Silent Struggle: Why People Don’t Disclose Suicidal Thoughts

As it’s Mental Health Awareness Month, I’m reminding folks that 10 million U.S. adults experience suicidal thoughts and 1.7 million attempt suicide every year.

Did you know that many persons who think about ending their lives don’t tell anyone—not their closest friends, family members, or even their therapists?

How prevalent is this phenomenon, and why?

Nondisclosure of significant facts such as suicidal thoughts occurs frequently and across multiple topics, settings (clinics, hospitals, and private practices), and therapeutic orientations.

Farber et al. (2019) found that 93% of a sample of over 500 clients in therapy admitted to having lied to their therapist, and the mean number of topics that they reported lying about was 8.4.

What are the most common forms of nondisclosure that clients report? Studies (D’Agata & Holden, 2018; Hales-Ho & Timm, 2023; Hogge & Blankenship, 2020; Hogge et al., 2023) corroborate that suicidal ideation (SI) in particular is subject to significant nondisclosure.

Calear and Batterham (2019) found that 58% of adult clients reported they had not disclosed their SI to any healthcare professional.

Further, Hallford et al. (2023) found that less than 46% of people with suicidal thoughts disclosed their SI. The overall conclusion of the study was that 50-60% of people do not disclose their SI to family, friends, or professionals, and thus remain unidentified and possibly untreated (Hallford et al., 2023).

Fulginiti and Frey (2018) found that 29% of survivors did not reveal an actual suicide attempt to anyone in their family, and survivors reported that approximately half (46%) of their family members held stigmatizing views of suicide attempters, indicating high degrees of stigma exposure in familial systems where survivors often reside during their recovery process (Fulginiti & Frey, 2018). So, in many instances, family members do not know when a member has attempted suicide or is struggling with SI.

Why do clients or patients conceal or withhold important truths about their deep psychological pain and thoughts of ending their lives from helping professionals?

Taboo subjects such as suicidal thoughts (Al-Halabi et al., 2021; Hales-Ho & Timm, 2023) can elicit profound levels of shame, embarrassment, and vulnerability, and these feelings can be associated with clients pulling back from discussing SI openly and candidly (Baumann & Hill, 2016; Farber et al., 2019).

Individuals may hesitate to share their thoughts to end their lives because of “codes” or “cultural scripts of silence” regarding emotional distress and suffering (Szlyk et al., 2019, p. 779), or they may feel that suicide is a “mortal sin,” rendering it even more taboo. In the case of SI, clients may fear hospitalization, impact on their career, being placed on watch, alarming the client’s 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).

Persons in law enforcement (Syed et al., 2020) and the military (Bernecker et al., 2019; Drew & Martin, 2021; Thomas et al., 2023) may worry that disclosure of trauma symptoms and SI will be perceived as a sign of weakness or an indication 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 cause of death in the US armed forces (Gutierrez et al., 2021; Mann & Fischer, 2019).

While therapists frequently would prefer to see themselves as allies to persons struggling or in recovery (Baier et al., 2020; Tilden & Wampold, 2017), there are numerous potential sources of working alliance rupture (Doran, 2006), and those suffering from SI can see even their therapists as possible adversaries.

So, while we would like to think that our best friends and confidantes, as well as intimate partners and close family members, would tell us when they are thinking of suicide, there are many reasons why they might not do so.

This means that we had best not assume everyone we know “is doing alright or they would tell us.” Instead, we should venture to ask difficult questions, and wait for honest answers to those questions. Finally, helping professionals might benefit from use of an indirect, subtle screening of suicidal ideation that accurately detects suicidal thoughts without directly asking. I have undertaken this project.