People who are suicidal or depressed are often in intense pain. Their experience of meaning and purpose in their life is quite impoverished. Often the death instinct is higher than life instinct. Maintaining your calm while working with a suicidal client is a fairly challenging task because most of us are afraid of dying as we maybe of living fully. However, it is crucial to be able to assess and intervene appropriately when faced with a client who is suicidal. And this is possible if you as a therapist have a fair amount of awareness about the meaning and purpose of your life. It’s helpful if you have coped with your own pain around isolation, freedom, meaninglessness and death. It’s additional strength if you have at any time thought about suicide, have been depressed and have an understanding of the meaning of your life and death! The guidelines given below are usually helpful while dealing with a client who is suicidal. These have been compiled from literature as well as my practice experiences. Ultimately you can only assess, support and engage in prevention.

1. Establishing Safety and Trust

The therapist role is to understand the nature, magnitude, intensity and frequency of the client’s pain. A starting point is to create a safe space to help client share their despair. One of the greatest strengths of being a Gestalt therapist is one’s ability to stay with pain, uncertainty and the existential realities of life. This is achieved through the therapist demonstrating an ability to stay with whatever client shares while adhering to the paradoxical theory of change. It’s important to let the client know that he may find it hard to talk about, but you are accustomed to hearing about suicide and willing to not try to dissuade him. To convey that you are open to listening to his rationale for wanting to die without trying to push him towards ‘positive thinking’. A crucial factor is to demonstrate the skill of talking about suicide, about painful emotional states, without wanting to fix it immediately and without giving too many reassurances first. This conveys that the therapist is able to tolerate the client’s pain in particular and human distress in general.

2. Being Curious

Imagine that you are trying to understand the essence of your client’s experience. Follow the clients’ subjective experience. Asking questions, exploring feelings, looking at it from different perspectives, identifying your sensory responses while staying connected to your clients’ process. Curiosity is your best instrument. Ask questions like, “How do you experience your suicidal thoughts? When do you feel them most? What time of day? How do you feel in your body when you experience this? What are the occasions when you think most about dying? What are your earliest memories of feeling this way? What are the occasions when you have thought of living?” Try to elicit specific triggers. Facilitate mindfulness towards thinking, feelings, bodily sensations, impulses and actions. This also helps in psychoeducation. Explain that suicidal thoughts are like other feelings, they ebb and flow in their intensity. If you don’t act on them, they subside. One can make a choice to give into or not to impulses.

3. Assessment

If you don’t have a specific assessment tool that you use, then use the following semi-structured assessment. Ask targeted questions with confidence. In my experience clients don’t feel threatened by questions instead they feel heard and cared for. Genuine interest and ability to listen is validating for the client. Ask —

• Are you thinking of killing yourself now? When did you last think of it?
• Remain calm.
• Listen more and speak less.
• Limit questions to gathering information calmy like an impartial and compassionate physician.

Explore the frequency of thoughts, intensity, the lethality of intent, the extent of plan, level of impulsivity and judgment.

4. Be Attentive to Warning Signs

• Ideation — thoughts
• Substance abuse
• Meaninglessness and Purposelessness
• Anxiety or feeling Trapped
• Hopelessness and Helplessness
• Withdrawal and Isolation — lack of or inability to access social support
• Rage and Anger
• Impulsivity and Recklessness
• Severe fluctuations in Mood
• Listlessness and inability to do routine tasks and daily functioning

5. Hierarchical Layering of Risk

• Imminent/high risk – Firm plan, prepared with the means, very poor social support, severe mood disturbances, disturbed sleep, abuse of substances, highly impaired judgment.
• Moderate risk – Ambivalence, willingness for treatment, no clear plan, few social supports like friends/family, a fair level of judgment.
• Low risk – No plan, no clear intent, has support, compliant to treatment goals, high ambivalence, a fair level of judgment.

6. Ambivalence and Desire to Live

Explore the ambivalence, tap into it.  Ask, “What reasons are there for you to die? Why do you want to live? What has kept you alive so far? How do you envisage life-changing if you die? Who will be impacted? What kind of impact do you believe will be there after your death? If you wanted to be alive then how do you want to live this life?”

7. Case Formulation

MAKE A CASE FORMULATION OF SUICIDAL RISK. Create a meaningful understanding of your client’s way of operating in different domains of life. For e.g. ability to deal with stress, loss, failure, personal history, support systems, strengths and weaknesses. Identify under what circumstances a client is likely to be at risk.

8. Support

Seek supervision, consult peers and access your support systems for self-support and supporting your client.

9. Personal Assessment

In your assessment, if you think the risk is high then have a plan in place with your client about informing the right people and/or hospitalisation.

10. Collaboration

Collaborate with fellow professionals like psychiatrists, physician and hospital team to support your client through this.