THE PROBLEM OF SUICIDE
In 2018, the US Centers for Disease Control and Prevention (CDC) reported that the suicide rate in the United States had increased by 25% since 1999.1 The increase in deaths by suicide over the course of 2 decades is a cause of considerable concern on a national level and within the mental health field, and it is associated with increased attention to developing better methods to screen for, evaluate, and prevent death by suicide. Accrediting bodies like The Joint Commission have also increased attention to assuring the safety of inpatient units where suicide is a prominent risk. Much of this laudable effort to move the needle on death by suicide, especially from The Joint Commission, focuses on increased security of the environment of care.2 However, outpatient therapists have long recognized that there is little that can be done with the environment of care within which they work. Outpatient therapists realize that more than attention to security is ultimately required to address the issue of suicide with patients. Indeed, the tool they must rely on in their work with suicidal outpatients is the relationship within which psychotherapeutic care is provided. It is these outpatient therapists, treating suicidal patients one at a time, who are often left to sit with and endeavor to be useful to the increased number of individuals struggling with whether life is worth living.
This column offers recommendations about individual psychotherapeutic work with those suicidal patients who can be conceptualized as having the capacity to be responsible for their own safety and to engage in psychotherapy. Many of this group of patients will be those with mood disorders and/or personality disorders, especially borderline personality disorder, plus a host of other comorbid disorders. To be sure, those patients caught up in severe major depressive or manic episodes, or struggling with psychosis, or actively using substances, or unable to commit to or to utilize a course of psychotherapy often require a different kind of outpatient therapy than is described here. Many others are subacutely or chronically at risk of suicide, though, and in need of therapists who can help them meaningfully engage and address the issue of suicide.
PSYCHOTHERAPIES FOR SUICIDAL PATIENTS
Fortunately, there are multiple manualized behavioral and psychodynamic psychotherapies for patients struggling with suicide that have been found to be efficacious.3–14 Some of these treatments are stand-alone therapies primarily targeting the symptom of suicide, whereas others address additional issues with which patients may struggle in their lives. The manualized therapies include psychodynamic therapies such as mentalization-based therapy and transference-focused therapy, as well as behavioral therapies such as dialectical behavior therapy and schema therapy, and a mixed and integrated form of therapy known as good psychiatric management that has psychodynamic and behavioral features. There is also some evidence supporting the use of cognitive behavioral therapy and an alliance-based intervention for suicide with patients struggling with suicide.15–18 Unfortunately, the daunting truth is that few therapists are trained to use any of the evidence-based manualized psychotherapies for suicide, although many, perhaps most, therapists will be called upon to treat patients struggling with suicide as an issue.
Recognizing this vexing reality, a number of individuals and groups with expertise in psychotherapy with suicidal patients reviewed the data in an effort to understand and extract shared elements of psychotherapy for suicidal patients that might be taught to trainees or practicing therapists for whom full mastery of a manualized treatment may not be feasible. The individuals and expert consensus panels undertaking this task included the Boston Suicide Study Group (BSSG),19 Paul Links,20 Anthony Bateman,21 and the Group for the Advancement of Psychiatry Psychotherapy Committee (GAPPC).22 This column presents an overall integration of the recommendations from all 4 expert consensus panels and individual experts.
RECOMMENDATIONS ACROSS ALL EXPERT REVIEWS
The GAPPC reviewed other expert consensus panels and found a high degree of overlap and unanimity, although sometimes the language or level of abstraction differed from panel to panel. Because I was part of the GAPPC panel and a co-author of its work product, the expert recommendations are presented here using the GAPPC language, with the addition of 1 item from the review of other panels that was not part of the GAPPC shared elements, but with which the GAPPC panel had no disagreement. Table 1 shows the summary recommendations across all expert reviews by panels or individuals.
NEGOTIATION OF A FRAME FOR TREATMENT IN THE PRETREATMENT PHASE
Behavioral and psychodynamic therapies for suicidal patients have in common a pretreatment phase during which the therapist and patient determine whether they will work together. This perspective on what is treatment and what precedes treatment differentiates any ad hoc meetings to obtain history, understand the scope of the problem, and learn about the patient’s strengths from a subsequent set of regularly scheduled meetings that follow a shared commitment by both parties to engage in ongoing therapy.
Of course, in some settings, therapists have little choice about whether to offer treatment to a patient who may be in a catchment area covered by a clinic and entitled to care, but whether the treatment will directly target the issue of suicide or be a more supportive and sporadic intervention is often up for negotiation even in such settings.
DIFFERENTIATED RESPONSIBILITIES WITHIN THE THERAPY
Part of the foregoing negotiation includes discussion of the shared but differentiated responsibilities of therapist and patient who are working together in psychotherapy. Patient responsibilities may include attending sessions, keeping a log of moods or other homework, paying the bill, and utilizing a mutually agreed upon safety plan if staying alive becomes too challenging—whether this is contacting the therapist, using emergency services, or some other plan. The patient has a responsibility to keep alive for the treatment to continue—and to utilize skills and resources should that commitment be threatened. Therapist responsibilities include attending sessions, listening carefully, containing emotions aroused in the course of the treatment, and using a range of skills that vary depending on the type of treatment being utilized.
PROVISION TO THE THERAPIST OF CONCEPTUAL FRAMEWORK FOR UNDERSTANDING AND INTERVENING
Both behavioral and psychodynamic therapies include a conceptual framework for understanding suicide and how best to intervene around it. This may be what is laid out in a manual or part of theory underlying the treatment approach. Behavioral treatments may prioritize skills deficits and the need to learn how to better regulate emotions. Psychodynamic treatments may search for the emotional underpinnings and meanings of suicide or look at upsurges in suicidal feelings through the lens of transference and wonder what has happened between therapist and patient that has shifted their intention to work collaboratively into an intention to end the patient’s life and, with it, the work to which therapist and patient had previously made a commitment as the culmination of the pretreatment phase.
USE OF THERAPEUTIC RELATIONSHIP TO ENGAGE AND ADDRESS SUICIDE ACTIVELY AND EXPLICITLY
Across behavioral and psychodynamic therapies with suicidal patients, the therapeutic relationship is used to engage suicide in an active and explicit way. This makes suicide an interpersonal event with meaning in the therapeutic relationship, giving the therapist a way to bring suicide into the consulting room and the therapist-patient relationship, rather than it being a symptom that is out in the world rather than in the consulting room. Increases in suicidal thinking or behavior may represent a patient’s experience of injury by the therapist, with the notion of rupture and repair as a framework for understanding upsurges in suicidal ideation or behavior, or may represent loss of hope in the therapeutic process.
ATTEND TO PATIENT’S AFFECT AND CONNECT IT WITH ACTIONS
This is the shared element that was not part of the GAPPC shared elements. Because it was part of other panel recommendations, and since the GAPPC panel entirely agreed with it, feeling it was implied in other of its recommendations, we decided to include it in the final set of recommendations across panels. Behavioral and psychodynamic therapies for suicidal patients attend to the patient’s overt and perhaps covert affects, while therapists from both approaches work to notice the link between affects and actions, especially suicidal actions.
PRIORITIZATION OF SUICIDAL IDEAS OR ACTIONS AS TOPICS TO ADDRESS
Across behavioral and psychodynamic therapies for suicidal patients, there is broad agreement that no issue is more important to discuss in a session than thoughts about suicide or actions in the direction of its implementation. Experienced therapists from all schools focus in sessions on the vicissitudes of suicide and attend carefully, as noted above, to how it may be related to affects.
PROVISION OF SUPPORT FOR THE THERAPIST
Work with suicidal patients is challenging and stressful even when successful, with the death of a patient by suicide often associated with longstanding distress in therapists.23 Hence, support for the therapist is an essential ingredient in such difficult work. This may take the form of individual or group supervision or manual adherence meetings to address challenges arising in treatment. Such support helps therapists endure the stress of working with suicidal patients and helps ensure that the treatment stays on track and aligned with the other elements of therapy.
With the increase in suicide in the United States, there is an increased need for therapists with skills to treat suicidal patients. Although there are several evidence-based manualized approaches to treating suicidal patients, relatively few mental health clinicians are trained to a level of competence in these approaches. Extraction of shared elements in the treatment of suicidal patients across behavioral and psychodynamic therapies offers clinicians who are not adept in the provision of an evidence-based treatment a useful set of guidelines to frame this kind of clinical work. Mastery of these should improve patient care and clinician confidence and competence in this difficult work. Furthermore, once familiar with the basics associated with a shared elements perspective, some clinicians will likely become interested enough to pursue additional training and expertise in psychotherapeutic approaches to work with these and other patients.
In the next column, I will review the principles of one psychodynamic approach for working with suicidal patients that is consistent with these shared elements. The Alliance Based Intervention for Suicide (ABIS) is an approach to treating suicidal patients with borderline personality disorder developed at the Austen Riggs Center that is not manualized and not a stand-alone treatment, but rather a way of establishing and maintaining an alliance with suicidal patients that engages the issue of suicide and allows the rest of psychodynamic therapy to unfold.17
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