Clients presenting in therapy with suicidal thoughts or plans can be challenging for even the most experienced therapist. Understanding the world of suicidal clients, knowing how best to respond in the therapeutic relationship and ultimately making decisions about the implications for confidentiality pose difficult dilemmas. The most helpful course of action for the therapist will be dependent upon many factors, including: the context in which the therapy is taking place, the relationship with the client, the boundaries of confidentiality agreed, the confidence of the therapist to explore the meaning of suicide.
Recognizing suicide risk: While clients will occasionally make explicit references to suicide, often such thoughts are expressed in other ways. For example, expressions such as 'I can't see the point any more', 'I'm too tired to carry on any more' or 'Everyone would be better off if I weren't here', may communicate suicidal thoughts of equal intensity to those of clients who state explicitly that they are thinking of killing themselves.
It can be difficult to know how best to respond to a client whom you suspect might feel suicidal but has not explicitly stated it. Often it is feared by therapists that talking about suicide will 'put the thought into the client's mind', or might be 'offensive or clumsy'. These understandable anxieties can often prevent therapists from feeling sufficiently confident to talk about suicide explicitly; for example, by naming it first.
There is no evidence that asking clients whether they have suicidal thoughts will put the thought into their mind if it was not there before.
There is, however, a great deal of evidence to suggest that being able to talk to clients about suicide is extremely important in providing a safe space for them to explore their feelings. Clients often describe a sense of relief at being able to talk about their suicidal feelings. However, some clients will not feel able to express their suicidal feelings at all, either implicitly or explicitly.
Other clients may feel suicidal but have no intention of acting on those feelings. Some clients say that knowing suicide is an option for them is sufficient to help them cope with distressing or overwhelming feelings. It is therefore important to ask clients about suicide if you suspect that they may be feeling suicidal, even if at that point they do not feel able to explore it further.
The wording of such questions is important and needs to be treated sensitively. Much will depend upon the setting in which the therapy takes place and the individual approach of the therapist. Just framing the question can communicate to the client that the thought of suicide is something that the therapist is able to hear. Clients can often perceive this as 'permission' to voice their most difficult feelings and then to begin to explore their suicidal thoughts as the therapeutic work progresses.
Asking clients whether they feel so low that they are considering taking their own lives is an honest and respectful way of giving clients 'permission' to voice their most difficult feelings. Additionally, exploring with clients how they are able to keep themselves safe or ways in which they are able to manage suicidal thoughts can help them reflect further on the meaning of their feelings.
Assessing risk: Suicidal clients need help to explore the nature and severity of their suicidal thoughts, as well as looking at ways in which they can manage their distress. Sometimes suicidal thoughts can be fleeting and general in nature, while for others suicide is a constant, intrusive idea. Talking more about suicidal feelings will begin to help clarify for clients, as well as therapists, how the thoughts are experienced and managed.
When assessing suicide risk, therapists need to consider whether the client has sufficient capacity or intellectual maturity to make a decision to end their own life. Expressing suicidal thoughts is generally in itself insufficient to justify breaking confidentiality against a client's expressed wishes. Bond (2000) provides a helpful summary of the specific factors that therapists need to consider in such circumstances, including three primary scenarios:
The client is competent to make their own decisions over treatment and to take control over their living or dying;
There is doubt about the individual's mental state and therefore their capacity to make decisions about suicide;
The client clearly lacks the capacity to understand the consequences of their potential actions and is therefore at high risk of suicide.
Determining the 'capacity' or 'mental state' of a client is notoriously difficult and often only clarified with the involvement of specialist mental health services. Therapists are not expected to undertake an assessment of an individual's mental state or capacity. However, in making judgments about the safety of the client and possible referral to a GP or mental health services, the therapist needs to be able to demonstrate that they have carefully considered the client's right to autonomy and confidentiality against the risk of suicide presented in the session.
Responding to suicide risk: There are a number of helpful ways in which a therapist can explore suicide with a client. Asking clients to rate the intensity of their suicidal thoughts can be useful. Offering a 0-10 scale (where 0 equals no intention to act and 10 equals an immediate intention to act) helps in the process of understanding the immediacy of risk. If the subjective score is high, ask the clients whether they have planned how they might kill themselves or consider whether the risk is from a more spontaneous or impulsive act.
Where the risk of suicide is from an impulsive act, help clients identify how or whether they feel able to resist such impulses, perhaps by talking through specific scenarios.
Some therapy agencies use different approaches to help identify actual or potential risk in their clients. For example, CORE (CORE System Group, 1998) can 'flag' risk issues for the practitioner. Some therapists find this helpful in structuring a discussion with their clients about risk as part of the contracting or therapeutic process.
A client's own coping strategies remain one of the most significant resources in managing suicidal ideas. Asking clients how they have kept themselves alive and ways in which they have prevented themselves from acting on their thoughts might help to develop or reinforce future coping strategies. A client's unwillingness or inability to continue to identify and use such strategies might indicate that they are no longer able to keep themselves safe.
Discussing what support might be available to suicidal clients outside therapy is crucial. This might include family, friends or other sources of help such as other professionals or out-of-hours 'helplines'. Equally important is the client's willingness or ability to access such support when needed. If a client does not feel able to contact support at times of higher risk it would be necessary to help them consider factors that might make using such support more likely. If the client is not able to consider ways in which they could use support when suicidal feelings are most intense then concerns might be increased about their ongoing safety.
Some therapists use what are called 'no-harm' contracts in their work. These are agreements, written or verbal, where the client gives a commitment not to act on suicidal thoughts between sessions and to contact support services should they feel unable to manage suicidal thoughts any longer. While 'no-harm' contracts should not replace an honest and open discussion with clients about their suicidal feelings or a more considered assessment of risk, they may be helpful in communicating an empathic response to a suicidal client while acknowledging the client's autonomy and responsibility. However, therapists should reflect on whether a very distressed client is able to make such a commitment over a longer period and to check the client's perception and understanding of the reasons for such agreements.
Risk assessment is an inexact science. It is impossible to be able to predict with any certainty how an individual will react to difficult or changing circumstances. Therapists should not think they have to achieve the impossible and predict the future. However, by discussing in detail with clients their suicidal feelings and thoughts, and how they might react to them, the therapist is better placed to make decisions about how best to respond. That might include continuing to work within the boundaries of the confidential therapeutic relationship or discussing concerns with other people with or without the client's permission.
Making a decision to disclose information remains one of the most difficult decisions for therapists to make. Careful contracting from the outset, in which the exceptions to confidentiality are clarified, together with an explanation of what action may be made in these circumstances, may avoid potential problems with disclosure. It is important to agree the parameters of confidentiality with the client so that there is transparency and an understanding of the circumstances in which a therapist may be obliged to disclose to another party. However, if the therapist feels that despite talking things through, the client remains at immediate risk to themselves and is unwilling or unable to consent to the disclosure of information to a third party, it is important that the therapist acts on their concerns quickly and appropriately.
It might be appropriate to contact the client's GP to express specific concerns about the nature of the suicide risk and to discuss how the client might need to be responded to. In some regions it might be possible to contact a Mental Health Crisis Team who could consider a range of responses with the therapist and the client. Some practitioners also agree with clients at the beginning of therapy the name of a person the client would like to be contacted in the event of an emergency.
However, if this person is a friend or relative, the therapist still needs to ensure that they have sufficient information about a client to contact a professional who is able to initiate additional specialist support, if required.
- Reeves, Andrew; When a client seems suicidal…; Healthcare Counselling & Psychotherapy Journal; October 2004; Vol. 4, Issue 4
Reflection Exercise #8
The preceding section contained information
about helping caregivers recognize and address suicidality. Write three case study examples
regarding how you might use the content of this section in your practice.
What are three statements that indicate suicidality caregivers might be aware of?
Record the letter of the correct answer the