Best Practices for Treating Suicidal Patients
What to do when faced with this challenging presentation
Posted Feb 18, 2019
The U.S. is currently witnessing an epidemic of suicides. Suicide rates have climbed by 30% in half of all states over the past two decades. In North Dakota, the rate has risen more than 57%. A number of demographic, economic, sociological, and other factors, as well as healthcare disparities and lack of access to quality care and early interventions, play a role. Yet even when a client seeks treatment, working with a suicidal person can be difficult. Seventy-one percent of psychotherapists have treated at least one client who attempted suicide, and 28% have had a client die by suicide. Here are evidence-based strategies for offering exceptional care and reducing the risk of a patient dying by suicide.
Understand the Importance of Interpersonal Connection
A client’s relationship with their psychiatrist or therapist is an important interpersonal connection that can help mitigate suicide risk. This relationship is extremely important and can be a site of healing and hope. To help mitigate the risk of suicide in treatment:
- Do not offer false hope.
- Don’t tell the client to just get over it or that they are overreacting. It is critical for the client to feel understood and heard.
- Don’t talk about suicidal thoughts and feelings in front of other family members unless you have the client’s permission.
- Consider seeing the client more frequently in times of crisis.
- Develop a crisis management plan with the client.
- Allow clients to express strong negative feelings, even if they are uncomfortable to hear.
- Follow up with patients who stop coming to therapy.
Know the Risk Factors for Suicide
A statement of interest in suicide is a strong warning sign of suicide, particularly if a client has a clear plan and the means to enact that plan. Other risk factors include:
- Behavioral signals such as a sudden change in mood or giving away possessions.
- Expressing feelings of hopelessness.
- Drug and alcohol abuse. About a quarter of suicides occur under the influence of alcohol or drugs.
- Recent end to a relationship.
- Firearm ownership.
- Sex. Men are significantly more likely than women to commit suicide, especially if they own guns.
- Living alone.
- Previous suicide attempts.
- A history of impulsive behavior.
- Rigid thinking.
- Lack of a sense of belonging.
Patients who are not suicidal at the commencement of treatment may become suicidal later, especially following a loss. So it’s important to conduct an ongoing evaluation of patients, and monitor all clients for signs of suicide.
Conduct a Suicide Assessment
Some clinicians mistakenly believe that they are legally obligated to report every client who mentions the word suicide. Check your state laws and consult with a lawyer to better understand your obligations. However, there is no obligation to report every client who discusses self-harm. Instead, the role of the clinician is to conduct a suicide assessment and evaluate risk. This assessment should include an evaluation of risk factors and protective factors, in addition to cultivating strategies to mitigate risk.
Work Together on a Suicide Prevention Plan
Directly talking about suicide is not dangerous. Indeed, it’s the single most important thing a clinician can do to reduce the risk of suicide. The evidence suggests that working together on a no-harm agreement can mitigate suicide risk, especially if the agreement contains a list of alternative strategies for managing suicidal emotions.
Talk to the patient about the situations and feelings that most frequently trigger suicidal impulses. Then help them draft a list of options for when they feel these emotions.
Use Effective Treatment Strategies
People who are at risk of committing suicide have difficulty managing feelings of distress. Additionally, with each subsequent attempt, research shows their ability to handle distress plummets. So treatment must focus on helping clients find ways to manage difficult emotions. Four specific treatment options have proven especially helpful:
- Assessment and treatment of underlying psychiatric conditions such as depression, anxiety, bipolar disorder and psychotic illness.
- Cognitive-behavioral therapy, which may help a suicidal person understand how their thoughts affect their feelings.
- Dialectical behavior therapy, which was originally developed for the treatment of borderline personality disorder, but which may help clients learn to better manage interpersonal difficulties and emotional distress.
Know Your Ethical Obligations
Each state has slightly different requirements for whether, when, and how to report a person who may be a threat to themselves or others. If the client is in immediate danger, the clinician should have the client hospitalized or ask them to voluntarily check into the hospital. When working with child and adolescent clients, it’s critically important to discuss suicidal ideation with parents in a way that promotes compassion and minimizes the risk that the parent will become punitive or dismiss the child’s emotions.
Discuss the Limits of Confidentiality
Patients must have a clear understanding of the limits of confidentiality. Some clients fear that any mention of suicide will trigger a call to the police. This can deter them from seeking treatment. So discuss when and under what circumstances you must break confidentiality, and help the patient understand what is likely to happen in these scenarios. You can even work together to develop a plan for if the patient becomes suicidal, including a person the client would like you to call or a hospital the client would like to check into.
Firestone, L. (n.d.). Suicide: What therapists need to know [PDF]. American Psychological Association.
Karakurt, G., Anderson, A., Banford, A., Dial, S., Korkow, H., Rable, F., & Doslovich, S. F. (2014). Strategies for managing difficult clinical situations in between sessions. The American Journal of Family Therapy, 42(5), 413-425. doi:10.1080/01926187.2014.909657
Recognizing, assessing, & responding to suicidal risk. (n.d.). Retrieved from https://www.kspope.com/suicide/