What to Do if a Client Is Suicidal: Guidance for Therapists

At some point in your work as a therapist, you may encounter a client who is at risk of suicide. Or perhaps a friend, or family member. Would you know what to do? Knowing how to respond to suicidal clients is an essential skill for therapists, even if you do not specialise in this area.

Why All Therapists need to Have Suicide Awareness

It’s easy to assume that this is something you won’t come across, particularly if you don’t work directly with suicidality. This is especially the case for hypnotherapists, where clients who present with suicidality may be contraindicated.

However, many of the issues therapists work with are closely linked with an increased risk of suicide. This includes anxiety, depression, hopelessness and insomnia. So, even if it’s not your primary focus, you may still find yourself supporting a client who is contemplating suicide. And it’s why all practitioner course students at YHT get the opportunity to take a free suicide prevention qualification as part of their studies with us.

How to Talk About Suicide: : Language Matters

We usually talk about ‘committing’ a sin or a crime. The term ‘committing suicide’ comes from a time when such an act was considered to be ‘self-murder’. Those who survived a suicide attempt could find themselves charged with a crime and sent to jail. The belongings of a person who died by suicide could be confiscated and given to the Crown instead of supporting their families. And the church would often refuse to bury them in hallowed ground.

To avoid this reference, and the connotations it brings, it’s best to use more neutral language. Examples would be ‘ending your/their own life’ or ‘died by suicide’.

Suicide was decriminalised in the UK in 1961. But if you want to know more about how things used to be, read THIS.

Suicide Prevention, Confidentiality and Legal Considerations

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’. So, your ability to break confidentiality in certain circumstances depends on the wording of your client contract.

Codes of Ethics for hypnotherapists generally have a bit to say about confidentiality in different scenarios. Here are 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 both 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 and has no force in law. Legally, your agreement with the client is the contract or T&C you ask them to sign.

That document must make it clear that you will break confidentiality if you believe someone is at risk. Or you could save someone’s life and later be sued for breach of contract. You might be happy to risk it, but I’d recommend tweaking your contract if that sort of clause isn’t already there.

*Other Views

It’s worth mentioning here that some professional bodies take different positions on balancing client autonomy and choice with the need to protect them from harm. That can lead to different assumptions about when and whether you might break confidentiality. It’s important to refer to your own code of ethics and seek guidance from your supervisor.

Assessing Suicide Risk in Clients

Some therapy clients experience suicidal thoughts without having any intention of acting on them. Others may be close to taking action. That means that some form of assessment is essential before you decide how to act.

There are formal assessments available, including 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 21, GAD 7 and PHQ 9 can all help to identify risk factors and indicators. They can be downloaded free from the internet (just Google the one you want). However, 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. 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. Also, isolation, mental health issues, a history of abuse, or easy access to the means to carry out the act.

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 respond and explore your concerns than to say nothing.

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 teach is a technique called QPR, which stands for Question, Persuade, Refer. We’ll go through the basics here, and you’d be welcome to come along to one of my Suicide and Prevention Awareness Courses . These are run on Zoom about three times a year.

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? (meaning 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?’  
• Avoid comments like ‘How do you think your family would feel if you did that?’. They 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 is not about trying to persuade someone 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 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. You’ll find many other useful resources there as well.

If you’re 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. Ask that person to collect the client from your office and take them to the GP.  
• Alternatively, https://www.nhs.uk/conditions/suicide/ has a list of useful numbers. You can find others that are local to you, or aimed at specific groups such as teenagers or older people.

This article is, of course, only a general guide to QPR for therapists. It is not a substitute for taking the course! Every situation is different, and if you are unsure how to proceed, seek advice from your supervisor, or appropriate services. Your client’s safety, and your own, should always come first.

Supporting People Outside the Therapy Room

Although we’ve focused on therapists and their clients so far, 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 interrupting someone’s thought patterns if you feel they are at risk in a public place MORE HERE   
• Mental Health First Aid England 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 honest 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.

Disclaimer
The information and ideas shared on this blog are based on the author’s professional experience, research, and training. They are intended for educational purposes and to support reflection and professional development. Therapists should always apply their own professional judgment and consider the needs of individual clients when using any techniques or suggestions discussed here.
While every effort is made to ensure the information is accurate and helpful, no responsibility can be accepted for any loss, damage, or difficulties arising from the use or misuse of material contained in these articles.