Dealing with suicidal clients

Whatever kinds of client you work with, and in whatever way, it’s possible that sooner or later you may find yourself faced with a situation where you are concerned that a client – or someone you know - may be at risk of harming themselves. Would you know what to do?

How to talk about suicide

We usually ‘commit’ a sin or a crime. The term ‘committing suicide’ comes from a time when such an act was considered to be ‘self-murder’ and when those who survived a suicide attempt could find themselves charged with a crime and sent to jail. To avoid this reference and the connotations it brings, it’s best to use more neutral language such as ‘ending your/their own life’ or ‘died by suicide’.

The law changed in the UK in 1961, but if you want to know more about how things used to be, read THIS

Confidentiality and the law

In British law, there is no legal obligation to act to save someone from a dangerous situation. This is sometimes referred to as having ‘no duty to rescue’. This means that your ability to break confidentiality in certain circumstances (including when your client is likely to harm themselves) depends on the wording of your professional body’s code of ethics, and on your client contract.

Codes of Ethics for therapists generally have a bit to say about confidentiality in different scenarios, but we’ll look at just two examples of what is said specifically about the subject under discussion here.

• The GHR says ‘Maintain strict confidentiality … always provided that such confidentiality is neither inconsistent with the therapist’s own safety or that of the client …’ (para 16)  
• The NCH says that you may use the client’s personal information outside of the usual therapeutic parameters ‘if you have good cause to believe that your client, you, or others may be harmed if you do not disclose information’ (para C2)

So, they – and most other professional bodies for therapists, to be fair - want you to ensure the safety of the client and others even if it means breaking confidentiality. It seems reasonable that suicidality would be covered by that. However, your Code of Ethics is a guide for you. Legally, your agreement with the client is the contract or T&C you ask them to sign.

Unless that document makes it clear that you will break confidentiality if you believe they are at risk, you could later be sued for breach of contract if you do so, however good your reasons. You might be happy to risk this, but I’d recommend tweaking your contract right now if that sort of clause is not already in it. Just remember to come back and read the rest of this article!

Assessing the risk of suicidality

There are formal assessments available such as the Firestone Assessment of Self-Destructive Thoughts (FAST) questionnaire but if you do not work with suicidal clients regularly they will probably be too detailed for your needs. The DASS 42, DASS 21, GAD 7 and PHQ 9 can all help to identify indicators, and all can be downloaded free from the internet (just Google the one you want). However, be aware that these are ‘circumstantial evidence’ and should not be relied upon too heavily when deciding if you should take action.

By far the best approach is to listen to your client and understand what they are saying, and even what they are not saying. Suicide indicators can be emotional, behavioural or verbal. High-risk factors include having attempted suicide before or having family members who have done so, isolation, mental health issues, a history of abuse, or easy access to the means to carry out the act. Space dictates my moving on now, but if you want to learn more about warning signs, there’s a great article HERE.

The upshot of this is that if your client indicates directly (‘I feel like killing myself’) or indirectly (‘My family would be better off if I wasn’t here’) that they might be thinking of harming themselves, then it’s better to take action than not. Listen and respond. Don’t let worry about doing the wrong thing get in the way of doing anything.

What to do if your client is suicidal

Be prepared

• know what to say and do so you don’t panic or avoid the situation  
• keep up to date helpline numbers and other useful information close at hand in your therapy room  
• take an emergency contact and GP details from every client

The approach I recommend is based on a technique called QPR, which stands for Question, Persuade, Refer. We’ll go through the basics here, but for further information and a training course visit THEIR WEBSITE.

Question –
don’t be afraid to discuss your concerns. The Victoria Suicide Line suggests checking four areas: intention, plan, means and time frame. This might mean asking questions like

• (Intention) Are you thinking about ending your own life? If yes,  
• (Plan) Do you know how you would do that? If yes,  
• (Means) Do you have a way to carry the plan out? (do they own pills, a gun, rope, etc) If yes,  
• (Time-frame) Do you have a time-frame for carrying that plan out?  

The more yesses you get, the higher the risk of suicide is. It may take courage on your part to start this conversation but stay calm and ask. If you get a yes, respond in a way that is supportive and empathetic. Remember:

• Asking about suicidal thoughts will not make your client more likely to harm themselves. People don’t become suicidal because you asked them about suicidal ideations.  
• Be direct. Ask ‘Are you thinking about suicide?’ and not ‘Are you thinking about doing something silly?’ ‘Silly’, according to the online dictionary, means ‘showing a lack of common sense or judgement; absurd and foolish’. Using it about suicide not only trivialises the situation but fails to acknowledge or validate what the person is feeling.
• Ask open, non-leading questions – again ‘Are you thinking about suicide?’ rather than ‘You’re not thinking about suicide, are you?’  
• Comments like ‘How do you think your family would feel if you did that?’ risk piling guilt on top of what the client is already feeling.

If your fears are ungrounded, the client may be quite shocked or surprised that you asked, but you can deal with whatever arises from that using your usual therapeutic skills. If your client is at risk of harming themselves, go on to the next step, which is

Persuade –
this step is not about trying to persuade them not to commit suicide at all, but about delaying - keeping them safe until they have spoken to someone who is trained to offer the right kind of support if you are not. Keep them with you until you have agreed on some kind of action, and obtain a promise not to do anything to harm themselves till after this has happened. (Most will keep that promise.)

If your client is not in immediate danger (for example they have expressed some intent but no plan, means or time frame) you could consider the use of a safety plan – these can be downloaded free from sites like GetSelfHelp or Therapist Aid which both have many other useful resources as well.

If you are not trained to work with people who are suicidal you can then go on to the next step, refer the client to someone who is.

Refer –

• Phone 999 if you think someone is in immediate danger and wait with them till help arrives
• If you don’t think the threat is immediate you have a bit more thinking-space. You could ask them to phone their GP for an urgent appointment while they are with you, and/or get in touch with their next of kin or emergency contact and ask that person to collect the client from your office and take them to the GP.  
• Alternatively, or as well, https://www.nhs.uk/conditions/suicide/ has a list of useful numbers and you can find others that are local to you, or aimed at specific groups such as teenagers or older people.

Outside the therapy room

Although we’ve focused on therapists and their clients in this article, you may come across people outside of your work environment who confide in you because they know you are a therapist, or who you simply come across in distress. You can use the same principles there.

• QPR can be applied anywhere and by anyone  
• The Samaritans recommend an approach based around interrupting someone’s thought patterns if you feel they are at risk in a public place, which can be used even by untrained individuals MORE HERE   
• Mental Health First Aid England (who also run courses) remind you to always ask twice if you are concerned for someone’s emotional wellbeing. If you simply say, ‘Are you OK?’ or ‘How are you?’ the usual response is ‘yes’ or ‘I’m fine’. Asking a second time might get you a more complete answer.
    

If you would like a more complete list of contacts (UK based) please email me and request one.

Knowing what to do in this situation is vital. Keep this article and your list of resources close at hand and one day you may save a life.

-----------------------------------------------------------------------------

Author: Debbie Waller is an experienced hypnotherapist and hypnotherapy trainer. She is the author of Their Worlds, Your Words and has co-written the Hypnotherapy Handbook, both of which are available from Amazon.
Find out more about Debbie's services on
Yorkshire Hypnotherapy Training - multi accredited hypnotherapy practitioner training, taster days and foundation levels.
CPD Expert - accredited CPD and other therapy training (online and workshops options), expert and qualified hypnotherapy supervision