How to treat chronically suicidal patients effectively in-person or online

How to treat chronically suicidal patients effectively in-person or online

“I don’t see treating a chronically suicidal person online as significantly different than in person because, either way, if there’s an issue you’re going to call crisis intervention.”

That’s what Belinda Barnett PhD and Clinical Psychologist with over 18 years of experience said in response to my question about what challenges or concerns a clinician might face with online therapy opposed to in-person therapy when serving chronically suicidal patients.

Turns out, the real question isn’t whether or not online therapy is a successful and safe option to provide care for chronically suicidal patients. 

But rather: Are your methods effective and are you capable of handling the stress and building yourself a structure of support so that you can care for yourself and your clients

It was evident throughout our conversation that Belinda’s heart is for her clients to not only manage risk but also to develop lasting systems to support themselves and see their own value.

Over the last 18 years her clients have had successful and measurable results. If you’re wondering whether or not your approach to serving chronically suicidal patients is effective, settle in because there are a few traditional approaches that Belinda has observed to be harmful and she’s here to share the alternative. 

Here are three specific approaches that Belinda believes have directly contributed to her clients’ success in not only managing risk, but creating the tool-belt necessary to thrive with mental and emotional freedom.

Knee-jerk Reactions

An understandable reaction when a client confides that they have had suicidal thoughts, have a plan in place, or are practicing self-injury is to immediately send them to the hospital.

This is harmful in a few ways. 

First of all, if this is always your first response as a therapist your client will be less likely to confide in you when they’re struggling with these thoughts. 

Secondly, the hospital is no longer a place where people go to get better over the long term. It’s a sterile building with lots of other sick people who are there to get stabilized medicated and returned home as soon as possible. 

Thirdly, if your client has been struggling with this for any length of time they probably have been to this exact hospital or ER more than once. It’s not uncommon for medical professionals to get frustrated seeing the same patient over and over again for the same condition. 

NOTE: This is not to slight medical professionals – this is a very understandable reaction. They work hard, serve us well, and we need them, especially in crisis circumstances. At work they are often stressed caring for a lot of individuals. 

Instead of immediately sending a client to the hospital when they share a suicidal thought take it seriously, but also take your client seriously by assessing their likelihood to actually act out and consider the following:

  • How long have you been working with the client?
  • Have you seen them implement the lessons you have assigned them?
  • What is their ability to keep a commitment to you?

I once negotiated with a client I had been working with for sometime to not do anything for 24 hours until they saw for an appointment the next day. At that point in the conversation I told my client, “I’m gonna trust you not to do THIS. You have to trust me that I’m doing what’s best for you. But I’m also trusting that if you start to struggle again before I see you you will call me. Does that make sense?”

“Individuals aren’t used to clinicians putting their trust in them.” Belinda stated. 

But trust is imperative to their healing. If they can’t learn to trust others and reach out when they’re struggling, how are they ever going to create a community of support for themselves? And if they do not experience trust in them how are they ever going to learn to trust themselves?

This section is not an invitation to take a suicidal comment less seriously. It is, however and invitation to take your client seriously, believe in them, and make the best decision for your client on their way to healing.


The idea that people self-injure for attention is traditional and often accepted, but more often it isn’t true. No one wakes up thinking “The way I’m going to live an adult life is by cutting myself.” 

While on the surface self-injury looks manipulative it’s truly an attempt at solving a problem. 

Cutting, or any form of self-harm for that matter, is a way an individual has learned to cope with their reality. It often serves as a neutralizer or a way to feel emotions. If someone is feeling dull or lifeless pain can make them feel alive again. If they could choose a different way they would.

Instead of feeling frustrated by your client’s seemingly attention-grabbing behavior you have help them three ways:

  1. Help your clients identify and name their emotions. Remember, self-injury often serves as a neutralizer or way to feel emotion, so if you’re able to help your client verbalize and put a name to their feeling, they will be one step away from inflicting physical injury as a form of resolution and personal-understanding. 
  2. Help your client learn to manage that emotion instead of letting it get out of control in their mind.
  3. Help your client develop skills to deal with the problem that generates the severe emotion.

Marsha Linehan says something along the lines of, “To work with borderline people you have to really like them.” Borderline individuals tend not to be likeable people a lot of the time. 

If you are unable to see through their drama to where their pain is coming from this is probably not the best clientele for you to be serving. Anger and blaming clients for their behavior is often very harmful and representative of a fundamental misunderstanding, but can prevent your clients from making the changes they need to in order to live a life of mental and emotional freedom.

Parental Role

It’s not uncommon for psychiatrists to approach their work with their clients from a very parental role. When the client doesn’t do it they feel like the client is being resistant. Keep in mind for one reason or another the client came to you for help. So, maybe they’re being resistant, but maybe this is really hard and they need someone with knowledge to come alongside, support them, and guide them in creating lasting systems for success. 

Instead of taking on the parental role in your work with your clients approach it like a partnership and communicate that. Belinda says something like this, “I have the book knowledge, but you have the YOU knowledge and our job is to bring knowledge together and create a better life for you. If we keep at this you are gonna make mistakes and I’m gonna make mistakes. What I’m asking for you to do is communicate with me and tell me when I make mistakes.” 

Again, you’re leveraging the influence of trust to build relationships with your clients and inspire them toward personal responsibility. A lot of chronically suicidal patients have been from clinician to clinician to clinician, this partnership approach starts you out on a different foot.

In Closing

I can’t summarize this post any better than Belinda herself, so I’ll just leave her closing thoughts from our interview with you!

“This work is never easy and even with 18+ years of experience I am far from an expert. I’m far from feeling like I have a handle on how to do all this. 

“While this work does get less difficult, it’s always scary. It’s never comfortable to hang up the phone when someone has called you, told you they were struggling, and you were able to convince them not to do anything until they get to your clinic the next day. It’s stressful.

“I don’t work with more than 3-4 clients struggling like this because that’s my limit. If you choose to work with this clientele you need to know your limits. And you need a support system for yourself.” 

If you’re wanting to serve chronically suicidal patients or improve your ability to serve them, reach out to Belinda HERE. She’s creating a course with specific strategies to serve your clients in a way that helps them manage risk but also develop a lasting structure to live with mental and emotional freedom.

If you’re wanting to provide online support that is HIPAA compliant to your clients schedule a call with us HERE.


April 13, 2020 / iTherapy Blog

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