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Hello Dr Saltzman,

I am a counselor undergoing training at this time. I've encountered a lot of literature and advice on what depression, anxiety, or any other illnesses present around all of us are, as well as ways available to face and overcome them, but as a counselor I am constantly wondering about how best to be when I'm approached by someone who expresses his/her grave disappointment of life, that life is not worth living at all (". . . I don't think life is worth living any more") .

I guess the (more) crucial point to note is the state of mind of the person saying this, at that point in time, and not so much the methods and treatment strategies to be employed in helping the troubled individual. Am I right to say this, doctor? As such, may I ask your expert advice how counselors or therapists should intervene if any client were to display such negativity, and obviously be in a rather vulnerable, delicate (unstable) state?

Thank you very much for your kind attention and advice. Truly appreciate your help.

Best regards,

Colin Ho

Dear Colin Ho--

Thanks for your question. Of course you are correct in saying that as a therapist it is important to note the state of mind of the person with whom you are speaking. That kind of noticing is the very essence of therapy whether the therapy deals with thoughts of suicide or anything else. In fact, in my opinion, a significant amount of healing may take place simply by the act of one person (the therapist) tuning in empathically to the thoughts and feelings of another (the patient).

However, dealing with thoughts of suicide has special requirements of which the therapist must be aware. This is because suicide, unlike most other actions, is final and irrevocable.

The first requirement is to assess how great and how serious the threat of suicide really is. This should be done with delicacy, but without beating around the bush. For example, I might say to a patient, "You know, when people begin to question whether life is worth living, sometimes they feel that suicide would be a good way to end their pain. I wonder if you have been feeling that way."

If your patient confirms that suicidal thoughts are part of his or her experience, you should then ask if he or she has thought about how to do it. In other words, you are asking if that person has a definite plan. If so, the risk of suicide is great, and must be addressed immediately. I like to make a contract with my patients which requires them not to commit suicide without first telling me that they are about to do it. This may seem pointless or foolish since anyone could break such a contract, but in my experience it can work well. After such a contract has been established, you should then go on to make a complete depression assessment (see my article on depression), and begin to explore the details of the patient's life.

To answer your specific question, if you want to be of help to those who question whether life is worth living, you should try to remember those times in your own life when perhaps you felt that way. After all, living can be difficult at times, and clinging to existence, while trying to enjoy something--life--which often is painful, and must end in death anyway, may even seem absurd. Try to go deeply into your own experience in order to determine what it is that makes your life worth living. This will help you to understand and tune in to others' doubts, fears, and ambivalence.

To repeat this in a different way: healing in therapy begins with the therapist's attunement to the inner world of another human being. That kind of attunement requires a keen instrument of observation and understanding, and this species of observation and understanding can only be based on the therapist's honest observation of and understanding of his or her own life. This is why all therapists must, in my view, have had their own therapy and asked themselves very serious questions before they presume to offer help to others.

Good luck with your training.

Be well.

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