Hi Mohsen,

Thanks for your important question. Because severe hopelessness is a risk factor/sign of depression and suicide, I’d consider the following:

1. Validation: I’d explore the emotional components of the person’s hopelessness (e.g., alienation, loneliness, forsakenness, perceived failure, powerlessness, helplessness, being trapped, etc.) and the sequence of events that precipitates, perpetuates, and predisposes his/her hopelessness (Scioli & Biller, 2009). I'd validate his/her feelings, and efforts and attempts made to deal with his/her problems.

2. Strengths-finding: Using a trans-theoretical approach, I’d explore the person’s risk factors (e.g., severe losses and/or setbacks, and/or illnesses, etc.) and protective factors (e.g., support system, internal and external strengths and resources, etc.).

3. Combating demoralization, instillation of hope, and enhancing motivation to become self-efficacious are some of the therapeutic principles and strategies to guide my interventions (Burns, 1999; Frank & Frank, 1993).

4. After some rapport building and problem exploration, a series of miracle questions and relationship questions via solution-focused brief therapy might help the person look at the future without his/her problems and thus instill hope and motivate and empower the person to work toward a more positive future (De Jong & Berg, 2013; Knekt et al., 2008).

Best,

Stephen

Stephen Cheung's answer covers most of what the suggestions I would have made except two other suggestions. 

Please do not assume that the hopelessness is the cause of the suicidality.  There is a common assumption that hopelessness or depression always comes first and that suicidality is a symptom of the hopelessness and / or depression.  Some patients are hopeless or depressed because of their suicidality.  (One example of a situation where someone feels hopeless because of their suicidality is a person experiencing command hallucinations to kill themself.  This person is simply tired of coping with these suicidal symptoms so they feel hopeless about their situation.)  If this patient happens to experience hopelessness because of their suicidality, it may be triggering for them if you approach their situation with the assumption that the hopelessness came first because it may cause them to feel even less understood.  Approaching the situation with this assumption may also make developing rapport more difficult.  I always recommend allowing the patient to explain which came first in their natural history instead of making these assumptions.   (I have spoken to a number of patients that experienced this assumption by their clinicians. They tended to report feeling worse and being less likely to trust the clinician afterward.)

I also recommend not approaching the factors are contributing to the hopelessness and / or suicidality with the hope that they can be 'solved".  It is important to realize that not all of these factors have solutions.  If a patient feels hopeless and is experiencing suicidality as the result of a terminal illness, there isn't a magical way for either the clinician or the patient to solve the issue of the terminal illness.  Sometimes the focus needs to be upon finding whatever good exists in their life and trying to increase that good instead of trying to solve the problems that exist.   

both complementing and comprehensive answers. Thank you 

Thanks, Jennifer, for your excellent input. Yes, command voices, and psychotic symptoms (e.g., visual, auditory, and tactile hallucinations including dreams), loss of rational thinking, substance abuse, or impulsive behavior are some of the risk factors of suicide. Validating the person's different feelings rather than resolving them is the way to go.

If there are suicidal risks, a regular and thorough suicidal assessment is in order (e.g., the person's history, intention, ideas, plans and/or means of suicide, plus possible risk factors as well as protective factors).

indeed.

Thank you BOTH, that was really helpful 

In addition to my prior comment, if you are going to manage this patient, I would suggest using the Sheehan-Suicidality Tracking Scale (S-STS).  If the patient has engaged in suicidal planning, I also recommend the Suicide Plan Tracking Scale (SPTS).  You can get the S-STS from the appendices in first link below.  You can get the SPTS by messaging me directly.  An example of how complex suicide assessment can be is illustrated in the case report in the last link.  The links take you to a special edition of the Innovations in Clinical Neuroscience journal that is entirely focused on suicidality.

http://innovationscns.epubxp.com/i/425963/92

http://innovationscns.epubxp.com/i/425963/164

excellent. I will message you 

I would concur with the above comments, though in addition suggest looking at Heather Fiske's application in SFBT terms of Shenidmans 10 commonalities.  I have found this very useful when providing interventions to those presenting with acute perturbation.

Since my point of view, suicidal risk must be studied through two main perspectives: Lethality and Intentionallity. Hopelessness may be the main feature of intentionallity, but not the only one of all of them.  What we now call Suicidality is a dinamic process that should be considered no matter if there were an actual crisis or there weren't,, it is always suicidality. So, hopelessness is just one of many factors that we should take care, and not the only one. I think we just can't improve a hole and complex construct of suicide by simply managing a single feature or symptom. My Mentor Dr. Guilherme Borges has largely  studied suicide as a dinamic and longitudinal process rather than a transversal situation. I'm agree with Dr. Cheung about the valuable coping strategies he suggested, but they might not work within very depressed patients. which often have distorted thoughts.

Another tool that may be helpful if you want to target the hopelessness is the Suicidality Modifiers Scale.  It is one of the scales mentioned in the prior paper on the complexity of suicide assessment (the second link in my most recent post).  It has a total of 6 questions focused on  the role the hopelessness has on the patient's suicidality.  Send me a message if you would like a copy of that scale. 

Thanks, Dr. Molina-Lopez, for your insightful comments on the dynamic nature of suicidality. Suicide is indeed dynamic, multidimensional and multidetermined and therefore requires an ongoing multidimensional assessment and a team approach to treatment.

For severely suicidal clients, medications together with psychosocial interventions are often needed; involuntary hospitalization is sometimes required in the States.

Solution-focused therapy is not a panacea, but it can engender hope and empower some clients to use their internal and external resources to better their lives. Thanks to Julie. Heather Fiske's Hope in Action: Solution-focused Conversations about Suicide seems to be an excellent resource:

http://www.amazon.com/Hope-Action-Solution-Focused-Conversations-Suicide/dp/0789033941#reader_0789033941

Great responses to an important and challenging question. I agree with the point about validation, as it is all to easy (and problematic) to assume the individual "just" needs to look on the bright side, because the hopeless patient's situation is often quite bleak. For example, we commonly see patients with lifelong struggles with affective disorders, with disappointing response to multiple medical and psychosocial interventions. It is important to acknowledge that such conditions by their very nature make it difficult to sustain hope. Taking a hopeful stance and trying to convince the patient not to give up hope is often experienced as invalidating and results in the patient trying harder to show the therapist why the situation is, indeed, hopeless. On the other hand, taking a collaborative stance that overtly labels hopelessness as a key issue that "we" will address together, can lead to creative strategies that involve the patient's strengths and values. An practical example of this is the Hope Kit from Aaron Beck's research, in which a collection of inspiring items, from photographs to music playlists, to inspirational passages are collected for use when the individual's hope wanes. The collaborative process puts that patient more on an equal footing with the therapist and helps to strenghten the therapeutic relationship.

Dear Colleague

this is a challenging question

I find Dialectical Behavior Tharpy of M.M. Linehan very effective with suicidal patients, especially if hopeless. It includes a compassionate attitude toward clinets coupled with a problem solving attitude and a very struictured way for teaching how to cope with heplessness and suicidal thoughts and actions.

Best

Lavinia Barone

I have seen many positive responses to DBT, but they didn't last for longer than a year or two at the most.  Many of the patients I have seen respond to DBT seemed to find an increase in their suicidality shortly after the DBT training had completed.  I have always thought that maybe this positive response to DBT is the fact that part of DBT requires clinicians to actually acknowledge the patient's experience of suicidality, as opposed to the common "If we ignore it, it will go away" concept that many clinicians use in terms of suicidality.  (I have actually heard a patient tell me their psychiatrist responded to their reporting of their suicidal ideation that, "We don't talk about that here" and have heard many other stories from other patients.

Based on the patients I have interacted with, the skill training in DBT does not seem to be helpful to them.  Some studies have shown that patients need repeated training on these skills over several years.  I would like to see a study conducted where one group of suicidal patients gets no DBT, one group gets complete DBT, one group gets only the skills training part of DBT, and one group gets only the acknowledgment of their experience of suicidality part of DBT.  I suspect that the acknowledgement only and the complete DBT groups would have similar responses and the no DBT and only skills training groups would also show similar responses.  I suspect the latter responses would be much less than the former two groups.  Until someone does such a study on DBT, to look at the impact of the different parts of DBT, I won't be convinced that the skills training is actually helpful for most patients.