One of the scariest things therapists work with is suicidality.
Suddenly, therapy feels like, and sometimes is, a life-or-death situation, one where clinicians hold a great deal of responsibility. To make matters worse, suicide continues to be one of the leading causes of death in the U.S. , and many believe the prevalence rates are a gross underestimate .
The numbers highlight the inevitability of encountering suicidality in our line of work. Early-career psychologists and practicum students may feel overwhelmed by the intensity and risk of working with suicidal clients.
Trust me, I know how that feels.
This year I have been administering suicide risk assessments for the local county mental health services as a member of George Fox University’s Behavioral Health Crisis Consultation Team . I have seen people on the worst nights of their lives, at rock bottom, and under extreme distress. As team members, we receive intensive training and supervision to prepare us to do this work, and now I want to pass along what I’ve learned.
So, what should we do when a client is suicidal? Here are six things you should know:
1. Know About Laws and Protocol
Legal and ethical requirements play an important role when we work with suicidal clients.
Before you begin working with clients at your site, make sure to brush up on the federal and state laws related to reporting suicidality in your client population. For example, in the state of Oregon clinicians may be mandated to report suicidal behaviors in order to maintain the client’s safety and provide additional care (see ORS 419B.005, 40.262 R 507).
Ethically, the most relevant issues involve confidentiality and avoidance of harm . In good conscience, can you trust your client to keep themselves safe? Confidentiality may be a hallowed principle in our field, but safety must outweigh privacy during crisis.
Have a conversation with your supervisor about reporting procedures for your site. If your client discloses suicidality, you need to know the proper protocol for ensuring their safety (and the safety of the practice). Also, consult your site’s handbook for any documentation for suicidality. If your site does not currently have documented procedures, offer your support in adding them to the handbook.
2. Know How to Ask
Always remember to ask each of your clients about suicidality.
Even that sweet old fellow who reminds you of grandad, or the 11 year old girl who presents with mild anxiety about cooties. Asking about suicidal thoughts can feel awkward at first, but your comfort will increase with practice.
The experience of suicidality is commonly broken down into three parts: ideation, intent, and plan.
Suicidal ideation, or SI, includes the thoughts and feelings about dying, ending one’s life, etc. One of my mentors at George Fox University said that “most of us have thoughts about suicide at times, but stress is what pushes people to the next level.” The next level, in many ways, is intent.
Intent includes the desire or motivation to carry through with suicidal thoughts. A client may have frequent or intense ideation with little-to-no intent because of protective factors (more on that later).
A plan includes the ideas for how one might carry out suicide. Clients who deny having a plan may not have strong intent or ideation (or, they may be attempting to hide suicidality).
When I ask about suicidality, I follow this structure:
- For ideation, ask “Are you having any thoughts of suicide or self-harm?”
- If YES, “How often do you have these thoughts?”
- Followed by, “On a scale of 1-10, how intense are these thoughts when they happen?”
- For intent, ask “How serious do you feel about carrying out those thoughts?” or “If you left here right now, what is the likelihood that you would follow through with your thoughts about killing yourself?”
- For plan, ask “Have you given thought to how you would kill/harm yourself?”
- If YES, “Tell me how you would do that.”
For the “how” questions, I also recommend using the 0-10 scale. For example, I might say “how often do you have these thoughts on a scale of 0-10, where 0 is ‘not at all’ and 10 is ‘constantly’ or ‘24/7.’”
Another important factor to note is how quickly these ratings might change throughout the day on a regular basis. For example, one client with suicidal thoughts might go from 2 to 10 in just a few moments when presented with certain stressors; whereas, other clients may generally have a much slower incline. For patients who have more time, there is more opportunity to notice the change and engage in safety planning activities, thus increasing protective factors and decreasing risk.
After you have asked these questions, you can often have a much better understanding of your client’s current level of suicidality.
3. Know About Suicide vs. Self-Harm
An important distinction to make when assessing for suicidality involves differentiating suicide from self-harm, sometimes referred to in literature as “non-suicidal self-injury” or “NSSI”.
Suicidality and self-harm fall under a broad definition of self-directed . As a therapist, recognizing the difference between suicidal and non-suicidal self-directed violence is important.
Some clients may be thinking about hurting themselves, but they may not necessarily want to die. Suicidality may include elements of self-harm with the additional goal of death (e.g. desire to cut wrists with intent to bleed out, or practicing self-harm behaviors to gain confidence in and progression toward suicidal acts).
The prevalence of emergency department visits appears to be higher for self-harm than for suicidality . For many, self-harm is a coping mechanism for stress and emotional pain. Intervention tailored specifically for those behaviors may be more appropriate than those intended for suicidality.
Behaviors that may be considered self-harm (rather than suicidal behaviors) might include:
- Superficial cutting of the skin
- Hitting or beating
- Initiating physical conflict
Although your client endorses self-harm, do not rule out suicidality. The emotional pain that motivates clients to self-harm may also promote their desire to kill themselves when stressed or if left untreated.
4. Know About Protective and Risk Factors
In addition to identifying the presence of suicidality and self-harm, you can estimate the relative risk of your client based on research.
The current literature is rich with correlations, predictive factors, and mortality rates, many of which can be very specific. For example, da Silva et al  found that people with Bipolar disorder who had good insight were less likely to commit suicide than those with poor insight. I highly recommend taking time to research your clinical population to better identify what factors put someone at your site at-risk, as this can provide you with a much more refined sense in your work.
In general, a few risk factors have been identified that most directly relate to suicidality. Fremouw, Tyner, Strunk, and Mustek  developed the Suicidal Adult Assessment Protocol (SAAP) which nicely lumped together many of the main factors we look for in suicide risk assessment. These factors are included below in no specific order.
Some of the moderate-high risk factors include:
- Suicidality (ideation, intent, plan)
- Rehearsal of attempt
- Previous and/or recent (within past 3 months) attempts
- Childhood trauma/abuse
- Family/friend attempts
- Drug and/or alcohol use (intoxication increases risk of SI)
- Mental Health diagnosis of Depression, Bipolar, and/or Anxiety
- Social isolation
- Major life stressors / transitions
- Having a suicide plan with preparation
- Access to means of suicide (“extreme risk” with access to firearm)
Although people may have some of these factors, the risk may be decreased by protective factors, such as:
- Support from friends/family/pets
- Religious beliefs
- Family responsibility
- Coping skills
- Other protective factors (ask your client “what are your reasons for living?”)
5. Know About Your Resources
The first time I did a risk assessment, I felt really alone. How was I, a meager psych intern, supposed to keep this person safe?
Luckily, psychologists and counselors only represent one piece of the continuum of care for at-risk clients. Let’s talk about what resources will be available for you and your client.
Hospital Emergency Department
If you believe your client may be at-risk, sending them to be evaluated at the Emergency Department (ED) is one option for getting them into more intensive care. Many major hospitals have behaviorists on-site (or on-call) who are trained in suicide risk assessment, and they can help with the process of stabilizing the client and coordinating care. Local law enforcement can provide transportation from your site to take the client to the ED if necessary.
Keep in mind that the Emergency Department setting is a fast-paced environment that may not feel highly supportive to a person in the midst of psychiatric crisis. But, it is a safer place for them to be than at home, alone, and contemplating suicide as a viable option. Many clients may need to have an opportunity to process their experience of visiting the Emergency Room with a therapist after the visit.
Acute Inpatient (Psychiatric) Hospitalization
Inpatient care is considered to be top-tier treatment for high-risk suicidality, including stabilization, intervention, medication management, and social work services. In order to qualify for this level of care, a client must fulfill your state’s requirements for voluntary/involuntary commitment. In Oregon, the basic criteria includes an imminent risk of harm to self/others or an inability to care for self (ORS § 426.005). These criteria may differ from state to state.
Subacute facilities, as the name implies, typically offer similar services for clients who do not fully meet criteria for inpatient care. For example, your client may be at-risk yet also has good insight and is able to self-manage without the intensive support of around-the-clock psychiatric services and observation.
Respite care facilities are ideal for clients whose suicidality is brought on by at-home stressors (or similar) and need time away for a brief period. Many respite care facilities can assist with things such as medication compliance and regular check-ins. The criteria for respite care differ dramatically from site to site, so I recommend having a call list of available services in case your client is not an appropriate fit.
Many local services can offer basic necessities for clients, such as food and shelter. Additionally, some services offer employment assistance, counseling, or family support. Similar to respite care, these services can be quite diverse depending on your area, and many local services are population specific (i.e. women’s centers, LGBTQ support, Christian-based, etc.).
If you are seeing this client for therapy, you have likely built a relationship that will keep them coming back for treatment. Empathize with your client’s pain, clearly communicate your understanding and desire to keep them safe, and incorporate evidence-based practices for self-harm and suicide in your work together.
6. Know What to Do
After you have identified the presence of suicidality/self-harm and calculated some of the risk, you can feel more confident about taking the next step in treatment.
So, what is the next step?
First, calculate your client’s safety risk.
If your client endorses suicidality and is at-risk:
- Don’t panic! Remember that this is relatively common and many clients experience this. Also consider what you are communicating to your client through your response. Staying calm can help them to know that you are okay, they are okay, and together you can handle the situation.
- If you are a student/intern, contact your supervisor and notify them of your client’s disclosure. After all, you are practicing under their license and therefore they will make the final call. If you are licensed, get consultation if necessary.
- Depending on your setting, you will likely have a policy for working with clients who are suicidal. Make sure you are familiar with the organizational/administrative policies before beginning client work.
- Clients who are at an imminent risk of harm to self (whether by suicide or inability to care for self) are often good candidates for hospitalization and inpatient care. This process may require that the client is assessed in the emergency room in order to get a referral.
- Create a safety plan that includes recognizing warning signs that they may be at risk of harming themselves, ways to distract themselves, people to call, crisis hotline numbers, and a referral to be assessed and/or enter inpatient care as needed. If possible, include family members or friends (with the client’s permission) in the plan. Additionally, removing access to means of suicide needs to be included in the plan.
- If the client is unwilling or unable to commit to a safety plan or enter treatment, discuss their reasons and, if necessary, alert local law enforcement to escort the client to your referral.
- Make sure to document well and clearly articulate any reasons for referral and reasons for choosing your course of action. For example, “Client endorsed occasional thoughts of death but denied intent or plan to harm self. Client agreed to safety plan and a follow-up therapy visit was scheduled in one week.”
- If a client is seeing you for therapy as part of their treatment plan, be sure to continue the discussion. Ask the client to rate their current level of suicidal ideation. Find out how it changed or stayed the same since the last visit. Revisit the safety plan and discuss what worked or what didn’t and revise if necessary.
If your client endorses low levels of suicidality:
- If you are a student/intern, discuss the client’s disclosure with your supervisor. If you are licensed, get consultation as needed.
- Collaborate with the client and create a safety plan if necessary. In other words, develop a plan for how the client may cope when they feel stressed. Part of your plan will likely include continuation of therapy.
- If possible, connect your client with additional supports in the area.
- Provide them with local crisis numbers (for example, Oregon has county-based crisis hotlines) for them to use if their suicidality increases.
- Make sure to document well and clearly articulate the client’s risk as well as any protective factors, or reasons for living, the client can identify.
If your client denies suicidality:
- Communicate to them that you want therapy to be a space where they can discuss those kinds of thoughts/feelings whenever they come up.
- Provide them with resources, including local crisis numbers and community supports if needed.
- Document that the client denied suicidality and include any protective factors they might have.
Suicidality is very common, and also very taboo. Make sure to create a space for your clients where they can talk about suicidal thoughts while knowing that you will be there for them.
You have the ability to help your client regain their health, sense of purpose, and life.
Yet suicidality affects us as well – and as compassionate, empathically attuned beings we tend to soak up those intense feelings of distress and hopelessness. Use your self-care support network, discuss it in supervision, and talk to your therapist.
You can do this, but you don’t have to do it alone.
**A big thanks to Dr. Luann Foster of George Fox University, one of my fabulous supervisors in my work in suicide risk assessment, for her training, mentorship, and contribution to this article.
References Centers for Disease Control and Prevention. (2014). National Suicide Statistics. Retrieved from http://www.cdc.gov/ViolencePrevention/suicide/statistics/index.html. Bakst, S. S., Braun, T., Zucker, I., Amitai, Z., & Shohat, T. (2016). The accuracy of suicide statistics: are true suicide deaths misclassified?. Social Psychiatry and Psychiatric Epidemiology, 51(1), 115-123. Jurecska, D. E., Tuerck, M. (2009) “National Register Graduate Student Corner: Training Psychologists as Consultants to Hospital Emergency Departments.” National Register Graduate Student Corner: Training Psychologists as Consultants to Hospital Emergency Departments. National Register. American Psychological Association. (2010). American Psychological Association ethical principles of psychologists and code of conduct. Retrieved Aug 1, 2016 from http://www.apa.org/ethics/code/ Meyer, R. E., Salzman, C., Youngstrom, E. A., Clayton, P. J., Goodwin, F. K., Mann, J. J., … & Greden, J. F. (2010). Suicidality and risk of suicide—definition, drug safety concerns, and a necessary target for drug development: a consensus statement. The Journal of clinical psychiatry, 71(8), 1046-1046. Centers for Disease Control and Prevention. (2011). Suicide and Self-Harm. Retrieved from http://www.cdc.gov/nchs/fastats/suicide.htm. da Silva, R. D. A., Mograbi, D. C., Bifano, J., Santana, C. M., & Cheniaux, E. (2016). Correlation Between Insight Level and Suicidal Behavior/Ideation in Bipolar Depression. Psychiatric Quarterly, 1-7. Fremouw, W., Tyner, E., Strunk, J., & Mustek, R. (2005). Suicidal Adult Assessment Protocol–SAAP. Washington, DC: American Psychological Association.
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