Note: "Unalive," meaning dead, is what is called algospeak, a way of preventing important but triggering topics from being flagged as inappropriate by social media sites.
At least 9% of adults and 20% of teenagers will experience suicidal thoughts (i.e., thoughts of intentionally taking their own life). Of course, because this is a taboo subject, the true numbers of people who have had suicidal thinking may be much higher than what is reported in research studies. I would imagine thinking about suicide is much more common than we realize.
Even people in therapy who are being very honest about the mental health difficulties they experience still are probably very uncomfortable or resistant to share if they are having thoughts of hurting themselves or ending their lives. It can be very intimating to disclose information that is so intimate and vulnerable.
In the mental health field, a lot of mistakes have been made in assisting people who are experiencing suicidal thoughts, plans, or actions or self-harm/non-suicidal self-injury. Until recently, there were no evidence-based treatments (now Dialectical Behavior Therapy is the gold standard) and hospitalizations were probably the most likely course of action.
I believe most people are afraid to disclose their suicidal thinking in therapy because they believe that they will be hospitalized against their will or their therapist will not be able to continue working with them.
To be fair, I’m sure that has been the experience for many people! As shocking as this probably sounds, most mental health professionals (therapists, psychiatrists, etc.) do not receive adequate training in working with people who are experiencing suicidal thoughts and behavior. If a professional is not competent in working with suicidal patients, they may make mistakes or refer out to hospitals or other providers who have more experience in this area.
I’m going to share with you what ideally would happen once someone discloses suicidal thoughts or actions or self-harm to their therapist. Of course, we do not live in a perfect world and I cannot guarantee that this will be the procedure. However, if something close to this is not your experience, then I would suggest finding a more qualified provider.
First, I hope your therapist would respond with compassion, understanding, and validation. What a vulnerable and brave thing to disclose to someone! Thankfully, you’ve disclosed it to someone who actually knows how to help. Although it is hopefully atypical for one person in their own life story to want to die, I truly believe suicidal thinking is not uncommon.
Second, your therapist will have to ask you a lot more questions. Get ready, because I know this stuff is hard to talk about! They have to know the when, where, why, how often, etc. because it’s super important in keeping you safe. They might ask questions about the timing, intensity, and frequency of the thoughts, whether you have plan, intent, or means to end your life, your social support network, and more.
[Note: It would be very unusual for you to disclose these thoughts to your therapist and them not respond at all. If that happens, you definitely want to seek out a new provider!]
Third, your therapist will work with you to create a safety plan. A safety plan is a list of ideas to help keep you safe outside of the therapy office. It might include coping skills, crisis hotline numbers, and ideas for making your environment safer for you. For example, if you have things in your home that could be used to hurt yourself, you may be asked to have a family member or friend help you remove them.
Hospitalization should only be considered if it is the absolute best option to keep you alive. If you imminently plan to end your life, hospitalization may be the best fit. Therapists do have a right to place someone on an involuntary hold in a psychiatric hospital in the short term (usually 2-3 days) but this is only if the person is truly incapable of keeping themselves safe from harm. Other factors that might play into this would be having a manic or psychotic episode, making someone truly incapable of staying safe without support (in the short term).
For an involuntary hospitalization, this may involve a police/ambulance escort to a hospital. Sometimes people present to a regular emergency room and then have to be transferred to a psychiatric (rather than purely medical) hospital.
We try to make involuntary hospitalization the last resort in keeping someone safe. Rather than an involuntary hold, adults who are willing to seek a short-term hospitalization can be voluntarily placed. This might mean a family member or friend escorts them to the hospital.
There are many other options for helping someone who is experiencing suicidal thoughts/actions and/or self-harm/non-suicidal self-injury. These are called “higher levels of care.” I’m going to list them from most to least intensive. Some people are placed in residential care, meaning that they live in a psychiatric facility for some amount of time (months). Again, this would be for someone dealing with extreme symptoms who is having trouble keeping themselves safe at home. The next level is called a partial hospitalization (PHP), which means that you stay in the hospital during the day and return home at night. This program is more short-term (weeks). An intensive outpatient program (IOP) is usually group-based therapy for approximately 10-15 hours per week for 2-8 weeks total. Lastly, someone might be required to attend group therapy (Dialectical Behavior Therapy, for example) in addition to their individual therapy to ensure they are rapidly learning skills to keep themselves safe. This is the least intensive option; groups are usually 1.5 hours per week.
If you are seeing a qualified therapist and you are very in control of your suicidal thoughts and/or self-harm urges (meaning, always or almost always able to keep yourself safe from harm), you may be able to stay at the level of outpatient therapy, which is usually 1-2 sessions per week for 50-90 minutes. I would say this should be the most common solution.
One thing I will mention is that we do have to be strict about our recommendations, which can sometimes feel unfair. For example, if we recommend group plus individual therapy as the best option to keep you safe, there is not negotiation. Believe me, although a group would feel like much time added to your week, it is much less impactful on your life than the other options I outlined above.
Just because I explained all the options, I don’t want this to feel scary. I want this to be informative and empowering. To give some context, I have been a therapist for 8 years and am comfortable (and competent) working with people experiencing suicidal ideation and self-harm urges. I’ve worked in many settings (including IOP and consultations related to overdose at the hospital) with a variety of colleagues from my and other mental health disciplines. In my experience, involuntarily hospitalizations are very rare. The most common levels of care needed beyond outpatient therapy are IOP and group + individual therapy.
[Note: Now that I do outpatient therapy, of course, I cannot work with someone while they are requiring a higher level of care, but would be able to work with them when they graduate from a program and are in control of their safety again.]
Here is my summarized answer to the original question of “What happens if I tell my therapist I want to die?”: Mental health professionals have made mistakes in their recommendations and care for people who are experiencing suicidal thoughts/actions or self-harm, and so I can understand there is a legitimate fear about disclosing these thoughts. If you are working with a qualified therapist, however, disclosing these thoughts should lead you toward safety. The most likely outcome is not being hospitalized, but this will be considered, depending on your level of ability to keep yourself safe outside of the therapy space. Whatever happens will hopefully be the best scenario to ensure that you remain safe and can learn skills to help you get to a point at which you no longer have any desire to hurt yourself.
If you are experiencing frequent or intense suicidal thoughts, urges, or actions and do not currently work with a therapist or psychiatrist, you can call 988 for immediate support. You can also seek emergency care at a local medical or mental health facility.