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In the framework of mental dysregulation we look at mental distress differently. Not as a collection of separate disorders, but as a dysregulation in the relationship between the self and what happens in consciousness.

Human consciousness is dialogical. As a human being you have thoughts, feelings and desires, but you also always stand facing them and can ‘think something of them’. You can think and at the same time notice that you are thinking. You can feel something and at the same time feel that you feel it. There is always a relationship between the self and what presents itself in consciousness.

In mental distress that relationship becomes dysregulated

A feeling, thought or desire can become so large that it dominates the dialogue. It becomes compelling. It takes up room. It isolates. The self that normally relates to that experience has less and less freedom.

We see this in many forms of mental distress:

• In compulsion a thought becomes compelling
• In panic, fear becomes compelling
• In depression, low mood becomes compelling
• With voices, an inner voice becomes compelling
• In addiction, desire becomes compelling

And in suicidality the thought of death can become compelling.

In all these situations it is not only about the content of the experience. It is above all about how you relate to it. The feeling that you no longer have any room in the face of it. That you are trapped.

That feeling of being unfree often goes together with hopelessness. People feel that there is no future any more. That everything is stuck. That no other possibility seems to exist.

The thought of death is then not only a thought about dying. It is often an expression of deep dysregulation in the relationship with your own consciousness. The question is then not only how you get rid of the thought. The question is how you change your relationship with it.

In the same way that people can learn to deal with voices, people can also learn to deal with a thought of death. Not by denying it, but by exploring it. By bringing it into the dialogue.

The aim is not always that the thought disappears. The aim is that the balance of power changes. That room arises again. That someone can say again: there is a thought of death, but it does not decide everything.

The best suicide prevention is talking about it from within a relationship

There is a persistent misunderstanding that talking about suicide is dangerous. As if you would plant the idea in someone’s head. The opposite is true. What makes a thought of death dangerous is not the conversation, but being left alone with it.

If someone with a wish to die does not experience a relationship in which this can be said, the thought withdraws inside. There it can grow. The world becomes narrower. The thought can develop into a tunnel in which only one direction is still visible.

A conversation breaks through that isolation. But that only works when there is a relationship. When someone sits opposite you who stays, listens and does not want to solve things straight away. From such a relationship you can explore the wish to die together.

Exploring together, not solving

• What does that wish feel like exactly?
• How often is it there?
• When does it get stronger?
• What makes you no longer see a future?
• What used to give you a future?

These questions are not a checklist. They are a way of looking together at what is happening inside. In this way the thought of death comes out of isolation. It becomes part of a shared exploration, and stops being a lonely conviction.

Many people feel relief when they notice that their wish to die may be spoken within a relationship. The thought no longer has to be hidden. It no longer has to be carried alone.

It also helps to acknowledge that a thought of death is not in itself a moral failure. People think about death. That is part of human existence. The philosopher Martin Heidegger described the human being as a ‘Sein zum Tode’: a being that lives with the awareness that life is finite.

Everyone lives towards death. And every person in the end has influence on how that life ends. Acknowledging that does not mean encouraging suicide. It means taking someone seriously as a human being.

For many people it brings calm when they notice that their autonomy is respected. That control, panic or moralising does not follow straight away. That acknowledgement can open up room.

When the thought of death is no longer forbidden and can be carried in a relationship, it often loses part of its power. And in that room something other than only the end can sometimes appear again. Perhaps still small, but present. A possibility of living on.

The danger of the taboo

When suicidality is not talked about, more danger often arises. The thought then keeps circling in the head. It becomes stronger, lonelier and more absolute. People get stuck in what researchers call entrapment: the feeling of being locked in with no way out.

The same can happen when a care provider starts talking about euthanasia without being asked. Sometimes this happens out of discomfort. The wish to die is then translated into a legal or medical procedure.

But then the thought of death turns into a fixation on euthanasia. The conversation shifts from the experience to a procedure. And then the room to explore the relationship with the thought of death often disappears. That makes help harder.

That is why it is important first to dwell at length on the wish to die itself. What does it mean? Where does it come from? What is it trying to say?

Trauma, psychosis and the thought of death

In many cases a wish to die is connected with experiences of trauma, psychosis or long-lasting dysregulation. Trauma can lead to feelings of being stuck, shame and hopelessness. Psychosis can disturb the relationship with your own consciousness so much that thoughts and feelings become overwhelming. In all these situations the core is not only the content of what someone goes through. The core is how they relate to it.

Recovery then often means that the dialogue with those experiences slowly returns. Not that everything disappears. But that room arises again. Room to feel, to think, to doubt. And sometimes also room to see, despite everything, a little bit of future again.

And sometimes that recovery begins with something very simple. That someone may at last say out loud: I sometimes think that I want to die. And that someone sits opposite, from within a relationship, who says: tell me.

Jim van Os

Do you need help now?

PsychosisNet offers information. We do not offer a chat, a helpline or crisis support. If you or someone else is in immediate danger, call the emergency number in your country. If you are thinking about suicide, or you need to talk to someone now, see Need help now? for helplines by country.

Prof. dr. Jim van Os, Chair Division Neuroscience, Utrecht University Medical Centre. Jim works at the interface of ‘hard’ brain science, health services research, art and subjective experiences of people with ‘lived experience’ in mental healthcare. 

Jim has been appearing on the Thomson-Reuter Web of Science list of ‘most influential scientific minds of our time’ since 2014. In 2014 he published his book ‘Beyond DSM-5‘, and in 2016 the book ‘Good Mental Health Care’. In 2026 he published 'Wat psychisch lijden is'.

Want to read more?

Blogs by Jim van Os can be read here

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