I’m working on a Suicide Assessment and Treatment Planning manuscript and here’s a small piece of what I just wrote:
Rosenberg (1999; 2000) and others have described a helpful cognitive reframe intervention for use with clients who are suicidal. She wrote,
The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self (1999, p. 86).
Shneidman’s (1996) guidance on this was similar, but perhaps even more emphatic. He recommended that therapists partner with clients and with members of the client’s support system (e.g., family) to do whatever possible to reduce the psychological pain.
Reduce the pain; remove the blinders; lighten the pressure—all three, even just a little bit (p. 139).
Suicidal clients need empathy for their emotional pain, but they also need to partner with therapists to fight against their pain. Framing the pain as separate from the self can help because therapists can be empathic, but simultaneously illuminate the possibility that the wish isn’t to eliminate the self, but instead, to eliminate the pain.
Rosenberg (1999) also recommended that therapists help clients reframe what’s usually meant by the phrase feeling suicidal. She noted that clients benefit from seeing their suicidal thoughts and impulses as a communication about their depth of feeling, rather than an “actual intent to take action” (p. 86). Once again, this approach to intervening with suicidal clients can decrease clients’ needs to act, partly because of the elegant cognitive reframe and partly because of the therapist’s empathic message.
Here’s a case vignette to illustrate how therapists can work with clients to separate the emotional pain from the self and then partner with clients to reduce the pain. As always, this case vignette is a composite compiled from clinical work and simulations with various individuals.
Case Vignette. Kate is a 44-year-old cisgender married female with two children. She arrived for counseling in extreme emotional distress. She was also agitated, stating, “It just hurts so badly to be alive. It hurts so badly.”
Much of Kate’s emotional pain was centered around the recent death of her mother, whom Kate had cared for over the past seven years. Kate had an ambivalent relationship with her; her mother had been diagnosed as having schizophrenia and caring for her was extremely challenging. Kate’s acute emotional distress was accompanied by fears of turning out like her mother and thoughts of reunifying with her mother. She said, “I just need to be with her.”
To help Kate separate her intense emotional pain from the self, I began by noticing that there were two different parts of Kate, and that these two different parts had different ideas about how to move forward. Noticing and articulating different perspectives of the self is a common approach from a person-centered theoretical perspective. Because of Kate’s family history of schizophrenia, I wouldn’t use an expressive Gestalt technique to separate her different ego states, but it felt like reflecting her obvious ambivalence was a safe approach. Specifically, I said, “Sounds like a part of yourself thinks the solution is to die, and that your kids will be better off. But there’s another part of you that says, maybe the solution isn’t to die. Maybe I can come in here and talk. Maybe my kids actually would suffer if I died.”
Kate accepted that she was “of two minds” about how to go forward. Next, I tried to further clarify these parts of herself, emphasizing that I wanted to align with the “second” part of herself, so that we could work together on her emotional pain.
The one part of yourself thinks your only hope of dealing with the pain is to kill yourself. The other part thinks, maybe I can stay alive, work in counseling to get rid of the pain, and then my children wouldn’t suffer from my death. How about, for now, we work from that second perspective. We can be a team that works hard to decrease the emotional pain you’re feeling. It might not go away immediately, but if you stay alive and we work together, we can chip away at the pain and make it shrink.
You may notice the words I used were somewhat redundant. Using redundancy with clients who are feeling suicidal may be needed because the agitated, depressed state of mind makes cognitive focusing difficult. Sometimes, if you don’t repeat the therapeutic perspective and keep focused on it, the therapeutic perspective can slip away from your clients’ cognitive grasp.
Linehan often uses a more provocative way of talking about partnering with clients to diminish their pain. For example, she might say, “Getting through this is like going through Hell. But I know therapy can help and I want to work with you on this. But I have to tell you this, therapy will only work if you stay alive. Therapy doesn’t work on dead people. So I want you to stay alive and work with me at attacking your pain. Will you give me six months for us to go through hell together so we can get control of your pain?”
Either way, the goal is to partner with clients to work on decreasing emotional or psychological pain. This approach combines empathic listening, with an emphasis on the therapeutic alliance. As therapist and client partner together, then cognitive-behavioral problem-solving can commence.