Beyond Magic: How Do We Detect Suicidal Thoughts?

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Pilot suicide

No objective test exists for suicidal thoughts – no X-ray to detect broken hope, no CAT scan to reveal intolerable emotional pain, no blood test to expose toxic intentions.

This reality is disappointing, even devastating. People understandably want professionals to predict and prevent suicide. For example, in the aftermath of the pilot Andreas Lubitz intentionally slamming a Germanwings plane into a mountain in the Alps, some people have called for airlines to screen pilots for suicidal thoughts.

There seems to be a hope that screening pilots for suicidal thoughts would automatically reveal which pilots secretly long to die. Unfortunately, it is not that simple.

The Benefits of Screening for Suicide Risk

Screening people for mental illness and suicidal thoughts undoubtedly identifies many people whose suicidal thoughts would otherwise remain hidden. And it appears that screening can save lives.

As Time Magazine reports, “When the U.S. Air Force began requiring annual suicide prevention and awareness training in 1995, including screening for mental illness, the suicide rate plummeted from about 16 suicides per 100,000 members to about 9.”

Suicide screening tools are used in primary care physicians’ offices, schools, the military, and more. Often, we simply cannot know if someone is considering suicide if we do not ask.

The Limits of Screening for Suicide Risk

Yet suicide risk screening is no panacea, for several reasons.

First, millions of adolescents and adults in the U.S. seriously consider suicide in any given year, and the vast majority – all but 40,000 – do not die by suicide. This means that suicidal thoughts alone do not convey whether the person is at high risk for suicide.

As Dr. Seena Fazel, professor of forensic psychiatry at University of Oxford, explained to NBC News:

“…If you apply a reasonably good [suicide] screen to 100,000 persons, for whom you expect 10 to die from suicide (based on population averages), this suicide screening tool would lead to eight correct screens, two missed suicides, but importantly nearly 30,000 persons who would be identified at high risk but would not die from suicide.”

And those are the people who reveal suicidal thoughts. Even when asked directly if they are thinking of suicide, many others keep such thoughts secret.

Screening people for suicidal thoughts is as effective as each person lets it be. It depends on the person’s honesty.

Why Do People Hide Suicidal Thoughts?

Hiding suicidal thoughtsMany forces conspire against the honest disclosure of suicidal thoughts:

There is embarrassment, as if suicidal thoughts signify a weakness of character or will.

There is fear, a fear that others will judge, and perhaps, too, a fear of loss – loss of one’s job, loss of one’s identity, and loss of one’s freedom, too, if hospitalized.

There is hopelessness, a conviction that telling others of suicidal thoughts will do no good.

And then, most dangerous of all, there is on occasion determination – that is, determination to not be stopped from dying by suicide.

What Can We Do, Then?

With these realities in mind, we must recognize that there is only one way to learn about suicidal thoughts in people who do not volunteer or otherwise reveal their intentions: coax them out.

To coax the suicidal thoughts out, professionals need to skillfully ask questions, often posing the same question in different ways. As I explain in a different post, there are techniques for drawing out this kind of sensitive information.

Professionals can also look at situational crises, recent developments, risk factors and warning signs to form an opinion about whether a person is at high risk for suicide. Again, obtaining this information depends on skillfully asking questions, as well as looking at medical records and talking to people who know the person well.

If we want the suicidal person to open up, we also must provide an environment where it is safe to get help, safe to share what is terrifying to share, safe to make oneself vulnerable in a world with too much stigma, judgment, and hate.

What We Should Not Do

Suicide precautionsThe reaction to the crash of the Germanwings flight, in particular the reaction to reports of the pilot’s apparent history of depression, creates the  opposite environment of one that would help suicidal people feel safe to disclose their thoughts.

Some people question why pilots with depression would be allowed to fly. Yet a ban on flying would assure that pilots who have depression and who want to keep their jobs would not disclose their depression to others. Such pilots almost certainly would be less willing to seek professional help if a doctor or therapist had to report the results to the pilots’ employer.

And then what would we have? We would have pilots with depression flying planes carrying hundreds of passengers while feeling even more desperate and trapped than ever, unable to get help without tremendous loss to their career, professional identity, and income. This is a recipe that certainly will not improve passenger safety.

A Plan Beyond Magical Thinking

To help people from endangering others with their suicidal plans, we as a society must make it OK to ask for help.

We must be careful not to brand people with depression and suicidal thoughts as potential murderers, as if one suicidal pilot’s mass murder speaks for all people with depression. (In reality, many millions of people in the U.S. alone experience major depression every year. Among people who receive mental health services for depression, only 2% ultimately die by suicide, and roughly the same amount do physical harm to others.)

We must remain vigilant for suffering souls, and ask with compassion and concern about the welfare, feelings, and thoughts of those who are hurting.

We must stop stigmatizing mental illness and mental health treatment.

Coaxing out suicidal thoughts, by skillfully asking questions and creating an environment in which it is safe to answer honestly, is hardly an objective test to detect suicidal thoughts. But presently, in the absence of magic or medical advances, it is the best we can do.

 

© Copyright 2015 Stacey Freedenthal, PhD, LCSW, All Rights Reserved. Written for www.speakingofsuicide.com

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  1. mike says:

    I have never had a situation where sharing my thoughts about considering suicide turned out to be a positive or helpful solution. Therapists don’t want to know, employers don’t want to know, and friends and family don’t want to know. I’ve learned to tell these people what they want to hear. I’ve found one outlet for sharing exactly what I’m thinking, and it’s only possible because it’s completely anonymous, if I want it to be.

    It is certainly unfortunate there are not more resources for those who are seeking help, but, as with so many health care and legal assistance situations, there is legal liability that becomes part of the picture, and it is often a driving factor in how care is provided.

  2. Fred says:

    There is another reason. I was told by my psychologist, that if I say I am suicidal again, she will send the police to my house. So I’m going back to hiding it. I am suicidal all the time. Every day. I can’t have people calling the police every time I mention it.

  3. mnw says:

    it can be hard to know someone is having these thoughts etc unless you are close to them. If you truly know them u will see the changes and you will know something is not right and you will want to help them as much as you can and you feel heartbroken that they are so sad but do your best to get them the help they need whatever it takes show them you care don’t ignore it work on making it better everyday and you will start to see changes for the better and you will be extremely thankful you were abe to help this dear person on time you will see them feel and do better in time. Talking and being there is extremely important love them

  4. Zara says:

    Perhaps if we stopped stigmatizing and criminalizing suicide (de facto, not de jure) by means of involuntary commitment laws people would be more willing to talk about their problems. Locking people up for merely contemplating something that is not illegal is madness. Obviously suicide isn’t the ideal or in a lot of cases even a good/rational solution to life’s problems but imo it’s isolation and fear of losing even more control that drives a lot of people over the edge.

    Given the potentially very severe consequences of revealing a suicide plan it’s actually rational to avoid discussing it, unless you like surrendering complete control over your life and choices and being kept in prison (in theory indefinitely) by people who claim to be professionals and scientists yet don’t have a clue about the cause(s) of your problems or solutions other than the obvious like changing behaviour and circumstances that are mentally harmful. To expect suicidal people to trust you as a professional when they know you’re legally obligated to have them committed when it’s clear they’re serious about their intentions is highly irrational and personally I don’t get how a therapist can work under these circumstances. People pay you to listen to them and support them but ultimately cannot rely on you being a staunch ally who won’t go against their wishes: this begs the question why they should be paying you in the first place. Honest and well-meaning therapists and psychiatrists should be lobbying to remove involuntary commitment laws and make suicide legal: then and only then will they be able to truly help their clients the same as any other professional. By analyzing the problem, providing information, offering a solution based on their knowledge and abilities with the ultimate responsibility laying with the user of their services(s). Given that most people don’t really want to die I’m sure suicidal people will be far more inclined to come forward and let a professional take a look at their problems: after all what would they have to lose by it?

    In my experience the solution to mental problems and suffering is to look deep within (knowing oneself is the first step towards wisdom) and take action yourself: like god therapists only help those who help themselves and if you’re not willing to change, take risks and make a real effort you’ll be stuck in the same rut forever. Of course this road is difficult and it takes a lot of courage but once you’ve taken that crucial first step you’ll discover the vital truth that living by your own values and working towards your own goals is extremely liberating and even intoxicating once effort and careful planning bear fruit and you feel the power within yourself grow. Others will notice this and laud your efforts but that is secondary to regaining your self-esteem and the joy that comes from gradually becoming the man/woman you always wanted to be. Just imagine how much pride overcoming severe problems will generate: your life will be so much richer and meaningful than the mere existence of those who never had to battle their own demons. Read about the experiences of great minds who went through similar problems and know that countless others went through what you’re going through and not only survived but flourished. For what reason are we on this earth but to grow and overcome difficulties and hardships?

    Therapists and doctors should stop pretending most mental problems are medical in nature and can only be cured by people with specialized training and knowledge: you yourself are the best guide in this and it’s you who ultimately decides your fate. If you’re physically ill by all means find a good doctor and heed his advice but if you feel bad, anxious etcetera maybe you should start by examining what is wrong with your life and how to fix it. Talking about this with others can be helpful but unlike cancer, meningitis etcetera in the end only you can mend yourself. Who else knows you like you know yourself and how would it be possible for another to live in your stead?

    I found great meaning and value in these quotations:

    “By endurance we conquer” (Ernst Shackleton)

    “Willing liberates, thus teacheth Zarathustra” (Nietzsche)

  5. JS says:

    The biggest barrier to speaking of your feelings is that you will drive your friends away. It is too large a burden for them to hear. It creates distance in friendships that once never existed, and the depressed and suicidal person has yet another item to feel dreadful over.

  6. Anne DiNoto says:

    kudos for this post. I’m grateful it seems more people are speaking out about the media coverage of this case. Why do people hide suicidal thoughts? I would also add they hide these thoughts because they hide these thoughts from themselves and they don’t know how to express the pain they are in.

  7. Dave says:

    Good post.. have attempted myself . thank God I wasn’t successful .. I would hope that you might look at spreading information about the use of ketamine.. if not for general use.. for use in the ER for suicidal people.. research is clear on it’s rapid relief.. for often there is no bed for people and they are let go home.. this can be catasrophic in what could follow.. Certainly other things may come to the market .. but today.. every hospital has ketamine on hand..

    for your consideration..
    thanks
    david

    • Anonymous says:

      ketamine’s place in treatment has yet to be established. Only one research study last year and the effect had fully gone in 7 days!

    • Dave27 says:

      Not so simple. Although 4 studies have shown some improvement in suicidal ideation with ketamine in patients with affective disorders, it’ place in management is unclear and not yet used in practice. There is no evidence that it reduces suicide, but may be useful in “buying time”, but the effect is variable and lasts less than 1 week.

    • David Newman says:

      the negative responses I got to suggestion of ketamine,, clearly shows how uninformed your audience is.. when there have been so many studies.. yes people.. other countries OTHER than the usa do studies too.. hmmm there are a number of countries.. yep, they found the benefit to be worthy of use… and have you heard of sketamine.. anyway.. a waste of energy here… bye

    • Stacey Freedenthal, PhD, LCSW says:

      David, I’ve read research with positive findings about ketamine, but those studies also indicate that replication is needed and that the effects of ketamine are short-lived, sometimes extremely so. Personally, I think even short-lived relief can be helpful, because it can break the continuous stream of hopelessness and show the person that it is possible to feel better. But some people, upon feeling better temporarily, might feel even more despairing upon being plunged back into depression. Maybe. Maybe not. This is why more research is needed, both to continue testing ketamine’s effectiveness and to investigate it’s long-term effects on people.

  8. Canam girl says:

    Your new post comes in as I sit here and try to decide whether or not to tell my therapist and psychiatrist that I am once again very suicidal. I feel so stuck and trapped with no way out, and I want out of this nightmare. I need to decide if I want my life to be over, or if I keep fighting. I know that this battle is not getting better any time soon. I managed to get back to work, a safe place for me, and now I am told I should quit and ” get well”. I know I will isolate and it will not end well. If forced to quit I will feel like a complete failure, a feeling I have battled for a long time.
    If I tell them I will probably end up in the hospital again, once again a fail. I can’t win.
    Will it be inevitable, will it end the same way either sooner or later?

    • davecn says:

      Imagine a world that was open to the use of Ketamine for rapid relief of suicidal tendencies in the ER

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