I Told My Therapist I'm Suicidal, What Happens Next?

There is a lot of anxiety and distrust around disclosing suicidal ideation, intent and attempts to therapists. There is a fear of the information being used against clients, clients losing control over their choices and being admitted into hospital without warning, all of which can be very damaging and traumatic.

To limit this anxiety I explain below how I approach disclosure of suicidal ideation. Where I put client autonomy and informed consent at the forefront.

The disclosure of suicidal thoughts

Clients express their suicidal ideation in many ways, but it is often through the use of phrases that can be brushed over or not noticed or minimised if not enquired about, clients often test the waters and the therapist before a disclosure. This can be due to a lack of trust as mentioned above or as a way to test whether the therapist is listening and if they care, it can also be due to not wanting to alarm or overburden the therapist and therefore approaching the subject lightly.

Either way, it is important to notice these phrases and check in with the client. In my practice I tend to ask plainly, "Is this a suicidal thought?" "Have you thought of commiting suicide?" To show that I noticed and am not scared of the word "death", "suicide", "self harm" etc. and to ensure that I am understanding the client's meaning.

If the answer is that these remarks are suicidal thoughts the conversation moves on to understanding the nature of these thoughts. This determines the level of risk and the type of response that is necessary.

Passive Suicidal Ideation

These are the times when you feel like you would be better off dead, or wishing you were dead as a coping mechanism to deal with an overwhelming situation or to 'unburden' others but without any plan or will to execute this.

Such thoughts might include "They'd be better off without me." "I wish all of this would just stop.""I wish I could just rest forever." "I just can't do this anymore."

In such cases the situation around the suicidal thoughts is explored, the existential lens might be used to help the client identify what they consider a meaningful or worthy life and how they might find meaning in their current situation. We would look at ways in which to alleviate or manage their distress and symptoms. Lastly, a periodic check in with the client about their suicidal ideation might be necessary to ensure it is not escalating.

I would explore the support networks the client has already available, including their GP which I’d encourage them to contact. I would also offer additional resources relevant to their situation.

I would discuss this disclosure with my supervisor to ensure I best practice.

Active Suicidal Ideation

This is when a client expresses suicidal thoughts and has a plan on how to execute it. The specificity of the plan and access to the means increases the risk significantly.

These might sound like "Sometimes I just want to jump off the bridge on my way to work.”

Due to the higher risk a full assessment would take place where we discuss in detail what the client’s suicidal thoughts are, what triggers them, how often they have them, what is their plan, whether they have access to execute it and any past history with suicide attempts and self harm.

We would then move on to devising a care plan where we explore what has kept the client alive up until now, who they can call in an emergency, their attitudes to going to an A&E, and techniques for ways to distract themselves whilst suicidal.

I would urge the client to speak with a trusted person and their GP, or would request consent to contact their emergency contact and GP on their behalf.

If such a disclosure is made the session might over run the usual 50 minutes to ensure all of this is completed on the day.

Following the session if I have your consent I would contact your GP and/or the emergency contact about your suicidal ideation.

I would also speak to my supervisor on the day.

Active Suicidal Attempt

In the most severe case the client might turn up to the session having already executed the plan (such as taking lots of pills) or made contact with me over text/phone/email about their attempt in which case an ambulence would be called to the therapy room or client’s location and the client would be taken into an A&E.