Abstract
Every day in the United States, about 89 people take their own lives. For every person who completes suicide, there are an estimated 10 to 20 who have attempted suicide. Suicide rates are 50% higher than homicide rates. Understanding the suicidal mind is daunting, and working with the client afflicted with such a mind can be difficult. There is no consensus on strategies for intervening in the decision of the suicidal mind, but all agree that mental pain or psychache is the common factor in almost every attempted and completed suicide. Any therapeutic approach with suicidal individuals requires an empathic clinician who reaches out to clients and conveys to them that their suffering matters.

The Value of Understanding Psychache when Treating Suicide Patients
Every year approximately 32,000 suicides occur in the United States (Centers for Disease Control and Prevention [CDC], 2005). In the United States, approximately 650,000 people per year are seen in emergency rooms after attempting suicide (U.S. Public Health Service [PHS], 2001). Suicide is the third leading cause of death among American youths and the eleventh for Americans of all ages (CDC, 2005). For the past hundred years, the number of reported suicides has been higher than the number of homicides, by approximately three to two. It is estimated the cost to society in lost productivity each year is approximately $11 billion (Goldsmith, Pellmar, Kleinman, & Bunney, 2002).

Nine years ago, the United States Surgeon General sounded the alarm about the profound impact of suicide in his Call to Action to Prevent Suicide (U.S. Public Health Service, 1999) imploring the public health, mental health, and medical communities to seriously address the issue of suicide. Soon after, the National Strategy for Suicide Prevention (PHS, 2001) presented a comprehensive assessment of future goals and objectives to combat suicide. Despite the increased awareness of suicide as a major public health problem, gaps remain in the knowledge, strategies for prevention, and research designs for the study of suicide (Goldsmith et al., 2002). For many years, suicidality has been the most commonly encountered clinical emergency for mental health care professionals, yet remarkably few efforts have specifically focused on the development of effective clinical assessments and treatments of suicidal individuals (Jobes, Moore, & O’Connor 2007).

Instead, contemporary suicidology has primarily focused on the empirical identification of risk factors associated with attempted and completed suicide. The goal has been to identify individuals most likely to engage in suicidal behavior in order to provide appropriate prevention and intervention. While the pragmatic approach has led to the identification of numerous psychological, sociological, and behavioral risk factors, such as gender, age, and psychopathology, there is little evidence that this focus effectively decreases the rates of suicide, reduces the occurrence of other suicidal behaviors, or furthers the understanding of the suicidal mind (Flamenbaum & Holden, 2007). One reason for this could be that in terms of clinical treatments for suicidal risk, there has been limited empirical literature about the practical aspects of treating suicidal patients (Rogers, 2003). It appears to be time for researchers to move away from the mere identification of empirical correlates of suicide to an understanding of how these correlates of suicide interconnect at the individual level. An understanding of suicidality is necessary to determine the motivation that leads an individual to a decision to end his or her life.
Relatively little is known about why individuals attempt suicide; however, the motivation for self-harm has important implications for both the treatment and prevention of subsequent attempts. While mental health professionals have posited that suicide attempts are a means of communicating anger or affirming that one is loved, suicidal patients most frequently endorsed motives for suicide attempts were to escape an unbearable situation or to stop feeling an unendurable pain (Berlim et al., 2003). Shneidman (1993) has asserted that understanding suicidality requires an understanding of psychache. The only way to properly understand psychache is through the words of the suicidal individual not through a clinical diagnosis.

Theories

Many practitioners, researchers, theorists, and scholars in the fields of psychology, psychiatry, sociology, and biology have contributed a broad range of theories to explain suicidal behavior. Attempts have been made to develop viable and heuristic theories of suicidal behaviors. However, solid, conceptually adequate, and applicable theories simply do not yet exist in the suicidality treatment literature (Berlim et al., 2006). Most of the major theories in suicide literature emphasize distinct features, aspects, or characteristics of suicidal behaviors, but little progress has been made toward constructing a comprehensive theory of life-threatening behavior applicable in a clinical setting. Only recently has a concerted effort been made toward integrative theoretical approaches that prove promising in delivering practical applications in the field of suicidology (Rudd, 2000). Major theories considered relevant and specific to suicide are highlighted in this section, in order to gain an understanding of the present status in the field of suicidology.

Sociologists were among the first to formally develop theories pertaining to suicide. Emile Durkheim’s classic work Suicide: A Study in Sociology (1897/1951) established an important sociological model of suicide, which has led to an extensive line of research and subsequent theory construction. Durkheim purported that suicide resulted from society’s strength or weakness of control over the individual. He identified four basic categories of suicide based on individual motivation and the individual’s relationship to society: egoistic, altruistic, anomic, and fatalistic (Berman, Jobes, & Silverman, 2006).

Thomas Joiner (2003), one of the field’s leading contemporary theorists, addressed some of the limitations of purely sociological approaches by attempting to synthesize both interpersonal and intrapersonal variables that influence suicidal behavior. According to his Interpersonal-Psychological Theory of Attempted and Completed Suicide, an individual will not die by suicide unless both the desire to die by suicide and the ability to do so are present. The desire to die comes from two important sources: thwarted belongingness and perceived burdensomeness (Van Orden, Witte, Gordon, Bender, & Joiner, 2008). The theory proposes that the needs to belong and to contribute to the welfare of family members are so fundamental that the thwarting of these needs is a proximal cause of suicidal desire. This is in line with one of the clearest findings in the literature on suicide: Individuals who die by suicide often experience social isolation before their deaths (Van Orden el al., 2008).

There is also a wide range of psychological theories of suicide beginning with the psychoanalytically oriented thoughts of Sigmund Freud. In his classic work Mourning and Melancholia, Freud (1917/1957) outlines the psychological mechanisms involved in turning hostility against the self, which explains the self-loathing and suicidal ideation often seen in depression (Berman et al., 2006).

However, the primary emphasis over the past 40 years has centered on behavioral and cognitive aspects of suicide (Westefeld, 2000). From a behavioral perspective, Frederick and Resnick (1971) first applied the principles of learning theory to describe how suicidal behaviors are actually learned. They argued that a variety of behavior approaches could be effectively used to treat suicidal patients. Although behaviorists initially addressed the issue of understanding in treating suicidality, emphasis has centered on the cognitive aspects of suicide most fully and fundamentally defined by the seminal thinking of Aaron Beck (1995), the founder of cognitive therapy. He suggests that individuals’ distress can be reduced by teaching them how to change their behavioral and thought habits. For many years, Beck and his colleagues have emphasized the role that cognitive errors and distorted thinking play in suicidal behavior. Recently, in accordance with the cognitive model of emotional disorders, as well as the empirical work linking hopelessness with suicidal behavior, Beck and his colleagues presented a 10-session cognitive treatment approach for adolescent and young adult suicide attempters (Henriques, Beck, & Brown, 2003).

By integrating a range of perspectives, Edwin Shneidman (1993) developed a theoretical model of suicide based on ten common psychological variables associated with suicidal death. He posits that the etiology of suicide can be conceptually understood schematically in terms of a suicidal cube that has three planes: pain, press, and perturbation. Based on this model, lethality is fundamentally caused by a synergy of intense psychological pain, overwhelming pressures, and intense emotional energy and upset (Westefeld et al., 2000).

Mental Pain Defined

Nearing the end of his career in suicidology Shneidman (1993) concludes, “I think I can now say
what has been on my mind in as few as five words: Suicide is caused by psychache” (p. 51). He argued that when an individual perceives intolerable psychological pain as unbearable, it will lead to suicide. Indeed, pain has been the constant factor in every suicide (Flamenbaum & Holden, 2007), thus this psychache, a term Shneidman coined for mental pain must be explored to better understand and treat the suicidal person.

Mental pain is a basic condition of existence, and it appears in a variety of forms brought about by a variety of instigators (Orbach, 2003). Popular culture has been fascinated by this human condition, as seen in the works of many writers, philosophers, artists, and poets. Yet, in the professional literature of psychology and psychiatry, few attempts have been made to define and explain mental pain. Generally, mental pain is referred to as intense negative emotions, such as depression, anxiety, humiliation, and shame (Flamenbaum & Holden, 2007). There are, however, a few attempts to define mental pain more specifically; some have been short and concise while others have been more elaborate. Freud (1917/1957) attributed this concept to feelings of mourning and longing. Frankl (1984) believed that mental pain and suffering are reflections of emptiness due to loss of meaning in life. Other theoreticians and investigators imply that mental pain is the result of the perception of a negative change in the self, instigated by trauma and loss (Worden, 1982; Herman, 1992; Orbach, 2003).

Those who have been personally afflicted by mental anguish have offered the most elaborate, humanistic, and comprehensive definitions that capture the depth of the experience and meaning of mental pain. In The Savage God: A Study of Suicide, Alfred Alvarez (1979) eloquently describes life consumed with psychological pain as “so cluttered and obstructed that I could hardly breathe. I inhabited a closed, concentrated world, airless and without exits” (p. 270). William Styron (1990) offers one of the most moving descriptions of his first-hand experience of mental pain, describing mental pain as a “gray drizzle of horror” (p. 50) that has the quality of physical pain but is not identifiable like that of a broken limb. He elaborates further by writing:
It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion (p. 50).

What is particularly salient in Styron’s description of mental pain is a profuse sense of being controlled and destroyed by an inner estranged and hostile force slowly destroying the consciousness, leaving but an anguished mind (Orbach, 2003).

Bolger’s (1999) definition of mental pain is another account based on actual experiences described by suffering individuals. According to Bolger’s analysis, at the heart of mental pain is the sense of brokenness accompanied by panic and a loss of control caused by a rupture in significant relationships (Orbach, 2003).

Baumeister (1990) and Shneidman’s (1996) descriptions of mental pain are based on theoretical perspectives. Baumeister’s theory describes mental pain as the strong desire to escape from the negative self. Self-deprecation grows as the individual becomes aware of being inadequate and incompetent. It is the unbearable psychological pain of self-disappointment that the suffering person wishes to escape. Baumeister’s proposal that the goal of suicide is to escape from the aversive state is similar to what Shneidman refers to as psychache. Both argue that the reason people attempt suicide is to escape from a terrible state of mind (Flamenbaum & Holden, 2007).
The most extensive and elaborate theory on mental pain within the context of suicidal behavior is presented by Shneidman (Orbach, Mikulincer, Gilboa-Schechtman, & Sirota, 2003). He describes mental pain, psychache, as the hurt, anguish, sorrow, aching, or misery in the mind. This is an elaboration of his conceptual model of suicide noting the convergence of pain, press, and perturbation (Rudd, 2000). Essentially, suicidal behavior is “intrinsically psychological – the pain of excessively felt shame, guilt, fear, anxiety, loneliness, angst, dread of growing old or of dying badly, or whatever” (Shneidman, 1996, p. 13). This psychological pain that is so central to suicide is driven, generated, and maintained by frustrated, distorted, blocked, or thwarted psychological needs (Berlim et al., 2003). Specific psychological needs most relevant to suicide are the need for autonomy, achievement, recognition, succor, and an avoidance of shame, humiliation, and pain (Westefeld et al., 2000). Any one of these thwarted needs or a combination of them can turn into a generalized experience of unbearable mental pain – a state of emotional perturbation. According to this perspective, as individuals become increasingly upset and their pain becomes unbearable, they move into dichotomous thinking and a narrowing of focus to few options. At this point, the afflicted person concludes that there is no foreseeable change in the future and view suicide as their only option to escape the pain (Orbach, Mikulincer, et al., 2003).

According to Shneidman (1993), clinicians can best understand, assess, and treat suicidal behavior by attending to the patient’s specific experienced mental pain and attending to the poor pain tolerance. Essentially suicidality is psychological in nature, although identifying the numerous potential causes for the thwarted psychological needs that are the source of a patient’s psychache contributes to the complex nature of suicidality. Each suicidal death is multi-dimensional and multifaceted, containing concomitant biological, cultural, sociological, biochemical, and philosophical elements (Rudd, 2000), but the common stimulus is the unendurable psychache. There is a great deal of psychological pain without suicide, but there is no suicide without excessive psychache. Suicide occurs when the psychache is deemed by the suffering individual to be unbearable. It is an escape from unendurable pain and suffering, and thus is functional in that it solves the problem by abolishing the pain (Pompili, Lester, Leenaars, Tatarelli, & Girardi, 2008).

This psychological view carries with it many implications in terms of intervention for suicidal individuals. Most importantly, it means that understanding suicide does not come through the study of the structure of the brain, nor the study of social statistics, nor the study of mental diseases, but directly through the study of human emotions described in the words of the suicidal person (Shneidman, 1996). To treat suicidal people one must address and reduce their psychache. If, for example, feeling depressed makes one suicidal, it does so only because it is painful (Rogers, 2003). As Shneidman says, “Theoretically, no one has ever died of depression -it is not a legitimate cause of death on a death certificate - but many people, too many, have died of suicide (p. 54-55). No psychache, no suicide. Accordingly, amelioration of the depressive symptoms is not sufficient in an effective intervention for suicidal individuals. Rather, efforts need to be made to reduce the psychache that stems from blocked psychological needs, particularly needs for achievement, autonomy, succorance, and shame (Pompili et al., 2008). Effective intervention that reduces psychache should focus on identifying and addressing these thwarted needs and developing new problem-solving strategies to help the patient increase the tolerance for pain (Holden & Kroner, 2007).

Intervention

The complex web of factors, with the varying interpersonal and intrapersonal variables of each
individual contributes to the complexity of suicidality. This is consistent with the fact that most clinicians find suicidal patients to be the most diagnostically complex and therapeutically challenging patients to manage (Rudd, 2000). The complexities of assessing and treating suicidal patients generally stems from the myriad of correlates which vary from individual to individual. While it is important to be aware of the many correlates, it is more valuable to concentrate on two recurring characteristics of suicidal individuals. Those two characteristics are psychache and
self-damaging reactions to distressing situations.

The ultimate goals in treating suicidal patients are to first reduce the pain and then help them develop new skills for reacting to distressing situations in order to prevent future attempts (Rudd, 2000). One of the best predictors of eventual completed suicide and future suicide attempts is a prior attempt (Van Orden et al., 2008). Prior suicide attempts are estimated to occur in 25% to 33% of all completed suicides. Further, a prior attempt increases the likelihood of a future attempt 18-fold (Spirito & Esposito-Smythers, 2006). An emphasis on reducing the patient’s pain and focusing on the development of new skills during the early sessions decreases the likelihood of another attempt. Thus, certain key elements must be put into action beginning with the initial assessment and continuing through to the conclusion of the treatment process to maintain safety and increase the likelihood of a positive outcome.

The first key element in the assessment and treatment of suicidal patients is regarding suicidal behavior as the primary clinical problem, independent of diagnosis. Heavily influenced by the traditional Kraepelinian approach, contemporary care has viewed suicidality as a symptom of some central psychiatric illness. Emphasis is focused on treating the diagnosed psychiatric illness with the assumption that treating the illness will reduce the symptom of suicidality (Konrad et. al, 2002). When such an approach was used, patients often perceived clinicians to be unhelpful, disapproving or unsympathetic, and treatment for their suicidality was overlooked. This does not diminish the value of a careful Kraepelinian evaluation; the clinical importance of a psychiatric diagnosis for risk assessment and for management of a suicidal patient is well established (Rogers, 2003). However, the initial encounter with a mental health professional should not just be diagnostically driven. This contact should also be seen as an opportunity for the clinician to reach the person in distress through a collaborative assessment in which a joint construction of the meaning of the patient’s suicidality is achieved (Jobes et al., 2007). The assessment thus becomes interventive and a strong therapeutic alliance is built.
Unfortunately, today’s clinician typically assumes an underlying pathology and tries to identify it accordingly. The clinician takes on the role of the expert leaving little opportunity for the patient to share his or her experience or for the clinician to understand and appreciate the patient’s suicidality (Konrad et al., 2002). Indeed, research has shown striking disagreements between patients’ explanations of suicide attempts and those of the clinicians. In one study, clinicians most frequently posited that suicide attempts are a means “to show desperation” or “to make someone feel sorry.” In contrast, patients most frequently indicated that they attempted suicide in order to “get relief from a terrible state of mind” or to “escape for a while from an impossible situation” (Henriques et al., 2003). According to Shneidman (1996), unendurable anguish, is the central matter that drives individuals to suicide. This psychache is mental agony that fuels a need to escape. In order to fully understand the client’s inner world of meanings and feelings, clinicians need to refer to the patient as the expert of his or her experience.
Accordingly, another central element in intervention is the notion that the suicidal behavior is understandable given the patient’s frame of reference. One task in the early sessions is helping patients tell their story. The therapist asks the patient to talk about the events that led up to the suicide attempt and the details of the suicide attempt itself (Henriques et al., 2003). Suicide is rarely a matter of the immediate present, nor does it have a simple cause. Rather, it is often the culmination of life events and it has a developmental history (Konrad et. al, 2002). Baumeister (1990) argues that the suicidal patient’s history reflects negative experiences and setbacks that result in self-hatred so extreme that suicide becomes a compelling means of escape. As part of the intervention process, it is imperative that the clinician and the patient review the past together to learn how the patient’s life and the perspective for the future have become unendurable (Jobes & Drozd, 2004). While doing so the therapist listens and questions the patient in an empathic, respectful, and nonjudgmental manner to elicit the thoughts and feelings that led to the attempt.

There are several reasons for having patients describe details, or tell their story, about the suicide attempt. An important reason is that it offers an opportunity for the patient to feel heard and for the clinician to both understand and validate the patient’s experience. In doing so, the sharing of the story facilitates rapport building and trust, encouraging patients to engage in treatment (Henriques et al., 2003). Optimally, this is done in the initial assessment constructed in a way to provide plenty of opportunity for discussion and joint effort. Early collaboration beginning with the initial assessment provides an important framework for understanding the idiosyncratic nature of the patient’s suicidality so that both parties can intimately appreciate the patient’s suicidal experience (Jobes & Drozd, 2004).

The heart of any intervention approach with suicidal patients is a strong therapeutic relationship where both client and clinician work together to develop a shared understanding of the patient’s suicidality and to collaborate on a treatment plan (Orbach, Mikulincer et al., 2003). Researchers have consistently found that the strength of the therapeutic alliance is predictive of therapeutic outcome. In addition, the therapeutic alliance is seen as a common factor across therapies and some researchers have even begun to argue that the quality of the alliance is more important than the type of treatment in predicting positive therapeutic outcomes (Martin, Garske, & Davis, 2000).
Interventions with suicidal patients must emphasize the importance of a strong therapeutic outcome. Thus, a collaborative assessment in which the clinician maintains an empathic, validating position while at the same time keeping the focus on the problem is the preferred method to use in building the partnership. During this time, key problems and goals naturally emerge; what is learned through this assessment is used to directly shape the treatment plan (Jobes, 2007).
It is also important that intervention embrace the fundamental understanding that virtually all suicidality seen in patients represents some effort to cope or problem-solve (Henriques et al., 2003). The most common reason suicidal patients give for their suicidal behavior is to escape from the unendurable and unending pain in the mind (Orbach & Drozd, 2004). This suggests that suicidal behavior may result from the use of ineffective problem-solving alternatives and the inability to initiate effective alternative solutions to problems (Spirito & Esposito-Smythers, 2006).
A recent study was conducted by Foster (2003) to determine if suicide note themes might offer insight into the mind of the suicidal individual, thus providing invaluable information for assessing and predicting suicidal behavior. He found that three quarters of suicide notes contained the theme “apology/shame” which suggests that the afflicted person may have welcomed alternative solutions for their predicaments. One study showed that individuals who participated in cognitive therapy were 50% less likely to attempt suicide then those who participated in non-cognitive therapy care (Brown, Have, Henriques, Xie, Hollander, & Beck, 2005). Thus, intervention for suicidal patients should focus on developing competent problem solving skills and coping strategies with a focus on cognitive restructuring and behavior change (Rudd, 2000). Through empathizing with why the patient has come to see the situation as hopeless and validating the patient’s experience, the therapist can help the patient see that even in the worst of situations, hoping is a more functional way of responding to adversity than hopelessness and despair (Henriques et al., 2003).
From this perspective, clinicians must approach suicidality in an empathic, matter-of-fact, and nonjudgmental fashion striving to understand the viability and attraction of suicide as a coping option (Jobes et al., 2007). This approach seems to provide the ingredient for forming a strong therapeutic alliance necessary if more adaptive methods of coping are to be explored. The main goal of intervention of suicidal patients is to reduce the suicidal behavior by reducing the psychache and to prevent future attempts by helping patients develop more adaptive ways of thinking about their situation and more functional ways of responding during periods of acute emotional distress (Henriques et al., 2003).
An assessment and treatment protocol called the Collaborative Assessment and Management of Suicidality (CAMS) addresses the above key elements and concerns. The CAMS approach emphasizes the importance of the clinician and patient working together to develop a shared understanding of the functional role of suicidality in the patient’s phenomenological world. Through a collaborative and interactive suicide risk assessment, key constructs underlying the patient’s suicidal state emerge. This sets the stage for a treatment planning process where the patient and clinician co-author a treatment plan that includes a problem-solving approach designed to reconstruct more viable ways of coping and living (Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005).
Unlike traditional Kraepelinian approaches that are diagnostically driven, CAMS is designed to specifically target suicidal behavior as the central clinical problem (Jobes et al., 2007). Most importantly, the CAMS approach emphasizes an intentional move away from the directive counselor as expert approach and focuses on understanding and appreciating the client’s mental pain and suffering that led to suicide as a means of coping through the patient’s own words. In one study, CAMS patients resolved their suicidality significantly more quickly than suicidal patients involved in more traditional treatment. In addition, the study suggest that collaborative aspects of CAMS may be more effective than more traditional directive treatments (Jobes et al., 2005).
Clinical Implications
Suicidality is the most commonly encountered clinical emergency for mental health professionals, yet clinicians typically have few suicide-specific treatment plans to use. Further, working with suicidal patients is increasingly more challenging and stressful than working with any other patient (Rudd, 2000). Although suicidal behavior represents a serious mental health problem, few suicide-specific clinical approaches have been developed specifically to target it. In order to improve clinical work with suicidal patients, psychosocial interventions, like CAMS, which focus specifically on suicidal behavior regardless of other diagnoses, may be helpful.
The clinician must engage the patient in a therapeutic relationship from the very first assessment intake. The clinician’s attitude should be nonjudgmental, supportive, and open to listening to the patient’s self-narrative, understanding that only the patient can be the expert of his or her own individual experience. The goal for the clinician is to understand the patient’s state of mental pain and validate the patient’s suicide actions as goal-directed attempts to escape that pain. Both patient and clinician work collaboratively to reduce the pain and create a treatment plan to manage future distressing situations.
The collaborative engagement of the patients in their own assessment and management of their suicidal struggle is instrumental in helping suicidal patients put their crisis into perspective and begin to reestablish a sense of mastery over their lives. The ability of the clinician to express genuine interest in understanding the patient’s unbearable intrapsychic pain in a nonjudgmental way is vital when working with a suicidal person. To a potentially suicidal person, the most important question “is not an inquiry about family history or laboratory tests of blood or spinal fluid, but ‘Where do you hurt?’ and ‘How can I help you?’” (Shneidman, 1996, p. 6).
Future Research
While quantitative research has helped guide clinical interventions, there is an increasing need for more qualitative research focusing on the patients’ own internal suicidal processes. This will make it possible to add new dimensions to the existing knowledge of the suicidal process in the study of psychopathology.
One of the most significant associations yet to be directly examined using the construct of mental pain is suicidality. Shneidman (1993) argued that unendurable psychological pain, when viewed as unbearable by the individual will lead to suicide. Orbach, Mikulinger, Gilboa-Schechtman, and Sirota (2003) conducted a study to test Shneidman’s proposition. Using the Orbach and Mikulincer Mental Pain (OMNP) Scale for assessing the dimensions and intensity of negative feelings, they confirmed the hypothesis regarding the positive relationship between mental pain and suicidology. In addition, the construct of mental pain provided a broader insight into the suffering of suicidal patients than standard distress measures, such as depression and hopelessness.
Understanding the suicidal person’s mental pain is of utmost importance in assessment, intervention, and treatment plans. However, future research is necessary to empirically validate psychache as an assessment tool in clinical settings. Future research should identify unique aspects of the mental pain experience to characterize a particular individual and different suicidal dynamics. One dimension of Shneidman’s (1993) theory that needs further investigation is the level of a person’s tolerance to mental pain experiences. Finally, future research is needed to test the association between psychache and suicidality beyond the effects of depression and hopelessness.
Personal Thoughts
Every day in the United States, about 89 people take their own lives. For every person who completes suicide, there are an estimated 10 to 20 who have attempted suicide. Suicide rates are 50% higher than homicide rates (CDC, 2005). That means that in the United States, a person is more likely to kill himself or herself than to be killed by someone else. Suicidal behavior touches all levels of socio-economic status, all races, both sexes, every age group. Behind every statistic is a story, a life, a person so full of psychological pain that self-destruction seems like the only escape. Suicide is a lonely act, a desperate and preventable act. Understanding the suicidal mind is a daunting process, and working with the client afflicted with such a mind can be difficult and anxiety-provoking. As clinicians, it is easy to focus on the research, theories, statistics, and complexities that come with working with suicidal clients, but Shneidman (1996) cautions clinicians never to lose sight of the human being and the unique experience of the person sitting in front of you.
There is no consensus on strategies for intervening in the life-and death decision of the suicidal mind, but all agree that mental pain is the common factor in almost every attempted and completed suicide (Berman et al., 2006). At the heart of any therapeutic approach with suicidal individuals is the empathic clinician who reaches out to clients and conveys to them that their suffering matters.

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This paper was authored by Ilsa L. Araki, Spring 2008, for the graduate counseling course Human Development. The professor for the class was Anthony Centore Ph.D. www.thriveboston.com.