In her memoir, Judy Collins (2003) wrote, “Two questions that are at the heart of treating someone who wishes to end their life are: ‘Where does it hurt?’ and ‘How can I help you?’” (p. 117). The “hurt” Collins refers to is not always located in a single place. Chronic pain, social isolation, lack of employment or shelter, emotional turmoil, constricted thinking, destructive habits, addictions, existential nihilism, and many more factors can trigger suicidality.
Given the immense range and complexity of human suffering and helping options, we believe that organizing our search for “where it hurts” and “how we can help” is essential. Using the seven-dimension model for case formulation will make it easier to notice and nurture client strengths. In addition to Collins’s questions of “Where does it hurt?” and “How can I help you?” we add “Where are you strong?”
TABLE 1.1 Brief Descriptions of the Seven Dimensions
| Dimension | Evidence-Based Suicide Driver | Wellness Goal |
| Emotional | ||
| All human emotions Cognitive | 1. Excruciating emotional distress | 1. Emotional peace and calm |
| 2. Specific disturbing emotions (guilt, shame, anger, or sadness) | 2. Specific positive emotions (happiness, joy, etc.) | |
| 3. Emotional dysregulation | 3. Emotional regulation | |
| All forms of human thought, including imagery Interpersonal | 1. Hopelessness | 1. Hope |
| 2. Problem-solving impairments | 2. Problem-solving skills | |
| 3. Maladaptive thoughts | 3. Adaptive thoughts and beliefs | |
| 4. Negative core beliefs | 4. Positive core beliefs | |
| All human relationships | 1. Social disconnection and perceived burdensomeness | 1. Social connection and perceived usefulness |
| 2. Interpersonal loss and grief | 2. Skills for coping with loss | |
| 3. Social skill deficits | 3. Positive social skills | |
| 4. Repeating dysfunctional relationship patterns | 4. Repeating functional relationship patterns | |
| Physical | ||
| All human biogenetics and physiology | 1. Biogenetic predispositions and physical illness | 1. Healthy biogenetics and wellness |
| 2. Sedentary lifestyle, poor nutrition | 2. Active lifestyle, positive nutrition | |
| 3. Agitation, arousal, anxiety | 3. Physical calmness | |
| 4. Trauma, nightmares, insomnia | 4. Skills for coping with trauma | |
| Cultural-spiritual | ||
| All religious, spiritual, or cultural values that provide meaning and purpose | 1. Religious or spiritual disconnection | 1. Religious or spiritual connection |
| 2. Cultural disconnection or dislocation | 2. Cultural connection | |
| 3. Meaninglessness | 3. Meaningfulness | |
| Behavioral | ||
| All human action and activity Contextual | 1. Using substances or cutting for desensitization | 1. Openness to experience |
| 2. Suicide planning, intent, and preparation | 2. Life planning and preparation | |
| 3. Impulsivity | 3. Self-control | |
| All factors outside of the individual that influence human behavior | 1. No connection to place or nature | 1. Connection to place or nature |
| 2. Chronic exposure to unhealthy environmental conditions | 2. Healthy environmental conditions | |
| 3. Socioeconomic oppression or resource scarcity (e.g., poverty) | 3. Socioeconomic support, resources, and social justice | |
Using the Seven-Dimension Model for Initial Treatment Planning
Although we have only minimal information about Alina in the opening case presentation, the seven-dimension model can contribute to a holistic understanding of her and her situation. We offer a brief description of how you might use the dimensional model to guide further assessment and treatment planning.
Emotional Dimension
Alina’s previous attempt, her cutting behaviors, and her presenting affect speak to her intense distress. At a minimum, initial work with her could focus on strategies for emotional regulation and practical methods for distress tolerance.
Cognitive Dimension
Alina’s statement about not being sure that anything will ever help her feel better is an indication of hopelessness. Much more assessment is needed, but beginning with questions about what gives her hope and what diminishes her hope is a reasonable place to start.
Interpersonal Dimension
Alina is isolated and lonely. Not only does she long for a romantic relationship, but she also feels estranged from her family. Gathering more information about her relationship history, patterns, hopes, and skills is essential to building a comprehensive treatment plan.
Physical Dimension
Alina is opposed to antidepressant medications. To provide a complete treatment plan, it is important to gather more information about her medical history and her exercise, sleep, and nutritional habits.
Cultural-Spiritual Dimension
Alina’s sexual identity may have made her a target for micro- or macroaggressions as well as cultural oppression. In addition, it would be helpful to know more about