Why They Work

If mental illness is unrelated to the reduction of suicidal behaviors in suicide-focused treatments, what is the “something else” that these treatments are acting upon? Based on the research reviewed in the previous chapters, I would argue that the “something” involves decision-making processes related to self-regulation. Specifically, DBT and CBT-SP seem to reduce the probability of suicidal behaviors because they strengthen individuals’ internal braking systems, helping them to choose not to act upon suicidal impulses and urges in stressful situations.

DBT, CBT-SP, and the CRP focus on teaching individuals how to respond to stressful situations in a more balanced and less extreme manner, thereby helping them to adopt a safer decision-making style and to stick with successful methods even when they occasionally do not work.

They may still experience emotional distress in response to life events, but the magnitude of this stress may be reduced. Many patients who have completed CBT-SP say, for example, that the treatment helps them to “not get so worked up,” or to better modulate their emotional distress.

Why Suicide-Focused Treatments Work Better than Status Quo Treatments Neuroscience research suggests this enhanced ability to self-regulate may be associated with positive changes in brain functioning and connections. 

Evidence that a stronger wish to live inhibited or blocked the emergence of suicidal behavior, even among those who possessed a strong wish to die. A weaker wish to die did not inhibit the emergence of suicidal behavior, however, suggesting that positive rather than negative psychological states and experiences played an especially important preventative role.

These patients continued to experience stressful situations in life, but they had acquired the capacity to inhibit their initial reactions to these situations, to consider alternative responses, and to select other goal-directed behaviors.

Reasons for living reflect those aspects of one’s life that motivate the wish to live; if you have a reason to live, you are much less likely to make decisions that threaten this motive.

Because reasons for living seemed to play such an important role in overcoming suicidal thoughts and reducing the probability of suicidal behaviors, we subsequently integrated reasons for living into the CRP by asking acutely suicidal individuals in the midst of an emotional crisis to spend some time thinking about their reasons for living or for not killing themselves.

We found that one of the most effective ways to help people who felt they had no reasons for living was to approach this situation like a lost set of keys. Most of us have lost our keys at some point and experienced the frustration and despair that often comes with this situation. Being unable to find our keys is not the same as our keys ceasing to exist, however. Those keys were somewhere, and we probably used one or more of the following strategies to find them: thinking of where we were and what we doing when we last had them, retracing our steps, and asking others for help. Reasons for living, we explained, were the same. Sometimes we can’t find them but that doesn’t mean they don’t exist, and we can use some of these same strategies to find them: thinking about what we were doing when we last felt that we had reasons for living, retracing our steps in life to revisit times and places when we had reasons for living, and asking others to help us find them. Just as we may not have found our lost keys right away, we also may not find our lost reasons for living right away, but if we remind ourselves that they must exist somewhere, we may be able to keep up the search long enough to find them again.

Most suicidal people are eventually able to identify at least one reason for living, at which point we would ask them to tell us a story about that reason.

 In the midst of a suicidal crisis, taking a few minutes to reflect upon what makes life worth living can help someone find their internal braking system and slow down.

Reasons for living that are motivated by the desire to generate or experience positive emotional states may, therefore, be better at offsetting suicidal thoughts and reducing the probability of suicidal behaviors than reasons for living that are motivated by the desire to avoid or withdraw from uncomfortable situations and negative emotional states.

For some, reasons for living and positive emotional states can provide an opportunity to create a new sense of purpose and meaning that didn’t exist before. 

Many individuals question the purpose of living, finding it hard to remember their reasons for living and what gives their lives a sense of meaning. Over time, the majority of suicidal individuals come to realize that they really do have purpose and meaning and reasons for living, even though they also may have problems that still need to be solved,

Not everyone experiences these improvements at the same rate, of course, but these results suggest there is a better than 50–50 chance that someone who is currently thinking about suicide will report an average level of well-being within a few months.

Although positive emotional states do not necessarily eliminate negative emotions, research suggests they support perspective-taking and planning for the future, and help us to identify and use adaptive coping strategies. Positive emotional states may therefore “undo” the harmful effects of negative emotions such as cognitive rigidity, cognitive bias, and avoidance, all of which increase vulnerability to suicidal behavior.