What Happens When You Mention Suicide in Therapy?

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The first time John came to my office for treatment, I asked him many questions about his background, his symptoms, his strengths, and his goals. And then I came to a standard question about suicide: "Have you been thinking you'd be better off dead or wishing you were dead?"

John hesitated, then replied, "No . . . Not really."

"Not really?" I asked, sensing there was more to be said.

John looked away and sighed. He then explained that at his lowest points, he sometimes feels like maybe it'd be better if he were dead, and at times, he had wished he could go to sleep and never wake up. I spent some time assessing how serious the risk was that John might end his own life, and concluded that the risk was low. We made a plan for how John and I would monitor and manage his thoughts of suicide.

At the end of the meeting, John said he was relieved that I hadn't overreacted to his occasional thoughts of wanting to die. "I thought you might have me locked up," he confessed, "which is why I didn't want to tell you at first. But I thought you should know."

John isn't alone in this fear when it comes to disclosing thoughts of suicide. Many people I've worked with have expressed a similar sense of relief that we can talk about suicide without automatically making it an emergency. Unfortunately, fear about the therapist's response, based on a person's own experience or what they've heard, might discourage them from seeking treatment if they've thought of suicide. Similarly, a person in therapy might hide his thoughts about wishing he were dead, as John did at first.

A person might also be ashamed of her suicidal thoughts, believing they represent a personal failing on her part, when in fact they're a fairly common response to intense distress. If she doesn't feel free to be open about these thoughts in therapy, she may have no place to discuss them. Most disturbingly, choosing not to seek treatment for this reason could prevent a person from getting the help she needs, thereby increasing the risk for acting on the suicidal thoughts. Clinicians generally consider it a positive sign when a patient discloses thoughts of wanting to die; it's much more concerning when a suicidal person says nothing, and thus remains at higher risk.

While the specifics will vary among mental health professionals, the standard approach for discussing suicide includes asking about:

• Thoughts of wanting to die or thinking one would be better off dead (called "passive suicidal ideation").
• Thoughts of actually harming or killing oneself.
• A desire to kill oneself.
• A plan for killing oneself.
• Steps a person has taken to prepare for suicide (e.g., giving away belongings).
• Ready access to the means of suicide (e.g., owning a gun).

Obviously the later steps represent a more serious level of risk; many more people will have had passing thoughts of not wanting to be around anymore versus actually formulating a suicide plan. In addition, the clinician will ask about reasons not to take one's life, such as, "I could never do that to my children."

The severity of the risk will determine the course of action. A high level of danger for the person might require hospitalization to ensure their safety. When the clinician concludes that there is no emergency, they will likely develop a safety plan (Stanley & Brown, 2012) with their patient. The plan will include ways for the person to manage suicidal thoughts and impulses, arranged as a series of steps:

• Step 1: Identify the warning signs — thoughts, feelings, behaviors, or situations — that increase the risk for suicide. For example, a person might recognize the thought, "I'd be better off dead." The presence of warning signs leads to Step 2.
• Step 2: Use coping strategies that don't require contacting anyone else, such as listening to relaxing music or exercising. The advantage of these approaches is that they're always available, in principle. If they're not sufficient to defuse the potential crisis, it's on to Step 3.
• Step 3: Contact people who can provide distraction and relief — not necessarily people to confide in about the suicidality, but people the person enjoys being with. The plan will include a list of people's names and their contact information, as well as social settings that can provide distraction (e.g., going to the mall).
• Step 4: If needed, contact a friend or family member specifically to ask for help. This is more intensive than the previous step, because it involves disclosing one's thoughts of suicide. The safety plan will include the names and contact information for multiple people the individual could contact.
• Step 5: Contact professionals or agencies, including one's psychiatrist or other mental health professional, if applicable. It can also include local urgent care services and 24-hour treatment facilities, as well as the National Suicide Prevention Lifeline (800-273-TALK [8255]) for those in the U.S.

It's also important to keep the environment as safe as possible, like not having easy access to the means of suicide (e.g., a stockpile of potentially lethal medication). Finally, the plan will list what is most important to the person — what makes life worth living.

Many clinicians may have been trained (like I was initially) to obtain a signed "safety contract" or "no-suicide contract" from the patient, which in essence is a "promise" from the patient not to attempt suicide. However, these contracts obviously aren't enforceable, and there is minimal evidence that they lower the risk for suicide. As Stanley and Brown (2012) point out, these contracts also don't include a plan for how the person will reduce their chances of hurting themselves. Moreover, they can interfere with the therapy relationship, especially if the patient feels coerced into signing the contract. Patients might also suspect — perhaps rightly — that the contract is more about protecting the therapist than the patient.

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In contrast, formulating a safety plan together can strengthen the bond between the therapist and patient, as they collaborate toward a shared goal of keeping the patient safe so the work of healing can continue. It's also an empowering approach, as it includes the patient in planning and decision-making at a time when the person is particularly vulnerable and may fear an automatic loss of freedom and autonomy by mentioning the word "suicide."

Mental health professionals should be trained in how to respond confidently and compassionately when a person says they've thought of suicide. The response should include a collaborative discussion to determine the level of risk, and the development of a plan for safety.

If you have had thoughts of suicide and are concerned about your safety, please tell someone you trust. You can also call the National Suicide Prevention Lifeline which is available 24 hours a day, 365 days a year, at 800-273-TALK (8255). In a true crisis, call 911 if you live in the U.S. or the appropriate emergency number if you live elsewhere.

Click here for a Safety Plan Template.

To find therapists near you, see the Psychology Today Therapy Directory.

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