Many psychotherapists have treated patients who denied suicidal ideation, and then attempted suicide later. This can leave the treating psychotherapists upset, bewildered, and asking what they could have done differently.

Sometimes patients who unexpectedly attempted suicide developed their suicidal thoughts after their psychotherapists asked them about suicide. At other times, these patients already had suicidal thoughts but falsely denied having them. Psychotherapy patients frequently misrepresent their suicidal thoughts. Blanchard and Farber (2016) found that 31% of patients at least once lied or misled their psychotherapists about their suicidal thoughts and further found (Blanchard & Farber, 2020) that 21% of patients consistently lied or withheld their suicidal thoughts. Other patients may admit to suicidal thoughts or behaviors but minimize their importance or omit relevant information. They may, for example, admit to suicidal thoughts but falsely deny that they have a plan to kill themselves, or they may admit to having a plan to kill themselves but falsely deny having a past suicide attempt. Patients may falsely deny suicidal thoughts for many reasons, although many deny them out of shame (Sheehan et al., 2021) or because they have internalized the stigma against suicidal persons.

Shame

Shame is one of two emotions (along with guilt) that people commonly feel when they have violated a social norm or failed in a moral obligation. However, guilt and shame differ in important ways. Guilt focuses on the wrongness of a behavior and motivates the offenders to apologize or make amends for the wrongdoing. In contrast, shame involves a global and stable belief in one’s deficiencies that undermines any effort on the offender to make amends for their wrongdoings and motivates them to withdraw socially. With guilt the focus is on “what I did;” in shame the focus is on “what I am” (Tangney et al., 1996). Shame is transdiagnostic and can be a feature of depression, PTSD, or other diagnoses. It may interact with other emotions such as anger (Cassiello-Robbins et al., 2018), social anxiety, humiliation, or sadness (Swee et al., 2021).

Self-Stigma

Shame and self-stigma share similarities in that they both assume that the offenders have defects that are so severe that they believe that they do not deserve the benefits of interacting with others. Those with self-stigma are aware of and have internalized the societal prejudices against people like them. Shame is “the main emotional component of stigma” (Luoma & Platt, 2015, p. 97).

Suicidal patients may adopt the negative stereotypes of suicidal persons as cowardly, selfish, or weak (Joiner, 2010), or as attention-seekers. Shame and self-stigma are especially pernicious for suicidal patients because they devalue their already fragile sense of self-worth, increase their social isolation, distance them from others, add the burden of trying to conceal aspects of themselves, and keep them from being authentic with others. Those with self-stigma may monitor the reactions of others for signs of disapproval or may interpret ambiguous social behaviors as evidence that they are a burden to others (Frey et al., 2017). Those with suicidal thoughts and self-stigma have a higher risk of suicide than those with suicidal thoughts without self-stigma (Mayer et al., 2020), although the link between self-stigma and suicide is reduced among those who have strong social support networks (Wastler et al, 2020).

Many suicidal persons have multiple stigmas, such as the stigmas of being suicidal and gay (Williams et al., 2018). The self-stigma may be even greater for patients who have attempted suicide (Oxele et al., 2019), spent time in a psychiatric hospital (Mathison et al., 2021), or for men if it violates their perceived masculine ideal of self-reliance and stoicism (Coleman et al., 2020). Those with strong religious beliefs may sometimes believe that the presence of suicidal thoughts itself is a sin that violates tenets of their faiths.

Patients who have internalized the stigmas associated with suicide may keep aspects of themselves secret or avoid seeking help from others. They may be less likely to seek psychotherapy and, if they do, may be less likely to disclose their suicidal thoughts. One patient with suicidal thoughts said, “there are still parts where you feel shame and different things. When you’re out of the depression, you don’t feel that way. When you’re in it, you want to protect the way you feel” (Richards et al., 2019, p. 2079). Another patient who falsely denied having suicidal thoughts stated that she did not disclose her suicidal thoughts because doing so “adds more shame and self-loathing that exasperates [sic] everything” (Blanchard & Farber, 2020, p. 129).

Addressing Shame and Self-Stigma in Psychotherapy

Psychotherapists should be aware of shame and self-stigma when they evaluate or treat suicidal patients and remember that shame and self-stigma may keep some patients from disclosing their suicidal thoughts. Patients decide to share their suicidal thoughts when they believe that the benefits of doing so would outweigh the disadvantages. They will be more likely to disclose their suicidal thoughts to someone that they trust and who they believe will support them (Sheehan et al., 2021). Those who feel shame may be more likely to fear their psychotherapists’ disapproval. As stated by O’Connor, “when stigma increases, help-seeking declines, ignorance flourishes and deaths soar” (2021, p. 79).

Of course, most patients who deny suicidal thoughts do not have suicidal thoughts, and it would be unproductive to repeatedly ask patients about suicidal thoughts if they are denying them. On the other hand, psychotherapists can increase the likelihood that patients will reveal suicidal thoughts if they ask all patients twice about suicide by using a written question about suicide on an intake form as well as asking them about suicide in an in-person interview. Respondents will often disclose things in response to a written question that they will not acknowledge in a verbal interview and vice versa (Knapp, 2022).

Psychotherapists can also increase the likelihood that patients will disclose their suicidal thoughts by adopting a nonjudgmental and supportive stance with their patients. They can normalize the patients’ reactions by stating, for example, “A lot of people who went through such events would think about suicide. Do you ever have those thoughts?” or words to that effect. When patients disclose difficult thoughts or feelings, psychotherapists can praise their patients for the courage it took to share.

Some reluctant patients may disclose their suicidal thoughts indirectly, wherein they raise a topic obliquely, evaluate the response, and then decide whether it is safe to disclose more. Psychotherapists can follow up on micro disclosures or indirect communicators of suicide such as thoughts of passive suicide (e.g., “I won’t kill myself, but I want to die”), entrapment (e.g., “I don’t think anyone could endure the pain I feel much longer”), perceived burdensomeness (e.g., “Others would be better off if I were dead”), or despair (e.g., “What is the use of trying anymore?”). Instead of overreacting or criticizing their patients for their thoughts, effective psychotherapists will listen without judgment and may offer their patients alternative ways of responding or looking at their problems. As one former patient advised, psychotherapists should “Mak[e] the patient feel heard and validated and not like they’re another number or statistic or someone to blame,” (Hom et al., 2021, p. 368). Others urged psychotherapists to “[be] compassionate and understanding” and to “respect and validate the emotions and thoughts” (Hom et al., 2021, p. 370).

Those with self-stigma may be more likely to “punish” themselves for having thoughts of suicide by, for example, telling themselves that they are stupid for having such thoughts, or getting angry at themselves for having those thoughts. However, punishment related strategies tend to increase the frequency of suicidal thoughts (Tucker et al., 2017). Psychotherapists who show compassion offer an effective alternative to self-punishment.

Those with self-stigma tend to have less psychological flexibility (Krafft et al., 2018) and therefore it would make sense that treatments that promote psychological flexibility may help reduce self-stigma. Programs that involve self-compassion or mindfulness, which promote nonjudgmental awareness of one’s feelings, appear to be effective in reducing shame and self-stigma (Stynes et al., 2022).

Self-compassion involves compassion for oneself, appreciation of the commonality of experience with all humanity, and a refusal to identify one’s emotions too closely with one’s essence as a person. Self-compassion programs reduce social isolation and reinforce self-kindness (Luoma & Platt, 2015). Several effective treatments for suicidal patients, such as Cognitive Behavior Therapy (Bryan & Rudd, 2018) and Acceptance and Commitment Therapy include mindful elements (Ducasse, 2018).

Summary

Shame and self-stigma increase the emotional burden on suicidal patients, discourages them from disclosing their suicidal thoughts, and increases their overall risk of a suicide.

Psychotherapists can reduce the impact of shame and self-stigma by adopting an accepting, curious, and nonjudgmental approach with their patients, normalizing their patients’ reactions to stressful events, and following up on oblique or indirect references to suicide.

Self-compassion or mindfulness-based treatment approaches which increase psychological flexibility may help to reduce the shame or self-stigma that many suicidal patients feel.

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Samuel Knapp, Ed.D.

Samuel Knapp is a retired psychologist who formerly worked as the director of professional affairs for the Pennsylvania Psychological Association.