Suicidal Thoughts

DENISE: I feel bad. I feel bad for wasting the day. I don’t get to things that I need to take care of . . . like my bills, like cleaning, like taking a shower. I usually end up feeling kind of pathetic . . . and guilty.

THERAPIST: On the one hand you seem to feel soothed and on the other hand, afterwards, you’re a bit critical of yourself?

Note that the therapist did not try to debate or exhort Denise to get out of the house or become involved with necessary daily tasks. Rather, through questioning, the therapist en- couraged her to examine more closely her as- sumption that she was really better off watch- ing TV all day in her house. This is the process we call “collaborative empiricism.” By the sec- ond session, Denise had reexamined her hypothesis about watching TV and remaining in the house all day.

DENISE: About watching TV in the house ver- sus getting out, I thought about that the other day. I remember telling you that it made me feel better to stay there. When I paid attention to what I really felt, it didn’t make me feel better. It just kind of blocked out feeling bad, but I didn’t feel better.

THERAPIST: It is funny then that when you talked about it, your recollection of the ex- perience was more positive than it actually was, but that sometimes happens with peo- ple. It happens to me too. I think that some- thing is good that’s not so hot when I actu- ally check it out.

We now return to the first session. After some probing by the therapist, Denise men- tioned that it sometimes feels like cognitive therapy “is my last hope.” The therapist used this as an opportunity to explore her hopeless- ness and suicidal thinking.

THERAPIST: What was going through your mind when you said, “This is my last hope”? Did you have some kind of vision in your mind?

DENISE: Yeah, that if this doesn’t work, I feel like I couldn’t take living like this the rest of my life.

THERAPIST: If it doesn’t work out, then what?

DENISE: Well, I don’t really care what happens to me . . .

THERAPIST: Did you have something more concrete in mind?

DENISE: Well, right this minute I don’t think I could commit suicide, but if I keep feeling this way for a long time, maybe I could. I don’t know, though—I’ve thought about suicide before, but I have never really thought about how I would do it. I know certain things stop me, like my kids. I think it would really hurt them and some other people too, like my mother. My mom is in good health now, but she may need me some day. . . . Yeah, those are the two things that stop me, my children and my mother.

THERAPIST: Now those are the reasons for not committing suicide. Now what are some of the reasons why you might want to, do you think?

DENISE: Because sometimes it just feels so empty and hopeless. There’s nothing to look forward to—every day is the same. My life is such a waste, so why not just end it?

The therapist wanted Denise to feel as free as possible to discuss suicidal thoughts; thus, he tried hard to understand both the reasons for her hopelessness and the deterrents to suicide. After determining that she had no imminent plans to make an attempt, the therapist said that he would work with her to make some changes. He then asked her to select a small problem that they could work on together.

THERAPIST: Now are there any small things that you could do that would affect your life right away?

DENISE: I don’t know. Well, I guess just calling my friend Diane in Florida. She called about a month ago and then again last week. Both times I told her I was busy and would call her back, but I haven’t. I’ve felt so down. I have nothing to say to her.

THERAPIST: Well, when she lived in the area, what kinds of things did you talk about?

DENISE: We have kids about the same age, so we would talk about our kids. We both like to read and we used to go to a book club together—so we would talk about the books we were reading. Both of us liked art. We used to attend lectures at the museum during the week, so we would talk about art and the lectures. We would spend time making plans to do things together in our free time.