This is the second follow up post to the MUS Suicide Summit in Bozeman this past week. It focuses on specific suicide interventions. As I looked through this and the material in the previous post, it reminded me that Dr. Janet P. Wollersheim was a huge influential force in my understanding of suicide assessment. Thanks Dr. Wollersheim!
The following sections consist of basic ideas about suicide intervention options during a suicide crisis. These guidelines are consistent with Shneidman’s (1996) excellent advice for therapists working with suicidal clients: “Reduce the pain; remove the blinders; lighten the pressure—all three, even just a little bit” (p. 139).
Listening and Being Empathic
The first rule of working therapeutically with suicidal clients is to listen empathically. Your clients may have never openly discussed their suicidal thoughts and feelings with another person. Use basic attending behaviors and listening responses (e.g., paraphrasing and reflection of feeling) to show your empathy for the depth of your clients’ emotional pain is a solid foundation.
Establishing a Therapeutic Relationship
A positive therapy relationship is important to successful suicide assessment and effective treatment. In crisis situations (e.g., suicide telephone hotline) there’s less time for establishing therapeutic relationships and more focus on applying interventions. However, whether you’re working in a crisis or therapy setting, you should still use relationship-building counseling responses as much as possible given the constraints of your setting.
Within the CAMS approach, assessment is used to help therapists understand “the idiosyncratic nature of the client’s suicidality, so that both parties can intimately appreciate the client’s suicidal pain and suffering” (Jobes et al., 2007, p. 287). At some point after you’ve “intimately appreciated” your client’s suicidality, you may then make an empathic statement to facilitate hope:
I hear you saying you’re terribly depressed. Despite those feelings, it’s important for you to know that most people who get depressed get over it and eventually feel better. The fact that we’re meeting today and developing a plan to help you deal with your emotional pain is a big step in the right direction.
Clients who are depressed or emotionally distressed may have difficulty remembering positive events or emotions (Lau et al., 2004). Therefore, although you can help clients focus on positive events and past positive emotional experiences, you also need empathy with the fact that it isn’t easy for most clients who are suicidal to recall anything positive.
Clinician: Can you think of a time when you were feeling better and tell me what was happening then?
Client: (in a barely audible voice) No. I don’t remember feeling better.
Clinician: That’s okay. It’s perfectly natural for people who are feeling depressed to not be able to remember positive times.
Suicidal clients also may have difficulty attending to what you’re saying. It’s important to speak slowly and clearly, occasionally repeating key messages.
Helping clients develop practical plans for coping with and reducing psychological pain is central to suicide intervention. This plan can include relaxation, mindfulness, traditional meditation practices, cognitive restructuring, social outreach, and other strategies that increase self-soothing, decrease social isolation, improve problem-solving, and decrease feelings of being a social burden.
Instead of traditional no-suicide contracts, contemporary approaches emphasize obtaining a commitment to treatment statement from clients (Rudd et al., 2006). These treatment statements or plans go by various names including, “Commitment to Intervention,” “Crisis Response Plan,” “Safety Plan,” and “Safety Planning Intervention” (Jobes et al., 2008; Stanley & Brown, 2012). These statements describe activities that clients will do to address depressive and suicidal symptoms, rather than focusing narrowly on what the client will not do (i.e., commit suicide). These plans also include ways for clients to access emergency support after hours (such as the national suicide prevention lifeline (800) 273-TALK or a similar emergency crisis number.
Stanley and Brown (2005) developed a brief treatment for suicidal clients, called the Safety Planning Intervention (SPI). This intervention was developed from cognitive-therapy principles and can be used in hospital emergency rooms as well as inpatient and outpatient settings (Brown et al., 2005). The SPI includes six treatment components:
1. Recognizing warning signs of an impending suicidal crisis.
2. Employing internal coping strategies.
3. Utilizing social contacts as a means of distraction from suicidal thoughts.
4. Contacting family members or friends who may help to resolve the crisis.
5. Contacting mental health professionals or agencies.
6. Reducing the potential use of lethal means. (Stanley & Brown, 2012, p. 257)
Stanley and Brown (2012) noted that the sixth treatment component, reducing lethal means, isn’t addressed until the other five safety-plan components have been completed. Component six also may require assistance from family members or a friend, depending on the situation. All six of these components should be included in your documentation, including firearms management.
Identifying Alternatives to Suicide
Engaging in a debate about the acceptability of suicide or whether with clients with suicidal impulses “should” attempt suicide can backfire. Sometimes suicidal individuals feel so disempowered that they perceive the possibility of killing themselves as one of their few sources of control. Rather than argue, your focus is on helping clients identify methods for coping with suicidal impulses and find more desirable life alternatives. .
Suicidal clients may be unable to identify options to suicide. As Shneidman (1980) suggested, clients need help to “widen” their view of life’s options.
Shneidman (1980) wrote of a situation in which a pregnant teenager came to see him in suicidal crisis. She had a gun in her purse. He agreed with her that suicide was an option, while pulling out paper and a pen to write down alternatives to suicide. Shneidman generated most of the options (e.g., “You could have the baby and give it up for adoption”), while she systematically rejected them (“I can’t do that”). He wrote them down anyway, noting they were only making a list of options. Eventually, he handed her a list of options and asked her to rank her preferences. To both of their surprise, she indicated death by suicide was her third preferred option. They worked together to implement options one and two. Happily, she never needed to choose option three.
This is a straightforward intervention. You can practice it with your peers and implement it with suicidal clients. There’s always the possibility that clients will decide suicide is their #1 choice (at which point you’ve obtained important assessment information). However, it’s surprising how often suicidal clients, once they’ve had help expanding their mental constriction symptoms, discover more preferable options; options that involve embracing life.
Separating the Psychic Pain From the Self
Rosenberg (1999; 2000) wrote, “The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self” (p. 86). This technique can help suicidal clients because it provides empathy for their pain, while helping them see that their wish is for the pain, rather than the self, to stop existing.
Rosenberg (1999) also recommended helping clients reframe what’s usually meant by the phrase feeling suicidal. She noted that clients benefit from seeing their suicidal thoughts and impulses as a communication about their depth of feeling, rather than as an “actual intent to take action” (p. 86). Again, this approach can decrease clients’ needs to act on suicidal impulses, partly because of the cognitive reframe and partly because of the therapist’s empathic connection.
Becoming Directive and Responsible
Both ethically and legally, when clients are a clear danger to themselves, it’s the therapist’s responsibility to intervene and provide protection. This mandate means taking a directive role. You may have to tell the client what to do, where to go, and whom to call. It also may involve prescriptive therapeutic interventions, such as urging clients to get involved in daily exercise, recreational activities, church activities, or whatever is preventative based on their unique individual needs.
Clients who are acutely suicidal may require hospitalization. Many professionals view hospitalization as less than optimal, but if you have a client with acute suicide ideation, hospitalization may be your best alternative. If so, be positive and direct. Clients may have negative views of life inside a psychiatric hospital. Statements similar to the following can aid in beginning the discussion.
- I wonder how you feel (or what you think) about staying in a hospital until you feel safer and more in control?
- I think being in the hospital may be just the right thing for you. It’s a safe place. You can work on coping skills and on any medication adjustments you may need or want.
Linehan (1993) discussed several directive approaches for reducing suicide behaviors based on dialectical behavior therapy. She advocated:
- Emphatically instructing the client not to commit suicide.
- Repeatedly informing the client that suicide isn’t a good solution and that a better one will be found.
- Giving advice and telling the client what to do when/if he or she is frozen and unable to construct a positive action plan.
These suggestions can give you a sense of how directive you may need to be when working with clients who are suicidal.