Suicide Risk Assessment and LGBTQ+ People in Psychotherapy: Safety, Surveillance, and the Conditions of Care

LGBTQ+ people face elevated suicide rates alongside long histories of clinical pathologization. Suicide risk assessment is a central practice in contemporary mental health care, yet client-centered qualitative accounts of these encounters remain rare, particularly accounts that attend to how risk assessment operates within institutional and relational conditions. This study takes up three connected questions about suicide risk assessment as experienced by LGBTQ+ people who have undergone it: how clients understand what happened in those encounters, what their accounts reveal about the relationship between clinical practice and clients' capacities to speak and be heard, and what conditions support or undermine care. Semi-structured interviews were conducted with eight Canadian LGBTQ+ adults who had undergone suicide risk assessment in psychotherapy more than 24 months before interview. Data were analyzed using reflexive thematic analysis within a critical qualitative inquiry orientation. Six themes were developed. Five located harms within risk assessment: The Paradox of Protective Harm, Stuck in the Logic of Risk, The Erosion of Autonomy as a Structural Feature, The Dance of Strategic Disclosure, and Reading the Clinician. A sixth, Risking as Relational Possibility, identified conditions under which risk conversations supported recognition and access. Participants described how safety-oriented practices generated harm through their protective aim, how risk-based clinical reasoning narrowed access to care, and how they performed continuous labor to remain intelligible and safe within assessment encounters. Participants' accounts position LGBTQ+ clients as authorities on the conditions of their own care and suggest implications for relational, transparent, and non-carceral clinical practice.