Through our workFootnote 1 with military service members and their family members who have experienced a recent suicidal crisis, we have learned that emotions immediately preceding such crises vary significantly from person to person. During individual psychotherapy sessions, our clinicians ask patients to share their suicide stories to better understand the circumstances that resulted in the suicide-related hospitalization and which circumstances resulted most often in the decision to attempt suicide. While providing this narrative, patients report a wide range of emotions that preceded the suicidal crisis such as intense despair, extreme excitement, agitation, uncontrollable anger, numbness, or indifference, as well as debilitating feelings of inadequacy.
We believe that an important clinical strategy in working with suicidal patients is to first identify emotions that activate and shape a patient’s trajectory from suicidal thinking to suicidal behaviors. The next step is to understand the intensity of these identified emotions so that we can teach the patient to modulate these emotions more adaptively in the future. By mapping out the patient’s emotions in a stepwise fashion, the clinician is able to help the patient identify key points for early intervention strategies, such as a self-soothing technique, deep breathing exercise, or other healthy coping technique (e.g., calling a friend, engaging in strenuous exercise) to impede further escalation.
We have found that the use of a simple tool known as an emotional thermometer is an effective way to help patients identify and map out the intensity of the emotions they experienced during their suicidal crises. The emotional thermometer is a worksheet that contains a drawing of a mercury thermometer with blank hash marks that represent degrees of temperature. The top of the thermometer represents the patient’s emotional state at the peak of the suicide crisis, while the bottom represents a calm or neutral state. The clinician works with the patient to identify the typical emotions (in temporal order) that the patient experiences as the suicidal thoughts become activated and escalate into a suicidal crisis.
When filling out emotional thermometers, individuals often indicate that depression is a chronic stressor in their lives. As such, depression is conceptualized as an amplifier,—increasing the intensity of other emotions,—as well as an escalator,—increasing the speed at which one moves toward the top of the emotional thermometer (or gets worked up). In a similar fashion, anxiety is viewed as a chronic stressor that typically works to increase one’s overall sensitivity. Hence, anxiety also works as an amplifier and an escalator in most individuals’ thermometers. While depression and anxiety states are certainly important to pay attention to, it is important to note that intense emotions (whether related or unrelated to these states) appear to directly shape the patient’s suicidal thinking and planning.
Emotional thermometers offer several benefits to individuals who struggle with suicidality. First, the emotional thermometer organizes chaotic suicidal experiences and enables patients to increase self-awareness and self-understanding. Second, by not focusing exclusively on one emotion, patients can understand how different emotions interact with and build upon one another in an escalating process. Third, the systematic examination of the emotions in a crisis allows the patient to develop an objective perspective, which the patient can then reference in the event of a future crisis. Fourth, and most importantly, clinicians and patients can use emotional roadmaps of suicidal crises to develop suicide prevention plans tailored to each individual’s unique experiences, preferences and abilities.
- Ghahramanlou-Holloway, M., Cox, D., & Greene, F. (2012). Post-admission cognitive therapy: A brief intervention for psychiatric inpatients admitted after a suicide attempt. Cognitive and Behavioral Practice, 19, 233-244.
- Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Journal of the American Medical Association, 294(5), 563-570.
- Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., … Bruce, T. O. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry, 172(5), 441-449.
DCoE offers free mobile applications providers can use with their patients to help manage stress, anxiety, and depression:
- Breathe2Relax: Offers exercises to teach deep breathing techniques that help with stress management
- T2 Mood Tracker: Allows users to monitor and track their emotional health
- Virtual Hope Box: Award-winning app that contains simple tools to help patients with coping, relaxing, distraction, and positive thinking
[Return from Footnote 1] The intervention that we use is called Post-Admission Cognitive Therapy (PACT), which is an inpatient adaptation of the efficacious outpatient cognitive behavioral treatment.