Suicide risk isn’t binary
Private Practice, December 2024

I remember early in my career, when working in statutory services, a consultant psychiatrist telling me that counsellors wouldn’t routinely see clients at risk of suicide because, as she put it, they would immediately refer them on to specialist services who were best placed to do such work.

Across my career, I’ve worked in schools, universities, the third sector and statutory services as a counsellor, and have met many clients with thoughts of suicide. Likewise, as a private practitioner of over 25 years, suicide risk has been an ever-present profile in my work. The inaccuracy of the early advice given to me comes back often and, additionally, I’m reminded daily of the important – and life-saving – support counsellors offer in meeting their clients at a point of suicidal crisis. 

It's my core assertion here that private practice counsellors offer something valuable and important to clients around suicide risk, and such exploration can often be a central component of therapeutic work; after all, risk isn’t binary, is it? Clients aren’t ‘at risk’, or ‘not at risk’: rather, risk in its broadest sense is woven into the fabric of our everyday lives for us to explore, consider and navigate as best as we’re able, at any given point. Risk of suicide is, arguably, part of some people’s existential engagement with the world and, as therapists, we’re well-positioned to create an opportunity for such exploration, consideration and navigation.

Why private practice is so critical 

Of course, counsellors in the broadest range of contexts work with clients at risk of suicide, but there’s something about private practice that perhaps is unique in this respect. In almost all other settings, processes around working with risk are set by an organisation, which counsellors generally must follow. Sometimes, that will be consistent with a counsellor’s own professional values, but at other times it might be at odds. In private practice, however, counsellors have the freedom to define much of their own practice and offer a space that’s most consistent with their way of working, as well as the ethical, philosophical and existential position they take; only a few aspects of practice are defined by law, and ending your life through suicide is not one of them. 

Clients will often access services at the point when they’re most available to them: a student accessing school, college or university counselling, or someone with depression or anxiety being referred for talking therapy following a GP consultation. In private practice, however, clients can make an independent choice about their preferred counsellor – perhaps defined by gender, age or culture etc, and around who they feel most able to ‘…share the immediacy of their pull towards death’.¹ 

As I’ve written much in the public domain about suicide and therapy, I often have potential clients contact me in private practice because they feel I’m best able to hear their thoughts about suicide. In short, the private practitioner sits outside of organisational demands and expectations, and crafts their own practice, consistent with their own values and the ethical requirements of practice. Importantly, in relation to that latter point, the key ethical requirement around private practice with suicidal clients is that the client is clearly communicated with about the counsellor’s approach to working with suicide, and where the boundaries of confidentiality sit, so that the client can make informed consent about who they work with and how that work will be framed.

Drawing on the latest evidence 

Working in organisations has additionally typically required counsellors to make use of risk assessment tools – tick boxes and questionnaires – to determine levels of risk and make decisions about allocation and discharge. While such tools can offer a gateway into a more meaningful dialogue, they’ve often been the start – and end – of working with suicide risk. This has, for a long time, been inconsistent with many counsellors’ belief systems about practice. 

NICE² guidance about working with suicide and self-harm makes clear that, drawing on the latest evidence, mental health practitioners (including counsellors) shouldn’t use such tools for that purpose, essentially because there’s little evidence they have any reliable predictive value. For a fuller discussion of this, it’s worth looking at BACP’s latest guidance on working with suicide risk more generally.³ Suffice to say, however, we’re instead drawn back to working in a way I suspect many counsellors have always done anyway – to talk to the client about their suicidal thoughts. 

Five core principles for the private practitioner 

Before briefly exploring the ‘tripping hazards’ of talking about suicide risk, however, I offer here five key principles for the private practitioner to keep in mind for their work with suicidal clients, as these can help position practice – and the practitioner – well in their work: 

1. In its varying forms, risk is an integral part of all relationships, including therapeutic relationships. All clients who present in private practice will do so with some degree of risk, which may include suicide risk
2. Given that risk is integral, it’s helpful for us to embrace that reality, and rather than viewing risk as something that should simply be identified and minimised, we should embrace it as a therapeutic opportunity: ‘What does this risk mean for you?’ ‘What sense do you make of it in your life?’
3. Risk is not binary and will bring with it different meanings for clients. Our therapeutic task around working with risk is about meaning making, so that the client can make their best sense of their own thoughts and experiences. We must remember that – assuming a client has capacity to make their own decisions – it’s not us who will keep the client alive Rather, our task is to equip the client with their own resources for keeping safe and help-seeking
4. We must ask questions about suicide risk, clearly, transparently, directly and with empathy. ‘I wonder if you have had thoughts about ending your life?’ ‘When you say that, I wonder if you’re talking about acting on your thoughts about suicide?’ Not through metaphor or alluding to risk, but directly and in plain language, to create a less-stigmatising space for an honest exploration
5. It is, of course, not a one-off conversation. Discussions about suicide risk need to be woven through our therapeutic dialogue, when appropriate, so that it becomes a normalised area for exploration and thus, more accessible for the client to begin to think about self-care and self-support 

These principles not only support ethical practice, but they provide a mechanism for the private practitioner to check out the client’s capacity for safety. The recommendations here clearly speak to a context within which the counsellor and client are willing and able to work collaboratively. In the event where the counsellor is concerned about the client’s immediate safety, or the client is unwilling or unable to work with the counsellor to explore these issues, this might be a ‘red flag’ for referral. 

Dangers of the unexplored 

Talking about suicide is notoriously challenging, however, and the research around ‘unacknowledged countertransference’ or ‘edge of awareness’ anxieties can silence us, me included.⁴ I offer below a summary of some of these aspects: 

• Our own sense of feeling overwhelmed or helpless in our capacity to bring about change can impair our sense of ‘being’ in the relationship if we don’t recognise it. However, it can be a powerful mechanism for helping clients to feel really understood, if named appropriately
• Projecting our own fears of how the client might experience our questions about suicide might lead to us fearing that questions about suicide will be experienced as clumsy or insensitive. Yet often, clients tentatively bring their suicidal thoughts into the room, in the hope their counsellor will take the lead in naming it
• Suicidal thinking can often be centred in feeling worthless or unimportant. We can pick that up too: what difference can we make? Naming suicide and taking the time to explore it can be hugely validating
• Clients will often bring their suicidal thinking – at the first mention – through metaphor or by alluding to it. It’s very easy, therefore, to allow our anxiety to not pick it up. Naming thoughts of suicide can be one of the biggest steps in reducing risk
• Colluding with a sense of minimising risk, to help support our own sense of anxiety, can lead us into telling ourselves we’re OK when we’re not – minimising our own experience of crisis. As counsellors, we can collude with this by not gently challenging these internal dialogues
• Hearing our client’s narratives through an unconscious selective frame (not hearing implicit references to suicide) can make some things hard to hear. If we don’t hold this in our awareness, we can select the positives and sidestep the more difficult areas, like suicide
• Fearing getting it wrong and being blamed for not doing enough, or doing too much, can mean that we’re pulled into avoiding talking of it entirely. The important factor here is that naming suicide can support us – and particularly our clients – in navigating these concerns
• Fear, anger, a sense of incompetence and impotence when working with suicide are held by many counsellors; our terror can be immobilising. 

Private Practice, December 2024

Ten key tips for practice

In summary, private practitioners have much to offer clients at risk of suicide but must first see risk differently – rather than something to be avoided or overwhelmed by, it’s a critical part of any therapeutic process. We must be willing to name it clearly and directly, often taking the lead in doing so, and then working with our clients to build their capacity and capability to keep themselves safe. This can be supported through referral to additional services, where available, with the client’s consent, but we must be willing to act if we believe a client is at immediate risk or is no longer willing or able to work with us around their suicidal thinking. 

In bringing this together, I offer 10 top tips for the private practitioner to support themselves in this work: 

1. Risk tolerance: We need to reflect on our own tolerance to risk: how able do we feel we are to work with risk in our private work, using self-reflection and supervision to explore this? Keeping in mind that our tolerance to risk will be shaped by a variety of factors, including crises in our own lives, health, faith, a sense of overwhelm in our work generally, etc
2. Crisis, or not crisis: Be clear what it is we’re offering: some private practitioners offer out-of-hours crisis support, whereas others don’t. If we do, do we have the training and capability to hold that risk, and are we sufficiently embedded in mental health systems for support? This shouldn’t be offered in isolation. If we don’t, this needs to be clearly communicated to the client. While I worked in a statutory mental health crisis team for many years, I personally choose not to offer out-of-hours crisis support
3. Fitting in with the system: Make sure we’re aware of service availability before we need them. How would we access crisis services, or other support? If working online with a client out of the area, we must have their GP contact details as part of the registration and contracting process. We don’t want to find ourselves needing that information at a point of immediate crisis to realise we don’t have it (and such details must be kept up to date too)
4. Contracting: Contracting is the first point where we can explore suicide risk (but not the last), as well as clearly communicating to the client our ways of working and any boundaries of confidentiality that sit around working with suicidal thoughts. We must obtain informed consent from the client before commencing therapy with them
5. Working practices: While organisations typically have policies around risk, as private practitioners, we can do the same. It can be hugely helpful to write out our own working practices around suicide risk, as this can help support equitable delivery of services, and can also inform our discussions with clients to help gain informed consent about our work
6. Supervision: Supervision is critical at times of crisis, but it’s equally critical to talk to our supervisors before a crisis comes along: what are our mutual expectations around risk and preferences around work? It’s not a good time, when a crisis arrives, to find out we see practice differently
7. Referral routes: If we need to make a referral for a client (with or without their consent), do we know how? It’s important to find that information out before we need it
8. Record keeping: We must always include in our record keeping specific details of discussions about suicide risk: what was said, by whom, what was agreed, and the outcome of any actions. This supports good practice, as well as allaying practitioner anxiety
9. Keep-safe plans: NICE talk about ‘keep-safe plans’, and these can be the cornerstone of good practice in supporting clients to keep themselves safe. These are discussed in more detail in the BACP resource,⁵ as well as the online resource, listed below
10. Regular review: Remember, this is not a one-off process. Review keep-safe plans and broader discussions around risk regularly, so that such discussions become a normalised aspect of our therapeutic explorations.