In 2020, there were 46,000 deaths due to suicide, and an estimated 12.2 million adults seriously thought about committing suicide. With statistics like this, therapists will have a client that is at risk for suicide at some point over the course of their practice. Being prepared for those clients is paramount to making sure the most appropriate help and intervention is provided. There are laws - both state and federal - that come into play, as well as established protocols within most practices. And while therapists are legally bound by these laws, it’s important to not lose the human being during the process of identifying and intervening with a suicidal client. It’s also important to have a clear sense of how to identify and assess risk factors, and what and when to pursue interventions.
Interacting with these individuals, including tone of speech, word choice, body language, and facial expression can give away thoughts, feelings, and judgements if the mental health professional is not very methodical and intentional during these sessions. It’s also critical to understand the difference between self-harm, suicidal ideation, and being suicidal. The topics are not easy, but they can definitely be the difference between life and death.
Self-harm leads to a significant number of ER visits each year, and it’s most likely significantly underreported. This is a major mental health challenge to be sure, but It’s important to note that most people engaging in self-harm do not want to die. Self-harm can be self-directed, i.e. a client injuring themself, such as cutting, burning, hair pulling, or hitting. But self-harm can also be caused by someone else - the individual initiates physical conflict with someone else and suffers injury or harm because of it. There’s a common misconception that suicide and self-harm are the same thing, or that one leads to the other, but this isn’t necessarily the case. It’s also commonly construed that individuals who engage in self-harm are being manipulative, or even more dismissive, attention seeking, and this couldn't be further from the truth. As therapists, it's important not to downplay self-harm in a client, but the correct intervention(s) should be set in place.
While self-harm does not necessarily indicate suicidal thoughts or even suicidal ideation, it is important not to rule it out. The most important thing for a therapist to do with a self-harm client is to establish their intent. Does the client intend to end his or her life? As a general rule, self-harm is a way of coping. Utilizing coping mechanisms doesn’t equate to wanting to end one’s life, whereas, with suicide, the person doesn’t seen any other way to end their suffering. There is no coping.
Talking with clients about suicide is difficult at the best of times. It’s an extremely sensitive subject, with the potential for several significant outcomes;, significantly affecting the life of the patient, as well as the therapeutic relationship between client and therapist. Knowing about laws and protocols in regard to suicidal patients is a major responsibility of any therapist - specifically, what are the procedures regarding privacy and confidentiality when someone is in danger? What are the reporting procedures for your specific office or practice? What assessments are used to make sure interventions are appropriate? It's always a good idea to review the laws and protocols at least annually, and definitely before the information is needed.
When talking with a suicidal client, it’s important to be mindful of not just what the patient is saying, but also their body language and other non-verbal signals. And that’s good advice not just in regards to the patient, but also for the therapist. Attentive listening is critical. Suicidal patients need to be heard. They need to know for sure they are being listened to. Using non-threatening, non-judgmental eye contact and body language is essential for giving patients space to openly discuss such a sensitive and painful subject.
Upfront and direct questions are an integral part of understanding a suicidal patient’s headspace. If immediate danger is suspected, clear yes or no questions are advisable. Avoid asking questions where the client needs to answer with a “no.” Repeat or summarize information to verify you are listening intently, and use language that validates their feelings and struggles. Remember, suicide is a last resort of trauma and pain; empathy and understanding are absolutely critical for helping the patient feel recognized and supported.
It seems like common sense, but never be dismissive of a patient’s trauma or their admitting considering suicide. It’s also equally important not to give a patient who is going through a particularly troubled time false hope. It’s human nature to be positive and uplifting, especially for therapists, but it’s important to be realistic while still being positive. Equally important is to let suicidal clients express their negative feelings in a safe environment. It’s a balancing act, for sure, and the conversations and questions will look different for each client and each particular circumstance.
It’s essential to determine immediately if the person is in any immediate danger. Conduct a suicide assessment. The first stage is ideation - thinking about suicide or what it would be like if they went through with it. The second stage is intent - this is the desire to actually carry out suicide. Generally, people in this stage have the motivation to carry through with suicide but do not yet have a plan. That’s the third stage, when they actually begin to form an idea or a plan on how to carry it out. Knowing what stage a person is at is critical to providing the most appropriate intervention.
It’s also prudent to determine what thoughts, feelings, or situations are causing the suicidal urges or tendencies. Can these be mitigated? Work with the client on ways they can address those triggers immediately in the moment. It’s important to remember here that talking very directly with clients about suicide is not going to make them any more likely to carry it out.
Once you determine triggers and any potential for immediate danger, it’s time to make a safety and intervention plan. Note: a safety plan should always be created when a person is not in crisis, and has at least a little positivity for the future. Hospitalization has a place, but it’s important not to hospitalize clients who are not yet in crisis, or have only reached the ideation stage. Hospitalization when unnecessary can sever the therapeutic relationship between client and therapist, and could potentially do more harm than good.
When a suicidal crisis hits ( a specific time of heightened risk), a safety plan can serve multiple needs. It will be an immediate resource for clients, as well as a blueprint for therapists. There are 6 steps to a safety plan: Identify warning signs of crisis, internal distractions, external distractions, people that can help, professionals who can help, and ensure a safe environment.
Learn to identify the signs of a suicidal crisis. Gather a list of triggers, and write down exact situations, thoughts, and feelings that happen during times of suicidal crisis. Being aware of these triggers and warning signs can help a person identify and implement intervention techniques.
Develop some internal coping strategies. These are things the person can do by themselves when they've identified any of the above warning signs. Some internal coping strategies are spiritual - such as prayer or meditation, therapeutic such as writing or journaling, physical - such as exercising or going for a walk, or sensory - such as listening to music, or singing. Any internal coping strategies included in a safety plan should be specific to the client and their life - not generic or chosen by the therapist. They should also be relatively easy to do. An activity that requires significant planning is not ideal for a coping intervention.
External coping strategies are ones that require the client to interact with other people. These can be put into place when internal coping strategies aren’t working or aren’t distracting enough. Call or text a friend or family member or friend. Going for coffee, going out to eat, attending church or a yoga class, or even something as simple as walking through the mall around other people can be beneficial.
Create a list of trusted people that can be contacted for help. This list should be kept on the client at all times if possible. There should be multiple ways of contacting each person on the list as well. These are the people the suicidal person can safely call if the distraction techniques aren’t helping and if they’re still in crisis.
Besides personal friends and family who can be available as a support network, a list of professional resources, including some available 24 hours a day, should be created as well. This should include the name of the therapist and their emergency line, and at least one local hospital. It should include the National Suicide and Crisis Lifeline (dial 988) or the lifeline chat at 988lifeline.org.
Lastly, a safety plan should include making sure environments are safe for the client in crisis. Do they have access to firearms or other weapons? What about medications that can be used to end their life? This is absolutely a difficult conversation, but one that must take place in order to make sure the client stays safe. Come up with a plan for dealing with those items - a lock box and a trusted friend to dispense for medication if that’s an issue. Or someone to come and remove any weapons from the home. Limiting access to ways in which the client could hurt themselves is key.
There are many resources available to people who engage in self-harm, suicidal ideation, or are planning to commit suicide. One of the best - and most widely available - is the 988 Suicide & Crisis Lifeline, which takes calls 24/7. They also have a chat function available at 988 Suicide & Crisis Lifeline chat, since some people can’t talk or prefer the anonymity of typing. For LGBTQIIA+ communities, the Trevor Project also has suicide prevention resources and trained counselors that are available via phone, chat, and text at We’re here for you Now – The Trevor Project. Their services are also available 24/7, 365.
Working with clients who are suicidal or in a suicidal crisis is one of the most difficult and stressful aspects of a therapist’s career. Understanding how to talk and interact with these clients in a way that is respectful, responsible, and caring is paramount to having a positive outcome. Is the client in immediate danger? Is hospitalization required? If not, what intervention techniques should be utilized for this individual? Creating a suicide safety plan - which includes all the necessary information and resources needed - before a crisis occurs will give both client and therapist a blueprint for successful intervention.
Being a therapist can be a stressful job, and Advekit is here to help out in any way we can. If you’re looking for additional resources for your practice, such as good social media policies for therapists, information on pet therapy benefits, the best ways of protecting confidential information, advice on online therapy, and more, make sure to check out our resource center to find answers to these questions.