Signs of Suicidal Ideation

Suicidal ideation is of vital importance in mental health care. Although ideation does not always signal a client’s intent to attempt suicide, it is always a major concern that must be addressed. However, the signs of suicidal ideation are not always obvious, particularly when clients are hesitant to divulge their thoughts. Likewise, determining the extent and meaning of suicidal ideation may prove challenging.

Compounding these difficulties is the fact that counselor training programs may not adequately prepare students to treat suicidality (Cureton et al., 2021). This is held out by research findings that counselors report limited training in suicide assessment (Wakai et al., 2020; Wachter et al., 2012).

“Counselor education programs should make sure to integrate the topic of suicide throughout the curriculum versus solely in one or two classes,” says Ashley Pechek, PhD, NCC, ACS, LPC, Associate Professor at Commonwealth University of Pennsylvania.

Dr. Pechek is the lead author of “Teaching Suicide Assessment and Intervention Online: A Model of Practice,” published in The Professional Counselor and a coauthor of “The Development of Self-Efficacy to Work with Suicidal Clients,” published in The Qualitative Report.

It is important that counselors ask clients directly about thoughts of suicide, but there are many indicators to watch for, says Dr. Pechek.

“I often think of this as a change in a client’s baseline,” she explains. “There is a wide variety of signs a client may show when experiencing suicidal ideation, but the main thing is to know what your client’s baseline is and be able to identify when there is a change from that baseline.”

Changes may show up in emotional presentation, thoughts, or behaviors, says Dr. Pechek. These could include a sudden shift in mood, emotional withdrawal, hopelessness, or irritability. Risk-taking behaviors, withdrawing from friends and family, or neglecting their own needs are other signs to watch for. Verbal cues might skirt around the topic, such as expressions of feeling like a burden to others, or the subject of death and dying more broadly.

Some of these signs might be overlooked or misinterpreted, even by a professional. Sudden changes in thoughts and behavior might even appear positive but mask suicidal ideation.

“This is why it’s imperative for counselors and counselors-in-training to be familiar with many of these signs and indicators,” says Dr. Pechek. “This may look like someone who experiences a sudden increase in energy after experiencing severe depression. Sometimes we as counselors can see this as a positive sign that they are coming out of their depression, but in fact it can be a subtle sign of increased suicidal ideation.”

If the reasons underlying a change in behavior aren’t clear, it’s best to be direct.

“A good route to take if a client shows these types of behaviors is to have an honest conversation with them about your observations, ask them directly if they are having suicidal ideation, and work to maintain the therapeutic relationship so that they know they can confide in you.”

It is common for people to have thoughts of suicide without having intent or a plan, but ideation should always be taken seriously. A thorough risk assessment, alongside active listening, is necessary to determine the best course of treatment for a client experiencing suicidal thoughts.

“A thorough assessment should better understand aspects of the ideation, such as the frequency, duration, intensity, and triggers of these types of thoughts and feelings,” explains Dr. Pechek. “Counselors should assess for any potential plans the client has or has had in the past. They should also assess whether or not the client has means to the method of suicide they may have mentioned. Understanding any past suicide attempts is another important aspect to accurately assess a client who may experience suicidal ideation. It is important to assess protective factors and risk factors. Documenting and consulting with a supervisor or colleague is an important step in this process.”

However, direct questions may not be enough if a client is hesitant to discuss suicidal thoughts, as is sometimes the case.

“Despite efforts in our communities to normalize mental health challenges and suicidal ideation, it can still be a taboo topic for people to talk about, even with their counselor,” explains Dr. Pechek. “Sometimes clients can feel ashamed that they are having suicidal thoughts, may fear consequences of feeling this way, or may not trust that others will understand them. That is why it is so important for us as counselors to normalize these thoughts and feelings and truly listen to our clients.”

In fact, taboos around discussing suicide may even ensnare counselors. Even a professional may experience trepidation at broaching the subject if the client’s situation is unclear. For counselors who are hesitant to ask about suicidal ideation—and for all counselors—Dr. Pechek recommends consultation, supervision, and counseling.

“I am a firm believer that we, as counselors, are never on an island by ourselves,” says Dr. Pechek. “Regardless of the years of experience we have, we should be actively engaged in consulting with other mental health professionals. I am also an advocate for counselors regularly engaging in their own counseling. If we are experiencing some hesitancy in broaching the topic of suicide with a client, we need to be exploring why this is and work to overcome those hesitations. This is why it’s so important to consistently incorporate the topic of suicide throughout the curriculum so that counselors feel comfortable talking about suicide.”

Ashley Ascherl Pechek, PhD, NCC, ACS, LPC-CO, currently works as an Associate Professor at Commonwealth University of Pennsylvania in the Clinical Mental Health Counseling Graduate Program. She has been a Licensed Professional Counselor in Colorado since 2010 and has worked with a variety of clientele (e.g., children and adolescents, military families, at-risk youth). In addition, Dr. Pechek earned her PhD in counselor education and supervision from Adams State University in 2018 and has taught in online CACREP-accredited programs for the last 10 years. Her research interests include online learning, creativity in counselor education, military families and veterans, self-care, and suicide assessment and intervention.

**Opinions and thoughts expressed in NBCC Visions Newsletter articles belong to the interviewees and do not necessarily reflect the opinions or practices of NBCC and Affiliates.  

References

Cureton, J. L., Clemens, E. V., Henninger, J., & Couch, C. (2021). Readiness of counselor education and supervision for suicide training: A CQR study. Journal of Counselor Preparation and Supervision, 14(3). Retrieved from https://research.library.kutztown.edu/jcps/vol14/iss3/1 

Elliott, G. M., Audsley, R. W., Runck, L., Pechek, A. A., de Raet, A., Valdez, A., & Wilde, B. J. (2018). The development of self-efficacy to work with suicidal clients. The Qualitative Report, 23(12), 3004–3018. https://doi.org/10.46743/2160-3715/2018.3084

Pechek, A., Vincenzes, K.A., Forziat-Pytel, K., Nowakowski, S., & Romero-Lucero, L. (2024). Teaching suicide assessment and intervention online: A model of practice. The Professional Counselor, 14(1), 100–112. https://doi.org/10.15241/aap.14.1.100

Wachter Morris, C. A., & Barrio Minton, C. A. (2012). Crisis in the curriculum? New counselors’ crisis preparation, experiences, and self-efficacy. Counselor Education and Supervision, 51(4), 256–269. https://doi.org/10.1002/j.1556-6978.2012.00019.x

Wakai, S., Schilling, E. A., Aseltine, R. H., Blair, E. W., Bourbeau, J., Duarte, A., Durst, L. S., Graham, P., Hubbard, N., Hughey, K., Weidner, D., & Welsh, A. (2020). Suicide prevention skills, confidence, and training: Results from the Zero Suicide Workforce Survey of behavioral health care professionals. SAGE Open Medicine, 8, 1–12. https://doi.org/10.1177/2050312120933152