Dr. Olson,
My husband is struggling with his sexuality, and sometimes he speaks about wanting to “end it all.”
I can’t tell if this is a cry for help, a manipulation, or a real imminent danger. It is hard to know which kind of risk I am dealing with. How can I decide which it is?
Kristy
Kristy,
You wrote, “Often it is hard to know which kind of risk I am dealing with.” I would respond that it’s impossible even for mental health professionals to know what kind of suicidality we are dealing with as well.
In my clinical experience, every patient who has successfully committed suicide has been a surprise to me—until I analyze it retrospectively. We are not good at predicting.
We can place a person in a risk category based on their risk factors (depression, alcohol and drugs, losses, guns, comorbidities) and use those to make decisions about hospitalization, particularly involuntary hospitalization. But all we have done is put someone into a grouping of people at risk rather than predict an outcome for each individual.
But after years of experience, I take every threat seriously. Too many variables are involved.
The underlying characteristic of most severe attempts is a feeling of hopelessness. That feeling can be long-standing or momentary. Many times it is facilitated by alcohol. Drugs and alcohol increase the risks significantly.
The other element operating here is that the rescuer may downplay the significance because of their own issues, such as guilt, shame, or anger. Your own subjective feelings make it impossible for you to make an accurate and objective assessment of risk.
If you’re angry at someone, you may—unconsciously or consciously—think, “F*ck it! Go ahead! See if I care!” And then they do, and you realize how much you did care.
In the men that I deal with, most have considered or attempted suicide without broadcasting their intent. Some jerks try to manipulate, but these folks have usually shown their character pathology before threats are made. But even having said that, these people are also at risk through impulsivity and poor judgment.
The bottom line for me is a threat must always be taken seriously and shared, discussed, or reported to an objective observer. The worst-case scenario for the spouse is to not take it seriously and then deal with the guilt of their partner’s death.