Be Prepared to Help At-Risk Clients It’s one of the most difficult positions you could find yourself in as a clinician: dealing with a client who is contemplating suicide. Plan ahead for handling this situation, because what you do is critical. Features
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Features  |   May 01, 2014
Be Prepared to Help At-Risk Clients
Author Notes
  • Joseph Donaher, PhD, CCC-SLP
    is academic and research program director at the Center for Childhood Communication at The Children’s Hospital of Philadelphia. He is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. ■donaher@email.chop.edu
  • Lisa A. Scott, PhD, CCC-SLP
    is director of clinical education at the School of Communication Science and Disorders at Florida State University. She is an affiliate of ASHA SIGs 4; 10, Issues in Higher Education; and 11, Administration and Supervision. ■lscott@fsu.edu
Article Information
Professional Issues & Training / Language Disorders / Features
Features   |   May 01, 2014
Be Prepared to Help At-Risk Clients
The ASHA Leader, May 2014, Vol. 19, 52-58. doi:10.1044/leader.FTR3.19052014.52
The ASHA Leader, May 2014, Vol. 19, 52-58. doi:10.1044/leader.FTR3.19052014.52
Imagine the isolation of not being able to communicate with others. Imagine the alienation of not feeling accepted, the frustration and hopelessness of feeling beyond help. Imagine the deep depression and angst that could drive a person to consider suicide. These feelings are reality for many of our clients struggling with communication disorders, especially those with coexisting mental health issues.
Fortunately, speech-language pathologists and audiologists can play a vital role in lessening the impact of communication difficulties and in helping our clients see that there is hope for the future.
Increasing awareness
During any given year, 25 percent of adults and 20 percent of teens experience a diagnosable mental illness, yet more than half will go without services for their condition, according to the National Alliance on Mental Illness. The mental health conditions we most often see in clients are anxiety (for example, generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder) and mood disorders (for example, dysthymia, depression, bipolar disorder). These all present at varying levels of severity—and it should be noted that single symptoms or isolated events do not constitute mental illness.
When trying to determine if there’s a problem that requires a mental health professional’s intervention (see the related article), consider whether symptoms have occurred frequently, have lasted several weeks, or are becoming a general pattern of behavior. Signs that a client may be experiencing a period of mental illness include marked personality change over time, prolonged severe feelings of depression or anxiety, and social withdrawal (see the box below for a more comprehensive list).
Despite the drastic nature of some of these symptoms, they may not be readily apparent, even to professionals. To catch them, we need to carefully heed the client’s attendance and variations in performance or interest levels not tied to a communication disorder. Again, these observations are related to changes in behavior that have been observed frequently and over time.
Knowing signs and symptoms of mental illness can help SLPs and audiologists make better and earlier referrals, so that a client’s mental health status doesn’t escalate to the level of suicide risk. It’s also critical that we know what to do if a client’s desperation does escalate, to help keep self-harm at bay.
Suicide risk
The vast majority of people with communication disorders are not at risk for suicide, and determining suicidal risk does not fall within the scope of practice for SLPs or audiologists. It is the mental health professional’s responsibility to do a systemic, thorough suicide evaluation, note Lydia Flasher and Paul Fogle in their 2012 book “Counseling Skills for Speech-Language Pathologists and Audiologists.” However, they add that the communication sciences and disorders professional can provide important information to help with this evaluation.
Stigma is one issue that can stop people from seeking help. But for our clients, the barriers are greater because a staple of mental health treatment is talk therapy—which poses obvious difficulties for them. When a patient’s primary mode of communication is sign language, for example, or when someone has a severe stutter or has lost the ability to speak after a stroke, communication options may be significantly restricted. At these times, SLPs and audiologists can offer other professionals insights on the real-life impacts of the communication disorder.
No single risk factor or combination of factors perfectly predicts a client’s vulnerability to suicide, so awareness and judgment are a clinician’s best tools. It’s not always easy to tell when referral to a mental health professional is necessary, but seeing more than one risk factor in a patient should set off alarm bells.
SLPs and audiologists, acting in their professional roles, are considered mandated reporters. As such, they are legally obligated to report to law enforcement officials or an abuse/neglect hotline when they suspect a client is at risk for suicide. Requirements vary by state, so be aware of your state’s specific laws.
What to do
So how can you be ready to respond to a client’s suicide ideation? First, construct an “emergency plan” for handling this situation:
  • Read up on the policies and guidelines of your school or institution and your county’s crisis response protocols regarding suicide and mental illness.

  • Clearly identify who you will contact at the time of crisis and have those numbers handy. This list should include someone who is easily accessible to assist immediately. That person may be asked to stay with the person at risk or to contact others for help.

  • Be ready to connect your client quickly with a mental health professional or counselor. If none of these options is available, be ready to call 911 for speedy help getting your client to an appropriate service provider.

To determine whether a person is in danger of acting on suicidal tendencies, be ready to ask some difficult questions. Remember that asking about suicidal feelings will not push someone to do something that person has not already considered. In fact, being able to talk openly about suicidal thoughts and feelings may reduce the likelihood that he or she will engage in self-injury. To help determine if the person could be in immediate danger, ask the following questions:
  • You have seemed very depressed lately. Do you ever feel like giving up?

  • From what you are saying, it sounds like you are thinking about suicide. Are you?

  • Have you thought about how or when you would do it?

By asking such questions, knowing risk factors and having an emergency action plan, SLPs and audiologists can play a significant role in suicide prevention. It’s true that the typical person with a communication disorder does not struggle with mental health issues and is not at risk for suicide. However, continued discussion of topics like this among communication sciences and disorders professionals will foster increased understanding and a readiness to take action in a moment of crisis.

Signs and Symptoms of Mental Illness

Depression

  • Low mood.

  • Confused thinking, difficulty concentrating/making decisions.

  • Loss of pleasure/interest in typical activities.

  • Dramatic changes in eating/sleeping habits.

  • Loss of energy.

Anxiety

  • Significant fear of humiliation, embarrassment or negative evaluations by others.

  • Irritability, easily startled.

  • Frequent complaints of fatigue, headaches, muscle tension.

  • Fear of loss of control or impending doom.

  • Feelings of detachment, numbness.

Source: National Alliance on Mental Illness, www.nami.org

Signs that someone may be at risk for suicide

  • Talking about wanting to die or threatening to kill oneself.

  • Looking for a way to kill oneself, such as buying a gun.

  • Feeling hopeless or having no reason to live.

  • Feeling trapped with no way out of a situation.

  • Talking about being a burden to others.

  • Increased alcohol or drug use.

  • Behaving recklessly with no caution or worry.

  • Withdrawing from friends, school, work and family.

  • Becoming enraged or talking about seeking revenge.

  • Displaying extreme mood swings.

Source: The National Suicide Prevention Lifeline: 1-800-273-TALK (8255), suicidepreventionlifeline.org

When a Client Threatens Suicide

Until a successful hand-off is made to a mental health professional or counselor, the SLP or audiologist should:

  • Interpret any suicidal ideation as serious.

  • Stay with the client.

  • Listen without debating whether suicide is “the answer.”

  • Avoid promising that “everything will be all right” and instead stress that “things can get better.”

  • Destigmatize the importance of getting help with statements like, “I am calling a colleague who is really helpful in situations like this.”

  • Resist swearing secrecy—don’t say, “I won’t tell anyone.”

Resources

References
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS) [online]. (2010). Retrieved from www.cdc.gov/injury/wisqars/index.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS) [online]. (2010). Retrieved from www.cdc.gov/injury/wisqars/index.×
Center for Psychiatric Rehabilitation. (2014). How I might recognize signs of mental illness in the workplace. In How does mental illness interfere with work performance? Retrieved from http://cpr.bu.edu/resources/reasonable-accommodations/how-does-mental-illness-interfere-with-work-performance#howrecog.
Center for Psychiatric Rehabilitation. (2014). How I might recognize signs of mental illness in the workplace. In How does mental illness interfere with work performance? Retrieved from http://cpr.bu.edu/resources/reasonable-accommodations/how-does-mental-illness-interfere-with-work-performance#howrecog.×
Duckworth, K. (2013). Mental illness: Facts and numbers. Arlington, VA: The National Alliance on Mental Illness.
Duckworth, K. (2013). Mental illness: Facts and numbers. Arlington, VA: The National Alliance on Mental Illness.×
Flasher, L., & Fogle, P. T. (2012). Counseling skills for speech-language pathologists and audiologists (2nd ed.). Clifton Park, NY: Thomson Delmar Learning.
Flasher, L., & Fogle, P. T. (2012). Counseling skills for speech-language pathologists and audiologists (2nd ed.). Clifton Park, NY: Thomson Delmar Learning.×
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May 2014
Volume 19, Issue 5