Many people dealing with suicidal thoughts often don't share their feelings, even with doctors or family members. As it's Mental Health Awareness Month, it's important to note that 10 million U.S. adults have suicidal thoughts and 1.7 million attempt suicide each year. Did you know that many people thinking about suicide often don't share their feelings with anyone not even with their closest friends, family, or therapists? How common is this, and why does it happen?
Nondisclosure of critical information like suicidal thoughts happens frequently in various settings (clinics, hospitals, private practices) and across different therapeutic approaches. Farber et al. (2019) found that 93% of a sample of over 500 clients in treatment admitted to lying to their therapist, with the average number of topics they lied about being 8.4. What are the most common types of nondisclosure clients report? Studies (D'Agata and Holden, 2018; Hales-Ho and Timm, 2023; Hogge and Blankenship, 2020; Hogge et al., 2023) confirm that suicidal ideation (SI) is significantly subject to nondisclosure. Calear and Batterham (2019) found that 58% of adult clients did not disclose their SI to any healthcare professional.
Furthermore, Hallford et al. (2023) found that less than 46% of people with suicidal thoughts revealed their SI. The overall conclusion of the study was that 50-60% of people don't disclose their SI to family, friends, or professionals, and thus remain unidentified and potentially untreated (Hallford et al., 2023). Fulginiti and Frey (2018) found that 29% of survivors did not disclose a suicide attempt to anyone in their family, and survivors reported that about 50% (46%) of their family members held stigmatizing views of suicide attempters, indicating high levels of shame in familial systems where survivors often live during their recovery process (Fulginiti and Frey, 2018). Therefore, in many cases, family members are unaware when a relative has attempted suicide or is struggling with SI.
Why do clients or patients hide or keep significant insights about their emotional pain and thoughts of suicide from helping professionals? Farber et al. (2019) found clients' desires to "look good"—to be seen as competent, somewhat composed, or a "good person"—and to be viewed positively by their therapist can make nondisclosure an enticing option. Suicidal thoughts (Al-Halabi et al., 2021; Hales-Ho and Timm, 2023) can evoke high levels of shame, embarrassment, and vulnerability, and these feelings can be associated with clients withdrawing from discussing SI openly (Baumann and Hill, 2016; Farber et al., 2019).
People may hesitate to share their thoughts about suicide due to "codes" or "social scripts of silence" regarding emotional distress and suffering (Szlyk et al., 2019, p. 779), or they may feel that suicide is a "mortal sin," making it even more taboo. In the case of SI, clients may fear hospitalization, impact on their career, being placed on watch, upsetting their family members, being forced to receive additional treatment or unwanted medication, and the possibility of re-traumatization (Farber et al., 2019; Sheehan et al., 2019). People in law enforcement (et al., 2020) and the military (Bernecker et al., 2019; Drew and Martin, 2021; Thomas et al., 2023) may worry that disclosing trauma symptoms and SI will be seen as a sign of weakness or a sign that they are unfit for duty, leading to denial of SI, even though suicide in active-duty military members has rapidly increased in recent decades (Love et al., 2017) and is the second leading cause of death in the U.S. military (Gutierrez et al., 2021; Mann and Fischer, 2019).
While therapists typically see themselves as allies to individuals struggling or in recovery (Baier et al., 2020; Tilden and Wampold, 2017), there are various potential sources of therapeutic alliance rupture (Doran, 2006), and those experiencing SI can view even their therapists as potential adversaries. Therefore, while we might like to believe that our closest friends and companions, as well as intimate partners and family members, would tell us when they are contemplating suicide, there are many reasons why they might not. This means we should not assume everyone we know "is doing okay or they would tell us." Instead, we should dare to ask difficult questions and wait for honest answers to those questions. Ultimately, helping professionals could benefit from the use of indirect, subtle screening for suicidal ideation that accurately detects suicidal thoughts without directly asking. I have attempted this approach.