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Going through a mental health crisis can be one of the loneliest experiences you'll ever have. Some people call it "the dark night of the soul," while others call it "rock bottom." Whatever you call it, despair is heavy and hard to navigate. When psychological pain, echoes of trauma, social isolation, or personal hardship bring you to a point that you're thinking about suicide, it can feel impossible to move past it—like trying to get to the end of a long, dark hallway that only seems to be growing in size.
Instinct drives us to ask for help when we become lost, but hopelessness defies that instinct. Even when it doesn't, most people don't know what to say or how to help when you tell them you're not sure you can go on living. They might panic, stumble over their words, minimize your pain, or try to quell your agony with platitudes. You might even have been turned away by a therapist.
When your first attempt to ask for help fails, it's easy to shut down and fall further into the vortex of suicidal thoughts. It can seem like the world is confirming what your renegade brain keeps telling you: that you're not worthy of help or that you can't be helped. It might feel like no one can reach you in the sunken place you're in, and like it's impossible to climb out on your own.
But it's not true—suicide isn't the only way out. The hallway of despair isn't endless after all, and has an exit. You can get pulled out of the sunken place in a flash. Suicidal despair can actually be a turning point, the first light of clarity after a long night of confusion: the point you know you need to address the internal or external issues that brought you to this place. All you need to do to step out of the darkness and into the light is to know who to talk to and what to tell them to get the help you need.
One of the first steps in finding your way out of the dark hall of despair is understanding that two things are true:
It's also important to know that you are not alone. You are not alone in having reached this place; other people have been here and have found a way out. You also don't have to struggle alone; there are people who aren't afraid to look into the abyss with you and who can help you cross it.
If loved ones have made you feel like you shouldn't talk about what you're thinking or feeling, understand that they are probably afraid, that they probably want to help you, but that they definitely don't know how. If a therapist turned you away, understand that there are specific reasons that this happened, none of which mean you can't get the help you need.
There are different levels of risk associated with different types of suicidal thoughts. If you don't specify what kind of suicidal thoughts you're experiencing, most therapists default out of caution to thinking you're reached a level of crisis they can't address. You may well have, or you might be a perfect candidate for therapy. You can find out which is true by learning how professionals assess suicide risk and what level of care they recommend for each risk level.
Before we review risk levels, it's important to understand that it's not your job to figure out your suicide risk level. If reading this is difficult for you and you just want to talk to someone, that is a wise and valid response to your circumstances. Consider calling the National Suicide Hotline (1-800-273-8255) or a local mental health crisis line for live support and guidance. (Click here for a listing of international crisis numbers.) The people who answer won't judge you and can help connect you with local mental health treatment options.
Philosopher Friedrich Nietzsche famously said, "The thought of suicide is a great consolation; by means of it, one successfully gets through many bad nights." Like musicians who have explored suicide in their song lyrics, Nietzsche didn't believe people should end their own lives. Instead, he wanted to help people find the strength to rebel against suicidal thoughts and the circumstances that produce them. Like other existentialist philosophers, he believed the only way to overcome suicidal despair was to honestly confront its reality.
Why do people have suicidal thoughts? The main reason people think about suicide is that they want to get out of an unbearable situation or end the pain they are in. This is why Nietzsche said that the thought of suicide can be a consolation—it is preferable to the thought of endless pain or torment. The problem is that suicide is permanent, while the circumstances that make people think about suicide are not. Many people who have been in despair and gotten help have later found great happiness that seemed impossible at the time.
Some people approach the topic of suicide philosophically, but it's more typical to first think about it vaguely, in response to pain or hopelessness: "Maybe I'd be better off dead." If you're like many people, you've had such a thought, immediately followed by all the reasons you want to be alive and the reasons you wouldn't end your own life. Just because you've ever had a thought like that doesn't mean you're in crisis now or are a poor candidate for therapy.
Your suicide risk level is higher if you've thought about suicide recently. It increases as you think about suicide more often and in greater detail. The following infographic shows the risk levels associated with each kind of suicidal thinking and the recommended level of care for each:
More than therapy is needed when suicidal thoughts develop two dangerous features: intent and a plan. If you've progressed from considering suicide to actively wanting to end your life, you're in much greater danger than when the thoughts are vague or passive. Your risk of acting on the thoughts is even higher if you've started planning how you would end your life. Using substances also increases your suicide risk by increasing your risk of acting on a sudden impulse.
When you're actively considering suicide, you're in crisis and need something more intensive than a weekly therapy session. When you've reached the point you're planning to act, you need to immediately seek emergency care.
When mental health professionals evaluate a person's suicide risk, they also consider what they call risk and protective factors. These are elements in a person's life that either increase or lower the risk of suicide. While the type and severity of suicidal thoughts is the most important factor in making care decisions, the presence of risk or protective factors can support intermediate alternatives like intensive outpatient treatment with a safety plan.
In general, you're more at risk of acting on thoughts of suicide if you're struggling with pain, trauma, or chronic stress at work or home and aren't talking to anyone about it. You're less likely to act on suicidal thoughts when you feel supported and connected, whether to a therapist, friends, family, a community of like-minded individuals, or all of these.
One of the important things to understand about depression is that it isolates you and convinces you that you're alone because you deserve to be or because there's something wrong with you. This isn't true. Many more people than you'd think go through periods of isolation; they just don't tell the people that they meet on the other side just how lonely it got for them.
Just like thoughts of suicide can be overcome, so can social isolation. The more connected the world becomes, the more we all learn we have a tribe out there somewhere. You can find yours and enjoy a very different quality of life than what feels possible for you now. Getting the help you need to get through a crisis is often only the first step on the journey of healing.
People who offer online therapy are often more reluctant to provide care to clients who report suicidal thoughts even when therapy is the right level of care. This may have less to do with concerns about the limitations of online therapy than it does with how much harder it is to accurately screen for suicide risk using an online form. Many times, if you select the "wrong" box, you're automatically routed elsewhere—like this page—without the chance to explain further.
It also has to do with the importance of in-person supports for people with severe symptoms. While online therapy can be as effective as in-office therapy, there are times when it is not. It is much easier to create and follow a safety plan and find and utilize other local resources when you work with a therapist in your local community.
While it's not necessary or your job to figure out your suicide risk level, knowing it can help you feel more confident when you talk to mental health professionals and can help you collaborate with them to get the right level of care.
Two ways to get mental health care immediately are to call 911 or go to a local emergency room. If you want to talk to a counselor instead of or before talking to a 911 dispatcher, you can call the National Suicide Hotline (1-800-273-8255) or a local crisis line. Mental health crisis lines are part of the public mental health system in every state and typically operate 24/7 or have after-hours alternatives. There are also international crisis lines.
The people who answer crisis and suicide hotlines can counsel you and connect you with the care you need. If you are in need of immediate help and cannot transport yourself to an emergency room, they may be able to connect you to a local dispatcher and get first responders to come to you. Note that once first responders become involved, you are no longer in control of all decisions about your care. If you say you're thinking of harming yourself, then try to leave, you may be temporarily detained for involuntary treatment.
If you've had vague or passive suicidal thoughts, no suicide plans, and no intent to act on them, therapy can be a great place to start, especially if you have other protective factors that can help. The best way to help a potential therapist accurately assess the care you need is to explain all of your symptoms and circumstances in detail and provide the necessary context to help them determine your risk level. You'll be able to communicate with more nuance when you're in the room together.
If you and a therapist determine that therapy is appropriate for your risk level, addressing suicidal thoughts will be an important element of your therapy plan, though not likely the only one. Your therapist will want to explore your personal and mental health history, determine whether you have a mental health condition, and assess your current stressors.
Your therapist will want to understand the factors in your life that affect your mental health the most, whether those are circumstances at work or home. They will want to learn more about the specific nature of the thoughts you are having and develop a safety plan with you for what to do if they become more intense, frequent, or specific.
As you and your therapist get to know one another better, you'll start delving deeper and finding out what triggers your suicidal thoughts and other symptoms. You'll work together to address these triggers and any underlying issues you may have, such as unresolved trauma, untreated depression, or unhealthy life circumstances. You'll collaborate on an action plan for things to work on in therapy and things to do at home to improve your mental health.
You'll engage in similar tasks in any mental health program. Higher levels of care usually include individual therapy as part of your treatment plan. Intensive and day programs work not by providing a totally different type of care, but by complementing it with additional interventions.
In general, higher levels of care involve spending more time each week in treatment than you would if you were seeing a therapist once a week. Intensive outpatient programs usually provide 6-8 hours of care per week, while partial hospitalization or day treatment programs meet for 8 hours a day, five days a week. Some programs offer flexible scheduling options when those are appropriate for your risk level.
In partial hospitalization and intensive outpatient programs, you usually participate in individual therapy sessions at least once weekly and sometimes as often as every day. You go to multiple group therapy sessions each week as well as instructional classes where you learn more about your condition or symptoms. Many intermediate programs offer self-help groups on campus where you can talk to peers without a counselor present. Depending on the program, you may also be able to participate in additional activities or therapies like art therapy or yoga.
Inpatient treatment usually involves a similar treatment schedule as partial hospitalization or day treatment programs. The extra time you spend on the unit isn't as much about spending more time in groups or therapy sessions as it is about having extra security and immediate care when you need it. Staff are available around the clock. If you're in an inpatient program and wake up in the middle of the night in crisis, you can immediately connect with professional care.
Another important feature of inpatient treatment is that it removes you from circumstances that may be triggering or aggravating suicidal thoughts or other mental health symptoms. This allows you to stabilize in a safe environment and gain perspective on what you need to change at home to support improved mental health. One of the most important things you'll do in an inpatient program is work with your care team to develop a discharge plan to make your transition back to life at home smoother. Most people follow up inpatient care with outpatient care.
Though many people have thought about suicide at some point in their lives, it remains a taboo topic. Even some mental health professionals are uncomfortable with it and refuse to meet with people who tell them over the phone that they've thought about suicide. Sometimes, they're right to refer people to a higher level of care, but sometimes they're wrong.
If this has happened to you, don't lose hope. Understanding that there are different kinds of suicidal thoughts and knowing your risk level can help you work with professionals to get the level of care you need. There are experienced therapists who can help clients who are not in acute crisis, and you're more likely to get in to see one if you can explain your symptoms in detail. You may have more luck with group practices or agencies who treat a wider range of clients. You can find both kinds of therapy providers using the search tools on OpenCounseling.com.
If you've had more than vague, passing thoughts about suicide, you may need more than therapy. If you've been thinking about suicide a lot, feeling like you want to die instead of vaguely wondering if you'd be "better off dead," or planning how you might end your life, you're at an elevated risk of suicide and should call a local crisis line, the National Suicide Hotline (1-800-273-8255), 911, or an international crisis line. The person who answers will talk to you about what you're going through and help you get the right level of care.
No matter what it feels or looks like now, there is hope. You've been through a lot, and you're stronger than you know. Your life has potential that's hard to see in the dark, so please don't give up. There are people who care and want to help. The more of them you get to know, and the more you learn about yourself, the more tools you'll have to find your way out of the darkness.
