Lisa Firestone on Psychotherapy with Suicidal Clients

Lisa Firestone on Psychotherapy with Suicidal Clients

by Rebecca Aponte and Victor Yalom
Lisa Firestone shares what every therapist should know about how dissociation and suicidal thought patterns influence suicide and self-harm.
Filed Under: Lisa Firestone, Suicidality


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Something to Lose

Rebecca Aponte: One thing that I'm really interested to know is: what are the rewards of working with suicidal clients?
Lisa Firestone: Wow. Well, obviously, the ultimate reward is if you can make somebody's life worth living so that they're no longer feeling suicidal. But it's often a real struggle—often, people who are suicidal have complex problems that are not easily solved. They also have issues with being able to regulate their emotions and tolerate strong negative emotions. While it's a diverse population of people who become suicidal, they seem to have those two things in common. Those issues have to be addressed to have any long-term effect. You could ride out crises, but they will resurface if the person doesn't learn some basic ways of dealing with their emotions.
RA: How do you stay motivated as a therapist working with these sorts of very complex issues?
LF: There's nothing like working with a suicidal patient to make you feel motivated, because there's so much concern and fear involved in what the outcome can be if it doesn't go well. Israel Orbach, who we interviewed for our film on suicide, talks about how it's really important to find something that you'll lose if the patient would die, and I think that's a really powerful idea. He's not talking about losing in terms of your status or professional or legal liability—he's talking about what you come to value in that person.
A lot of suicidal people are brilliant, funny, charming in various ways; there are a lot of positives there, too. One of the last suicidal patients I worked with was a brilliant young student. It's easy to see the things to admire from the outside. It's helping the person see themselves in that perspective, because they're seeing everything through a very negative filter.
A lot of suicidal people are brilliant, funny, charming in various ways; there are a lot of positives there, too. One of the last suicidal patients I worked with was a brilliant young student. It's easy to see the things to admire from the outside. It's helping the person see themselves in that perspective, because they're seeing everything through a very negative filter. They're not seeing their positive attributes, or potential positives in their life, very clearly.

Victor Yalom: It sounds like you're emphasizing the importance of finding a way to connect to aspects of that client.
Lisa Firestone: Aspects of the client—the part of them that wants to live.
All suicidal people are ambivalent: part of them wants to die, but part of them wants to live as well.
All suicidal people are ambivalent: part of them wants to die, but part of them wants to live as well. And if you can connect with and help strengthen that part of them that wants to live, then you're on the right track. The trick is to not do anything to support the negative side. I just consulted the other day for a man whose wife is very distraught because her adult son committed suicide. =The night before he did it, she went from having been catering and caretaking, to blasting him. And of course now she feels very guilty about that, and is experiencing a lot of self-recrimination. She's also suicidal, herself, at this point. The husband reported that a famous drug and rehabilitation counseling center counseled the son, saying basically, "You can't even take care of yourself; how do you expect to take care of your family?"—which is actually a voice on our scale for predicting suicide risk. That's what he reported their counselor said to him the night before he died!
RA: Wow.
LF: So that's siding with the part of the person that wants to die. And it's easy to get caught up in those kinds of statements or sentiments, because the client will provoke those kinds of reactions. And I'm sure he may have precipitated that reaction, but it still was not a very therapeutic way to respond to him.
VY: So the whole idea of suicide and working with suicidal clients, as you said, brings up a lot of fear—it's very threatening to therapists.
LF: Absolutely—especially in our litigious society, where wrongful death cases do happen. And especially with suicide, because when somebody dies by suicide, there's a lot of anger, but there's a lot of reluctance to direct that anger at the person who is primarily responsible: the person who died. So there's a lot of anger on the part of families, of wanting to accuse therapists of being the problem. There's a lot of anger on the part of therapists, of wanting to accuse families of being the problem. There is a lot of anxiety around it. And most people going into to our field are not looking to be dealing with life-or-death situations. They want to help people, have a feeling for people, and yet with suicide we are dealing with a life-and-death situation where somebody could actually lose their life. So that in itself is anxiety provoking.

Suicidal patients tend to provoke negative countertransference feelings, as well. They tend to make therapists feel like getting rid of them, just like they feel like getting rid of themselves. And they do that with friends and family members, as well. That's part of what I mean by complex problems: because they've been interacting with people in ways that reaffirm their own negative view of themselves.

Bending the Rules

RA: When you're forging a therapeutic alliance with these types of clients, how do the normal boundaries come into play? Do you bend the rules? Are you self-revealing? Certainly the stakes are significantly higher.
LF: The stakes are significantly higher, and the need to connect with them in a manner that inspires hope, and to keep that connection with them, is crucial. When they looked at people who committed suicide while they were in treatment, there was some breakdown in the relationship where the suicidal person felt like, "Even this person can't help me." This reinforced the hopelessness and helplessness that they were feeling, as well as the desperation, which was found in the same study to be the strongest negative emotion associated with suicide. So keeping that connection is really important. But it's a complex process, and certainly
if you talk to people who are specialists in suicide, they will all tell you about times that they did things that were outside the boundaries of what we usually consider the limits of psychotherapy.
if you talk to people who are specialists in suicide, they will all tell you about times that they did things that were outside the boundaries of what we usually consider the limits of psychotherapy.

Edwin Shneidman, the father of suicidology, talks about a student at UCLA who came to see him ready to kill herself over an A-. He needed to buy time to form a relationship with her, so he went to the teacher and got the grade changed. He decided the difference between an A and an A- to UCLA was nothing; the difference to this girl was life and death at that moment. Now, we wouldn't do that with most of our clients, and I'm not suggesting that we always should, but there is a need to build and maintain that connection. And if you look at Dialectical Behavior Therapy—one of the therapies with the strongest research track record in terms of affecting people who are suicidal, particularly those with Borderline Personality Disorder —there is an emphasis on maintaining the connection through phone contact between sessions, frequent sessions, and skill building classes. As Marsha Linehan describes it herself, it's shepherding them through, checking up on them, and teaching them how to regulate and tolerate their emotions.
VY: I had a client who was suicidal in a somewhat unusual way. This was maybe 10 years ago, and AIDS was more of a death sentence. He was talking about actively going out and having unprotected sex to infect himself. I was quite concerned about him and ended up driving him to the hospital in my car because it seemed like the best alternative. I thought he needed to be hospitalized and he agreed to that. I didn't want to call an ambulance and have him strapped into that. So I just walked down with him to the garage and got him in my car and drove him to the hospital. That certainly is not something I would normally do with a patient, but it felt right and I think it was helpful.
LF: Yes. I think, in each case, we just have to reflect on what's in the best interest of the client. And we're going to end up doing things that are, like you said, not what you would do with every client, but that are important for this particular client at this point in time. John T. Maltsberger, who is a suicidologist in Boston, talks about a client he got just prior to Christmas break, during which he usually took a skiing vacation. She was suicidal, and he was really torn: “Do I go and feel guilty the whole time and worry about her, and ruin my vacation? Do I not go and resent her for having interrupted my vacation, which will come out in the countertransference, or one way or another in the therapy?” The agreement they made was that they would have a phone call every morning at 7:00 a.m. during that vacation. She felt very cared about and contained by that intervention. He felt relieved at the end of those phone conversations: he could go skiing and enjoy his day knowing he was going to talk to her the next morning. And it worked.
RA: Is it common to collaborate with the client in figuring out what kind of things can work like that?
LF: I think working collaboratively in the relationship is the most important thing. And there's actually a group that meets in Switzerland every two years that is devoted to working on that issue of collaborative, relationship-oriented work with suicidal clients. At this conference, I have experienced a psychoanalytic person speaking right before a behaviorist, and they're saying the same thing about what you do with a suicidal client. So it's really interesting—even though the presenters represent the theoretical spectrum, they're talking about the relationship being primary.
VY: I think most of the research shows that if you really dig deep and tune into the client's perspective, you find it's their sense of you—that you really do care about them, that you're willing to go outside the normal boundaries if necessary—that is what's ultimately important to them.
LF: Certainly in some cases, and often these are people for whom the attachment relationships they had early on were not secure, and were not such that they were able to learn to either tolerate or regulate their emotions. These are things that an infant originally needs from the outside. An attuned parent provides these functions, but a parent who is depressed, substance abusing, or who can't regulate their own emotions is going to have a hard time filling that function for a young baby.
RA: And then there's a fear to get attached to these people because, should they commit suicide, that's a great loss to whoever is attached.
That's the thing about suicide: there's no suicide without other people being hurt.
That's the thing about suicide: there's no suicide without other people being hurt. It's not a private act between a person and themselves. Nobody's an island unto themselves enough that their suicide doesn't affect other people. Certainly, when you're the therapist, you get hurt if it happens, but also the family members, the loved ones. No matter how complex their relationships to the individual might have been, they get hurt.
VY: One of the first clients I ever saw, his father committed suicide when my client was a child. I think for children, as in this case, the sense that a parent would take their own life rather than being there for them is intensely damaging.
LF: I don't think anybody's fully studied the impact on children of losing a parent to suicide, and I think it's huge. I don't think there's a simple way to deal with it. But that's a very understudied population, and a high-risk population for suicide. Losing a parent during childhood puts somebody at greater risk for both suicide and violence.

Finding the Family

RA: Do you often bring the family into the therapy session? If you have someone coming to you who is suicidal, do you talk to their family or friends?
LF: Ideally you talk to the people on the ground, and that could be the family, spouse, or roommate. The subtle changes in behavior that are going to alert you to the likelihood of an actual suicide attempt are going to be noticed even better by the people who are seeing the person daily than by the therapist.

Some families are too toxic; they're not going to be helpful. It's going to make the situation worse. Sometimes there are a lot of complex dynamics going on in the family, so it's not an absolute given that you're going to want to involve them. But you certainly will learn information about your client that you do not know. And if you're dealing with a younger person who's still in a lot of contact with their parents, it makes a huge difference to have the family on board to understand both the level of risk and what the management and treatment plans entail.
VY: I think many of us are still overly influenced by this neutral, passive role of the therapist with the focus on boundaries. I think for almost any client it's helpful to be in touch with family and friends. If a client's siblings are in town, I bring them in for a session. I find out so much more about my client every time I do this—things I might have never expected.
LF: Their support system can strengthen what you know and how you can intervene. I also tell family members, if you're concerned about your loved one being suicidal, and they're in therapy, you've got to advocate for them. You have to call the therapist. Even if the therapist can't talk to you because of confidentiality, they can listen. They don't even have to acknowledge whether this person is their patient or not. But say, "I think this is really important for you to know." I had a mother contact me in Santa Barbara whose daughter was in another state and in therapy and was not doing well on her antidepressants: she was sleeping 20 hours a day on them.
VY: That's one indication of not doing well.
LF: Right, but she wasn't telling her psychiatrist this. So how was he supposed to know? It's very hard to adjust somebody's medication if they're not giving you the feedback you need in order to do that. Families can have some power, but they can't ultimately necessarily save the person's life any more than you can as the therapist. There still is frustration because the final decision is going to be up to the person, but there's also a lot families can do.

When possible, therapists should really communicate with the family and make them part of the treatment team. I see therapists very resistant to that, like you said. Even though they may not see themselves as Freudian, they see themselves as having good boundaries, even with children. You would think that anybody who was seeing somebody under 18 would obviously be letting parents know this, but
I've heard stories over and over again of people who wanted to pull their kids out of therapy for whatever reason, and the therapist said, "Oh, no, you can't do that—this child is suicidal."
I've heard stories over and over again of people who wanted to pull their kids out of therapy for whatever reason, and the therapist said, "Oh, no, you can't do that—this child is suicidal."
RA: And that's when the parent finds out?
LF: And the parent says, "Wait a minute, you never told me that before? How could you be treating my child and not letting me know that you thought that?"
VY: It sounds like you've done a fair amount of consulting to other therapists with suicidal clients.
LF: Yes, I have. That's one of the things that I do: people call me when they're concerned.

Suicide is an Acquired Ability

VY: Of course, every case is different, but do you find that there are some common types of advice you give, or some common types of problems you see in the way that therapists approach or deal with suicidal patients?
LF: Yes. Unfortunately, I think one of the problems is that, because it causes therapists so much anxiety, they tend to minimize or want to think the person is less suicidal than they are. And I think families do that too.
VY: Any examples of that pop into your mind?
LF: A therapist from the East Coast, who was seeing an adolescent boy, called me. He was sixteen at the time, and he made his first suicide attempt when he was fourteen: he took a very minor amount of medication, not even very serious. Second suicide attempt happened about a year later: he took a more significant amount of medication, but told his mom. He got taken to the hospital, and had his stomach pumped. In therapy, the day before his third suicide attempt, he basically said that he felt suicidal; he felt unloved and uncared for by his mom, who was there in the session. His mom had a new baby, was distracted as well as sick, and hadn't been paying as much attention to him as a result. The next day, he jumped off a low bridge and broke every bone in his body. He has minimal brain damage and will survive—miraculously. But everything he said the day before in therapy should have told the therapist what was coming.
There's a tendency to minimize or to think, "Well, his past attempts weren't serious." There's a tendency to not want to think that this could really happen.
There's a tendency to minimize or to think, "Well, his past attempts weren't serious." There's a tendency to not want to think that this could really happen.
RA: I read an autobiography about a woman who had dissociative identity disorder and had also attempted suicide. The author wrote that as she kept talking about suicide, she was getting more comfortable with the concept, while everyone else around her was beginning to tune out what she was saying. Do you find that that's common?
LF: Yes. And there's a desensitization process to suicide attempts that makes the person feel like, "This is a course of action I could take." It gets easier and easier to do as they make attempts. And people do get tuned out to it, because they think, "Oh, they're just trying to manipulate us," especially with kids or teenagers. They downplay the risk and don't really hear it. I also think the therapist or the family member sees all the good traits in this person. It's hard to realize that they could really feel the way they do about themselves.
VY: So one obvious implication of this is to take people's threats seriously.
LF: Absolutely. Take people's threats seriously. You're better off overreacting than underreacting. When a therapist seems panicked or made afraid by the patient's suicidality, it often increases the patient’s sense of hopelessness. It's experienced as basically admitting defeat or lack of ability, which makes them feel more helpless and hopeless. So it's not that we need to panic about it, but we do need to take it seriously and do whatever we need to do to make them safe, including hospitalization when that's necessary. And also really following up closely when they get out of the hospital, because that's the highest risk time: the three weeks post-hospitalization.
VY: But don't you think it's helpful, if you're really concerned—if you're scared, even—to share that with the client? Isn't that being real?
LF: Absolutely. But not in a manner as to communicate that you are helpless to help them. Instead, what you want to communicate is that you want them to be safe, so whatever is necessary to keep them safe needs to be done.
RA: And you have to monitor how it's impacting you.

Some Uncommon Advice

Absolutely. Making yourself a real person to them is important because that strengthens the connection. What you're trying to build is trust: you want them to see you as a safe haven, as well as the attachment for them that they may never have had.

I think another problem is trying to get a client to stop behaviors that are self-destructive but that are helping them manage their emotions, like self-harm behaviors. Many therapists just want it to stop. Many parents just want it to stop when it's their teenager. But you don't want to rip that away from somebody for whom that's a self-soothing behavior that's working, until you replace it with a more healthy coping strategy.

We have a mother whose son committed suicide days after his 15th birthday. The year before, he started to cut himself, and she took him to therapy. The therapist got him to stop, and he spent the next six months searching the attic for the bullets to the gun in the house. And the day he found them, he died.

You don't want them to just stop.
RA: Wow. I don't think that's advice you hear everywhere.
LF: No. I think it's hard because to most people, self-mutilation behaviors seem horrifying and painful. But to people who use them, they are very soothing. You want them to develop healthier coping strategies, certainly, but you want to do that before you just say, "Stop." So you're really looking into how they cope:
what works for them when they're stressed? Maybe that's cutting themselves, or maybe that's burning themselves. That may not sound very good to you, but for them it's working. And when it's working is not when they're going to die. It's when things aren't working.
what works for them when they're stressed? Maybe that's cutting themselves, or maybe that's burning themselves. That may not sound very good to you, but for them it's working. And when it's working is not when they're going to die. It's when things aren't working.
VY: But what does the therapist do with that? If you don’t urge them to stop, then what?
LF: I think you want to slowly replace it. You want to work with them on developing healthier strategies so that those other behaviors can fall out. But you have to respect what works for them when they're in distress, and what worked for them in the past. Then, how can we move to something that would be even a better strategy for them? But you don't want to do things to expose them more to their pain—you want to help ameliorate that pain. You've got to deal with their pain. The deep underlying psychological pain they're experiencing often has to do with their early pains and hurts, and feeling that they don't deserve to live—these core beliefs that they basically should be dead, that they shouldn't have been born in the first place.

The Power of Dissociation

VY: Sometimes. And maybe sometimes it's just real-life crises that trigger vulnerabilities.
LF: They trigger vulnerabilities, but those vulnerabilities are there. And you talked about somebody who has dissociative identity disorder.
Certainly dissociation, I think, is a key piece in suicide, and this is one of the under-researched issues.
Certainly dissociation, I think, is a key piece in suicide, and this is one of the under-researched issues. The role that dissociation plays in violent behavior is much better researched and more spoken and written about than it is with suicide, and yet I think it's a key component to the acquired ability to kill yourself. We have some clients that feel very suicidal, but they don't have the acquired ability to do it, so it's not going to happen. But that desensitization of making attempts, of physically experiencing or being exposed to a lot of pain, of being able to dissociate… I don't think you get suicide without that ability to dissociate. And I don't mean having to have full-blown dissociative identity disorder, but certainly, having the ability or tendency to dissociate is there in people who complete suicide.

If you think about it, just on a basic animal level, an animal that's injured gasps for every last breath; so do human beings. But with people who are suicidal, they have to go so against that to actually take actions against their own body that they have to be in a pretty disconnected state. And the suicide attempt often reconnects them to themselves. They snap back to themselves.
RA: Yes, I remember that from Voices of Suicide.
LF: Kevin Hines talks about that: how he felt like he was worthless, he didn't deserve to live, he was a burden to his friends and family. He jumped, and the minute he lost physical contact with the bridge it was, "Wait a minute, I don't want to die. Wait a minute! And these people love me!”
RA: Not dissociated anymore.
LF: Not dissociated anymore—reconnected, whole different perspective. And that's one of the problems with suicide: when people use not-so-lethal means like pills or things like that, they can call somebody—they can potentially save themselves, and people can potentially find them and have time to save them. The problem with very lethal means like guns, which are the number one method here in the United States, is it's over in a second. You have to have sustained intent for such a brief period. Jumping off a bridge takes moments of sustained intent. And there's no going back, in most cases.

A Personal Philosophy on Suicide

VY: What's your philosophical stance on suicide? Do you make any distinctions? For example, certain states are talking about the right to die if you have a physical illness. Where do you draw the line between “someone is insane” or “it's a permanent state of pain”? What happens if someone has been chronically depressed for twenty years, and they're miserable and they're unhappy, and they just want to end the pain?
LF: It's a very hard one for me, because I generally believe people should have the freedom to make decisions about their life and live in any way that is meaningful to them. The problem around suicide, for me, is that the person is almost never in a rational state of mind. Even in research that has been done with terminal cancer patients, those who wanted to hasten their death were in a depressed state. Depression is treatable, even for those at the end of their lives.

We don't have optimal end-of-life care here. We do for some, but we don't for all. So there are people who feel like they're a burden to their family or they're going to eat up all the family's money, because they are. That's what will happen. That puts outside pressures on the situation, certainly, so I think it's very difficult. And I think it's a kind of slippery slope issue. Even in countries and states where it's legal, there are cases of people who have been depressed for short periods of time who get assisted in killing themselves, and I have a lot of trouble with that—people who have not had a chance to receive adequate treatment. And with optimal pain management, I don't think people generally want to hasten their own deaths. I don't think we should make people be in pain. Currently, when a person speaks up and provides feedback to their doctor, we can have optimal pain management for most situations. So I hate to make it a moral issue, but I do think that suicide always hurts other people, so I think that does make it a bit of a moral issue. It's not just between the person and themselves. And I've heard Thomas Szasz speak on this; I've heard very reasonable researchers on the other side who have reached a different conclusion. I heard somebody present on it at the International Association of Suicidology once who said, "Any doctor who feels good about assisting somebody in their own suicide shouldn't be doing it." That should be one of the qualifications: that you don't feel good about it. And who does those evaluations that decide that somebody's in the right state of mind to do that? What does that even mean?
My belief is that when anyone is in a suicidal state, they are not thinking rationally, they are at the mercy of a destructive thought process
My belief is that when anyone is in a suicidal state, they are not thinking rationally, they are at the mercy of a destructive thought process, what we refer to as the “voice.” These voices are tormenting them, causing the psychological pain they are expressing, and encouraging them to get out of the pain by killing themselves. These voices represent the “antiself,” which is opposed to the person’s going on being.
RA: You mentioned earlier that the role of the therapist in helping the suicidal person is to help them find ways to alleviate their psychological pain. Do you get to a point that you do start to explore the pain and start to work through it?
LF: You want to get to the bottom of the process that is causing the pain. You want to bring to the surface these destructive thoughts or voices, challenge them, separate from them, and act against them, helping the client to take his or her own side. You want to help make life worth living to them. So what gives them meaning? What lights them up? What matters to them? That's strengthening that self system, so from the beginning you're wanting to connect with that and support that. What you don’t want to do is anything that sides with the ways they've turned on themselves and the ways they're thinking negatively about themselves, the antiself. And it's easy to do in those moments. Even saying things like, "How could you do this to your kids?" can be interpreted as, “I really am a bad parent.” What you want to communicate is, “People really need you to stick around, and your kids need you to stick around.” It's choosing your words. It's thinking through what you're communicating or how it's coming across to that person in that moment in time. It's the same content in both of those statements, but they come across very differently.

Keeping it Real

VY: Someone reading this interview might get a little concerned that they have to weigh their words too carefully—like if they say the wrong words, suddenly they could be responsible for having their patient commit suicide.
LF: I don't think anybody can be completely responsible for another person's suicide, first of all—and
I caution therapists against thinking either that they can save every patient or that they're going to be responsible.
I caution therapists against thinking either that they can save every patient or that they're going to be responsible. But it's having the right intent to what you're trying to do with the person, and knowing where you really sit in your feelings. And trying to communicate that: that you really do care about them, that you really do want to see them be able to live and to feel better than they do now, and offering that hope that they can feel better than they do now. And when you recognize that there has been a misattunement or the client has taken something you said wrong, you admit your mistake and repair the relationship. And really helping them develop the skills and the ability to get there, partly by looking at what is driving them to feel suicidal in the first place, and unearthing the negative thoughts that they're experiencing and what behaviors they engage in when they're thinking that way. Often, when they're thinking negatively about themselves, they isolate themselves. That's when these negative thoughts take more hold over them. So getting them out of their isolation is huge.
VY: So you take a very active advice-giving role when you think someone's at risk.
LF: No, you are active and engaged, but you are not advice-giving. When somebody's in suicidal crisis, I think they do really need you to provide the structure. It's not that you're the expert telling them how they should live their lives, but you're collaborating with them on how you can make this work.
VY: Maybe it’s a dirty little secret that I think almost all of us at some point in our lives have felt some level of despair that may involve some vague, or not so vague, suicidal thinking. This includes therapists, of course.
LF: Oh, absolutely. And having tolerance for that and for those feelings is really important. But I think for therapists it can be very scary, because any of those feelings in them could get stirred up in sitting with somebody who is really feeling that way so strongly.
VY: Do you think it's helpful for therapists to share that they've had experiences like that—that they can really relate?
LF: I think it can be helpful. Again, it's how you use it and how that's going to be received by that individual. If you have somebody who's on the brink of suicide, who's really in suicidal crisis, and you say, "I know how you feel," they're often going to feel like you just obviously aren't paying attention, because you haven't had that experience. Even if you've been there, they're going to have a hard time believing that you were there and that you got where you are now. It's going to be hard for them to really feel it. So it's important not to minimize it. It's like saying to a parent who's lost a child, "I know how you feel." If you haven't had that experience, you probably don't really know how they feel. You can empathize with it—you can think about what it would be like to be in their shoes—but that's a bit different. And I think people in suicidal crisis can be very sensitive to that. So I just think it's important not to overstate it, because it will be experienced as disingenuous.
RA: It's kind of like what you were saying earlier—that you just have to be so real, and that even amongst the different disciplines of therapists who work with suicide, it's so incredibly obvious that it's the relationship that matters. It sounds like that honesty is crucial.
LF: I think it's huge and yet I think there are plenty of therapists out there who do not realize this.
And I think, in managing our own anxiety about dealing with suicidal clients, it's a very good idea to get consultation.
And I think, in managing our own anxiety about dealing with suicidal clients, it's a very good idea to get consultation. It puts another person's perspective on it that can be helpful. And from a legal perspective, it's also very important because it's like taking a biopsy of the standard of care. If you consult with somebody and they agree with your treatment approach and you document that, that's also very protective. But it's also helpful for your client because if you get too distressed or feel overwhelmed by it, I don't think that's helpful for them.

And I think it's important not to have too many suicidal patients in your practice at any one time; it is just much too stressful for anybody. When we were doing testing for our suicide assessment, we were in therapists' offices all over the country, and in one case a woman had seven people in her practice that tested as being highly suicidal. She didn't intend to get in that situation. It had just sort of happened that she had taken on that much, and it was probably not the right thing to do, for her or for the patients.

Identifying Suicidal Thoughts

RA: Let's talk about the assessment. There's the FAST (Firestone Assessment of Self-Destructive Thoughts) that you and your father worked out. Can you describe that briefly?
LF: Sure. We started to look at what we knew about suicide, and at a continuum of negative thoughts that contribute to suicide in particular. We looked for statements from people who had made serious suicide attempts and were in the voice therapy groups we were doing at the time. All of the statements that we put on the scale were taken directly from the clinical material—things that people actually voiced. And we looked at the whole continuum of self-destructiveness, from mild self-critical thinking that we all have at one time or another, to extreme self-hatred, all the way up to suicidal thoughts. We took statements from 11 levels along that continuum and determined the statements that best fit their category based on expert reviewers. We then looked at those that distinguish between suicidal and nonsuicidal people in our pilot study. Then we tested people all around the country who were in outpatient psychotherapy, and then we did the second study of people who were in inpatient psychotherapy and had been diagnosed with the disorders most associated with suicide risk. We found that you really could distinguish between people who are very depressed and are suicidal from those who aren't, or people who have bipolar disorder and are suicidal from those who have bipolar disorder and are not. We found that people who have borderline personality disorder endorse more negative thoughts than any other group. Still there are very different negative thoughts for those who are suicidal than those who aren't suicidal.

It's interesting that cognitive-behavioral therapists focus on negative thoughts as being the underlying driver of a lot of self-destructive behavior, including suicide, but the tests that they've developed are not based on thoughts.
We ask people directly: “Do you have these thoughts toward yourself?” And we have found that people are a lot more honest about their thoughts than about their behavior.
We ask people directly: “Do you have these thoughts toward yourself?” And we have found that people are a lot more honest about their thoughts than about their behavior. For instance, there's a whole subset of items on the FAST that have to do with the kind of thoughts that lead to addictive behaviors. "Do you have an alcohol problem?" That's an opinion question and most people will say no to it—even people whom you might consider as having an alcohol problem. We're not very good at opinion questions. But if you ask them specifically, "Do you have this negative thought, or that negative thought..." They're more likely to say, "Oh yeah, I have those thoughts."
VY: So the thoughts that they identify through the FAST can reliably predict suicidality?
LF: Yes. Suicidality, substance abuse, self-harming behavior—all can be identified by the FAST. We've found that in half the cases in which a patient had a history of suicide attempts, they hadn't told their ongoing therapist. Same with self-mutilation behaviors: in half the cases, their ongoing therapist didn't know about these behaviors.
VY: What does that tell you?
LF: Well, in the case of suicide, one thing it tells you is that therapists aren't asking. The patients weren't hiding it; they just had never been asked about it. They don't want to burden their therapists with the anxiety of having to feel that they're suicidal or that they're engaging in self-mutilation. And yet, as a therapist, as much as it might cause you anxiety, you want to know those things.
RA: There may be some level of shame associated with it for the patient.
LF: There is some level of shame, and there is a level of protectiveness toward the therapist, too. And I think it's really important to draw those things out and to ask. And then I think we need to really address them as well.
RA: And take it seriously.
LF: Yes, take it seriously. And it's interesting—if you sit there with somebody while they take the FAST, when you get to the items they think only they have, they sort of startle, or they almost laugh. People will say, "Wow, where'd you get that thought?" A lot of people say things like, "I'm talking to myself a lot more than I thought I was." They start to self-identify their patterns of negative thoughts: “I can see that when I get stressed I start to isolate myself.” This is very helpful because it moves things forward in the therapy.

The reason we put these thoughts on a scale is because we've found in our research that these thoughts that people verbalize are not just thoughts, unfortunately.
The thoughts actually direct how people live their lives day to day, and how they conduct their relationships. That's why tapping into these thoughts, and really getting to the bottom of them seems so important to us.
The thoughts actually direct how people live their lives day to day, and how they conduct their relationships. That's why tapping into these thoughts, and really getting to the bottom of them seems so important to us.

Who's Calling the Shots, Anyway?

RA: I hear what you're saying. Watching some of the voice therapy that I've seen—and we'll get into voice therapy in a second—a lot of the thoughts that people voice in these sessions sound more like commands or directives.
LF: They often are more like directives and commands. And they really do direct how these people are living their lives. For instance, the voices in the film about relationships [make a link to this DVD], you look at how a man who has a voice telling him that he needs to take care of women marries someone who can barely get across the street by herself, and then he takes care of her and resents her. Or a woman who feels like she has to get a man and hang onto him marries someone who's a child molester and stays with him. It's just really powerful how much people live out these thoughts.
VY: Maybe it would be helpful if you said a little bit about what voice therapy is.
LF: Voice therapy is really a process of giving language to the defensive process that we see the voices representing. So it's a way of getting people to verbalize their negative thoughts, and we have them do it in the format of putting it in the second person. So instead of, "I'm no good," "I'm a failure," "I'll never amount to anything," we have patients put their negative thoughts toward themselves in the second person, as though they were another person speaking to themselves. "You're no good." "You're a failure." "You're never going to amount to anything."
VY: Why do you do that?
LF: For two reasons: One is it helps to start to separate this very negative point of view from a more realistic, compassionate point of view toward the self. The other is that it brings to the surface the affect that goes along with these thoughts. This is not just a cognitive process. These thoughts have a lot of affect associated with them, so a lot of strong anger, rage toward the self, and a lot of pain and sadness come up as well. And even when we have people pair up in adult education classes and say some of their negative thoughts to each other in the second person, the emotion starts to come to the surface.

Patients also find that they start off with the thoughts that they're aware of on the surface. As one therapist described it in our workshop in LA, “You read the ones you wrote down on the paper, and then you just sort of get into a flow with it. And then all this stuff comes out that I didn't even know I really thought.” And what quickly come are the very core beliefs that they have about themselves. Often people will do this and they'll say a number of statements, and then they'll pause. And if you just leave it alone and sit with it, what come next are much stronger core beliefs about the self. So it very quickly brings that material to the surface. Also, when people are verbalizing it in that way, we encourage them to say it with the full emotion associated with it, maybe to say it louder. Often there's a very derogatory, taunting, sarcastic kind of tone to these negative thoughts as they occur. We encourage them to say it with the full feeling behind it, maybe to say it louder. And often, as they're saying it, they take on the accent, the body posture, or the tone of voice of their parent. Their vocabulary changes. Sometimes they change into their language of origin. Someone whose parents came from Eastern Europe switches into their parents' accent. It's a very powerful process. So that's the first step in voice therapy.

The second step has to do with really looking at: where do these thoughts come from? And this is not a therapy where we interpret to the person. We don't say, "Oh, this must be your father's voice; this must be your mother's voice"—first of all, because we don't know; they're the expert in this. Secondly, it's much more powerful for them to make those connections.

Talking Back

RA: And how does that then shift from recognizing where the attitudes about the self come from to actually formulating new attitudes?
LF: I think it's a really important process, because that accountability of knowing where that came from really helps the person get some compassion for themselves. It's not that we want to blame parents. Often, if you really look at it, it came from your parent, and it came from their parent; it goes generations back. And sometimes it's their peers that taunted them, or their sibling who was particularly cruel to them.
RA: So the self-compassion is the first step. And the next?
LF: In starting to break with this way of thinking about oneself, I think it's a very important step. The next step really is answering back. And sometimes if they've gotten into it emotionally, the person will have a very strong feeling of wanting to get angry back at those voices. Often a lot of interesting material about what life looked like from their perspective as a child will come out in their answering back, as well. You get a real picture of what the parent looked like to them when they're verbalizing the voice, and what they experienced as a child in answering back.
VY: This sounds somewhat similar to what occurs in psychodrama, except in psychodrama, rather than saying voices that your parents said to you, you actually roleplay being the parent, or talking to your mother, and then being your mother talking back to yourself.
LF: Right. We try to separate it not so much as a conversation, but really to just have the person fully verbalize the negative thoughts first and go through all of what's there—and then, after making the connections about where they come from, really answering back, emotionally at times. An important part of the answering back, though, is just objectively stating what's true about yourself.
RA: And is that typically when the clients begin to learn how to self-regulate their emotions?
LF: It's a helpful piece of it—and starting to really say who they are and what's true about them. Seeing ourselves as divided is an unpleasant thought, and people often side with their voices, and side with the negative part, and that's their identity: "I really am stupid," or "I really am unattractive," or "I really am" whatever. And answering back can be very difficult.

Starving the Monster

RA: I have a personal question from watching one of the videos. I think that what I was seeing was the first stage—I was seeing a lot of speaking in the second person…
LF: The voices, yes.
RA: …and a lot of encouragement to stay in that voice, to keep speaking in that voice. I'm curious, and I imagine some of our readers might be curious, too: Does that shift in another stage? Does the encouragement for them to speak in the second person and to go to that place, does that shift as the client begins to build their own boundaries around becoming vulnerable and choosing to be vulnerable in that way?
LF: It can shift. The next step in Voice Therapy is to look at how these voices are affecting your life. What actions are you engaged in based on these thoughts? And the next step in Voice Therapy is to collaborate with the person on changing their behavior, to act in their own self-interest, and resist acting on the voices. I think that what happens initially—if they start to act in their own self-interest, or refrain from the self-destructive behaviors so they're acting against the voices—is the voices are going to get louder. That's the first thing that's going to happen. And I always educate people about that. First, they're going to get louder. It's almost like it’s this monster inside of you. Every time you give into it, you're feeding it, and the monster gets stronger and takes more and more control over your life. You want to starve the monster. But the monster's not going to be happy about that. It's going to throw a tantrum. It's going to get louder. And it's almost like a parent yelling at you to get you back into line.
RA: Do you find that the ferocity of the voice dies over time?
LF: If you can stay with that behavior and go through that anxiety, which you're going to feel, the monster is going to get weaker and weaker—almost like a parent that gets tired of nagging and sort of fades into the background.

And it doesn't mean you'll never have that thought again. Particularly, either at times of stress or, conversely, at times when you're acting the most different from the parent in positive ways—out of nowhere, some of those self-destructive thoughts will come up. Something can happen in the person's current-day life, a particular stressor. I think about this financial crisis we're currently facing: somebody who has underlying self-destructive thoughts but has come a long way from that in their life could get triggered back to feeling like a failure, for instance, because their stock went down or they lost all their retirement funds or they lost their job.
VY: In the Great Depression a lot of people jumped out buildings, but most people didn't.
LF: Yes. And that's actually probably a misconception. According to the research that's been done on it, there were a couple of high-profile suicides you could really link to the Great Depression, but the suicide rate didn't go up dramatically at that time. It was rising slowly at that point and it continued to rise slowly after that, when things got better, too. But certainly when a person has underlying vulnerability… And then there are people that have what David Rudd would call fluid vulnerability for suicide. These are people who have usually had a lot of trauma in their early lives, and they can easily get triggered back into that state of being suicidal, even from things like seeing a method. He talks about a business executive who had had some very serious suicide attempts, but who was doing really well in his treatment and was feeling a lot better. But then he went on a business trip out of town, and the hotel room happened to have a balcony that was over a great height. He went out on it and he had the thought, "Just kill yourself, just jump." And he was like, "Oh, no, my treatment isn't working; I'm a failure." And Rudd said no, you are doing fine in therapy, but even just seeing a method can trigger somebody who has a lot of fluid vulnerability back into that vulnerability.
RA: That coping mechanism's still alive.
LF: Yes. I would say that self-destructive, incorporated parent is still alive. And it's like somebody with a substance abuse habit who encounters one of their triggers: it can start a whole thought process that could go down that road.

The Impact on Therapists

VY: Have there been studies on what the effect is on therapists who have clients that have successfully committed suicide?
LF: There's not a whole lot of research. There are now support groups online for therapists who've lost clients to suicide. It can be really beneficial for therapists to talk to other therapists who've had that kind of loss. It happens to one in seven people in their training years. One in five clinical psychologists will lose a client to suicide in the course of their clinical career, one in two psychiatrists. And it's not because psychiatrists do a worse job; it's that they tend to see more disturbed patients.
VY: So what have you found in terms of effects it has on therapists?
LF: I think it's all the same kind of effects that there are on surviving family members. I think there's first the shock: it is hard to believe that somebody you care about could actually do this. And if you've been working with the person for a while, there’s often a lot of care and concern you've had for this person, and involvement with them. I think there is a lot of self-recrimination that people go through: “If only I'd done this. What if I had done that? I should have said this.” There's also a lot of anger, of wanting to blame it on somebody else, too. And that can be the family; it could be somebody else in the person's life who did something that wasn't helpful.

For a family member,
if somebody killed your loved one, you'd clearly be angry at the murderer. But when the murderer and the victim are the same person, it's very confusing.
if somebody killed your loved one, you'd clearly be angry at the murderer. But when the murderer and the victim are the same person, it's very confusing. And then there are often fears about, “What does this mean about me and my confidence? What does it mean about me? Could this happen to me?” Family members feel that a lot. Or, “Should I kill myself because I didn't do this or that?” And then there can be a slow process of resolving it, but I don't think it's something you can rush or say it should just be over. It's a process. It's worth getting help with that process, because it is really difficult on an emotional level to lose a client.
RA: And as you said earlier, and I'm sure the support groups would really help with this, but you can't take responsibility when someone else does it.
LF: Ultimately, you can't. I think there's an idea that therapists can foresee these things with some kind of magic lenses. And about violence potential of clients, too—that somehow, magically, we can do that. I don't think that the research shows that we're necessarily very good at either of those things. But I think we can really be listening and we can be paying attention and take action to help prevent a client’s suicide. And when we have clients that feel like they're a burden, and when they feel like they don't fit in anywhere, and when they have that acquired ability to commit suicide because they do dissociate or they do disconnect from themselves, then you've got a high-risk mixture of somebody who's likely to actually do it.

What's Up Next, Doc?

VY: Well, we've covered a lot of ground today.
RA: Yes.
LF: We have.
VY: And you've covered a lot of ground in your career. What's currently interesting you most?
LF: We’re currently going to write a book about couple relationships—well, about individuals, about learning to love and develop yourself in your capacity to be close and vulnerable and giving in a relationship. People will pick it up because they want their partner to learn how to do all those things.

We have learned the form that these negative thought processes take in relationships—that the voice is really almost like a coach: coaching you to protect yourself, coaching you to take a certain stance toward your partner, not to be too giving, to take control of the situation and not be too vulnerable, to look at all your partner's potential flaws as opposed to focusing on their good traits. And this coaching sounds friendly to yourself—it sounds self-protective as if you're taking care of yourself—but it's often destroying your relationship. And it's really based on a posture of defending yourself and maintaining your original fantasy bond or connection with your parent, and being self-parenting; listening to this voice is really destructive to having the satisfaction and closeness and fulfillment you really could have in a relationship. It's often what destroys relationships. People who are perfectly good choices for one another often play this out in such a way as to destroy the relationship, or to make it a whole lot less satisfying than it could be even if they stay in it. We really want to try to help people with that. We have a couples group we're doing now with some young couples, trying to help them earlier on in their relationship life to be able to stick in there and take back the projections they make onto one another that really have to do with the people they grew up with and not with the person they're with.
It's amazing how much, as partners in relationships, we take on the projections of our partner and really feel like we are that way. And pretty soon we’re reenacting that person for our partner.
It's amazing how much, as partners in relationships, we take on the projections of our partner and really feel like we are that way. And pretty soon we’re reenacting that person for our partner.
VY: So projective identification doesn't happen only in therapy.
LF: Unfortunately, no. Wouldn't that be nice if we had to walk into a therapist's office to do that? I think we do that with our partners, certainly, because, if you think about it, all the same emotions are triggered. If you look at the attachment research on how early attachments affect your later adult attachments, and if you look at just biochemically what's going on, it's the same kind of hormones and neurochemicals that are being released in long-term relationships as in parent-child bonding. All of those neural pathways get triggered in a close relationship where we want to make ourselves vulnerable, but we're very afraid to make ourselves vulnerable, too. But if people can think about these thoughts that they have, which seem self-protective, as a coach that's actually out to destroy your relationship, not to help you, I think it can be really helpful for people to start to catch on to what they're doing. I think it's a tool that therapists could use to help couples understand themselves better, too, and understand what's going on in the relationship.
VY: Speaking of attachment, it's time for us to detach.
LF: Yes. I will let you detach. I will go teach.
RA: Thank you so much.
VY: Or as they say in this field, "Our time is up."
LF: Yes, our time is up, right.

Copyright © 2009 All rights reserved. Published March 2009.
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Lisa Firestone Lisa Firestone, PhD, is Director of Research and Education at the Glendon Association. Since 1987, she has been involved in clinical training and applied research in suicide and violence. In collaboration with Dr. Robert Firestone, her studies resulted in the development of the Firestone Assessment of Self-Destructive Thoughts (FAST) and the Firestone Assessment of Violent Thoughts (FAVT). Dr. Firestone has published numerous professional articles, and most recently was the co-author of Sex and Love in Intimate Relationships, Conquer Your Critical Inner Voice, and Creating a Life of Meaning and Compassion: The Wisdom of Psychotherapy.
Rebecca Aponte Rebecca Aponte was the Operations Manager for from 2008-2012. She then left California for graduate school, earning a PhD in Psychology from Colorado State University - an experience that only deepened her appreciation for the experience she was exposed to during her time with Rebecca now works for the California Department of State Hospitals.
Victor Yalom Victor Yalom, PhD is the founder and resident cartoonist of He maintained a busy private practice in San Francisco for over 25 years, but now sees only a few clients, devoting the bulk of his time to creating new training videos for He has produced over 100 videos, conducted workshops in existential-humanistic and group therapy in the US, Mexico, and China, and currently leads consultation groups for therapists.  More info on Victor and his artwork and sculpture at

CE credits: 2.5

Learning Objectives:

  • Explain the role of negative thoughts in suicidality
  • Explain the role of negative thoughts in suicidality
  • List the causes and impacts of therapist anxiety with suicidal clients
  • Recognize causes and impacts of therapist anxiety in working with suicidal clients
  • Describe several key points of Voice Therapy
  • Describe several key points of Voice Therapy

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here