I think there is a distinct difference between suididal ideation and the I am going to perform the act now. If there is no imment danger to the client then they are not obligated to send the person to the ER. My therapist wants you to tell her if you are feeling this way so she can help when you are going through such a hard time. She assures herself that you are being honest, will be safe and will contact her if things get worse. I suppose that is a hard call for her to make but she thinks it is part of the job. If she thinks there is immenent danger she would tell you to go to the ER. I don't understand a therapists/client relationship that won't allow such an important part of what the client is feeling.