Suggested Tips for Clinicians:
Revealing her thoughts of suicide was a moment of extreme vulnerability for Judy as she let me know that her pain was so deep that not existing was actually an attractive option. There is a strong stigma attached to suicide, despite greater mental health awareness in recent years, and I’m sure Judy knew that thoughts of self-harm are still considered taboo. She probably knew as well that I had the power to take away her freedom if I thought it was necessary; my consent form let her know as much.
It was a vulnerable moment for me, too. I didn’t know exactly how great Judy’s risk was for imminent self-harm, and the potential costs were high in either direction if I misjudged the situation. Underestimating the risk could contribute to her death, while overreacting could result in a rupture in our relationship or an unnecessary involuntary stay in a psychiatric ward, which is not a benign experience.
These perils and apprehensions notwithstanding, a unique opportunity opened to me when Judy told me she was suicidal. This moment invited me to meet her as a full human being in a deeply human encounter.
Meeting Clients Where They Are
When one of my clients is suicidal, I know they’re in extreme pain, whether physical or emotional. But research and my clinical experience show that pain alone doesn’t invariably lead to suicidality — it needs to be paired with hopelessness. Believing that the pain will never end, however, is strongly linked to becoming suicidal. Having strong connections to other people buffers against the risk of suicide in the face of pain and hopelessness, while feeling disconnected from others predicts more severe thoughts of suicide. When someone I’m treating is in a suicidal crisis, the best I can hope to offer them is hope and connection.
However, I’ve often struggled to give my clients what they need in these moments which are fraught with anxiety. I felt my stomach drop when Judy told me that she had been suicidal. I had lost a patient to suicide about a decade earlier, and the reassurances from everyone around me that it wasn’t my fault didn’t make it any less heartbreaking or traumatic. Since that loss, I feel an even stronger sense of responsibility to help my clients and to do everything I can to keep them safe, while at the same time balancing safety with not wanting to overreact and encourage or require that the person go to the emergency room if the risk is not that severe. The threat of legal liability also looms large if I underestimate the risk and my client ends their own life.
As a result of these competing tensions and fears, there have probably been times when I unwittingly diminished hope, short circuited therapeutic connection, and left a client alone with their deepest pain. I was taught during my master’s program to be sure to “contract for safety,” which meant having the client sign a form that said they promised not to kill themselves. Even as a new trainee I could feel in my core that something was fundamentally wrong with this approach, which seemed like the ultimate gesture of pointless self-interest. It was clear to the client, too, that the agreement was meaningless, and that it was designed to protect me and the clinic where I was working as a practicum student.
Even though safety contracts are largely a thing of the past, I still need to be careful not to give more subtle indications that my focus is on mitigating risk, perhaps not mostly out of concern for my client. Without intending to, I could send the message that I care more about the possibility that my client might end their life than about the pain and hopelessness that are making their life unbearable.
Perhaps I might signal my nonverbal disapproval when a client describes being suicidal and react more positively when they reassure me that they’ll be OK. Or I might try to nudge a client toward agreeing that they “would never act on their urges,” or show with my body language that this conversation is making me extremely uncomfortable. In one way or another, I could discourage future openness.
It's easy to understand my fear in these situations. There is a widespread assumption that if a client ends their life, the therapist must somehow be to blame. I’ve witnessed organizations where there was a presumption that the therapist must have messed up unless they could prove otherwise. This toxic mentality burdens therapists with the illusion of an absolute ability to prevent suicide, but the truth is that a client may decide to end their life even when I’ve done everything possible to prevent it. Not surprisingly, I’ve found it hard at times not to focus on risk mitigation at the expense of the therapeutic alliance and the hurting human being in front of me.
Looking Back
Months later, Judy told me that my equanimous response to her confession in that first session was the main reason she continued in therapy with me. “I was afraid you might have me locked up,” she said, “or that you’d say you couldn’t treat me.” Instead, she felt she could trust me, and that I cared about her and not just about “covering your ass,” as she put it.
But there was a moment when I was less receptive to Judy’s suicidal thinking, which I didn’t understand (or share) at the time. In one of our later sessions a couple of years after that first meeting, she said with conviction that nobody in her family would care if she killed herself. I reacted with an intensity that surprised both of us.
There was no validation of Judy’s feelings, no gentle Socratic questioning to test the evidence. Instead, I replied, “I have to tell you, that is categorically untrue.” I was nearly shaking with emotion. She looked taken aback. I continued, “I can guarantee that your family would be devastated, and the effects would ripple through multiple generations.”
Judy told me later that she was startled by the fierceness of my words and tone of voice, which I attributed to my own family history of suicide. My dad’s dad, a veteran of World War II, died from a self-inflicted gunshot wound seven years before I was born. That loss colored not just my dad’s adulthood but my parents’ relationship and our family’s emotional life. But while I don’t doubt that the echoes of my grandfather’s suicide were in the room when I snapped at Judy, there were more recent and personal forces at play.
For the past few months, I had been in a moderate major depressive episode following a prolonged illness, which included a frequent desire to die. I was plagued by recurrent thoughts that I was letting down my wife and three young kids, and that they would be better off without me. I knew rationally that the last thing my family needed was my suicide, but the thoughts came with such conviction, as if they were established fact, that they were hard to dismiss. When I responded to Judy in that session, I wasn’t speaking just to her. I was addressing my own ambivalence about staying alive.
Based on my clinical experience with Judy and other clients who have shared their suicidality with me, I offer the following self-awareness exercises to enhance your therapeutic presence when you encounter these challenging moments with your own clients.
Foster Awareness
My lived experience inevitably affects my work as a therapist. The more aware I am of my thoughts and feelings around suicide, the more constructively I can put them to use in the therapy room. Just as I might encourage my clients to develop greater self-awareness, I can practice mindfully attending to my own reactions when a client has suicidal thoughts.
Try this: Notice what’s happening in your body when a client is suicidal — are you tensing? Is your breathing restricted? Are you moving away, or adopting a self-protective posture? You can mind your emotions, too. Are you anxious? Annoyed? Sad? Fearful? Take an easy breath in and out and see what it’s like to observe those reactions with a bit of distance, rather than letting them necessarily drive your words or actions.
Question the Story
What I feel often comes from the stories my mind is telling me. By noticing my thoughts, I can recognize that the stories may not be true.
Common thoughts I’ve had in reaction to a client’s suicidality include:
Open Continually
My automatic impulse in the face of vulnerability is to shut down: to close my heart, resist discomfort, quickly resolve ambiguity, and fall back on well-worn habits. These default reactions may be effective at managing my anxiety, but they can shut down my flexibility, creativity, and ability to connect with the person in my care.
Try this: When you sense the urge to shut down, take a slow breath in and out, feeling the points of contact between your body and your chair. Then ask yourself, “Can I open to this?” Even if part of us is resisting the experience, another part wants to stay present and to seek connection. Gently nurture that willingness.
Embrace Uncertainty
My mind doesn’t sit easily with not knowing how something I care about is going to turn out—especially when the outcome could be catastrophic. My automatic reaction is to try to resolve the uncertainty as quickly as possible, and to make sure things turn out okay. But when my client is thinking of suicide, the only thing I can know for sure is that they’re in real pain and are looking to me for help.
Try this: Rather than trying to know the unknowable, lean into not knowing what will happen. Accept that you have imperfect knowledge, and that you can decide only with the information in front of you. Make as much space as possible for the outcomes you fear—not because you’re indifferent to what happens, but because uncertainty is the reality you’re faced with.
File under: The Art of Psychotherapy, A Day in the Life of a Therapist
- Explore your own preconceptions of suicidality and how they impact your interventions
- Meet clients where they are rather than where you think they should be
- Manage your own fears and anxiety around client suicidality
- Develop a strategic therapeutic plan including supportive clinical resources
***
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Revealing her thoughts of suicide was a moment of extreme vulnerability for Judy as she let me know that her pain was so deep that not existing was actually an attractive option. There is a strong stigma attached to suicide, despite greater mental health awareness in recent years, and I’m sure Judy knew that thoughts of self-harm are still considered taboo. She probably knew as well that I had the power to take away her freedom if I thought it was necessary; my consent form let her know as much.
It was a vulnerable moment for me, too. I didn’t know exactly how great Judy’s risk was for imminent self-harm, and the potential costs were high in either direction if I misjudged the situation. Underestimating the risk could contribute to her death, while overreacting could result in a rupture in our relationship or an unnecessary involuntary stay in a psychiatric ward, which is not a benign experience.
These perils and apprehensions notwithstanding, a unique opportunity opened to me when Judy told me she was suicidal. This moment invited me to meet her as a full human being in a deeply human encounter.
Meeting Clients Where They Are
When one of my clients is suicidal, I know they’re in extreme pain, whether physical or emotional. But research and my clinical experience show that pain alone doesn’t invariably lead to suicidality — it needs to be paired with hopelessness. Believing that the pain will never end, however, is strongly linked to becoming suicidal. Having strong connections to other people buffers against the risk of suicide in the face of pain and hopelessness, while feeling disconnected from others predicts more severe thoughts of suicide. When someone I’m treating is in a suicidal crisis, the best I can hope to offer them is hope and connection.
However, I’ve often struggled to give my clients what they need in these moments which are fraught with anxiety. I felt my stomach drop when Judy told me that she had been suicidal. I had lost a patient to suicide about a decade earlier, and the reassurances from everyone around me that it wasn’t my fault didn’t make it any less heartbreaking or traumatic. Since that loss, I feel an even stronger sense of responsibility to help my clients and to do everything I can to keep them safe, while at the same time balancing safety with not wanting to overreact and encourage or require that the person go to the emergency room if the risk is not that severe. The threat of legal liability also looms large if I underestimate the risk and my client ends their own life.
As a result of these competing tensions and fears, there have probably been times when I unwittingly diminished hope, short circuited therapeutic connection, and left a client alone with their deepest pain. I was taught during my master’s program to be sure to “contract for safety,” which meant having the client sign a form that said they promised not to kill themselves. Even as a new trainee I could feel in my core that something was fundamentally wrong with this approach, which seemed like the ultimate gesture of pointless self-interest. It was clear to the client, too, that the agreement was meaningless, and that it was designed to protect me and the clinic where I was working as a practicum student.
Even though safety contracts are largely a thing of the past, I still need to be careful not to give more subtle indications that my focus is on mitigating risk, perhaps not mostly out of concern for my client. Without intending to, I could send the message that I care more about the possibility that my client might end their life than about the pain and hopelessness that are making their life unbearable.
Perhaps I might signal my nonverbal disapproval when a client describes being suicidal and react more positively when they reassure me that they’ll be OK. Or I might try to nudge a client toward agreeing that they “would never act on their urges,” or show with my body language that this conversation is making me extremely uncomfortable. In one way or another, I could discourage future openness.
It's easy to understand my fear in these situations. There is a widespread assumption that if a client ends their life, the therapist must somehow be to blame. I’ve witnessed organizations where there was a presumption that the therapist must have messed up unless they could prove otherwise. This toxic mentality burdens therapists with the illusion of an absolute ability to prevent suicide, but the truth is that a client may decide to end their life even when I’ve done everything possible to prevent it. Not surprisingly, I’ve found it hard at times not to focus on risk mitigation at the expense of the therapeutic alliance and the hurting human being in front of me.
Looking Back
Months later, Judy told me that my equanimous response to her confession in that first session was the main reason she continued in therapy with me. “I was afraid you might have me locked up,” she said, “or that you’d say you couldn’t treat me.” Instead, she felt she could trust me, and that I cared about her and not just about “covering your ass,” as she put it.
But there was a moment when I was less receptive to Judy’s suicidal thinking, which I didn’t understand (or share) at the time. In one of our later sessions a couple of years after that first meeting, she said with conviction that nobody in her family would care if she killed herself. I reacted with an intensity that surprised both of us.
There was no validation of Judy’s feelings, no gentle Socratic questioning to test the evidence. Instead, I replied, “I have to tell you, that is categorically untrue.” I was nearly shaking with emotion. She looked taken aback. I continued, “I can guarantee that your family would be devastated, and the effects would ripple through multiple generations.”
Judy told me later that she was startled by the fierceness of my words and tone of voice, which I attributed to my own family history of suicide. My dad’s dad, a veteran of World War II, died from a self-inflicted gunshot wound seven years before I was born. That loss colored not just my dad’s adulthood but my parents’ relationship and our family’s emotional life. But while I don’t doubt that the echoes of my grandfather’s suicide were in the room when I snapped at Judy, there were more recent and personal forces at play.
For the past few months, I had been in a moderate major depressive episode following a prolonged illness, which included a frequent desire to die. I was plagued by recurrent thoughts that I was letting down my wife and three young kids, and that they would be better off without me. I knew rationally that the last thing my family needed was my suicide, but the thoughts came with such conviction, as if they were established fact, that they were hard to dismiss. When I responded to Judy in that session, I wasn’t speaking just to her. I was addressing my own ambivalence about staying alive.
Based on my clinical experience with Judy and other clients who have shared their suicidality with me, I offer the following self-awareness exercises to enhance your therapeutic presence when you encounter these challenging moments with your own clients.
Foster Awareness
My lived experience inevitably affects my work as a therapist. The more aware I am of my thoughts and feelings around suicide, the more constructively I can put them to use in the therapy room. Just as I might encourage my clients to develop greater self-awareness, I can practice mindfully attending to my own reactions when a client has suicidal thoughts.
Try this: Notice what’s happening in your body when a client is suicidal — are you tensing? Is your breathing restricted? Are you moving away, or adopting a self-protective posture? You can mind your emotions, too. Are you anxious? Annoyed? Sad? Fearful? Take an easy breath in and out and see what it’s like to observe those reactions with a bit of distance, rather than letting them necessarily drive your words or actions.
Question the Story
What I feel often comes from the stories my mind is telling me. By noticing my thoughts, I can recognize that the stories may not be true.
Common thoughts I’ve had in reaction to a client’s suicidality include:
- I don’t know how to handle this
- This is going to end badly
- I’m going to get sued
- Images of the client’s death
- Being questioned by investigators
- Feeling inadequate to the task
Open Continually
My automatic impulse in the face of vulnerability is to shut down: to close my heart, resist discomfort, quickly resolve ambiguity, and fall back on well-worn habits. These default reactions may be effective at managing my anxiety, but they can shut down my flexibility, creativity, and ability to connect with the person in my care.
Try this: When you sense the urge to shut down, take a slow breath in and out, feeling the points of contact between your body and your chair. Then ask yourself, “Can I open to this?” Even if part of us is resisting the experience, another part wants to stay present and to seek connection. Gently nurture that willingness.
Embrace Uncertainty
My mind doesn’t sit easily with not knowing how something I care about is going to turn out—especially when the outcome could be catastrophic. My automatic reaction is to try to resolve the uncertainty as quickly as possible, and to make sure things turn out okay. But when my client is thinking of suicide, the only thing I can know for sure is that they’re in real pain and are looking to me for help.
Try this: Rather than trying to know the unknowable, lean into not knowing what will happen. Accept that you have imperfect knowledge, and that you can decide only with the information in front of you. Make as much space as possible for the outcomes you fear—not because you’re indifferent to what happens, but because uncertainty is the reality you’re faced with.
***
Self-awareness and greater openness are the foundation for all the effective risk-management techniques I’m trained in such as asking about desire, plans, preparatory steps, access to means, and documenting what my clients tells me. I still collaborate with clients to make safety plans, which reduce suicide attempts by over 40 percent — one suicide attempt is prevented for every 16 clients who receive a safety plan — and I aim to take these lifesaving steps in the context of nurturing lifegiving connection.
***
Questions for Thought:
In looking back on your clinical work with suicidal clients, what might you have done differently with a few in particular?
What is it about working with suicidal clients that you find most challenging both professionally and personally?
What about this blog touched you or challenged you in a way you hadn’t anticipated?
What might you do differently next time you take on work with a suicidal client?
File under: The Art of Psychotherapy, A Day in the Life of a Therapist