Do’s and Don’ts of Talking About Suicide as Therapists

Have you ever felt uncomfortable or unsure about what to say when clients bring up suicide during a therapy session? 

Did you know that approximately 22% of therapists have had at least one client complete suicide (McAdams & Foster, 2000)? How about the fact that 29% of psychotherapists reported in a national survey of having thoughts of suicidal ideation (Pope & Tabachnick, 1994)?

Navigating the conversation around suicide in therapy sessions can be a challenging experience, even for the most seasoned therapists. 

I know from my own journey as a psychotherapist how daunting it can feel to approach this sensitive and critical topic. There were moments when I felt unprepared and uncertain, questioning whether I was saying the right things or providing the support my clients truly needed.

In our profession, it's essential to be equipped not just with knowledge and skills, but also with a deep sense of empathy and understanding to effectively address the complexities of suicide. This blog post is a guide to help you navigate these difficult conversations with compassion and competence. We'll explore the nuances of discussing suicide in therapy, highlighting the approaches that can be most helpful and those that are best avoided. Let’s delve into this delicate topic and try to provide the best support we can to those who entrust us with their most vulnerable moments.

Statistics Highlight The Importance of Discussing Suicide

Suicide is a public health concern that can affect individuals from all walks of life. Despite its prevalence, there's a stigma surrounding it, often leading to underreporting and a lack of open dialogue. Here are some notable statistics regarding suicide in the United States:

1. Suicide Rates: In 2023, more than 50,000 Americans died by suicide, which is more than any year on record. According to the Centers for Disease Control and Prevention (CDC), in 2021, suicide was the 9th leading cause of death in the United States.
2. Demographic Variations: The CDC also reports variations in suicide rates among different age groups and genders. For example, men have higher rates of death by suicide, while women have much higher rates of attempt. Additionally, certain age groups, such as men over the age of 75, often show higher rates of suicide.
3. Impact on Young People: Suicide is a particularly pressing issue among younger populations. It was the second leading cause of death among individuals aged 10-34 in the United States in 2021, as per the CDC data.
4. Rates in Differing Racial Groups: Among the adolescent population, Latina teens statistically have the highest attempted rates of suicide. Meanwhile Native Americans have the highest suicide rates overall, with up to three times higher rates than any other racial or ethnic group in the United States.

These statistics underscore the significant impact of suicide on public health in this country. They also reflect the critical importance of suicide awareness, prevention efforts, and the need for accessible mental health resources in the United States for certain age certain age and racial demographics. 

Identifying and Understanding Suicide Risk Factors 

Early intervention and de-stigmatization play pivotal roles when addressing the topic of suicide in a therapeutic setting. As a therapist, recognizing the early signs of suicidal ideation – such as changes in mood, withdrawal from social interactions, or expressions of hopelessness – is vital for timely intervention. 

However, equally important is the approach taken towards these discussions. Creating a non-judgmental, empathetic, and open environment can help de-stigmatize the conversation around suicide. 

By fostering a safe space where clients feel understood and free from judgment, you can encourage honest and open dialogue. This approach not only aids in early detection but also contributes significantly to breaking down the barriers of stigma that often prevent individuals from seeking help.

Identifying Protective Factors and Building Trust

Identifying protective factors is just as important as recognizing risk factors. Often, clinicians may instinctively focus on the latter, which, while important, can inadvertently overshadow the significance of understanding and bolstering an individual's strengths and supports. Protective factors, such as strong personal relationships, a sense of responsibility to others, problem-solving skills, and access to mental health care, can be vital shields against suicidal thoughts and behaviors. By prioritizing the identification of these positive elements early in the therapeutic process, you can foster a more trusting and supportive environment. When you’re willing to discuss difficult topics like suicide, it helps in building trust and openness in the therapeutic relationship.

Understanding Risk Factors

Discussing suicide helps in identifying risk factors and triggers, which is crucial for effective treatment and prevention. These factors can include a history of mental health disorders, particularly depression and substance abuse, previous suicide attempts, family history of suicide, chronic illness or pain, and significant life stressors like relationship problems or financial difficulties. Environmental factors, such as exposure to suicidal behavior in others and access to lethal means, also play a critical role. 

Recognizing these risk factors enables us to assess the level of suicide risk more accurately. It's essential that we stay informed about these risk factors, as it helps in identifying individuals who are at a higher risk of suicide and in providing targeted interventions. However, remember that risk factors are not predictors of suicide; they merely indicate an increased likelihood.  By maintaining a careful and compassionate approach when addressing these issues, you can ensure that the focus remains on support, prevention, and care.

Understanding the Sensitivity of Discussing Suicide

Suicide is often intertwined with intense emotional pain, existential questioning, hopelessness, and despair. By approaching this topic with utmost sensitivity and empathy, you can recognize the unique experiences and feelings of each client.

What Therapists Should Do When Talking About Suicide

When you engage with you clients about the sensitive topic of suicide, your approach should be carefully considered and empathetic. Here's how you can effectively handle these discussions:

Creating a Safe Space

The first step for therapists is to create a safe space. Clients need to feel safe, understood, and free from judgment. This requires a non-judgmental, open, and empathetic approach. It’s important for therapy clients to know that their feelings and experiences are being taken seriously and treated with respect and sensitivity.

Active Listening

Active listening plays a key role in these conversations. Often, clients may not explicitly express suicidal thoughts. Instead, they might hint at them through changes in behavior or subtle verbal cues. By being attuned to these underlying messages, you can listen carefully to what is said and what remains unspoken. Acknowledging and validating the client’s pain and struggles is a vital part of this process.

Direct Inquiry

If you suspect that there are suicidal thoughts, you shouldn’t feel hesitant to inquire directly with the client. Contrary to common misconceptions, asking about suicide doesn't increase the risk. It demonstrates your genuine concern for the client's feelings and safety.

Hearing the Client’s Story

Before jumping into risk assessment, it’s important that we understand the client's personal journey towards having suicidal thoughts. Hearing their story helps build trust, which is essential for them to open up about such a sensitive subject. During this process, instead of a checklist approach, it's recommended to try integrating assessment questions naturally into the conversation.

Risk Assessment

Assessing the level of risk is a critical step. This involves determining the immediacy and severity of the risk to guide intervention strategies. It's not just about identifying the presence of suicidal thoughts but understanding their intensity and immediacy.

Providing Support and Resources

Offering emotional support is a key part of the therapist’s role. Additionally, guiding clients towards specialized resources or emergency services when necessary can be life-saving. The support offered should be empathetic and tailored to the individual's needs.

Collaborative Safety Planning

Safety planning is a continuous and flexible process throughout treatment. It involves working collaboratively with 

the client to develop a plan that includes coping strategies and a list of contacts for times of crisis. The plan can take various forms – a written document, a digital list, a poster, or even a shoe box filled with reminders. The most effective safety plan is personally meaningful to the client, often incorporating photos, quotes, or reminders of future goals and dreams.

If a client shows hesitance towards safety planning, it may be useful to explore their past experiences with the process. Sometimes, negative experiences with non-collaborative safety planning can hinder their openness to the process. Addressing these concerns first can lead to greater receptivity. Additionally, using language that resonates with the client can make a significant difference. Some may prefer alternative names for their plan, like a "Well-being Action Plan," "Stayin' Alive Plan," or a "Reasons for Living Plan."

What Therapists Should Avoid When Talking About Suicide

When therapists address the topic of suicide with clients, there are certain approaches and behaviors they should consciously avoid to maintain a supportive and effective therapeutic environment. Here's an elaboration on these aspects:

Avoid Minimizing Feelings

Therapists must steer clear of minimizing or dismissing the client's feelings. Phrases like "It's not that bad" can be particularly harmful, as they trivialize the client's experience. This approach can lead to feelings of being misunderstood and isolated, which can exacerbate the client's distress. It's vital to validate and acknowledge the client's emotions and experiences, no matter how severe or minor they may seem.

Refrain from Offering Simplistic Solutions

Given the complexity of suicide, it's important that we avoid offering generic advice or quick fixes. Suicide and its underlying issues are intricate and deeply personal, requiring a nuanced and individualized approach. Simplistic solutions or generalized advice can come off as insincere and can fail to address the unique challenges the client is facing.

Be Mindful of Confidentiality

Confidentiality is a cornerstone of the therapeutic relationship, and its unnecessary breach can be detrimental. While client safety is the top priority, therapists should be well-versed in the legal and ethical guidelines concerning confidentiality, particularly in situations involving imminent harm. It's essential to balance the need for intervention with respect for the client's privacy and trust. Unwarranted breaches of confidentiality can erode the therapeutic alliance and potentially discourage clients from sharing their feelings openly in the future.

Don't Avoid the Topic

Avoiding the topic of suicide can be harmful. When a therapist shies away from discussing suicide directly, it might send a message to the client that this subject is taboo or off-limits. This can be particularly invalidating and damaging for clients who are in a vulnerable state. 

It's important that we approach the topic with sensitivity and directness, demonstrating to clients that their concerns are valid and that they are in a safe space to discuss even the most difficult topics.

Navigate This Delicate Topic with Support from Other Therapists

Talking about suicide in therapy is challenging, but essential. It's important to approach this subject with care, understanding, and professional knowledge. By providing a safe space, actively listening, and offering appropriate support, therapists can play a pivotal role in helping clients navigate through their darkest times.

Additional Resources:

These organizations offer valuable information, support, and guidance for individuals struggling with suicidal thoughts, as well as for their loved ones and mental health professionals:

988 Suicide and Crisis Lifeline (USA):

Website: https://988lifeline.org

24/7 Helpline: Dial 988

Provides free and confidential emotional support to people in suicidal crisis or emotional distress.

LivingWorks ASIST:

Website: https://livingworks.net/training/livingworks-asist/

A 2-day training course teaching suicide first aid skills for free to organizations with staff that may interact with individuals experiencing suicidal thoughts.

Samaritans (UK):

Website: https://www.samaritans.org/

24/7 Helpline: 116 123

Offers a safe place for anyone in the UK and Ireland to talk about whatever is troubling them.

The Trevor Project (Focused on LGBTQ+ Youth):

Website: https://www.thetrevorproject.org/

24/7 Helpline: 1-866-488-7386

Provides crisis intervention and suicide prevention services to LGBTQ+ young people.

Befrienders Worldwide:

Website: https://www.befrienders.org/

Offers information about suicide prevention helplines available worldwide.

Crisis Text Line:

Website: https://www.crisistextline.org/

Text "HELLO" to 741741 in the United States.

Provides free, 24/7 support via text for those in crisis.

American Foundation for Suicide Prevention (AFSP):

Website: https://afsp.org/

Offers resources for coping with loss, educational programs, and advocacy for suicide prevention.

International Association for Suicide Prevention (IASP):

Website: https://www.iasp.info/

Provides resources for suicide prevention, including worldwide crisis center contacts.

Mental Health America:

Website: https://www.mhanational.org/

Provides resources on mental health and how to find help.

Canadian Association for Suicide Prevention:

Website: https://suicideprevention.ca/

Offers information, resources, and a directory of local crisis centers in Canada.

Beyond Blue (Australia):

Website: https://www.beyondblue.org.au/

Helpline: 1300 22 4636

Provides support for Australians experiencing anxiety, depression, and suicide.

It's important to note that these resources can provide immediate support, but they are not a substitute for professional medical advice or therapy. For those in immediate danger, contacting emergency services is always recommended.