A therapist hands a crying man a tissue box.Working with suicidal clients can be intimidating and potentially even traumatic. It is also fairly common. A 2003 survey of 238 predoctoral psychology interns found that 99% had treated at least one suicidal client. Among the same survey respondents, 5% had experienced the suicide of a client. Other research suggests the chance of losing a client to suicide rises as psychotherapists progress in their careers. In one survey, 28% of psychotherapists reported losing at least one client to suicide at some point. 

Deaths by suicide are increasing, reaching a 30-year high in 2016. This suggests that more therapists than ever before may treat suicidal clients. Building a strong therapeutic relationship with these clients is key to supporting them through the crisis and may inspire the client to be honest about any immediate suicide plans. 

Why Talking About Suicide in Therapy Is Important

Research consistently finds that most people who attempt suicide tell at least one person they are considering suicide. Thirty-eight percent of people who attempt suicide see a doctor the week before the attempt. This suggests that people who feel suicidal want help, and they often reach out to health care providers for support. 

Discussing suicidal ideation in therapy empowers the client to explore feelings of hopelessness and despair, process trauma, and feel less alone. A therapist can help the client navigate the suicidal crisis and, with appropriate care, help them feel more hopeful and less despondent. 

Research on people who were once suicidal suggests that three elements of therapy can help a client move beyond suicidality: 

  • Building a validating relationship. Clients who feel validated by their therapist may feel better equipped to understand themselves and connect with others. 
  • Cultivating a sense of autonomy. Talking about suicidal thoughts can help a client become more self-aware. Therapists can also help clients build self-esteem and a sense of identity. This enables clients to establish healthier behaviors and coping skills.
  • Working through difficult emotions. Clients often need an outlet for discussing the intense emotions that lead to suicidal thoughts. Acknowledgment of a client’s feelings of despair and helplessness offers validation that may help a client move beyond these emotions.

Assessing Suicide Risk

Therapists should take all suicide threats seriously. Some suicide threats, however, are more critical than others. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends the following guidelines for assessing a client’s risk of attempting suicide: 

  • Identify risk factors for suicide, such as firearms in the home. Note ways these risk factors can be mitigated, such as having a client commit to removing guns from their home. 
  • Identify protective factors, such as support from loved ones or a commitment to therapy. 
  • Talk to the client about their suicidality. Ask them about their emotions and level of despair. Explore whether they have a suicide plan. More detailed, specific plans often indicate higher risk. 
  • Determine the level of risk and appropriate interventions to mitigate that risk. 
  • Document the process, and note areas for follow-up. 

Some strategies that can reduce the risk of suicide include: 

  • Ask the client to commit to treatment. Some therapists even have their clients sign a “suicide contract” in which the client promises not to attempt suicide during treatment or vow to call the therapist if they feel they are about to attempt suicide. 
  • Develop a treatment plan, including treatment goals. This can give the client hope and reassure them that their recovery is important to the therapist. 
  • See clients more often when they are in crisis. A client who has recently gone through a breakup or suffered a similar loss typically needs more frequent contact. 
  • Listen to the client, making eye contact and giving them your full attention. Clients who feel unheard or devalued may be more likely to attempt suicide. 
  • Help the client identify the reasons for the current crisis. Try asking them which things would need to change for them to no longer feel suicidal. This can help with establishing treatment goals. 
  • Follow up with clients who leave therapy. 
  • Allow the client to express strong negative emotions without judgment. Do not guilt the client for their emotions or make them feel as if their intense emotions are too difficult for you to hear. Expressing negative emotions can reduce their power. 
  • Develop a crisis toolkit and a plan for managing suicidal thoughts. The client might make a list of reasons to live, people to call for help, or mantras to repeat at difficult moments. 
  • Help the client cultivate a list of things to do instead of attempt suicide. People experiencing thoughts of suicide often ruminate on negative emotions. A distracting activity can disrupt this process. Music, movies, books, and activities with other people may help. Encourage the client to create a list of coping tools so they can scan the list and choose from many options when they feel overwhelmed. 

When Do You Have to Report?

Therapists have an ethical duty to report a client to a third party when there is no other option for protecting the client. Therapists do not have a duty to report every suicidal client. Indeed, doing so may intensify suicidal feelings in clients who struggle to trust their therapist. 

Every situation is different, and each state has its own duty to report and duty to warn guidelines. In general, a therapist must report suicidality when: 

  • A suicide risk assessment indicates that the risk is high, that there are few protective factors, and that the client may attempt suicide in the immediate future. 
  • The client says they are going to attempt suicide and will not agree to any harm reduction measures. 
  • The client contacts the therapist in crisis and disappears, stops talking, or gives another indication that they have done or intend to do something to harm themselves. 
  • The client indicates clear, specific intent to harm someone else. 

Discuss with the client the specific scenarios in which you would have to report suicidal thoughts. Some clients worry that the mere mention of the term “suicide” may cause a therapist to break confidentiality or even to call the police. Work together to jointly develop a plan for helping the client when the therapist must report suicidal feelings. For example, you might discuss whom the therapist should call. 

After the Crisis

When a therapist must report a client to a third party, it might put the therapeutic relationship in jeopardy. The client may feel that the therapist made the wrong call, told the wrong person, or that the consequences of the report—such as a psychiatric hospital stay—made life worse. Other clients may feel grateful. 

The therapeutic relationship is an ideal space for clients to practice relationship skills, assert their needs, and resolve conflicts. Therapists should discuss suicide reports openly, with humility and compassion. During these difficult discussions: 

  • Listen without judgment. 
  • Do not be defensive. Be open to the possibility that you might have made the wrong call. Collaborate with the client to develop a plan for any future suicidal ideation. 
  • Be sympathetic to the challenges the client faced because of the report, even if you believe you made the right call. 
  • Continue working with the client to reduce the risk of future harm. 
  • Assess whether the therapeutic relationship can be salvaged. If it cannot, consider referring the client to another provider. 

Counseling suicidal clients can save lives. It can also expose therapists to vicarious trauma. Support from other professionals can help therapists manage stress and better serve their clients. GoodTherapy offers numerous educational programs for therapists, including programs related to suicide. GoodTherapy members also benefit from a listing in our therapist directory, helping them connect to new clients. Become a member today! 

References: 

  1. Ahmedani, B. K., Stewart, C., Simon, G. E., Lynch, F., Lu, C. Y., Waitzfelder, B. E., … Williams, K. (2015). Racial/ethnic differences in health care visits made before suicide attempt across the United States. Medical Care, 53(5), 430–435. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25872151
  2. DeAngelis, T. (2008). Coping with a client’s suicide. gradPSYCH Magazine, 11(1), 18. Retrieved from https://www.apa.org/gradpsych/2008/11/suicide
  3. Dos and don’ts of managing a client who is suicidal [PDF]. (n. d.). Retrieved from https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Session%204%20Handouts.pdf
  4. Firestone, L. (n.d.). Suicide: What therapists need to know [PDF]. Retrieved from https://www.apa.org/education/ce/suicide.pdf
  5. How to help someone you know who is suicidal. (n. d.). Retrieved from https://wmich.edu/suicideprevention/basics/how-help
  6. SAFE-T [PDF]. (n. d.). Retrieved from https://www.integration.samhsa.gov/images/res/SAFE_T.pdf
  7. Winerman, L. (2019). By the numbers: An alarming rise in suicide. Retrieved from https://www.apa.org/monitor/2019/01/numbers
  8. Working with the client who is suicidal: A tool for adult mental health and addiction services [PDF]. (2007). Retrieved from https://www.health.gov.bc.ca/library/publications/year/2007/MHA_WorkingWithSuicidalClient.pdf