Article Published: 9/20/2023
According to the National Council on Aging (NCOA), though older adults make up only 12% of the population of the United States, they account for approximately 18% of its suicides. One in four seniors who attempt will die by suicide, as opposed to 1 in 200 young people. NCOA also reports that in 2020, of the 46,000 suicides that took place in the United States, 9,137 were among individuals aged 65 and older.
The need to help older adults is critical, and counselors are poised to help save lives.
“I believe from my experience and the current literature that older adults have such high suicide rates due to (a) higher instance of physical health problems, (b) increased social isolation and losses, (c) feeling like a burden to others, (d) access to lethal means, and (e) the mental health professional’s dismissal of these problems as a normal part of the aging process, resulting in a lack of appropriate screening and treatment,” says Anna Lieber, NCC, CCMHC, LCMHC, clinical director for Westminster University’s Counseling and Counselor Education Department.
Lieber recommends that counselors remember Erik Erickson’s Stages of Development to understand some of the more common causes of suicidal ideation among older adults with a particular focus on integrity vs. despair.
“This is an apt description, as older adults often face numerous psychosocial challenges—grief and loss, declining health, financial insecurity, increased social isolation, and a loss of independence,” she says.
“The risks associated with suicidal ideation in older adults are the same for all other age groups: depressive symptoms, loss of a loved one, co-morbid medical conditions, relationship issues, substance use, pain, sleep disturbances, and access to lethal means, among others,” Lieber says, stressing that “Mental health counselors often make the mistake of believing that depressive symptoms, feelings of loneliness, burdensomeness, or physical problems in older adults are a natural part of the aging process; this is not the case.”
At-risk older adults may present signs such as social withdrawal, increased drug or alcohol use, discussing feelings of being a burden to others, or hopelessness about their future. These indications warrant a full evaluation for many reasons.
“Older adult clients may also mask their suicidal ideation due to embarrassment, feelings of shame, or worries about hospitalization. Thus, it becomes extremely important for the clinical mental health counselor to ask about suicidal ideation frequently, normalize the suicidal wish, and conduct routine screenings that specifically focus on suicidal ideation/intent. In fact, research shows that suicide attempts in older adults are generally less impulsive and not disclosed to loved ones or professionals. A discussion of access to lethal means becomes vitally important.
“The more comfortable we are at talking openly about suicidal thoughts and behaviors, asking often, and empathizing with the suicidal wish, the more honest our clients will be, and we have the potential to not only save a life, but provide the foundation to improve a life.”
Counseling older adults with suicidal ideation differs somewhat from counseling those clients in other age groups, and there are some special considerations counselors should take when working with them.
“It is vitally important for the mental health counselor to practice cultural humility and understand the older adult’s generation and mindset, especially as it relates to suicidal behavior,” Lieber says. “It is also vitally important to work with an interdisciplinary team and for the mental health counselor to be aware of any physical conditions, medications, and treatment. I always obtain a release of information and communicate with primary care providers; this is especially important if the older adult has sleep problems or chronic pain. Also, it is important to invite family, friends, and loved ones into the therapeutic progress with the client’s consent. Often there is a great fear to ask for help of loved ones, so when I can help facilitate that process and improve relational support, treatment becomes more effective.”
Counselors must also understand what suicidal ideation means to the specific individual, she says.
“For example, is it comforting or frightening? Also, explore the individuals’ beliefs about suicidal ideation and behavior; is it a sin? a blessing to others? etc. Understand the older adult’s individual phenomenology and their view of themselves and their world. It is critically important to develop a treatment plan focusing on improving life, not just preventing death. It is important for mental health counselors to accept that many individuals with suicidal ideations are thinking about death in order to stay alive.”
We often discuss the importance of self-care as counselors, and working with this population can be especially demanding, Lieber says.
“Typically, the mental health counselor is simultaneously treating suicidal ideation and a DSM-V-TR diagnosis (if there is one present), and providing grief counseling and counseling for the older adult’s change in life circumstances and/or loss of independence. There is a lot going on. In addition, one of the most traumatic experiences for a mental health counselor is the loss of a client due to death. When working with older adults, natural death is part of life, and it is important for counselors to seek out their own therapy, consultation, and supervision.
“When suicidal ideation is also present, counselors have increased emotional reactions, including fear, sadness, anger, and feelings of ineffectiveness,” she continues. “Again, consultation is key. In my professional career, I have never practiced without supervision or consultation, and at times my own mental health counseling, and I never will. I do not believe—just like our clients—that we can be effective in isolation.”
She shared the personal routine that she finds helpful.
“My self-care measures are to engage in consultation routinely, not just when I think I need it; maintain effective boundaries; and always remember why I do the work I do. I find the joy in my work each and every day,” even on the most difficult days, she says. “I also remember that being a mental health counselor is just one part of my identity. I have many other aspects to my life that I rely on for support, fulfillment, and a sense of purpose. Having a life outside of work has helped me manage my feelings of compassion fatigue and vicarious trauma.”
She recommends reading Healing the Suicidal Person, by Stacey Freedenthal, PhD, LCSW; Brief Cognitive Behavioral Therapy for Suicide Prevention, by M. David Rudd, PhD, ABPP, and Craig J. Bryan, PsyD, ABPP; and “The Course and Evolution of Dialectical Behavior Therapy,” by Marsha Linehan, PhD, ABPP, and Chelsey Wilks. She also recommends The Assessing & Managing Suicide Risk (AMSR) training.
In addition to Lieber’s recommendations, we have compiled some NBCC Approved Continuing Education Provider (ACEP) programs to consider below. You can find a complete list of NBCC ACEPs here.
Suicide and Older Adults on demand from CAMS-care, LLC (ACEP No. 7039)
Other helpful resources:
Suicide Prevention Resource for Action, a free downloadable guide from the Centers for Disease Control and Prevention
Suicide prevention information from The National Institute of Mental Health
Promoting Emotional Health and Preventing Suicide, a SAMHSA toolkit for senior centers
Talk Saves Lives: An Introduction to Suicide Prevention for Seniors live webinar Oct. 20 from the American Foundation for Suicide Prevention, and its calendar of events
Anna Lieber, NCC, CCMHC, LCMHC, has over 25 years of experience in behavioral health in direct client care, program development, and administration. Lieber’s clinical focuses are suicide prevention and treatment, personality disorders, trauma-informed care, clinical supervision, and organizational practices that support clinical outcomes. Before joining Westminster University, she served as chief clinical officer of a psychiatric hospital where she oversaw all inpatient and outpatient clinical programming. Lieber is a National Certified Counselor and member of the American Association of Suicidology, ACA, ACES, AMHCA, and the LGBTQ+ Affirmative Therapist Guild of Utah.
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