if I join into that type of pain? And you had mentioned boundaries. We talk so much in this program about self-care, confidence, experience, training. All of those things, I think, help us know that we're not alone in it. That we have what it takes to engage that level of intensity and be OK.

But your client is struggling in that well, and I like to remind my students that this is part of what we've signed up for. Not to join in with someone's distress when it's convenient for us, but when they show up, we show up, and meet them there. It does no good to stand at the edge of the well and yell down, you're going to be fine.

Or I sometimes in my mind think-- I'm a very visual person-- of this idea of when people are drowning, and the Coast Guard is rescuing them, so they lower a basket down, and they come with them, and they secure the person in the basket. They don't just lower it down on top of them.

SUE BANKS: It's a process, and reminding students that there is a process to assessing risk-- suicide risk. There's a process in everything that we do, or method to everything that we do. But at the same time, we are to be human. I think sometimes we get so-- or it's an opportunity for students to become so theoretical or so focused on the process and the steps and what you do, that they forget the human part in being with the client as you go through that. The more human you are, the more you respond to what is actually happening in the client's experience, then it makes the process or the steps that you have to take through suicidality, or whatever the other risk is more personal, more relatable.

MICHELLE SLATER: Authenticity is critical. A lot of times, I think, beginning counselors trying to pretend that they're not freaking out about this person is really in despair. And I'm looking down, and realize I have to go into the well. But to be able to say-- and I, over the years in very genuine moments, I can think of a couple of different situations with clients that were in intense pain, where I have just naturally, my hand just goes to my heart.

It sounds unbearable. I can't even imagine how you're carrying that type of pain. I don't know if that response is in a textbook somewhere, but I know that in the moment, that's my honest reaction to what they've shared. And being able to say, I don't have all the answers. The scariest clients for me have asked very directly, give me a reason to live. When I share that with students in training situations, you can see the look on their face. Oh my gosh, if a client ever asks me that, it sounds like, what would you do in that situation?

How to Accurately Assess and Help a Client

SUE BANKS: So what do you have to say, or what are your thoughts about vicarious trauma and clients who have attempted suicide?

MICHELLE SLATER: For me, boundaries, of course, self-care, compartmentalizing-- some of that is essential. But also, I have a way a of viewing-- people have said over the years, how could you do that kind of work, or how could you respond to a completed suicide and not just be devastated? Or how do you not take that home with you?

And I think, honestly for me, it's the way that I look at it. I see it as a growth. Crisis is danger and opportunity. And I see a lot of pain. But I also see a lot of people overcoming and coping and surviving and growing. And reminders of that give me perspective. I can't save anyone.

SUE BANKS: Yes.

MICHELLE SLATER: That's not my job, but I'm walking alongside of you in your pain. I do a disservice to my clients if I try to carry that for them. They don't get stronger.

SUE BANKS: Absolutely.

MICHELLE SLATER: And so perspective really helps me to be aware of what's mine to carry and what's theirs? And that it's patronizing to assume that they need me to save them or take care of them or to care-- I'm empowering them. So knowing my role and my limits, I think, is really the most important part of how I'm able to, at the end of the day, I know.

And I'm asking myself that if I were to see this on the news, what would I have wanted to do differently? Is there anything I would have wanted to say or do? And to the best of my ability, I finish my day, I finish my session, not having regrets about things that I could've, would've, should've said or done. And that would really be my advice to any counselors that are working with high-risk clients.

Just know that in that moment, you're pushing yourself to do the uncomfortable things, to ask the questions that need to be asked, and that you're willing to risk. And that that leaves me feeling satisfied at the end of what I've done.

SUE BANKS: Yeah, I agree. I agree with the boundaries-- understanding your role as a counselor and not believing that you are there to solve any of the client problems or to be that fairy who fixes it all.

MICHELLE SLATER: The nature of crisis really is that there are no easy fixes. And for beginning and counselors in training, I think that's really the tricky part. There's still a tendency to want to solve the problem. And there isn't an easy

How to Accurately Assess and Help a Client

answer. The only way is to connect. And so in the absence of that, if you're doing the best you can to connect, then you've done all you need to do-- all you can do.

With the clients that I referenced, they are asking, looking for a reason to live. The answer then is I would if I could. But what can I do for you? I can sit through this with you. I can journey alongside you, and I can help you try to find the hope that's going to keep you going. And I would think that really a part of being able to cope with this type of intense work is knowing what you can do.

SUE BANKS: Yeah, I think that sometimes students-- especially beginning students-- really seek for something to do. They feel like they have to be doing something.

MICHELLE SLATER: They're not doing enough.

SUE BANKS: As opposed to being. I focus on just being-- being with, being there, being human. And that, oftentimes, is what gets clients through crisis, as opposed to doing something.

MICHELLE SLATER: Absolutely.

SUE BANKS: So in that, I think that there are no steps, finite steps, that we can suggest to say-- do this and this is the outcome. But to be mindful, again, what the role is, what their boundaries are. Having the approach, how do you address certain things? There are approaches and steps to take. And just being mindful of that and then being-- being with.

MICHELLE SLATER: That's great, great advice. And just even talking with you about it, you realize it emphasizes the importance of consultation, peer support, of connecting with people who understand what you're going through. So there are opportunities to a long day, you vent with family or friends, or it's really, it was just a hard day, or it was a difficult client.

But really it is important to have your own network too of-- I have fabulous counselor that are friends and our colleagues at Walden are an amazing source of support. Even in private practice, I have people that I can call up if I need to process. And that's with regular clients, and then I have people who specialize in crisis work and have the same background.

And diversifying that, and making sure that you have a good support system of people who understand you. Sometimes, I don't want to talk about it at all. So I've got those friends too, and just crafting a good network, I think, is so important.

SUE BANKS: When I have clients who present with suicide, I tend to always conference those-- just in case there's something that I missed. Or that there's some precaution that I should take, or something that I should think about the

How to Accurately Assess and Help a Client

next time that I meet with them, or in the next situation beyond when they leave my office. So just having the network to discuss and to conference cases is what is important.

MICHELLE SLATER: And the value is twofold. You get to learn from your experiences if needed, and then just debriefing.

SUE BANKS: Yes.

MICHELLE SLATER: In my crisis work, I do a lot of debriefings in response to crisis in the community. And I never underestimate the power of bringing people together and just letting them, like you said, tell their stories, share what impacted them, and we need to do that as counselors too.

SUE BANKS: Yes.

MICHELLE SLATER: Tackle that continuum. Sometimes helping professionals are guilty of-- we're on a different category as well. We're supposed to be able to handle this. And I do think that is it gets to a, speaks to a fear, that a lot of students may have as well. That they're going to get out there, and be on their own not-- overwhelmed and not able to cope with it. And I mean, we have to work to build that network. And we have to allow ourselves to be vulnerable to access support.

SUE BANKS: So we have a few more minutes left, and I do want to know what are your thoughts about suicide contracts?

MICHELLE SLATER: Well, I do not use a written contract. I think it's critical to get some verbal agreement. There's research out there that confirms getting clients to agree to a plan, a safety plan, does impact their safety. And, again, that plays to the ambivalence.

They want to live, and so they follow through with the plan because it gives them a sense of security-- something to count on. And I can't tell you how many times in my work at the Crisis Center, I've been working the phone lines and had someone call back in and just say, I'm calling because I said I would or I agreed. Sometimes, they're even annoyed.

And, yet, this sort of drive to want to stay alive compels them to do what they've agreed to do. So, I mean, I think it's absolutely critical. I'm glad that there has been a move away from written contracts in a lot of places. It doesn't seem to work for me, in terms of the relationship nature of what I'm doing with my clients.

If I ask you to do something and you say yes, then I'm not going to have you sign it. I'm going to believe you would do it. And so that the spirit of it feels very important to me and how you communicate that to your client.

How to Accurately Assess and Help a Client

SUE BANKS: I-- my experience is a little different. I tend to work with more of the public agencies, so suicide contracts are almost mandated that you have some type of written contract or agreement for between you and the client, for the most part. Just to verify that you have documentation and addressed the-- and assess the suicidality and had some kind of documentation. So for the most part, I think, in my experience, the contracts are used as that last documentation or verification that you, the counselor, has addressed.

MICHELLE SLATER: That brings up a really good point about you knowing your agency's policy--

SUE BANKS: Yes.

MICHELLE SLATER: --on safety-- whatever that might be. If it's homicidal or suicidal-- whatever risk factors are involved, you're going to have a policy and procedure in place. And as we were talking earlier about consulting, that's mandated in some places.

In my work in the corporate world, there was a mandatory consultation process in place. Where if that has happened, and you've assessed the validity, you're required to then notify-- at the time, I was the clinical director. The team has to notify, so that that keeps you from not feeling isolated in that. And, certainly, with a written contract, the agency is at risk then having documentation that is critical.

So knowing your policy, I have to document in private practice. And we did, we kept notes at the Crisis Center as well. That I'm documenting that I've done it somewhere it should be documented and you should know what the policy is where you're working. And that's critical because again, you're not functioning in isolation. Even if you're in private practice, there's notes that are being taken and some accountability. And I think that's a great reminder for students-- know what's expected of you.

SUE BANKS: Yes, you have to follow the policies of the agency that you work. And, oftentimes, like I said, the contract is that client signature acknowledging that they are aware that they've been assessed, and that this is a concern. And so moving forward, I'd like to kind of wrap up with the last question of, what advice would you give to students who are worried about not being able to effectively assist suicide in a client?

MICHELLE SLATER: I think we've touched on a couple of the kind of tips for managing it in terms of trusting yourself and confidence. But really, this is one class that students are taking, and there are lots of great trainings, great organizations out there for students that I think are going to be working with population, where they may experience this more than others.

How to Accurately Assess and Help a Client

Agencies would definitely benefit from participating in additional trainings. And research is out there to suggest that the practice builds confidence. Learning, reading builds knowledge, but really the difference is can you do it when it matters? And so getting more training is good-- support, things that we've talked about.

But I also think maybe not giving it so much power. It's the same skills that you're using to connect with a client. It's just a different scenario. It's a different intensity level, and maybe students allow themselves to blow that up bigger. If you know how to be with a client, you know how to be with a client in distress.

You know how to be with a client in crisis, and you know how to be with a client who is suicidal. And just remembering that because confidence is huge. Trust yourself. That's primarily the advice I would give, and get help when you don't or can't.

SUE BANKS: Absolutely. I agree with that. Oftentimes, we want to be reactive as opposed to proactive. And so there are ways that you can be proactive with every client-- whether they are presenting with suicide or not-- and having that process that when a client presents with suicide, what are steps that you are naturally going to take with that client?

Either they be, if you are in private practice, then you develop those prior to you seeing clients. If you're in a public agency, then know the protocols and the procedures of addressing, and how you address a client who presents with suicide ideation and following those steps. And not only that, aside from the training, sometimes you may work with-- or students may work with clients infrequently, who present with suicidal ideation. And so that when it does appear, you're like, OK, I forgot. What do I do? Those annual trainings and refresher courses that you can take on how to assess suicide clients and how to work with suicide clients will keep you mindful of the steps it takes, and how to address clients when they do present.

And then, finally, for me, is supervision. Either you're in private practice, you should have a supervisor or someone you can call if you feel stuck and don't know what to do. You can be genuine. I'm sorry. I'm going to need some help with this. This is a little bit out of my comfort, and seek that supervision. If you're in an agency and the supervisor's down the hall, just break for a moment and show that you are human and seek help.

MICHELLE SLATER: That's funny. I was thinking, again, it comes up with authenticity. I'm a bit of a truth pusher, and to be able to just say to your client, this is-- it's overwhelming.

SUE BANKS: Yes, it can be.

How to Accurately Assess and Help a Client

MICHELLE SLATER: I need for you to partner with me, and we'll create a safety plan together. It's very difficult to invest in our clients if they're not willing to invest in themselves. And so to try to create that balance together. And in 20 years of doing this work, one of the things that stands out for me is I have not had a client involuntarily hospitalized.

Now, many times, I have had them have someone come pick them up, and they have self-- they have taken themselves for help. And I think that really speaks to my process is very collaborative in nature. We do have the power and the ability to ensure that they get treatment. But what we do with that power is really important.

And there have been moments where I've said to clients, like, I need you to work with me because I'm concerned about you, and I don't feel comfortable letting you leave. So here's our options. So we can do this. We could do this.

There's a lot of different plans. With my kids, I say it's the easy way or the hard way. So it's some sort of version of that that we're presenting to our clients. There are options.

SUE BANKS: There are.

MICHELLE SLATER: And in crisis, it's helpful to have someone who is clear and calm and able to present those. And clients, again, they want to live if you tap into that. I have found more times than not that they are willing to self-refer, or check themselves in, or to get the assessment on their own. So, again, you can work that out some with your clients of shutting down and feeling like you have to handle it, fix it yourself.

SUE BANKS: So we've had an extensive discussion about this topic of suicide. And I want to thank you, Dr. Slater, for sharing your thoughts and your views and your experiences today. I'm also hopeful that you've gained quite a bit from our discussion, and thanking you for allowing us to share with you our experiences in working with clients who present with suicidal issues. I'm really hopeful that you are able to use this information as you move forward in your training as future counselors.

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