Understanding Suicidal Thoughts

Although she’s been working in, studying and teaching about suicide prevention for more than 25 years, University of Denver Graduate School of Social Work Associate Professor Stacey Freedenthal is still finding novel avenues to explore as she seeks to help people stay alive. Most recently, Freedenthal and Professor Nicole Nicotera embarked on a qualitative pilot study of how people react cognitively and emotionally to their suicidal thoughts.

Understanding a wide range of these responses is important, Freedenthal says, because how a person responds to their suicidal thoughts might increase or decrease their risk of following through with suicide. That, in turn, has implications for treatment of suicidal individuals.

“In most of the clinical literature, the risk assessment proceeds as if the client agrees that stopping suicidal thoughts is a goal,” Freedenthal says. “The literature doesn’t encourage practitioners to ask people their reactions to suicidal thoughts.”

But in some cases, she explains, suicidal thoughts may benefit a client: They could be a way of coping. A different treatment approach may be needed for those individuals.

Interviews with acutely suicidal adults (N = 15; ages 18–59) receiving care at Denver Health Psychiatric Emergency Services are providing insight into the wide range of responses to suicidal ideation.

Those responses are cognitive (what people think about the fact that they have suicidal thoughts), emotional (feelings such as fear, comfort, relief or anger), or behavioral (such as drinking or using drugs to distract themselves). The research team categorizes responses as resistant to ideation, receptive to ideation, or neutral.

Those who are receptive are open to suicidal thoughts and may consider them to be normal or logical, Freedenthal explains. They may also experience thoughts of ending their life as comforting or calming. “It’s still very surprising to hear that suicidal thinking can be positive for people,” Freedenthal says. “It can serve a function for them.”

Those who are resistant, however, may think that their suicidal thoughts are bad or abnormal, and they may feel anxious, worried or guilty, for instance.

“If someone reacts to suicidal thoughts with shame and fear, does that protect them or put them at higher risk? We don’t know,” Freedenthal says.

Although data collection is ongoing, initial findings are that most individuals in the study sample responded to their suicidal ideation with some level of resistance or with both resistance and receptivity. In April, Freedenthal, Nicotera and Denver Health emergency physician Scott Simpson will present a paper on their pilot study at the 52nd Annual Conference of the American Association of Suicidology.

Freedenthal says a nuanced understanding is critical for practitioners, who may otherwise assume that all people regard their suicidal thoughts as “bad” and want to change those thoughts. “Our overriding goal is, how can this help practitioners and suicidal clients?” Is it possible to get those who are “receptive” to their suicidal ideation and who aren’t seeking help into treatment, and what type of treatment intervention would be most effective?

As she’s investigating questions such as those, Freedenthal also teaches classes and publishes articles, maintains a private practice, writes and moderates her website — Speaking of Suicide — gives media interviews and presents frequent lectures, workshops and trainings. 

“It’s profoundly meaningful work,” Freedenthal says. “It’s life or death.”