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Suicide Interventions and Treatment Planning for Clinicians: A Strength-Based Model
by John Sommers-Flanagan, Ph.D.

3 CE Hours - $74

Last revised: 08/25/2019

Course content © copyright 2019 by John Sommers-Flanagan, Ph.D. All rights reserved.

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Learning Objectives

This is an intermediate level course. After completing this course, you will be able to:

These course materials are based on contemporary theory, research, and practice pertaining to suicide assessment and treatment. However, because the scientific literature on suicide is voluminous and ever-changing, additional information will always be available to clinicians who want to keep learning. You should be aware that reading about suicide can be triggering. Additionally, although the knowledge and skills in this course may improve your ability to develop treatment plans and provide interventions for clients who are suicidal. Because suicide is inherently difficult to predict and prevent, using the information herein does not guarantee positive outcomes.



Suicide interventions and treatment planning are crucial in two situations: (a) crisis-driven contexts, and (b) ongoing counseling or psychotherapy with clients who are intermittently or chronically suicidal. This course will develop your skills for intervening with and managing suicidal crises as well as help you create treatment plans for managing client suicidality in longer-term contexts. This course is the second of two courses in this series on suicide. The first course, Suicide Assessment For Clinicians: A Strength-Based Model, addresses personal reactions of the therapist to suicide and self-care, myths about suicide, a comprehensive suicide assessment, as well as decision-making skills with suicidal clients.

In this second course you’ll learn a holistic, strength-based model for assessment and treatment of suicidality which focuses on six domains of human functioning:

This strength-based suicide assessment and treatment model is consistent with the American Association of Suicidology (AAS) competencies for working with clients who are suicidal, as well as with other practitioner competencies (Cramer, Johnson, McLaughlin, Rausch, & Conroy, 2013).

Evidence-Based Suicide Treatment Protocols

Beyond this general model, you also may want to obtain advanced training in one or more evidence-based treatments for suicide. Four protocols have significant empirical support. These include:

1. Dialectical Behavior Therapy (DBT): DBT was developed as a treatment for patients diagnosed with borderline personality disorder (Linehan, 1993). The foundational principles include (a) acceptance; (b) change; and (c) dialectics. DBT training and practice is especially good preparation for providers who work with clients who engage in repeated self-destructive behaviors.

2. Collaborative Assessment and Management of Suicide (CAMS): CAMS is a “philosophy of care” that includes foundational principles of empathy for suicidal distress, a collaborative spirit, and honesty (Jobes, 2016). Use of a clinical tool called the Suicide Status Form (SSF) guides CAMS treatment. The SSF is used to integrate therapeutic assessment and monitoring of suicidal states into the psychotherapeutic process. Overall, CAMS involves “coauthoring” a treatment plan that will be implemented to address client suicidality.

3. Cognitive Therapy for Suicide (CTS): With a primary focus on maladaptive thinking, CTS is in the tradition of Aaron Beck’s cognitive approach (Wenzel, Brown, & Beck, 2009). Based on data and experiences derived from numerous clinical trials, the unique problems and presentation of suicidal patients are integrated into a traditional cognitive therapy platform. CTS involves a commitment to cognitive case formulation and treatment.

4. Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT-SP): BCBT-SP is a three-phase CBT model to treat suicidality (Bryan & Rudd, 2018). Phases include: (a) extensive assessment, focusing on recent suicidal episodes, patient-specific suicide triggers or factors, and collaborative development of a crisis response plan; (b) application of cognitive strategies to help patients reduce hopelessness, perceived burdensomeness, and guilt/shame; and (c) a relapse prevention imagery task where patients visualize themselves successfully dealing with a suicidal crisis by applying a skill or skills they’ve learned in therapy (Rudd et al., 2015).

Along with principles and practices from these four evidence-based treatments for suicidal clients, suicide-specific interventions from other sources also will be integrated into this course (Sommers-Flanagan, 2018).

Suicide Interventions and Treatment Planning: Foundational Principles

Before focusing on the strength-based model, two essential principles that cut across all modern evidence-based protocols and evidence-based interventions should be highlighted:

Collaborative practitioners work with clients, not on clients. Clients experiencing suicidal thoughts and impulses typically know their struggles from the inside out. Their self-knowledge makes them an invaluable resource. Carl Rogers (1961) put it this way:

It is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried. It began to occur to me that unless I had a need to demonstrate my own cleverness and learning, I would do better to rely upon the client for the direction of movement in the process. (p. 11)

Compassionate practitioners resonate with client emotions and engage in respectful and gentle emotional exploration. Although compassion involves an empathic emotional response, it also includes tuning in to and respecting client cognitions, beliefs, and experiences. For example, some clients who are suicidal feel spiritually or culturally bereft or disconnected. Regardless of their own beliefs and cultural values, compassionate counselors show empathy for their clients’ particular spiritual or cultural distress.

Clients who are or who become suicidal are often observant and sensitive. If they feel judged, they’re likely to experience a relationship rupture (Safran, Muran, & Eubanks-Carter, 2011). When ruptures occur, clients typically become less open, less engaged, and less honest about their suicidal thoughts and impulses. They also may become angry, aggressive, and critical of your efforts to be of help. In both cases, relational ruptures signal a need to work on mending the therapeutic relationship.

Components of the Strength-Based Model for Treatment Planning

The strength-based model blends traditional case formulation content with six common-sense life domains. Treatment planning and case management flow smoothly from this model. Case formulation and treatment planning can be divided into four interrelated components (Sommers-Flanagan & Sommers-Flanagan, 2017):

Identifying Client Problems

Most clients arrive for counseling with problems on their mind. When clients are able to share these problems during an initial interview, the main problem is referred to as the chief complaint. Some clients will need help from therapists to identify and articulate their problems (including whether or not suicidality is a problem).

Mutually Generated Goals

All problems imply goals. Clients may need help exploring what they want in life and from therapy. Just as with problems, client goals may be vague and may shift over time. Effective therapists are able to listen to clients and summarize goals that underlie client distress. As goals are distilled from client problems, it helps for therapists to ask permission to begin a goal list (e.g., “Is it okay if I put down getting connected with new and positive social relationships as a goal for us to work on together?”). Asking permission is a core tool in motivational interviewing; it’s also an effective method for initiating a mutually generated goals list. Throughout the therapeutic process (e.g., problem identification and goal generation), therapists should always notice, reflect, and nurture client strengths. For example, when developing problem and goal lists, you might make supportive, strength-oriented comments such as,

As you comment on strengths and focus on goals, clients will often react with negativity; in essence, they’ll spoil your positive feedback in ways similar to how they spoil their own positive experiences. When clients return to negativity, be accepting, but stop short of completely endorsing their negative frame (e.g., “I hear you saying that you don’t feel the least bit strong, and so what I said to you doesn’t feel accurate. I suppose it’s possible for both perspectives to have truth. You feel weak, but from where I’m sitting, it seems like, at least sometimes, you’ve been strong.”). Because clients who are suicidal are often so caught up in their depressive experiences, in psychoanalytic terms, they may need to borrow from your healthy ego strength to begin to see exceptions to their overwhelmingly depressive self-perceptions.

Collaborative Treatment Planning, Including Interventions

The treatment plan, including interventions that target specific problems, is the map that clinicians and clients use to travel from identified problems toward mutually generated goals. Optimal treatment plans include specific interventions that clinicians and clients agree as tasks to work on within sessions and as outside-session homework. Early on, Frank (1961) described how having a culturally sanctioned rationale contributes to positive treatment outcomes. Clients who are suicidal need clinicians to provide specific interventions that can be easily understood as having a reasonable chance of decreasing or eliminating problems and distress. Suicide-specific interventions, most of which have empirical support, will be sprinkled throughout this course.

Theoretical Mechanisms

The model described in this course draws from several theoretical foundations:

Person-centered: Therapeutic interventions should be delivered using foundational principles of congruence, unconditional positive regard, and empathic understanding. As noted previously, “The client knows what hurts…” and therefore all interventions should flow from the client’s lived experiences and address the client’s pain and suffering (Rogers, 1961). To facilitate this process, clinicians should proceed with gentle exploration, repeatedly express respect for the client’s perspective and experiences, use open-ended questions, ask permission when shifting focus or using directive techniques, and regularly check in with clients for ongoing feedback or progress monitoring (Meier, 2015).

Solution-focused (strength-based): When working with clients who are suicidal, it can be easy to forget to focus on strengths. To integrate solution-focused or strength-based theory and practice into your work, traditional problem-focused diagnostic interviewing can be coupled with (a) questions about what helps or that orient clients toward solutions; (b) simple paraphrases that highlight anything clients say that reflect insights, hope, or positive views of the self; and (c) genuine appreciation for whatever clients are able to contribute to the therapeutic relationship and treatment process. Clinicians should try to integrate something positive, hopeful, or supportive into every 5-10 minutes of psychotherapy.

Cognitive-behavioral: For most clients who are suicidal, CBT is the default theoretical orientation for developing and implementing individualized interventions (Wenzel, et al., 2009). Formal interventions should be concrete, practical, easily understood, easily practiced within and outside of therapy, and primarily focused on immediate distress and distress reduction. After clients are stabilized, technical interventions that are abstract, interpersonal, or psychodynamic can be integrated into longer-term case formulations.

Existential: Existential psychodynamics are universal experiences that are woven intobeing sentient human beings. Yalom (1980) described these as death, meaninglessness, isolation (ultimate aloneness), and freedom (the burden of making choices). For most people, most of the time, existential psychodynamics operate under the surface and are not consciously contemplated. However, when clients are suicidal, existential psychodynamics often become palpable; clients may become preoccupied with death, lose a sense of meaning in their lives, experience painful aloneness, and be burdened by the significance of their daily decision-making. Clinicians should listen empathically for existential angst and collaboratively explore the significance of this important dimension of their clients’ lives.

The Six Life Domains

Working with clients who are suicidal can be overwhelming. To help organize and streamline the assessment and treatment planning process, it’s helpful to consider the six distinct, but overlapping life domains listed earlier. These domains provide a holistic description of human functioning. When clients experience suicidal thoughts and impulses, you can be sure the suicidal state will manifest through one or more of these six domains. See Table 1 for a brief description of the six domains. All case examples and content that follows use these six domains to focus and organize client problems, goals/strengths, and interventions.

Table 1: Suicidality as Manifest through Six Life Domains

The Emotional Domain. A driving force in the suicidal state is excruciating emotional distress. Shneidman called this “psychache” and toward the end of his career concluded, “Suicide is caused by psychache.” (1993, p. 53) Extreme distress is experienced subjectively. This is one reason there are so many different suicide risk factors. When a specific experience triggers excruciating distress for a given individual (e.g., unemployment, insomnia, etc.), it may increase suicide risk. Reducing emotional distress and facilitating positive emotional experiences is usually goal #1 in your treatment plan. Treatment plans often target general distress as well as specific and problematic emotions such as (a) sadness, (b) shame, (c) fear/anxiety, and (d) guilt/regret.

The Cognitive Domain. Suicidal distress interferes with cognitive functioning. The resulting constricted thinking impairs problem-solving and creativity. The emotional distress and depressed mood associated with suicidality decreases the ability to think of or value alternatives to suicide. Several other cognitive variables are also linked to suicidality, including hopelessness and self-hatred. Most treatment plans will include collaborative problem-solving and gentle challenging of maladaptive thoughts. Specific interventions may be employed to support client problem-solving, increase client hopefulness, and decrease client self-hatred.
The Interpersonal Domain. Hundreds of studies link social problems to suicidality, suicide attempts, and suicide deaths. Joiner (2005) identified two interpersonal problems that are deeply linked to suicide: thwarted belongingness and perceived burdensomeness. Many risk factors (e.g., recent romantic break-up, family rejection of sexuality, health conditions that cause people to feel like a burden) can exacerbate thwarted belongingness and cause people to perceive themselves as a social burden. Improving interpersonal relationships is often a key part of treatment planning.
The Physical/Biogenetic Domain. Physiological factors can contribute to suicide risk. In particular, researchers have recently focused on agitation or physiological arousal; these physical states tend to push individuals toward suicidal action. Additionally, chronic illness or pain, insomnia, and other disturbing health situations (including addictions) contribute to suicide, especially when accompanied by hopelessness. When present, physical conditions and biogenetic predispositions should be integrated into suicide prevention, treatment planning, and risk management.
The Spiritual/Cultural Domain. Meaningful life experiences can be a protective influence against suicide. No doubt, a wide range of cultural or religious pressures, spiritual/religious exile, or other factors can decrease an individual’s sense of meaning and can contribute to suicidal thoughts and behaviors. Including spiritual or meaning-focused components in a treatment plan can improve outcomes, especially among clients who hold deep spiritual and cultural values.
The Behavioral Domain. All of the preceding life domains can contribute to suicide, but suicide doesn’t occur unless individuals act on suicidal thoughts and impulses. The behavioral domain focuses on suicide intentions and active suicide planning. When clients actively plan or rehearse suicide, they may be doing so to overcome natural fears and aversions to physical pain and death; natural fears and aversions stop many people from suicide. Joiner (2005) and Klonsky and May (2015) have written about how desensitization to physical pain and to ideas of death move people toward suicidal action. Several factors increase risk in this domain and may be relevant to treatment planning: (a) availability of lethal means (especially firearms), (b) using substances for emotional/physical numbing, and (c) repeated suicide rehearsal (e.g., increased cutting behaviors).

Note: These domains will always overlap, but they can prove helpful as you collaboratively identify problem areas and goals with your client.

The Strength-Based Model in Action

For each of the six domains, clinicians can formulate problems, identify goals, implement interventions, assign homework, and continue to assess client functioning. In this section, interventions for addressing problems and attaining goals are described and illustrated with case examples. Tables are included as sample treatment plans.

Working in the Emotional Domain

Excruciating distress is a hallmark of suicidality. The primary goal of most suicide interventions is to help clients move out of their dark, excruciating distress toward the light – toward positive affect, emotional balance, and even joy. But of course, if moving out of emotional darkness toward lightness was easy, our clients would have already resolved their suicidality. Urging people who are in pain to simply “cheer up” is a recipe for creating anger, hostility, and staunch resistance to treatment. Expecting clients who are suicidal to quickly feel better will likely activate a powerful interpersonal phenomenon called psychological reactance (Brehm & Brehm, 1981).

Psychological reactance occurs when clients perceive their therapist (or others) as coercive or as limiting their freedoms. In response to perceptions of limited freedom, clients often engage in behaviors designed to restore their sense of independence. Psychological reactance is one explanation for why clients who are suicidal sometimes vehemently resist help and insist on their right to think about and act on their suicidal impulses.

Key Emotional Issues to Address

Many emotional issues are salient to suicide treatment planning. These issues range from the general (e.g., excruciating emotional distress) to the specific (e.g., guilt). At least three key emotional issues are likely to emerge with clients who are suicidal.

Excruciating distress. Shneidman referred to the emotional state surrounding suicide as “psychache,” or unbearable distress. I use the terms extreme or excruciating because they capture the intensity of the distress, but refrain from labeling the emotions as unbearable. In fact, shifting distress from unbearable to bearable is frequently an immediate treatment goal. As we’ll see in this section, exploring your client’s excruciating distress is often your first focus.

Affect dysregulation. Clients who are acutely or chronically suicidal are also prone to affect dysregulation. Affect dysregulation may become obvious during here-and-now interactions with clients. For example, clients may be emotionally labile, shifting from being angry with you to expressing love, appreciation, and deep connection. Although unstable relationships, emotional swings, and explosive anger are part of the diagnostic criteria for borderline personality disorder, clients who are experiencing excruciating situational distress may seem borderline, even though they don’t meet the diagnostic criteria.

Acute or chronic guilt or shame. Guilt and shame are similar emotions, but are distinctive. Shame usually connotes a deep feeling 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 a certain action or omission of action. Chronic or acute shame and/or guilt can contribute to suicidal states. Reducing or resolving shame and/or guilt is often a primary therapeutic goal.

Other emotions, including anger, fear, or anxiety, can also be linked to suicidality. Overall, to the extent that specific emotions contribute to overwhelming and excruciating distress, they will be relevant to your therapy interventions and reducing these difficult emotions will be a treatment goal.

Intervention: Focusing First on Client Distress

There are exceptions, but usually clients who are suicidal are preoccupied with, and will want to talk about, their emotional distress. Although it doesn’t feel strength-based and it doesn’t feel like a formal intervention, if you don’t identify and resonate with your client’s emotional and psychological distress from the beginning, you may not learn about the depth of their pain. Consequently, the wise counselor focuses first on emotional distress.

Case Example: Sophia – Emotional Distress

In the following excerpt, I’m working with Sophia, a 15-year-old girl whose parents referred her to me because she was thinking and talking about suicide (see Sommers-Flanagan, 2018). As is true throughout this course, to preserve anonymity, all case examples and vignettes are composites of video simulations and clinical work, and have been compiled from different individual cases.

My opening exchange with Sophia is important because in contrast to what you might expect from a strength-based approach, my focus is distinctly negative.

John: Sophia, thanks for meeting. I know you’re not exactly excited to be here. I also know your parents said you’ve been talking about suicide off and on for a little while, so they wanted me to talk with you. But I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so I guess if you’re even willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is you’re feeling?

Before meeting with Sophia, her parents told me about her suicidality, and so I tell her that to start the meeting. If I pretend I don’t know about her situation, it will adversely affect our rapport. This is a basic principle for working with teens, but also true for adults: Lead with a statement of what you know and then move on to what it is you don’t know but would like to learn.

My opening question for Sophia has a negative focus. The reason I’m starting with a question focusing on what makes her feel “bad or sad or miserable” is because I want to immediately (a) begin linking her emotional distress to triggering situations, and (b) I want to avoid activating psychological reactance (aka resistance). Also, by tuning in to her negative emotions, I’m focusing on the presumptive primary treatment goal for all clients who are suicidal – to reduce the perceived intolerable or excruciating emotional distress (Shneidman, 1993).

Sophia: I think I’m just like really busy every day. I’m in volleyball, and I got a lot of homework, and I don’t get a lot of sleep. So, it’s really stressful getting up early, and my parents are always fighting, and sometimes I miss the bus, and they don’t want to drive me. So, I have to call one of my older friends to drive me, and sometimes I’m late. It’s stressful, and the teachers get mad, but it’s not my fault.

John: Yeah. So, you’ve got stress piling up, volleyball, school, sometimes being late, and your parents arguing. Of those, which one adds the most misery into your life? [I want to know what adds the most misery to Sophia’s life so that I can help her decrease her misery.]

Sophia: Being at home is the hardest. In volleyball at least I find some joy. I enjoy being on the court and playing with my team. They’re there to lift me up. But I don’t like being at home.

John: Okay. What do you hate about it?

When Sophia says, “I don’t like being at home” she’s not providing specific information about the trigger for her distress, so I stay with the negative and use a word (“hate”) that’s a good match for how teenage girls sometimes feel about being with their family.

Sophia: I just – they’re always fighting. Sometimes my dad will leave, and my mom cries, and I’ll cry. And he’s just mean, and she’s mean, and they’re both mean to each other. And I just lock myself in my room.

John: Yeah. So, even as I listen to you talk, it feels like this is a – just being around them – I don’t know what the feeling is, maybe of just being alone. Like they’re fighting, and you retreat to your room. Any other feelings coming up when that happens? [I’m being tentative and vague so as to collaboratively explore the right words to use with Sophia.]

Sophia: I don’t know. Just sometimes I don’t feel like – I don’t feel like I have a home, or my family is not there for me, and sometimes I just don’t feel like living anymore.

John: Yeah. So, there are times when the family stuff feels so bad, that’s when you start to think about suicide?

Sophia: Yeah.

A summary of how Sophia’s emotional distress might be incorporated into an initial treatment plan is in Table 2.

Table 2: A Treatment Plan for Sophia– Emotional Domain
Problems in Emotional Domain Goals and Strengths Interventions/Plan

1. Sophia reports significant emotional distress linked to hearing her parents argue and fight.

[Note: Excruciating distress can involve one or many trauma, loss, or emotionally disturbing experiences. Some of these experiences will require additional time, trust, and assessment to uncover.]

1. Develop effective distress tolerance strategies.

2. Parents stop or reduce their fighting in Sophia’s presence.

Strengths: Notice, reflect, and nurture Sophia’s ability to articulate her distress and the life situations contributing to her distress.

1. Engage in collaborative brainstorming with Sophia to identify, select, and practice individualized distress tolerance and immediate coping strategies.

2. Solicit Sophia’s permission to meet with her parents to discuss alternatives to fighting in Sophia’s presence.

3. Refer Sophia’s parents for couples counseling.

There are always therapeutic obstacles and concerns. For Sophia, as I focus on the specific situational variables that trigger her emotional distress and suicide ideation, I need to simultaneously monitor our relationship. Further, as we collaboratively explore her distress and how her parents’ fighting affects her, I’ll keep in mind that it may be difficult to get Sophia to enact a distress reduction plan and probably even more difficult to get her permission for me to work directly with her parents on their fighting.

Intervention: Shifting from Distress to the Positive

After initially exploring your client’s excruciating distress, the next step is to pivot toward the positive by asking a question such as, “What helps?” or “What has helped in the past?” Although this is the next logical step, each client is unique and therefore you may or may not be able to quickly transition to asking about what helps. For example, if you’re working with a client who has a trauma history, and the client wants to talk about past trauma experiences, you may need to linger and empathically listen for much longer than you would if you’re working with clients without a trauma history or with clients who prefer not talking about their trauma.

Exploring what helps now or what has helped in the past involves a cognitive problem-solving process. You will read more about problem-solving with Sophia in the cognitive section below. In the meantime, here are brief descriptions of several additional interventions that focus on working through excruciating emotional pain.

Intervention: Separating the Pain from the Self

Shneidman’s (1993) guidance on working in the emotional domain was unequivocal. He recommended that clinicians partner with clients and with members of the client’s support system (e.g., family) to do whatever possible to reduce psychological pain.

Rosenberg (1999) and others have described a helpful cognitive intervention for reducing emotional pain. 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” (p. 86). Similarly, Rosenberg 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). This can decrease clients’ needs to act, partly because of the cognitive reframe and partly because of the therapist’s empathic message of siding with the client to battle the pain.

Case Example

Katie is a 44-year-old cisgender married female with two children. She arrived for counseling in extreme emotional distress. She stated, “It just hurts so badly to be alive.” Much of her emotional pain was centered on the recent death of her mother, whom Katie had cared for the past seven years. Katie had an ambivalent relationship with her mother, who had been diagnosed as having schizophrenia. Katie’s acute emotional distress was accompanied by the thought of reunifying with her mother, “I just need to be with her.”

To help Katie separate her intense emotional pain from the self, I began by noticing that there were two different parts of Katie, with different ideas about how to move forward. Noticing and articulating different perspectives of the self is a common person-centered approach. Specifically, I said, “Sounds like a part of yourself thinks the solution is to die, and 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 here and talk. Maybe my kids would suffer if I died.”

Kate accepted that she was “of two minds” about how to go forward. Next, I aligned with the “second” part of herself so we could work together on her emotional pain. “How about, if for now, we work from that second perspective. We can be a team that works to decrease the emotional pain you’re feeling. It might not go away immediately, but if you stay alive, we can chip away at the pain and make it shrink.”

Interventions: Mindfulness, Distress Tolerance, and Emotional Regulation

Marsha Linehan (1993), the developer of Dialectical Behavioral Therapy, wrote, “DBT emphasizes learning to bear pain skillfully” (p. 147). DBT practitioners work hard to get client buy-in. They might say something like, “Getting through this is like going through hell. Therapy can help, but only if you stay alive. Therapy never works 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?” Clients are also involved in group work aimed at developing cognitive-behavioral skills to help manage excruciating distress. These skills include mindfulness, emotional regulation, and distress tolerance.


Counselors using DBT break mindfulness skills into three “what” skills and three “how” skills (Linehan, 1993). “What” skills focus on teaching clients to observe, describe, and participate. Observing involves getting distance from one’s own experiences and noticing what’s happening, even when the situation is distressing. Describing involves using verbal labels to describe experiences. The emphasis is on accurate description of experiences. Participating involves engaging spontaneously in activities without self-consciousness.

“How” skills include taking a nonjudgmental stance, focusing on one thing in the moment, and being effective. Taking a nonjudgmental stance involves accepting life, events, and the self, as is. There’s no need to categorize experiences as good or bad. Focusing on one thing in the moment involves focus and absorption. The goal is to control attention on one thing, rather than experiencing divided attention. Being effective involves focusing on what works in specific situations, rather than obsessing on what’s fair or right. Given that much of life is unfair and emotionally destabilizing, being effective counters the idea of “I must be right” with the practical doing of whatever gets you through an experience.

As a skill, mindfulness is impossible to completely attain and sustain. Helping clients accept imperfection is an ongoing part of mindfulness training. Developing and practicing mindfulness skills in and out of therapy is a reasonable part of a treatment plan for handling and decreasing excruciating emotional distress and improving emotional regulation.

Distress tolerance

Distress tolerance is an extension of mindfulness into especially difficult and emotionally provocative situations. Clients learn to accept their current environment, their emotional state, and their thoughts and actions, but they’re also taught that practicing acceptance does not equal approval.

Emotional regulation

Emotional regulation can be improved through mindfulness training, but DBT also involves directly teaching clients seven emotional regulation skills:

  1. Identifying and labeling affect
  2. Identifying obstacles to changing emotions
  3. Reducing vulnerability to “emotion mind”
  4. Increasing positive emotional events
  5. Increasing mindfulness to current emotion
  6. Taking opposite action
  7. Applying distress tolerance techniques

DBT was developed to treat Borderline Personality Disorder (BPD). Many clients who are suicidal experience intermittent problems with emotional regulation. Regardless of your client’s diagnosis, if emotional dysregulation is the problem, and emotional regulation is a goal, then it’s reasonable for you to integrate aspects of the skills training component of DBT into your treatment plan.

Intervention: The Three-Step Emotional Change Trick

The three-step emotional change trick is an Adlerian-based intervention (Sommers-Flanagan & Sommers-Flanagan, 2007). At its foundation, the three-step emotional change trick is an emotional education and regulation intervention. Primarily geared for younger clients, this intervention breaks coping into three steps, plus one final step.

Step 1: Feeling the feeling

The first step involves labeling the emotion, honoring its existence, and being with the emotion (instead of trying to immediately change it). I usually open the process by asking young clients if they’ve ever had someone tell them to “cheer up.” Then, we discuss why they “hate” being told to cheer up and why it doesn’t work (it’s invalidating). Instead, I ask them if they’re interested in learning how to change their own difficult emotions – when they’re ready. The first step also includes actively honoring and being with the emotion and noticing what its presence might mean. This could involve talking, crying, making faces, or using any method that’s safe, and consistent with the emotion.

Step 2: Think a new thought or do something different

Clients are coached to start the second step at the point when they (not others) have decided to move away from the disturbing emotion. During step two, clients can distract themselves with fun, funny, or meaningful thoughts and/or do something that grabs their attention and draws them away from the disturbing emotion (and accompanying thoughts). Creative brainstorming is important during this step.

Step 3: Spread the good mood

Once the bad or disturbing mood has passed (more or less), it’s possible for young clients to focus on other people and spreading their good mood. As long as they avoid using the “just cheer up” strategy on others, I encourage youth to identify ways in which they have a positive emotional influence on others. Usually this involves smiling, doing a favor, offering a surprise compliment, saying “I love you” to a parent or caregiver, and other creative ideas.

Plus, Step 4: Teach someone the three steps

Emotions are complex. When teaching this emotional management skill, I like to surprise clients by including a fourth step (even though I’ve told them it’s a three-step technique). Typically, young clients immediately protest, saying, “You said it was three steps!” My response is to compliment them for noticing, and then explain that emotions are so complex that we need four steps, even for a three-step technique. Clients are then given the homework assignment to teach the three-step technique to someone before our next session.

If you’re interested in learning more, a free video example is available here.

Working in the Cognitive Domain

Negative mood adversely affects cognition content, especially for individuals with a history of depression and suicide ideation (Lau, Haigh, Christensen, Segal, & Taube-Schiff, 2012). As emotional distress increases and problem-solving skills diminish, clients become preoccupied with negative thoughts about the self, others, and the future (i.e., Aaron Beck’s cognitive triad). Previous research and clinical knowledge point to three core suicide drivers in the cognitive domain:

Problem-Solving Impairment

As noted previously, after an initial focus on your clients’ excruciating distress and suicidal thoughts, there comes a time to naturally move toward the positive with questions such as:

What helps?

When you’ve felt bad in the past, what helped the most?

What are some of the ways that you cope with your suicidal thoughts?

Clients who are suicidal often make comments that signal problems in the cognitive domain. Statements such as, “I’ve tried everything” and “Nothing helps” are extreme and represent distorted thinking and hopelessness. No client could possibly try everything, and although it’s possible that “nothing” the client does helps very much, it’s doubtful that all efforts to help oneself are of equally poor quality (i.e., black-white or polarized thinking; see Sommers-Flanagan, 2018).

Intervention: Problem-Solving

Problem-solving therapy is an evidence-based approach to psychotherapy (Nezu, Nezu, & D’Zurilla, 2013). Although problem-solving therapy isn’t considered evidence-based as a specific treatment for suicidality, components of problem-solving should be used to assess and intervene with clients who are suicidal.

Case Example: Sophia – Problem-Solving

After exploring the distress linked to Sophia’s suicide ideation in the emotional domain, I shifted to a problem-solving assessment and intervention strategy in the cognitive domain.

John: Okay. So, let me ask you this: What helps? When you’re at home, what helps you if you’re feeling suicidal? Let’s say your parents are fighting. You’re feeling suicidal. You’re in your room by yourself. What do you find that is at all helpful in that moment? [My intent is to shift Sophia into active problem-solving.]

Sophia: I do have a cat. His name is Douglas. And sometimes he makes me feel better. He’s diabetic, so I don’t think he’ll live that much longer, but he is a comfort to me right now.

John: Okay. I’m going to write some notes here. Is that okay?

Sophia: Yeah.

John: Good. My memory’s not perfect. I want to write down a list of all the things that help a little bit in that difficult time. And so Douglas the cat helps you be in a better mood. What else is helpful when things are going badly at home?

Sophia: Well, I like music. Blasting music makes me feel better. And I play the guitar, so sometimes that helps. And obviously volleyball is a comfort, but I can’t play volleyball in my room.

John: Yeah. So, I hear that things you do, like music, guitar, volleyball, are positives and being with your cat. How about friends? You got some friends who are positive supports in your life?

Although Douglas the cat having diabetes has a depressive tone, the good news is that Sophia immediately engages in problem-solving. Also, it’s important to note that throughout problem-solving, regularly summarizing positive coping strategies back to the client is important. Finally, because interpersonal connection is so important, I’ve specifically asked her about interpersonal resources.

Sophia: Yeah, but we’re all busy. It’s hard to find time to hang out. One of my friends lives up the road. Her name is Liz. We hang out quite a bit. I can walk into her house, and it will feel like my house. But we’re both in volleyball, so we’re both really busy. But our season will end soon, so hopefully that will help.

John: [More summarizing.] I’m making this list of things that seem to help, especially when you’re in a hard place with your parents fighting. We got Douglas the cat. We got music. We got guitar. We got volleyball, but obviously you can’t do that in your room. But I guess you can think about it in your room, and it’s something you enjoy. You’ve got friends. Anything else to add to the list of things that bring you up a little bit?

Sophia: I don’t think so.

Clinicians shouldn’t criticize any client-generated alternatives during this process (even destructive alternatives), but clients are free to criticize ideas that clinicians offer. When client criticism happens, you should accept the criticism with a paraphrase, but add it to the list anyway, noting, “We’re just making a list and you don’t have to vote for any of these ideas if you don’t want to.”

Overall, the goal is to use brainstorming to intervene with mental constriction. During our brainstorming, Sophia and I generated the following list (my ideas are denoted with an asterisk).

If you’re familiar with the evidence-based Safety Planning Intervention (SPI; Stanley & Brown, 2012), you’ll note that Sophia’s list is an example of item two on the safety planning protocol: identifying internal coping strategies (note: I’ll review the SPI in detail later, in the behavioral domain).

Intervention: Using Motivational Interviewing

Motivational Interviewing (MI) was developed, in part, because when clinicians try to educate or confront clients who are engaging in self-destructive behaviors, the efforts often backfire, and clients resist, clinging ever more tightly to their unhealthy habits or self-destructive behaviors. Because MI represents a nuanced way to avoid activating client resistance or reactance, using MI during brainstorming and problem-solving can be extremely beneficial. Specifically, I’ve found that if I pre-label my own ideas as negative, it works like an amplified reflection, making it more likely for clients to accept my ideas, or at least they don’t feel compelled to resist them. Here’s an example,

John: You have Douglas the cat as number one and all kinds of music as number two and then you have kill yourself as number three. Volleyball in your backyard is four. I notice that all my ideas are pretty bad, the ones that I put down there, and that’s okay. I have another bad idea that I’d like to share with you. You all right with that?

Labeling my option as “another bad idea” can be beneficial in several ways. First, I’m modeling that it’s okay to continue to put any ideas on the list, even bad ones. Second, I’m circumventing resistance by pre-judging my ideas as bad ideas before Sophia gets a chance to judge them herself. Third, I’m reducing the likelihood of Sophia viewing me as a know-it-all authority figure, who thinks he has all the best ideas.

With all this information as prequel, here’s my “bad” idea.

John: I’m super glad to see Douglas and singing and music up here as things that you can do instead of killing yourself. But I would like to make a plan for how your parents can stop fighting so much in front of you… What I would like to do, if you’re willing, is to have a meeting with the four of us, both your parents, you, and me. My plan is to give them instructions about how to avoid that fighting in front of you, because I hear you saying week after week, what increases your thoughts of suicide is virtually always your parents fighting. Is that right?

Sophia: Yeah.

John: So, I would like your permission to say to them, “Hey, we need to have a family session. I need to give you guys some ideas about how to be helpful to Sophia.” And I will give them some strategies for how they can avoid fighting in front of you. I will recommend couples counseling, so that they learn to communicate respectfully. The way they’re fighting now isn’t helpful to anyone. Right? I know I called it a bad idea, but I want to know what you think of it.

Sophia: I don’t really want to sit in a room with my parents. I feel like it’s not going to go well.

Sophia doesn’t like the idea. In response, I accept her perspective, while continuing to modify the idea in ways that might make it more palatable to her.

John: Yeah. You’re pretty sure it won’t go well? Okay. How about this? How about I meet with them separately and then meet with you and them after that? And if at any point they start behaving in a way that you think is too stressful, you don’t have to stay. You can go to the waiting room.

Sophia: I think they’ll just get mad at me at home, even if I’m not in the room.

John: So, even if you’re not there, they’ll get mad at you at home and that will be upsetting?

Sophia: Uh-huh.

John: Hmm. So, you think that the family meeting and the couples counseling are bad ideas? Any way that you’d give me a chance to try it?

As a last ditch effort (which maybe I should have tried sooner), I ask Sophia to shape the idea to give me a chance to try it out … and she gives me permission.

Sophia: I mean, we can try it once. I just don’t think it will work.

John: That’s fair enough. Maybe we could make a plan to try it once, see if it works. Okay? Well, I want it to work, so I’m going to try to set it up so that it does. Afterwards, you can be the judge. You can tell me, “that sucked, it was totally worthless,” or you can tell me that it worked out okay.

Sophia: Okay.

John: And later, we’ll decide together, you and me, whether or not it’s worth having other family meetings, whether or not I should try to boss your parents around and get them to go into couples counseling, and whether or not you and I will continue working together in counseling.

The preceding exchange captures the four components of the “underlying spirit” of MI (Miller & Rollnick, 2013, p. 22). First, I’m being transparent and collaborative with Sophia about my intentions. Second, I accept her views as valid. Third, I show compassion . Fourth, I’m interested in evoking her strengths and empowering her to provide feedback after the experience.

Sophia is only reluctantly cooperative with my ideas about meeting with her parents. She’s not optimistic about a positive outcome. As is natural with young clients, she fears parental retribution if we openly talk about family dynamics. Nevertheless, when working with children, incorporating parents into your treatment plan is required. If you decide NOT to engage parents in the process of working with teenagers who are suicidal, you’ll need to support your decision with a very strong (and documented) rationale (e.g., previously reported parental abuse).

Table 3: Treatment Plan for Sophia – Cognitive Domain
Problems in Cognitive Domain Goals and Strengths Interventions/Plan

1. Sophia lacks positive coping skills for when she’s in distress and experiencing suicidal thoughts.

[Note: Including a skills-training component is a core part of working with clients who are suicidal (Linehan, 1993). Sophia needs in-session practice and out-of-session homework.]

1. Have Sophia practice specific coping skills during counseling sessions.

2. Have Sophia and/or her parents monitor her coping skills application at home and report back.

Strength: Sophia is able to engage in constructive problem-solving in session.

1. Actively engage Sophia in practicing distraction and coping techniques for 20 minutes during each counseling session.

2. Give Sophia homework: Implement distraction and coping (aka distress tolerance) strategies outside the counseling office.

Intervention: Alternatives to Suicide

In the Sophia excerpt, you can see how a session might look when clients actively participate in brainstorming and problem-solving. However, clients who are significantly depressed and suicidal are sometimes unable or unwilling to problem-solve; this can be part of their problem-solving impairment.

Case Example: Katie – Alternatives to Suicide

Shneidman wrote of a procedure to assess and intervene with clients who were experiencing mental constriction. This procedure is called “Alternatives to Suicide” (Sommers-Flanagan & Sommers-Flanagan, 2017). Alternatives to Suicide is similar to, but slightly different from, the procedure illustrated with Sophia. With Sophia, I focused on behavioral coping in the moment of distress.

John: I’m wondering, what are some alternatives to killing yourself? Let’s make a list of what you could do instead?

Katie: I don’t know. Maybe to focus on other things and keep coming here.

John: Nice. We’re just making a list. You don’t have to do anything we list, but it’s good to know what options there are. And so you could kill yourself, but you could also talk through it here, and focus on other things. What else?

Katie: Yeah, but it’s just so hard. I have so much, so much, so many. It’s hard to focus right now.

John: Sure. It is hard to focus. But let me just ask this … Let’s say you just had a couple of weeks to live, what meaningful things would you want to do in that last couple of weeks? What would be important to you?

Katie has trouble focusing. To make the process easier, I reduce the possible duration of her life. Sometimes making the question narrower can help clients focus, and it seems to work here.

Katie: Hmm. Being with my family, my husband, my kids. Maybe my brother.

John: How old are your kids? [Because Katie is struggling with problem-solving, I want to pull out details and I want to ask her questions that she can answer.]

Katie: My kids are – they’re older. They’re in high school, and they’re pretty independent now.

John: Uh-huh.

Katie: So, 17 and 14.

John: I’m putting on the list quality time with your family, including your 17-year-old, your 14-year-old, and your husband.

Katie: Uh-huh.

John: I’m also putting down quality time with brother.

Katie: Uh-huh.

John: Anything else that would be meaningful instead of choosing to die?

Katie: Uh-huh. Yeah, but – yeah.

John: Any kind of employment things, volunteer things?

During all problem-solving activities, repeating the specifics is important. It can feel redundant, but clients need to hear what they’ve said to help with focus and to show you’re listening. Because Katie continues to struggle to come up with specific alternatives to suicide, I become more directive and lead her to specific topic areas, the first of which is employment.

Katie: I haven’t been volunteering for a long time now. I just can’t do it anymore.

John: Okay. Can’t do that.

Katie: Yeah.

John: I’m going to put it on the list anyway, because this is just a list.

Katie expresses feelings of hopelessness, haplessness, and constricted thinking, saying, “I just can’t do it anymore.” I reflect those words back to her, because I want to accept how she’s feeling and thinking, but I put the idea on the list anyway. Including “rejected” items on the list is a key part of the alternatives to suicide process. Even if the client says, “I just can’t do it anymore.” You can respond with something like, “We’re just making a list and you don’t have to actually do any of these ideas.” Clients need help to open up their constricted thinking.

Katie: Yeah.

John: So, I’m putting volunteering. And what’s something you’ve had passion for?

Katie: In the past?

John: In the past, sure.

Katie: Horses.

John: Okay. So, maybe some kind of activity with horses. I’m actually going to put that down as a recreational thing.

Katie: Uh-huh.

John: So, on the list, we’ve got kill myself, talk through it, focus on other things that are either distractions or meaningful. In the meaningful category, we have quality time with your family, quality time with your brother. I put down a volunteering category. And things you have passion for. You said horses, and that made me think of recreation, although I’m sure you could do volunteer work with horses.

Katie: Uh-huh.

John: But you also might do some recreation with horses. Anything else that we would put on this list?

Katie: Uh-huh. Yeah, I mean, I don’t know. It used to be a passion of mine. And so my friends took me out for a day, and we rode horses and, I don’t know, it didn’t really work, didn’t help. [This is a classic example of a depressive cognition that spoils or undermines a positive behavioral activity.]

John: Yeah, didn’t fix things, didn’t make things better. So, I have horses down here. I put it in the recreation category.

Katie: Yeah.

John: Because we’re just making a list, and none of the things on the list have to be things you’re going to do. I also put volunteering. I remember earlier when we were talking, you said that you had some interest in the arts.

Katie: Uh-huh.

John: And so could I put volunteering? There are a lot of art galleries in town.

This exchange is an example of interactive problem-solving with a client who’s depressed. I alternate between leading, following, checking in, and connecting throughout the brainstorming process. I keep adding ideas, but I try to match them up with her interests and ideas. Sometimes I label the ideas as falling in categories (e.g., recreational). Sometimes I put something on the list without asking (i.e., volunteering), but then double back and ask permission. Mostly Katie is following along, but even if she’s not tracking perfectly, I keep being redundant and hopeful and positive about every idea, and they all go on the list. You may also notice that the alternatives include potential social connection (interpersonal domain), potential distress reduction (emotional domain), and potential meaningful life activities (spiritual domain).

Katie: Uh-huh.

John: And there’s the art museum.

Katie: Uh-huh.

John: So, I’m going to put down volunteering for the arts in town here.

Katie: Uh-huh.

John: Okay.

Katie: Yeah, maybe working with kids.

John: There’s something about working with kids that seems important.

Katie: Maybe, yeah.

John: Yeah.

Katie: Yeah, I mean, I used to work with kids doing art programming, kids who had had trauma in their life, different kind of trauma than I’ve had.

Intervention: Psychoeducation on Behavioral Activation

In the previous exchange, Katie managed to peek out from behind her depression and shared something that feels important and may be useful in therapy. Consistent with MI, instead of getting too enthused and eager (which might cause her to backpedal), because she had spoiled the idea about horses, I take a side road into psychoeducation about behavioral activation.

John: There’s a puzzling thing about depression, and the research bears this out. People stop doing things that are naturally reinforcing or rewarding. And when naturally rewarding behaviors decrease, like you don’t go horseback riding, it seems to increase depression. You get to the point that you don’t think doing anything will help. But, if you reinsert those things into your life, at first nothing might happen, but eventually your mood lifts back up.

Katie: Hmm.

John: And it doesn’t even involve any thinking. It’s like this, just plan and do a horse activity every week, right?

Katie: Uh-huh.

John: Let’s plan volunteering with doing art with kids, right?

Katie: Uh-huh.

John: Let’s plan quality time with the family.

Katie: Uh-huh.

John: And when you start to systematically put those things back into your life, it’s not a magic pill or a magic wand, but over a few weeks almost everyone starts to feel better. And so as we look at this list –

Katie: It feels so hard, though, to get it planned, and someone else has to plan it.

John: Yeah. Okay. So, get someone else to plan. So, we got that on the list, too. And then I’m going to put down here good idea, bad idea? You have a husband. I’m going to put down couples counseling.

With this response, Katie shows that she’s tracking. She also gives an “it’s too hard” depressive response. Katie can’t imagine planning healthy activities in her life that might act as natural antidepressants. She needs help and support. Although challenging, this is an extremely helpful insight. Because behavioral activation is an excellent strategy for improving Katie’s mood, the rest of the session is all about finding her a planner, and I add couples counseling to the list. Then I direct Katie to rank order suicide and her alternatives to suicide.

John: So, what I’d like you to do now is to take over the pen and just rank them one through whatever number we have there, and then I’ll take a look at what seems like the first thing that you want to try next.

Katie: Okay. So, one being what I want to do first?

John: Your first preference.

Katie: You want me to go all the way to ten?

John: You bet.

Katie: Okay. One, two, three. Well, don’t you think this should be last? [Katie points to the “Kill myself” option.]

John: I don’t know. Do you think it should be last?

Although I was directive and helped generate many of Katie’s alternatives to suicide, it’s important that I don’t rank suicide for her. The process is to reduce her mental constriction, but I also want her to genuinely rank where suicide fits for her; that way the assessment data are valid.

Katie: No.

John: Where would you put it? Are there some things here you’d put before it? Like before you were to kill yourself, would you like quality time with your family?

Katie: Yeah, of course I want more time with my family.

As we move toward the end of the session, I’m nervous about Katie’s stability, but my best judgment is to go forward without hospitalization. To establish adequate safety, with Katie in the room, I call her husband and discuss how I’d like him to give her extra support for the week and suggest that he come in for the next session as a support person. He agrees, and communicates his interest in supporting Katie. Although integrating Katie’s husband into the treatment plan is an interpersonal intervention, my goal is for him to supplement her impaired cognitive functioning (i.e., she’s having trouble with focusing, problem-solving, and decision-making, and the content of her thoughts continue to drift toward suicide).

Decision-Making Dilemmas

When discussing Katie’s situation and other scenarios that involve outpatient work with highly suicidal clients, the following question usually comes up, “What if your judgment is wrong and she either makes a suicide attempt, or she kills herself before your next session?” This is a great question and gets to the core of anxiety for many practitioners.

The answer is that, yes, she could kill herself, and if she does, I’ll feel terrible about my clinical judgment. Also, I might get sued. And, if I’m inclined toward suicidal thoughts myself, Katie killing herself might precipitate a suicidal crisis in me. Sometimes suicide tragedies happen, and sometimes we will feel like the tragedy was our fault and that we should have or could have prevented it. That said, most suicides are more or less unpredictable. Even if you think you’re correct in categorizing someone as high or low risk, chances are you’ll be wrong; many high-risk clients don’t die by suicide and some low-risk clients do.

More depressing is the reality that hospitalization – the main therapeutic option we turn to when clients are highly suicidal – isn’t very effective at treating suicidality and preventing suicide (Large & Kapur, 2018). Hospitalization sometimes causes clients to regress and destabilize, and suicide risk is often higher after hospitalization. Because hospitalization isn’t a good fit for many clients who are suicidal and because we can’t predict suicide very well anyway, some cutting edge suicide researchers recommend intensive safety planning as a viable (and often preferred) alternative to hospitalization. In the case of Katie, as long as she’s willing to collaborate with me, and I’m able to contact her husband, and we can construct a plan that provides adequate safety, then I’m on solid professional ground (or at least as solid as professional ground gets when working with highly suicidal clients).

Focusing on Hope and Hopelessness

Hopelessness is a broad cognitive variable related to problem-solving impairment and linked to elevated suicide risk (Hagan, Podlogar, Chu, & Joiner, 2015). Hopelessness is the belief that distressing life conditions will never improve. In many cases, clients hold a hopeless view even when a rational justification for hope exists. Hope for a better future can protect people from self-destructive actions. In contrast, when hope for improvement is absent, suicide potential is stronger (Klonsky & May, 2015). Clients with depressive symptoms may make unequivocal statements representing hopelessness (e.g., “Nothing helps and nothing will ever help”).

Working with hopelessness was discussed in the first course in this series. To summarize, when hopelessness is present (e.g., “I will never be happy”), rather than immediately focusing on how to become hopeful, it is better to show empathy and then ask about what efforts have been the least effective. Continue to show empathy, but at the same time, begin to gently ask about what therapeutic efforts have been “slightly less bad.” The goal is to build a continuum of previous therapeutic efforts, starting at the bottom and working your way up. By doing so, you’re assessing hopelessness, and also intervening on the “black-black” (as opposed to black-white) distorted thinking that you’re witnessing in session.

Hopelessness can emerge related to any of the six life domains:

The ways in which clients articulate their hopelessness can help illuminate the underlying core beliefs they hold about the self, others, and future.

Negative Core Beliefs and Self-Hatred

Many clients who are suicidal have acute or chronic negative core beliefs. These negative beliefs are activated by specific environmental situations. For example, failing an examination or flunking out of an academic program can activate deep core beliefs of being “unworthy” or “stupid.” When activated, core beliefs can permeate daily life and contribute to excruciating distress.

Negative core beliefs also often fall into the six life domains. Here are some examples:

Deconstructing and reconstructing negative core beliefs is generally associated with longer-term therapy. But, there can be benefits to acknowledging negative core beliefs early in therapy, even in short-term therapy models. Talking about core beliefs helps clients feel known and understood on deeper levels. In many cases, abuse and trauma may be at the root of self-hatred or chronic negative core beliefs. If so, initiating a trauma-oriented treatment can relieve distress and reduce the intensity of negative thoughts (e.g., trauma-focused cognitive-behavioral therapy, Cohen, Mannarino, & Deblinger, 2012; eye movement desensitization reprocessing, Shapiro, 2001). Alternatively, to address negative core beliefs, the cognitive therapies, including the suicide-specific treatment protocols (i.e., Bryan & Rudd, 2018; Wenzel, Brown, & Beck, 2009), schema therapy (Young, Klosko, & Weishaar, 2003), as well as the narrative therapies (Schauer, Neuner, & Elbert, 2011) are often the treatments of choice.

Working in the Interpersonal Domain

Clients who are suicidal nearly always have interpersonal issues that contribute to suicidality. In Sophia’s case, her parents’ fighting is a trigger. In Katie’s case, she feels over-identified with and disconnected from her deceased mother; she also needs interpersonal assistance in therapy and at home to implement a positive behavioral activation schedule into her life. Addressing the interpersonal domain in your treatment plan is essential.

Thwarted Belongingness and Perceived Burdensomeness

Joiner (2005) developed an interpersonal theory of suicide that emphasizes thwarted belongingness and perceived burdensomeness as contextual interpersonal factors linked to suicide. Thwarted belongingness involves unmet wishes for social connection. Many different scenarios can trigger real or perceived social disconnection. Most commonly, romantic relationship break-ups or rejections cause immediate distress and can spiral downward, activating core beliefs of being defective, unlovable, and destined to a life of isolation and interpersonal alienation. Many other alternative relational scenarios also cause distress and activate suicidal thoughts.

Joiner also writes about perceived burdensomeness, which occurs when clients see themselves as flawed in ways that make them a burden to others. Clients who are physically ill or incapacitated often feel they’re a burden to the important people in their lives. Statements such as “everyone would be better off without me” communicate burdensomeness. When clients with a history of independent-mindedness experience physical or mental impairments, they may quickly conclude that death is a positive alternative to life.

Intervention: Improving the Social Universe

In the following case example, when exploring his interpersonal relationships, Clark, a 35-year-old gay male, describes how people he thinks of as friends treat him in ways that he experiences as toxic. As you may be aware, familial, religious, and interpersonal rejection are risk factors for suicide. Such rejections can especially elevate suicide risk among LBGTQ+ clients (Ahuja, Webster, Gibson, Brewer, Toledo, & Russell, 2015) because the judgment touches on rejecting core identity. This rejection triggers immense distress which can lead to suicidal thoughts and impulses. The treatment of choice for LGBTQ+ clients requires, at minimum, acceptance and affirmation of their sexual identity (Bigner & Wetchler, 2012). Statements such as “nobody understands me” can be a signal that clients are experiencing emotionally painful interpersonal disconnection.

Interpersonal interventions with clients who are suicidal can focus on modifying many different social dynamics. Typical interpersonal goals may include: (a) increasing positive social connections, (b) decreasing negative social connections, (c) social skills training, and (d) managing obstacles that make social connections more difficult (e.g., anxiety, unhelpful self-talk, negative core beliefs about social worth).

Case Example: Clark – Toxic Relationships

Clark is a 35-year-old gay male with several previous suicide-related psychiatric hospitalizations. He begins the session describing his frustration and agitation, and says that he doesn’t know what to do. Two days earlier he had purchased a construction razor blade at a hardware store as part of a plan to die by suicide. In the session, he described that somehow the blade didn’t function, so he failed at his suicide attempt. Clark’s initial presentation included excruciating distress and difficulty in problem-solving. He reported that everyone had abandoned him. His alcohol use was elevated, he believed his life was meaningless, and he indicated an intention to die. His suicidal state was manifest through all six life domains. Clark was at extremely high risk for suicide.

Given the breadth of Clark’s suicide symptoms, it would have been reasonable to initiate goal-setting and treatment in any and all of the six domains. However, as the session progressed, it became clear that the interpersonal domain was most directly linked to his excruciating distress.

Clark also had difficulty focusing. Consequently, rather than restricting our discussion of his interpersonal relationship to the verbal mode, I chose to use a visual and practical activity to explore Clark’s interpersonal relationships. As with many suicide-related clinical procedures, using the social universe activity to explore Clark’s interpersonal relationships can function simultaneously as both assessment and intervention.

John: You started feeling suicidal at around age 15, and you’ve been hospitalized a few times, once at 15, and then at some point after that.

Clark: Just fairly recently, within the last year or so. I’ve been in the hospital a few times.

John: And what was going on just before your recent hospitalization?

Clark: The people I was hanging out with, used me. I started hanging out with them a few years ago, and they’re a gay couple, and I thought maybe I could find some sort of, I don’t know, identity or something. It just didn’t happen. It’s toxic. I give everything I have to them, and they’re still not interested. I try to do so much just to feel validated. When I don’t receive that, it takes me down.

John: If it’s okay with you, I want to focus in on your social relationships.

Clark: Okay.

John: I’m drawing a circle in the middle of this paper. This is Clark. I know in your life you probably have people who are more validating and less validating. I’m wondering, who, in this in the universe of Clark, are people you get more validation from, and who are people you get less validation from? I’ll draw them in closer to you if you get more validation and further if you get less validation.

Clark: I honestly don’t know if there’s anyone who gives me any sort of validation.

John: Okay. Who’s the least validating, the worst of all. Who’s really toxic?

Clark: Brad.

John: Okay. So, I’m going to put Brad here, and this is somebody who – I’m putting the word toxic in here because you used it before and he sounds so invalidating that it’s toxic.

Clark: Uh-huh.

As I start the social universe activity with Clark, he does something very characteristic of depressed clients. When asked about something positive, he comes up empty. He says, “I honestly don’t know if there’s anyone who gives me any sort of validation.”

My response to Clark’s negative disclosure is similar to the protocol for working with hopelessness. Instead of sticking with a positive, strength-oriented question (i.e., “Who are people you get more validation from?”), I switch to a negatively worded question (“Who’s the least validating, the worst of all. Who’s really toxic?”). Switching to the negative serves several purposes: (a) Clark is more tuned into his negative emotions and thoughts, so it’s a question he can answer, and it keeps our interaction moving, (b) identifying the most toxic person resonates with what Clark is feeling, and therefore more empathic, (c) if I can get Clark to name the most toxic person, then I’ve got a chance to work up the continuum to people whom he experiences as less toxic, and (d) once I know who’s more toxic and less toxic, we can begin planning for how he can spend less time with toxic people and more time with less toxic people.

John: Okay. Who is also toxic but less toxic than Brad?

Clark: Bill.

John: Okay. So, somebody named Bill. And is that the couple?

Clark: Yeah.

John: And so between the two of them, they’re ranking as the most toxic.

Clark: Right.

John: If you were to look around, is there anybody in your world who’s neutral or who you would put as significantly less toxic than Brad and Bill?

Clark: Debbie. [After focusing on the most toxic people in his life, Clark is able to immediately identify people who are less toxic.]

John: Okay. So, we can put Debbie on the less toxic end.

Clark: Right.

John: Anybody else who’s more in that neutral category?

Clark: My brother maybe.

John: Okay. Your brother. Maybe he’s the least toxic of your family in terms of connection and relationship?

Clark: Yeah, I’d probably say it’s between him and my dad, but I don’t really talk to him that much.

At the end of the social universe activity, it’s important to check in. Asking simple reflective questions can help discern what directions clients want to go with their relationships. For example, you might ask, “What are your thoughts about this activity?” and “What changes in your relationships does this map of your social universe inspire you to make?” Overall, you want to develop mutual interpersonal goals with your clients and then engage in collaborative tasks that will move your client toward the mutually identified social goals.

Mapping a client’s social universe can transform vague social dynamics into visible relationship patterns. It helps conceptualize relationships quickly and identify practical methods for changing patterns and dynamics. For Clark, his behavioral pattern of spending most of his interpersonal time with people who treat him poorly (are “toxic”) is a salient negative factor that can be addressed in therapy. The treatment focus is for Clark to distance himself from individuals or groups that contribute to his distress, identify alternative social connections that might be more validating or reinforcing, and then begin taking actions to modify his social universe. Treatment also may focus on obstacles to making positive social relationship changes; this focus may include: how to improve dysfunctional relationships (communication skills training) and anxiety (relaxation training or mindfulness).

Table 4: Treatment Plan for Clark – Interpersonal Domain
Problems in Interpersonal Domain Goals and Strengths Interventions/Plan

1. Clark spends most of his time with a gay couple whom he finds interpersonally toxic.

2. Clark has very few relationships, if any, that feel validating to him.

1. Increase time spent with interpersonally validating people.

2. Decrease time spent with interpersonally toxic people.

3. Clark will identify and then socialize in group settings where he can have his sexual identity affirmed.

Strengths: Clark is interested in interpersonal relationships, and appears ready to contribute to reciprocal intimacy.

1. Develop plan for determining which people are socially validating and then contact them for positive social time.

2. Identify steps needed to extricate Clark from toxic relationships

3. Engage in roleplay social skills practice in anticipation of entering new social groups.

4. Learn and practice relaxation skills that Clark can use in new social situations.

Intervention: Working from a Collectivist Interpersonal Perspective

Clients from diverse cultural backgrounds may present with collectivist social dynamics. Understanding and working from a collectivist perspective can be difficult for individualistically oriented therapists.

When working with clients with collectivist social values, it’s important to remember that factors related to suicidality (e.g., shame, failure, addiction, loss, etc.) will be viewed as components of family, tribe, or culture, not as components of the individual self. Collectivist orientations require reconceptualization of problems, treatment goals, and interventions.

Case Example: Mitchell – A Collectivist Orientation

Mitchell is a 28-year-old Lakota-Sioux cisgender male. He is an Iraqi war veteran who is returning to college after two tours of duty in the Middle East. Mitchell reported excessive alcohol use and a feeling that he was markedly different from other college students. He also reported a range of sleeping problems secondary to post-traumatic stress disorder symptoms. He acknowledged suicidality. Early in the first session, Mitchell made his cultural identity and some of his cultural values clear.

John: How about we start with you telling me things about you that would be good for me to know.

Mitchell: I come from a small reservation in Eastern Montana. It was a comfortable life growing up. I didn’t know anything different. I remember sitting there with my family watching the war and it kind of spurred us to want to help bring honor to our tribe. So, I signed up at 17.

John: What tribe?

Mitchell: I’m from the Lakota Sioux tribe from the Fort Peck Indian Reservation.

John: Okay. Great, thank you. Sorry for interrupting.

Mitchell: So, I left at 17, and it was kind of a big deal. We had a big honor, big gathering for me, big sendoff, and it was pretty great and I felt pretty good. Deployed when I was 18 years old over to Iraq. It was going great. I felt like I was doing something. I didn’t get to talk to my family much, maybe every three months. And I didn’t know what was going on at home. Had a fiancee when I left. Life was great. Eventually time to come home and came home. And my family was in disarray. My grandma died. I didn’t get to go to her funeral. They didn’t tell me.

John: Yeah.

Mitchell: So, kind of tore me up. My fiancee left me for one of my best friends. That was the shock of my life.

John: At this point I’m hearing that you were on kind of a high and feeling good at 17, you got a big sendoff from your tribe, from your family, and you go to Iraq. And you get back, and things are a mess.

Mitchell: Yeah. Meth kind of hit our reservation pretty hard. And family members on meth and in prison and the whole world changed, I guess. Eventually, I just started drinking. Not sure who I was anymore. That was difficult, didn’t have many people to turn to anymore. Never had a father growing up. My mom was always raising us while working a couple jobs. Eventually her and her boyfriend got into drugs, so that was pretty difficult. I didn’t know what to do anymore. And I was feeling down and just kept drinking. I don’t know what to do anymore. For us it’s an honor to serve and kind of makes us who we are.

John: Yeah.

Mitchell: We view it as becoming a warrior.

John: Yeah.

Mitchell: I felt like I did that, and that I’d bring honor back to my culture, my tribe. Yeah, just I came home. Everything’s in disarray, and I thought I was pretty stable. Eventually – and one thing, on the reservation we don’t – or culturally we don’t talk about our feelings or emotions. So, every time we do, feel pretty shamed. A lot of shame comes from it. So, you just deal with it.

John: Yeah, so a couple of cultural pieces. One is that sense of honor of serving, and you hooked onto that and were living that. And then another cultural thing is, it’s a little shameful to express emotions, sadness, that kind of emotion or others.

Mitchell: Yeah, I guess I could just describe it as shame. Like I feel guilty talking about it because we’re supposed to be men.

John: You’re warriors. You’re strong.

Mitchell: Yeah.

John: And so you keep it all –

Mitchell: Yeah, it’s part of who we are, death, fighting, honor, celebrating together, just part of who we are.

John: Yeah, yeah. And then as you get back, and you’re in this disarray, and the meth on your reservation is prevalent, and you start drinking, and it sounds like that could be connected with the emotional warrior. Is that one of the ways that you might cope?

Mitchell: I guess I just – kind of just helped me feel nothing.

Several challenges emerge early in this session. Mitchell has a culturally-based warrior mentality and views emotional expression as shameful. Despite that mentality, in the session he’s sharing experiences that convey emotional pain. Although it’s hard to estimate how much subjective emotional pain he’s experiencing, his language of “kind of tore me up” and “shock of my life” (and the fact that he’s facing shameful feelings by coming for counseling) implies that his distress is substantial. One dilemma we can talk about without getting too focused on emotions is his painful emotional experiences. Using words such as “torn up” and “shock” might be better than “hurt” or “sad.” In addition, his alcohol use is emotionally desensitizing (i.e., a risk factor in the behavioral domain) and so we’ll eventually need to discuss his use as increasing his risk of self-destructive behavior.

Mitchell: That’s how I dealt with it because I couldn’t talk about stuff that happened over there, and I had no male role models in my life to talk with or anything.

John: Yeah. So, I’m aware of the fact that you’ve told me, and I really appreciate it, some cultural things about you, about being a Lakota Sioux, about the reservation that you grew up on and some of the things you experienced, about the honor, about the shame, about the warrior mentality. And I’m going to do my best to track all those things. Occasionally if you think I’m just not getting it from your cultural perspective, I would love it if you would tell me, but I don’t want to put all that responsibility on you. So, I will probably every once in a while just check in to see, am I getting this right? Is that okay with you?

Mitchell: Yeah, that’s fine.

John: Because I just don’t want to misunderstand things because of my lack of the same cultural experience as yours. And so as I’m imagining it, you’re back. You’re drinking. It’s part of being numb.

I’m trying to show cultural sensitivity and humility by: (a) expressing appreciation for his cultural openness, (b) trying to accurately summarize some of what he’s told me about his cultural perspective, (c) acknowledging that I have gaps in my cultural understanding of his perspective, (d) inviting him to tell me if I’m not understanding his cultural perspective, and (e) avoiding putting all the responsibility on him for cultural checking-in, letting him know that I’ll also initiate cultural checking-in.

When working across cultures, one of the biggest challenges is to make an interpersonal connection and build trust during the first session so that the client is comfortable returning for a second session. My efforts to connect with Mitchell are part of an interpersonal focus, but also because I know I can’t help him if he doesn’t come back for a second session. Another way I try to integrate my evolving understanding of his collectivist perspective is through collectivist goal-setting. In the next excerpt, after Mitchell has admitted that he was previously suicidal and is feeling suicidal again, we focus on two different problem situations and turn them into therapy goals for the interpersonal domain.

Mitchell: Sometimes I avoid calling home because talking to my family members that are on meth makes me mad. I know that’s a trigger because the first thing they ask for is money. I know what it’s for.

John: So, that brings you down.

Mitchell: Yeah. I want to talk and feel connected with them, but they just care about their next high.

John: I’m wondering, it seems like connection to family is important. Is there a time, or a state of mind, or a person who would be better for you to call? I’m just brainstorming because it seems like if the contact is a time when you’re already feeling down, and they take you down further, that could be a dangerous spot.

Mitchell: Yeah, I could call middle of the week. I could call my niece. I’ve done that and we talk about school, and she tells me what she’s doing in school.

John: Okay. And that is more of an up…

Mitchell: Yeah, definitely.

John: For you.

Mitchell: Yeah, that feels better because I want to be a good role model for my niece.

John: Okay. So calling mid-week and talking with her helps.

Balancing Mitchell’s emotional well-being with his family and tribal relationships is a delicate situation. He wants contact, but their situations and requests for money bring him down. The preceding exchange is an example of problem-solving on an interpersonal dynamic. Mitchell engages well, and later we include calls to his niece as a part of his plan for maintaining family connection. In this next segment, Mitchell helps me understand how to define his academic goals in a collectivist way.

John: Any other situations that will trigger you and get you into a negative, sad, mad, suicidal place?

Mitchell: When I do bad in school, I feel like a failure.

John: Okay.

Mitchell: I feel like I’m not going to be able to accomplish my goal of helping out my community.

John: Yeah. So, then you feel like, maybe I won’t be successful at this honorable thing I’m trying to do.

Mitchell: Yeah, I mean, I have no family here to turn to. Nobody understands. Nobody can pick me back up. So, I guess, yeah, then the hopeless feeling comes in because I don’t know who to turn to, can’t call home, can’t go home. It’s a nine-and-a-half hour drive. So, that’s a lot of money. I can’t just drive there and back.

John: Lot of money, lot of time.

Mitchell: Yeah.

John: We can brainstorm how to find someone who can understand and pick you back up, and we can talk here, but I want to honor your style which, it seems like, is not to just vent or feel sad about a bad score you got, but instead the conversation is focused in a problem-solving way, in a strategizing way. Not just on how you feel bad that you got a poor score, but what can you do next time to try to address the issue so that you can do better? Would that be an okay way for us to talk about it?

Mitchell: I think so.

John: So we can talk, but the overall thing I hear from you is that when you do poorly in school, you feel bad, because one of your life goals right now is to bring something back to your community that has a chance of lasting.

Mitchell: Yeah.

John: And maybe what we want to talk about is, what are small things that you can bring back to the community? Because almost always goals are better in small steps. Then there’s measurable progress, and you could say to yourself, well, here’s something I brought back. Here’s an idea I brought back. Here’s an award I brought back. Here’s something I contributed. We might try to count those things up and set small goals about what you can bring back to your community.

Mitchell: Okay.

John: Okay?

Mitchell: Sounds good.

When working across cultures, determining what’s culturally universal and what’s culturally specific can be difficult. Showing respect, cultural humility, and listening well to what clients say are likely universal therapist behaviors that facilitate connection, trust, and make it easier for culturally diverse clients to return for a second session. Listening nonjudgmentally, and being accepting and affirming of Mitchell’s culturally specific values and worldview (e.g., the shame of seeking help, expressing emotions, and collectivist goal-setting) are equally important.

Working in the Physical Domain

The physical domain includes everything within the biogenetic spectrum. Although all six domains overlap and interact, boundaries between the physical and behavioral domains are especially permeable because the external environment and human behaviors shape physical and neurophysiological structure and function. For example, aerobic, i.e., cardiovascular, exercise, ingesting psychoactive substances, and many other behaviors directly affect brain structure and function, and brain structure and function unarguably affect behaviors. In this section, we consider research-based physical symptoms (e.g., arousal, insomnia, nightmares) linked to increased suicidality, as well as physical protective factors (e.g., physical exercise). We’ll address substance use and abuse in the behavioral domain because it is an immediate behavior linked to suicide.

Agitation or Arousal

Suicide researchers use arousal or agitation to describe the increased heart rate, respiration, and other characteristics of individuals who feel mounting internal pressure to take action. When clients say, “I don’t know what to do” they’re often speaking of their internal pressure to “do something!” Combined with excruciating distress, problem-solving impairments, and social disconnection, agitation adds substantially to suicide risk. Trauma, insomnia, drug use (including starting on a trial of serotonin-reuptake inhibitors), and many other factors increase arousal and contribute to suicidality (Healy, 2009; Ribeiro, Silva, & Joiner, 2014). In the following exchange, Mitchell describes a mix of excruciating pain, social disconnection, and agitation – much of which can be tracked back to a traumatic war experience.

When I first came back from Iraq, I did feel suicidal. Things are getting bad again. I’m trying to sleep at night. Every time I go to sleep, I remember one time in Iraq, we were sitting there, and Al-Qaeda blew up a whole city block, and every building came down. We were there trying to help, and you had kids with missing arms and missing eyes and moms with no legs and crying, screaming. We were trying help and at the same time people are shooting at us. My friend’s crying. Like why the fuck are we here? Like what are we doing here? Like this isn’t what we, this isn’t what we’re here for. Yeah, I just remember a mom with a missing leg carrying her helpless child in her arms, and the child was dead. Just every time I go to sleep, I remember that kid helpless laying there. And so I’m not sleeping much, I’m doing a lot of drinking still. I guess I don’t know what to do anymore.

Mitchell’s description is helpful for understanding how trauma-related physical triggers can exacerbate suicide related symptoms (aka risk factors) in other life domains.

Trauma, Nightmares, and Insomnia

Trauma is often the root of many emotional and behavioral problems, including suicidality (Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). Renowned psychologist Donald Meichenbaum reflected on his 35-plus years of working with and consulting on suicidal clients.

In reviewing my clinical notes from … suicidal patients and the consultations that I have conducted over the course of my years of clinical work, the one thing that they all had in common was a history of victimization, including combat exposure (my first clinical case), sexual abuse, and surviving the Holocaust (Meichenbaum, 2006, p. 334).

Meichenbaum isn’t alone in his observations. In one research study on 200 outpatients, child sexual abuse was a better predictor of suicidality than depression (Read, et al., 2001). Similarly, data from the National Comorbidity Survey (n = 5,877) showed that men sexually abused as children were 4 to 11 times more likely to attempt suicide, and women who experienced child sexual abuse were 2 to 4 times more likely to attempt suicide (Molnar 2001).

Trauma is an external event that manifests itself through physical, emotional, behavioral, and psychological symptoms. Perhaps the most pernicious of trauma’s physical effects is sleep disturbance. Following trauma, many individuals become sleep-avoidant because sleep regularly brings horrific nightmares. The nightmares are filled with threats that result in mental and physical hyperarousal (Krakow & Zadra, 2010). As sleep loss accumulates, other suicide-related symptoms increase, including excruciating distress, agitation, impaired problem-solving, and spiritual/existential disorientation. Many clients turn to substances as a means to desensitize their memories, numb their emotions, and dull their consciousness. Although PTSD often triggers insomnia, insomnia is also an independent risk factor for suicide (Bernert, Turvey, Conwell, & Joiner, 2014).

Interventions: Evidence-Based Approaches

Clinicians who work with clients who are suicidal should obtain skills for trauma treatment, insomnia treatment, and nightmare treatment. Targeting trauma, insomnia, and nightmares with evidence-based treatments can give clients hope and relieve them of emotional distress and physical agitation.

Depending on your clients’ age, symptoms, the treatment setting, and your preference, several different evidence-based treatments may be effective for treating trauma. The following list includes therapies that are strongly recommended either by the American Psychological Association (2017) or the VA/DoD Clinical Practice Guideline Working Group (2017), or both (Watkins, Sprang, & Rothbaum, 2018).

Although the preceding list includes the most scientifically supported approaches to treating trauma, you may have preferences for other approaches, many of which are suitable for treating trauma (e.g., body-centered therapies, narrative exposure therapy for children [KID-NET], etc.). In addition, specific treatments for insomnia and nightmares can also reduce arousal/agitation. The two main evidence-based treatments for insomnia and nightmares include:

Targeting trauma symptoms in general, and physical symptoms in particular (e.g., arousal, insomnia, nightmares) can be a crucial component of your treatment plan. Directly addressing physical symptoms in your treatment plan can give clients hope and provide near-term symptom relief (see Table 5).

Table 5: Treatment Plan for Mitchell – Physical Domain
Problems in Physical Domain Goals and Strengths Interventions/Plan

1. Mitchell exhibits agitation and physiological arousal.

2. Mitchell has insomnia and nightmares, both of which contribute to his emotional distress and problem-solving impairments.

1. Mitchell is able to use relaxation or meditation to calm his body and mind.

2. Mitchell experiences a reduction and greater perceived control over his insomnia and nightmares.

Strengths: Mitchell is physically fit, and interested in using fitness and other physical approaches to improve his health and well-being.

1. Introduce Mitchell to progressive muscle relaxation (PMR) and mindfulness meditation (MM) as tools for arousal reduction.

2. Mitchell will implement PMR or MM in-session and as daily homework to manage physiological arousal.

3. Initiate imagery rehearsal therapy (IRT) with Mitchell and begin homework assignments related to nightmare reduction.

Intervention: Physical Exercise

Common sense, clinical intuition, and non-experimental research studies all support the likelihood that physical exercise can reduce depressive symptoms. To the best of my knowledge, only one, very small, randomized controlled study of exercise for treating major depressive disorder in youth has ever been conducted (the Depression in Adolescence Treated with Exercise, or the DATE study; Hughes, Barnes, Barnes, DeFina, Nakonezny, & Emslie, 2013). A brief review of this study provides a glimpse into the potential of exercise as an intervention for treating depression in youth.

The DATE study randomized youth ages 12–18 years into an aerobic/cardio group (n = 16) vs. a stretching group (n =14). Although participants exercised independently and were given a variety of exercise alternatives, both groups were involved in 12 weeks of rigorously monitored treatment protocols.

The results were statistically and clinically significant, with the aerobic condition showing remarkably fast responses and achieving a 100% response rate (86% complete depression remission). The stretching group improved more slowly, but also had a significant positive response (67% clinical response rate; 50% complete depression remission). In contrast, documented response rates in comparable fluoxetine (Prozac) studies with youth, showed 52% (Prozac) and 37% (placebo) response rates. Although fluoxetine shows beneficial treatment effects, clients prescribed fluoxetine and other antidepressants commonly experience uncomfortable side effects and occasional health-threatening adverse events. In summary, the DATE study authors (all of whom were high-level psychiatric researchers who primarily study the effectiveness of antidepressants) noted that, compared to antidepressant medication treatment with adolescents, exercise resulted in (a) a faster rate of response, (b) a better overall response, (c) fewer relapses (n = 0) at six- and 12-month follow-ups, and (d) no side effects or adverse events (Hughes, et al., 2103). In addition, 12 weeks of monitored stretching was also superior to antidepressant treatment. One caveat: at the beginning of the study none of the participants were exercising.

The DATE study supports the systematic use of exercise in youth with depressive symptoms who are not currently exercising. Whether physical exercise might be an effective treatment for adolescents who are suicidal is unclear. However, given the distinct advantages of exercise over medical treatments, encouraging youth and adults to exercise as a part of a holistic treatment program is recommended.

Working in the Cultural/Spiritual Domain

Cultural and spiritual practices are deeply meaningful and central to many clients. This domain contains complex, powerful, and multidimensional beliefs, values, and practices that sometimes protect individuals from suicidal impulses. However, other times these same dimensions can increase suicide risk, and still other times, they may have no bearing on suicidality (Lawrence, Brent, Mann, Burke, Grunebaum, Galfalvy, & Oquendo, 2016).

For the purposes of assessing and intervening in suicidality, the main concern is whether cultural and spiritual values and practices contribute to emotional/psychological distress or provide emotional comfort and relief. Clients who have disruptions or issues in this domain are often willing to talk about these topics. Asking directly, or inviting input can be helpful.

We haven’t talked much about [religion, spirituality, culture]. I know sometimes [religion, spirituality, culture] can be a positive force in life and sometimes it can be negative. How is it for you and your life?

Clients who are experiencing rejection, exile, or cultural/religious disconnection are likely to view these factors as contributing to feelings of shame and self-hatred. On the other hand, clients who are disconnected from their spirituality and/or culture can find comfort and solace at finding ways to reconnect.

Religion and Spirituality

Some researchers report that religiosity and frequency of church attendance are linked to lower suicide rates. Others find no relationship, and to make matters more confusing, some researchers report that religiosity and church attendance are associated with increased suicidality. The bottom line is that religion has unique influences on individuals; therefore, clinicians should approach religion and spirituality carefully, nonjudgmentally, and with openness to their clients’ personal experiences.

Case Example: Jane – The Six-Months-to-Live Question

Jane is a 66-year-old white, cisgender, heterosexual woman who came to therapy shortly after the death of her second husband. Having experienced substantial grief after her first husband’s death, Jane felt uninterested in dealing with the death of her second husband. She stated, “I’ve been through this before…” She had little motivation for diving into and working through her deep grief and loss a second time.

Along with her immediate grief symptoms, Jane reported passive suicide ideation. She wasn’t actively suicidal, but she spoke longingly of the “joy” of dying and moving on. She wished she could go to sleep and not wake up. Her religious beliefs were woven together with her passive suicidality.

Jane was easy to engage but showed little motivation for change. I tried asking, “What gives you hope,” “What makes you laugh,” “With whom do you enjoy spending time?” and “What do you do for fun?” In response, Jane pleasantly expressed no interest in exploring anything positive or engaging in grief work. She stated, “I love my friends, but I’m tired of feeling like the person they’re trying to cheer up. I’m tired of being the third wheel.”

When Jane articulated how she believed death would be joyful, it was easy to make a bridge to asking about her religious beliefs.

John: I don’t know what your religious or your spiritual values or beliefs are. I’m wondering how those fit in with you feeling that it might be joyful to pass on?

Jane: Well, it’s conflicting there. I believe in heaven.

John: Yeah.

Jane: I have almost a childlike belief that you really do meet up with people you love when you get there. My dad and my husbands will be there waiting at the gate. I’ve always enjoyed that scenario. I don’t try to probe it intellectually, because I don’t want to not have that scenario in my mind.

Jane directly expressed that she’s not interested in an intellectual analysis of her beliefs. If I tried questioning her religious beliefs, there’s a good chance she would not come back. As we discussed religion, Jane shared beliefs about the suicide prohibitions of Catholicism. Despite these prohibitions, Jane derived comfort her image of “floating up” to Saint Peter at the Pearly Gates.

The Six-Months-to-Live Question

After exploring her religious beliefs, I used a six-months-to-live existential question/intervention (Yalom, 1980).

John: I just thought of an interesting question. What if you had six months to live? What would you want to do? How would you spend your time? What would be the most meaningful way that you could live that last six months?

Jane: Now that’s a neat thought. That could get me excited.

John: Yeah.

Jane: That feels like I’m planning for the short-term, not trying to figure out how I’m going to live for another 25 years, potentially with a heavy heart. I would probably travel some.

John: Where would you go?

Jane: Oh, Italy, Greece, Mississippi, Louisiana, listen to Cajun music.

John: Yeah.

Jane: A million places.

John: Okay.

Jane: I’m getting excited.

John: Yeah.

Jane: Along the way, I’d connect with friends that I haven’t seen in a long time, rather than just relying on friends who are here to bolster me up, I’d reconnect with folks around the country who I cherish but don’t see regularly.

John: So if you had six months to live, you’d connect with friends who are around, travel, and reconnect with friends you’ve lost touch with.

Jane: Yeah, yeah.

Once Jane began describing her focus during her final six months, several things happened. I began asking questions to draw out Jane’s ideas about exactly what she would do, whom she would see, and other important details. Jane’s affect brightened and she displayed increased energy and motivation. Having clients elaborate on details linked to their positive ideas is a solution-focused strategy (Murphy, 2016).

After a few minutes, Jane moved past talking about traveling, and focused on activities she could immediately start doing in her life, like art. She said, “I love to do art. I’ve been thinking about doing art during retirement, but the art I pictured myself making was vibrant, and because I don’t feel vibrant, that doesn’t seem right. But maybe taking art lessons would open that creativity faucet a tiny bit. Maybe the vibrant colors could be a way to express grief.”

For Jane, the idea of traditional grief work was unpleasant. Although her religious beliefs provided her with comfort, she was still experiencing passive suicide ideation. In this case, instead of focusing directly on improving her affect, increasing her religious activities, or countering her suicidal thoughts, the existential six-months-to-live question re-focused Jane on what would be meaningful and pleasurable to her in the short-term. The six-months-to-live intervention isn’t a great fit for every client, but for Jane, it moved her away from thinking bleakly about, in her words, “soldiering on toward death.”

Table 6: Treatment Plan for Jane – Cultural/Spiritual Domain
Problems in Spiritual Domain Goals and Strengths Interventions/Plan

1. Jane’s religious views are supporting her joyful views of death.

2. Jane feels emotionally stuck and unable to identify meaningful activities in her life.

1. Instead of fantasizing the joy of “floating” toward the Pearly Gates, Jane will identify and engage in activities in the here-and-now that increase her sense of meaningfulness.

Strengths: Jane has a strong religious identity that mostly provides her with emotional support and stability.

1. Continue to ask Jane to elaborate on and plan short-term activities that she is likely to find fulfilling.

2. Refocus Jane on concrete parts of her religious life that provide her with social, emotional, and spiritual comfort (rather than abstract beliefs about the joys of dying).

Intervention: Using a Meaningfulness Reframe

Jane had strong religious beliefs. Her Catholicism pushed her in two directions: away from suicide and toward viewing death as joyful. Directly focusing on religion led to exploration of the six-months-to-live question. Interestingly, Jane didn’t mention anything religious in response to the question. This may have been because she was already settled and at peace with her religious views. With her foundation of faith intact, when faced with six months to live, she focused on interpersonal and creative sources of meaning.

Frankl (1967) was an early advocate of the “will to meaning” as a basic human motivation. He viewed activation of this natural motivation to pursue meaning as deeply therapeutic for clients who were experiencing depression and suicidality. He used a meaning reframe in the following case example:

An old doctor consulted me in Vienna because he could not get rid of a severe depression caused by the death of his wife. I asked him, “What would have happened, Doctor, if you had died first, and your wife would have had to survive you?” Whereupon he said: “For her this would have been terrible; how she would have suffered!” I then added, “You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now you have to pay for it by surviving and mourning her.” The old man suddenly saw his plight in a new light, and reevaluated his suffering in the meaningful terms of a sacrifice for the sake of his wife. (pp. 15-16)

If clinicians can help clients frame their suffering as meaningful, or help them actively pursue meaningful activities, depressive and suicide symptoms may decrease. The key is to collaboratively explore ways to reframe difficult client experiences as more meaningful and then, together, consider specific behaviors that might add to that meaning. One way to think of this is to refocus clients toward the pursuit of meaningfulness, instead of the pursuit of happiness. Or, to paraphrase Nietzsche, helping clients discover a meaningful why to live can inspire them find the strength to cope with suffering.

Asking about Culture

In any helping relationship, it is unwise and unethical to ignore a client’s cultural identity and worldview. Whether it is immediately salient or not, clients who are suicidal are often affected by this aspect of themselves and will benefit from talking about how their values and cultural identity are interacting with their distress. A vignette from Mitchell illustrates a unique cultural perspective that wouldn’t have been identified without establishing a respectful relationship and gently exploring cultural beliefs. Notice that I’m simultaneously asking about Mitchell’s suicidal thoughts and his cultural values around suicide. Although Mitchell responds well, asking both of these questions at once might be too much for some clients.

John: As you talk, one question that comes to mind to me, and my guess is that this would be a dishonorable thought to have, although not an abnormal thought, because it’s not unusual when people come back from the military and life is disappointing and hard, it’s not unusual to have a thought about suicide. My guess is that thinking about suicide would be in opposition to your culture, but I don’t know.

Mitchell: Yes and no. One way we look at it is that we’ve had everything taken from us. That’s one thing you can’t take from us. Our life is ours to give to the Creator, to Wakan Tanka, which is our God. So, when it’s our time, it’s our choice.

John: Okay.

Mitchell: The sad thing about it is, as I grew up I was probably nine years old when my best friend committed suicide. And it brings the community together. We had a big honoring, a big feast for his family, for him, and just days of celebrating. It brings the family back together. I had another friend do it after that because he couldn’t graduate high school and he wanted his family to come back together, so he committed suicide. He just felt like it was going to bring his family back together. And it did for a bit, but meth came in again, and tore it back apart.

This is a tough scene. Mitchell spoke of ways suicide is viewed within his religion and within his tribal community. Although I had wondered if perhaps suicide was prohibited within this culture, Mitchell told me that – based on his religion – that suicide isn’t prohibited, and then shared dynamics within his culture that sometimes promote suicide. Fortunately, for Mitchell’s well-being, he reported not viewing suicide as a solution to family or community problems. Knowing this information about Mitchell was useful, because as we talked and planned together, we focused on how he can bring family and community together, while also working to reduce suicide in his community. Later, Mitchell finds that becoming a suicide prevention advocate, and working to bring family and community together, to be culturally and spiritually meaningful.

Many other treatment methods focus on the culture and spirituality domain (see Johnson, 2013). Additionally, evidence exists that indicates focusing on religion and spirituality in counseling – for clients who want that focus – is linked to positive outcomes (Worthington, Hook, Davis, & McDaniel, 2011). Consequently, integrating culture and spirituality into your treatment planning is recommended as a method that may be useful for addressing suicidality.

Working in the Behavioral Domain

The behavioral domain includes several areas that contribute to suicide risk and several interventions to enhance client safety. These include: (a) suicide planning or intent, (b) dealing with suicide desensitization, (c) lethal means restriction, and (d) safety planning.

Suicide Planning or Intent

Suicide ideation is a poor predictor of suicide. Nevertheless, ideation is an important marker to explore with patients; exploring ideation can lead to asking directly about whether patients have a suicide plan. When clients have a suicide plan, they’re usually preparing to act … which is why suicide planning and suicide intent are included in the behavioral domain.

Suicide plans may or may not be associated with suicide intent. Some clients keep a potential suicide plan on reserve, just in case their distress becomes unbearable. On the other hand, sometimes planning is associated with suicide intent. Suicide intent becomes especially disturbing when it begins to involve repeated suicide attempts or rehearsal of specific suicide methods. Strategies for collaborative exploration of suicide plans and previous attempts were covered in the first course in this series.

Intervention: Reasons for Living

For decades, suicide research mostly focused on psychopathology and maladaptive qualities within individuals that increase suicide risk and drive people toward death – In 1983, Linehan shifted the focus with the development of the Reasons For Living (RFL) inventory. Following the thinking of the existentialist Victor Frankl, Linehan believed that individuals who experience profound distress and yet continue to embrace life could inform us about how to live through excruciating emotional distress and hope-depleting life circumstances.

The RFL inventory includes 48 items; there’s also an RFL for older adults (RFL-OA) with 69 items. Both instruments have good psychometrics and include positive items linked to happiness, hope, and meaning, as well as negatively worded items focusing on moral objections, fears of suicide, and social disapproval.

Case Example: Emily and Gracie

Emily is a 50-year-old Lesbian woman, single mother, with an 11-year-old daughter, Gracie. Emily presented as anxious, depressed, and reported having lost trust in herself after discovering that her life partner had betrayed her. She was tearful and acknowledged frequent and intense suicide ideation, along with intermittent suicide intent (“Yes, I want to kill myself”), and a specific and lethal plan (i.e., using her handgun). While talking about her distress and suicide plans, Emily also describes a reason for living.

Emily: Yeah, because I’m not sleeping, I’m not focusing in on things I should be focusing in on, and I don’t trust the decisions I make at work. I don’t trust myself. I don’t want to make mistakes with Gracie. She deserves a better mom and a better life. I’m ready to kill myself, but I can’t do it without hurting Gracie.

John: You’re saying you’re feeling miserable and you don’t trust yourself, and, if I’m getting this right, you’ve got a suicide plan, and you would go ahead and kill yourself if it weren’t for Gracie.

Emily: Yes. I really think I would.

John: And so you’ve got one reason to live.

Emily: But that’s all I’ve got.

The fact that Emily has a reason to live is good news, but, as we all know, when parents are heading down the behavioral track toward suicide and focus too much on their children as their sole reason for living, they’re vulnerable to a tragic murder-suicide outcome. One immediate goal with Emily is to expand her reasons for living beyond Gracie, while also emphasizing that Gracie is a great reason for living (but not the only one). Emily’s treatment plan also needs specific interventions that counter her behavioral impulses.

Using Linehan’s RFL inventory was one method for focusing on and expanding Emily’s personal reasons for living. Using a collaborative approach, I was able to go through the RFL scale items, discuss them with Emily, and, most importantly, we were able to critique them together. As it turned out, Emily was able to resonate with a few items on the RFL, but more importantly, her critique revealed specific ways in which she would change the RFL to include what she viewed as meaningful. She found many of the items “stupid” and “too dramatic.” As a practical person who had always pushed herself in the workplace, Emily was angry that there weren’t any “work-related” items on the RFL. As a consequence, we worked together to develop Emily’s own version of the RFL, and it included Gracie, but also much more.

Suicide Desensitization

“The truth about suicide may prove unsettling – it is not about weakness, it is about the fearless endurance of a certain type of pain” (Joiner, 2007, p. 9)

Joiner (2005) and Klonsky and May (2015) described how fear of death or aversion to physical pain is a natural suicide deterrent present in most individuals. However, at least two situations or patterns can desensitize patients to suicide and reduce natural suicide deterrence. First, some patients may be predisposed to high pain tolerance. This predisposition is likely biogenetic (Klonsky & May, 2015). Second, patients may acquire, through desensitization, a numbness that reduces natural fears of pain and suicide. Chronic pain, self-mutilation, and other experiences can be desensitizing. Often, clients who make suicide attempts or who die by suicide, use alcohol or drugs to desensitize themselves to suicidal thoughts and acts.

Desensitization to suicide is a challenging factor to understand and address in counseling. The most direct method for addressing desensitization is to collaboratively develop a list of prohibitions regarding desensitizing behaviors. Such a list might include:

The problem with generating or acting on a list of behavioral prohibitions is that doing so can be polarizing and ignite reactance. Consequently, the key to such a list is to approach it collaboratively. Overall, when clients are regularly using methods (e.g., alcohol, drugs, cutting, suicide rehearsal) that are likely to increase desensitization, clinicians may need to pursue hospitalization, or engage family, friends, or other supportive people to assist with lethal means restriction and safety planning.

Intervention: Lethal Means Restriction

Access to a lethal means is a situational dimension that substantially contributes to suicide risk. Firearms are far and away the most lethal suicide method. Specifically, Swanson, Bonnie, and Appelbaum (2015) reported that firearms result in an 84% case fatality rate. Although firearms can quickly become a politicized issue in the U.S., researchers have repeatedly found that access to firearms greatly magnifies suicide risk (Anestis & Houtsma, 2017).

Bryan, Stone, and Rudd (2011) published an article on how to engage clients who are suicidal in “means-restriction counseling.” As they noted, although mental health professionals are expected to talk with clients about locking up and removing lethal means for suicide, there is very little practical advice on how to do so.

In my experience, the best approach to lethal means restriction is direct, straightforward, and matter of fact. The core message is that because often suicidal impulses briefly escalate, but then pass, all methods that are highly likely to cause death should be locked away or removed. Bryan and colleagues (2011) offer the following guidance:

Present options for restricting access, including: (a) completely remove the means from the home by disposing of it, (b) remove the means by giving it to a supportive person, (c) lock up the means and give the key to a supportive person, and (d) “dismantle firearm and give critical piece” to supportive person (adapted from Bryan, et al., 2011, pp. 341-342).

As already mentioned, discussing firearms in particular can escalate into a polarized political debate. Tto prevent such escalation, I’ve found it helpful to state unequivocally, “I support your second amendment rights” but I also want you (or your daughter) to be safe and to live a long and fulfilling life.

Intervention: Safety Planning

Contemporary approaches to treating suicidality emphasize obtaining a commitment to treatment statement from clients. These treatment statements go by various names including, “Commitment to Intervention,” “Crisis Response Plan,” “Safety Plan,” and “Safety Planning Intervention” (Stanley & Brown, 2012). Safety or crisis response plans are used to plan for activities that clients will use – when in a suicidal crisis – to address suicidal impulses. These plans also include ways for clients to access emergency support after hours (such as the national suicide prevention lifeline 800-273-TALK, or similar emergency crisis numbers or textlines).

Stanley and Brown (2005) developed a brief treatment for suicidal clients, called the Safety Planning Intervention (SPI). Based on a cognitive-behavioral approach, the SPI can be used in hospital emergency rooms as well as inpatient and outpatient settings. The SPI includes six treatment components that clinicians collaboratively generate with clients:

Cognitive, emotional, behavioral, physical, physical sensations, and environmental triggers.

Ask: “How will you know when to implement this safety plan?”

Activities clients can use to distract themselves from escalating suicidal thoughts or impulses.

Ask: “What can you do in the moment to distract yourself from your suicidal feelings?”

Places to go and people to be with that distract and dampen suicidal impulses.

Ask: “Who could you be with to stay safe? Where’s a safe place you can go and be with people?”

A list of names of people from whom the client can directly ask for help.

Ask: “Who can you turn to and ask for help if you’re in crisis?”

A list of emergency contact numbers that the client is willing and able to contact.

Ask: “Who should be put on your professional contact list?”

Reducing the potential use of lethal means.

Ask: “What do we need to lock up or store so that you can’t kill yourself in an impulsive moment?” (Adapted from Stanley & Brown, 2012)

The last treatment component, reducing lethal means, isn’t addressed until the other five safety-plan components have been completed (Stanley & Brown, 2012). Component six also may require assistance from family members or friends, depending on the situation. All six of these components should be included in your professional documentation, including lethal means management.

Intervention: Becoming Directive and Responsible

When clients are a clear danger to themselves, it’s your responsibility to intervene and provide protection. Sometimes, despite the strong preference for working collaboratively with clients, we need to take a directive role. You may have to tell clients what to do, where to go, and whom to call.

Linehan (1993) discussed several directive DBT approaches for reducing suicide behaviors. She advocated:

Linehan’s ideas can give you a sense of how directive you may need to become when working with clients who are suicidal.

Concluding Comments

Working with clients who are suicidal is stressful and challenging. The model reviewed in this course focuses on strengths, six life domains, how suicidality emerges through these domains, and how interventions can be tailored to address domain-specific suicide-related symptoms. Although the six domains were emphasized as separate areas through which suicidality is manifest, they always overlap. Overall, the goal of this treatment planning and intervention model is to help guide you in understanding and developing specific therapeutic interventions – these interventions focus on specific domains, but are developed to address the whole person.

Working with clients who are suicidal can also be gratifying. The interventions and treatment planning guidance presented here were designed to help you deal with the stress, face the challenge, and experience the gratification of working successfully with clients who are struggling to embrace life. I hope you will find this information useful in your very important clinical work.


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