Ten Faces

April 2008 Poster for the 41st Annual American Association of Suicidology conference

Abstract: I have written this paper to talk about my experience with suicide and how the works of Dr. Shneidman has helped me to find the words to the dark demons that are below the surface. This paper also talks about how I think more clinicians need to focus on the psychological pain their clients feel when suicide begins to look like the only answer to their problem. I hope that by sharing my experiences and introduce the works of David Jobes that there are assessments that are out there even if they do not fit the category of validity.


I began my research into suicide and psychache in the spring of 2006 while taking a psychological testing class. My assigned term paper topic was psychometric assessments or psychological tests which interested me. I chose the subject of suicide assessment/risk because of my past experiences; I had barely survived another severe episode of depression the previous winter. Despite my clouded thinking, I had carefully planned my own death. Researching this paper would reveal what the so-called experts knew about these destructive, echoing thoughts I’d suffered from and what kind of assessments and/or treatments my therapist could potentially offer me during these terrible bouts.

What I found astonished me. Despite finding over thirty articles about assessments and risk factors, not one focused on assessment of psychological pain, or, as Dr. Edwin Shneidman refers to it, psychache. In an article by Ramsay and Newman (2005) states that most mental health providers have little standardized training in treating suicidal patients during clinical graduate work, and, are equally lacking during continuing education. I also found, not surprisingly, that some clinicians, once they realize their client is or has been suicidal, opt to transfer care to another professional, especially after a suicide attempt (Ramsay & Newman, 2005). In another article by O’Carroll et al.(1996), I was dismayed to read that there is no standard definition of what it means to be suicidal.

But the intent of this paper is not to review the literature of the past twenty-years. This paper is to talk about what Dr. Shneidman calls the “human stuffy of emotions, the words of a suicidal person” (1996, p. 6). It is to focus on the three P’s of suicide: “perturbation, press, and psychache”.

In 2004, my illness permitted me a break in the gloom; I gained some insight into my suicidal thoughts. I imagined writing a book about my experiences, hoping it would help someone. Alas, that book was already written, and was entitled The Suicidal Mind by Dr. Edwin Shneidman (1996). Finding this book made me feel discouraged. My therapist encouraged me to write my book based on

personal experience rather than from a clinical perspective. I didn’t go back to Dr. Shneidman’s book or work until a year and a half later, when I was taking that psych testing class.

The terms psychache, constriction, perturbation, and press are vital components of suicidal thinking. The cubic model Shneidman(1995) writes about is the best indication, in my opinion, of how likely someone might commit suicide. When pain, perturbation, and press, the three P’s, are at their highest level, individuals are much more likely to feel trapped. Thus they feel there is no way out. Suicide then becomes the answer they seek to end their pain and their life.

Although I heartily agree that assessments of the lethality of suicidal ideation are important, the one element that has been frequently overlooked is the psychological pain that the individual is feeling. What I have learned is that there needs to be an assessment of psychological pain whenever a client is feeling suicidal or having suicidal thoughts. A good analogy is the following: Think of a time when you had to go to the emergency room because of a physical ache, maybe abdominal pain or a severe headache. One of the tools the clinician might use is a scale to rate your physical pain from 1-10 with 10 being severe. Some emergency rooms have drawings of ten faces with varying expressions of discomfort that children and non-English speaking patients can utilize to evaluate their pain. No such scale exists

in the psych world. Even most psychiatric emergency services at major hospitals do not ask about mental pain. That is what I find so striking about Dr. Shneidman. By asking, “Where do you hurt”, the three P’s of suicide, perturbation, press, and mental pain can be assessed and taken into account of how likely a suicide attempt might occur.

Current research studies by Holden et al. (Flamenbaum & Holden, 2007; Holden, Mehta, Cunningham, & McLeod, 2001) at Queen’s University in Ontario are validating a pain scale that I think is efficacious, especially in times of crisis, and possibly life saving. From my experience of those darkest moments, there are no words for the depth of pain that I feel. Holden and Mehta’s scale (2001)can help communicate how much pain the client is feeling. This scale is essentially a self-report of psychache, enabling the clinician to quantify psychological pain. It can also determine whether that pain is the driving force for a potential suicide attempt. This scale is, in my opinion, the best measure to pinpoint all three aspects of perturbation, pain, and press. As Dr. Shneidman points out, the best source of understanding suicide is through the “words of the suicidal person” (1996, p. 6).

Once the level of pain has been determined, assessment can be tracked through the work of David Jobes described in his latest book, Managing Suicidal Risk (2006). He uses the continuum of

initial interpretation, tracking, and outcome to manage a suicidal client. These forms are called the Suicide Status Form (SSF). These forms have gone through the process of refining to become efficient and use of ease in managing suicidality (Jobes, 1995, 2006; Jobes & Drozd, 2004; Jobes et al., 2004). He stresses that he will do all he can to prevent his client from fulfilling their plan, and he offers the client a more positive way of dealing with these thoughts. Through his work, he facilitates the client managing his or her own treatment, collaborating on what will effectively decrease suicidal thoughts and impulses.

I hope that someday these tools become more widely available to those that want to help the suicidal clients, even if they have not been empirically tested. As Dr. Shneidman once said, “relevance has precedence over precision, and that ‘validity’ does not exhaust the category of ‘usefulness’”(1999, p. 287).


Flamenbaum, R., & Holden, R. R. (2007). Psychache as a Mediator in the Relationship Between Perfectionism and Suicidality. Journal of Counseling Psychology, 54(1), 51-61.

Holden, R. R., Mehta, K., Cunningham, E., & McLeod, L. D. (2001). Development and preliminary validation of a scale of psychache. Canadian Journal of Behavioural Science, 33(4), 224-232.

Jobes, D. A. (1995). The challenge and the promise of clinical suicidology. Suicide and Life-Threatening Behavior, 25(4), 437-449.

Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York, NY: Guilford Press.

Jobes, D. A., & Drozd, J. F. (2004). The CAMS approach to working with suicidal patients. Journal of Contemporary Psychotherapy, 34(1), 73-85.

Jobes, D. A., Nelson, K. N., Peterson, E. M., Pentiuc, D., Downing, V., Francini, K., et al. (2004). Describing suicidality: An investigation of qualitative SSF responses. Suicide and Life-Threatening Behavior, 34(2), 99-112.

O’Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the Tower of Babel: A Nomenclature for Suicidology. Suicide and Life-Threatening Behavior, 26(3), 237-252.

Ramsay, J. R., & Newman, C. F. (2005). After the Attempt: Maintaining the Therapeutic Alliance Following a Patient’s Suicide Attempt. Suicide and Life-Threatening Behavior, 35(4), 413-424.

Shneidman, E. S. (1995). Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior: Rowman & Littlefield Publishers, Inc.

Shneidman, E. S. (1996). The Suicidal Mind: Oxford University Press.

Shneidman, E. S. (1999). The Psychological Pain Assessment Scale. Suicide and Life-Threatening Behavior, 29(4), 287-294.

copyright 2008 collerone, g

4 thoughts on “Ten Faces

  1. Psychache is not really felt in the brain. It is more like inside your chest. Every one’s description of it will be different, which is why the validity of measuring psychache through the psychological pain scale assessment was not well documented. Mostly it is rating your pain and going from there, but that hardly ever happens, which is why I wrote the article.


  2. A fascinating writing. The idea of evaluating psychache intrigues me. Can you give an example of how a person would describe “where does it hurt” as far as psychological pain goes? Being stuck in the physical aspect of this question, would mean someone could point to their arm or head, etc. but how can you point to where it hurts inside your brain?


any thoughts?

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s