Universal Themes Emerge for Psychotherapy With Suicidal Patients

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.