Chronic suicidal ideation poses its own unique set of challenges. If you’ve worked as a therapist or counsellor for any considerable length of time, you would have had a client present in distress or, at the last few moments of a session, said something that makes us wonder, “Are they safe?”.
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Suicidal ideation can be a complex topic to manage both for clients and their therapists. There are, however, some key factors to keep in mind when working with clients with suicidal ideation, in particular, chronic suicidal ideation.
What is Chronic Suicidal Ideation?
Suicidal ideation can happen in a lot of circumstances and for a variety of different client cohorts. The most challenging of them all is the individual with chronic suicidal ideation. Why do I say they are the most difficult? Simply because they fall into that uncomfortable space that is safe enough for now, yet at the same time, not safe at all.
They are the clients we often decide it is not justified to send to the emergency room. Yet, their circumstances and presentation linger in our minds after the session has ended, and we worry about whether they will be fine until next week's appointment. Learn about somatic experiencing therapy for trauma here.
The typical individual with chronic suicidal ideation is the person who has, for an extended period, experienced passive thoughts of suicide such as ‘maybe it would be better if I wasn’t around” or “if I didn’t wake up tomorrow, that would be ideal”.
They are the type of person who rarely has an actual plan in mind of acting on these thoughts, and if they do, it is often a vague idea rather than a forthright set of steps. Most importantly, they usually do not have a present desire to act on their thoughts. Now, of course, there are variations of intensity and planning in individuals with chronic suicidal ideation. Still, we would often characterise them as individuals with thoughts but no apparent intent to act.
Does this mean we don’t worry about them? No, of course not. As practitioners, we know that suicidal behaviours are often acted upon spontaneously. Hence, any client with suicidal ideation needs to be monitored, and a safety plan should be developed together with the client.
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Treatment for Chronic Suicidal Ideation
With clients facing chronic suicidal ideation, we rarely need to act on an immediate risk of harm. Instead, the focus is often on long-term safety and well-being planning. This includes identifying the frequency and intensity of thoughts, understanding any plans, and any previous or current intent to act on the thoughts. In addition to this, a good safety plan will include the following components:
- They can reach out to safe individuals if they start to feel they cannot keep themselves safe.
- Crisis support number.
- A list of triggers or signs that they are not doing well.
- A plan for limiting access to means of harm.
- A plan or schedule for regular treatment appointments and practitioners involved in their care.
- Strategies for distraction and self-soothing when urges to act on self-harm or suicidal thoughts come up.
- A plan on accessing urgent care if needed (e.g. emergency services numbers, a person they can call to take them to the hospital, etc).
- A list of activities that keep them feeling well and engaged with essential people in their day-to-day lives.
- Their reasons to live.
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In addition to having a clear, written safety plan in place that the client and practitioner both agree to and that the client can access at any time, it is also essential to discuss the goals of treatment for chronic suicidal ideation. If we know there are specific triggers for the imagination, such as previous trauma or depression, then these concerns need to be a priority in treatment to help stabilise the client long-term.
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Safety Plan Tools and Templates
Keeping simple and effective templates on hand to complete with clients when needed can make the safety planning process more efficient. A safety plan is a crucial staple in any therapist’s toolbox, and numerous versions are available.
Key features of a quality safety plan include ease of accessibility (e.g. in digital format and kept on the phone or computer) and that are detailed enough to contain essential information for maintaining safety, yet brief enough that the client does not feel overwhelmed at the thought of completing or accessing the tool when feeling unwell. If you want a clear, simple and effective safety plan template for your clients, you can find our safety plan template bundle via the link below.
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Our safety plan worksheets bundle has been developed to assist therapists and counselors in identifying and managing risk with their clients and makes an ideal resource for effectively managing distress tolerance and suicidal ideation.
