Managing Suicidal Clients

CW: This post discusses suicide and suicidal ideation.

I understand why the ethical codes are in place around suicide prevention. I get that counselors are at the front of the line in hearing about suicide from their clients and students. I see why laws are in place around continuing education for suicide prevention and having them as a requirement for license renewal. Also, suicide prevention, while there is ethical stuff around it, is very much not in the realm of ethics for me. While I do love me some ethics, when I have an actively suicidal client sitting in front of me, ethics are not even in the car we’re driving together. If at any point of my career I’m sitting with a client and say, “hmmm, let me consult the ethical codes about your issue,” I will personally give you, reader, $20. Or maybe I won’t because I will need it, because that will also be the day that I will quit being a therapist.

Woo, tangent! ANYWAY.

I don’t have any specific letters about this topic, so I’m just going to talk about it for a little while. It’s that time of year, especially for those of us who work with kids – the school year is settling in, and all of a sudden, people don’t necessarily struggle more, but instead they start to show it more. “But my kid was doing so well over the summer!” I hear it from SO MANY caregivers (and counselors who work with kids). Well, yeah, but they also go three months without having to “put on a face”, so of course they are. As a clinician, if there’s ever a time that I consistently lose sleep over my clients, it’s the stretch between the beginning of the school year and Thanksgiving, and I know I’m not alone in that.

Over the past week, I’ve had two clients go to the emergency room to wait for an inpatient bed. I remember when I was a new counselor, I really struggled with this (and I worked in community mental health, an inherently high-risk population, so I struggled with this a lot more than than I do now). Did I miss something? Was there some kind of something that I could have helped them with that I missed and that’s why they’re in the hospital? The impostor syndrome was strong in this way, and so in my mind, there was ample evidence that when my client was hospitalized, it was because I did something wrong or missed something. Now I think the opposite.

We can safety plan with clients all we want. We can make these neat little plans and say what a client’s triggers are, what their coping skills are, who their supports are that they can reach out to, what their crisis point looks like. We can do all of the suicide assessments we want. All of this is ethically necessary due diligence – I’m definitely not arguing that point. We can ask all of the right questions and utilize that training that we get in suicide prevention. Don’t get me wrong – our training in this area is important and necessary, and there is no more important work that I do than suicide prevention. That being said, the more I do this work, the more I am convinced that absolutely none of it matters if your client doesn’t trust you enough to tell you what’s actually happening. Do you know how easy it is to lie on those assessments? Do you know how easy it is to tell a counselor that you’ll follow a safety plan, do the work to put it together and then throw it in the garbage when you get home? These documents give clinicians such a false sense of safety and control, and the truth is that we have none when it comes to the safety of our clients.

I used to feel this sense of hopelessness about this. There have definitely been times in my career where I have thought to myself, “well then what’s even the point in having a concrete safety plan in writing?” What’s the point, indeed, reader. Safety plan documentation, I become more convinced by the day, exists to make us as clinicians feel safer and helps us build a false sense of trust that these documents will work. There are clinicians who will print out a safety plan and send it home with their clients. “Hang it on your refrigerator or put it somewhere that you can see it every day.” For sure, I used to be one of those therapists and even now, if my client wants a document, we make one. If that will bring them some measure of whatever internal resources they need to summon in order to stay safe, sure. The thing is, and I find this incredibly interesting, the second that I stopped insisting on sending a written safety plan home with my clients, the more candid they became about their safety-related issues and their ability to plan for safety and actually follow through on it. Do I document their safety plan? Of course, but that’s what their chart is for. If they don’t want a copy, that’s ok, but they’re going to talk about their safety plan out loud every time I meet with them, because what good is any kind of plan if you don’t know what that plan actually is?

Now, when I hear that a client is in the ER, you know what I do? I breathe the biggest sigh of relief that I could possibly breathe. My client is safe. My client is in an environment where they don’t have access to means to hurt themselves. Is it stressful to hear “yes” when you’re asking some pretty scary yes-or-no questions? Of course it is. But the thing that I have to remember is this: not only is this situation WAY more stressful for my client than it is for me, those conversations about their safety got through. Those conversations of how they’ll know when it’s time to go to the ER, and who they would tell, and why their life is important, something got through. Will I ever know what that is? Probably not, and I’m ok with that. It doesn’t matter to me what got through – it only matters that what my client internalized was enough to keep them safe and alive and to be able to trust themselves to work within their will to live.

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