Suicidal thoughts & therapy

August 26, 2004 9:36 AM

If someone admits to having suicidal thoughts, what (if anything) can be done to them? [More inside.]

I have a friend (really -- a friend -- not code for "me." I'm fine.) who has admitted to having suicidal thoughts. I think he's pretty far from actually doing anything, but he thinks about it.

The good news is that he's going into therapy. The bad news is that he's afraid to admit to his therapist that he's contemplated suicide. I think it's important that he does. But he's afraid that the therapist can have him committed.

I don't think a therapist can do this. From what I gather, it's actually really hard to commit anyone (unless they're a danger to others) without their consent.

Does anyone know if I'm right? Surely no one can do anything to you because of your THOUGHTS.

And out of curiosity, what if my friend did make an attempt? At what point can "authorities" step in and force him to do whatever? And what IS whatever? Go into a mental institution? A hospital? A jail?

If it makes a difference, I live in New York.

posted by grumblebee to health & fitness (16 comments total)

Therapy will not work for your friend if he lies to his therapist about something so important. His therapist won't have him committed for suicidal ideation...that's one of the most common symptoms of depression there is. One's therapist usually asks if or suggests that one might need hospitalization (usually 72 hours to one week in a hospital psych ward)...IANAL or a therapist, but you'd have to be a serious danger to yourself or others before you could be committed without your consent. Tell your friend to be honest...he has nothing to be afraid of.
posted by gokart4xmas at 9:45 AM on August 26, 2004

Grumblebee,

When I was quite a bit younger, I looked into this for my wife (at the time); she was very depressed, tried suicide, that sort of thing (quite a bit of stories there.)

As I recall, almost anyone can swear out a 48 hour involuntary commitment on anyone (friends, family). They get evaluated by a psyche in an inpatient ward. Now, there was a story written (or linked) on the blue (I think) recently, about how poor the process is (a slate? reporter committed himself on purpose to write a story; wondered how they got anyone better)

I found two links of note. I'm sure there is the right link out there, my google fu can't take the time.

Summary of State Statutes on Involuntary Outpatient Commitment

my experience with involuntary commitment » katia

And of course, you know how to reach me personally about other details.
posted by filmgeek at 9:57 AM on August 26, 2004

If your friend has just begun therapy, it make take a little while for him to trust his therapist enough to open up. In the meantime, I would gently encourage him to open up about it.

No therapist is going to commit someone who's simply "thought" about suicide--especially if that person is already in outpatient therapy. I think that, at one time or another, many (if not most) people think about it.

Besides, according to filmgeek's first link, New York requires that a person "Pose, by clear and convincing evidence, a substantial threat of physical harm to himself or to others" before they can be committed involuntarily.

A couple of questions: How old is your friend? What kind of "therapist" are we talking about? A real psychiatrist? A psychologist? A social worker? And how did your friend find him/her?
posted by jpoulos at 10:14 AM on August 26, 2004

Thanks for the help, folks.

jpoulos, I don't know all of the details. I think he's going to a psychiatrist for some anti-depressants, and also to a "talking cure" therapist (not sure if it's a social worker or what). He's in his mid 30s.

I posted a question here a while back, about trying to find a good therapist in NYC. It's hard. It's hard to find one who you click with who is also on your insurance plan.
posted by grumblebee at 10:19 AM on August 26, 2004

Actually, that will probably be one of the first things the therapist will ask HIM.

If he answers in the affirmative he will be asked more detailed questions such as does he have a thought out plan, etc etc...they will NOT commit him or threaten it unless they think he is in imminent danger. What they do sometimes is make a contract with the client to NOT suicide, etc...I have never done such a contract but lots of folks on the bipolar forum I frequent have.

Let him know that indeed, suicidal ideation is very common in depression-actually it is one of the symptoms-and with proper treatment that should go away.

With me, when I start thinking about death, I know that my mood is heading toward depression and I act accordingly to derail it. I see it as JUST a symptom.
posted by konolia at 10:40 AM on August 26, 2004

Yeah, to amplify on a few things...

Yes, someone can be "committed" on the basis of their thoughts.

But, no, his therapist isn't likely to do so on the basis of only some suicidal ideation. Or, at least, vague suicidal ideation.

If he's making detailed plans, that's a very bad sign. If he's acted on any of those plans, that a worse sign. If he reports this type of thing to his therapist, his therapist may well take measures. But he should. You should, too.

But general suicidal ideation by itself can run the gamut from being not a big deal to the sign of imminent danger. It has to be evaluated in the context of the person's life and whole personality.

In general, I suspect your friend's fear of being committed is unrealistic. It's an extreme measure, really, that can be counter-productive if it's not simply averting an imminent suicide attempt. A therapist isn't going to want to do that unless he/she thinks that he's really and truly likely to attempt suicide very soon. If their concerns are significant/moderate but not at emergency level, they'll do the contract thing mentioned above.

However, one final thought: people who have persistent suicidal ideation or threaten suicide and who don't get treatment are far more likely to eventually attempt it than folk wisdom thinks. This should always be taken seriously.
posted by Ethereal Bligh at 10:59 AM on August 26, 2004

Thinking about death is not a sign of mental illness. It is a sign of mental health. Considering suicide is a sign of mental illness.
posted by jpoulos at 11:14 AM on August 26, 2004

jpoulos, I am referring to something a bit more specific. When I am going downhill, my thoughts are incredibly morbid. Death everywhere.

I'm not talking about the kind of thinking about death that Kubler-Ross did, for instance.
posted by konolia at 11:47 AM on August 26, 2004

I am a therapist, among other things, and I've worked at a crisis clinic in which I had 5150 authority (that's the section of the California Welfare & Institutions code that lends authority to people to commit involuntarily), and in private practice.

Speaking in general terms, the whole history of involuntary committment is a fairly sordid one, replete with people who had the best intentions ending up acting as agents of social control to repress deviancy. Although those ways of being are no longer as present as they used to be, involuntary treatment is still a reality, and it's a very complex and hot topic. These days many states have what are called outpatient committment, entailing court orders for forced medication, as it's cheaper than hospitalization.

The legal underpinning of it is not that suicide is against the law, but that people who attempt it *may* have a mental disorder which compromises their ability to make judgements, so the State then is entitled to act as a "parent" to protect a person from themselves (the doctrine is called parens patria). The assumption is that if someone committed suicide for a rational reason, then that would be ok. The catch 22 is that if someone is suicidal, then some would say that's prima facie evidence that they *must* have a mental disorder. The recent back and forth about assisted suicide in Oregon is a thrashing around of this issue.

I could go on about this (my dissertation dealt with this topic), but it's probably not really germane to grumblebee's question.

Being a therapist in private practice, I've had many people tell me about suicidal thoughts. Just that, in isolation, has never made me consider hospitalization as a viable treatment alternative. If someone talks about it, I follow up with questions to establish the risk involved. Higher risk elements would include a plan to do it, access to the means to do it, high impulsivity in general, use of alcohol and/or drugs (lowering inhibitions), lack of perspective about their situation, inability to consider a future beyond the current problem state, the "statement" value of the suicide attempt (e.g., "this'll show the bastards!"), lack of a useful support network, etc. A prior attempt ups the risk, though it's always important to know how come they didn't die - like sometimes people will overdose just before someone's about to come over.

Mostly, the important factor in my assessment is how imminent the threat is, and what the person's relationship is with me. If someone feels that they've *got to* do it now, and I don't trust that they'll be able to call me or an ER at the moment, then I'll surely consider hospitalization. When this has happened, it's rarely been necessary to use the involuntary path - most people who talk about suicide to a therapist are scared of it, and want to be stopped.

I think your friend should consider whether he trusts the therapist and generally feels ok about their work to date. If the answer is "yes," then I'd advise him to go ahead and tell the therapist in general terms. Expect some follow-up questions and see where it goes. If the therapist seems like they're over-reacting, your friend can always ask what it is about what they've said that makes the therapist seem so worried. If your friend doesn't like the response, shop around for another therapist.

It's hard for me to imagine a good therapist jumping to consider hospitalization for the circumstances you've mentioned. Hospitalization is very expensive, restrictive, and should be the last alternative considered. My guess is the fantasy that he might be hospitalized is most likely an indicator of your friend's anxiety about his thoughts.
posted by jasper411 at 11:49 AM on August 26, 2004

Second to everything that's been said. Involuntary commitment is drastic. Even voluntary commitment is drastic. I've had friends who were committed after making serious attempts, and twice came very close to commitment myself. Therapists do NOT take this step lightly, and the mere presence of suicidal thoughts isn't going to cut it. During a decade of treatment by numerous therapists for severe depression, the only time inpatient treatment (voluntary or involuntary) was ever even brought up was when there was an serious and imminent risk of suicide. And both times, the therapist still supported my desire to pursue outpatient services instead.

Your friend needs to know that he can trust the therapist to respect his privacy, autonomy and choices in all but the most utterly extreme circumstances. Honesty is critical to getting well. If he doesn't trust the current therapist, he's not going to be able to get the real help he needs. The most compassionate thing you can do is help him to find someone who he can willingly trust with the truth. He (or you?) can prescreen candidates anonymously by phone, probing them about how they have handled patient in his situation and what they can do to reassure him that the relationship is a "safe" environment for opening up. Therapists also vary in overall treatment approaches, so it's worthwhile to call a few different types (to grossly overgeneralize: psychiatrist=meds, psychologist or MFT=one of the talk therapies, social worker=personal responsiblity/empowerment) to get a sense of which approach feels right for him. It's common for a therapist to offer a free consult of a 1/2 hour or so, which is a good time to go into more depth about his fears and explore what this counselor can offer.

If he's unwilling to reveal any suicidal thoughts to a therapist who knows his identity, then help him get in touch with one of the anonymous crisis lines. The larger hospitals or regional health agencies often have a hotline staffed by professionals, so it'd be an alternate way for him to be upfront about his fear of commitment and find out that a professional's response is a lot more compassionate than what he's imagining.

Good luck.
posted by nakedcodemonkey at 11:58 AM on August 26, 2004

Any discussion of suicidal ideation is very serious. It is often helpful to ask the person to promise you that s/he will not hurt her/himself. Meanwhile, read this, and give it to your friend. It's one of the best things I've ever read.

On preview, jasper's comments are excellent.
posted by theora55 at 12:10 PM on August 26, 2004

jpoulos, I am referring to something a bit more specific.

Point taken. I reconsidered after I posted. I, personally, know I'm in trouble when I find myself getting frustrated while driving.

Another great resource for someone learning to deal with depression is William Styron's Darkness Visible.
posted by jpoulos at 12:52 PM on August 26, 2004

It might not be likely (I don't think it's quite as out of the question as everyone here thinks) but it's absolutely possible. The first 48-72 hours, generally, depending on the state, he can be held on any random person's say-so; after that, two doctors' signatures will keep him there as long as they want him. Not exactly my idea of due process, and even 48-72 hours of involuntary hospitalization is enough to seriously fuck with your life (by costing you a job, by running up insane medical bills, etc.) Once you're in, if you want to get out there is generally some theoretical right to petition to get taken before a judge and convince him you don't need to be there; generally, though, the staff will threaten you if you try to bring this up. Seeing as the staff are pretty omnipotent over you when you're in there, it's extremely hard to resist that pressure.

Personally, I think your friend is doing the only remotely sensible thing -- as every single shrink I've ever seen (and I've seen oodles of 'em) has blatently violated patient confidentiality systematically and unapologetically I have about as much respect for their "professional ethics" as I do those of your garden-variety street-corner crackhead. Trusting a shrink is a stupid, stupid mistake which most people I've met haven't made twice.
posted by IshmaelGraves at 5:55 PM on August 26, 2004

I think hospitalization is doubtful. Why not start with something small - why not say "I am thinking about death a lot - thinking of suicide, but would never, ever do it." The basis for sending someone away is that they must be a danger to themselves. This way your friend can gauge his / her pyschiatrist's reaction, and, perhaps, in time learn to trust them completely. You definitely wouldn't be hospitalized for just thinking about it, only if you were a threat to yourself.
posted by xammerboy at 11:25 PM on August 26, 2004

A psych student friend of mine once told me that shrinks distinguish between suicidal thoughts and suicidal intentions. Just contemplating it now and then is called "suicidal ideation." I am not a shrink, but I highly doubt that your adult friend could be forced into a hospital for saying he'd contemplated suicide. I suggest he bring it up in therapy, but make it clear that he doesn't immediately intend to kill himself, doesn't believe he's an immediate danger to himself, but would like to talk about his thoughts and feelings on the subject.

Shit. I've contemplated the motherfucker. Hasn't everyone?
posted by scarabic at 12:30 AM on August 27, 2004

I am a board-certified New York State licensed neurologist.

A doctor can cause a person to be held for 48-72 hours; after that, in most states a court order is required. In the L.A. County psych ward where I trained, a judge made rounds with the psych team every 3 days in order to approve or deny the requests for longer-term commitments. Except in the cases where the patients were clearly expressing their intentions to commit suicide or homicide, the patients who desired to leave were let go. In order to be allowed to leave, a patient had only to lie and state that he was not intending to commit suicide or homicide.

Patients who had already committed crimes, including in some cases homicide and attempted suicide, were kept on the jail ward and had no option to leave - they were chained to a bed behind locking barred doors.

When admissions for suicidality seem required, mostly we have patients 'contract for safety' and admit them on a voluntary basis so as to engage them as teammates in the healing process.

No licensed mental health professional will neglect to ask a depressed person about suicidal ideas, and a good one will make the consequences of an affirmative answer clear. The consequences are usually more talking: therapeutic conversations, and suggestions to take medicines.

In my experience people often say "I've thought that maybe I shouldn't be alive," (passive suicidal ideation), "I've thought about ending my own life, but I have no serious plans to do so," (also passive SI). These people need mental health care, but they needn't be involuntarily made to do anything - they are still humans and citizens and they retain their civil rights.

Occasionally you hear something like "I keep the barrel of a loaded revolver in my mouth, thinking about pulling the trigger, for several hours every day" or "I have 900 sleeping pills and a gallon of vodka stockpiled by my bed." When I hear that is when I think that some sort of change of scene for the patient might be beneficial. I've never had a patient disagree at this point when I suggested that they needed a change of scene.

If they did disagree though, this is about the point when I'd tend to step out of the room, summon a security guard, and escort the patient down to the psych E/R.
posted by ikkyu2 at 11:25 PM on August 28, 2004