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This article provides a brief synopsis of the research regarding the use of psychotherapy to manage suicidal behavior, followed by several examples of strategies that such treatment employs.
In the past 30 years, a considerable body of research has been amassed regarding the use of psychotherapy to manage suicidal behavior. Much of this research included the premise that suicidal behavior must be dealt with as a problem separate from a primary diagnosis (eg, depression) and that techniques must be used to both manage the risk in the present and prevent recurrences in the future. Most clinicians are not aware that suicide risk should be addressed specifically and separately from the primary psychiatric diagnosis. Practical, evidence-based approaches have been developed that decrease the risk of present and future attempts. We aim to provide a brief synopsis of the research evidence, followed by several examples of strategies that such treatment employs.
Cognitive behavioral therapy for suicide
Several systematic reviews have analyzed existing data on the effect of therapeutic interventions to reduce suicide risk. In 2008, Tarrier et al1 examined 28 randomized controlled trials (RCTs) involving adults and adolescents. The researchers concluded that cognitive behavioral therapy (CBT)-based interventions demonstrated effectiveness in reducing suicidal behavior. A subsequent systematic review by Mewton and Andrews2 in 2016 limited its focus to RCTs examining the benefits of standard CBT in adults. Their conclusion agreed with the observation of Tarrier et al1: Treatment is more effective when directly targeting suicidal thoughts and behavior as opposed to when treatment is designed to address mental illness with the assumption that benefits will also impact suicidal behavior. Hence, the literature underscores the need for specific interventions targeting suicidal behavior.
The meta-analysis by Ougrin and colleagues3 in 2015 supported the effectiveness of therapeutic interventions including CBT, dialectical behavior therapy (DBT), and mentalization-based therapy in reducing self-harm in adolescents. The dearth of independently replicated studies impeded drawing firm conclusions on the comparative benefit of specific therapeutic strategies. Independent trials have looked at the effectiveness of DBT in adolescents who are at high risk for suicide. The RCT by Mehlum et al4 in 2014 and the recently published RCT by McCauley and colleagues5 suggest definite benefits of short-term DBT in adolescents with borderline personality traits who had engaged in prior self-harm and suicide attempts. The latter study also showed superiority of DBT with respect to treatment retention.
Engagement and retention of patients is a significant challenge in managing suicidal behavior. Often, such patients do not seek outpatient therapy and present for emergency care with suicidal crises. The emergency department (ED) must therefore be a key site for intervention. The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study by Miller and colleagues6 designed interventions for screening and provision of safety plans with follow-up phone calls to patients and significant others. Stanley et al7 discussed the benefits of such ED-based interventions in reducing suicidal risk. Their comparative cohort study showed that safety-planning interventions coupled with structured follow-up reduced the risk of suicidal behavior by 50% and achieved a twofold increase in the odds of treatment engagement over a 6-month period. The safety-planning intervention consisted of six specific strategies: identifying early warning signs, encouraging internal coping strategies, reaching out to family/friends, identifying other individuals who can provide support during suicidal crises, contacting mental health professionals, and lethal means planning. This large-scale study illustrates a feasible, pragmatic approach to suicidal behavior that does not demand extensive resources and can be easily delivered in an ED setting.
Cognitive behavioral therapy for suicide prevention is another short-term intervention designed to specifically address suicidal behavior that has significant effects in reducing future suicide attempts.8 It is composed of three phases: an initial phase promoting treatment engagement, an intermediate phase focused on cognitive and behavioral strategies targeting suicidal thoughts and mobilizing reasons to live, and a final phase that targets relapse prevention and consolidates the ability to effectively use strategies in the setting of future suicidal crises.
Each of the preceding studies have common psychotherapeutic strategies that may be employed by any clinician. All are rooted in the fundamental principle of the therapist as an empathic partner who forms a strong therapeutic alliance with patients and who acknowledges their suicidal thoughts and behaviors as a response to intolerable pain or acute subjective distress. The patient is enlisted as an active partner in the process of understanding personal risks for future suicide crises and developing remedies for such occurrences.
The following section describes four specific strategies common to these approaches, including lethal means reduction, safety planning, developing reasons for hope, and inspiring delay.
Lethal means reduction
Lethal means reduction is the process of assessing whether patients have access to firearms or other lethal means to commit suicide and then working with them and their support network to restrict access to such means. It is one of the most important and most supported interventions to reduce suicide attempts. Collaborating with the patient by expressing genuine concern about his or her safety, explaining that reducing access will lower the risk of suicidal actions, and then negotiating with the patient and supportive others to make the environment safer is critical for success. In the event that the lethal means available is a firearm, one must assess for multiple firearms and then advocate for removal of all of them. Gunlocks, removal of ammunition, or gun safes are also possible ways to restrict access if the patient refuses to remove the gun(s) from the home.
Methodical inquiry about possible methods and what might limit the ability of the patient/family to remove them is the central task for the clinician. If the patient is hesitant, it helps to assess the pros and cons of restricted access, reminding the patient that this may be time-limited. As in all work with suicidal patients, the more collaboration that is possible with supportive others, the better.
Generally, suicidal behavior occurs as a reflexive response to certain triggers. It is common for patients who engage in such behavior to regard suicide as a means of solving problems that they view as insolvable. Such patients often have significant problem-solving deficits. When patients have no relief from relentless worry or concern about problems, and they think of suicide, the relief it may provide reinforces suicidal thinking and increases the risk for further action. Skill deficiencies that patients have-in problem solving, distress tolerance, emotion regulation, and conflict resolution-may increase their risk for future vulnerability to suicidal behavior.
A particularly good strategy is to plan alternatives that keep the patient safe until skills can be learned or other solutions put into place. Safety planning, as described by Stanley and colleagues,7 is an intervention with which the clinician actively and collaboratively determines with the patient a prioritized and personalized list of warning signs that a crisis is beginning to occur. The clinician then finds coping strategies and internal and external resources that the patient can use at this time. This plan is derived from a risk assessment and the narrative description of the patient’s crisis. It is designed to be over practiced (like a fire drill) so that the plan will be available for use during a suicide emergency. Making a safety plan begins with a chain analysis of the minute-by-minute thoughts, emotions, and behaviors that led to suicidal thoughts or an attempt and the subsequent consequences. The patient must understand that suicidal thoughts are transient and vary in intensity.
The plan provides time for these urges to decrease before permanent harm occurs. The patient is consulted as the expert on his or her own suicidal behavior: “What have you done on your own to decrease suicide urges?” and “How do you get your mind off of it?” If the patient cannot generate options, the clinician may provide suggestions. These may include distracting activities, alternative thoughts, or strategies to decrease painful emotions. After formulating a plan for distractions, the patient is asked to identify two groups of social contacts: a group with whom she or he may be distracted from the suicidal thoughts, and a group that can help with suicidal thoughts. Finally, emergency services are identified that the patient can access if a crisis is imminent.
At each step of the safety planning intervention, the patient is asked about the likelihood of using the intervention, the obstacles he or she anticipates to its use, and those obstacles solved. If the patient cannot solve obstacles or commit to the use of the plan, then more restrictive care is indicated. Once the plan is completed, the written plan is given to the patient and the patient is asked where it will be kept for review and use.
In later sessions, the therapist may provide training in skills that are absent and that increase the patient’s vulnerability to suicide and then mentally rehearse the deployment of those skills in a similar setting in the future. Patients must repeatedly practice new ways of thinking and behavior so that they have other solutions besides suicide available at times of future stress. Patients who develop better ways of coping in a crisis and repeatedly practice such skills (even in their imagination) have greater resilience during stressful circumstances and reduce their reliance on suicide as a solution.
A 45-year-old construction worker sustained a crush injury of his right arm 2 years ago. He has had four surgical procedures and extensive physical therapy, but has continued to experience intractable pain and has been unable to return to work. His family has struggled to make ends meet. He has used opiate pain medication since the accident but never exceeds what is recommended. He needs help with all of his activities of daily living, including dressing.
After his last surgery, he has been more despondent. He meets the full criteria for major depression. He has started to drink to fall asleep at night. His wife brought him to the ED after he told her that he thought she and the family would be better off without him.
After assessing him in the ED, the psychiatrist determines that there are no weapons in the home. The patient indicates that he had plans to overdose on his oxycodone when he got his monthly prescription this week. He and his wife agree that she will keep the pills locked at her place of work and give him access to only a day at a time. The psychiatrist then turns her attention to making a safety plan with her husband. They first discuss all the triggers that produce his intense thoughts of suicide. The patient is asked what would prevent him from using the plan. He says that if he were unable to contact a friend or his wife, he might have trouble. They review professional help that he can contact. He discusses his feeling that this makes him “weak” but eventually commits to doing so.
When asked for reasons to stay alive, the patient says, “My children.” The psychiatrist asks for more detail: “What is important to your children that you do together? What do you value about being with your children? What would you miss in your children’s lives if you died today?” As he describes more about their relationship, he becomes tearful, and the psychiatrist probes further about what he might miss in the future with his children were he to die. He is much more certain about using the safety plan reliably after this discussion.
Developing reasons for hope
Most CBT/DBT interventions approach suicidal patients with an eye toward managing hopelessness. A cornerstone of DBT is the idea that the patient must build a life worth living, even when the patient has many life problems and a wish to die. In CBT, a core premise is monitoring and managing hopelessness, because the presence of hopelessness is a significant risk factor for suicide even in the absence of depression.
Methods that improve hopelessness generally connect patients to core values and attachments to inspire the patient to tolerate current pain and stay alive. Making a list of reasons to live generally is a part of the safety plan. The psychiatrist must ask the patient to describe vividly the attachment the patient has to these reasons to strengthen resolve.
Another technique is to build a hope box. This is a tangible collection of items that remind the patient of reasons to stay alive. It may include photographs, inspirational scripture or quotes, poetry, letters, meaningful mementos, and reminders of things that the patient wants to do in the future. These items inspire more emotional connections to the commitment to stay alive. Such items can be actual or virtual (ie, in a phone app) so that the patient has easy access.
Generally, the impulse to suicide is momentary. If the patient can delay action on the impulse, it may be life-saving. Several strategies facilitate delay. First, the patient can be asked to reflect on the things that will be missed if they die, year by year. This brings to light the finality of death and the reality of what the patient will miss. Second, the patient can be asked to commit to “taking suicide off the table.” Many patients who are suicidal are beset with a significant number of psychosocial problems and experience relief when they think about dying as an escape. The patient needs time to begin to resolve these problems. Working with such patients is a challenge because it is impossible to discuss anything except suicide if that is a genuine possibility. Thus, it is often necessary to agree that the patient will commit to a delay to determine if things can improve enough to allow work on psychosocial problems to occur.
These are just a few examples of how it is possible to use psychotherapeutic interventions to more effectively manage the patient with suicidal thinking and behavior. Although these patients are challenging, there are some tools that we know make a difference.
Dr Sudak is Professor and Vice Chair for Education, Drexel University, Philadelphia, PA, and Dr Rajalakshmi is a Resident, Department of Psychiatry, Drexel University, Philadelphia, PA.
The authors report no conflicts of interest concerning the subject matter of this article.
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