hey, I'm wondering what the protocol in therapy is for if you say your (passively) suicidal. At beat its like confidential, but I also fear like legal results from it if I say it directly without code words or only implications like being forcefully locked away "for my own safety" forced to pause my life with negative results.
Ok, so before I get into this, I wanna clarify that I am *a* therapist, not your therapist. That is EXTRA important for this type of question because approaches to addressing suicidal ideation (SI) vary SO so so widely that it’s not fair to try and answer this question for the whokle I keep typing and re-typing a response to this question because it is so difficult to answer succinctly. My job isn’t just to make people feel good immediately, it’s to help them make meaning of their life and if they intend to take their life then my job becomes guarding their life so they can live long enough to actually make their life meaningful.
Maybe it’s actually JUST an legal CYA thing and I’m trying to delude myself into making it a good thing, but in my mind the act of hospitalizing someone is not something to be taken lightly and so it is really only something that I, personally, utilize if I cannot get someone to credibly engage in safety planning.
For passive or ego-dystonic suicidal thoughts it’s often not seen as inherently requiring hospitalization, but even then I’m hesitant to say that since some providers see it very differently. I can really only speak for myself, but in my personal therapeutic work if someone expresses passive SI or ego dystonic SI I will engage in safety planning in most cases.
My typical approach is to say something along the lines of “If the thoughts are passive now then it’s good to make a safety plan while we have the opportunity, because if they move from passive to active thoughts it can sometimes be hard to think clearly enough to know what to do.” It’s not meant to be a punishment or a shameful thing, it’s taking the opportunity to keep you safe before it feels overwhelming so if it DOES become overwhelming you don’t have to think about what to do, you can just focus on the doing. Safety planning with me involves three steps:
1) Identifying reasons to live: These are often varied, but this is a no-holds-barred type of move so literally anything works here. Sometimes people will feel pressured to say things like “My family” even when they know that when the thoughts are more active their family is not a motivating factor to stay alive, so I always try and let people know that honesty is crucial to this aspect of safety planning. I had a patient once tell me their reason to live was that they had a date that evening and they couldn’t die before knowing if the person they were going out with was going to pick a good movie to watch. I had a client tell me they couldn’t die until their little brother apologized for overwriting their save in a video game. Anything works here, tbh, as long as it can get you even another 3-4 days worth of time. Other things people talk about as reasons to live are: Wanting to see their siblings grow up, wanting to see their spouse achieve a significant goal, wanting to outlive shitty parents, wanting to be present for parents, wanting to see their favorite band perform live, wanting to go on a specific vacation, needing to finish a specific book series or T.V. show, wanting to buy their own home or get their dream job, wanting to own a pet, etc. These are all equally valid reasons to live.
2) Once some reasons to live have been determined, I like to establish safety behaviors – this part is twofold. The behaviors include behaviors which limit access to means of dying by suicide, as well as behaviors that help reduce distress. For behaviors that reduce access to means, this can include: Giving your sharp implements or firearms to a trusted friend or even throwing them away, getting rid of rope, storing pills with a therapist/parent/friend, or putting heavy furniture in the way of a balcony. I had a client once lock their car keys in a safe they didn’t have the code to open for a bit. Anything counts – putting your pills in a place that requires a stepstool to access gives you an extra 1-2 minutes for the urge to pass or for a better next step to come to mind. The name of the game with active SI is waiting – the urges will pass with time and in many instances they pass within a relatively short timeframe. I had a patient once tell me that they always took a nap before acting on thoughts because napping is “like dying for an hour,” so that counts as a strategy. I had a patient tell me that her strategy when it got bad wasn’t to think of family because she hated her family. She said she dealt with SI by reading morally questionable smut and getting shitfaced on cheap wine. I had a conversation with my own therapist at one point that one of my strategies is to go for runs until it physically hurts. Other things people have come up with is going for walks, listening to music, kneading dough, watching a comfort show, calling a crisis line, calling me to ask for a crisis appointment, calling family/friends for support or distraction, etc. These are all coping strategies. Not all of these are ideal long-term strategies, but when your back is against the wall and it’s between napping through a class or dying by suicide, honestly, fully fuck that class. Stay alive. Take the nap. Stay alive, call your ex. Stay alive, buy that shirt you don’t need.
3) The last stage is identifying safe people to talk to. This one also requires honesty to a degree – maybe the person you WANT to talk to is your dad, but if he’s not a person who can meet your emotional needs then don’t call him first, call someone who CAN meet your needs. Call a crisis line, call a local therapist, call your big sister or your best friend you haven’t spoken to in a month, but call someone, because not only should you not have to worry alone, the human species is genuinely not good at worrying alone.
If a patient of mine can engage in safety planning and credibly commit to utilizing their safety plan then I’m always happy to leave involuntary hospitalization on the wayside unless things get worse.
Having talked about this to some extent, I can now return to your question of “What happens if *I* disclose that information to a therapist?” and the answer really still is “it depends.” Suicidal ideation is more common than many would guess, but it is still something that requires providers to address seriously, and not just because it’s a CYA legal move but because it’s also a serious aspect of mental distress and deserves to be treated as such.
For what it’s worth, I hope this does not deter you from speaking to your therapist about these thoughts. It’s always a scary conversation to start, but with a good therapist it can often feel beneficial and even helpful to discuss it openly.
For anyone currently experiencing suicidal thoughts, especially if the thoughts are causing you to feel distressed, I highly suggest contacting suicide prevention resources.
https://findahelpline.com/countries/us
Call 988 if you’re in the U.S. or text 741741 for a text chat. For help finding a therapist, I can recommend utilizing your insurance company to find in-network providers if possible, or utilizing the Find A Therapist option on Psychologytoday. If cost is a factor, look for community mental health centers, which often offer reduced pricing. If you can find a clinic that is training providers, they often offer reduced pricing on services as well, and group therapy is often more affordable than individual therapy and has been shown to be as-effective (if not MORE effective) than individual therapy for issues like depression, social anxiety, generalized anxiety, posttraumatic stress, and addiction. If you re a university student, try contacting your university’s health center to gain access to local resources which could be available and covered by your tuition.
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