Tag Archives: prevention

education, Happiness, mental health, Personal Reflections, Writing

The Future of Mental Health Awareness (Month)

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I wrote my reflections on mental health awareness and prevention as an Op-Ed piece and pasted it below.

The Future of Mental Health Awareness

As we exit Mental Health Awareness Month version 2026, I’m already anticipating May 2027. It’s time to rethink, rebrand, and reboot mental health awareness and prevention.

Think about it. Can you name a single mental disorder that, in your lifetime, has decreased in significance?

Depression? Anxiety? ADHD? Bipolar? As a mental health professional for the past 45 years, I’ve watched mental disorders in America stubbornly increase, despite more national, state, and local mental health awareness and prevention programs than ever before.

Mental health awareness and prevention are failing for multiple reasons, none of which are the fault of all the compassionate, hard-working, and well-intended people involved with mental health prevention. More likely, our collective failure begins with confusion over how to define mental health. Most Americans use “mental health” to describe mental health problems, mental disorders, or mental illness. Mental health is supposed to be positive and include joy, happiness, meaning, and mutually supportive relationships.

Instead, even the term “mental health prevention” is awkwardly phrased. Wait. Does mental health prevention mean we’re preventing mental health? Ironically, that might be exactly what we’re doing.

Without a positive vision of mental health, we’re left trying to manage, eliminate, or run from negative symptoms. Mental health should be something positive to strive toward. How about we start with the World Health Organization’s (WHO) definition of mental health? “A state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn and work well, and contribute to their community.”

Pretend for a moment that you’re a young person. You have two options. You can enroll in a program designed to reduce your anxiety and depression. Or you can enroll in a program designed to help you strive toward happiness, meaning, and realizing your abilities. Of course, this is a false dichotomy, but which direction do you find more hopeful and inspiring?

We also need to stop using unidimensional slogans to bludgeon community mental health from bad to better. Mental health awareness is a great example. Too much awareness of negative symptoms is not a good thing. More on this soon.

Research indicates that school-based mental health programs can adversely affect students. Providing prevention programming that simultaneously helps all students is a worthy, but unrealistic goal. Because preference is a powerful determinant of effective therapy, students might be better served by choosing from a menu of indirect mental health education activities.

Contemporary prevention programs also ignore several basic psychological principles.

When young people begin learning about mental disorders, a natural and powerful process begins. First, they learn about psychiatric symptoms. Then, they’re told these symptoms represent mental illnesses. Inevitably, they see these symptoms in themselves (or their friends) and begin self-diagnosing. Sometimes, the labels help explain their experiences and youth experience temporary relief. Who’s not reassured to learn that social anxiety is a thing? But, when the label gets too closely linked to identity, diagnosis becomes self-limiting. Students think: “I can’t pay attention because I have ADHD” or “My anxiety stops me from having fun and being around people.” And, because labels are sticky, it becomes difficult for young people (and adults) to shake the label and pursue their potential.

As you read these words, thousands of American youth are learning about their so-called mental disorders in at least two ways: on social media (via Tik-Tok, in particular) and through school-based mental health literacy/awareness workshops. More awareness and more information can make mental health worse—especially if the information is inaccurate or not applied with sensitivity and nuance.

Another psychological principle operates to sustain and deepen negative labeling. Like everyone, young people are inclined toward “confirmation bias.” They easily find evidence for their pre-existing beliefs while discarding evidence inconsistent with their pre-existing beliefs. If I believe I have anxiety and my anxiety limits my ability to participate in social activities, I will become skilled at noticing when my anxiety is adversely affecting me, while dismissing evidence that I’m strong and resilient enough to socialize with my peers.

What we pay attention to grows. Although my teenage clients would respond to this statement with “duh,” prevention programs ignore this concept by paying far too much attention to what’s wrong. We will not shrink problems by paying more attention to them. This is fundamental brain science. The more we focus on and talk about our problems, the better we become at focusing on and talking about our problems. The famous neuroscientist Donald Hebb put it this way: “Neurons that fire together, wire together.” The more we think about our problems, the more we’re teaching our brain to think about our problems. Soon, it becomes automatic, and you’ll be thinking about your problems all day long.

For 2027, let’s reboot mental health. Let’s redefine mental health as a positive emotional, psychological, and relational state. Then, let’s help young (and older) people develop strengths, skills, empathic relationships, positive experiences, and resources to successfully pursue positive mental health.

Together, we can turn Mental Health Awareness Month into a collective experience of joy and wellbeing for everyone.

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John Sommers-Flanagan, Ph.D. is a clinical psychologist and founding director of the Phyllis J. Washington Center for the Advancement of Positive Education at the University of Montana. He is coauthor of 10 books and many professional articles. The opinion expressed here is solely that of John Sommers-Flanagan and does not represent his current or former employers. You can email your thoughts to: john.sf@mso.umt.edu. For more information, go to https://johnsommersflanagan.com/ or https://www.umt.edu/education/cape

Clinical Interviewing, Personal Reflections, Suicide Assessment and Intervention

Welcome to Enterprise, Oregon

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I’m in Enterprise, Oregon today and tomorrow morning. I got here Sunday evening after a winding ride through forests and mountains. Yes, I’m in Eastern Oregon. Even I, having attended Mount Hood Community College and Oregon State University, had no idea there were forests and mountains in Enterprise.

The scenes are seriously amazing, but the people at the Wallowa Valley Center for Wellness-where I’m doing a series of presentations on suicide assessment and prevention-are no less amazing. I’ve been VERY pleasantly surprised at the quality, competence, and kindness of the staff and community.

Just in case you’re interested, below I’m posting ppts for my three different presentations. They overlap, but are somewhat distinct.

Here’s the one-hour intro:

final-enterprise-suicide-one-hourDownload

Here’s the two-hour session for clinicians and staff:

final-enterprise-two-hours-9-20-22Download

Here’s the upcoming 90 minute session for the community:

final-community-happiness-for-enterprise-2022Download

And here’s a view!

Boys and Men, Personal Reflections, Writing

Robb Elementary School, Highland Park, and Other Mass Shootings: Let’s Talk about Young Males and Semi-Automatic Weapons

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Nearly every mass shooting in the U.S. includes three main factors, the first two of which no one seems to want to talk about.

  1. The shooter is male.
  2. The shooter is under 25-years-old
  3. The weapon is a semi-automatic.

Why don’t we talk about the fact that the Highland Park shooter, along with so many others before him, was a male under age 25?

Last week, in an article on The Good Men Project website, I proposed banning sales of semi-automatic weapons to males under 25-years-old. Obviously, this guidance still holds.

Below I’ve pasted a couple excerpts from The Good Men Project article. For the whole thing, go to: https://goodmenproject.com/featured-content/age-to-own-guns-should-be-25-not-21-heres-why-kpkn/

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Why target age 25? Because brain and developmental research indicates that male brains have greater variability in structure and development and may not be completely mature until age 25. After age 25, males become less impulsive and more capable of moral decision-making. Automobile insurance companies recognize this truth with hefty rate reductions after males turn 25. In addition, due to American socialization pressures around masculinity, older boys and young men are especially reactive to threats to their perceived manhood. These reactions often include acts of violence designed to restore a sense of masculine honor.

Anyone paying attention knows young American males are not doing well. They’re lost. They’re angry. They’re confused. They have few constructive rituals to help them become men. Manhood may be overrated and outdated, but boys need to strive for something. Becoming a man is a tried and true tradition that’s hard to escape—if only because the media pushes it so hard. Boys need to man-up, but what does that even mean? Join the military? Smoke cigars? Take stupid risks? Watch American football? Hunt? Fish? Play violent video games? Retreat to a “man cave,” Join the Proud Boys? Grow beards? Deny COVID? Fight? Have sex? Get revenge? Never apologize or show weakness? Demean women and gays? Buy an AR-15?

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We need to address the emotional and psychological well-being of boys and young men. We also need to stop allowing them access to semi-automatic weapons.

To access the full article, click here: https://goodmenproject.com/featured-content/age-to-own-guns-should-be-25-not-21-heres-why-kpkn/

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Suicide Assessment and Intervention

Coping with Suicide Deaths

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A recent smoky sunrise on the Stillwater River

As most of you know, I recently published an article in Psychotherapy Networker on my long-term experience of coping with the death of a client by suicide. In response to the article, I’ve gotten many supportive responses, some of which included additional published resources on coping with client death by suicide.

This blog post has two parts. First, I’m promoting the Networker article again to get it more widely shared as one resource for counselors and psychotherapists who have lost a client. Below, is an excerpt from the article. . . followed by a link. Please share with friends and colleagues as you see fit.

Second, at the end of this post I’m including additional resource articles that several people have shared with me over the past two weeks.

Here’s the excerpt . . .

The Prevention Myth

I’d worked with Ethan for about 20 sessions. Stocky, socially awkward, and intellectually gifted, he often avoided telling me much of anything, but his unhappiness was palpable. He didn’t fit in with classmates or connect with teachers. Ethan felt like a misfit at home and out of place at school. Nearly always, he experienced the grinding pain of being different, regardless of the context.

But aren’t we all different? Don’t we all suffer grinding pain, at least sometimes? What pushed Ethan to suicide when so many others, with equally difficult life situations and psychodynamics, stay alive?

One truth that reassures me now, and I wish I’d grasped back in the 1990s, is that empirical research generally affirms that suicide is unpredictable. This reality runs counter to much of what we hear from well-meaning suicide-prevention professionals. You may have heard the conventional wisdom: “Suicide is 100 percent preventable!” and, “If you educate yourself about risk factors and warning signs, and ask people directly about suicidal thoughts or plans, you can save lives.”

Although there’s some empirical evidence for these statements (i.e., sometimes suicide is preventable, and sometimes you can save lives), the general idea that knowledge of suicide risk, protective factors, and warning signs will equip clinicians to predict individual suicides is an illusion. In a 2017 large-scale meta-analysis covering 50 years of research on risk and protective factors, Joseph Franklin of Vanderbilt University and nine other prominent suicide researchers conducted an exhaustive analysis of 3,428 empirical studies. They found very little support for risk or protective factors as suicide predictors. In one of many of their sobering conclusions, they wrote, “It may be tempting to interpret some of the small differences across outcomes as having meaningful implications, . . . however, we note here that all risk factors were weak in magnitude and that any differences across outcomes . . . are not likely to be meaningful.”

Franklin and his collaborators were articulating the unpleasant conclusion that we have no good science-based tools for accurately predicting suicide. I hope this changes, but at the moment, I find comfort in the scientific validation of my personal experience. For years, I’ve held onto another suicide quotation for solace. In 1995, renowned suicidologist Robert Litman wrote, “When I am asked why one depressed and suicidal patient dies by suicide while nine other equally depressed and equally suicidal patients do not, I answer, ‘I don’t know.’”

Here’s the link to the full article: https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility

Here are the additional resources people have shared with me:

Ellis, T. E., & Patel, A. B. (2012). Client suicide: what now?. Cognitive and Behavioral Practice, 19(2), 277-287.

Jorgensen, M. F., Bender, S., & McCutchen, A. (2021) “I’m haunted by it:” Experiences of licensed counselors who had a client die by suicide. Journal of Counselor Leadership and Advocacy. DOI: 10.1080/2326716X.2021.1916790

Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-in-training who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37(5), 547-557.

Ting, L., Jacobson, J. M., & Sanders, S. (2008). Available supports and coping behaviors of mental health social workers following fatal and nonfatal client suicidal behavior. Social work, 53(3), 211-221.

As always, thanks for reading, and have a great day!

Clinical Interviewing, Suicide Assessment and Intervention

Montana Conference on Suicide Prevention — My Powerpoints

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Good morning. I’m listening to Dr. David Jobes talk about innovations in approaching suicide assessment and treatment. I’m struck by the breadth and depth of his knowledge . . . and also discouraged by him acknowledging how difficult it is to change people’s mindsets regarding suicidality and its treatment. At this point we ALREADY have many effective psychosocial treatments, but disappointingly, the media and public knowledge still leans toward profiling hospitalization and the potential of medication (both of which show very mixed results).

I’ll stop with my rant here and post my ppts. Thanks for reading . . . and be sure to get the word out on innovations in suicide assessment and treatment (aka psychosocial treatments).

mcosp-july-30-2021Download
Clinical Interviewing, Suicide Assessment and Intervention

Tomorrow – Another Suicide Prevention Conference with Free CEUs

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The second of two consecutive suicide prevention conferences with free CEUs is tomorrow! Just in case you didn’t know, this conference, the Montana Conference on Suicide Prevention, has two full hours of David Jobes–the creator of CAMS–in the afternoon. How often do you get to listen to Dr. Jobes for two hours, for free, and get CEUs? Not often, I suspect.

Here’s the conference link. Go to the bottom to find the registration button: https://www.montanacosp.org/

In related news, I just got an email from the Association for Humanistic Counseling about an upcoming all-day conference on Strengths-Based Suicide Assessment and Treatment (with me presenting!). The date is: 9.24.21. This one has a small fee for CEUs . . . but it’s cheaper if you become an AHC member. Here’s the registration link for that one: https://events.r20.constantcontact.com/register/eventReg?oeidk=a07eibjc7x5afb40bd4&oseq=&c=&ch=

Have a great evening and I hope to “see” you tomorrow at the Montana conference.

Clinical Interviewing, Suicide Assessment and Intervention

Suicide Assessment Should be Therapeutic Assessment

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This morning (or afternoon, depending on your time zone), I’ll be participating on a panel discussion titled, “Treating and Preventing Suicide.” Although the event has reached maximum capacity, the link for more information is here: https://catalog.pesi.com/sq/pn_001386_essentialstreatingpreventingsuicide_panel_aca-139059?fbclid=IwAR2QYfDxVFjdnnDHV1JwKUYh54JqKzvhpneB98FF-yNrk5fcbFfPMdtyuWs

As a resource to complement the panel discussion, I’m posting some information on suicide assessment. Below is the opening from the suicide assessment chapter in our forthcoming book with the American Counseling Association. We emphasize that suicide assessment isn’t purely data collection. Instead, professionals need to simultaneously keep their eye on how to be therapeutic. Here’s the excerpt:

Suicide assessment integrates science and art. Assessment science helps practitioners determine what information is most important during a clinical interview and how to best obtain reliable and valid assessment data (Sommers-Flanagan et al., 2020; Wygant et al., 2020). The art of assessment includes how and when to ask questions, relational methods for offering empathy, and how clinicians can partner with clients to explore symptoms and strengths in ways that facilitate trust and stimulate honesty (Ganzini et al., 2013). Because suicide is a painful and provocative topic, advanced assessment skills are essential.

When clients or students experience suicidality, exposure to an assessment process can feel threatening. As a consequence, we believe counselors should embrace principles of therapeutic assessment (Fischer, 1970, 1985). Therapeutic assessment originated in the late 1960’s, when Constance Fischer began practicing and publishing about a radical new assessment approach. Unlike traditional objective and unilateral approaches to assessment, Fischer (1969, 1970) began viewing clients as “co-evaluators.” Stephen Finn has extended Fischer’s ideas; the approach is now called therapeutic assessment (Finn et al., 2012).

Therapeutic assessment principles are consistent with the professional counseling paradigm (Capuzzi & Stauffer, 2016); they include collaboration, compassion, openness, honesty, and a commitment to valuing clients as ultimate experts on their lived experiences. Although information gathering remains important, relationship connection during assessment interviews takes priority. Every assessment finding needs to be validated and understood within each client’s unique personal context. Collaboration is the cornerstone; assessments are done with clients, not on clients (Martin, 2020; Sommers-Flanagan & Sommers-Flanagan, 2017). As Flemons and Gralnik (2013) wrote, when conducting suicide assessments, “Our goal is not to remain objectively removed but, rather, to become empathically connected” (p. 6).

There are several “therapeutic” strategies for suicide assessment interviewing. Jobes’s (2016) book is a great resources, as is Freedenthal’s (2018). You can also check out our Clinical Interviewing suicide assessment chapter, or read this free blog post on using a mood scaling method: https://johnsommersflanagan.com/2018/05/25/suicide-assessment-mood-scaling-with-a-suicide-floor/

Obviously, there’s not enough time and space to go into great depth on suicide assessment in a little blog like this. And so, if you looking for depth, check out the video series I did with Victor Yalom and Psychotherapy.net. You can even watch a short demonstration video clip: https://www.psychotherapy.net/video/suicidal-clients-series

I wish you all the best as you face the challenge of engaging with and treating clients who are suicidal with the therapeutic respect they deserve.

Counseling and Psychotherapy Theory and Practice, Happiness, Personal Reflections, Writing

Happiness Homework — Week 3: University of Montana

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Stone Smirk

This week we’ve only got one active learning assignment (see below). That’s probably because there’s a Moodle quiz later in the week and, of course, there are things for students to watch and listen to, like these:

  1. Listen: Science vs. Podcast – All Aboard the Snooze Cruise https://gimletmedia.com/shows/science-vs/o2hx57
  2. WATCH: Hacking your brain for happiness by James Doty: https://www.youtube.com/watch?v=q4TJEA_ZRys
  3. Listen: The Practically Perfect Parenting Podcast, Episode: Teens and Depression — https://podcasts.apple.com/us/podcast/teens-depression/id1170841304?i=1000383659996

And here’s the active learning homework for the week!

Active Learning Assignment 5 – Your Favorite Relaxation Method

As you likely recall from the Thursday, January 23 lecture, in 1975, Herbert Benson of Harvard University published a book titled, The Relaxation Response. Benson wrote that for humans to achieve the relaxation response, they needed four components:

  1. A quiet place.
  2. A comfortable position.
  3. A mental device.
  4. A passive attitude.

For this assignment, your job is to identify and practice your favorite relaxation method. The good news is that you don’t really need a quiet place and a comfortable position (although they help, they’re not essential). But you do need a mental device and a passive attitude.

Unfortunately, as it turns out, for some people, the act of trying to relax creates anxiety. This is a puzzling paradox. Why would trying to relax trigger anxiety?

The intent to relax can trigger anxiety in several different ways. For some, if you try to relax, you can also trigger worries about not being able to relax. This is a relatively natural byproduct of self-consciousness. If this is the case for you, take it slowly. Self-awareness can trigger self-consciousness and self-consciousness can trigger anxiety . . . but time and practice can overcome these obstacles.

For others, a history of trauma or physical discomfort can be activated. This is similar to self-consciousness because the turning of your attention to your body inevitably makes you more aware of your body and this awareness can draw you into old, emotionally or physically painful memories. If this is the case for you, again, take it slowly. Also, manage your expectations, and get support as needed. Support could come in the form of specific comforting and soothing cues (even physical cues), an outside support person, or a professional counselor or psychotherapist.

Trauma and anxiety are common human challenges. Although trauma and anxiety can be terribly emotionally disturbing and disruptive, the core treatment for these problems usually involves one or more forms of exposure and can be traced back to Mary Cover Jones. You can read more about Mary Cover Jones and her amazing work on my blog: https://johnsommersflanagan.com/2018/06/04/the-secret-self-regulation-cure-seriously-this-time/

Okay, that’s enough of my jibber-jabbering. Here’s your assignment:

  1. Try integrating your favorite relaxation method (no drugs please) into your daily life. You can do it for a minute here and there, or 20 minutes all at once.
  2. Write me a paragraph or two about how it went. Include reflections on (a) what helped you relax more? and (b) what got into the way of you relaxing (obstacles)?
  3. Write me a paragraph about how you might try to do more relaxing in the future—including how you will deal with those pesky obstacles.

Thanks for reading and have a fantastic Sunday.

 

 

 

Personal Reflections, Suicide Assessment and Intervention, Writing

The End of Suicide Prevention Week

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Chair

The September 12 edition of the New York Times included an opinion piece titled “What Lies in Suicide’s Wake” by Peggy Wehmeyer. Ms. Wehmeyer previously worked as a correspondent on ABC’s “World News Tonight.” In the opinion piece, Ms. Wehmeyer shared experiences following her husband’s death by suicide in 2008.

Wehmeyer’s account of widowhood by suicide grabs you by the throat and brings you to your knees. If you’re a suicide survivor, read it with caution, because it will bring you anger, sadness, pain, and guilt.

Wehmeyer’s story also made me want to take action. I wanted to do to her what Robin Williams did to Matt Damon in his role of the therapist in Good Will Hunting. Williams looked at a file on Damon’s history of abuse, and then stood in front of him, saying,

“All this shit. This is not your fault. Look at me son. It’s not your fault.” Then Williams repeated “It’s not your fault” until Damon collapsed crying in his arms.

Some burdens are too big. I want to take Ms. Wehmeyer in my arms and tell her she’s taking on too much. Her former husband chose suicide. That’s a tragedy. But it’s not her fault.

After a suicide, shame and guilt spread like warm butter on hot toast, seeping into crevices, muscles, joints, and neurons. Guilt stabs you in the heart and then pummels your brain with the most obvious, most painful, most important, and most impossible question, “Why?”

Why . . . is a stupid, impenetrable, devious, and unhelpful question. But suicide survivors can’t stop themselves from painfully ruminating on, Why did this happen? If I were the god of suicide recovery, I’d cancel that question from the genetic blueprint. After a suicide, the question Why is pointless and unanswerable.

I’m a psychologist and a counselor. I’ve got plenty of friends in the mental health professions. Many of my friends, being of the post-modern or existential ilk, like to exclaim, usually with intellectual delight and breathless discovery, that “Humans are meaning makers!!” Well, duh.

Of course humans are meaning makers. Basically, that’s all we do. We make up shit all the time in an effort to explain our existence and our experiences. Let’s say your romantic partner breaks up with you, if you’re like most humans, you’ll wonder “Why?” And then you’ll painfully exfoliate your soul until you corner yourself with some irrational bullshit like, “I must be unlovable” or “I’m defective” or “I’m undesirable.” Or, if you’re inclined the other direction, you’ll quickly conclude, “He was an asshole” or “She’s defective” or “I hope my ex gets hit by a train.” And there are the new-age explainers who repeatedly wax philosophical, saying, “It wasn’t meant to be” or “The universe is telling me that it’s not my time for a romantic relationship.”

Asking why shit happens (and then answering yourself) is simply not helpful; it’s not helpful because you will, being human, come up with dozens of stupid, irrational, and unhelpful explanations for terrible things that happen. In the aftermath of suicide, if you’re like Ms. Wehmeyer, and many of us are, most of your stupid, irrational, and unhelpful explanations will involve blaming yourself. You’ll think things like, “I should have loved him better” or, you’ll embrace the ultimate piece of bullshit, that, somehow, as Ms. Wehmeyer wrote, “I missed those [suicide] signs until it was too late.”

No she didn’t. Wehmeyer didn’t miss the signs. And neither did you. Predicting suicide is impossible for even the best suicide researchers on the planet. Like Robin Williams said: It’s not your fault. You’re not the god of suicide prevention. Things happen. Shit happens. People kill themselves. Suicide started eons before you were born and it will continue for eons after.

Accepting tragedy sucks. It sucks more than nearly anything else we can think of. But tragedy strikes. And most of the time, tragedies are outside our control. Does that mean you should stop trying to prevent suicide and save lives? Of course not. Do what you can when you can. Does it mean you should stop blaming yourself for actions and choices that other people make and that are beyond your control? Hell yes!

In case you missed it, National Suicide Prevention Week is just ending. All week we’ve been encouraged to watch for warning signs, to follow up on our concerns by directly asking friends, family, and colleagues how they’re doing, and if they’ve been thinking about suicide. All this is great stuff. But, along with the many educational messages we’ve heard, somebody has to point out the cold, hard truth.

Sometimes you track the warning signs, you ask all the right questions, and you love people with all your heart, and they’ll still die by suicide. If that happens, it doesn’t mean you missed the signs or that you weren’t lovable enough. If suicide happens, you need to take care of yourself; you need to talk about your sadness, pain, and regrets. But you need to add one more thing. You need to listen to Robin Williams (who also died by suicide) and forgive yourself, because . . . All this shit. This is not your fault. . . . It’s not your fault.

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Resources for help

  • National Suicide Prevention Lifeline: Call 800-273-TALK (800-273-8255)
  • Crisis Text Line: Text HOME to 741741
  • Bozeman Help Center – 24-Hour Crisis Line: (406) 586-3333

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Separating the Psychological (Emotional) Pain from the Self: A Technique for Working with Suicidal Clients

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Blogs I follow

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.