How can you build trust with clients who are suicidal?

My view is to give assurance that having suicidal is not a right or wrong thing. Besides that we as therapist need to be comfortable talking about suicidal. Giving the safe space for client to talk about their suicidal is very crucial as I believe they would find it hard to talk with people in their life afraid of the critism and being judged.

When I was practising in primary care a man came into my clinic. Middle aged, lived alone, divorced, lost his job, drank a lot , previous attempt. Alarm bells were ringing. I suggested hospitalisation but he refused stating that he's fine and that all he wanted was a refill. With kindness and compassion I explained that I have a duty of care and I need him to be in hospital willingly. The alternative was that he would be sectioned and be forced to be admitted where discharge will take much longer. He went voluntarily. A month later the man walked in my clinic with a bounce in his step and was smiling. He never knew so many people cared and visited him in hospital including his ex- wife! He thanked me for making my stand.

Building trust under normal circumstances with clients is challenging within itself, but if you add in the issue of suicidal ideation it only becomes harder. One of the first things that I do with every client (child, teen, or adult) is to always disclose the exceptions to confidentiality with them and ensure that they understand them. I have found that if you are upfront from the beginning that it not only builds trust, but allows clients to feel safe about opening up due to knowing the potential results. If it is a voluntary situation involving active S/I, I as their therapist start working on finding an inpatient treatment facility to get them more assistance. Above all…. be there, be truthful, and be real.

One thing that has really resonated with a lot of my clients has been a skeptical perspective check. The way we see the world isnt always static as our brain my tell us -- so responding to thoughts and feelings with a compassionate "What if you were wrong?" --- I have found it helps give some space for exploring what is really important to this client in pain.

One thing I've found helpful is to use a 1 to 10 scale with clients to explore their feelings and motivation. When you ask the client why the number is what it is you get more information to help you understand their current motivators. And when you ask them how the number could be higher you get to understand the challenges, barriers, and potentially what the client's goals or desires might be.

I work with people with complex trauma and dissociation. Ambivalence is everywhere, and suicidality is an on-going challenge. I regularly check for the level of risk - what is their history of attempts, how often and how severe. Then I help them explore the meaning and purpose of suicidal thoughts and feelings. For many of the people I've worked with, feeling suicidal and having suicidal thoughts have been ways they've tried to feel in control of their lives - everything else felt out of their control, so they would thing/feel 'if it gets too bad, I can end it'. That actually helped them stay alive. Knowing that, I'd focus on empowering them in other ways, while constantly postponing suicide. Never lost anyone through suicide.

We need to boldly go into the suicidal ideation hope - what one is hoping to gain by dying. That will give us a description of what that want, IN LIFE. It’s a door into ambivalence.

One of the most successful techniques I've used when assessing and treating suicide is exploring ambivalence, which MI excels at. For one, disclosing SI during session means they want help. Secondly, before they tell me about them, clients have usually had suicidal thoughts for a while, which means that they've had opportunities to go forward with suicidal thinking - but haven't. It can feel deeply uncomfortable, but - from a place of genuine curiosity - I've asked clients why they haven't killed themselves yet or taken more steps towards suicide. Their answers tell me a lot about a client's motivations ("Because I thought about my mom.") - or risk ("Because my roommate was home."). Any hope, however, is hope you can work with.

As a health coach, it is impactful for my clients when I use a series of open-ended questions to elicit the client's experience around a story they have told. Questions like "Can you explain your perspective on..." or "You seem to be saying..." allow me to open inroads for them to identify areas of discrepancy between their current behaviors and their ultimate goals. When they are empowered to uncover these gaps themselves, that is where the change happens. That is where the magic lives.

One of the most important tasks in helping clients overcome suicidal thoughts is to help them recognize that they have the power to change things for the better. Clients usually see suicide as the only action they can take to relieve suffering that overpowers them. However, when they see the power they instead have over their suffering, suicide is no longer the best option. You can help clients recognize their power by finding exceptions, pointing out client strengths, and highlighting times their actions have successfully eased their pain. The more mastery they feel, the more hope they have that they will overcome their struggles.

Many clients often display low self-esteem and self-confidence, leading them to feel inadequate and unaccepted. Empowering them involves helping them identify their strengths and the positive actions they can take, resulting in a transformation of their mindset. As they become aware of their capabilities to navigate life, they begin to undergo profound changes. They develop a deeper understanding of their identity, learn to trust, appreciate, respect, accept, and ultimately love themselves.

Some things I have found helpful is grounding strategies to ground them into the present. This helps their emotional intensity come down so they can take the moment.

MI is a truly powerful tool for assessing and creating an initial intervention for clients considering suicide, but other approaches are necessary to effect change. MI identifies hope, protective factors, and motivations for moving forward, but clients have to develop insight, skills and meta-cognition in order to truly overcome suicidal thinking. DBT helps clients understand and separate their emotions from their actions, as well as building coping skills. CBT allows clients to challenge thinking patterns that cause hopelessness and interferes with functioning. SFT and other client-centered approaches help clients develop goals and gain confidence in their ability to heal. Treatment must be flexible, always starting where the client's at.

I think adding ACT and/or mindfulness/grounding strategies can be really helpful here. DBT has some of these skills incorporated, but a huge thing with suicide is that really people just want to feel better. If we can give them a few extra tools to hang on a bit longer, maybe until the sunsets of the dawn breaks… that can go a long way

Le plus urgent est de s’enquérir de la volonté ferme ou non du client: vous voulez vous suicider? quand? avec quel moyen? on peut je pense parler sincèrement. S'il c'est pour une date déterminée et un moyen déjà existant, il faut prendre très très au sérieux et protéger. Puis explorer la souffrance du client et l' écouter relachera la pression. Promettre de tenir jusqu'au prochain rendez-vous....

This is an important part of working front line with SI or HI clients. Knowing how to utilize the emergency support system in your community is a must. Having tools at your hand to do clear SI or HI assessments to keep clients and other safe is a critical part of the work we do. Staying up-to-date with risk training, safety plans and crisis plans is a good way to make sure you are a responsible clinician.

I did this with a lady who had bipolar disorder. I was with her when she was sectioned under the Mental Health Act. She had refused to take her medication which controlled her disorder for the most part. She was very angry with me for a few weeks, but eventually we sorted her anger out, and I explained why I had done what I did.

When responding to a crisis, it is vital to remain calm and maintain clear communication. Clients in this stage may be anxious and impulsive, so we need to be patient and actively listen. It is important to validate their feelings, thoughts, and emotions while also paying attention to certain words and patterns in their behavior to better understand what they are experiencing. This can help us make prompt and wise decisions to ensure the client's safety and minimize any potential dangers.

Key steps in suicide prevention include: 1. Joining together to understand the deeply personal journey that led to the suicidal feelings or attempts 2. Exploring community, friends, and/or family connections that client could trust, if any. 3. Making a safer plan; steps to take if the feelings arise again. 4. Reinforcing that suicide is a permanent solution to a temporary problem. When suicidal thoughts and feelings occur it is important to address them immediately and take the person seriously- not just as a clinician but, as a family, friend, or community member. Anyone can perform the aforementioned steps with someone in crisis who is thinking about ending their own life.

I have found making a safe space to talk about death, in any way the most helpful. In my years of practice I have found many people want a space to talk about it but fear being "locked up" or "sent away". The first question I always ask is if the person has a plan to actively and intentionally harm themselves right in that moment, OR do they have thoughts about death. Both answers prompt a "tell me more about that" response. it reveals so many other things that were at the root of the pain and the hopelessness. Being able to regularly talk about death, thoughts of death and all the contexts of death make it safe for clients to come when its a passing thought, or they notice a change. We run coping strategies, emergency plans and safety

I thought I’d share some thoughts on what suicide prevention means to me. Suicide prevention is for every day, not waiting for the crisis… it’s in every interaction, without expectations, the genuine ‘how are you?’ Suicide prevention, is about listening, it’s about deep empathy and showing compassion. Suicide prevention is sitting down with someone in the ashes of their pain, present and connected. What’s shareable is bearable, no matter what it is, even when it feels like it’s not, regardless of the thoughts and emotions that might arise. We don’t necessarily even have to ‘do’ anything, we just have to ‘be’.

While the principles and techniques of MI are extremely useful and important, I find it’s also important to have a sound theoretical model of suicidal ideation that validates parts of self who wish to die and facilitates awareness of and dialogue with other parts of self who are disturbed by those thoughts and do not want to die. Internal Family Systems (IFS) and Ego State Therapy both offer great ways to conceptualize S/I and facilitate internal dialogue between all parts of self, not just a dichotomy between two ambivalent parts on either side. CBT and DBT can sometimes be too aggressive in their attempt to challenge S/I without addressing the pain underneath. An increase in anxiety and S/I may indicate complex trauma and dissociation.

If a client indicates they are suicidal or pondering suicide, it's important to establish a safety protocol that includes guidelines for them in the event their primary therapist can't be contacted... and to work to establish who their immediate support system is. Often their caregivers need support as well.

Acknowledge that, no matter how much we are there for those who are experiencing suicidal ideation, not all suicides can be prevented...as disheartening and controversial to hear or read. Ensure that support is driven by the person who is in need of or express interest in such support. Don't dominate the conversation or act self-servingly. Allow the peer in distress to express him-/her-, themself, etc. in a comfortable yet controlled environment without judgement or automatically reaching for solutions. Be solution-minded only if the peer requests such.