Talking to Your Therapist About Suicidal Ideation
October is National Depression Education & Awareness Month! You are probably here because you or a loved one may have experienced the symptoms of depression or a depressive episode and are looking for support. You are not alone: depression is a condition that an estimated 21 million U.S. adults experience every year and is considered one of the most common mental health disorders in the United States.* Here at Woven, we want to be able to provide information and support for you. Today we’ll cover talking about suicidal ideation with your therapist. Let’s dive in.
Suicidal ideation (SI) is a symptom of depression that some people experience. Suicidal ideation and suicide are stigmatized topics, but I believe that knowledge and conversations about suicide reduce stigma. I wrote a blog about Active SI and Passive SI that provides foundational information to understand the components of SI. This information helps us better understand what we’re experiencing and have the language to express it. Today we’ll cover talking to your therapist about SI to destigmatize those conversations.
Informed Consent
When you have your first appointment with a therapist, they will go over what is called informed consent. Informed consent is a combination of legal information and the therapist’s policies. You will probably cover topics like cancellation policies, frequency of sessions, confidentiality, and limits of confidentiality. Your therapist is legally and ethically bound to confidentiality, but there are a few exceptions.
The first exception is in the case of a court order. This is a legal intervention, and if this occurs, your therapist will walk through this with you every step of the way.
The second exception is a legal mandate to prevent harm. This covers mandated reporting for abuse and neglect of children, dependent adults, and elders. It also includes when a client poses an imminent threat to themselves or someone else. Today we’ll be focusing on when a client poses a threat to themselves.
Going through informed consent might feel overwhelming. You are meeting with a new therapist, getting a lot of new information, and determining if this therapist is a good fit for you. When they talk about breaking confidentiality to protect you if you are suicidal, you might not know what that means, and you might worry that you can not bring up thoughts of suicide without your therapist hospitalizing you. Because of this, you might never bring up suicidal ideation or ask follow-up questions about breaking confidentiality. I hope that this blog can help clarify some things, and help you feel more comfortable having these conversations with your therapist.
Imminent Risk for Suicide
I want to cover situations where your therapist might have to break confidentiality first, and then we’ll talk about other conversations with your therapist. When I cover informed consent with my clients, I tell them that in terms of suicidal ideation, I only break confidentiality when it is the only way to prevent harm. As we talked about in the Active vs. Passive SI blog, there are multiple components to SI. These include thoughts, a plan, means, intent, time frame, and severity. If you share about suicidal ideation with your therapist, they should assess what that looks like for you in terms of these components, so they know how to support you.
Your therapist cares about you and wants to help you stay safe. The severity of SI is what your therapist is looking for in their assessment. Someone with imminent risk for suicide typically has a plan, access to the means to follow through with their plan, a time frame, and the intent to follow through. Your therapist should help you deal with your SI in the least invasive way possible (this is not always the case, but should be the goal). This process should also be collaborative so that you can voice your concerns and what kind of support you need and want.
Suppose you are at imminent risk for suicide, and you and your therapist determine that you might need additional social support. In that case, they might bring up the idea of breaking confidentiality to build this support collaboratively. This does not always mean hospitalization. Including social support might mean calling a trusted person to let them know what’s going on or maybe to have them come pick you up from your session. This type of social support may not always be available or the right fit for what you’re experiencing.
Hospitalization
Hospitalization is a tough decision and not something that your therapist takes lightly. We know that there are many difficult factors when thinking about hospitalization, including finances, insurance, work, family, responsibilities, and psychiatric trauma. We want to work with you to find the best support for your safety. If your therapist determines that hospitalization might be the best support for you, they will work with you to try to pursue a voluntary hospitalization. This means that you would decide together that this is the best fit and willingly agree to admit yourself.
The last option is involuntary hospitalization. In California, this is called a 5150 and provides the legal context for involuntary hospitalizations.
5150. (a) When a person, as a result of a mental health disorder, is a danger to others, or to himself or herself… may, upon probable cause, take, or cause to be taken, the person into custody for a period of up to 72 hours for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment in a facility
Every state has provisions for involuntary hospitalizations and you can find what these are and the specifics by googling [state name + involuntary hospitalization].
The In-Betweens
The above situations are the circumstances in which your therapist can legally break confidentiality to protect your safety. There are a lot of gray areas in between imminent risk for suicide and no suicidal ideation. Your therapist should create safety in your sessions for you to share what you’re experiencing and thinking about, including suicidal ideation.
Asking your therapist how they respond to suicidal ideation can open up the conversation between the two of you. You can ask general questions or be more specific with things like “How do you respond to clients who are experiencing passive suicidal ideation?” or “Under what circumstances would you hospitalize a client?” Asking these questions will hopefully help clarify how your therapist responds to SI and assess your level of safety working with this therapist.
Your therapist will hopefully be grateful for your honesty about your suicidal ideation. We welcome your vulnerability and the invitation into your life. We want to know what you’re experiencing so that we can help support you. We earnestly strive to provide a safe environment in therapy sessions to talk about everything, including suicidal ideation.
We know that it can be scary or overwhelming to experience suicidal ideation, especially if this is a new experience. We want to help relieve some of the pressure you’re feeling. Experiencing SI does not mean that it controls you or your life. Having a safe person and place to talk about SI can decrease its power. Talking about SI provides the knowledge for you and your therapist to create a safety plan and coping skills for the specific factors impacting you.
Safety in Session
You should feel safe and comfortable talking to your therapist about how you’re doing. If you find yourself filtering what you share with them, this might indicate that you do not feel safe with your therapist. Sometimes, you might feel comfortable talking with your therapist about what would make you feel safe in session. You can say, “I feel anxious bringing up SI because I don’t know how you’ll respond.” Hopefully, you’ll receive a response that is caring and making you feel seen, something like- “I’m sorry that you’ve been feeling anxious about this topic. I’d love to share with you how I respond to SI, and collaborate with you on how to make this a safe space.” You get to decide what safety feels like for you.
You might not feel comfortable or safe having these conversations with your therapist, which might mean that your therapist is not a good fit for you. It can be difficult to break up with a therapist, but sometimes it’s necessary to get the support you need. Therapy should be a safe place for you to talk about SI.
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If you are interested in learning more about depression therapy, you can read more here.
Want to learn more about how Woven treats depression? These blogs talk about our approach to depression treatment.
All therapists at Woven Together Trauma THow We Treat Treatment-Resistant Depressionherapy are trauma-informed and specialize in treating all forms of trauma. We also offer EMDR Therapy, Ketamine Assisted Psychotherapy, and Brainspotting Therapy which have shown to be extremely effective in treating and healing depression as well as treatment-resistant depression. Want to read more about our unique therapy options?
These blogs talk more about the basics of EMDR Therapy:
You can read more about Ketamine Assisted Psychotherapy here:
If you would like to learn more about Brainspotting Therapy, check out our blog: What is Brainspotting?