What We Don't Talk About When It Comes to Suicide Prevention

"If I call that number you gave me, will they call the cops?"

With the rollout of 9-8-8, I, like most therapists, have been enthusiastic to give the number. Still, it has sparked several questions. I want clients to be comfortable using resources when needed, so I answer as best as I can. Yet, the fear is real. Discussing thoughts of suicide can ramp up anxieties on both the client's and clinician's sides. We clinicians worry about making the 'right' choice regarding appropriate intervention, the client's well-being, the possibility of missing something, and ultimately the risk of life. For individuals reaching out for help, fear tends to center more on coercion, such as police involvement, involuntary hospitalization, or even feeling more misunderstood at a critical moment.

Before I go on, the answer to the question, 'Will they call the cops?' is usually no. The goal of resources such as crisis intervention is to offer support without coercion unless it is necessary. Most calls to crisis lines do not result in police intervention.

Clinician Fears

I began my career in crisis intervention, meeting with individuals amid a mental health crisis, which often included thoughts of suicide. I learned about forms to measure suicide risk, risk factors, and protective factors as well as the importance of remaining human. It's amazing how something as deeply personal as crisis counseling can become mechanical if we are not careful to keep a person-centered focus.

In crisis intervention, the primary objectives are often the assessment of risk and the creation of a plan to minimize that risk. Meeting the person and their needs is also essential. While structured suicide risk assessment tools exist, there is no clear calculator for such. No form can tell the future. The experience of feeling both responsible and ultimately not having control of the outcome can be overwhelming.

Therapists often share fears related to client suicide. It is perhaps the greatest hazard of our work. We care about clients. Effective management of that anxiety is essential.

Still, some anxiety is unavoidable. Current figures of suicide are at an all-time high (Center for Disease Control, 2024) with each of those numbers representing a human life and loss for many who loved them.

Client Fears

On the other side, clients often carry their fears. In my experience, one of the top concerns has been going to the hospital. This has typically been from individuals who attempted suicide in the past or had psychiatric hospitalization for other reasons.

Meta-analysis has found that about one in five individuals who attempt suicide go on to make a second suicide attempt, and individuals with a history of suicide attempt are at some of the highest risks of dying by suicide (de la Torre-Luque et al., 2023). Historically, psychiatric hospitalization following medical stabilization has been standard practice following a suicide attempt or presentation to an emergency room with intentions of suicide. Yet many individuals report negative experiences regarding hospitalization.

A qualitative study of 11 women hospitalized due to thoughts of suicide found that many felt dehumanized during their stay (Hagen et al., 2020). Most locked wards are highly secure and individuals are stripped of the comforts of things like shoelaces, their usual shampoo, and even many clothing options, all in the name of safety. Other qualitative research found that many who received psychiatric hospitalization found it to be prison-like and isolating. This is especially concerning as feelings of hopelessness, powerlessness, and isolation are strong contributors to a suicidal mindset (Lindgren et al., 2019).

Restraint, seclusion, and sedation are common in inpatient units and can be frightening to witness, adding a threat component. Also, while group interventions may be offered in a hospital, robust individual therapy usually does not take place there. Groups in an inpatient environment are often facilitated by techs who have little in the way of formal therapy training. Sessions with a psychiatrist are typically short and pointed to stabilization over longer-term goals. Hospitalization is a safe place to bridge between a crisis and a more sustainable treatment plan, however the overall quality of therapeutic treatment within acute inpatient settings is often poor.

Ironically, death by suicide after release from an inpatient mental health unit is all too common and some have suggested that adverse experiences in inpatient settings may play a role here (Chung et al., 2016). To date, there is no publication to show that hospitalization reduces the risk of suicide. On the contrary, some have suggested the potential harm of psychiatric hospitalization, citing the marked increased risk of death by suicide after an inpatient stay and other negative outcomes (Ward-Ciesielski and Rizvi, 2021).

A study of 66 individuals who admitted to concealing thoughts of suicide from their therapists found that fear of involuntary hospitalization was by far the chief reason reported (Blanchard et al., 2020). The study found that many clients feared even mentioning the slightest thought that could result in hospitalization even when they did not feel at significant risk.

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Fears of sharing these thoughts can leave individuals who are in a space of suicidal crisis feeling alone when they most need support.

Reality

The reality is that clinicians cannot help what they do not know. Clients must feel comfortable enough to share their thoughts of suicide when needed, and we must have effective ways to intervene. The truth is, we do.

Crisis intervention is not synonymous with hospitalization. At times, hospitalization may be necessary to rescue an individual at imminent risk, yet it exists on a long continuum of intervention options ranging from safety plans to the removal of lethal means to follow-up phone calls to staying with a friend to spending a few hours at a crisis intervention center. Effective suicide prevention measures are individualized.

Most individuals reaching out to a crisis intervention line do not find themselves faced with coercive measures. Rather, they are given a lifesaving opportunity to be joined by another person when they are in a state of need. Still, these fears remain.

What We Know About What Prevents Suicide

Beyond our fears, suicide prevention initiatives have shown success.

Research shows that involvement in psychotherapy reduces the risk of suicide in individuals who have made a prior attempt (Sobanski et al., 2021). As long as immediate risk can be kept at bay, psychotherapy can focus on addressing the problems underlying an individual's thoughts of suicide, augmenting a sense of hope, rallying their support system, and ultimately moving toward what the individual deems a life worth living. For many, thoughts of suicide develop over a long course of time, so active monitoring of these thoughts met with appropriate ongoing support is often necessary.

In addition, especially for younger individuals, sudden changes in circumstances (such as a breakup or a failing grade) can lead to a rapid change in mental state. These individuals may benefit from psychotherapies that offer 24-hour skills coaching calls with a therapist between sessions as is offered in many Dialectical Behavior Therapy programs.

Follow-up after a mental health crisis has also been shown to be effective, as well as the creation of a specific safety plan (Nuij et al., 2021). It's important to note here that this is different from a 'no-harm contract.' Historically no-harm contracts were a method of suicide risk prevention that involved a person signing a paper that they would not hurt themselves. In contrast, a safety plan involves a discussion of what an individual needs to survive the crisis and is not meant to be coercive or liability-focused. It's a plan of how to work toward a person's safety and well-being between contacts with mental health professionals and what to do if a person does not feel they can stay safe.

Effective suicide prevention initiatives must also look beyond the individual to the community. While interventions for suicidal thoughts often focus on the treatment of conditions like depression, social factors also contribute to thoughts of suicide. According to the interpersonal theory of suicide, a sense of not belonging coupled with a sense of being a burden can trigger thoughts of suicide. Depression can strengthen this, yet thoughts of suicide often have social as well as psychological sources (Van Orden et al., 2010).

With the strong link between suicide and isolation (Motillon-Toudic et al., 2022), there is also a place for community intervention outside the formal mental health system. Resourcing someone's family and building a stronger sense of belonging are often key to resolving suicidal crises. A systemic review of 185 clinical trials found that social support interventions are often an effective suicide prevention strategy (Hou et al., 2022).

We Have to Talk About It

Suicide prevention is not only something for mental health providers to target but also something we must tackle together as a community. In our communities, we need to talk openly about loneliness, hopelessness, and the reality of suicide. We can encourage and guide each other to support.

On the clinical front, along with other measures, open conversations about suicide prevention need to take place about fear on both the clinician and client sides. Fear limits our effectiveness in a way that can be dangerous in these scenarios. Clients who have had negative experiences in the past when they have revealed thoughts of suicide might especially need support.

As well, consultation groups and supervision can assist clinicians in navigating these difficult terrains. Collaboratively, we can move toward more effective efforts to reduce suicide built on compassion and hope rather than fear.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.