INTRODUCING THE ALLIANCE BASED INTERVENTION FOR SUICIDE
The first column in this 2-part series1 explored the national problem of the increased rate of suicide over the last 25 years, noting the reality that many clinicians working with suicidal patients in individual therapy lack specific skills for this work. While there are manualized evidence-based behavioral and psychodynamic therapies for work with suicidal patients, few clinicians master these strategies. That column reported on the convergence of shared elements of such work across multiple therapeutic approaches and among several expert review panels. It also offered the hope that one step in addressing the problem of suicide might be teaching shared elements across therapies to trainees and practicing clinicians (Table 1).
This column describes one approach to establishing and maintaining a viable therapeutic alliance in psychodynamic therapy with such patients. The approach, called an Alliance Based Intervention for Suicide (ABIS), is not manualized and is not a stand-alone treatment. Rather, it is a way of negotiating the terms of treatment and responding to the emergence of suicidal thoughts or actions in a way that supports psychodynamic therapy with suicidal patients.2–5 ABIS is consistent with the summary recommendations from expert consensus panels discussed in Part 1 of this series and shown in Table 1.
When I came to Austen Riggs as a fellow 40 years ago to begin psychoanalytic training in its hospital-based continuum of psychiatric care, I quickly learned two things. First, many of the patients we treated struggled with suicide as a prominent issue in their lives, including many with histories of medically serious suicide attempts—yet we were treating them in a fully open and voluntary setting with no restrictions on their freedom beyond the responsibility for their safety that we negotiated with them as a condition of admission. Second, I learned that I needed help mastering a way of working with patients with such complex illnesses, while managing my own tumultuous reactions to the work. I set about studying what those therapists who seemed able to manage such patients were doing. On the basis of my observations, supervision, and experience working with such patients, I extracted the principles of ABIS, which are listed in Table 2.
Before embarking on a description of the specific principles, it is worth noting a few general points about them. First, ABIS is not an approach to therapy for all suicidal patients. As noted in last month’s column, patients suitable for ABIS must be able to think and act on their own behalf and not be at such risk of suicide that they require hospital treatment. Many suitable patients will present with personality disorders comorbid with mood, anxiety, or substance use disorders or posttraumatic stress disorder.
Second, the clinical goal of the principles is to move suicide from the status of symptom to that of an interpersonal event with meaning in the therapeutic relationship. This makes suicide an issue available in vivo, within the therapeutic relationship, thus offering a handle on suicide that is absent when suicide is viewed primarily as a symptom of a disorder or as primarily related to issues occurring outside therapy in the patient’s life. For example, if suicidal thoughts emerge after a rejection by a romantic partner, that loss is explored in ABIS, but ABIS proposes that we should also explore what kind of rejection may have been experienced from the therapist that leads to thoughts of ending the therapy by ending the patient’s life. To the extent that the patient has chosen therapy to help find a life worth living, an expectation of commitment to the work of therapy becomes part of every struggle over living versus dying that the patient experiences.
Third, in ABIS, suicide is viewed as an aspect of negative transference. It is assumed that, over time, a positive transference and attachment will develop between therapist and patient. Noting that to some extent patients will wish to get better to please the therapist, Freud referred to the therapeutic alliance as an unobjectionable part of the positive transference. Seen through the same lens of transference, though, ABIS views suicide as a quite objectionable part of the negative transference—and thus as worth directly engaging and interpreting.
Fourth, of necessity the principles are presented and explained here one at a time, but it would be an error to assume that they are carried out in a precise sequential order. Of course, therapy begins with a pretreatment phase and frame setting, but other principles are teased apart for ease of presentation even though the order of their engagement with patients may vary.
DIFFERENTIATE PRETREATMENT (CONSULTING) PHASE FROM TREATMENT (THERAPY) PHASE
Consistent with the expert consensus recommendations, ABIS makes a clear distinction between two kinds of meetings. Some meetings occur in a pretreatment phase, during which the patient is assessed and an alliance and frame for treatment are negotiated in one or more ad hoc sessions, with no commitment to continue meetings over time. Other kinds of meetings are those that are part of treatment. Treatment includes an agreement to explore the patient’s mind and meaning in ongoing sessions for a defined or indeterminate period of time, but with set appointment times and expectations that both therapist and patient will be present and committed to the work of therapy. Pretreatment sessions are consultations, with no expectation that they will continue over time. The frequency of treatment sessions is often once weekly, but more frequent and sometimes less frequent sessions may be utilized.
INCLUDE SELF-DESTRUCTIVE BEHAVIOR IN THE THERAPEUTIC CONTRACT FROM THE OUTSET
The therapeutic contract, which serves as a frame for the treatment, includes recognition that the therapy can only continue if the patient remains alive. Moving into therapy from the pretreatment phase requires that patients grasp that they are responsible for their safety. If they cannot or will not agree to this, therapy cannot begin.
In ABIS, potentially lethal and nonlethal behaviors are conceptualized differently. Potentially lethal thoughts or behaviors, which carry with them a risk of ending the treatment, are always a relevant topic for discussion in therapy whenever they are in the patient’s mind. Nonlethal behaviors surely have meaning worth understanding, but engaging the meaning of these occurs as the patient wishes. Of course, sometimes these force their way into discussion, too, as when the patient who cuts superficially stains the therapist’s furniture with residual blood.
Part of setting the frame for treatment includes developing a safety plan for what to do if the patient is unable to keep the terms of the agreement. Again, this principle of ABIS is consistent with recommendations from the expert review summary.
It is true that an agreement or contract, even one negotiated as part of an authentic and serious interpersonal engagement, cannot be relied on to keep patients alive. However, such an agreement, and its terms, are a necessary if not sufficient condition of ABIS for initiating and continuing psychodynamic therapy with suicidal patients.
CONTAIN AND “METABOLIZE” THE COUNTERTRANSFERENCE
It is assumed that suicidal thoughts or actions will likely arise in the course of therapy. Negotiating a frame making it clear that patients are responsible for their safety rarely makes the issue of suicide recede entirely. The point of this principle is to help the therapist confronted by suicidal thoughts or threats—but especially by suicidal actions—find a way to acknowledge, bear, and put into perspective intense countertransference reactions to suicide. Supervision or consultation with colleagues is a valuable part of metabolizing the countertransference so that it can be contained rather than enacted.
ENGAGE THE AFFECT
When suicidal thoughts or behavior do emerge, ABIS calls for an authentic engagement of the affects involved. At such moments, patients may retreat into sullen dismissal, and therapists may retreat from engagement of the (self-) murderousness that has arisen, while focusing single-mindedly on the potential need for medications or hospitalization. Of course, these are important considerations, but they cannot entirely displace our attention from what is going on in the relationship that leads a previously side-by-side collaboration to shift toward something more akin to a toe-to-toe fight to the death.
Remaining affectively engaged with and accepting of the negative transference associated with suicide is not an easy task, but it is an essential part of the work of ABIS. This principle of ABIS links to the recommendation from the expert consensus panel summary recommendations to attend to the patient’s affect and connect it with actions.
NONPUNITIVELY INTERPRET THE PATIENT’S AGGRESSION IN THE DECISION TO END TREATMENT
Given the framing of the meaning of suicide in ABIS as an aspect of the negative transference, and the patient’s responsibility for staying alive so that the treatment may take place, the emergence of suicidal thoughts or behavior inevitably means that the patient is considering or has already decided to end the agreement to do the work of therapy. Finding a nonpunitive, nonjudgmental way to bring this into discussion with the patient is part of the conceptual framework for understanding and intervening in ABIS. This is part of the use of the therapeutic relationship to engage and address suicide actively and explicitly that is noted in the expert consensus panel recommendations.
Given this stance, if a patient has survived an attempted suicide, ongoing therapy ends. Future meetings are usually possible, but these are consultations comparable to pretreatment phase meetings. The focus of such meetings often includes attention to the principles delineated below.
ASSIGNMENT OF RESPONSIBILITY FOR PRESERVATION OF THE TREATMENT TO THE PATIENT
This principle is closely linked to the previous one. Just as the patient has apparently found a reason to end the treatment despite the agreement to be committed to it, responsibility for finding a way to preserve it belongs to the patient. This principle of ABIS links to the expert consensus panel recommendations for provision of a conceptual framework and differentiation of responsibilities.
SEARCH FOR THE PERCEIVED INJURY FROM THE THERAPIST THAT MAY HAVE PRECIPITATED THE SELF-DESTRUCTIVE BEHAVIOR
In ABIS, therapists, too, have differentiated responsibilities. A central one is the obligation to search for the perceived injury from the therapist that may have precipitated the emergence of suicide. The shift from side-by-side collaboration to toe-to-toe fight to the death generally follows some kind of injury from the therapist. The injury may be perceived rather than intended (eg, a reaction to time away) or represent an actual experience of injury (eg, an empathic failure), but it is often precisely the kind of injury to which the patient is especially vulnerable given the dynamic formulation. For example, a patient struggling with a long history of abandonment experiences who becomes suicidal in the context of an abandonment by a romantic partner may be understood as responding to a familiar injury in life. In ABIS, though, while the therapist empathizes with and explores that abandonment, the therapist is also curious about what abandonment the patient may have experienced from the therapist that led to the decision that the best way forward was death, and with it the end of therapy.
It is remarkable how consistently this stance of inquiry leads to revelation of injury in the transference that explains the emergence of suicide as an issue. This principle of ABIS and the last one listed below address suicide as part of a cycle of rupture and repair, which is a frequent component of psychodynamic work.
PROVISION OF AN OPPORTUNITY FOR REPAIR
If there has been a suicide attempt that has ended the therapy, consultations about whether it is worth resuming are often in order. Here therapist and patient have work to do. Can the patient reach a new understanding of the importance of staying alive in order for the work to resume? Can the therapist get past the sense of betrayal, guilt, injury, worry, and anger in the relationship with the patient? In many instances, repair of the rupture in the relationship is not only possible, but serves to deepen the work and deepen the patient’s commitment to staying alive in the future to do the work of therapy.
The principles of ABIS are sometimes misunderstood as involving a stance of “If you attempt suicide, I will quit as your therapist.” This misunderstanding misses the nuances of ABIS. A more accurate statement would be, “If you attempt suicide, it is inevitably a choice to end our work. What is going on with us that makes you want to end our work? Have I in some way pushed you to that choice?”
There is no magic in ABIS, and it will not work in all cases, but these principles are effective in making suicide an interpersonal issue with meaning in the relationship. This allows direct engagement of the issue of suicide in the therapeutic relationship and direct discussion of the central question of whether the patient can and will commit to the work. ABIS supports the therapist in efforts to assess whether the therapist has the will and the wherewithal to meet the patient’s anger and hate, as manifested by suicide, as fully as the therapist is prepared to meet the patient’s love and attachment. Neither side of the transference alone is adequate in work with suicidal patients.
There are no randomized trials of ABIS, but it is a way of working that has evolved at Austen Riggs over the course of a hundred years. In a study of previously suicidal patients at Riggs, at an average of 7 years after admission, 75% were free of suicidal behavior as an issue in their lives.6 These patients were considered “recovered” rather than “in remission,” using the same slope-intercept mathematical modeling as in cancer research. These findings offer encouraging support for the value of ABIS as an intervention to add to psychodynamic psychotherapy as a way to establish and maintain a viable therapeutic alliance with suicidal patients.
For those seeking more information about ABIS, including clinical examples of the technique, several references are available.2–5 A workshop presenting the principles of ABIS with a case illustration has been part of the American Psychiatric Association annual meeting for 20 years and it will likely be available as part of the scientific program in the foreseeable future.