Abstract
Working with people at risk of suicide is rewarding, but difficult at times. When someone’s life may be at risk, clinicians often feel nervous and concerned, both for the patient and for themselves. In Chapters 5 and 6 we looked at how to form a connection with an at risk person and how to formulate an assessment of their risk relative to other groups and to themselves at other times. In this chapter we consider what constitutes a good response to this risk.by suggesting four categories that can be used to organize the planning, implementation, and documentation of responses to suicide risk. Having a clear framework for what constitutes a solid response ensures consistent care is comforting for patients, families, and providers.
A Introduction
Working with people at risk of suicide is rewarding, but difficult at times. When someone’s life may be at risk, clinicians often feel nervous and concerned, both for the patient and for themselves. In Chapters 5 and 6 we looked at how to form a connection with an at-risk person and how to formulate an assessment of their risk relative to other groups and to themselves at other times. In this chapter we consider what constitutes a good response to this risk by suggesting four categories that can be used to organize the planning, implementation, and documentation of responses to suicide risk. Having a clear framework for what constitutes a solid response ensures consistent care and is comforting for patients, families, and providers.
Providing treatment and mini-interventions to target drivers and promote recovery
Engaging patients and support persons in meaningful plans for safety
Adjusting contact/observation to support the least restrictive environment
Seeking and documenting consultations with colleagues
Clinician Worries
“I love my job and it’s incredibly rewarding, but it’s also stressful at times. I worry. Primarily, I worry that a precious human being could lose their life and future. But I also worry about me. “Have I done enough? Can I go home and stop thinking about this?” And there’s always part of me wondering what someone else is going to think if something bad happens and my work and documentation is reviewed.”
B Principles
When risk changes, your response should change too.
To inspire hope, think and talk beyond safety toward long-term health, recovery, and attaining personal goals.
Whatever your role, in everyday practice you can draw on techniques and tactics used in evidence-based interventions.
Be familiar with the locally used standardized Safety Planning Intervention form.
Develop specific contingency plans for each foreseeable change identified during the Assess stage. In doing so, draw on the available resources identified during assessment.
In addition to planning for addressing suicide risk in a crisis, it is critical to also develop plans to support long-term recovery.
Make the environment safer for a person by collaborating with them on reducing their access to potential means of suicide, paying particular attention to their personal and culturally preferred means.
Determine if there are unmet social or medical needs that might decrease risk if they are removed.
Develop safety plans that employ contact and observation tools to support the individual in the least restrictive environment possible.
Dealing with suicide risk can be hard for clinicians: consult with other team members and supervisors to gain new perspectives or to help relieve the pressures involved.
C Treatments and Mini-Interventions to Address Drivers and Promote Recovery
This category is listed first to serve as a reminder that the goal in responding to suicide risk is ultimately the person’s recovery, and not fire-fighting a sequence of crises.
Providing treatments means offering access to suicide-specific evidence-based psychotherapies and medications where they are available and appropriate.
Psychotherapies. There are now a number of powerful and creative therapeutic programs that have been tested with adults, and some have also been validated or used widely with adolescents. Therapists can become certified in these evidence-based treatments through specialized training programs, and new programs and research showing positive results are emerging all the time. Examples of such evidence-based therapies include:
Cognitive Behavioral Therapy (CBT). Manualized, individual psychotherapy for persons who have recently attempted suicide. A number of different cognitive behavioral interventions have achieved good results with suicide attempt survivors and with military personnel.1 These treatments have achieved 50%-60% reductions in suicide reattempts by targeting cognitive distortions that may motivate suicidal ideation and behavior.
Dialectical Behavior Therapy (DBT). Manualized psychotherapies based on cognitive behavioral theory and techniques. DBT was initially developed to treat suicide risk in patients with borderline personality disorder. It targets suicidal behavior and other behaviors that contribute to suicide risk (e.g., reactive behaviors or behaviors that interfere with treatment or that destabilize the individual). Recent studies have shown that DBT can reduce attempts by 50%-70% when compared to a control group.2
Collaborative Assessment and Management of Suicidality (CAMS). A therapeutic framework for assessment and treatment of suicidal ideation. The CAMS framework emphasizes the importance of collaboration with the patient and working with them to co-author their own safety plan, giving them agency throughout the process.
Promising Brief Interventions
Teachable Moments Brief Intervention.3 This single-session intervention takes advantage of the period immediately following an attempt to make use of a particularly effective window for learning. The clinician explores with the patient what the attempt meant to them and patient and clinician work together to develop a stabilization plan.
Motivational Interviewing.4 The clinician interviews the patient in a way that leads them to reflect on their attempt and on the underlying motives. The goal of motivational interviewing is to shift motivation away from suicide and toward living and recovery by a nonjudgmental exploration of reasons for and against living. This inquiry allows patients to feel safe and free to explore their reasons for living and dying in a nondefensive manner, leading to increased openness to building on reasons for living.
Attempted Suicide Short Intervention Program (ASSIP).5 A person-centered brief intervention based around a narrative-based interview. The clinician helps the person tell the story of their suicide attempt in order to elicit the core information that is central to their own understanding of the events.
Medications
A guide to medication therapy for suicide risk is provided in Chapter 9. To summarize the medications that have the most evidence for suicide risk reduction:
1. Lithium: One of the oldest treatments used in modern psychiatry, lithium has been underutilized in suicide prevention. Lithium has suicide preventive effects in the long-term treatment of both depression and bipolar mood disorders.
2. Clozapine: The first medication with a US Food and Drug Administration (FDA) indication for suicide risk reduction (for patients with schizophrenia). Still underutilized at present.
3. Ketamine: Rapid reduction of depressive symptoms and suicidal ideation. Esketamine is FDA-approved with an indication for Treatment-Resistant Depression and for adults with MDD who have suicidal ideation.
4. Antidepressants: Antidepressants can be used judiciously and effectively to address depression and anxiety. On a population level, suicide preventive effects are associated with increased population rates of antidepressant use.
Please see Chapter 9 and Stahl’s Essential Psychopharmacology Prescriber’s Guide for more detailed guidance.
Clinical Tip: Lithium and Mood Disorder
Consider lithium for patients with any mood disorder who may be at risk of suicide, and additionally if full remission has not been achieved. Also consider lithium for mood disorder patients, especially when suicide risk is present. Lithium should be utilized as a longer term approach, not a short-term antisuicidal agent. It is not clear how rapidly lithium works on suicide risk, given the methodological limitations of the data. Follow usual baseline laboratory and regular monitoring for renal, thyroid, and other metabolic side effects.
Chapter 9 also contains important caveats and considerations for using medication to address suicide risk.
“I’m much more likely to trust someone, to stick with them for the next step, if they’re honest with me – even if they’re stumped. I’d rather you be speechless than have a bunch of easy answers to problems that seem unsolvable to me.
I’ve heard professionals say they worry about validating how bad I feel. But to me, someone actually acknowledging those feelings, how hard my situation is … and that I’m not crazy to want out … that’s comforting. And I’m usually not hung up on them saying it the exact right way. I don’t need you to be eloquent, just empathetic.”
Mini-Interventions
While evidence-based therapies are becoming more accessible, most clinical interactions with individuals at risk of suicide occur outside the structured bounds of an evidence-based psychotherapy session. To address this reality, clinicians can draw on tools and tactics that appear in manualized, evidence-based psychotherapies and apply them in other settings. Sometimes, being able to offer up an appropriate, simple, evidence-informed comment at just the right time can make a real difference.
The table below lists a catalog of useful mini-interventions that can be implemented very quickly and can have powerful effects when working with somebody who is struggling with suicidal ideation or behavior.
Mini-interventions: tactics, strategies, and phrases from evidence-based therapists that can be used anytime.
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