Suicidal Behavior and the Three I’s

The treatment of patients exhibiting suicidal behavior utilizes a spectrum of therapeutic approaches. I’d like to advise you to keep two points in mind: First, suicidal behavior co-occurs with a variety of mental illnesses, and your approach needs to be tailored to the diagnosis with which you are dealing. Also, patients with chronic suicidal behavior may carry more than one diagnosis, for example, a personality disorder, depression, a substance use disorder, and a significant nonpsychiatric medical problem. In contrast, a suicidal patient may have no discernible psychiatric diagnosis at all. It is best to treat suicidal behavior as a distinct problem occurring in the context of other treatable disorders.

Second, when you are evaluating suicidal behavior, view the behavior not as a problem but as a solution to a problem. As my coauthors and I describe in the book Clinical Manual for the Assessment and Treatment of Suicidal Patients, Second Edition, there are three key characteristics to the problems driving suicidality, which we call the three “I’s.” The problem can be seen as intolerable (I can’t stand it), interminable (it will never end), and/or inescapable (I cannot get away from it). If your work can produce a nonsuicidal approach to the pertinent problem or problems, you are on the road to success.

Evaluation is part of the treatment process. The first minute, and every minute thereafter, should be conducted in a treatment framework. Focusing primarily on assessment and management of suicidal risk can be a missed opportunity at best and counterproductive at worst. Perform due diligence in meeting your risk management criteria, but do your best to leave your patient with the sense that suicidality is a legitimate but quite costly form of problem solving and that, between the two of you, you can come up with positive and effective ways to deal with whatever life has thrown your patient’s way.

Suicidal behavior almost always occurs in the context of distressing and unwanted mental pain that occurs in a variety of states—sadness, guilt, anxiety, grief, fear, loneliness, boredom, shame, anger—to name the most common. Your patient is suffering and doing so in a culture that places emphasis on feeling good all the time and is quite happy to sell you a quick fix if you don’t. While pain is an inevitable part of life’s journey, prolonged suffering is not.

In our book, we detail techniques to move your patient from the emotional avoidance and passivity that are the core factors in suicidality to the use of active and positive problem-solving techniques accompanied by the ability to accept and move on from residual mental suffering. The basic task is to destabilize your patient’s belief that mental pain is inescapable (show that the problem can be solved), interminable (show that the negative feeling will end), and intolerable (show your patient that he or she can stand negative feelings).

Stress that suicide is a permanent solution to what is most often a temporary problem. Suicidal behavior increases mental pain and creates new problems producing more mental pain. At the same time, acknowledge that suicidal feelings are a valid and understandable response to this pain. Show empathy and understanding of your patient’s pain, and dignify the pain by portraying it as a reflection of your patient’s values and intentions. Things are not going the way they should; it’s not right, and it hurts. Stress that it is OK to talk openly and honestly about suicide and be direct and matter of fact in your comments and demeanor. Consistently assess for suicidal ideation comments and demeanor and self-injurious behavior. Do not make value judgments about the act of suicide. For many of your patients, friends and family have done plenty of that already. Acknowledge that such behavior is one of several options for dealing with problems and mental pain but that other options may well work more effectively: “Let’s take a look at them.” Your approach should be collaborative, not confrontational.

Avoid power struggles over behavior. Your value comes from offering effective solutions to life’s problems and showing that mental pain can be accepted in a way that allows life to have meaning and be enjoyed. Identify specific skill sets that can be developed through structured behavioral training—mindfulness and acceptance skills, detachment skills, problem-solving skills, and self-compassion skills.

Treatment of suicidal behavior is rewarding work, but it can be difficult. Acquiring the necessary skills and the right therapeutic demeanor can be hard. Know your limitations. Know your own hot-button emotional issues. Have colleagues available who are happy to talk things over with you. Last, know how many suicidal behavior patients with whom you are comfortable treating at any given time, and stick to that number. ■