Every crisis provides an opportunity, and the depth of a suicidal crisis is an opportunity for your patient to develop a better understanding of suffering and its role in the experience of the world. Many people who have worked through suicidal behavior describe what they have learned in these terms.
They see themselves as individuals with a greater capacity to tolerate a variety of emotional states. The primary goal during the intermediate phase of treat-ment is to help your patient develop a tolerance for emotionally distressing events. The focus is on learning that emotional pain can be tolerated and brought to a resolution. Your patient needs to understand that the meaning of events, and, importantly, suffering associated with these events, is pro-duced in the private realm of his or her own thoughts, feelings, and thoughts about feelings. Emotional distress is a direct result of accepting only one way of thinking about things. Think of this situation as your patient’s attaching to certain “hot” cognitions. Low tolerance arises when these hot cognitions refer to the unacceptability of feeling bad. For example, many hopelessness cogni-tions are hot because they raise provocative implicacogni-tions about suffering (i.e., there is no purpose in staying alive if one has to suffer). In this mode your pa-tient can experience depression, anxiety, despair, sadness, and, eventually, sui-cidal ideation in relation to these thoughts.
Two major therapeutic models can be followed during the intermediate phase of therapy. The more conventional route is to use cognitive therapy to help your patient develop more realistic self-talk about either the life events or
the negative feelings that occur in relation to life events. This approach is more traditional and culture supported because it relies on logic as a way to change your patient’s thinking, feeling, and behaving. The suicidal patient is always a victim of taking a particular stand with regard to a difficult life situation. The phenomenon of tunnel vision is not limited to the suicidal depressive patient but is a characteristic of suicidal patients in general. You and your patient should work collaboratively to uncover critical cognitive errors and to con-struct field tests of their validity. In cases in which your patient clearly agrees there is a distorted interpretation, he or she can experiment with a more rea-sonable interpretation and see whether it works better the next time the situ-ation occurs. Many of the deeper assumptions that indirectly or directly lead to suicide as a viable option can be examined by the patient and the clinician.
To learn more about this approach, study the work of Beck et al. (1979).
A second approach, and one we often favor, is to develop an acceptance of emotional pain through the use of distancing and of nonevaluative self-obser-vation strategies. The goal in this approach is to learn to make room for dis-tressing thoughts and feelings while doing what needs to be done to respond to the demands of the outside world. There are two key strategies for increas-ing acceptance of uncomfortable emotions and thoughts. First, recontextual-ization is the process of teaching your patient to look at the relationship of thoughts, feelings, and behaviors in a way that provides more options for han-dling problems. Second, the act of comprehensive distancing involves stepping back from one’s thoughts and feelings and looking at them as an observer rather than a participant.
Recontextualization
Each day brings all of us an incredible array of thoughts and feelings. Humans process literally thousands of cognitive and emotional experiences daily, usu-ally with only minimal awareness. These processes are not unconscious be-cause they can be accessed directly through voluntary shifts of attention. The processes are better thought of as automatic conditioned responses. Many of us tend to treat thoughts and feelings as if they were literal substitutes for ex-perience; that is, cognitions and emotions are put in a position of being at least as real as the situations that are responsible for them.
For people in both acute and chronic crises, thoughts and feelings take on a consistently negative overtone. The relationship your patient establishes
with negative thoughts can be viewed as the cause of suffering. The analogy to use is the distinction between chronic pain and disability. Some people are able to live with chronic pain by realizing they have new limitations and the job is to carry on with life. They accept the pain and continue their life’s work, embracing challenges as they come. Other persons with chronic pain, how-ever, see pain as a reason why life cannot go on, at least not until a cure is pro-duced that will get rid of the pain. Many people in the grip of these chronic pain emotions and cognitions seem fixed on the idea that such a cure is some-how, somewhere available, and they suspend many aspects of their lives as they search, often futilely, or wait, often angrily, for relief. For these persons, pain becomes a reason for not working, not participating in family life, and avoiding intimacy. Their pain experiences usually worsen, and the person be-comes disabled. This person does not accept pain, and the pain bebe-comes the dominant theme in the person’s life—a life that becomes increasingly less sat-isfying.
To be suicidal, a person must be unwilling to accept emotional pain and must see suicidal behavior as a way to get rid of unacceptable thoughts and feelings. Pain avoidance may be why suicidal behavior and other conscious-ness-numbing avoidance behaviors, such as alcohol use, drug use, and eating disorders, tend to occur together. All these behaviors serve the same purpose:
to take the edge off pain. When acceptance is low, most of the person’s re-sources are spent trying to eliminate suffering rather than making adaptive changes in behavior. Like the functionally disabled pain patient, the suicidal patient is not doing what needs to be done to adapt to life’s circumstances and uses language that implies negative thoughts and feelings are responsible (causes) for the dysfunction.
The objective of recontextualization is not to get rid of disturbing thoughts or feelings but to teach the patient to make room for them and do what needs to be done to get on with life. The objective is met when your pa-tient learns that negative thoughts or feelings do not block adaptive behavior.
The two can coexist. Needed behavior change can occur even in the presence of ongoing suicidal ideation and emotional distress. Your patient can learn how to accept negative private events without excessive self-evaluation. When the thought-feeling-behavior relationship has been recontextualized, your pa-tient does not need to engage in a contest to see whether suicidal thinking can be eliminated or whether the urge to follow through on the thought can be
resisted. When you encourage your patient to bring negative, ambivalent, and positive feelings into the problem-solving process while at the same time re-maining committed to change, the patient learns that tolerance for emotional distress means seeing distressful thoughts and feelings for what they are (a co-vert influence on the way one behaves), not what they adco-vertise themselves to be (monsters waiting to devour us if we allow them in the house).
Comprehensive Distancing
The act of comprehensive distancing is accomplished when your patient es-tablishes a willingness to detach from active participation in suicidal thoughts or affective distress. A powerful strategy is the dual-thermometer exercise. Have your patient keep a daily diary, rating two dimensions of experience on a 1–
10 scale at the end of each day. The first scale is a willingness thermometer, de-scribing a noncritical openness to have whatever experiences occur during the day. This state is best described as being present for, mildly interested in, and observant of these experiences. The other scale is a suffering thermometer, de-scribing how much distress your patient feels in the presence of these experi-ences. Have the patient rate both scales each day, making short notes on any factors that seem associated with an increase or decrease on either scale com-pared with the previous day. The two thermometers will typically reveal an inverse relationship between willingness and suffering. In general, as willing-ness goes up, an active sense of suffering goes down. Use your patient’s own positive experience with moments-of-willingness ratings as a jumping-off point to build willingness skills. These techniques help your patient develop a healthy skepticism about the usefulness of attaching to hot thoughts and feel-ings. For some better-functioning suicidal patients, increases on the willing-ness scale can occur in treatment, often with strong clinical results in one or two sessions.
An additional advantage of comprehensive distancing strategies is that you are able to use them to both monitor and use recurring suicidal ideation as part of treatment. A difficult clinical task at any stage of treatment is find-ing a way to be attentive to your patient’s ongofind-ing suicidal experiences with-out inadvertently making that the sole focus of clinical intervention. Once comprehensive distancing becomes a viable strategy, suicidal thinking or be-havior can be framed as just another example of low acceptance of certain emotions. In other words, suicidal thinking is designed to get rid of, rather
than make room for, negative feelings. Remember, even when other problems are the current focus of treatment, suicidal behavior can easily be brought back into the mainstream in the event of a crisis. Along with many highly use-ful therapeutic strategies, Hayes et al. (1999) provide a detailed formulation of acceptance as behavior change.
Personal Problem-Solving Skills
During the intermediate phase, you will want to help your patient develop specific skills that can increase adaptive social and interpersonal behavior.
Specific behavioral skills training can be delivered during individual therapy sessions or in skills-training groups. We find that a particularly effective model is to combine skills-training groups with individual therapy sessions.
This approach allows your patient to continue working on developing pain tolerance and problem-solving abilities individually while learning new skills in a supportive group environment. If skills training is delivered without work on acceptance, your patient may see the skills as a new, more sophisticated tactic for avoiding or eliminating emotional pain. In other words, the skills will be put in the service of the same self-defeating agenda as before. It is often helpful to say, “The reason we are focusing on these skills is that you have a job to do in life while you are in pain. The better you know these skills, the more likely it is you will use them even while you are hurting.”
Effective personal problem solving evolves through several discrete stages:
1) problem identification, 2) identification of alternative problem-solving strategies, 3) evaluation of the likely utility of different problem-solving re-sponses, 4) selection of a specific problem-solving technique and formation of a plan, and 5) implementation of the response and evaluation of the effects of the response. Deficits in any of these skill areas may put your patient at risk of lingering problems and chronic life stress. This pragmatic approach to per-sonal problem solving underscores the empirical, trial-and-error nature of ef-fective efforts at addressing life problems. Teach your patient the absolute necessity of using feedback in approaching life’s difficulties. Feedback empha-sizes a “no failure” aspect in that all problem-solving approaches are viewed as
“best guesses.” The process of problem solving must be done repetitively until enough information is obtained to effectively overcome the obstacle. Given the well-established problem-solving passivity of the suicidal individual, this
model offers a concrete, teachable alternative that will give your patient the tools for performing in an active mode.
Even when the specifics of this model are being taught in a group or psy-choeducational format, you can and must simultaneously work with your pa-tient on beliefs that undermine proactive problem solving. The use of active problem-solving homework assignments will stimulate the patient’s feelings of hopelessness, predictions of personal failure and abandonment, and many other performance-stopping beliefs. You can help the patient test some of these negative predictions through the use of highly structured homework as-signments that are based on the problem-solving model.
Interpersonal Effectiveness
In the interpersonal skills arena, you should emphasize an approach that in-tegrates interpersonal, social, and assertiveness skills. The three key compo-nents of interpersonal effectiveness are conflict resolution skills, general social skills, and appropriate assertiveness.
Conflict resolution skills generally emphasize finding a common ground on which a conflict with someone else can be worked out in a way that satisfies everyone’s interests. Because of the suicidal patient’s passive style and ten-dency to make black-and-white judgments, it is difficult for this person to imagine a resolution of some interpersonal conflict that would obtain the desired outcome, maintain the relationship, and enhance the patient’s self-esteem. By learning negotiation skills, including techniques for developing a common best interest, your patient is more likely to steer this delicate course to an effective resolution. Again, a combination of individual therapy and skills-training groups is a very effective package. The therapist generally takes responsibility for working on personal issues associated with application of skills, and the group leaders focus on teaching basic component skills.
General social skills and appropriate assertiveness are important. These areas of functioning can be very difficult ones for the suicidal patient, who often has poor skills (e.g., does not maintain eye contact, apologizes instead of saying no) and very negative beliefs (e.g., “If I stand up for myself, my spouse will dump me”). When working with assertiveness skills, focus on the ability to maintain an assertive response in the face of strong opposition. The suicidal patient of-ten lives in interpersonal environments marked by increased dysfunction and interpersonal conflict. The other players in this environment may not be
par-ticularly well put together either and may respond to healthy behavior with undermining, cajoling, or demeaning responses. It is important to confront the patient with these responses in skills-training groups so that the patient can develop a “thicker skin.” There is often a person in your patient’s social net-work who is routinely negative and problematic. Try to teach skills that will enable the patient to consistently set limits despite negative feedback from that dysfunctional person. The more realistically your patient is able to practice by role-playing, the better he or she will be able to handle the real event. It is use-ful to do role reversals in which the patient plays the role of the dysfunctional person and has to model the reactions the other person would have. The trainer takes on the role of the patient and models limit-setting responses.
There are excellent books that can be used as a guide to such training. We encourage you to consult these more comprehensive texts, some of which are listed in Selected Readings. It is important to realize that skill deficits are im-portant determinants of your patient’s suicidal behavior. Skill deficits may have occurred because of faulty training from a dysfunctional family, specific cultural deprivation or aberration, or just plain lack of available role models.
The keys to forming better adaptive relationships are the presence of effective cognitive and emotional perspectives and the ability to act appropriately in one’s environment (i.e., do what needs to be done when you need to do it).
Three Clinical Pitfalls of the Intermediate Phase of Treatment
The first major pitfall in the intermediate phase can be the tendency to lose focus once the acute suicidal crisis has passed. The principal symptom of this pitfall is a lack of session-to-session continuity and more of a “what’s on your mind this week” approach. Clinicians often feel emotionally winded at this stage and prefer to let the patient direct the form and content of the therapy.
This style is unfortunate, because this phase provides the opportunity to ad-dress key cognitive, emotional, and spiritual issues. The therapist’s goal is to increase both the patient’s problem-solving flexibility and the patient’s prob-lem-solving view of the world. The optimal time for reaching this goal is when your patient is not operating in the crisis mode.
A second pitfall is to assume that the absence of crisis means that suicidal behavior has stopped. This phase often involves the persistence of chronic low-level suicidal ideation. Because it does not represent a crisis, the ideation is not
focused on in treatment. Chronic low-level suicidal ideation is an ideal target for work in the intermediate phase. Because the pain associated with such ex-periences is not so intense, it is easier to get your patient to experiment with tasks such as emotional pain tolerance, observational interventions, and per-sonal problem-solving plans.
A third and more subtle pitfall is negative countertransference, which can be ironically linked to the patient’s improvement. In other words, your need to rescue has been fulfilled and yet your patient has not finished therapy. This pitfall is dangerous if you begin to lose interest and become distracted. You can also begin to engage in subtle behaviors indicating a lack of commitment to continuing to the end of the treatment. It can look as if you are no longer concerned about your patient’s quest to address different life problems. Be-cause your attention is a powerful reinforcement, your patient may respond to this shift by resuming or escalating suicidal behavior.
Session Scheduling and Course of Treatment
The intermediate phase of therapy is more difficult to gauge in terms of both its beginning and its ending points. In general, this phase begins when the acute crisis has been defused to the point that the patient can talk about sui-cidal ideation, negative thoughts, and emotional distress as part of a single continuum. Some patients find it easier to adapt to this mindfulness approach, especially if they have had spiritual experiences such as prayer, meditation, or yoga that have given them some ability to be distant from and contemplate events. Patients with strong obsessional traits or highly rationalized defense styles tend to move more slowly into the acceptance and commitment model.
These patients rigidly defend against their negative thoughts. Asking them to become more accepting can be perceived as quite dangerous (i.e., “If I let the thoughts in the house, they will burn it down.”). Try to focus on developing split perspectives with such patients. With this strategy each thought sequence about an event is seen as a story. The exercise is to have your patient tell the story over and over, each time with a different connotation. Some endings can
These patients rigidly defend against their negative thoughts. Asking them to become more accepting can be perceived as quite dangerous (i.e., “If I let the thoughts in the house, they will burn it down.”). Try to focus on developing split perspectives with such patients. With this strategy each thought sequence about an event is seen as a story. The exercise is to have your patient tell the story over and over, each time with a different connotation. Some endings can