Rethinking how to help people with suicidal thoughts

Much as most of us who are not drawn to it don’t want to think about suicide, the Centers for Disease Control tells us that about 12.2 million American adults considered it seriously in 2020; 3.2 planned it, 1.2 actually attempted to kill themselves, and 46,000 succeeded in doing so that year.

Dr. Yosef Sokol of Passaic, a clinical psychologist with a Ph.D. from Hofstra University, an assistant professor at Touro University’s school of health sciences and a research scientist at the VA medical center in the Bronx — and also a rabbi with smicha from Yeshiva Bais Yosef — “wanted to create a therapy that would help people” who think about, plan, or survive suicide attempts, he said. “I don’t want just to maintain them in being alive, but to help them have a sense of who they are, and who they want to be.

“I’ve done a lot of research and have found that when people have a sense of themselves as growing over time, and of liking who they are becoming, it helps them get better.”

Most work with people with suicidal ideation — there’s no easy term for the people in this group, Dr. Sokol acknowledged, but he prefers this one to suicidal — tends to try to help them get beyond preventing thoughts of suicide, or at least reducing those thoughts. Most work now aims at a cure.

“In the standard medical model, the goal is to cure,” Dr. Sokol said. “Then people will no longer care about suicide, and they’d be at no more risk for it than anyone else.

“But the reality is that once people have attempted suicide, it’s unlikely that they’d never consider it again. So our goal is not necessarily to get rid of that, but to help them gain lives that are full of meaning.”

It’s not that a full cure — the total cessation of suicidal ideation — wouldn’t be wonderful and entirely welcome, he added; it’s just that it’s unlikely. “If you make the goal a cure, then people feel like they’ve failed if they haven’t reached it,” he said. “People feel self-judgment, and also that other people are judging them. They feel like their doctors are judging them.”

He feels that the standard cognitive behavioral models that generally are used “don’t deal with people’s sense of identity. Not just their thoughts or emotions, but a core sense of themselves. The working model that people have of themselves, that they use to interpret everything that happens in their lives.

“We’ve learned a lot about identity in the last 20 or 30 years, but we haven’t integrated as much of it” into work with people with suicidal ideation as has been used in work with people who have such conditions as schizophrenia.

“That led me to this study,” Dr. Sokol said. “I was trying to develop a theory that is recovery-oriented and helps people grow. No one knows what recovery is for people with suicidal ideation, and no one had figures for it. And how could I create a therapy for recovery if no one knows what recovery means?

“So I did a comprehensive review of everything out there.” This work, which he undertook with a team, underwent the standard rounds of feedback, revision, more feedback, more revision, and has resulted in a model of recovery that he is using with his patients at the VA and elsewhere. He got a grant from the VA to do that work, and he’s published the model in the journal BJPsych Open.

The model can be summarized — very briefly — as COURAGE; that acronym stands for Choosing life; Optimizing identity; Understanding yourself; Rediscovering; Acceptance; Growing connectedness; and Empowerment. “Taken in a general sense, the seven processes span the scope of human life — what it is to live, grow, and find meaning and purpose,” he said.

Dr. Sokol’s work so far has concentrated on veterans, whose experiences have made them more likely than non-veterans to think about suicide. But the model applies to other communities as well.

“I’m an Orthodox Jew, and part of a community,” he said. He’s a scientist but he’s also a rabbi. “I learned through my own religious experience about the importance of meaning and growth and the transformation of people’s lives,” he said. “The truth is that we’re all people. We do science, but we are people.” His spiritual development informs his clinical work; it applies to all people, not just Orthodox Jews, or for that matter just Jews.

It’s both general and specific; the specificity has to do with the way each community applies it. “The actual therapy I created was for veterans,” Dr. Sokol said. “The Orthodox community also has a specific culture, and that allows us to focus a little more on the spiritual side, although many veterans also are spiritual. And I talk a little less about physical courage with the Orthodox community. We have to make sure that each therapy is tailored to the specific community.

“I am also working with one of my students at Touro, a Black woman, who tells me what makes sense for her community. It may be more of a peer model, based on her community and culture.”

Community is an important part of this model. “Many veterans are not part of a community, but they want to be,” he said. “This model both gives people the tools to be part of a community” and forms a community; most of the therapy is done in groups. “The idea of group therapy is new in the VA,” he said.

“I am also developing an individual version, but I really love doing it in groups,” he continued. “People end up trying to help each other, which becomes part of the recovery process.

“Then people feel that they are not alone. Being alone often is part of suicidality. When you grow connectedness, you have the sense that your identity is connected with others. You become part of something. You get a sense of belonging. You feel that you overlap.

“You feel that you belong.”

Not everyone needs that, he added. “Every individual has their own needs. Many try to grow into the sense of belonging to something bigger than yourself.” It isn’t necessarily a religious group. “It could be a family, a group that you share values with. It could be a political group.”

Going back to his COURAGE model, “not everybody needs every one of these things,” he said.

“And a good clinician probably does some of these things anyway, and probably knows intuitively that connection and social networks are important,” but having that intuition researched, formalized, and put in writing is new. “Suicidality doesn’t exist in a vacuum,” Dr. Sokol said.

It will take about 10 years for his model to be accepted widely, he concluded. “Things that are meaningful take time.” But he wants people to know about it, to think about it, to act on it. “This work should not be just about keeping people alive, but about helping them have productive, meaningful lives.”

He invites anyone who would like to talk to him about their experiences to email him at sokol.yosef@gmail.com.