In honor of National Suicide Prevention Month, I’m offering another chunk of information about suicide assessment and treatment. This information is an excerpt from our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach. In the book, we discuss assessment and treatment planning using a dimensional approach. The first (and central) dimension for suicide assessment and treatment is the emotional dimension.
To get a bigger sense of the topic, you can read 33 pages of the book for free on Google Books: https://www.google.com/books/edition/Suicide_Assessment_and_Treatment_Plannin/bOQUEAAAQBAJ?hl=en
Here’s the excerpt:
Working in the Emotional Dimension
When clients are depressed and suicidal, everyone—including family, friends, co-workers, counselors, and clients—wish for an improved emotional state. But often the process is slow, and as a result, the very people upon whom the client relies for support may lose patience. Supportive people, even counselors, may feel urges to say things that are emotionally dismissive, like, “Cheer up” or “Come on, you need to exercise!” or “Why can’t you do something to make your life better?”
Moving clients out of despair and into the light is difficult; if it were otherwise, clients would resolve suicidality on their own. Directly or indirectly suggesting to clients in suicidal pain to “cheer up” often backfires, creating anger, hostility, and resistance to treatment; this resistance is a powerful phenomenon called, psychological reactance(Brehm & Brehm, 1981).
Psychological reactance occurs when clients perceive their ultimate freedoms as threatened. If clients sense that clinicians want to coerce them to stay alive, in response, they may dig in their heels and engage in behaviors designed to restore feelings of autonomy. Psychological reactance is one explanation for why clients who are suicidal sometimes vehemently resist help, insisting on their right to think about and act on suicidal impulses. Repeated empathic acceptance of the client’s emotional pain is one way to avoid activating reactance; empathic acceptance also allows clients to begin exploring and addressing key emotional issues in counseling.
Key Emotional Issues to Address
Many emotional issues are relevant to suicide treatment planning. These include: (a) excruciating distress, (b) specific disturbing emotions, such as, acute or chronic shame and guilt, anger, or sadness, and (c) emotional dysregulation. In this next section, we briefly review core emotional issues that you may guide your treatment planning. Later in the chapter we provide case examples and vignettes illustrating methods for working in the emotional dimension.
Shneidman referred to the emotional state surrounding suicide as “psychache” or unbearable distress. He wrote: “The suicidal drama is almost always driven by psychological pain, the pain of negative emotions—what I call psychache. Psychache is at the dark heart of suicide; no psychache, no suicide.” (2001, p. 200, italics added).
Even when using a strength-based or wellness model, exploring the “pain of negative emotions” or excruciating distress is usually your first focus. Sometimes, to avoid activating reactance or resistance, you’ll need to stay with your client’s emotional pain longer than you’d prefer. Staying with your clients’ pain not only helps bypass resistance, it also models that facing negative affective states without fear, avoidance, or dissociation requires personal strength. Even so, as you focus on suicidal pain, you might wish the client would immediately adopt a more positive mindset, or find the process difficult to bear. You also might need to turn to colleagues or your self-care plan for support. Nevertheless, job one in the emotional dimension is to recognize and resonate with your client’s emotional pain.
Acute or Chronic Shame and Guilt
Shame and guilt are non-primary emotions because they involve significant self-reflection. Shame connotes beliefs of being unworthy, defective, or bad. Shame is often directly linked to core beliefs about the self, and activated by particular life situations. In contrast, guilt is more specific, often associated with certain actions or lack of actions (e.g., “I should be doing more to fight racism” or “I shouldn’t have been so critical of my professor”). Generally, guilt can lead to shame, and shame is more likely to ignite suicidality. Reducing or resolving shame or guilt may be a crucial therapeutic goal.
Suicidal thoughts are often accompanied by shame. Cultures around the world have historically judged death by suicide as a shameful or sinful event, and many still do. Your client’s experience may be something like, “Not only do I have suicidal thoughts—which are terrible in their own right—but the fact that these thoughts exist in my mind also make me a bad person.” This double dose of negative judgment, emotional pain plus self-condemnation, often needs to be addressed in counseling. One strategy that may fit into your treatment plan is to help clients develop greater self-compassion as a method for countering their self-condemnation.
In graduate school, we had a professor who suggested we consider this question: “Who is this client planning to commit suicide at?” Often, people who are suicidal carry great anger toward one or more friends, lovers, or family members and thus think of suicide as an act of revenge. Counselors should listen for underlying themes that involve using suicide as a behavioral goal for getting even or intentionally hurting others (Marvasti & Wank, 2013).
Thoughts of dying by suicide sometimes emerge as a revenge fantasy. Thoughts like, “I’ll show them” or “they’ll suffer forever” represent anger, along with the desire to punish others. It can be tempting to point out to clients that death is an irrationally high price for fulfilling revenge fantasies. However, helping clients express, accept, and understand the depth of their anger will usually reduce suicidality more efficiently than pointing out that death is a maladaptive revenge strategy. If revenge is central and forgiveness isn’t a viable option, then an apt philosophy to gently infuse into your clients is that the best revenge is a well-lived life.
Major depression is the psychiatric diagnosis most commonly linked with suicide attempts, especially among older adults (Melhem et al., 2019). Clients who present with sadness as a dominant emotion may or may not meet diagnostic criteria for major depression. However, when sadness and the associated emotions and cognitions of irritability, regret, discouragement, and disappointment are central sources of distress, we recommend targeting those symptoms with evidence-based counseling interventions. Weaving positive psychology or happiness interventions into treatment planning is especially appropriate for clients struggling with sadness and depression (Seligman, 2018; Rashid & Seligman, 2018). More information about evidence-based approaches and positive psychology interventions is provided later in this chapter and in upcoming chapters.
Clients who are suicidal may exhibit emotional dysregulation during counseling sessions and in their everyday lives. Clients may be emotionally labile, shifting from expressing anger to feelings of affection, appreciation, and deep connection. Clients may share stories of repeated maladaptive emotional overreactions to life’s challenges. Although unstable relationships, emotional swings, and explosive anger fit with the diagnostic criteria for borderline personality disorder, when clients are experiencing excruciating distress, they may behave in ways that resemble borderline personality disorder. However, instead of pathologizing clients with a personality disorder diagnosis, we recommend framing client behaviors using a social constructionist strength-based orientation, such as: Given enough situationally-based stress, including, as Linehan (1993) noted—emotionally invalidating environments—nearly everyone becomes dysregulated and appears unstable. Normalizing dysregulation as a natural response to intense distress helps maintain a strength-based perspective.
Treatment plans for clients who are suicidal often include teaching emotional regulation skills; this translates to helping clients become more capable of regulating themselves in the face of emotionally activating circumstances. Linehan’s (1993, 2015) protocols for working with clients with borderline personality characteristics are recommended for emotional regulation skill development. However, alternative approaches exist, some of which come from positive psychology, happiness, and well-being literature (Hays, 2014; Lyubomirsky, 2007, 2013; see Wellness Practice 4.1).