HEALTH-SUICIDE 1143 words

Suicidal thoughts are often hidden. Here's how to talk about it.

Special To The Washington Post · Stacey Freedenthal · HEALTH, HEALTH-FEATURES · Dec 17, 2022 - 7:28 AM

In Stephen "tWitch" Boss's final Instagram video, a Christmas tree twinkles with white lights as the famous dancer and "Ellen" DJ fluidly bounces to an upbeat song. As he and his wife, Allison Holker, bop to the rhythm, he smiles. He looks happy.

A few days later, on Dec. 13, in a motel room, the 40-year-old father of three died by suicide, according to the Los Angeles coroner.

As a psychotherapist and professor, I understand how jarring it can be when someone who seems happy ends their life. It can make you worry a loved one's smile is a deceptive mask.

Roughly half of people who die by suicide don't reveal or hint at their intentions beforehand. Research on people who have experienced suicidal thoughts reveals they might fear the person they confide in will call the police and have them hospitalized. Or they may cherish their privacy, fear burdening people with worry, dread others' reactions or judgment, or just not want to be stopped from carrying out their suicide plan.

The best way to learn if someone has suicidal thoughts is to ask. I often meet people who are afraid to pose the question. They fear giving someone the idea to die by suicide. But research consistently indicates that asking about suicidal thoughts doesn't trigger or worsen suicidal thoughts.

No method is guaranteed to coax suicidal thoughts out of someone, and if someone dies after you talk with them about suicide, it doesn't mean it's your fault. The reality is, sadly, even if you do everything that experts recommend, suicide can still happen.

With those important caveats, here are some ways to make disclosure more likely.

- Use direct language. Many people use phrases such as "hurt yourself" or "self-harm" as euphemisms for suicide. Self-harm isn't always suicidal, however, and someone with suicidal thoughts might not view suicide as hurting or harming oneself. By using terms such as "suicide," "kill yourself," and "end your life," you also show that you can handle talking about suicide. It's not unspeakable.

- Build up to the question. If it makes you more comfortable, start generally and get more specific. You can say, for instance, that you've observed the person seems sad or stressed and ask how they're doing. After listening, you can ask if things get so bad that they wish they weren't alive, and then after some more listening, you can directly ask about suicidal thoughts.

- Normalize suicidal thoughts. In the United States, 12 million adults a year seriously consider suicide, and so do almost 1 in 5 high school students. By invoking other people, you make clear that thinking of suicide isn't freakish. An example would be, "A lot of people who are going through what you're describing feel so bad that they think of suicide. Do you have suicidal thoughts?"

- Avoid negatives. Some people ask, "You're not thinking of suicide, are you?" or the question's more judgmental cousin, "You're not thinking of doing something stupid, are you?" This kind of question broadcasts the answer you're hoping for, which can inhibit the person.

- Acknowledge jokes, hints and other warning signs. Suicide is such a taboo topic that some people drop hints. It's a good idea to ask directly about subtle signs. Possibilities include: "You've made a number of jokes about killing yourself. Do you have suicidal thoughts?" or "I've noticed you haven't been your usual self lately. Are you feeling depressed?"

Once you ask someone about suicidal thoughts comes the challenge of how to respond. That depends on their answer.

- What to say if a person denies having suicidal thoughts. Be careful about expressing relief. You might be tempted to let out a massive sigh of relief and exclaim, "Oh, that's so good!" Keep in mind, half of people with suicidal thoughts deny it when asked directly. If the person you're concerned about is considering suicide, your relief could convey you don't want to hear it if the answer is yes. I recommend to my social work students that they say something with less judgment about suicidal thoughts, such as, "That's good for me to know."

Ask if the person will tell you in the future. This question is quite revealing with my therapy clients. Those who say no, they don't have suicidal thoughts, often also say no to my question, "In the future if you had suicidal thoughts, would you tell me?" This gives me the opportunity to explore and understand their reluctance, which usually stems from their certainty I'll recommend hospitalization. More times than not, after I explain that I would suggest hospitalization if they were resolved to end their life within the next day or two, they say something like, "Oh, I'm not thinking of suicide that intensely." Now we're having a conversation about something they denied minutes earlier.

- What to say if a person says they are thinking of suicide. Show empathy and compassion. This tip might seem obvious, but many people respond with questions to allay their own fears: "Do you have a plan?" or "When would you do it?" are examples. Unless the person clearly is in immediate danger - for example, they have a weapon or have already overdosed - have a conversation. Make empathetic statements such as, "That must be so hard" or "It makes sense your mind would go to ways you can end pain."

Don't judge, rebut, persuade or otherwise try to talk the person out of suicide. At least, not yet. There may be a time later to try to discuss the person's thinking. For now, such an approach will probably shut down the conversation, not open it up.

Don't guilt the person. Some mental health professionals disagree on this. Last year, psychiatrist Allen Frances tweeted that he tells self-blaming, depressed suicidal patients, "People who care about you will be haunted by your death for the rest of their lives. You must stay alive to save them." It's true, concern for others deters some people from acting on their suicidal thoughts. Statements like that, however, can convey that the person's current suffering isn't as important as others' future pain. Such statements also can exacerbate guilt in people who already fault themselves for their suicidal urges.

Help the person get help. Some psychotherapies and medications have demonstrated effectiveness at reducing suicidal thoughts or behaviors. The nationwide 988 Suicide & Crisis Lifeline, reachable by calling 988, can guide you on resources in your area. You also could help the person make a plan for how to stay safe amid their suicidal urges.

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Stacey Freedenthal is an associate professor of social work at the University of Denver and a psychotherapist in private practice. Her latest book is "Loving Someone With Suicidal Thoughts: What Family, Friends, and Partners Can Say and Do."