Listening to Suicidal Clients

The thought of a client dying by suicide can keep even experienced therapists up at night. We fear the slightest hint of it, the legal and ethical implications of it, and therefore may not always screen for it. How does this discomfort affect the help we offer suicidal clients?

In 2017, Stacey Freedenthal penned an article for The New York Times titled “A Suicide Therapist’s Secret Past,” in which she exposed her own history with suicidality and how it informs her work as a therapist in private practice and suicide researcher at the University of Denver Graduate School of Social Work. “I started my long journey from suicidal to suicidologist, not only a person with mental illness but also a mental health professional, with all the contradiction, fear, hope and redemption that those two identities entail,” she writes. This intimate, vulnerable essay freed her of the perceived need to have it all together in order to help people who felt like her.

Her website, speakingofsuicide.com, gets millions of visitors. Her book, Helping the Suicidal Person: Tips and Techniques for Professionals, gives no fewer than 89 tips to help clinicians better understand their role, assess their clients, and alleviate the pain of what comes with suicidality. She took the time to share about her own journey, the issues facing therapists today around suicide prevention, and the future of suicide research.

Ryan Howes: Do you find many therapists get freaked out by the topic of suicide?

Freedenthal: Oh yes. I see this in my trainings all the time. Although therapists will recognize it’s not rational, they fear that bringing up suicide with clients might put the idea in their head or make their suicidal thoughts worse. But there’s significant research that shows asking about suicidal thoughts doesn’t increase their risks.

Then there’s the fear that clients will actually say yes, they have been thinking of suicide. Few therapists get adequate training in their approach to suicide risk, so it brings up understandable worries, like “Am I competent? Will I do the right thing to prevent this person from dying by suicide on my watch?” Therapists have a lot of fears around liability and professional reputation.

It’s a natural human impulse to want to talk someone out of dying, but this may be an area where therapists have a real conflict of interest.

RH: What do you mean?

Freedenthal: We’re trained to set aside our own needs and agenda and engage in client-centered care, where we’re trying to put ourselves in someone’s shoes and look at things through their eyes, but it can be very hard to do that when somebody has suicidal thoughts, because now we have needs, too, that sometimes take precedence.

RH: We have legal and ethical concerns, as well as wanting to make sure that we’re saving their life.

Freedenthal: Exactly. Some therapists have a knee-jerk reaction and immediately hospitalize clients if they disclose a suicidal thought. It’s hard for me to see how that’s therapeutic or helpful. I know other therapists who downplay the suicidality and don’t really take it seriously. The extreme of that is the clinicians who say, “Well, if they want to kill themselves, there’s nothing I can do to stop them.” That’s a very dangerous stance to take because we can do things that don’t involve involuntary care. If someone’s sitting in front of us, a part of that person wants help. It’s our job to align with that part.

RH: You wrote in The New York Times piece about your own struggles with suicidal thoughts. What was it like disclosing that to so many people?

Freedenthal: It felt good to come into the light. I don’t think I’d realized how exhausting it was to hide that significant piece of myself, especially given that my career is in suicide prevention. I feared that if people knew my history, they might question my competence. I feared stigma and judgment, so I often muted myself in contexts where it could’ve been useful for me to share my story. But I’m living more authentically now by not keeping this secret. Obviously, everybody has boundaries and things that they don’t want to go into with just anybody, but it was taking a toll on me. I was hearing other people in the therapy world talk about their experiences and really feeling like I had something to add.

RH: Like Marsha Linehan’s disclosure of her suicidal history?

Freedenthal: Yes, and Ursula Whiteside, who spoke at a conference I attended where some therapists were sharing their own lived experiences with suicidality. In fact, one woman stood up and said, “I’ve never been suicidal. I don’t understand how somebody can get to that place of despair. Am I still competent to help suicidal people?”

That blew my mind. I realized that with the right boundaries, my experience could be an advantage. That was a real pivotal point in my journey. Plus, by writing that piece, I knew I could help other people chip away at the stigma.

RH: What is it that therapists tend to get wrong about suicide?

Freedenthal: Oh, well, how much time do we have?! Being so fear-based and concerned about liability are big things, as they can get in the way of practicing sensitively and really hearing a person’s story. Just look at the standard risk-assessment interview: it can seem like an interrogation because it’s just question after question we’re asking for our own benefit. I have yet to hear a client say, “I knew when I woke up this morning that I’d feel much better when I was asked 15 yes-or-no questions about my suicidal thoughts.” Those questions are for us! A client who’s struggling with suicidal thoughts has very different needs from ours. Sometimes a client will tell me, “I need help staying safe.” But usually they say things like, “I need to feel better. I need to stop hurting.”

So rather than hearing a client’s story, too many therapists end up interrogating them. Rather than sit with somebody in the pain that’s causing them to think of suicide, they end up jumping in and trying to problem-solve prematurely, or trying to talk them out of it without really understanding first what got them there.

In the journal Suicide and Life-Threatening Behavior, someone wrote an article called “What Would You Say to the Person on the Roof?” It basically lists things like “think of your family,” “you’re young,” “things will change,” and other messages of hope. And the journal published a rebuttal article called “How Would You Listen to the Person on the Roof?” I think most therapists are operating from what to say versus how to listen when suicide risk is present.

RH: What else do therapists get wrong?

Freedenthal: There’s a common perception in our field that with suicide, we have to balance therapeutic work with legal peril. The reality is that the laws aren’t as rigid as people think. I often encounter not just students, but therapists with years of experience who think their role is to be “mandatory reporters” for suicidality. But I’ve only found one or two small jurisdictions where therapists are mandated reporters for suicide. In about 99 percent of the country, we’re allowed to use our professional judgment in deciding what to do, whereas in mandated reporting, you don’t get to use your judgment: you have to report.

RH: I think people get concerned about the lawsuit that could come afterward if someone does complete suicide.

Freedenthal: They do, and that’s a legitimate concern, but lawsuits aren’t very common in cases of suicide. I don’t have hard numbers for outpatient therapists, because insurance companies aren’t reporting them as much, but when they do, it’s rare that the plaintiff prevails. The courts recognize that, as outpatient therapists, we can’t control what people do when they leave the office, or even when they’re in the office. Inpatient treatment centers, hospitals, and residential treatment centers have more of a responsibility. They have more liability if somebody dies by suicide.

RH: I have some colleagues who swear by suicide contracts, and others who’d never use them. Where do you stand?

Freedenthal: Evidence consistently shows that the contracts don’t work: people still attempt suicide, regardless of agreeing to a contract. Beyond that, I strongly discourage their use for other reasons. They present a power struggle between client and therapist that can create problems. Qualitative research shows that people who were suicidal and asked to sign a suicide or safety contract said it came off as if their therapist was attempting to cover their own ass. Plus, they don’t protect the therapist at all legally. I’m not aware of any case where a judge or jury said, “Well, the person promised not to act on suicidal thoughts, so therefore the therapist is off the hook.” That’s not adequate evidence of providing good care.

But the biggest reason I don’t like promises and contracts is that clients may not tell me if they do attempt suicide. They may be scared or feel guilty, and the last thing I want is for somebody to keep that a secret from me.

Of course, don’t confuse safety contracts with safety plans. Evidence shows those are effective. They may sound similar, but they’re very different devices. A safety contract is where the client makes a promise not to act on suicidal thoughts. With a safety plan, the client and therapist come up with ways the client can avoid acting on suicidal thoughts. The client isn’t asked to make a promise.

RH: What’s in a typical safety plan?

Freedenthal: The one that’s most often used starts with the client identifying triggers or warning signs of a suicidal episode. The next step is identifying things they can do to distract themselves by themselves, then places and people they can go for distraction, then people they can explicitly ask for help because they’re in distress, followed by professionals they can go to. It’s kind of a hierarchy: how you help yourself, how others help you, how professionals help you. There’s also a piece about keeping the environment safe. For example, if a person has a firearm, what can they do with the firearm to have a safe environment? Of course, this can create a whole other power struggle.

RH: I’m in Pasadena, California, and our Colorado Street Bridge is, unfortunately, known as “suicide bridge.” Local people have debated whether the newspaper should report every time someone jumps, out of fear of copycats. What does the research say about that?

Freedenthal: Research shows that talking about it in a helping context doesn’t pose problems. What does are suicidal acts. So if someone at a high school dies by suicide, there’s an increased chance that others will make an attempt. What also increases suicidal behavior are communications that aren’t constructive, such as news reports that give gratuitous information about the method, the scene, and suicide notes, or coverage of celebrity suicides.

When Kate Spade died by suicide, The New York Times published an article that described how she did it, the fabric she used, even the color of the fabric. Why do you need to know that? It was terrible.

RH: What are you working on in your research these days?

Freedenthal: I’ve got a small study going with people who present at a psychiatric emergency room with suicidal thoughts. We’re looking at their cognitive, emotional, and behavioral responses to those thoughts. I think clinicians tend to see suicidal individuals as a homogeneous group, and to think that all people who have suicidal thoughts share the belief that those thoughts are unhealthy and wrong. But there’s information coming out now suggesting that thinking about suicide actually makes some people feel better. Just knowing they have an escape if they need one calms them down.

RH: What would you want to tell therapists about addressing these thoughts?

Freedenthal: Many therapists don’t even ask clients if they’re having suicidal thoughts. They assume that clients will volunteer it, and that’s not the case much of the time. A piece of advice I’d offer therapists in bringing it up is to use direct language. I’ve heard my students say things like, “I’m sorry to have to ask this. I have to ask it of everybody,” and I say, “No, no! Don’t apologize. We need to not treat this a stigmatized subject.” If clients react in a manner that clearly shows they’re disturbed by the question, then we can respond. But we don’t need to assume that everybody is going to respond that way. I encourage all therapists to ask and create a space for clients to talk about their feelings without judgment.

We can empathize with suicidal thoughts, and that doesn’t mean we approve of suicide. We can say that as humans we’re wired to avoid pain, and that a natural response to pain is to want to end that pain. And if you’re not seeing other ways to end the pain, then it’s not surprising that the mind goes to suicidal thoughts.

I want to be conscious of not only talking about the risky, frightening, and hard aspects of working with suicidal clients. The focus should also be on the fact that we have the potential to help people. When somebody is in a suicidal state, there’s a lot of room for growth and healing, and we get to be a part of it.