September is Suicide Prevention Month. This is a cause near and dear to my heart. As a psychologist, I have worked with many people who were dealing with suicidal thoughts and impulses. What troubles me is that suicide scares off most therapists. They shy away from asking about it at all, let alone helping someone to overcome their thoughts. I want to give a brief guide on caring for someone experiencing suicidal thoughts or self-harm and what should be happening in therapy.
Many people are afraid to disclose to their therapist that they are having suicidal thoughts because they worry that they will be immediately sent for a hospitalization. Unfortunately, this might be the case with an unqualified therapist!
For therapists with strong training in helping people with suicidal thinking, hospitalization (e.g., a 48-hour hold in a psychiatric unit) is a last resort reserved for people who truly are a danger to themselves and are not able to maintain their own safety in that moment.
What should happen is a thorough assessment of risk of harm to self, often using a standard questionnaire such as the Columbia Suicide Severity Rating Scale. Answering these questions could bring up fear or shame. Someone also might not want to fully share the truth because, to be frank, they don’t yet want the therapist to interfere with their plans to end their life! The therapist will then help someone to create a safety plan, which includes things like encouraging statements (e.g., “This too shall pass”), how to contact hotlines and family/friends for support, and basic coping skills. The plan will also cover how to remove access to ways to harm oneself.
Many people think the suicidal thoughts or self-harm urges are a symptom of depression and will go away if the person is no longer depressed. Actually, these symptoms can be present in many mental health conditions other than just depression, and they often require their own set of skills.
Dialectical Behavior Therapy (DBT) is the most well-known therapy that specifically targets suicidal thinking and self-harm with a set of coping skills. Generally, it is expected that someone will not graduate from their DBT program until they are no longer actively harming themselves or wanting to end their life. This would be my #1 recommendation for someone with a persistent history of suicidal thinking/action or self-harm. [Find a DBT program here.] There are also some specific programs for teens, including CBT for Suicide Prevention (CBT-SP) and Safe Alternatives for Teens and Youth (SAFETY).
Actually, one symptom that can be treated and prevent suicidal action is insomnia (poor sleep quality). CBTi has some evidence that it can reduce suicidal thinking.
As a caregiver or loved one, how can you support someone who is suicidal or self-harming? My #1 tip is to remember that you are not responsible for maintaining someone else’s safety but knowing what to say and do can be really beneficial. Try a DBT skill called validation, signaling to your loved one that you understand why they are feeling and behaving this way and you’d like to help them maintain safety.
I’m a big fan of using 0-10 scales. This can be a quick and less shameful way to check in. For example, a parent might say, “Hey, where are you 0-10 right now?” when they notice their teen is being quiet or isolating. The scale might be something like 0 is totally safe, 10 means that they are imminently wanting to die, and the in-between numbers are connected to suicidal thoughts or self-harm urges. Obviously, anything other than a 0-1 might be cause for concern, but not panic. The caregiver or loved one could simply ask, “How can I support you?” and maybe even just help them remember to use their safety plan or spend time with them. If a higher number, they might support them in seeking an evaluation at a local emergency room or mental health crisis unit.
Loved ones might also be involved in helping maintain safety through limiting access to means of harm. For example, I might ask a parent to lock up all “sharps” (e.g., knives, razors) in the home. A friend of an adult might help them put a lock on their gun and allow them to store it in their home instead of their own for the time being.
For the person experiencing these thoughts or urges, it really is about reviving hope, reasons for living, purpose, and riding the wave of strong emotions. Remembering that these urges will pass and that you are valuable and your life has meaning can be really helpful. You are not a burden. Your problems are not too big to bear, and they don’t have to be dealt with alone. Also, increasing problem solving can be helpful. It may seem that suicide is the solution to a problem such as loneliness, traumatic stress, or having made a huge mistake. It is not the solution and there are so many other ways to solve these concerns, even though they seem so huge in this moment. These are the things I and other therapists are helping people discover (or remember) in therapy.
Resources
National Suicide Hotline: Call or text 988
LGBTQ Suicide Hotline: Call 1-866-488-7386 or text 678-678
A safety plan tool to use alongside a therapist: suicidesafetyplan.com
An app to access coping skills in a moment of distress: https://apps.apple.com/us/app/virtual-hope-box/id825099621
An app to create a safety plan: https://play.google.com/store/apps/details?id=au.org.beyondblue.beyondnow&hl=en_US
A guide for caregivers of teens: https://afsp.org/teens-and-suicide-what-parents-should-know/
A guide for any loved one: https://www.nami.org/relationships/how-to-talk-and-listen-to-someone-experiencing-suicidal-thoughts/
It can be so scary supporting yourself or someone else through this time, but it is worthwhile when these tools work and someone uses their reasons for living to maintain their safety! I’ve seen it happen with so many patients.
If you want to support this cause, there will be national American Foundation for Suicide Prevention walks over the next months. If you’re in the Atlanta area, you can join the team I’ll be walking with here.
Please pass this post along – you never know when you could help save a life.
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