“I wish it were all over”, “I’m a burden to everyone”, “life has no incentive for me”, “I see no way out of my suffering”, “I want to disappear”, “I can’t take it anymore”, “it’s not worth living like this anymore”, “I’d be better off if I got out of the way”…

These phrases are examples of people who are undergoing great suffering and who may contemplate suicide as a way out. Listening to these kinds of statements should trigger an “alarm” signal in us. As psychologists, what should we do in such complex situations?

In this article we are going to explain some guidelines for psychological intervention in people at risk of suicide that may be useful for those professionals or students of Psychology who may find themselves in similar situations, in which the patient-client manifests in a more or less concealed way his or her desire to end it all.

First step before intervention: detecting the risk of suicide

Logically, before intervening we must be able to detect the risk of suicide and evaluate it adequately .

Indicators

Some indicators of suicide risk would be the statements discussed in the previous paragraph, although sudden changes in the patient’s life should also be taken into account (e.g., moving from a state of nervousness and agitation to one of sudden calm, for no apparent reason), as they may indicate that the patient has made the decision to commit suicide.

Other more visible indicators would be the preparations that are the prelude to death : giving money, making a will, giving away valuables to loved ones…

Suicide risk assessment

Suicide should be discussed naturally and openly in therapy, otherwise it may be too late to do so in the next session.
There is a misconception that asking a depressed patient about suicide can lead to more positive thinking and even acceptance of suicidal thoughts.

However, asking the patient directly makes them feel relieved , understood and supported. Imagine that you have been thinking about suicide for a long time and that you cannot talk about it with anyone because it is considered a taboo subject and uncomfortable. What burden would you bear, right? On many occasions, talking about it with a psychologist can be therapeutic in itself.

In cases where the patient has never raised the issue of suicide and has not verbalized things like “I want to disappear and end it all”, it is best to ask in a general way. For example: sometimes, when people go through bad times they think it would be best to end their life, is this your case?

If the risk is very high, we must proceed to take measures beyond the psychological intervention in our practice .

Principles of psychological intervention in patients at risk of suicide

The following is a list of exercises and principles from the cognitive-behavioral model to intervene with patients at risk of suicide. In some cases it will be necessary to have a support co-therapist (to mobilize the patient) and/or his or her family. In addition, according to the criteria of the professional, it will be convenient to extend the frequency of the sessions and facilitate a number of 24-hour care.

1. Empathy and acceptance

One of the fundamental premises for psychological intervention is to try to see things as the patient sees them, and to understand their motivations for suicide (e.g., bad financial situation, very negative emotional state that the patient sees as endless, divorce…). We psychologists should do a deep exercise of empathy , without judging the person in front of us. We must try to get the patient involved in the therapy, and explain to him/her what things can be done to help him/her, in order to establish continuity in the therapy.

2. Exercises of reflection and analysis

It is interesting to propose to the patient to write and analyze in a reflective and detailed way the pros and cons, both in the short and long term, for him/her and for others, the options of committing suicide and of continuing to live.

This analysis should be carried out taking into account several areas of your life (family, work, children, partner, friends…) so that you do not focus on what causes you most suffering. We must convey to him that we are trying to help him make a reasoned decision based on deep analysis.

3. List of reasons for living

This exercise consists of the patient writing a list of their reasons for living , and then hanging it up somewhere visible in their home. You are asked to consult this list several times a day, and you can expand it as many times as you wish.

In addition, you may be asked to look at the positive things that happen in your day-to-day life, however minimal, in order to focus your selective attention on positive events.

4. Cognitive restructuring of reasons for death

When the patient identifies in the previous analysis the reasons to die, in therapy we will see if there are incorrect and exaggerated interpretations (e.g., everyone would be better off without me because I made them miserable) as well as dysfunctional beliefs (e.g., I cannot live without a partner).

The aim of cognitive restructuring is for the patient to understand and see that there are other alternative and less negative interpretations of seeing things (the aim is not to trivialize his situation or paint the situation “rosy”, but for him to see that there are other interpretations halfway between the most positive and the most negative). The patient can also be made to reflect on past difficult situations he has overcome in life and how he resolved them.

If there are unresolved problems that lead you to consider suicide as a valid path (relational problems, unemployment…), it is useful to use the problem-solving technique.

5. Emotional management and time projection

In cases of Borderline Personality Disorder, for example, it may be useful to teach the patient skills and strategies to regulate very intense emotions , as well as to use the time projection technique (to imagine how things would be in a while).