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When clinicians don’t know how to help clients struggling with suicidality, they often refer them to a higher level of care, like partial hospitalization programs or inpatient settings…

But while these programs can be helpful for those in acute danger, many clients find them to be unhelpful in the long term and, at worst, even traumatizing experiences.

Upon discharge, clients vow to pretend that everything is all right and never speak up again as a way to avoid having to return. This kind of “care” doesn’t work.

So how do clinicians best address suicidality in a way that is helpful and that quells their fears about their clients’ well-being and their own liability?

Stacey Freedenthal, PhD, LCSW, provides candid answers to five questions you may have been afraid to ask – but critically need the answers to.

1. During the pandemic, more of my clients have been experiencing suicidality. How can I support them?

Many of the basics apply that we would use during ordinary times.

Ask your clients if they’re having suicidal thoughts. Don’t wait for them to bring it up. Use the word suicide or terms specific to suicide such as “thoughts of killing yourself” or “thoughts of ending your life.” Many clinicians use phrases like “harm yourself” or “hurt yourself” but these are different constructs. A lot of people who are suicidal don’t want to hurt themselves; they want the pain to end.

Next, have a conversation, not an interrogation, about these suicidal thoughts. Ask the client to tell you the story of how they came to think of suicide. There are a lot of risk assessment questions we’ll want to go over as well, but it’s useful to glean the answers through conversation. While a bunch of yes/no questions can get us the information we need, it isn’t therapeutic for the client.

Regarding the pandemic, we need to keep in mind that it’s affecting people differently. Some people have lost a loved one, others have become ill and are struggling with long-term side effects, and others may have lost a job. Many have experienced social isolation or an extreme disruption in their regular life due to the pandemic. Explore how the pandemic has affected your client individually and don’t make assumptions.

Long story short: ask about suicidal thoughts, assess what the person’s situation is and how the pandemic may relate, and use your skills to begin treatment while also keeping in mind the unique stressors of the ongoing pandemic.

2. How do I know when involving the police is appropriate?

This should absolutely be a last resort.

I attended a talk in Denver some years ago where a very established psychologist said to send clients to the emergency room if they had suicidal thoughts, and that if they wouldn’t go to the emergency room, to then call the police. This is incredibly unhelpful advice from the stance of a suicidal person, and I’m happy to tell you that most clinicians don’t operate that way. However, there is a certain subset who panic or who are preoccupied with their own liability.

There are so many problems with calling the police. Some research shows that a substantial proportion of fatal shootings by police result from a loved one calling for a welfare check; while that’s not a therapist making the call, my heart goes out to people who call the police with the intent to help their loved one stay safe, only for tragedy to result.

It’s also traumatic to have the police show up. I know people who were handcuffed when the police were called, and there are few things I can think of that would be less therapeutic than handcuffing a suicidal person and putting them in a police car in front of their family and neighbors. So when should you call the police?

If someone is experiencing suicidality and has a firearm, call the police. There’s extreme danger that you can’t handle by yourself. If someone is in a state of psychosis where they’re so out of touch with reality that they’re placing themselves and the people around then in danger, call the police.

I called the police once many years ago because someone came to my office after having attempted suicide minutes earlier and wouldn't accept my suggestion of calling an ambulance for help. They were in the midst of a medical crisis and fled the office, so I called the police in the hopes that they would be found and taken for medical assistance.

It’s appropriate to call the police if the situation is out of your control or out of the person's control and people are in danger. Some would say that simply having suicidal thoughts means the person’s in danger, but that’s not true. We should never call the police just because someone has suicidal thoughts.

3. What can help me break through clients’ chronic suicidal thoughts?

Don’t try to break through the client's chronic suicidal thoughts. I know this sounds paradoxical, but when somebody has chronic thoughts of suicide, it's usually become a habit of the mind. I’ve had clients who have thought of suicide for decades. We’re not going to be able to help them get rid of their suicidal thoughts, because they’ve become a cognitive habit, but we can help them relate differently to them.

Rather than trying to get clients to change their suicidal thoughts, we can work with them from a stance of acceptance while also helping them learn skills to distance themselves from their thoughts and not take them so literally. If you’re familiar with Acceptance and Commitment Therapy (ACT), this would be called cognitive diffusion.

We can also help clients develop their “transcendent self” so they can observe themselves having suicidal thoughts. One tool that I find exceptionally powerful is so simple. It’s to have clients restate their suicidal thoughts by prefacing them with the words “I am having that thought that…” Thus, instead of saying to themselves, “I should kill myself,” they’re saying, “I am having the thought that I should kill myself.” This effectively distances them from their thoughts and allows a sort of metacognition to occur. It also makes the suicidal thoughts less dangerous and threatening.

If someone can challenge their suicidal thoughts and make changes that dissipate the need for suicidal thoughts, that's wonderful if they don't think of suicide anymore. However, many times suicidal thoughts will persist, and the challenge is to relate differently to them rather than changing the thoughts. It’s a matter of changing one's relationship to the thoughts.

4. Are safety plans really helpful?

Yes! There’s been gold standard research on this. Randomized control trials have found that when compared with “safety contracts,” safety plans are more effective. In another study, safety plans were compared to treatment as usual and found to be effective at reducing suicide attempts and hospitalization.

Safety plans are effective. Safety contracts are not. This is often confusing for students and clinicians, because these terms sound so simple, but they’re really quite different.

A safety contract involves having a client promise not to do anything to take their life. Sometimes, it’s an actual contract they sign stating “I will not attempt suicide” or “I will first go to an emergency room or call my therapist.”

In contrast, developing a safety plan involves talking to the client about different things they can do when they have suicidal thoughts. What different options do they have, and how can they problem solve when they experience suicidality?

Essentially, a safety contract is a wish. If a client comes to me for help because they’re having suicidal thoughts and I say, “I need you to promise not to kill yourself,” that’s sort of like someone with chest pain going to a cardiologist, and the cardiologist saying, “I need you to promise not to have a heart attack.”

If the goal is for the client to not kill themselves, we need to talk with them about the things they can do instead. Typically, a safety plan starts with them recognizing their warning signs that suicidal thoughts are brewing. When these thoughts start, what can they do to distract themselves? Next, what people in their lives can offer support, such as family, friends, teachers, or religious figures? Then we get into professionals they can ask for help.

Another piece of safety planning is removing things from the environment that they might use to kill themselves. Firearms are especially relevant here. If someone does not want to remove firearms from their home, there are intermediate steps that can be taken such as using a gun safe.

5. I feel panicked when working with suicidal clients. How do I stay calm?

The biggest way to stay calm is to get training in suicide assessment and intervention.

There's research that shows that training increases perceived competence, which then increases confidence, which can enable clinicians to stay calm. Unfortunately, studies of graduate programs in psychology and social work and counseling consistently show that training in helping suicidal clients is minimal and sometimes not existent at all.

Another thing you can do is keep the line of communication open with your client. One of the biggest areas of panic I’ve observed in consultation with clinicians is that they don’t know what their client is thinking, and sometimes that’s because the client withholds, but other times it’s because the clinician isn’t directly asking.

And while I don’t want to minimize the danger of suicide, I do wan to point out that roughly 12 million people in this country report having suicidal thoughts in the past year. Of that group, the 45,000 deaths by suicide are a huge tragedy. However, these numbers show that suicidal thoughts by themselves don’t mean that death is imminent, that hospitalization is necessary, or that panic is warranted. If you can hold onto the fact that suicide is still thankfully an uncommon event, maybe that can help soothe you.