Tag: collaborating in the management of suicidal patients

Building a Therapeutic Alliance

by Midnight Demon, posted in mental disorders, mental illness, mood disorders, suicide, suicide attempt

Building a Therapeutic Alliance with the Suicidal Patient. Eds: Konrad Michel and David Jobes

This book is a work of genius among the top suicidologists in the U.S. and Europe. The editors actually want to help suicidal people get better and try to make their life worth living. Like most of Drs. David Jobes and Konrad Michal work, they have done an excellent review of the literature and made the book easy to read without a lot of psychological jargon.  This book should be used as a handbook for anyone dealing with suicidal individuals.  As someone who has been through many suicidal episodes with many different therapists, this book is groundbreaking.  It lists his classic work of CAMS (collaborating and managing suicidality) which is a tried and true way of dealing with lethal suicidality in an outpatient setting. The other evidence based therapists will enhance therapy around this work.

The Chapters are broken down easy enough and progress from good to bad in my opinion, of the treatments that work.  The conclusion was brilliant by Dr. Jobes. He has stated with clarity the hardships that are faced with suicidality such as the IRB approvals for research, clinicians wanting to work with this population, and the need to try and keep these people in therapy.

The brilliance surrounding this book is the alliance part of it. Without a therapeutic alliance, you cannot have a good report with a therapist and the therapist cannot have a good report with the client. The essential element is having a good working relationship that builds on trust and collaboration. The therapist must want to know the client’s story in a non-judgmental, non-criticizing way. By listening to this story, the therapist engages the client and the client feels validated and understood. This is a central element to helping any client in psychotherapy, in any discipline.

This book covers most of the therapeutic disciplines and how it relates to treating someone with suicidal ideation. It also offers empirical evidence that supports treatment of suicidal individuals, from psychodynamic to cognitive therapies.

I believe this book should be read by every graduate student and post graduate in the mental health field. This book can also augment education for those that are already in the field and practicing psychology or psychiatry.

what do you say

by Midnight Demon, posted in depression, mental disorders, mental illness, mood disorders, suicide, suicide attempt

I have been asked to write about what you say to a person who has just attempted suicide. The answers are many but there is a song that I have in mind, another one by the Fray, that I think helps to explain it if only I can get the words out. You try and be supportive and not be a smart ass with things like I’ll kill you if you try this again. It is one of the WORST thing you can say to the person. Being there and hearing the person’s story of why they did what they did will be invaluable. It might even prevent another attempt. If this was a one time deal, the person will say this was the stupidest thing I ever did in my life and may not try again. If this was not and the attempter says, how could I be so stupid that this really was going to work, that they seem harder on themselves because they survived or are wicked PISSED OFF they did survive, there is a likely chance they will attempt again and again until they succeed. I know this from experience. I first overdosed when I was sixteen, April 12, 1992. I remember the day as if it was yesterday. I had carefully planned out my pills, the day, how I was going to do it. I even went to confession the day before (I was a practicing Catholic at the time) and went to church on this sunny Sunday. It was my Aunt’s birthday and I knew that the house would be all to myself. All I had to do was wait for it to be. I knew by the time I got home from church, my family would be heading over to Somerville and be down my grandmother’s house celebrating my aunt’s day of birth, not knowing meanwhile back home I was planning on ending my life. Except it didn’t work. I got wicked sick, puked everywhere, my eyes were dilated for days. And when I woke up Monday morning, I WAS FRICKEN PISSED OFF like no tomorrow. To my dissatisfaction, I went to school in a very pissed off mood. I couldn’t tell anyone what I had done nor could I tell them why I was so pissed off.  There was one person I did tell. It was not the school nurse or a friend but my therapist at the time, a social worker who a month or so before told me she was leaving the state and I would have to find someone else to take care of my mental health needs. I don’t remember what happened too much the day after, I was still drugged up and out of it but I remember being so mad at everyone, most of all myself for failing. I then fell into one of the worse depression of my life. This got really bad. I didn’t go into the hospital as I said I was never going to do it again and all the lying it took to avoid being in the hospital because I just was so PISSED and was not going to get help. The hell with the help. It failed me and I was really really angry. This therapist was my third and I figured strike three was called and I was out. I later did go into the hospital that year, in the summer. I lost another twenty pounds, had no appetite, thoughts on killing myself were great, I felt like the biggest asshole on the planet because I failed to kill myself and that kind of pain is hard to describe. You have no idea what failure is until you try and take your life and fail at it. It hurts and that is what I was feeling. This big hurt that no one knew because who would want to know how much it hurt to fail at killing yourself when you thought things out so perfectly, or you thought you did. Nobody knew I had done what I did and when I did it was met with over concern and I was left feeling more like a burden than I ever did before the attempt.  I also felt like who would listen to me. I was a pretty good student and who would believe that I was having problems holding things together after my parents had a massive argument that ultimately ended their marriage.  I felt that I should have been smart enough to sort through this all by myself.

 I remember that day the phone just kept on ringing. I couldn’t understand why. Didn’t the world know this was my day to end things? I’m not sure if the phone constantly ringing was a good or bad sign. It was my best friend wanting to play and I was half in the bag so to speak so there was no chance of me leaving the confines of my house to play ball. But I wonder if the panic of what I was doing forced me to throw up all that I had taken. I remember right before falling asleep that this was it, I was going to sleep for the last time. YEA RIGHT…

There have been at least ten times I have tried to end my life. Unfortunately, I don’t always remember what was happening with me when I was just about to take my life. I do remember and it is still the case today, that most of my attempts have been planned attempts and not an impulsive one which most are. I did have an impulse the first time I truly wanted to die as I was digging with a pair of scissors to draw out a vein and die that way but that was a lot harder than it seemed. I was introduced to the self-harm of cutting which can also look like suicide attempts, especially when the cuts are deep enough to cause stitches.  Though I am a former self-harmer, that is not the subject of this paper and will defer commenting on this for now.

The reason I had first cut was because I had wanted to die. I had tremendous stress with a parent that day and the day after and I just snapped. All I could think about was death. Up until this time, I was the perfect student in my high school freshman year. I was getting all A’s and nearly had a perfect attendance record. After this blowout, and that I put mildly, I didn’t care too much about anything. My grades slipped and my attendance faltered. I entered therapy and discovered more than what I bargained for. My psyche was exposed and I could not let anyone in on the hurt I was feeling.  I had grown up with the what goes on in the house stays in the house.   I just wanted the pain to end and so I had cut to end it. Fortunately, I wasn’t a good cutter and all I did was cause scratches on my wrist.  It wouldn’t be until a year later that I would take my first serious suicide attempt.

Like my pain that I tried to hide, I also kept my scars that were visible, hidden. Today they are a reminder of how bad things were and that I survived. I know it may sound strange but they are truly what saved me from attempting more serious attempts at my life.  Planning an attempt is not as easy as it sounds but it is what has kept me going. It is my escape hatch and though a lot of researchers have written about suicide as an escape, it truly can be as well as I know it to be. I have thought of many plans but have not acted on any since before 2001.  That makes over a decade of planning yet no action. You might think that I have been lucky but in 2005 I came close to acting on my plan. Things were going pretty sucky for me emotionally and I was still struggling with my nerve injury. Chronic pain and depression do not mix.  Seemed that both like to feed off one another and I was swimming in both physical and mental anguish. I could barely keep above water so created this wonderful plan, set a date, and all I had to do was get my affairs in order by Nov 5th, 2005. Except the one thing I was counting on, fooling my therapist in thinking I was “well”, failed horribly.  The way she recounts it today and is always be aware of someone making an effort at feeling good. This is true. The moment someone in a deep depression like I was in suddenly starts to feel better is the crucial time to ask about suicidality.  The reason being is that this provides the sufferer that they are no longer going to suffer. The so called “warning signs” of suicide can be just that, feeling better after a deep depression and suddenly giving away possessions.  With people with suicide careers such as mine these warning signs are not so subtle to the outside observer. Even a trained professional could miss them. I was under siege with suicidal thoughts yet no one knew until the day my therapist asked what was really, really, going on.  If not for her insight into my care, I probably would not be here today writing this for you to know. It is important to realize that the attempter does not want people to find out about their plan, especially when they have been thwarted many times in the past with hospitalizations after hospitalizations. Statistically, I should not be here yet as my therapist points out, I am the exception. Why I do not know. But holding my thoughts to myself was my haven. I thought carefully about my plan  every day and that brought me some reprieve from my pain.

Constant vigilance is key after someone attempts suicide.  If they are intent on ending their lives, they will try and try again until they succeed. If the suicide was a “wake up call”, and if they truly get the help they need at this time, they may not try again. But these types of preventions are not always sound. What holds true for one may not hold true for another. The biggest thing to worry about with attempters is the amount of guilt and sense of failure after the attempt that makes another attempt all that more eminent.

As mentioned earlier, hearing the person’s story is the most important thing you can do after or before an attempt. Just listening without being judgmental and criticizing can be important for the person and might be just the thing to prevent another attempt that will succeed. There is a book called building a therapeutic alliance with a suicidal patient by Konrad Michel and David Jobes, two of the foremost suicidologists in the world. They have written an awesome account of how to build an alliance with a suicidal person. It should be the textbook guide to anyone in the mental health field. It gives case studies of clients and the therapist’s reaction, good and bad. That is crucial to see how one person can be understanding and helpful and another not so helpful. If you are reading this and are a mental health professional, I STRONGLY urge you to get this book. I have studied the works on David Jobes for several years now, you might even call me a professional stalker as all I do is do a literature search on him at least every month to find out what new study he has done with his works on collaborating and managing suicide (CAMS). In this works, the SSF (Suicide Status Form) is the key element to help a survivor or someone who is about to attempt suicide to help work through their issues on why they think ending their life is the key to solve their problems.  But without knowing the story behind the pain, no one will be able to help this person that has just attempted to end their life.

My story mentioned above, and you can see how much pain I was in that caused me to think ending my life was the answer. While being in this bubble of hopelessness and despair, no good feelings can penetrate it. I guess that is why my therapist crossed the boundaries and told me she cared and when she started crying, I knew that to be the true. Hearing the person tell you why they are thinking about ending their life is so essential to saving that life.  To reassure this person that they are not a burden, not a bother, not a dipstick is the most important thing you can do to try and help bring some hope and ease the pain. There is really nothing more than you can do to help this person in need of help but just knowing you are there and that you are not going to leave or think less of them can help save this person from making another attempt. I have been through some very close attempts. One attempt was medically serious and I was forced in the hospital for three months because a previous therapist (who was more than pissed off at me) was so very certain I was going to try again. And I would have had I not given myself some time to heal while under the hospital’s care. I was in a very dark place and there was no other way out of my abyss other than suicide. I had tried all the medications, and they didn’t help me. I tried therapy for years and it didn’t help me. Still after all this time and energy of trying to plan the end of my life I still try and hold on to some hope that there will be a better tomorrow. Sometimes there is and sometimes things are just the same. This hurts. Knowing day after day that there is no way out other than suicide is a very lonely place. A place that is filled with hurt. I had tried and I failed again. There is no greater pain than that.

Today I read on facebook a quote, “when you fail, you learn from the mistakes you made and it motivates you to work even harder.—Natalie Gulbis

This is the worst thing you can say to someone who has just attempted suicide and is hell bent on suicide like I was. Yes, I have learned from my mistakes, I have learned not to trust people, especially mental health professionals, to speak of telling them of my suicidal plans because they will try and stop me from achieving those ends. I honestly have no idea how my therapist can deal with me sometimes because I am hell bent on ending my life and she I think lives in a fairy tale world where suicide doesn’t exist so when I tell her, the answer is always a NO. But then, could it really be a yes? If all therapists were to green light their client’s suicide there would be no hope for prevention. But therapy still is supposed to help those in need and yet after more than 15 yrs in therapy with different modalities, I still remain depressed and suicidal. Though I might get a respite every now and then it is far and too in between to really count and I have learned not to hold on to it because that usually means a big downfall and another hospitalization.

Now I find myself writing about every attempt I have made in my life and the consequences of those actions.  I don’t know if that is what people want to read about but I write about the aftermath and how it felt after each failed attempt.  Maybe I have just given up on trying to attempt again and that is why it has been so long since I have. True I feel like the biggest failure in the world knowing this but how can I not. This is deeply personal talking about the lowest point in my life and wanting to end it all and then by some grace, still be forced to live on afterwards because of some kind of divine intervention. Of the many attempts I have tried, only 1 was medically serious to warrant a hospitalization. The others were not so serious but did lead me to hospitalizations. Since the age of sixteen I have had close to 30 hospitalizations. Most have been involuntary as I posed a danger to myself and it is law to hospitalize for that reason. I just wonder why I have survived this long. Am I suicidal if I don’t attempt and just plan? We can go into the whole what makes a person a suicidal ideator vs. an attempter but most would agreed prevention lies in before the attempt not after. We hear stories about suicides and their survivors but what you don’t hear at all is about the attempter that survived. These truly are the ones that need the most attention to but because their world is so private no one really knows. Unless someone survives a shotgun wound or immolation or hanging attempt, you often don’t see the scars of attempters. True those that slice their wrist leave scars but most do survive to eventually tell their tale. There are countless overdoses every year that get under reported or if successful get ruled as accidental poisonings rather than suicides mostly to either spare the family the “shame” or because there was no clear indication that the poisoning was intentional. Most people believe that unless there is a suicide note, it is not a suicide because he or she wouldn’t do that. I would say that the majority of people who attempt and fail feel too ashamed to admit what they have done and so cover their asses by saying it was an accident or just a foolish impulse but for those that succeed we will never know.

Talking about an attempt is difficult for the survivor. They really need support after the attempt, to know that they matter and are not a burden to their friends and family. I know not all family members are supportive when it comes to mental illness and when someone they love and care about just tried to take their life, fear of losing them overtakes the care and compassion that they might feel.  I know with my family I did not have that kind of support but then I felt like a burden to most of my family because I had this illness I could not control that was causing me to feel like the scum of the earth. If you are reading this and truly want to help someone after and attempt, whether it be a friend, coworker, or family member, do not shy away from them. Let them know how much you mean to them and look them in the eye when you do. There is a lyric from Sugarland’s song Just make me believe that says “if you look in my eyes and tell me we’re going to be alright, if you promise never to leave, you just might make me believe.” This person feels so out of it they do not want to come back to the land of the living and the shame of what they have done and the guilt is killing them in ways the attempt never did before. If they thought that killing themselves was the answer, they may now know that it is not.  If the attempt caused an injury, that will be harder to deal with. Not only have they failed to kill themselves properly, they injured themselves without taking that into consideration. That will be hard. Words like saying they have their whole life in front of them will only make them feel worse or that they were “lucky” to survive. I still don’t feel lucky to have survived my attempts. I still feel ashamed of myself and worse like the biggest failure in the world.

ramblings 4

by Midnight Demon, posted in depression, mental illness, suicide, suicide attempt

My blog had quite a lot of views and comments yesterday which made me happy for a little while but I was in a deep funk and still am in a deep funk. I don’t know why but I should stop reading about suicidal stuff because it is giving me ideas. I know I already have them in my head but I keep thinking, if I am not suicidal, then should I kill myself? As the saying goes, you should NOT kill yourself when you ARE suicidal. Mostly that is because you are thinking irrationally. But if you have been thinking irrationally for so long, does it become rational at some point? That is where my thinking is heading. I tend to think about killing myself nearly every day. I have yet to act on it for various reasons. Usually it is an in the moment type of thing but lately I have been thinking of a plan and a date. I KNOW it is because of the time of year. Every late September/early October I get seriously depressed, more so than anything. Since 2005 I have planned my death every single year without fail. I don’t know what it is about this time of year that makes me want to kill myself. I know that baseball season is over and that saddens me to no end. I no longer see pitchers on the mound and balls and strikes being called. Right now it is Postseason but I know that baseball will truly end by mid-October. Around that time is when I always think of ending my life.

I don’t know why this time of year brings me to my knees. I just don’t feel like life is worth living anymore. It is a seasonal pattern but doesn’t fit the usual SAD (Season Affective Disorder) criteria (mostly because I have recurrent depression throughout the year anyways). If it did fit, I probably would not be so crazy this time of the year. I’d get a light box and be done with it. But this is something more. I call it the black dog as I show more signs of depression than at any other time of the year. I just feel so worthless and guilty that all I can do is think about my own demise. The physical symptoms I get is more psychological pain, lethargy, fatigue, loss of pleasure and loss of interest (also known as anhedonia), loss of appetite, crying for no reason, worthlessness, guilt, etc.

I don’t know what takes me out of the black dog. Sometimes it is just perseverance, sometimes it is just means extra support from my therapist and psychopharm. I also have the hospital when it gets too much to bear, but I only use that as the last resort. Some people would say that is not right but I have had over thirty hospitalizations over the past twenty years that I know when I need to be in and when I don’t.  Though there is some literature saying that the hospital is under-utilized for suicidal patients the same can be said that it is over utilized as most clinicians do not know how to treat suicidal clients. And that bothers the hell out of me because there is (going on my Jobes soapbox) there is an assessment form easy to use and is applicable to all modes of therapy called the Suicide Status Form (see Jobes, 2009). If more clinicians used this, there would be less hospitalization and suffering and possibly less suicides. Granted my therapist tries to use this during each suicidal crisis but I wave her off. Not because I am a hypocrite, but because it was my idea and not hers mostly. Could this save my life? Possibly but the thing that bothers me is that she only uses one piece of the form. If you are going to use the form, use the whole of it. It will make your notes easier and all you have to do is have each person sign it (it is a collaborative effort on both the client and clinician parts). I love this ingenious form but I hate it when it is not used properly. But then my therapist has known me for upteen years now so knows what information to get from me to get me away from my suicidal thinking. Another form that is NOT used at all that should is the psychache form by Richard Holden at Queen’s University in Canada. That I have used to monitor my psychache and even modified the form for my needs. Every journal I have has the psychache scale in it. I would reproduce it here but it’s not kosher and I don’t want to get in trouble with the web police for copyrighted information. Holden wrote the article in 2001 and it is printed in the Canadian Journal of Behavioural Science, 33(4), 224-232. I find Jobes and Holden to be the best suicidologists in the world because they have come up with assessments that are clinically useful and empirically validated.

Analysis of a Song–How to Save a Life

by Midnight Demon, posted in Bipolar Disorder, depression, mental disorders, mental illness, mood disorders, psychache, psychology, suicidality, suicide, suicide attempt

Analysis of a Song by: G. Collerone. Copyrighted 2012, all rights reserved

Music is an important part of the human race. Each individual has his/her own genre they prefer. Music can help heal a broken heart, discharge stress and to relax while going to sleep.
Often times music’s lyrics can hold a very powerful message. That is my goal with this essay to write about the song, “how to save a life” (The Fray, 2005). By using personal and clinical information, I hope to inform the mental health professionals about how to save a life when a client is thinking about suicide and what it means to get help from a mental health professional. This paper is written from the view point of a clinician and a patient who is engaged in therapy.
Jobes, Moore, and O’Connor (2007) have stated that assessing a patient’s suicide risk at each medical office visit as collecting vital signs. Quinnett (1987) has stated that there is only a ten minute window of when a person thinking of suicide will actually go through with it. It is extending those minutes that is an important step to prevent a suicide.
Sometimes there are signs indicating suicidal thinking such as, giving away of possessions, saying things will be better if I just “go away”. Sometimes these signs are not so subtle. In the wake of a completed suicide, one often wonders, “what they could have done differently”.
The rock band, The Fray, has written a song called, “how to save a life”(Slade, 2005). I would like to express in this essay, how important these lyrics are to help save a life, whether it is someone else’s or your own.

“Step one you say we need to talk
He walks you say sit down it’s just a talk
He smiles politely back at you
You stare politely right on through
Some sort of window to your right
As he goes left and you stay right
Between the lines of fear and blame
You begin to wonder why you came”

These opening lines talk about the initial conversation when the person who is having suicidal thoughts is being confronted. This is a crucial conversation as it allows you to assess what the person is thinking and to let them know you are concerned. The lyrics could also be viewed as the initial consultation a clinician has with his or her client, whether it was initiated by a friend, significant other, or family member. Family and/or friends are hoping that this person, who means so much to them, can open up to this person (therapist, minister, or counselor) to get the help that they (friend or family member) cannot offer or give. This is not to say that the friend or family has rejected the individual in his or her distress. The distressed individual may just need an unbiased, neutral person to talk openly about how they are feeling and what has brought them to the verge of suicide. Life for this person at this point is bleak, hopeless and unworthiness has invaded their soul. The individual feels he or she cannot confide in others. He or she feel they are a burden to friends and family members and have begun to shut himself off from those that love them. He sees only one option left to them: suicide. This is very dangerous thinking. The four letter word “only” is very significant and carries a lot of weight. Dr. Edwin Shneidman spent his career in working in the field of suicidality and forming the foundation for suicidologists in the United States. According to him, this word is the most “dangerous” word to be spoken by a suicidal person (E. Shneidman, 1985).
As long as there is human life, the threat of suicide is always going to be an issue. It is an indiscriminate symptom of mental illness, such as bipolar depression, major depression or schizophrenia. Some times suicide is not related to mental illness at all. It could be a response to a crisis that seems to have no end. Whatever the reason, “suicide will be a permanent solution to a temporary problem” (Quinnett, 1987).
Some experts will say that suicide is preventable, others believe that it is treatable. I say that it is manageable. When suicide becomes the only option, the question becomes what to do with this suicidal thinking: if the individual reaches out, they may go to a friend or family member for help or suffer along and pray his distress will end.
Most clinicians do not know much about suicide. Each clinician has their way of dealing with it or perhaps, not dealing with it at all. Some will refer their client to another clinician the moment suicidal thinking is mentioned. Most almost always use what is known as a safety contract: essentially an agreement, written, verbal, or both, saying that the client will not harm or kill himself or herself in any way until the next session with the therapist. If the client does not agree to this, the option is that the client will be hospitalized, often against involuntarily. If the clinician fails to hospitalize a client that is in danger of hurting themselves and the client dies, the clinician is subject to malpractice and potentially the loss of the licensure. In Rudd’s article (2006) 41% of clients under contract died by suicide or made a serious suicide attempt. These contracts have no legal standing but are used from a medicolegal point of view. To ensure the liability of the clinician, the client is placed in the hospital. In my opinion, this is the clinician’s get of jail free card and the jail term of the client. The lyrics: “Let him know that you know best/Cause after all you do know best” best describe this situation.
Is there a better way of dealing with this small yet extremely vulnerable population? There are structured treatment plans for patients at risk for suicide, but the knowledge of this across all mental health professionals is limited. It takes a mediocre trained clinician to have the courage to want to treat the client’s plea for help and to stick with that person through this difficult time.
There are two clinicians who have revolutionized the understanding of suicidal thinking and behaviors. Dr. Ronald Holden at the Queen’s University in Canada and Dr. David Jobes at the Catholic University of America in Washington, D.C., have two forms that are easy to use and are not time consuming. These forms, the psychache scale (Holden, Mehta, Cunningham, & McLeod, 2001) and the Suicide Status Form (SSF;David A. Jobes, 2006) can be used in the first fifteen minutes of a session to assess the client’s mental health status.
Dr. Holden’s psychache scale is a thirteen question self report of items based upon Shneidman’s book, Suicide as Psychache (1993). Psychache is defined as despair, anguish, hopelessness, psychological pain one feels. Each items are ranked on a 5 point scale ranging from either never to always or from strongly disagree to strongly agree (Holden, et al., 2001). Scores are from thirteen to sixty-five.
The chorus is what brought me to write this paper. The following is the lyrics:
Where did I go wrong, I lost a friend
Some where along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life
Sometimes in my own suicidal thinking I had wished “someone would have stayed up with” me all night. Just to have the reassurance that you are not alone and that someone cares that much, helps to diffuse the feelings of hopelessness and helplessness that the depression and weight of the world is bringing. It also helps to know that this difficulty will pass and the individual will get through this. It also helps to know that difficulties will pass and the individual will be able to move on. It is crucial that the individual knows this for tomorrow does not exist and the important thing is to get through today.
In Shneidman’s classic work, ¬Definition of Suicide, he states that “suicide should not be attempted while feeling suicidal” (1985, p. 139). The reason for this is because the thinking of the mind is focused solely like a never ending black tunnel. The constriction is so great; all you can think about is death and cessation. Time for them is in a warp full of pain and despair; there is no tomorrow. Their thinking is solely focused on what they need to do to ease their pain no matter what. Constriction is defined by Shneidman as the “honing in, the tightening down of the diaphragm of the mind. There is dichotomous thinking, a fixation on a single pain-free solution or death. Choices seem limited to two or one” (Shneidman, 1999).
Sometimes during this constriction, you are so overwhelmed by all that needs to be done you don’t know what to tackle first. This might be tasks at work, school, or just in general. Lists become an important tool that can help to prevent suicidal behavior. Dr. David Jobes at Catholic University created and designed a well focused, detailed, user-friendly form, called the Suicide Status Form (SSF, 2006). This form has three essential components that are initial, tracking, and outcome forms. Each section that both the client and clinician fill out to focus on the treatment plans, mental status at each office visit, treatment plan that the patient and clinician agrees to, and other relevant clinical material such as axis diagnoses for proper documentation. It essentially creates a written plan on getting better. The SSF is a very carefully made tool that clinicians can use to know how much pain, hopelessness, and likelihood the client may act on their feelings. This form is the best tool to know where the client is in their thought process because it clearly documents the distress they are feeling. The SSF also provides the client with a voice in their treatment rather than to have it dictated as the clinician seems fit, because after all “you do know best”. The client will feel more centered and relieved that someone is taking the time to listen to what is going on and work with them on what will work and what will not.
The next bridge is the crucial piece of what therapy is about:
Let him know that you know best
Cause after all you do know best
Try to slip past his defense
Without granting innocence
Lay down a list of what is wrong
The things you’ve told him all along
And pray to God he hears you
And I pray to God he hears you

According to Dr. Shneidman, “there are many pointless deaths, but never a needless suicide” (1995). Over his career, he has stated that the main element of suicide and suicidal thinking are frustrated needs. These are the “list of things that are wrong, things you’ve told him all along”.
In Shneidman’s Psychological pain assessment scale (1999), he lists twenty needs he feels are essential to the frustration one brings to think about suicide as an escape (for more detailed use of the scale, please see article). These needs are an adaptation of Henry Murray’s work, Explorations in Personality (1938).
The key to helping any suicidal person is to listen to what the person is saying. That is the most essential piece that any clinician can do. Jobes (2008) found in his clinical use of SSF’s one thing that was the level of the perturbation and stress involved with suicidal thinking as major correlate for suicidal behavior. This might be that pain becomes so jaded the person just doesn’t feel it and all they are left feeling is the urge to do something in the moment to relieve the pressure that is building up.
Learning new coping strategies may not be easy and some will work; others will not. In formulating this, it is up to the clinician to either “drive until you lose the road (client) or break with the ones you follow” (stick with what you know or try something different). O’Carroll (1996) did a survey of current assessments of suicide and found that not all clinicians (social workers, psychiatrists, psychologists, counselors) have the right definition of what it means to be suicidal. Each profession had their own beliefs and thoughts about what it means to be suicidal and propose a treatment for it. For a select few, some therapists even transferred the client to another clinician because of various reasons (David A. Jobes, 1995; David A. Jobes & Berman, 1993; David A. Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005; Joiner, Rudd, & Rajab, 1999; Joiner, Walker, Rudd, & Jobes, 1999; Meichenbaum, 2005; Michel, et al., 2002; Ramsay & Newman, 2005).
There is also David Rudd, et al (2006) Commitment to Treatment Statement (CTS). This is a formal written and verbal agreement, on paper, that the client is committing to live and as such, has decided to put suicide on hold to try and see if therapy can help achieve the goal of living rather than of dying. It is a novel way of thinking and is much better than the expense of the hospital (even though it might happen anyway) and the loss of life.
No one is an expert on suicide. There are predictive models that show the likelihood of risk factors that might cause a person to attempt. But these factors do not apply to everyone in the human race. Each suicide attempt or gesture is unique to that individual. There may be warning signs that go unnoticed until after an attempt or completed suicide. Psychological autopsies are valuable but they are too late to do much good to someone who is already dead. Their pain is no longer felt by them, just to those that knew them. You cannot save someone once they are dead. Nor can you learn much about the why and how they chose death to end their pain. As Dr. Shneidman points out, the best source of understanding suicide is through the “words of the suicidal person” (1996, p. 6).
In summary, these tools can be used in clinical practice. I know that most of these are not empirically based as of yet but does it matter to the client who is thinking these thoughts, is hurting so bad to want to end their life not to give it a try? You can “drive the until you lose the road, or break with the ones you follow”.

Lyrics to How to Save a Life: By The Fray (2005)

Step one you say we need to talk
He walks you say sit down it’s just a talk
He smiles politely back at you
You stare politely right on through
Some sort of window to your right
As he goes left and you stay right
Between the lines of fear and blame
You begin to wonder why you came

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life

Let him know that you know best
Cause after all you do know best
Try to slip past his defense
Without granting innocence
Lay down a list of what is wrong
The things you’ve told him all along
And pray to God he hears you
And I pray to God he hears you

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life

As he begins to raise his voice
You lower yours and grant him one last choice
Drive until you lose the road
Or break with the ones you’ve followed
He will do one of two things
He will admit to everything
Or he’ll say he’s just not the same
And you’ll begin to wonder why you came

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life
How to save a life
How to save a life

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life

CHORUS:
Where did I go wrong, I lost a friend
Somewhere along in the bitterness
And I would have stayed up with you all night
Had I known how to save a life
How to save a life

References:

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. (2008). CAMs workshop (lecture 41st American Association of Suicidology annual conference ed.).
Jobes, D. A., & Berman, A. L. (1993). Suicide and malpractice liability: Assessing and revising policies, procedures, and practice in outpatient settings. Professional Psychology: Research and Practice, 24(1), 91-99.
Jobes, D. A., Moore, M. M., & O’Connor, S. S. (2007). Working with Suicidal Clients Using the Collaborative Assessment and Management of Suicidality (CAMS). Journal of Mental Health Counseling, 29(4/October), 283-300.
Jobes, D. A., Wong, S. A., Conrad, A. K., Drozd, J. F., & Neal-Walden, T. (2005). The collaborative assessment and management of suicidality versus treatment as usual: A retrospective study with suicidal outpatients. Suicide and Life-Threatening Behavior, 35(5), 483-497.
Joiner, T. E., Rudd, M. D., & Rajab, M. H. (1999). Agreement Between Self-and Clinician-Rated Suicidal Symptoms in a Clinical Sample of Young Adults: Explaining Discrepancies. Journal of Counseling and Clinical Psychology, 67(2), 171-176.
Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice. Professional Psychology: Research and Practice, 30(5), 447-453.
Meichenbaum, D. (2005). 35 Years of Working with suicidal Patients: Lessons Learned. Canadian Psychology, 46(2), 64-72.
Michel, K., Maltsberger, J. T., Jobes, D. A., Orbach, I., Stadler, K., Dey, P., et al. (2002). Discovering the Truth in Attempted Suicide. American Journal of Psychotherapy, 56(3), 424-437.
Murray, H. A. (1938). Explorations in Personality. New York: Oxford University Press.
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.
Quinnett, P. G. (1987). Suicide: The forever decision. New York, NY: Continuum.
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. (1985). Definition of Suicide (softcover ed.). Lanham, Maryland: Rowman & Littlefield Publishers, Inc.
Shneidman, E. (1995). Definition of Suicide: Jason Aronson.
Shneidman, E. S. (1985). Definition of Suicide: Aronson.
Shneidman, E. S. (1993). Suicide as psychache: A clinical approach to self-destructive behavior. Lanham, MD: Jason Aronson.
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.
Slade, I. (2005). How to save a Life Retrieved may 21, 2012

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