From the Suicidal Mind to Building a Therapeutic Alliance: implications for risk assessment

Suicidal behavior is a complex phenomenon resulting from the interplay of multiple factors. While the prevalence and characteristics of suicidal behavior are consistent across countries, the causes are multifactorial, involving personality, cognitive, social, and environmental influences. However, for a proper understanding of the suicidal mind, it is therefore imperative to emphasize that a phenomenological approach is strategic in this context. It is essential to go beyond diagnoses and classical clinical pictures and pay attention to unbearable mental pain ("psychache"), intolerable emotion, or anguish. Most suicidal individuals do not want to die but seek escape from suffering. This article delves into the intricate mental processes at play beneath suicidal thoughts and behaviors, paying particular attention to how they affect the therapeutic alliance formed between mental health professionals and those at risk. It tackles a key difficulty in mental health care: that clinicians often struggle to engage with individuals, sometimes hampering outcomes effectively. Through qualitative data gathered from clinical interviews and case studies, the study sheds light on the subjective experiences of suicidal individuals. Perceptions of trust, understanding, and empathy, it turns out, are key to therapist-client interactions. The findings suggest that a greater awareness of these dynamics strengthens the therapeutic alliance and improves how suicidal patients perceive the quality of care they receive. This demonstrates the importance of mental health professionals developing tailored methods that prioritize empathy and trust.  This kind of approach is essential for assessing the risk of suicide, which is what this overview is all about.  This study shows how such risk and therapeutic relationship are connected, and it calls for a change in the way mental health care is given to people who are at risk of suicide.

INTRODUCTION

Globally, suicidal thoughts and behaviors represent a serious public health issue, impacting numerous populations with concerning trends.

Suicide risk arises from an interplay of biological (including genetic), psychological, clinical, social, and environmental factors, making individual risk assessment difficult. Effective suicide prevention requires a multi-sectoral approach involving health, education, law enforcement, and other sectors. Restricting access to means of suicide, treating depression and substance abuse, and school-based interventions are effective strategies. Open communication, empathetic listening, and direct questioning about suicidal intent are crucial for helping at-risk individuals.

Earlier research has demonstrated the complex link between mental pain and suicidal wishes and behavior, emphasizing the requirement for extensive strategies that go beyond standard treatments. Suicidal thoughts are complex, and individual circumstances vary considerably, necessitating a more thorough understanding of the suicidal mindset, specifically concerning mental health professionals’ interactions with these individuals. While a strong therapeutic alliance is vital for improved treatment results, studies suggest many mental health professionals struggle to connect meaningfully with suicidal individuals, often due to misunderstandings and biases regarding their experiences ¹. This article aims to tackle the core problem of inadequate engagement strategies for suicidal individuals in mental health care. The overall goal is to encourage a more empathetic and effective therapeutic relationship in clinical practice. The main goals are to investigate the mentalistic factors behind suicidal ideation, pinpoint obstacles to forming therapeutic alliances, and suggest practical ways to improve clinician-patient engagement. Consequently, it hopes to shed light on how to improve mental health outcomes for people dealing with suicidal thoughts and behaviors. This inquiry is significant not only academically but also practically for mental health professionals, as it may potentially influence best practice standards that emphasize empathy and understanding.

Narratives surrounding suicidal ideation and behavior reveal complexities that necessitate a comprehensive understanding of the suicidal mind, as well as the important therapeutic alliances. As research in suicidology progresses, it becomes evident that traditional approaches to mental health care, mainly on psychiatric diagnoses and risk factors, fail to adequately address the emotional and psychological needs of individuals grappling with suicidal thoughts and actions. There is therefore a need for a paradigm shift toward understanding the unique subjective experience of each suicidal individual.

The established significance of fostering strong therapeutic relationships emerges; effective engagement through compassion and empathy is essential for ameliorating suicide risk ². Literature underscores that establishing a therapeutic alliance — marked by trust, collaboration, and comprehension — is fundamental for effective therapy, especially for patients with suicidal ideation ³. By employing patient-centered approaches, physicians manage symptoms while also facilitating meaningful discussions to investigate the emotional suffering of their patients. Research underscores the significance of narrative therapy as a vehicle for validation and empathy, essential in the treatment of suicidal patients. Research indicates that traditional psychiatric models frequently overlook individual narratives, prioritizing symptomatology above emotional experiences, which leads to patient alienation and diminishes the efficacy of conventional therapies. Cognitive-behavioral methods targeting cognitive distortions linked to suicidal thoughts should be combined with compassionate therapy involvement to enhance good outcomes, according to the literature. The decrease in suicide risk associated with a strong therapeutic connection contests the idea that medication alone is enough for addressing the intricacies of suicidal thoughts and behaviors. Despite significant progress, deficiencies persist in the literature regarding customized therapy approaches tailored to individual experiences. A demand for sophisticated methodologies that integrate cognitive, emotional, and relational methods with standardized intervention protocols is apparent. The literature highlights the necessity for additional investigation into how physicians might adeptly address ethical concerns associated with suicidal patients, especially with confidentiality, risk assessment, and individual autonomy. The existing gaps underscore the necessity for forthcoming research to enhance ongoing practitioner education, augmenting therapeutic practice with empathy-focused frameworks that prioritize the patient narrative.

This overview synthesizes existing research to address knowledge gaps and enhance the practice of establishing therapeutic relationships, emphasizing sympathetic understanding and customisation. Ultimately, the integration of narrative, cognitive, and relational methods will be analyzed as we redefine therapeutic paradigms for individuals within the complex context of clinical practice. It is anticipated that this will yield a more transparent framework for comprehending and addressing suicidal individuals, thereby cultivating an environment that prioritizes emotional well-being and resilience in the face of crises.

SOME FACTS ABOUT THE SUICIDAL MIND

Classical suicidology supports the notion that the central concept is that unbearable psychological pain, or “psychache,” is the primary driver of suicidal behavior ^4,5. Suicide is viewed not as a movement toward death, but as an attempt to escape intolerable suffering. In this view, understanding the suicidal mind requires empathy and a phenomenological approach — clinicians must try to see the world from the patient’s perspective, recognizing their unique suffering and unmet psychological needs ⁶. Over the past decades, it has become clear that many suicidal individuals give warning signs or communicate their intentions before acting. Recognizing and responding to these signs by advocating for a collaborative, nonjudgmental, and supportive therapeutic relationship is crucial for prevention. Clinicians should validate the patient’s experience, encourage narrative storytelling, and focus on the person’s needs rather than just their symptoms. In investigating the suicidal scenario, a clinician may come across the “tunnel vision,” experienced during a suicidal crisis, that, through a dichotomous thinking process, individuals conclude to see only two options: continued suffering or relief through suicide. Feelings of worthlessness, loss, and emotional pain fuel this thinking.

Maltsberger et al. ⁷ investigated the psychological mechanisms contributing to suicide, emphasizing the significance of overwhelming subjective (internal) experiences over mere outward traumatic occurrences. The authors contend that trauma is not solely a result of external events (such as abuse or bereavement), but rather the mind’s incapacity to manage the profound feelings these events elicit. In this context, trauma is characterized as an overwhelming emotional experience from which the individual feels unable to escape.

Traumatic experiences can originate from both external events and internal psychological conditions. Intense feelings, including despair, hopelessness, self-loathing, fury, and annihilation anxiety (the sensation of the self disintegrating) are pivotal to the suicide crisis.

Not all individuals experience trauma from identical situations; the ability to withstand suffering differs among people, shaped by genetic and developmental influences.

Suicidal crises frequently manifest as recurrent, intense emotional states (sometimes perceived as flashbacks) that resonate with past traumatic experiences, particularly during childhood. Continual exposure to intense emotional crises might diminish hope and hinder the capacity to establish affectionate bonds, complicating the rehabilitation process.

The authors underscore the need of comprehending the subjective, interior experiences of individuals at risk for suicide, rather than concentrating exclusively on external events or diagnoses.

Apart from repetitive emotional and traumatic experiences of any kind, there is also a strong association between mental pain, childhood traumatic experiences, and suicide risk in psychiatric patients. Assessing and addressing mental pain and childhood trauma is crucial in suicide prevention strategies ⁸.

For the prevention of suicide to take place, there is a need to focus on the patient’s inner emotional world, especially the unbearable affective states that drive suicidal behavior. Repeated emotional trauma, whether from external events or internal mental states, can corrode hope and relationships, increasing suicide risk.

POINTING TO THE RELATIONSHIP WITH INDIVIDUALS IN CRISIS

Suicidal patients often have difficulty communicating their intent, and clinicians may not always address suicide directly. Conventional, physician-centered methods emphasize psychiatric symptoms and risk management, frequently resulting in a power disparity and overlooking the patient’s subjective experience. The Aeschi Working Group promotes a patient-centered approach that prioritizes attentive listening to the patient’s narrative and comprehending the significance of their suicidality ^9,10 contends that this agony transcends mere depression or sadness, representing a distinct, profound, and frequently ineffable feeling that may compel individuals to contemplate suicide as a means of escape. The profound, subjective psychological anguish (psychache) typically underpins suicidal ideation and actions. This suicidal anguish is characterized as an intolerable, all-encompassing internal suffering. Patients employ vivid, metaphorical language to articulate their anguish. This agony is frequently perceived as foreign, malevolent, or as a dominating force that overtakes the self. The anguish often revolves on many types of loss: the loss of loved ones, the loss of abilities or status, and self-imposed loss (such as renouncing one’s talents or relationships).

The initial clinical interaction is pivotal: commencing with the patient’s narrative before clinical evaluation helps cultivate trust and participation.

Hawton et al. ¹ emphasized that the conventional method of suicide risk assessment in mental health practice, which predominantly depends on risk prediction instruments and stratification (e.g., categorizing patients as low, medium, or high risk), is largely ineffective. The authors argue that these strategies are ineffective due to their low predictive value and lack of improvement in patient outcomes. Numerous persons who die by suicide are frequently evaluated as low risk immediately before their deaths, underscoring the inadequacies of existing predictive methods. The authors propose a transition to a more therapeutic, patient-centered methodology. This encompasses Collaborative Risk Formulation, which involves establishing a therapeutic alliance with the patient, dedicating time to comprehend their specific circumstances, and jointly identifying modifiable risk factors and unmet requirements. Acknowledging that suicide risk is variable and may fluctuate swiftly, evaluations must be continuous and responsive to emerging knowledge. Thorough Data Collection: Utilizing data from the patient, collateral sources (such as family, friends, and other professionals), and clinical observation to comprehend risk and protective variables, warning indications, and the patient’s story. Clinicians should collaborate with the patient and, when suitable, their support network to discern patterns that precipitate suicide crises and formulating methods to disrupt these patterns. This encompasses both short-term measures (e.g., means restriction, insomnia treatment, social support engagement) and long-term support (e.g., psychiatric therapy, social integration). Clinicians should jointly formulating a safety plan with the patient, delineating actions to undertake during a crisis, recognizing coping mechanisms, and guaranteeing a secure atmosphere. Safety strategies must be routinely assessed and revised as conditions evolve.

Narrative interviewing enables patients to articulate the context of their suicide attempt, establishing them as authorities on their own experiences.

This method requires the therapist to be receptive, impartial, and encouraging, thereby facilitating patients’ feelings of understanding and reducing the likelihood of their withdrawal from the therapy process.

An effective story interview is devoid of stigma, optimistic, and credible to both the patient and the clinician.

EXPLORING SUICIDE RISK THROUGH PATIENTS’ NARRATIVES

The therapeutic alliance — the collaborative, trusting relationship between therapist and patient — is vital for effective treatment of suicidality.

The quality of this relationship may influence treatment adherence and positive outcomes, even in pharmacotherapy for depression and bipolar disorder.

Pompili et al. ¹¹ investigated a large sample of psychiatric patients. They found that those with both high depression and high mental pain had the highest rates of suicidal ideation and behaviors. The high depression/high pain group also had the highest rates of serious suicidal thoughts, intent, and plans. Mental pain (sometimes called “psychache”) was a significant factor distinguishing patients with higher suicidality, even among those with similar levels of depression. The intensity, frequency, and duration of suicidal ideation were all higher in the high depression/high pain group. Patients with high depression and high mental pain were more likely to be treated with antipsychotics, antidepressants, mood stabilizers, and anxiolytics. The combination of high depression and high psychological pain identifies psychiatric patients at the most significant risk for suicidal ideation and behavior.

Patients’ narratives, which often convey the features of mental pain, if assessed routinely alongside the assessment of major depression in psychiatric patients, prove to be an additional strategic tool for the proper management of patients in crisis. Interventions should target both depressive symptoms and psychological pain to reduce suicidality.

Suicidal patients often feel misunderstood or processed impersonally, which can lead to poor trust in clinicians and high dropout rates. A collaborative and trusting relationship between the patient and therapist is essential for effective treatment, characterized by empathy, respect, openness, and a shared understanding of the goals.

Suicidal behavior is conceptualized as goal-directed action, often arising when life goals are threatened and self-evaluation is negative.

Narrative interviewing, where patients tell the story behind their suicide attempt, helps foster understanding and alliance ³.

Orbach ¹⁰ stressed that patients’ narratives reveal the deeply subjective, overwhelming, and often indescribable nature of their suffering. The pain narratives illustrate that suicidal mental pain is a complex, overwhelming, and isolating experience that is difficult to express in ordinary language. These stories highlight the importance of empathy, validation, and understanding in therapeutic settings. Individuals use intense and unique metaphors to describe their pain, such as “a toothache in the heart,” “a stunning dizziness,” or pain that “explodes in me silently, and yet it is deafening.” The pain is often described as an alien force that takes over the self.

Mental pain is frequently experienced as physical sensations — choking, pinching, constricting, or a sense of being strangled or suffocated. Sufferers feel that their pain is unique and incomprehensible to others, which increases their sense of isolation and makes it difficult to ask for help. The narratives often center around profound experiences of loss — loss of loved ones, abilities, self-esteem, or a sense of self. This can lead to feelings of emptiness, worthlessness, and a fear of “going crazy” or losing one’s mind. People in extreme pain may experience contradictory feelings (oxymoronic experiences)at the same time, such as wanting to live and die simultaneously, or feeling both hope and despair. The pain is often accompanied by self-hate, guilt, and a sense of being fundamentally flawed or unlovable.

EXPLORATION OF MENTAL PAIN IN PSYCHOTHERAPEUTIC WORK

It is of foremost importance to emphasize that understanding and addressing the unique, subjective experience of suicidal pain is crucial in therapy. Empathy, affirmation, and a robust therapeutic alliance are essential in assisting patients to feel less isolated and more equipped to manage their distress.

Orbach ¹² posits that mental anguish encompasses more than mere bad feelings; it also involves a perception of loss of control, emotional alienation, and behavioral inclinations such as withdrawal and escape. This anguish is formed by the enduring internalization of adverse experiences and inadequate coping strategies.

The therapeutic process has multiple phases ¹²: Phase 1: Preliminary Healing Engagement. The therapist must address their own worries regarding death and suicide to be truly present and empathetic towards the patient’s dying wish. Phase 2: Augmenting Interpersonal Interaction. Forming an authentic, empathetic, and individualized bond is essential. The therapist ought to identify a positive attribute in the patient to cultivate attachment and empathy. Phase 3: Navigating the Discomfort. The therapist helps the patient thoroughly examine and understand their pain, making it more tolerable and less daunting. This encompasses recognizing patterns, causes, and methods to mitigate distress. Phase 4: Addressing Self-Destructive Behaviors. The patient is encouraged to explore the origins of their self-destructive habits, often finding a connection to early life experiences and established patterns. Phase 5: Transforming the Internal Realm. The therapist assists the patient in questioning and reevaluating their negative self-beliefs, thereby creating opportunities for a new internal structure and significance. Phase 6: Conclusion and Future Readiness. Therapy extends beyond the patient’s improvement; it include equipping the patient for potential setbacks and fostering resilience to avert relapse. Rather than immediately trying to persuade the patient to live, the therapist empathizes with the suicidal wish, understanding why suicide seems like the only option. This deep empathy can paradoxically open the way for hope and alternative solutions.

In this context, the therapist helps the patient expand their reflective space between triggers and actions, and to find meaning or “presents” in their suffering, which can foster growth and resilience.

Therapists should advocate for a deeply empathic therapeutic stance, where the therapist seeks to understand and validate the patient’s pain without immediately trying to correct or fix suicidal thoughts. This empathy can reduce the patient’s sense of isolation ¹⁰. Therapists are encouraged to help patients find words or symbols for their pain, which can make the experience more manageable and less isolating. The therapist and patient should ally against the pain, using language like “we” and “us” to foster togetherness. Therapists can also engage in “symbolic giving” — reflecting positive qualities to the patient and sharing experiences — to help rebuild self-esteem. Hard as it can be, healing involves confronting and working through the most frightening aspects of the pain, not just alleviating symptoms.

SUICIDE RISK ASSESSMENT AND THE UNDERSTANDING OF THE SUBJECTIVE STATE

In dealing with suicide risk assessment and management, clinicians are called on to emphasize that suicide is a multifactorial phenomenon and not solely the domain of psychiatry, despite the high prevalence of mental disorders among those who die by suicide. The traditional medical model that places the entire responsibility for suicide prevention on psychiatrists should instead be replaced by a more collaborative, multidisciplinary approach involving families, carers, and other professionals.

The limitations of traditional risk stratification (categorizing risk as high, medium, or low) are now challenged by a dynamic, individualized approach. This entails evaluating both “risk status” (the individual’s risk in comparison to similar groups) and “risk state” (the person’s current susceptibility in relation to their baseline).

Risk assessment should focus on comprehending and mitigating risk rather than precisely forecasting individual suicide occurrences. The risk of suicide is dynamic, capable of rapid fluctuations, occasionally within hours or days, influenced by life events or alterations in mental state. Evaluation must be continuous and frequently revised, rather than a singular assessment ¹³.

According to Pisani et al. ¹⁴, a contemporary, prevention-focused risk assessment includes several key components. Risk Status entails evaluating an individual’s risk in comparison to similar populations (e.g., a depressed patient assessed against other patients with depression). Risk State: The individual’s current susceptibility compared to their baseline (e.g., are they experiencing a decline relative to their typical condition?). Clinicians should assess: 1) Available resources What internal (coping mechanisms, resilience) and external (family, friends, support networks) resources can assist the individual in managing crises? 2) Anticipated Changes: What imminent events or stressors may significantly elevate risk (e.g., job loss, relationship dissolution)? There are also key areas to explore in the assessment, such as protective factors, as seen in the case of “What Keeps the Person Going?” (family, children, religion, hobbies, etc.). Long-term Risk Factors are also of interest: Psychiatric history, family history of suicide, trauma, demographic/cultural factors.

1) Impulsivity and Self-Control: Substance use, ability to manage emotions, risk of acting on impulse. Past Suicidal Behavior: Previous attempts, ideation, plans, or intent. A particular emphasis is placed on assessing the current state, including suicidal ideation: the nature, frequency, and controllability of thoughts, as well as the presence of plans or intent. 2) Assessment of Stressors: Recent or continuing life events (e.g., depression, divorce, illness, shame, guilt, bereavement). 3) Indicators such as: Despair, social withdrawal, diminished autonomy, and lack of prospects. 4) Assessment of Reality: Is the patient truthful and participatory? Are they concealing information? 5) Engagement Level: Readiness to collaborate with healthcare professionals and family members.

Involving family, friends, and caregivers in the assessment and safety planning is also crucial, where feasible. For patients lacking a support network, identifying therapies is more complex and requires increased effort and short-term follow-up appointments.

The Columbia Suicide Severity Rating Scale (C-SSRS) serves as a validated instrument for evaluating suicidal ideas and behavior, hence enhancing identification and triage processes.

Healthcare professionals must record all evaluations, justifications for decisions, and therapeutic strategies. Risk assessments should be routinely updated, particularly following substantial alterations in the patient’s circumstances. To mitigate liability risk, the objective is not to forecast suicide with absolute precision, but to provide demonstrable, evidence-based care. The notion of foreseeability (reasonable prediction of danger) holds greater significance than predictability ¹³.

CONCLUSIONS

Clinicians should work with patients to develop a shared understanding of the patient’s suicidality, rather than relying solely on traditional diagnostic approaches.

Most suicidal patients are experiencing intense mental pain and loss of self-respect, making them vulnerable and withdrawn. There is a window of opportunity after a suicide attempt when patients may be more open to discussing their experiences. Clinicians should adopt a non-judgmental and supportive approach, listening openly to the patient’s perspective, as this initial encounter is crucial for future therapy adherence. Interviews should begin with the patient’s own story, placing the suicidal crisis in the context of their life history, which can help restore a sense of mastery. The ultimate goal is to establish a therapeutic relationship with the patient, helping them re-establish life-oriented goals through empathetic understanding. There is a need for new models that view suicidal behavior as goal-directed and related to life experiences, rather than simply given diagnoses.

Psychiatrists and other clinicians should be trained to assess and manage suicide risk using dynamic, individualized methods, while also involving families and support networks. Proper documentation, adherence to standards of care, and the use of validated tools are essential for effective prevention and legal protection. Suicide risk assessment is an ongoing process that involves understanding the individual’s unique context, current state, and potential future stressors, while leveraging available resources and support. It is collaborative, prevention-focused, and should be well-documented and regularly updated.

Given the peculiarity of the assessment, a collaborative risk formulation that paves the way to establishing a therapeutic partnership with the patient, dedicating time to comprehend their specific circumstances, and together identifying modifiable risk factors and unmet requirements, may prove to be a strategic perspective for risk management.

The author advocates for a shift from reductionist, quantitative approaches to more qualitative, empathetic, and collaborative methods in treating suicidal patients.

Conflict of interest statement

The author declares no conflict of interest.

Funding

None.

Ethical consideration

The paper regards a narrative review without ethical implications.