Chapter 18: Suicidality
Nearly thirty thousand Americans take their own lives each year (Minino, Arias, Kochanek, Murphy, & Smith, 2002). Suicidal behavior is one of the most commonly encountered emergencies among mental health professionals. In fact, one in four psychologists and half of all psychiatrists will have a patient complete suicide during their careers (Kleespies, Deleppo, Gallagher, & Niles, 1999). The informed assessment and intervention of suicidality is critical and complex for even the most seasoned clinician. This chapter offers an evidence-based approach for this patient population. First, we define suicidality. Second, we provide a list of key empirically- informed questions that should guide one’s assessment of suicidality. Third, a brief review of the literature evaluating the efficacy of treatment strategies for suicidal patients is presented. Lastly, we present our symptom-focused treatment strategies illustrated by a case example of an 18 year-old suicide attempter.
Our definition of suicidality includes three main factors: ideation, plan, and intent. These factors are directly related to suicide risk and need to be assessed thoughtfully and responsibly. Suicidality can range from suicidal ideation with no plan or intent to die to suicide attempts with intent to die. Suicidal ideation, most generally, requires that the individual have current thoughts of death, of killing oneself, or of being killed. Some patients may present with passive suicidal ideation (e.g., “I wish I were dead”) but report having no plan or intent to kill themselves. For a subgroup of these patients, the idea of actively taking their own life is unfathomable. In contrast, some patients report active suicidal ideation that is more alarming to the clinician (e.g., “I feel like killing myself”). These patients, when asked, may report having a specific plan to kill themselves. A suicidal plan involves identifying a specific method, and possibly a given timeframe, in which the individual plans to kill oneself. The most common method of suicide, regardless of age, race, or gender, is firearms (Minino et al., 2002). Other common methods used by men include jumping, hanging, and carbon monoxide poisoning. For women, the next most frequent methods include overdosing on pills or ingesting solid and liquid poisons (AAS, 2002).
Once a patient reports having a plan, the clinician must assess for suicidal intent. Intent characterizes the individual’s level of commitment in carrying out the plan. Interestingly, patients may report having a specific plan but have no intent to die (e.g., “I thought about jumping off a bridge but I would never do it”). Others may describe their intent as ambivalent (e.g., “I am thinking about taking an overdose but I am not sure if I can go through with it”), while still others may have full intent to kill themselves (e.g., “I intend to shoot myself with my own gun this Sunday after my wife leaves town”).
Clinicians may be faced with patients who have already attempted suicide (i.e., patients who have acted on their suicidal ideation and plan). Roughly 750,000 Americans make suicide attempts each year that require medical attention (Minino, 2002). As compared to patients who have only thought about suicide, this subgroup of attempters is in a higher risk category for future suicidal behavior. In fact, 10% of all suicide attempters eventually die by suicide (Linehan, 1993a). Having briefly reviewed information about suicide ideation, plan, intent, and suicide attempts, it is critical for the clinician to be prepared to assess the suicidal patient. Below is an assessment guide comprised of empirically derived questions to aid the clinician.
Table 1: Assessment Guide
1. Given what you are saying about your current life circumstances, are you feeling hopeless or discouraged right now?
2. Have you been feeling so unhappy lately that you are having thoughts about death or of killing yourself?
3. Do you have a plan for how you would do this? What is it and do you have the means to carry this out (i.e., accessibility of instrument)?
If Yes to Plan:
4. How intent are you on carrying out this plan? What reasons do you have to live right now (i.e., assessing for intent and protective factors)?
5. Have you ever attempted suicide before?
The field of suicidology is lagging behind other areas of treatment research with respect to the number of randomized clinical trials and the clear definition of the primary outcome variable. Regarding the latter, it has been challenging for suicidologists to come to a consensus on terminology used to differentiate self-injurious behavior with intent to die from non-suicidal self-injurious behaviors. Hence, our subsequent review of the literature includes studies that reflect this definitional obfuscation.
To date, there are four different psychosocial interventions and three psychopharmacological interventions that appear to reduce repeated deliberate self-harm and suicidal behavior. A summary of these studies can be found in Table 2.
Hawton and colleagues (1998) reviewed 20 randomized clinical trials of patients engaging in repeated self-harm. Interventions used in these studies included problem-solving therapy, dialectical behavior therapy, inpatient hospitalization, the use of an emergency contact card in addition to standard therapy, and intensive outreach (e.g., home visits). Based on this review, only one experimental intervention was better than a control condition in decreasing suicidal behaviors: dialectical behavior therapy (DBT; Linehan et al., 1991).
DBT is a principle based cognitive behavioral therapy that was originally developed by Linehan (1993a; 1993b) for the treatment of chronically parasuicidal adult outpatients diagnosed with borderline personality disorder (BPD). DBT blends standard cognitive behavioral therapy with Eastern philosophy and meditation practices and it shares elements with psychodynamic, client-centered, gestalt, paradoxical and strategic approaches (Heard & Linehan, 1994). Parasuicide, as defined by Linehan (1993), includes any acute, intentional, self-injurious behavior resulting in physical harm, with or without intent to die (i.e., suicide attempts and non-suicidal self-injurious behaviors). In a controlled treatment trial, DBT significantly reduced suicide attempts and other parasuicidal acts (Linehan et al., 1991). Results were generally maintained at 1-year follow-up (Linehan et al., 1993; Linehan, Tutek, Heard, & Armstrong, 1994). More recently, two other randomized clinical trials using DBT with suicidal outpatients diagnosed with BPD have obtained promising results (Koons, Robins, Tweed, Lynch, Gonzalez, Morse, Butterfield, & Bastian, 2001; van den Bosch et al., 2002).
In addition to DBT, a psychodynamically-informed treatment approach was found to reduce suicidal behavior among adults diagnosed with borderline personality disorder (Bateman & Fonagy, 1999). This was a randomized clinical trial conducted in a partial hospital program where subjects received the experimental treatment for 18 months.
The third psychosocial intervention targeted repeated deliberate self-harm among outpatient adolescents (Wood, Trainor, Rotherwill, Moore & Harrington, 2001). The adolescents in this study had to have engaged in at least two incidents of deliberate self-harm over the course of a year. The study compared a group therapy containing elements of CBT and DBT coupled with care as usual to care as usual alone. Results suggested that the experimental condition significantly reduced repeated, deliberate self-harm behaviors. Because the investigators did not assess suicidal intent specifically, it is unclear whether any of these behaviors had suicidal intent. Noteworthy is that acutely suicidal adolescents were excluded from the study.
The fourth intervention, a randomized controlled trial, investigated whether ongoing contact with a mental health professional would reduce suicide rates in persons at risk (Motto & Bostrom, 2001). Patients hospitalized for depression or suicidality were contacted 30 days after discharge about follow-up treatment. Those patients (N=843) who refused ongoing care were randomly divided into two groups. The first group was contacted by letter at least four times a year for five years and the second group received no further contact. Results found that patients in the contact group had a lower suicide rate in all five years of the study, with significantly lower rates in the first two years. By year 14, no differences between groups were observed, suggesting a diminution of the frequency of contact and discontinuation of contact appear to reduce and eventually eliminate this preventive influence.
Regarding medication, Hawton and colleagues (1998) reviewed studies examining the effects of pharmacological interventions on suicidality in adults. They found significant reductions in rates of suicidal behavior with trials of depot flupenthixol (a neuroleptic) as compared to placebo. Another recent review of the literature finds substantial evidence that long-term lithium treatment is correlated with reduced rates of suicide attempts and fatalities in patients diagnosed with bipolar disorder (Baldessarini & Jamison, 1999). Others have reported Clozapine to be effective in reducing suicidal ideation/behavior among adult patients diagnosed with schizophrenia and schizoaffective disorder (Meltzer & Ghadeer, 1995).
In an attempt to address the two most common presentations of a suicidal patient to a practitioner, we are first going to illustrate treatment strategies relevant for a patient recently discharged from an inpatient unit following a serious suicide attempt. The second scenario entails the same patient becoming acutely suicidal during outpatient treatment. The following is a case presentation that will be applied to both scenarios.
Bianca is an 18 year-old Hispanic female referred for outpatient treatment following a 2- week psychiatric hospitalization secondary to an overdose of 30 pills of her mother’s tricyclic antidepressants with intent to die. During initial intake, Bianca revealed a long psychiatric history of depression, panic attacks, multiple suicide attempts, and non-suicidal self-injurious behaviors (e.g., self-cutting) since age 13. Other areas of clinical concern include school truancy, significant relationship problems with family, peers and boyfriend, and a history of poor treatment compliance. Her family psychiatric history was remarkable for depression and suicidal behavior by her mother, paternal grandmother, and older brother, as well as substance abuse and criminal activity by her older sister. At the time of intake, Bianca denied experiencing suicidal ideation since discharge from the hospital. The following is a protocol that includes specific treatment strategies targeting Bianca’s recent suicidality, briefly outlined in Figure 1.
As with all patients, the first step for the clinician is to build a therapeutic alliance with the suicidal patient. Therapists working with suicidal patients have to consider several issues that are particular to this patient population. First, they have to strike a balance between expressing concern while not being overly emotional or shocked by discussion of suicidal content. Second, they need to exhibit confidence that they can truly help while at the same time not appearing wholly responsible or omnipotent. Finally, therapists need to find within themselves a centeredness that allows them to listen and intervene without becoming overly distracted by their own anxiety about working with this challenging population.
During the first session with a suicidal patient, the therapist must alert the patient to issues of confidentiality about working with a suicidal patient. The therapist explains that there may be occasions that the therapist is required to break confidentiality to ensure the patient’s safety or to keep the patient alive. These occasions typically involve more than passive suicidal ideation; more likely, the patient will be expressing at least a suicidal plan. Once a careful assessment has been conducted, rapport established, and confidentiality explained, the next major task for the therapist is to provide psychoeducation.
Psychoeducation of suicidal patients consists of three components. The first is reframing suicidal behavior as a maladaptive attempt at problem-solving. The goal here is not to overpathologize or judge the behavior as morally wrong, but rather to validate the patient’s attempt to ameliorate, albeit unskillfully, her seemingly overwhelming and insurmountable problems. The second component of psychoeducation is to orient the patient to the treatment options available for suicidality including a variety of possible psychological and pharmacological interventions. The final component of psychoeducation, if the suicidal patient opts to pursue outpatient treatment, is to reframe the treatment as a life enhancement program versus a suicide prevention program.
We go on to say, “there is no way that we can stop you from killing yourself if you are determined to do so; however, what we can help you with is to create a life that feels worth living and in so doing, reduce your wish to die.” The rationale for this introduction is twofold. First, we do not want to mislead the patient into believing that we have more power as clinicians than we in fact do. There are no data, including from inpatient units that suggest we can prevent patients from committing suicide 100% of the time. Second, framing the treatment as a life enhancement program begins to offer or highlight for the patient reasons for living instead of exclusively focusing on the problematic suicidal behavior. This positive reframe may begin to chip away at the hopelessness often present in these patients.
At the end of the first session, we educate patients regarding their tasks and responsibilities to the treatment process. First and foremost is obtaining the patient’s commitment to not engage in ANY suicidal or self-harm behaviors for the remainder of the treatment period. Considerable evidence suggests that the commitment to behave in a particular way, especially when the commitment is made publicly instead of privately, is strongly related to future performance (Linehan, 1999). When a patient does not readily agree to this condition (e.g., says, “I can’t commit to not hurting myself for 16 weeks), the therapist must apply specific commitment strategies to elicit some agreement to not self-harm even if it is pared down to only one week or even one day. Dialectical behavior therapists use numerous commitment strategies such as “door-in-the-face” (ask for as much as possible at first with the expectation of taking less) to encourage patients to contract for safety (see Linehan, 1993a). These same strategies are employed to obtain commitment to treatment, which is so important for engaging this difficult-to-treat, high drop-out patient population. In this vein, the therapist should schedule four subsequent sessions at the time of the first visit.
For the patient who expresses anxiety about maintaining her safety commitment, a common option is for the therapist to offer a replacement strategy for the suicidal behavior. That is, the therapist instructs the patient to page him or her before she engages in self-harm behavior in order to receive coaching on the use of adaptive coping skills. This also reassures the patient that she is not alone in coping with her suicidal feelings.
Another task for which it is important to obtain commitment is maintaining a daily diary card. The diary card prompts patients to self-monitor and records their suicidal thoughts and behaviors, their non-suicidal self-injurious thoughts and behaviors, a range of emotions and their use of new behavioral skills. Patients are given four reasons why they should complete and return the diary card to each session. “First, by self-monitoring your suicidal thoughts and behaviors, you are more likely to catch yourself in the process and thus reduce the likelihood of you carrying it out mindlessly. Second, by completing the diary card each day, you will have much better recall as to what you were experiencing so that we can discuss it during our next session. Third, this information is extremely important for us to have in order to set our session agenda each week. Fourth, having the diary card helps me to see your week at a glance to have a global overview of how you’re doing.”
“Changing behavior requires, at a minimum, a good understanding of the behaviors in need of change” (Linehan, 1999, p. 159). Following the initial evaluation, the clinician conducts a more thorough evaluation of prior suicidal behaviors in order to understand the function of those behaviors in the patient’s life. When a patient has a long history, special attention is paid to the most recent and the most severe suicidal behaviors. It is in this context that the therapist orients the patient to a primary method of assessment and treatment of suicidal behavior. Behavioral analyses are employed in order to understand the function of previous and current suicidal behavior and reduce the likelihood of future suicidal behaviors. Psychoeducation of a behavioral analysis with Bianca would sound like the following:
“Bianca, in order for us to better understand your suicidal behavior, we need to conduct a behavioral analysis. Now, what is a behavioral analysis (or as we say a “BA”)? A BA is a moment-to-moment analysis of your thoughts, feelings, and behaviors that led up to you attempting suicide. We may identify some of these thoughts, feelings, and behaviors as key links in your chain. We also want to understand if there were things that made you more vulnerable that day (e.g., sleep, eating, substance use, etc.), what the precipitating event may have been, and what the consequences of your actions were (both short-term and long-term). Once we have determined the key links in the chain, we can develop alternative solutions in order to help you avoid engaging in the same life-threatening behaviors.”
Once we orient Bianca to the function of a BA, the therapist initiates a BA on Bianca’s most recent suicidal behavior, which in this case was the overdose leading to her hospitalization. What follows is a snapshot introduction to a behavioral analysis.
Therapist: “So, Bianca, the problem behavior we are going to analyze is your overdose on your mother’s medication. Can you remember what time of the day this was, who was home, and what was going on when you took this overdose?”
Bianca: “It was late afternoon, my parents were both home. I remember that because I got into a fight with my father. I asked him to buy me a special pair of pants in Puerto Rico where he was going for a visit and he said he wouldn’t.
Therapist: “Why did he say no?”
Bianca: “He said because I didn’t deserve it.”
Therapist: “What was your reaction?”
Bianca: “I felt hurt and angry!”
Therapist: “I can see that your father really upset you when he said that. What happened next?
Bianca: “After my father said that, I tried to distract myself by washing clothes. My mother walked in on me and said I was doing it wrong.”
Therapist: “How did you experience that?”
Bianca: “That was the straw that broke the camel’s back. I thought that I could not do anything right and felt so alone that I ran into my mother’s bathroom and took all of her pills!”
Through this abridged BA, the therapist has already begun to elicit enough detail to clarify the environmental events, emotional and cognitive responses, and overt actions that sequentially led up to the suicidal response. Specifically, the therapist has identified Bianca’s reaction to her mother’s criticism as the precipitating event to her suicidal behavior. As with all BAs, the therapist would continue this analysis by inquiring about the presence of specific vulnerability factors and consequences. In Bianca’s case, she described having a conflict with her boyfriend two days earlier that resulted in her staying awake all night, both of which were identified as vulnerability factors. At this point, she attempted to obtain support from her father that proved futile, as described above. Regarding consequences, Bianca reported that after her suicide attempt, her boyfriend and family became loving, supportive, and nonjudgmental. In fact, her father offered to buy her the special pants she requested. After continued analysis, Bianca realized that her boyfriend and parents were inadvertently reinforcing her suicidal behavior. This positive reinforcement was found to occur in prior instances of her suicidal behavior as well.
Targeting Bianca’s vulnerability factors first, the assessment of the ongoing tension between her and her boyfriend revealed a communication skills deficit on Bianca’s part. Therefore, the proposed solution was to enhance Bianca’s interpersonal effectiveness skills. Bianca’s insomnia was targeted as her second vulnerability factor. A review of sleep hygiene and relaxation techniques was offered. Targeting the precipitating event (i.e., her reaction to her mother’s criticism), it was determined that when Bianca is in distress she had two options: 1) she could avoid her mother given her mother’s proclivity to invalidate her; or 2) she could directly express her feelings to her mother so that her mother knows that she is in distress. The problem with the latter option was that Bianca was unaware of what she was feeling. Thus, the recommended solution was for Bianca to practice identifying and labeling emotions when she was not in distress in order to prepare her for future scenarios in which she would inevitably become emotionally dysregulated. “Bianca, before you can choose a coping strategy, you need to know what you are feeling.”
Solutions are also applied to key links in the chain that contribute to suicidal behavior. Two key links that were identified were her thought that she could not do anything right and her feeling that she was all alone. The therapist employed cognitive restructuring techniques to target the cognitive distortion that she “cannot do anything right.” It was explained to Bianca that if she could restructure her thoughts in the moment next time, she would be less likely to become suicidal. A second point of intervention was Bianca’s experience of feeling “all alone.” Upon further analysis, Bianca identified sadness as the primary emotion underlying the experience of ‘aloneness.’ The intervention was to conduct formal exposure exercises to her sadness. “Bianca, it is important for you to be able to experience sadness as not dangerous and requiring escape. The better able you are to sit with your sadness, the less likely you will turn to your maladaptive coping strategy of suicidal behavior.”
The last component of the solution analysis is targeting the short-term and long-term consequences of the suicidal behavior. As mentioned above, Bianca’s boyfriend and parents inadvertently reinforced her suicidal behavior by lavishing her with affection and offering her gifts (i.e., positive reinforcement) after the attempt rather than before. The therapist role-played with Bianca to use her newly learned interpersonal effectiveness skills to explain to her boyfriend and parents that their actions are counter-therapeutic. Bianca requested that they try to give her the affection, attention, and gifts when she is not suicidal and less of these positive things when she is. She explained to them the principles of reinforcement and that she has learned (out of her awareness) that when she becomes suicidal, she gets what she wants from them.
Bianca acknowledged to them that her suicidal behavior also functioned as a method of escaping her emotional pain (i.e., negative reinforcement) and was effective to that end in the short-term. However, she also admitted to feelings of shame that she had to resort to this extreme life-threatening behavior to achieve a sense of relief. These feelings of shame outweighed the short-term benefit of escape that the suicidal behavior provided. Bianca and the therapist identified adaptive skills that could be used to achieve a sense of relief such as distraction and self-soothing. For example, Bianca agreed to watch her favorite comedic video or take a soothing bubble bath when feeling sad or thinking that she cannot do anything right.
A final intervention derived from the behavior analysis was the need for Bianca to practice paging the therapist during the following week when she was not in distress. “Bianca, as you said, this was an impulsive act. We need to help you slow down enough so that you can identify your distress, recognize your need for help, and generate alternative solutions. If you have trouble doing that in the beginning, which you may, I want you to page me for coaching. This way we can work together as a team. Therefore, I want you to practice paging me on Tuesday night when you are not in crisis so that calling becomes more comfortable and automatic.”
Cognitive behavior therapists emphasize solving problems by changing one’s thoughts, behaviors, or one’s environment. Cognitive behavior therapists working with suicidal patients need to suggest that one additional solution to their problems is to simply tolerate the painful consequences, including the negative affect, which the situation has generated. At first blush, many suicidal patients have trouble grasping the value and function of this solution. However, with practice, patients begin to recognize and appreciate the idea of tolerance as a solution. For example, urge surfing (i.e., observing the urge to self-harm and riding it out like a wave without reacting to it) is a skill taught to suicidal patients. Patients often believe they CAN NOT tolerate the painful affects and escape these affects by self-harming (negative reinforcement). If patients can ride out the wave without bowing out by harming themselves as the urge rises, patients experience that they CAN tolerate and survive the urges and negative affects.
Despite the therapist’s best efforts to effectively deliver interventions and the patient’s apparent commitment to follow through, it is inevitable that obstacles will arise. Troubleshooting refers to anticipating these obstacles before they occur and proposing solutions for managing them. When working with suicidal patients, it is even more imperative to troubleshoot the solutions, as it can be a matter of life and death.
Typically, the first problem to troubleshoot is noncompliance related to the diary card. The patient may forget to fill it out, fill it out but forget to bring it to the session, or refuse to do it altogether. “Bianca, I am glad that you agreed to do the diary card every night. My question is what might interfere with you not only completing it each night but also remembering to bring it in?” In Bianca’s case, she mentioned that although she has her own room, she worried that her mother or sister would find her diary card and invade her privacy. Once identifying this as an obstacle to her compliance, the therapist asked Bianca if she could generate a solution to this problem. Bianca responded that she could keep the diary in a school notebook that she would store under her bed. This particular notebook she used daily, which was another reminder for her to fill out the diary card.
It is equally important to troubleshoot the solutions derived from the behavior analysis. As mentioned above, while patients with their own best intentions in mind agree to solutions in the session, both as a consequence of time and unanticipated obstacles, their commitment and capacity may wane. For example, in session, Bianca recognized the value of broaching the issue of her parents and boyfriend’s positive reinforcement of her suicidal behavior. “Bianca, what do you think may interfere in your ability to actually say this to your family when you are not in session?” Bianca identified a worry thought that could interfere—that is, “my parents will never do what I ask in terms of not reinforcing me when I become suicidal.” Having identified this potential cognitive distortion, the therapist helps the patient challenge her automatic thought and has the patient agree to conduct a behavioral experiment to see if her hypothesis is in fact true.
The second scenario involves Bianca becoming acutely suicidal during her outpatient treatment. An active therapeutic response is needed when a patient communicates directly or indirectly an intent to commit suicide or engage in non-suicidal self-injurious behavior. The therapeutic goal is to help the patient, whenever possible, learn how to effectively cope with her stressful life as it is and NOT to remove the patient from this environment (i.e., hospitalization) with several exceptions to be highlighted later. The therapist conveys the philosophy that “now is the time to learn new behavior,” and thus, “we must strike while the iron is hot.” The following protocol addresses threats of imminent suicide during the course of an outpatient therapy session; a brief outline of this protocol can be found in Figure 2.
Explore the Current Problem Using a Macro-Behavioral Analysis
Summarizing and formulating the problem situation is often necessary during a crisis session since the patient (not to mention the therapist) may become emotionally dysregulated and lose focus on the problem at hand. Thus, it is important for both patient and therapist to retain their focus on the problem situation that precipitated the suicidal crisis so that they do not start trying to solve “the problem” without properly defining it. Due to anxiety, especially on the part of the therapist, the session may become overly focused on solving the problem of suicidal behavior (i.e., focus exclusively on safety planning) while often neglecting the actual problem(s) that precipitated the suicidal behavior. The therapist needs to maintain a balance of targeting the key links that precipitated the suicidal behavior while also establishing solutions that target keeping the patient alive in the here and now.
In Bianca’s case, she and the therapist identified that Bianca’s parents repeatedly criticized her for low grades despite the fact that she had recently worked hard to raise them from F’s to C’s. This parental criticism and the subsequent sadness, anger and, in particular, shame, was what precipitated her suicidal ideation. The therapist summarized for Bianca how this chain resembled prior chains that led to Bianca’s suicidal behaviors. Interventions included targeting Bianca’s unjustified shame response with cognitive restructuring and exposure. Bianca was oriented to the idea that if she could a) identify and restructure her automatic thoughts that induced shame and b) experience a non-reinforced exposure to shame in session, she would be less likely to experience suicidal ideation.
Second, the therapist acknowledged with Bianca the need to address high-risk environmental and behavioral factors associated with suicidal behavior. These risk factors will be discussed below.
There are a number of environmental risk factors associated with suicidal behavior. Because a therapist will be much less clear about the risk factors and functions of suicidal behavior with a new patient, the treatment needs to be more conservative in the early stages of therapy. The general rule regarding risk factors is that the higher the risk, the more active the therapist’s response should be.
Therapists working with suicidal patients must be familiar with these risk factors and be prepared to systematically address them in a crisis session. They include but are not limited to: availability of means, lack of social supports, and negative life events (Linehan, 1993). Social supports refer to marital status, interpersonal contacts, and employment. Regarding marital status, marriage has been shown to be a protective factor. Conversely, those who are divorced, widowed, or single (never married), respectively, are at greater risk for suicidal behaviors than those who are married. Those who live alone or who have few or no confidants are also at higher risk for suicide. Unemployed persons who do not have a method of earning a living or persons who have unsupportive colleagues in a workplace are also at higher risk for suicide (Hirschfeld & Davidson,1988).
Negative life events refer to interpersonal losses such as a death or separation from loved ones, sexual abuse history, imprisonment, and suicidal behavior by a family member to name a few. Persons with a family history of suicidal behavior are at higher risk for committing suicide themselves.
One of the most common negative life events, especially for youth, is interpersonal conflict. For Bianca, interpersonal conflicts with her parents and her boyfriend were common negative life events precipitating her suicidal ideation and behavior. Thus, in addition to targeting Bianca’s shame directly in session as mentioned earlier, the therapist urged Bianca to invite her parents to the next session in order to target the interpersonal conflicts that plagued her family, including the consistent criticism among them. The goal of the family session was to help each family member, including Bianca, learn how to communicate his or her feelings (especially negative) more constructively. While the therapist and Bianca recognized that this goal would not be accomplished in only one session, it was understood that this would be a first step. In the next session, the therapist informed the family that the interpersonal conflicts this family had were more than your average family conflicts. It was communicated that these interactions, despite their best intentions, had the potential to trigger a suicidal crisis in their daughter. Thus, it was imperative for each family member, including Bianca, to take a hard look at his or her communication style and figure out how to communicate in a more skillful and constructive manner.
The family was first asked to role-play in session and then practice at home, beginning each new communication with “I…” instead of “You…” Additionally, they were asked to describe their concerns without using judgmental language. And, where possible, family members were instructed to validate each other’s experiences even when they had a different perspective on the issue. Hence, instead of the parents saying, “You have the worst judgment when it comes to choosing friends and you are not permitted to see any of them ever again,” they were asked to reframe their statement. With coaching, they explained, “I (we) recognize that you enjoy spending time with your friends. However, I (we) feel concerned that your friends get into trouble at school and since you spend a lot of time with them, you are likely to get into trouble too. I (we) want to figure out the best way for you to spend time with your friends and also not get yourself into trouble. I (we) am (are) open to suggestions.” By the therapist validating the parents’ concerns about their daughter, the parents were able to be less critical and more validating of their daughter and her experience. Bianca and her parents negotiated a compromise that entailed spending time with two of her closest friends during the weekend but not after school. Bianca felt relieved and agreed to work out the plan with her friends that week.
Regardless of whether the lethal means is a gun, a liquid poison, or pills of some sort, it is imperative that the therapist spends a portion of the crisis session ensuring that the removal of lethal means has occurred or will occur. Depending on the acute nature of the crisis, the therapist may instruct the patient to bring the lethal items to the next session, or insist that the patient go home and bring in the items immediately. In other cases, when the patient calls the therapist in a suicidal crisis, the therapist may instruct the patient to flush the pills down the toilet and wait on the phone while the patient complies. Still in other cases, family members, significant others, or roommates, may be enlisted to facilitate the removal of lethal means from the patient’s home. Having a firearm in the home increases the risk of suicide five-fold (Brent et al., 1991). Locking up a firearm in the home or separating the ammunition from the gun is not sufficient. The weapon needs to be secured outside of the home.
After Bianca disclosed having increased suicidal ideation with a plan to overdose, the therapist tried to convince Bianca to remove all lethal means of suicidal behavior. Since Bianca denied having suicidal intent, she was reluctant to remove the Tylenol and Advil. Bianca replied, “I can always go out and buy more if I want to.” The therapist reminded Bianca that many suicide attempts, including the last one, are impulsive; hence, having less access to means may forestall suicidal behavior. After Bianca refused to follow the therapist’s recommendations, the therapist told the patient that he had to contact the family in order to achieve this goal. Hopefully the patient will consent in this case. If the patient refuses to consent and is noncompliant with the therapist’s recommendations to remove lethal items herself, it is typically a bad prognosis regarding the patient’s willingness and capacity to maintain safety and thus may require (in addition to several other factors mentioned later) an inpatient admission. Either way, because suicidal behavior is at issue, the therapist is justified in breaking confidentiality by calling a family member to remove the lethal means.
Interpersonal supports are a protective factor for the suicidal patient. Thus, in addition to coaching the patient on enlisting her family members and friends for support whenever possible, the therapist must also make him or herself available during these crises. The general rule is to stay in contact with the patient either in person or by phone until the therapist is convinced that the patient will be safe once the contact is broken off (Linehan, 1999). At these times, therapy sessions or phone calls may need to be extended until a safety plan is established and the patient is committed to comply. We suggest that therapists who carry pagers encourage their patients to make use of this method of contact.
Depending on the imminent nature of the crisis, the therapist may contact the patient’s significant others, family members, and certainly other treatment providers. As mentioned previously, confidentiality may be breached in circumstances involving suicidal behavior, and the patient is informed of this during the first session. The therapist should attempt to select the least intrusive intervention necessary (i.e., notify the fewest number of additional parties) to ensure the patient’s safety. That is often a very challenging judgment call to make when the issue of suicidality arises. Naturally, a non-medical therapist should always notify the patient’s prescribing doctor (if there is one) regarding the patient’s increased risk for overdose. In addition, suicidal patients and their significant others (if appropriate) are always referred to their local psychiatric emergency room or to call 911 if the suicidal impulses escalate and they are unable or unwilling to contact their therapist.
Every suicidal patient should receive a crisis card by the time they leave the session. At a minimum, the crisis card contains important telephone and pager numbers for all designated people. For example, in Bianca’s case, she was given a card that listed the therapist’s office and pager numbers, her aunt’s home and work telephone numbers, and her best friend’s cell phone number and pager number. Although Bianca had all of these numbers listed elsewhere, she now had them all in one place and could work down the list until she made contact with one of her identified supports. Her parents and boyfriend were not listed for two reasons: 1) they were typically the people involved in the interpersonal conflicts associated with her suicidality and 2) historically, they were prone to reinforce her suicidal behavior which was being addressed in treatment. Thus, other non-reinforcing yet supportive people in Bianca’s life were identified to serve this function. Additionally, some crisis cards contain a list of personalized coping skills. Patients can refer to this list when they are in a crisis since it can be extremely difficult to recall specific skills during a suicidal crisis when one is emotionally dysregulated. Bianca listed several DBT “crisis survival skills” (Linehan, 1993b) including distraction and self-soothing skills as well as pros/cons regarding her suicidal behavior. Moreover, she chose to list several rational responses to her most common automatic thoughts that often precipitated her suicidal behavior.
In addition to the environmental high-risk factors, there are several behavioral high-risk factors that should also be addressed during a crisis session.
When a patient is emotionally dysregulated, the therapist must help the patient identify her emotions, validate those emotions, and allow the patient to express them. The patient often experiences some degree of relief from the emotional ventilation and the emotional processing of traumatic events associated with exposure-based treatment approaches.
Related to the issue of focusing on affect, the therapist wants to communicate to the patient that she CAN tolerate what is experienced as intolerable. For example, Bianca expressed the feeling that she “couldn’t take feeling so sad and so ashamed….it’s too painful.” The therapist told Bianca, “despite feelings to the contrary, you CAN tolerate it… in fact, you have tolerated these painful feelings before and survived them….painful emotions DO NOT last forever. You have to fight the tendency to tell yourself that you CAN’T tolerate these feelings. I know it is painful but I am going to help you tolerate this pain! This is your number one job right now.” Bianca did not fully appreciate these remarks in the early stage of treatment but the therapist still made the case for affect tolerance.
For many patients in crisis, there is often anxiety, physical discomfort, as well as disrupted sleep. Bianca reported recent initial insomnia as well as symptoms associated with panic attacks (e.g., tachycardia, shortness of breath, lightheadedness, and feeling like she was going to lose control). Sleeplessness alone can induce a crisis for some patients. For some patients, teaching proper sleep hygiene and relaxation techniques (e.g., diaphragmatic breathing; progressive muscle relaxation) may be sufficient to address these aforementioned problems. For other patients, a rapid pharmacological intervention to address the insomnia and anxiety may be indicated as well.
Some patients self-medicate with drugs or alcohol or may abuse or become dependent for other reasons. Regardless, during a suicidal crisis, the patient needs to be instructed to discontinue any alcohol or drug use. Because substance use is a known risk factor for suicide due to their disinhibiting properties, a commitment to discontinue use is required. If the patient is unwilling to discontinue drug or alcohol use, the therapist must factor this high-risk behavior into the decision about psychiatric hospitalization.
One of the greatest problems for a suicidal patient is that she cannot see a way out of the hell she is experiencing. Many suicidal patients describe their experience as if there is a big mountain of accumulated problems in front of them that appears insurmountable. Thus, the challenge for the therapist is to model how to break down this “mountain” into more manageable problems that can be solved. Ideally, the therapist and patient will identify the problem(s) that are both most distressing and primed to be solved quickly. In Bianca’s case, a brief family intervention targeting communication skills was initiated within several days to help reduce the interpersonal conflicts known to precipitate her emotional dysregulation that often lead to her suicidality. In addition, the therapist immediately targeted Bianca’s own reactions to her parents’ criticism. Employing cognitive restructuring and exposure-based procedures related to her sadness and shame also helped to reduce the intensity of her reactions that precipitated her suicidal ideation. As the problems are systematically addressed, the patient’s sense of hope begins to be restored.
“Bianca, we are going to help you deal with these problems one by one until they no longer feel so overwhelming and insurmountable. Some of the solutions we employ will actually change the situations that upset you. I predict other solutions will require that you learn to radically accept certain situations in your life as they are. I know this may sound incredibly difficult if not impossible. Over time, you will find by truly radically accepting certain situations as they are, you will actually change the way in which you perceive and experience the problem. This idea of acceptance takes more time than the problem solving ideas I mentioned. So, let’s start today with the things we can change first.”
By using “we” statements, the therapist communicates a strong commitment to do whatever is necessary to help the patient get through the present crisis. Explicitly stated, “You are not alone. We are going to get you through this tough time!”
Another protective factor for suicide is when the patient can identify reasons for living. The therapist should ask the suicidal patient, “Tell me, what reasons do you have for living right now?” Hopefully the patient does not require significant prompting. However, because suicidal patients are often in acute emotional distress, the therapist might prompt with statements such as, “What about your family? What about your friends? How would they feel if you killed yourself? What about your future? What do you want to accomplish in your life in the next 5 or 10 years? What about your religion?” Without significant prompting, Bianca stated, “My mother would feel terribly guilty and that wouldn’t be so bad. But, my best friend would be so angry with me if I killed myself. She told me that it would be selfish if I killed myself and left her to go on without me. Also, I am Catholic and believe I would go to Hell. And, I decided I wanted to get through college so I could become a counselor that helps teenagers get through this awful stage of life!” These reasons for living were meaningful to the patient and demonstrated a significant protective factor against imminent suicidal behavior. If the patient cannot identify any reasons for living and is unable to demonstrate any future time perspective in terms of goals, the therapist must recognize this as an absence of protective factors that needs to be factored into the decision about psychiatric hospitalization.
It is important that the therapist provide a balanced perspective to the patient’s troubled life situation; hence, highlighting as many positive aspects of the patient’s current life circumstances (restoring hope) while also validating the intense pain and despair the patient is experiencing.
Once a sufficient number of solutions are generated, the therapist asks the patient to commit to a plan of action.
“Bianca, let’s review. Can you write down the things we discussed for you to follow up with before next session? I know your mother has disposed of the Tylenol and Advil in the house since I called. I want you to honestly tell me that when you get home, you are going to request that your mother double check that all pills are out of the house or secured. Also, you have your cognitive restructuring worksheet that lists your rational responses to your common cognitive distortions that lead to your feeling sad and ashamed. Will you keep that sheet handy and refer to it if your automatic thoughts return? Also, will you write down new automatic thoughts that relate to negative emotions you experience this week? You also have your crisis card that we developed. Will you commit to use that contact list if your suicidal ideation returns? Finally, and very importantly--will you commit to attend your next session with your parents and will you commit to not hurt yourself before our next session?”
Assuming Bianca agrees, the therapist shifts to troubleshooting mode. That is, “OK, now what is going to interfere in your capacity to carry out each of these items on your action plan?” It is important to carefully review each item with special attention to items that the patient expressed difficulty with earlier in the session. For example, Bianca expressed disagreement with the removal of available means, which resulted in the therapist calling her family. Hence, it is likely that she would have difficulty double-checking the house for additional pills.
“Bianca, I am pleased that you are not presently feeling suicidal. However, I am fairly certain given the stressors you are experiencing in your life and your recent emotional sensitivity to them, that you will likely experience suicidal ideation again. So, tell me in your own words how you are going to handle that when it happens.” Ideally, the patient will review the strategies discussed during the session and refer to the crisis card as a final safety check.
There are no empirical data that support the notion that acute, inpatient hospitalization is effective in reducing the risk of suicide. No studies find that hospitalization is the treatment of choice for the chronically suicidal patient (Linehan, 1999). However, based on clinical experience, there are some situations in which the therapist should consider recommending brief, inpatient hospitalizations. Below is a list of potential circumstances that may warrant this type of recommendation, the first five of which are adapted from Linehan, (1993a).
1) The patient is psychotic and is threatening suicide and/or having command auditory hallucinations to kill himself or someone else.
2) The patient is on psychotropic medications, the patient has a history of overdose on these medications, and is having problems that require close monitoring of medication or dose.
3) The relationship between the therapist and patient is severely strained which is contributing to the suicidal crisis. The inpatient staff might be helpful in repairing the relationship by facilitating a meeting with both parties.
4) The patient is not responding to outpatient therapy and there is severe depression or debilitating anxiety
5) Operant suicide threats are escalating and the hospitalization is considered aversive by the patient.
6) The patient is actively abusing alcohol or drugs and is refusing to reduce usage during the crisis.
7) The patient refuses to remove lethal items from the home and/or refuses to use a crisis card and call the therapist or other identified support personnel if suicidal ideation returns.
8) The patient is profoundly hopeless and unable to identify any reasons for living even with prompting.
9) The patient cannot identify any social supports that she is willing to use for help during the crisis period.
This list is not meant to be exhaustive but merely represents several common situations that may individually, or in combination, warrant inpatient admission for the suicidal patient. Of course, each of these aforementioned situations needs to be considered in a fuller clinical context. The therapist must always take into account the patient’s prior history of suicidal behavior, current suicidal ideation, plan, and intent, as well as the myriad of environmental and behavioral high-risk factors.
is one of the most commonly encountered behavioral emergencies among mental
health professionals. The
importance of an informed assessment and intervention of suicidality,
therefore, cannot be overstated.
In this chapter, we described an evidence-based, symptom-focused
approach for intervening with suicidal patients and illustrated this approach
with a case example of an 18 year-old suicide attempter. In an attempt to address the two most
common presentations of a suicidal patient to a practitioner, we described
treatment strategies relevant to a patient recently discharged from an
inpatient unit following a serious suicide attempt as well as treatment
strategies relevant to the management of an acutely suicidal patient in outpatient
treatment. In both scenarios,
therapists must actively assess and intervene to reduce risk and increase the
likelihood of a positive outcome.
Table 2. Controlled studies found to reduce deliberate self-harm and suicidal behavior
Linehan et al. 1991 DBT Suicide attempts; Outpatient adults
Meltzer & Clozapine SI/behavior Adults with Schizophrenia
Ghadeer 1995 and Schizoaffective D/O
Hawton et al. 1998 Depot flupenthixol SI/behavior Adults with psychotic D/O
Baldessarini & Long-term Lithium Suicide attempts Adults with Bipolar D/O
Bateman & Psychodynamic therapy Suicidal behavior Partial hospital program
Motto & Ongoing follow-up Suicidal behavior/ Outpatients discharged
Bostrom 2001 depression from hospital
Wood et al. 2001 CBT & DBT with Deliberate self-harm Outpatient adolescents
Care as usual
DBT=Dialectical Behavioral Therapy; CBT=Cognitive Behavioral Therapy; SI=Suicidal Ideation
Figure 1. Protocol for Persons with a Recent Suicide Attempt
Weave in solutions to the behavior analysis, potentially
targeting: vulnerability factors,
precipitating events, consequences, and key links Key links include specific cognitions, emotions, behaviors, and contingencies
Figure 2. Protocol for Managing Acute Suicidal Behavior in Session
Weave in solutions to the behavior analysis, potentially targeting:
vulnerability factors, precipitating events, consequences, and key links
Key links include specific cognitions, emotions, behaviors, and contingencies
Assess Risk of Immediate Suicide
Explore and Summarize Current Problem
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 All assessments of suicidality must include the presence or absence of psychiatric disorders including, but not limited to, affective disorders and substance-related disorders.