Section XXXVI: Suicidal Ideation

What Do I Have to Offer to Others?

Goals of the Exercise

1. Agree to a verbal or written no-harm contract with the therapist.

2. Identify and change dysfunctional beliefs about self, others, and the world.

3. Reestablish a sense of purpose and future orientation.

4. Eliminate suicidal ideation and intent.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “What Do I Have to Offer to Others?” activity is designed to counter suicidal ideation by correcting cognitive distortion in a key area in the suicidal state of mind, the perception that one doesn't matter to anyone else and wouldn't be missed. This assignment asks the veteran/service member to identify how important people in his/her life will be affected if he/she commits suicide and to write brief letters to himself/herself from the post-suicide perspectives of those people. The goal is to help the veteran/service member develop an acute picture of how he/she is valued and how loved ones would be hurt by his/her loss. Although the assignment uses typical close relationships as examples, you should help the veteran/service member tailor it to his/her situation. Keep in mind that this will be a very emotional exercise for the veteran/service member and should be processed with the therapist as soon as possible after completion. Depending on level of risk, it may be safer to do this exercise verbally in session using the “empty chair” technique rather than writing letters. A safety plan must be in place before its start, and prompt follow-up must be provided. Follow-up will include discussion about the assignment, and can use bibliotherapy with books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE XXXVI.A What Do I Have to Offer to Others?

People thinking of suicide often wonder how their death would affect others. It's impor-tant to take your time and really think through how losing you would impact your friends and family. If at any time you feel this exercise is increasing your thoughts of suicide, stop immediately and contact your therapist; tell a friend, family member, or superior; call 911; or go to the emergency room.

1. To get a clear picture of this, we need to start in a different place. Please think of times family members, friends, comrades, or role models have done things that were helpful and important in your life. For three examples, please say who they were, what they did, and why it matters:

a. _____

b. _____

c. _____

2. Now think of three people whose lives you've touched in a good way—again, say who they are, along with what you did that made a difference for them:

a. _____

b. _____

c. _____

3. Picture yourself asking three people close to you “What are some ways I can help someone, and who could I help that way?” and then record the answers they would probably give you here:

a. _____

b. _____

c. _____

4. Now please write a brief letter to yourself from each person listed. Write what you think they would want to tell you about the possibility of losing you:

Person: Spouse/Significant Other

Dear_____ ,

If you were no longer alive,

_____

_____

_____

_____

_____

Love,_____

Person: Father/Mother/Grandparent

Dear_____ ,

If you were no longer alive,

_____

_____

_____

_____

_____

Love,_____

Person: Child

Dear_____ ,

If you were no longer alive,

_____

_____

_____

_____

_____

Love,_____

Person: Friend

If you were no longer alive,

_____

_____

_____

_____

_____

Love, _____

Person: Other _____

If you were no longer alive,

_____

_____

_____

_____

_____

Love,_____

5. People close to you would want to help if they knew of your pain; how could they help?

_____

_____

6. Name three people who'd want to help. How can you ask them for their help?

a. _____

b. _____

c. _____

Please consider giving them the chance to be there for you. It is doing a good thing for them, a thing they'd want you to do and something they would wish for the rest of their lives you had done if you didn't. They'd feel the same way you would feel if the situation was reversed.

Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise.

Finding Emotional Relief and Support

Goals of the Exercise

1. Agree to a verbal or written no-harm contract with the therapist.

2. Identify and change dysfunctional and maladaptive beliefs about self, others, and the world.

3. Reestablish a sense of purpose and future orientation.

4. Decrease feelings of hopelessness and increase self-esteem.

5. Eliminate suicidal ideation and intent.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Finding Emotional Relief and Support” activity is designed to counter suicidal ideation by correcting cognitive distortions in two of the key areas in the suicidal state of mind: the perception on the part of a suicidal person that he/she is emotionally isolated and that no one cares or understands his/her emotional pain, and the perception that there is no way to relieve that pain except by dying. This exercise is intended both to help the veteran/service member gain more control over his/her thoughts to reduce his/her risk of suicide, and to initiate relief of some of the emotional pain underlying suicidality and instill hope in the veteran/service member. Although the examples in this exercise are typical thoughts of suicidal people, it's important to help the veteran/service member identify his/her own unique thoughts leading to the suicidal ideation in order to target those specific dysphoric cognitive distortions. Please keep in mind that it is important to have a safety plan in place while doing this exercise and ensure prompt and consistent follow-up, which could include reporting back to the therapist on actions related to this assignment and their outcomes, as well as bibliotherapy using books suggested in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE XXXVI.B Finding Emotional Relief and Support

How we think about ourselves, others, and the situations we're in greatly influences how we feel. Unfortunately, when we're hurting or depressed, those thoughts get distorted so that things look even worse. We see ourselves, our situations, and our futures in the worst possible way; furthermore, we underestimate how much we matter to other people and lose the ability to see solutions to our problems. One man who survived a suicide attempt described it by saying, “All the doors in my mind slammed shut except the one that led to death, and I had to get out somehow.” This is how the thought of suicide may develop. But it is not the only way to relieve the emotional pain—we can feel better by first testing our thoughts and replacing those that are dark distortions with more balanced and accurate ones. That, in turn, will let some of those doors in our minds start swinging open again as we regain our ability to see other solutions. In this exercise, you will develop more realistic alternatives to the negatively warped thoughts that are common when people's thinking is suicidal. Then you'll be asked to explore options other than hurting or killing yourself that you may be able to see more clearly by pushing through that distortion. If at any time you feel this exercise is increasing your thoughts of suicide, stop and contact your therapist; tell a friend, family member, or superior; call 911; or go to the emergency room.

1. Read through each of the hopeless, all-or-nothing negative thoughts below. For each, circle it if it's a thought you've been having; then think about evidence for and against it, and identify a positive and adaptive alternative thought that might be more true. After you finish this exercise practice doing this when you catch yourself thinking negative all-or-nothing thoughts.

a. “This emotional pain is worse than I can stand.”

Alternative thought:_____

b. “Nothing except dying can ease the pain I'm feeling.”

Alternative thought:_____

c. “Nobody understands or cares about me.”

Alternative thought:_____

d. “My family would be better off if I were dead.”

Alternative thought:_____

e. “Things will never get better.”

Alternative thought:_____

f. “I can't do anything right—I'm useless.”

Alternative thought:_____

g. “There's nothing good in my life—it's not worth living.”

Alternative thought:_____

h. Personal negative thought: “_____ ”

Alternative thought:_____

i. Personal negative thought: “_____ ”

Alternative thought:_____

j. Personal negative thought: “_____ ”

Alternative thought:_____

2. Usually, when people think of suicide, they don't actually want to die—they want to stop feeling so much pain, and can't see any other way to do it. Is this part of what you've been thinking?

_____

3. Before taking the irreversible step of suicide, it makes sense to try another solution if one turns out to be available. Look at the alternative thoughts you listed for items 1.b., 1.c., and 1.e. If you thought carefully, you were probably able to identify possible alternatives and ways to ease your pain without dying. You most likely thought of people who would probably understand if you shared your thoughts and feelings with them and who care and would want to help. And you also probably found ways to help things get better. Drawing on these ideas, please describe some possible solutions that would involve gaining some emotional relief and support:

_____

_____

_____

_____

_____

_____

_____

_____

4. Looking at item 1.f., you might want to consider that if you do find solutions and work through this time in your life, you would have a lot to offer other people who found themselves feeling the same way. You could potentially save lives and that good would ripple from those people through the others who care about them. Please record your thoughts and feelings about the idea that by overcoming the crisis you're experiencing, you would be in a position to save other people's lives down the line:

_____

_____

_____

_____

_____

_____

5. Finally, if it would feel rewarding to you to be able to help someone else stay alive, please consider that your friends and family will almost certainly feel the same way if you give them the chance to help you stay alive. Briefly share your thoughts on this idea:

_____

_____

_____

_____

_____

_____

_____

Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise.