Working with Suicidal Clients: Building Confidence, Compassion, and Clinical Competence

As a practising counsellor or psychotherapist, encountering a client with suicidal thoughts is not an if – it’s a when. Despite decades of clinical progress, suicide remains one of the most daunting and under-discussed aspects of therapeutic work. Whether you’re in training, newly qualified, or highly experienced, the fear of “getting it wrong” often looms large. Yet, with thoughtful preparation, reflective awareness, and evidence-informed strategies, you can create a therapeutic space where such conversations are not only possible, but potentially life-saving.

Learning Outcomes

Here are five key insights for enhancing your practice:

• Reframing Risk: Move away from binary understandings of suicide risk and adopt a more nuanced, relationally attuned model.
• Normalising Conversation: Understand that asking about suicide does not increase risk – it can reduce it.
• Ethical Clarity: Be proactive in establishing policies around risk, confidentiality, and safeguarding.
• Personal Awareness: Reflect on your own beliefs, fears, and biases to identify and overcome unconscious barriers to therapeutic presence.
• Positive Risk-Taking: Collaboratively support clients to explore suicidal ideation without defaulting to defensive or reactive measures.

Suicide Prevention Strategies for Counsellors and Psychotherapists

While formal suicide risk assessments like the Beck Scale for Suicidal Ideation can be helpful, they should not replace the nuanced understanding that comes from therapeutic dialogue.

When assessing risk, consider:

• Suicidal ideation: Are there thoughts about ending life? How frequent, intense, or intrusive?
• Suicidal intent: Is there a desire or commitment to act on these thoughts?
• Access to means: Does the client have access to lethal means?
• Protective factors: What anchors them to life?
• Immediacy: Is there an imminent threat?

Documenting these components and reviewing them regularly ensures clinical accountability and ethical clarity.

Reframing Risk in Your Practice

The term risk is often misunderstood in the counselling context. As Dr Andrew Reeves argues, risk is not binary (i.e. present or absent), but fluid and relational. All therapeutic encounters carry some level of risk, and a more useful framework involves positive risk-taking.

This involves:

• Acknowledging risk explicitly with clients.
• Implementing appropriate support and safety measures.
• Continually reviewing the situation within a strong therapeutic alliance.

Rather than viewing risk as a red flag to terminate or refer, many clients can be safely held within the therapeutic relationship, provided they have capacity and the risk is not immediate.

It’s important to distinguish between our responsibility to our clients and responsibility for our clients. We are not responsible for the client’s decisions. Still, we are responsible to them – to offer a non-judgemental space, ask the difficult questions, and respond with clinical integrity.

Risk is never static. A client might say they’re “fine” in session, but that doesn’t mean their circumstances or inner world can’t shift – sometimes rapidly. Risk must be seen as a dynamic, ongoing process. This means that even if we use tools like the PHQ-9 or conduct a thorough risk assessment at intake, our responsibility doesn’t end there.

As therapists, we need to stay attuned session by session: listening carefully, staying curious, and being willing to revisit risk whenever something feels different. It’s this sustained, relational vigilance that supports both safety and trust.

Breaking the Silence: Talking About Suicide

One of the strongest myths in suicide prevention is that discussing suicide might ‘plant the idea’. Research and practitioner experience alike affirm that asking about suicidal ideation often relieves distress. Counsellors must normalise and model open dialogue about suicide, which begins with confident, direct questioning such as:

“Have you had any thoughts of ending your life?”

When asked compassionately, this question communicates safety, presence, and a willingness to walk with the client through their distress.

Using Language That Reduces Stigma

The language we use when discussing suicide can either perpetuate stigma or reduce it. Avoid terms rooted in criminal or judgemental connotations, such as:

• “Committed suicide”
• “Successful/failed attempt”
• “Cry for attention”

Instead, use neutral, compassionate alternatives:

• “Died by suicide”
• “Attempted suicide”
• “They must have been in a lot of pain”
• “They needed support and attention”

Shifting our language can change the emotional atmosphere of the therapy room and make it safer for clients to disclose vulnerable feelings.

Understanding What Stops Clients From Talking About Suicide

Clients often avoid discussing suicidal thoughts due to complex emotional and social barriers.

These barriers can include:

• Fear of being hospitalised or losing autonomy
• Shame and embarrassment, especially among men
• Fear of children being taken away (particularly for mothers)
• Lack of trust in the therapist
• Internalised stigma from societal attitudes and language surrounding suicide

Understanding these fears enables us, as therapists, to approach the topic more sensitively and effectively. It also reinforces the importance of clarifying the boundaries of confidentiality in the contracting stage and normalising the discussion of suicidal ideation from the outset.

What Stops Us as Therapists from Talking About Suicide?

As therapists, we may have our hesitations that interfere with broaching the subject of suicide, including:

• Fear that asking may increase risk
• Worry about offending or alienating the client.
• Anxiety about getting it wrong
• Fear of breaking trust or damaging the therapeutic relationship
• Feeling unsure of what to do if the client says “yes”

Addressing these internal blocks through supervision and training is critical. The truth is, not asking is far riskier than asking. Talking openly about suicide has been shown to relieve distress, strengthen the therapeutic alliance, and create pathways for hope and safety planning.

Developing a Robust Safety Plan

When suicidal ideation is present, a well-crafted safety plan is a cornerstone of client care. A good safety plan should:

• Be collaborative and client-led.
• Focus on empowerment and realistic action.
• Identify warning signs, coping strategies, support systems, and emergency steps.

A bad safety plan, by contrast, can promote dependency, increase fear, and centre the therapist’s anxiety over the client’s needs. Importantly, these plans should be reviewed and adjusted regularly to remain relevant.

What Is Suicidal Ideation vs. Suicidal Intent?

Suicidal ideation refers to thinking about, considering, or planning suicide. It can range from passive wishes (e.g. “I wish I wouldn’t wake up”) to more structured planning.

Suicidal intent, however, suggests a more concrete desire to act on those thoughts, potentially with a plan, means, or time frame. Distinguishing between ideation and intent is crucial for assessing immediate risk and determining intervention steps.

Therapists should always ask open questions to explore where the client sits on this spectrum.

Risk Factors, Protective Factors, and Warning Signs

Understanding the context around suicide risk can help therapists navigate assessment more effectively. Risk factors may include:

• Psychiatric diagnoses (e.g. depression, bipolar disorder)
• Past suicide attempts or family history of suicide
• Social isolation, bereavement, or financial hardship
• Neurodivergence, particularly autism.

Conversely, protective factors include:

• Strong therapeutic relationships
• Willingness to talk about distress
• Social support networks
• Effective coping strategies.

Warning signs may be subtle: giving away possessions, sudden mood lifts after depression, or expressions of hopelessness should all be taken seriously, even if veiled or ambiguous.

Ethical Clarity and Supervision

Clear organisational policy, informed consent, and ongoing supervision are essential. Be transparent with clients about the boundaries of confidentiality and your responsibilities around safeguarding. Also, acknowledge when your own history, bias, or emotional limits suggest referral might be more ethical than continued work.

Supervision plays a key role in managing the emotional toll and clinical decision-making when working with suicidal clients. Therapists may experience vicarious trauma, compassion fatigue, or feelings of impotence, especially following a client’s death.

Therapist Self-Care When Working with Suicidal Clients

Supporting clients experiencing suicidal ideation can carry a high emotional toll. Therapists may experience vicarious trauma, anxiety, or doubt about their professional competence, especially in the aftermath of a client suicide.

Self-care must be:

• Proactive: Schedule regular supervision, peer support, and breaks
• Personalised: Know what replenishes you emotionally and physically
• Integrated: Make self-care a professional responsibility, not a luxury

Neglecting self-care can lead to burnout or impaired therapeutic judgement. Staying resilient enables you to remain present and focused.

Observations From Research

Recent data continues to highlight the complex landscape of suicide risk. A UK Government paper on suicide statistics (January 2025) reports that in 2023, suicide rates were highest among those aged 45 to 54, at around 16 per 100,000, and lowest for ages 14 to 19 with rates closer to 5 per 100,000.

The same report also notes that, statistically, men have a higher risk of suicide.

A May 2023 paper in the Primary Care Companion reports that suicide rates are 11–23% higher in spring and summer, with ED (Emergency Department) suicide attempts 1.2 to 1.7 times more common than in winter.

These trends may help us stay curious about how seasonal and demographic factors could shape client experiences.

Frequently Asked Questions

Final Remarks: Grounded Courage in the Therapy Room

There is no absolute formula for preventing suicide, and despite best efforts, loss may still occur. What matters is that you are equipped, present, and courageous enough to walk beside your clients in their darkest moments. By reframing risk, speaking openly, planning collaboratively, and maintaining your wellbeing, you offer clients not only support but a powerful, life-affirming presence.

Important Note:

This article is intended as a supportive resource for reflective practice. It does not replace formal training, supervision, or ongoing study in working with suicidal clients. Because of the complexity and gravity of suicide risk, we encourage all practitioners – whether in training or qualified – to seek out further CPD, ethical guidance, and supervision when working in this area. While no single resource can fully prepare you for this work, a commitment to ongoing development is a vital part of safe, compassionate practice.

References and Further Reading

Reeves, A. (2015). Working with Risk in Counselling and Psychotherapy. Sage.

Samaritans. (n.d.). Myths about Suicide

Chapman, E. (2020). Introduction to Suicide Awareness. CounsellingTutor.com

British Association for Counselling and Psychotherapy. (n.d.). Counselling and Psychotherapy for Suicide Prevention – Systematic Review

House of Commons Library, Suicide statistics. Commons Library Research Briefing CBP‑7749, 8 January 2025. Available at: https://commonslibrary.parliament.uk/research-briefings/cbp‑7749/

Della, D. F., Allison, S., Bidargaddi, N., Chan, S. K. W. & Bastiampillai, T. (2023) An umbrella systematic review of seasonality in mood disorders and suicide risk: the Impact on demand for primary behavioral health care and acute psychiatric services. Prim Care Companion CNS Disord, 25 (3), article 22r03395.

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