What to Do Now if Your Client is Suicidal

If you're genuinely concerned that a client may attempt suicide, this must be treated as a high-risk, potentially life-threatening situation.

Feeling a clear and imminent threat that your client may kill themselves can be terrifying.

Of course, I don’t want to worry you! It may be that you never see a suicidal client.

But I want to give you some clear and simple practical steps to take should you begin to suspect that a client has real intention to end their own life.

Agitation is concerning

In a recent blog post I described how language patterns can change in the pre-suicidal (and also how shifting language patterns may predict relationship breakdown). I also listed suicide risk factors. Most of these were fairly obvious, such as expressing a desire to die or at least that life feels too painful to bear, and a history of self-harm.¹

But, pointedly, catastrophic impulsivity driven by nervous agitation was a greater predictor of suicide attempts than low mood.

Research suggests that when agitation is present, the risk of suicide attempts may increase by up to 50%.^2,3

It may seem strange to think that a proportion of suicides may have been simply impulsive acts rather than long-planned ones, but this might account for at least some people’s deaths by their own hand.

A client who is exhibiting all the depressive thinking biases and who seems to be energized by agitation (perhaps pacing up and down, wringing their hands, compulsively tapping a foot or fingers) may be particularly at risk of doing something in the moment.

People need motivation to act in order to kill themselves which, paradoxically, deep depression robs them of.

Your duty of care

Now, the vast majority of people who come to see you will probably not be suicidal. Seeking help implies at least some hope that things can get better.

But if you’re genuinely concerned that a client may attempt suicide, this must be treated as a high-risk, potentially life-threatening situation, and there are well-established clinical and ethical steps to follow. The priority is always safety over confidentiality.

You can tell your client you have a duty of care, not just as a professional but from one human being to another.

But how exactly should you proceed?

One: Conduct an immediate risk assessment

We don’t want to assume someone is a great suicidal risk when they’re not. And ultimately we have to take people’s word at face value.

If someone says they don’t always want to be here but that they would never take their own life, we can believe that.

Yes, some people may hide their true feelings in order to make a more successful attempt, but we can only work with what we have.

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Having said that, some clinical guidelines (from, for example, the National Institute for Health and Care Excellence [NICE] and Zero Suicide in the UK) emphasize using a validated tool such as the Columbia Suicide Severity Rating Scale (C-SSRS) or the PHQ-9 item 9 to assess suicide risk rather than unstructured exploration alone.

If you are uncomfortable doing this kind of risk assessment you could recommend or request another professional do this as fast as possible. Or at least explore that possibility.

We can gently and calmly explore:

• Suicidal thoughts (frequency, intensity)
• Plans (specific method, timing, access to means)
• Intent: How likely do they feel it is that they might act? Have they set a date? Started saying goodbye to people? Made a will unexpectedly or begun to give possessions away?
• Any past attempts: How and why have they tried to take their own lives before? Afterwards, were they relieved the attempt had failed?
• Protective factors, such as family, beliefs, or reasons to live.

Asking about suicide does not increase risk. Rather, it helps clarify it. I might ask gently:

“You know, most of us at one time or another consider what it might be like to no longer be here any more… is that something you ever think about?”

Next you can decide just how dire the situation is.

Two: Determine level of risk

Perhaps most, or at least many, people have considered taking their own life as an option. Abstractly thinking about it may be a world away from becoming determined to do it.

So we might determine whether the level of risk is:

• Low: thoughts but no plan or intent. “Yes, I sometimes think about it, but I’m too scared to do it/I would never do it!” Someone with low risk might have more ties to life in the form of family, friends, and other contacts. Loneliness – a lack of social connection – is correlated with increased suicide risk.⁴ So what is their support structure like? Who can they talk to freely?
• Moderate: This might include expressions of wanting to kill oneself and perhaps some planning, but with a sense of doubt around it.
• High/imminent: Here we’d see a clear plan, intent, and access to means such as pills or firearms; evident emotional agitation and impulsivity; and/or a time, place, and date in mind.

How we respond would need to accord with the perceived level of risk. But we do need to do something if we perceive a significant risk.

Three: Prioritize safety (duty of care)

Ultimately we can’t guarantee someone’s safety, but we can do as much as possible. If you feel there is a genuine, imminent risk you might:

• Develop a safety plan that includes emotional coping strategies, emergency contacts they can call, and removing the means of suicide.
• Use a structured protocol such as the Stanley-Brown Safety Planning Intervention (SPI), which is evidence based and widely recommended in US and UK guidelines.
• Encourage or arrange urgent support (trusted person, crisis line, GP, emergency services).
• If the client tells you they plan on doing it immediately or you suspect they might, stay with them (in person or on the phone) until help is secured.

Removing the means of self-harm

Often people are afraid of what they might do to themselves. Many people don’t want to die but still worry they ‘might do something stupid’. So it is critical to ensure ‘means restriction’.

We can ask clients to remove or lock away lethal means (especially firearms and stockpiled medications). This is a straightforward and obvious way of diminishing suicide risk.

In fact, it is one of the most evidence-backed interventions available and is a distinct item in standard safety planning frameworks.⁵

I encouraged one woman to leave her big bottle of sleeping tablets with me when she came for her session, and she did. (I had also ensured her husband was there to pick her up from the session and that both he and her GP knew about the thoughts she’d been having.)

Four: Break confidentiality if necessary

One worry some practitioners have is that if they intervene too much when a client seems suicidal they are breaking confidentiality. So we need to address this.

Under widely accepted ethical guidelines, confidentiality can be broken if there is serious risk of harm.⁶ The therapist may contact:

• Emergency services (999, 911, or whatever the emergency number is in your area)
• A crisis team
• A nominated emergency contact.

To do so is to fulfil our ‘duty of care’, that is, our broad ethical obligation. This should be distinguished from ‘duty to protect’, which is a specific legal doctrine that varies by jurisdiction. It’s advisable to check your own jurisdiction’s law, as the duty to warn/protect does not automatically exist in all countries.

Depending on severity of risk, if a client intimates to me they are seriously planning to kill themselves I will tell them that I have to make this known to other professionals.

We need to be transparent. Ultimately we should always tell the client that we need to break confidentiality before we do it, and help them understand why.

If needed, we might have to:

• Refer for urgent psychiatric evaluation
• Arrange, or suggest to other bodies, hospital admission (voluntary or involuntary)
• Coordinate with other professionals (GPs, psychiatrists).

Even as we pursue these avenues, we should still involve the client in decisions whenever possible.

Five: Document everything carefully

In the – hopefully highly unlikely – event that you have an actively suicidal client, this next point is important.

You can record:

• What your client said
• Risk assessment details
• Decisions made and why
• Actions taken (for example, who was contacted).

This is essential for ethical and legal accountability.

Once we help our clients through the immediate crisis, we can consider their long-term wellbeing.

Six: Longer-term care

We can monitor and support our clients once the immediate crisis is over.

I might ask a client who has gone through a ‘suicide crisis’:

• “If you ever started feeling that way again, what would you do to nip those feelings in the bud and prevent that happening?”
• “What is the most important thing you’ve learned from coming through this recent time?

Suicidal ideation can be terrifying for some clients (although some people report feeling calmer and, paradoxically, happier when they have decided to kill themselves, so there’s no hard rule).

But we can help post-suicidal crisis clients feel more empowered to handle these feelings effectively if they should ever arise again.

After the immediate crisis:

• Increase session frequency if possible, at least for a while.
• Revisit and update safety plans.
• Work on underlying issues which may have been fueling the crisis, such as depression, trauma, isolation, and lack of a sense of meaning.

The vast majority of people who attempt suicide but survive don’t eventually die by suicide. So it might be the case that a good proportion of those who plan or attempt suicide but fail are eventually grateful they didn’t succeed.⁷

You may make all the difference.

You may save a life.

Do you work with clients presenting with suicidal ideation rooted in severe depression? The How to Lift Depression Fast Course equips you with an evidence-based approach to treating depression quickly and effectively, so you can intervene with greater confidence and skill. Explore the How to Lift Depression Fast Course.

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About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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