Exploring existential and emotion-focused change processes in persons with severe and persistent mental illness and a long-standing death wish

Persons with severe and persistent mental illness (SPMI) may sometimes develop a long-standing death wish with persistent suicidality and/or an euthanasia request. Despite growing ethical and clinical attention to this population, their possible change processes remain understudied. This cross-sectional mixed-methods study explored existential and emotion-focused change processes among persons with SPMI and a long-standing death wish attending a drop-in care and expertise centre in Belgium. Change Questionnaire data (N = 107, a subset of 2022–2024 attendees) showed that a minority reported change (31.6%) and half of the participants reported helping factors. Longer duration of attending the care services was associated with greater experienced change. Qualitative analysis revealed fragile, variant change processes: increased self-compassion, self-assertion, relief, and peace through openly expressing the death wish, renewed hope and ambivalence, and shifts in relating to life and death. Helping factors were the counselor’s relational presence (non-judgmental acceptance, experiential attunement) and peer support, while ongoing emotional pain, relational difficulties, trauma, and societal marginalization posed significant challenges. The findings suggest that experiential approaches may facilitate meaningful existential and emotional change in this population and highlight the importance of presence, validation, and meaning-making when working at the intersection of life, death, and enduring severe suffering.