Staff Perspective: Might ACT Provide an Important Inroad in the Treatment of Suicidal Thinking and Behaviors During COVID-19 and Beyond?

Staff Perspective: Might ACT Provide an Important Inroad in the Treatment of Suicidal Thinking and Behaviors During COVID-19 and Beyond?

Dr. Erin Frick

Our profession continues to bend and shape to meet the needs of clients amid the COVID-19 pandemic. However, one concern taking up space in most mental health professionals’ minds is how the pandemic will impact suicide risk. The conventional wisdom is that the associated life stressors, relational challenges, and greater access to firearms due to a surge in sales all may lead to a perfect storm whereby more people will be at risk of dying by suicide. While I’ve been wrestling with this concern, I’ve also begun leading parts of our two-day Acceptance and Commitment Therapy (pronounced as the word “ACT”) training. This got me thinking about how psychological flexibility, the key psychological process that ACT therapists target, is compromised leading up to and during periods of suicidal crises.

As a starting point for this consideration, I want to introduce the 3-Step Theory (3ST) of Suicide by Drs. Klonsky and May, which offers insight into the development of suicidal thinking and behavior. It is considered an “Ideation to Action” framework meaning that it describes both the development of suicidal thinking and addresses the progression from suicidal thinking to suicidal behaviors (often in the form of a suicide attempt). According to 3ST, step one involves the combination of pain and hopelessness that is required to bring about suicidal ideation. The second step suggests that connectedness plays a mitigating role to protect against strong suicidal ideation. As such, suicidal ideation strengthens when the pain and hopelessness experienced is greater than one’s sense of connectedness. When there is also suicide capacity present, then suicidal behavior is likely to occur. Suicide capacity is a combination of one’s dispositional traits (i.e., pain sensitivity); acquired ability- habituation to experiences associated with fear, injury, or death (which makes me wonder, might our vast exposure to the loss of life from COVID-19 work against us by building capacity?); and practical factors that make a suicide attempt easier such as knowledge of and access to lethal means (i.e., the surge of firearm purchases during the course of the pandemic certainly isn’t helping us on this front).

If you’re thinking about suicide, are worried about a friend or loved one, or would like emotional support, the National Suicide Prevention Lifeline network is available 24/7 across the United States.

CALL 1-800-273-8255 (English speaking)/ CALL 1-888-628-9454 (Spanish speaking)

The Lifeline is also available via chat

Let’s take a moment to consider, do most people (not just patients seeking mental health services) experience pain, which may also be framed as psychological suffering? I think it is fair to say that it would be difficult, if not impossible, to find anyone who hasn’t struggled from time to time, especially in the context of the current pandemic. Psychological pain may show up due to loss of loved ones, health scares and anxiety, disruptions in daily living, stress associated with families being in periods of lockdown, financial distress due to unemployment or job insecurity, etc. Realistically, that list could have just kept going. So, pain…CHECK. What about hopelessness? Are people feeling a sense of hopelessness as the pandemic is well into year 2 without an end in sight. Absolutely, some are…CHECK.

How about we turn our attention to connectedness, might there be people struggling with how their relationships have had to change due to the pandemic? For sure. I can’t begin to count how many times I’ve personally had to step back and really think about whether the social commitments of myself or our family are in our best interest due to the virus; determining where to draw that line over and over is stressful in and of itself. While many people have found ways through technology and safety measures to stay connected, this remains a challenge for a lot of people and the other aspects of connection noted by 3ST such as connection to a job, purpose, or activity may be compromised due to the pandemic. CHECK!

What this leaves us with is a group of people during the pandemic who may have developed serious suicidal ideation, with capacity for suicide being the buffer between thoughts and actions. The way forward may seem bleak from the picture I’ve just created. However, that’s ultimately where the magic happens in ACT. What if there was a way to…

  • Open up to one’s experiences of pain and hopelessness without avoiding?
  • Develop a present moment awareness of the internal and external events that are the source of these experiences without judgment?
  • Connect with others and within oneself around the difficulties brought on by the pandemic?
  • Engage in meaningful, purpose-driven actions that bring us closer to the life we want?

Lucky for us, there is…ACT! As I see it, ACT might serve as a powerful response to the hardships and suffering brought on by the pandemic, especially as it could aid in the mitigation of suicidal thinking and behavior. From an ACT perspective, Dr. Kirk Strosahl describes how suicidal thinking and behavior is ultimately a way that people try to solve the problem of pain. From this lens, we can view it as a form of avoidance behavior. By taking a functional perspective on suicide as ACT does, we can ask ourselves, “What is the function of suicidal thinking or behavior for my client?” Often what we might hear in response to that is, “I just don’t want to keep feeling bad. I can’t keep living like this.” From many other therapeutic perspectives, these statements might cause our own anxiety to heighten as a mental health professional. However, when working from an ACT perspective, that’s pure gold. We can agree with a client who says that their life in this particular moment is not worth living AND be curious about what is missing. Right behind that pain is a yearning that isn’t being voiced. Or maybe it IS being voiced and not heard. That is an invitation to acknowledge the unworkability of suicidal thinking and behavior in reaction to one’s pain. From this place of unworkability, we can begin focusing on making space and time for the pain and hopelessness to be voiced, felt, and experienced, something that is not happening when the mind participates in cognitive narrowing (often called “tunnel vision”) during the suicidal crisis.

In ACT, we work to move from this place of psychological stuckness that is experienced in a suicidal crisis, where suicide is believed to be the only solution out of the client’s suffering and move toward greater flexibility. In these moments of crisis and psychological rigidity, it’s as if the mind has decided that pain is bad, if pain can’t be eliminated with conventional strategies (because being human naturally involves pain at times), then the only way forward is to take the nuclear option of suicide. But what if the mind is simply wrong, operating from faulty rules to begin with? What if these rules are based on assumptions that ignore a basic fact of human existence: life is really, really hard at times….for everyone. From an ACT perspective, that is the stance. Through multiple processes of learning, language, and social conventions, the mind picks up these rules and applies them inappropriately and rigidly, even when the consequences are harmful like in the development of suicidal thinking and behavior. ACT as a transdiagnostic therapeutic approach can begin to help our clients, and people in general, to not take the mind so seriously and to question its conclusions. If the mind isn’t always right, if we can consider that its predictions and statements are not facts, then maybe there is space for new actions. In ACT, these new behaviors can be more closely aligned with one’s values and in doing so, opportunities for greater purpose may present itself. While for some, the option of suicide may not completely disappear. Suicidal thinking and behaviors may be especially prone to return in times of heightened distress, and with ACT tools, clients may learn to see suicide as an empty promise of relief from the mind, and simply one option out of many to choose from, to be free to choose a response rather than the mind running their life.

If you’re thinking about suicide, are worried about a friend or loved one, or would like emotional support, the National Suicide Prevention Lifeline network is available 24/7 across the United States.

CALL 1-800-273-8255 (English speaking)/ CALL 1-888-628-9454 (Spanish speaking)

The Lifeline is also available via chat 

For additional resources on ACT and Suicide, I highly recommend the following:

  • Listen to Dr. Kirk Strosahl’s interview on working with clients with suicidal thinking and behavior from an ACT approach
  • Read book: Chiles, J. A., Strosahl, K. D., & Weiss Roberts, L. (2018). Clinical manual for assessment and treatment of suicidal patients (2nd edition). American Psychiatric Association Publishing. 1615371370
  • Visit the website for the Association for Contextual Behavioral Sciences (ACBS), a learning and research community, and a living resource for anyone interested in ACT, Relational Frame Theory, and Contextual Behavioral Science
  • Visit Dr. Strosahl’s Heart Matters website

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Erin Frick, Psy.D., is a clinical psychologist and Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.