Suicidal ideation treatment

Suicidal ideation treatment is an intervention, such as CBT or DBT that a therapist recommends to a client considering suicide. If you ask multiple clinicians to name the most anxiety-provoking situation a therapist will encounter in treatment you are likely to hear the same answer: the suicidal client. Therapists feel responsible for their client’s well-being and a client with suicidal ideation is a source of constant concern.

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Unfortunately, the problem is not rare. Suicide is one of the leading causes of death in the world with over nine percent of people possessing suicidal ideation at some point in their life.

Therapists must take a particular approach when attending to a client with suicidal ideation. This includes assessment of suicidality and preparation for crisis intervention. Let’s take a closer look at how therapists treat the suicidal client.

Assessing suicidality

The first step in treating a suicidal client is to figure out if they are truly suicidal. Some people will be upfront and mention it as their presenting problem but others will be less forthcoming. The following risk factors and warning signs can help therapists identify a client who may want to self-harm.

Risk factors

Risk factors are long-term variables that are associated with suicidal behavior:

• Previous suicide attempt

• Family history of suicide

• Poor support network, isolation

• Chronic and severe mental or physical health conditions

• Exposure to trauma (e.g., abuse, violence)

• Recent loss of a loved one, either through estrangement, divorce, or death

Warning signs

Warning signs are recent behaviors or emotions that the therapist can identify during the course of therapy:

• Talking about suicide

• Expressing hopelessness and worthlessness

• Chronic pain, both physical and emotional

• Sudden improvement in mood (because the client is at peace with their decision to die)

• Worsening health

• Making preparations for death (e.g, giving away possessions, saying goodbye to people)

• Feel they are a burden to others

• Withdrawal from friends and family

Suicide assessment

When a client possesses risk factors and exhibits warning signs, the therapist must perform a suicide assessment. Despite some possible awkwardness, it is recommended that therapists directly discuss suicide.

Asking about suicide does not make it more likely a person will commit suicide and it shows the client that it is okay to discuss the topic.

Clinicians will find that the therapeutic relationship is paramount during a suicide assessment. The better the relationship, the more likely the client will be open and honest about their feelings.

When conducting a suicide assessment the therapist will ask about the following factors:

• Intent: Do you think about killing yourself?

• Plan: How would you do it?

• Method: Do they have the means to carry out their plan? For example, if they say they want to shoot themself, do they have access to a gun?

• Preparation. Have they taken steps to implement their plan? For instance, have they bought ammunition or written a suicide note?

Assessment measures

Although an informal suicide assessment will likely give you the necessary information to inform your next move, some therapists might feel more comfortable giving the client a specific assessment measure. Two popular tools are the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Suicide Behaviors Questionnaire-Revised (SBQ-R).

The strength of using formal assessment tools is that they provide therapists with scores that indicate the current severity of the client’s suicidal state. This is particularly helpful if you aren’t sure whether they meet the threshold for hospitalization.

Crisis intervention

If you determine that the client is actively suicidal (they have intent, a plan, and a means to carry it out), they need to be taken to the hospital for further evaluation. It is the therapist’s job to make sure someone is given the responsibility to get their client to the hospital. For children, parents or caregivers must be informed and they may take them.

For adults, therapists may accompany their clients to the hospital, inform a loved one, or call 911. If the client is on the border (e.g., they have intent and a plan, but no immediate way to carry it out), it is always better to be safe than sorry. Although therapists are not always expected to go with clients to the hospital, they do need to follow up to make sure they receive an evaluation.

Clinicians must be careful not to trust an adult who says they will take themselves. People who want to die probably won’t go to the hospital on their own.

Suicidal ideation treatment

For clients that aren’t actively suicidal. (e.g., they have suicidal thoughts but no plan), the therapist needs to work with them and develop a suicidal ideation treatment plan for a time when they may want to make a suicide attempt. It is essential to remind these clients that confidentiality may have to be breached if they become a serious threat to their own safety.

Suicidal ideation therapies

Cognitive-Behavioral Therapy (CBT)

CBT can be helpful for clients who have developed distorted beliefs leading to depression and suicide. For example, people who feel hopeless often have an overly negative view of themselves and their situation and believe it can never improve. CBT challenges these faulty thinking patterns and helps individuals think more realistically. CBT also teaches behavioral interventions that clients can use to improve coping skills and problem-solving abilities.

Trauma therapy

Trauma is a risk factor highly associated with suicide. Trauma-informed therapies, including trauma-focused CBT, help clients confront and process trauma healthily. Other trauma therapies, such as Eye Movement Desensitization and Reprocessing (EMDR), work in more mysterious ways but provide effective results and can be used in conjunction with other treatments. Successfully addressing trauma may prevent suicidal thoughts from developing in the first place.

Dialectical Behavior Therapy (DBT)

DBT was first developed to treat borderline personality disorder, an illness often associated with suicidal ideation and self-harm.

A few aspects of DBT make it particularly beneficial for treating suicidality:

• The development of a mindfulness practice assists individuals in coping with emotional dysregulation

• Teaching distress tolerance skills helps clients manage intense feelings without resorting to suicidal behavior

• Phone coaching allows the therapist to closely monitor the suicidal client without reinforcing self-harming behavior.

Family support and education

It is essential to involve family members in treatment for clients with suicidal ideation. Family therapy can address family dynamics and communication patterns that may contribute to suicide risk. Short of family therapy, simple education can help family members understand their loved ones better. Just knowing that family members care enough to be involved offers immense support to the suicidal client.

Medication for suicidal ideation

Anti-depressant, anti-psychotic, or mood-stabilizing medication is likely to be suggested for suicidal clients. If they go to the hospital, some medication will almost certainly be prescribed, depending on the client’s background and situation. After hospitalization, therapists must closely collaborate with medication providers to ensure the client is taking the medication and it is working as intended.

Safety plan

A safety plan must be developed for clients who express suicidal ideation. The plan usually consists of 1) recognizing triggers, 2) implementing strategies that will help one cope with suicidal feelings, and 3) identifying people or resources they can contact for help. The government has even developed a safety plan app that individuals can easily access on their phones. Clients are always encouraged to text or call 988 to reach the Suicide & Crisis Lifeline if no other resource is available.

Suicide contract

The suicide contract is a document the individual signs that states they won’t hurt themselves. Suicide contracts used to be in vogue but they are no longer recommended, mainly because they aren’t effective and may cause harm. A better alternative is a verbal agreement where the client promises to contact their therapist or a responsible adult if they feel suicidal.

Working with a client who exhibits suicidal ideation may be the most stressful situation a therapist will face. It requires close monitoring and specialized interventions, including the assessment of suicidality and crisis management.

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References

DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis. Behavior therapy, 50(1), 60–72. https://doi.org/10.1016/j.beth.2018.03.009

Hua Wu, Liu Lu, Yan Qian, Xiao-Hong Jin, Hai-Rong Yu, Lin Du, Xue-Lei Fu, Bin Zhu, Hong-Lin Chen. (2022) The significance of cognitive-behavioral therapy on suicide: An umbrella review.

Journal of affective disorders, 317,142-148. https://doi.org/10.1016/j.jad.2022.08.067

Hudenko, W., Homaifar, B, and Wortzel, H. U.S. Department of Veteran Affairs: National Center for PTSD. The relationship between PTSD and suicide. https://www.ptsd.va.gov/professional/treat/cooccurring/suicide_ptsd.asp

McMyler, C., & Pryjmachuk, S. (2008). Do 'no-suicide' contracts work?. Journal of psychiatric and mental health nursing, 15(6), 512–522. https://doi.org/10.1111/j.1365-2850.2008.01286.x

Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., Bruffaerts, R., Chiu, W. T., de Girolamo, G., Gluzman, S., de Graaf, R., Gureje, O., Haro, J. M., Huang, Y., Karam, E., Kessler, R. C., Lepine, J. P., Levinson, D., Medina-Mora, M. E., Ono, Y., Williams, D. (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British journal of psychiatry : the journal of mental science, 192(2), 98–105. https://doi.org/10.1192/bjp.bp.107.040113

Pomplii, M and Goldblatt, M. (2012, April 2). Psychopharmacological treatment to reduce suicide risk. Psychiatric Times, 29(4). https://www.psychiatrictimes.com/view/psychopharmacological-treatment-reduce-suicide-risk

Psychology Today. Trauma-focused cognitive behavior therapy. https://www.psychologytoday.com/us/therapy-types/trauma-focused-cognitive-behavior-therapy