Tag: therapist

a phone call

by Midnight Demon, posted in psychache, psychosis, suicide, suicide attempt

One crazy day at work I received a phone call from a number I didn’t recognize. I let it go to voicemail as I figured it was some bill collector. I couldn’t have been more wrong. Not only did this person leave me a message for me to call him back but he said that it was urgent to do so. This man was Dr. Edwin Shneidman, the father of suicidology. He was a man I deeply respected because of his work in trying to understand psychache and suicide. He was the first pioneer to create a suicide prevention center in the United States. He has spent his life trying to develop a scale for psychache and psychological pain assessment. Psychache is the unbearable psychological pain (despair, grief, guilt, hopelessness, frustration, perturbation, and pain all rolled into one). It is this pain that he and I believe causes people to think about taking their life. I sent him my paper “Is suicide caused by psychological pain?” and he wanted to talk to me about the pain scales I had mentioned. He was fascinated that there was a scale to measure physical pain but (as I argued) not for psychache. He was always thinking about how to have a psychometric assessment to gauge a person’s psychache.

Dr. Shneidman began his career by interpreting suicide notes. He began collecting them after he was sent to the morgue for confirmation of suicide autopsy. He and his colleague Farberow lead the early work of this important tool in forensic suicidology. In addition to this, he also co-founded the Los Angeles Suicide Prevention Center, the first in the United States to have one.

His message to me was for me to return his call and quickly (he wasn’t in the best of health). I didn’t know what to say to him or what he wanted of me. I was extremely nervous. Looking back I don’t remember too much of what we talked about. I know that we were on the phone what seemed like a half hour or so. I was too stunned to really remember anything but I know that he talked about his ill health and that he wanted to know what the physical pain scale was so I printed some off for him and sent them post haste to his house in LA. He died about a month afterwards.
After our conversation, my therapist was convinced I was going to be the next Shneidman. I would continue to follow in his work and in a way I have in my own way. I have book or downloaded/printed every article he ever wrote on the subject. I have scores of files on him. I also have the same on David Jobes but that is another matter.

what to call this

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

“…Our best route to understanding suicide is not through the study of the structure of the brain, nor the study of the social statistics, nor the study of mental diseases, but directly though the stuffy of human emotions described in plain English, in the words of the suicidal person.” (emphasis added)
– Edwin Shneidman, The Suicidal Mind

This statement is very true. How else would you know what lurks in the heart of a suicidal person. I have been there many times. My last episode of depression, if you want to call it that, almost caused me to end my life on Nov 5, 2005. Ten years ago around that time, I was in another severe major depressive episode and tried to take my life then. I didn’t want to suffer any more and decided to end my life on the anniversary of that day, to finish what I had started.
I don’t know what brought me to that point. I first started coming up with this plan some time in August 2005. I had wanted to go in the hospital around Labor Day as my mood was bleak and I felt a need to escape life for a while. I felt I needed to be in an environment that was safe and supportive. I had finally made plans to take off work and go in. I was then in a psychotherapy group. I had told the group leader that I wouldn’t be in for a couple of weeks because I was going in the hospital. The hospital has always been my escape. It was my way of re-cooperating, and a way of recharging my batteries so to speak. But this “professional” thought that I didn’t need to be in the hospital, that I could do this on my own. He thought an admission to the hospital would be more harmful to my pride than saving my life. But he had not clue how dark my thoughts were or how suicidal I was at that moment. Nor did he realize how much “psychache” I was in. He said the words that my “dark side” needed. For the first time in my life, I gave in to it. I was back to living a double life again, one that was deeply full of mental pain and misery that wanted nothing more to do with life and I living life by going to work, school and being ‘happy”. All the while, I was planning my death. I had heard on one of my favorite crime shows that the migraine medicine I was taking could cause cardiac arrest if taken in high doses. A ninety-day supply was all that I needed and I did have that. I no longer wanted to live after that day. If I couldn’t go in the hospital, what other option was there for me?

Looking back, I started to see my collapse. By the end of September, I had my date, my method, and my intent. All that was left to do was to “quit” therapy, get my affairs in order, write a will, and then, maybe, leave a note. I remember going to my classes and sketching all that I had to do before November. It was a month before I was to do it and if all went well, it would work. I had given myself a month to not only think this through, but also to give me time in case I wanted to back out. I had done this many times. During my adolescence, I had read Paul Quinnett’s Suicide: The Forever Decision. He described giving some time between the method and going ahead with it. On many occasions, it worked. But I knew that I was going to go ahead with my plans even if I did “feel better”. I had no rescue plan nor did I want to be rescued. I knew how I was going to do this for quite some time. I had been perfecting this plan for ten long years and finally; this was going to be my last episode of depression. I was no longer going to suffer anymore. No more pain, it was finally going to end.
At this time, with all this planning, I was getting bored in therapy. I no longer had anything worth telling my therapist about. I sure wasn’t going to tell her how suicidal I was. I certainly did not want to be forced to go in the hospital again and wreck my plans. I was making it look like I was “ok” and doing well so that when I would tell her I was taking the last few weeks off in October, she wouldn’t suspect anything. I came up with a game over the course of therapy that I liked to play. The game is called 20 questions, she could ask any question she wanted and I had to answer it, honestly. I am usually an honest person and on the spot, it would be difficult for me to come up with something bogus. I sat there that day and wanted nothing more than to leave but we had at least ½ hr to go. She is a stickler for keeping exactly fifty minutes, each session. We started playing my game and the first question she asked was “what is really, really, really, going on?” I remember I thought it was funny and laughed. Here I was portraying to be this highly functional person, all the while, stuck in such despair and constriction that all I could think about was Novemeber 5th. This was going to be my last depressive episode and I was determined to see it through. But I was shocked that she asked that question. I asked what she was talking about, she told me something that one of her supervisors had stressed during her training: it’s the highly functional depressed person that you need to look out for to be the most suicidal. I didn’t confess to her that day what was running through my mind. My body was still going through shockwaves about what to do. I felt like I had been caught with my pants down or something. I don’t know how I got out of that session without telling her then what was going through my head. I think I passed the question. I felt like I was walking a tight rope after that. The next session, I told her about my plans for November.

She then asked all the “right” questions. She assessed that I was highly suicidal, at high risk. But I didn’t think that I was. My thinking was “rational” even though I now realize that it was completely irrational.

It was now the second week in October and she was begging me to another way out of this mess. I told her that there wasn’t and in my clouded mind, I seriously thought she was going to let me leave so that I could kill myself. The sad thing is that I thought all of this was completely rational. All my thoughts made sense to me. I was in so much pain that I dissociated just to commit suicide. A different “ego state” had taken over as the rest of me just could not tolerate the “psychache” any longer. This episode had made me closer to my therapist than anyone in my life. I know that if she didn’t ask me that one stupid question, I wouldn’t be here today. For the next few months, we had contracts and increased sessions. We worked intensely on getting me to see that there could be another way out. I ended up going to a partial program for a couple weeks in November and then again in December. I was to turn thirty and I really did not want to see it happen. I didn’t see much of a future. All I saw was pain and misery that I so desperately wanted to end. I felt I was back to living in an abyss. I wore the pain like a heavy coat that no one saw. She thinks that it is some kind of miracle that I am alive and that I am a very resilient and “special” person. I don’t see myself as such and I doubt I ever will.

Even though I did not attempt suicide, I still went through a “post suicide” depression. I lost my appetite and had many physical symptoms of depression. I had stopped taking my medication, all of them, at this point. I just didn’t see the point. Some time in December, when the pain of living was wll beyond my breaking point, I went back to pharmacotherapy. This has helped to stabilize my mood for the last few months. I have been trying to sort out where I went wrong. One thing I noticed was that I had stopped writing my feelings, any feelings, in my journal. My journals had gaps of several weeks between entries. I was once an avid, daily journal writer. When I did write it would be a brief synopisis of the events of the day or weeks in between the last entry. No feelings, just events that had taken place. I had also stopped writing letters to my therapist. These letters would often speak of what was “really” going on.
I didn’t think much of my writing. I looked back on my previous entries from a few years ago. It is much different from what I write today. Looking over the past year’s journal entries, most of them have to do with “rushing” to do things. I gave my therapist a journal from 2001. Every page is written about the agony of my soul. It was therapeutic to write such despair. It listed my deepest, darkest, morbid thoughts, and feelings that the outside world hardly knew. Sadly, it also made me more depressed, as it was my “proof” that things couldn’t get better.
The entries leading up to my plan in November had nothing about the agony, the despair, and the anguish that was driving me to think about and execute my plan of ending my life.
I don’t know when I stopped writing. I think most of it happened before the breakup of my last girlfriend. She had made fun of what I wrote, as if my pain was a joke, something to be laughed at. I also grew tired of writing every day about my “psychache” and not feeling much change. I think a part of me felt that as long as I was writing something, even if no feelings were present, it was better than not writing at all. I always liked to record my events of daily living. However, when I stopped writing of my pain and thus ignored it, the more the dark side began to control me. It had no outlet, no way of showing itself. It then began using my subconsciousness to express itself. If I wasn’t actively thinking about suicide, my “other side” was planning and scheming on ways to commit the act. That is why I saw nothing wrong with my plan. The blinders came on and held on tight to the idea that the world would be better off without me. My “kids” (nieces and nephew) would be fine without me, my therapist would be ok, some how, and I really didn’t care much about what my friends would think. I couldn’t think about that. During what would be my last few weeks, a couple friends from out of state called me. I saw it as a way of God telling me that I was still important to these people, even if I felt completely worthless and didn’t deserve to live.
According to one study of Joiner et al, there are long-term beneficial effects that has shown writing about personal experiences can possibly have protective functions in that it reduces impulsive and maladaptive problem solving. It also can allow for more effective emotion regulation (both of which skills are key aspects of psychotherapy for suicidal patients (Joiner, Walker, Rudd, & Jobes, 1999). This protective function that I had used so well in the moments of my early years of therapy and throughout the course of late adolescence and early adulthood, I was no longer using. My feelings were not being recorded, at all. I chose instead not to feel and make myself as busy as possible with work and school, but mostly work.

For most of October through December 2005, I felt like I was living in a black cloud that was always around yet no one really ever saw. I felt so lifeless inside. It was so black. I truly was in an abyss. I was going down in flames and this time, I wanted it to be the last. Somehow, my therapist was able to get the blinders to open a little bit. I have a niece that was less than a year old. She is a cutie and when she saw me during this time, she gave me a look like as if to say, “Where have you been?” There was a period where I didn’t see her for a couple weeks because of working late. When I did see her, she “smacked” me almost as if she were saying, “Where were you?” Her older sister, who is almost like my own daughter, hugs me, kisses me, and tells me she misses me when she doesn’t see me often. I truly have no idea why I believed that they would be ok; I knew that they would be so heartbroken that their favorite aunt would no longer be around. I think it just helped me to rationalize my ultimate escape plan and make me go through with it without consequence. If I did stop and think about them and how it would make them feel, the protective factors Joiner et al talks about would have prevented me from executing my plan. I did not want that to happen this time. I wanted to die and I was going to do it.

Earlier this year (2005), I lost my cat, Stone. She was the closest thing to having a real child in my life. She was abused as a kitten and I had gotten her out of hiding. She trusted me. She would scratch other people and even the kids, if they got too close, but not me. I lived with my sister for a couple of years and during that time; I helped to make sure she was safe and gave her the affection that she needed. I miss her everyday. She died at the young age of six of renal failure. I felt she was the only “person” in my life to love me unconditionally. When she died, a part of me did too. I never felt a loss as great as this. That little fur ball captured my heart and soul and there was nothing I could do to help her live a long life. I have grieved a little. I still struggle with her loss.

Some days are better than others are. I would like to have a new cat but my living situation doesn’t allow it. This semester, I am taking psychological testing. Our term paper has to do with a testing element. Suicide assessment has always been an area where I am deeply curious and fascinated. I envy those people who actually are able to end their lives. They are no longer suffering emotional turmoil, no more psychache. I started the research a few months ago and was amazed to find that there isn’t a standardized method of training someone to be a suicide risk assessor. I remember in August of 2003, I had discovered that if I told of my dark thoughts, it helped. I guess you can say it was a catharsis. There is a paper written by Walker et al that looked into that theory (Walker, Joiner, & Rudd, 2001). But if I were to do that, I would have to attempt suicide and my therapist doesn’t want me to do that. We have talked about why I want to end my life. My theory is that if I try my plan and succeed, I was meant to die. If I failed, then I did deserve to live. The outcome is purely fate. I think I have a very lethal means of ending my life, but there is still the risk that I could live, end up a vegetable, or die. Those are the risks. Will it be cathartic? I feel I won’t know until I try. I have given my therapist my word that I wouldn’t try and that is the ONLY thing keeping me alive today is my friggin word. I am a gentleman, honest and true to my word. I don’t believe in lies and deceit. That only causes more trouble and a dishonest life.

My word. The fabric holds together my soul like the collagen that holds skin cells together. How many times have I broken it? Not many. To myself, I have broken more times than I can count. But in giving it to another person, it is as solid as a rock, most of the times anyways. When the blinders came off, I felt used. My therapist had used my word against me. She knew that if I gave her my word, I would keep it all costs. I was and still am at times very angry with her. I am not sure if it is justified or not. She kept me alive the only way she knew how. I hate her for it. I don’t want to live this life and yet she is allowing me to suffer, sometimes in silence, sometimes outspoken. I have tried to end therapy in the last few months because I cannot seem to face her. I think that is because she keeps reminding me of how close I was to death. I don’t feel like I was. I never attempted to go through with my plans so it doesn’t feel like it was an actual attempt. Just very strong thoughts and planning that never happened.

After being stabilized on meds for a month, my mood improved for the better. The contentment that I felt back in October 2004 came back. For the first time since then, I began to plan my future. I started looking at grad schools again and Rascal Flatts’ “Feels like today” and “I’m Moving On” held their significance in my life again. My kids were more precious to me.

The contentment started to fizzle the beginning of July 2006. It’s now the beginning of August and the psychache has returned. I am not writing. I am barely talking in therapy. I have so much to say yet can’t be bothered by talking about how I feel. I don’t see the point. I want to end therapy but as my therapist reminded me the other day, that will surely be a death sentence. I know that it is only a matter of time before the perturbation increases and I won’t be able to handle the pain of living anymore. I had put in safeguards when I was feeling well and could see things more clearly. The constriction that I feel right now is starting to cloud my judgment.

During my research, I had found some helpful tools. One is a psychache scale by R. Holden and Mehta. The other is the suicide status form by David Jobes et al. I have been using the psychache scale to monitor the ache. When I first started back in May, the score was high but as the weeks progressed, it got low. I can’t really make out what it means, as there is no standardization of what the scores mean. For a good measure, I gave the scale to an online support group to see what their psychache was. The lowest I got was a 20 and my score was well over 40. Most of these people suffer from chronic physical pain, not depression. I know that there have been studies where chronic pain contributes to depression, but that is a small percentage. I wanted to include these people in my research because I know they often get excluded because of their medical condition or because they are on pain medications.

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.

Walker, R. L., Joiner, T. E., & Rudd, M. D. (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-
Threatening Behavior, 31(2), 144-152.

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.

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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