Courageous Conversations in Evidence Based Treatment

Therapy clients often experience suicidal thoughts, and there is evidence that nearly one in three clients  lie to their therapist about it (Blanchard & Farber, 2018). As therapists, we hope to foster a comfortable environment that encourages difficult discussions. So, why would clients hide or conceal suicidal thoughts? The reasons fall into four categories:

1. Practical impacts

• Clients may fear being pressured into unwanted treatment, such as hospitalization or medications.
• They may fear their confidentiality will be broken, which could affect their relationships or career.
• They may fear that by disclosing such thoughts they will lose the ability to attempt suicide.

2. Emotional impacts

• Sharing suicidal thoughts may bring up feelings of shame, stigma, embarrassment, guilt, sadness, and weakness.
• By not disclosing suicidal thoughts, clients can avoid or minimize the experience of these negative feelings.

3. Beliefs about self or suicide

• Clients may fear a cultural, religious or gender-specific stigma around suicide.
• Often clients prefer to cope alone, or they believe telling others would not help.
• They may feel that talking about suicide will be difficult to endure.

4. Specific therapy/therapist reasons

• Clients may try to control therapy and focus on the “real” reason they’re in treatment.
• The therapist may appear to not care enough or look visibly uncomfortable when discussing suicide.
• Clients may believe that sharing suicidal thoughts will make the therapist feel ineffective.

Given these fears, how can clinicians effectively open the conversation about suicide? There appear to be two avenues (Nagdimon et al., 2021) that may be fruitful, and which might be combined for maximum effect.

Therapist behavior

• Increase your comfort discussing suicide. Convey that it is OK to talk about with you.
• Normalize experiencing suicidal thoughts. Validate the client’s feelings in that moment, and positively reinforce their choice to talk about it.
• Open up the conversation. Reading from a suicidality assessment may feel procedural and impersonal. Instead of checking off boxes, work the important screening questions into a meaningful conversation that demonstrates your concern for the client as a person.
• Look past the client’s attempts to minimize suicidal thoughts. While “I’m only joking!” may be true, showing concern for the client’s safety will minimize harm while also conveying your genuine concern.
• Use a variety of tools. A self-report form can be a more comfortable way for some to disclose, while others find that it makes suicidal thoughts easier to conceal. Use both interviews and self-reports when possible. Additionally, familiarize yourself with different theories of suicide to expand your questions to other factors that may not be captured on certain assessments.

Psychoeducation

• Minimize uncertainty by informing clients of the procedures that you follow after they disclose suicidal thoughts. What steps will you take next?
• Inform clients of your rules for breaking confidentiality. Be specific about each step.
• Define “imminent risk” for the client, since this is typically when you would decide confidentiality needs to be broken. Typically, a suicidal plan and intent to act on this plan are necessary components of imminent risk.
• Discuss hospitalization with your clients – when and why would it be used? Emphasize it is for their safety. Note that you care about their life, believe they can get better, AND there is a concern that they cannot keep themselves safe. People cannot improve if they are dead!
  • Hospitalization should be understood as a last resort. Studies show hospitalization is distressing, intrusive and feels manipulative to clients. Rather than increasing self-efficacy, for some clients it may suggest that you think they are out of control and need someone else to “rescue” them. After discharge, suicidal ideation and attempt rates increase and half of discharged patients refuse outpatient treatment or drop out after their first session (Borecky, Thomsen, & Dubov, 2019).

When you’ve talked about suicide and have determined your client is not at immediate risk, what comes next? This is based on clinician judgement, but two things are important to decrease the odds of suicide:

Limit means

• Means restriction is one of the most effective methods of decreasing suicide deaths (Yip et al., 2012). Have clients give guns, pills or other potential tools for suicide to a trusted person or even yourself, or have a plan to make them less accessible.

Increase hope

• Inform clients about effective methods for decreasing suicidal thoughts and behaviors (dialectical behavior therapy, cognitive therapy for suicide prevention, safety-planning interventions) and use these in practice.
• Cultivate motivation and self-competence. Suicide is related to feeling helpless; if clients feel they have autonomy to improve and are motivated to do so, they will improve.
• Put up reminders of the client’s reasons for living (e.g. photos of loved ones) in their environment or relevant areas for their suicidal behaviors (bedroom, gun safe, etc.)

Remember – suicide screening is important. Staying informed can increase client disclosure and decrease the odds they will attempt suicide. With that being said, suicide is extremely difficult to predict and prevent. If you are flexible, empathetic and informed, you as a therapist have the tools you need to get to the important truth about their suicidal thoughts.