Abstract
The proportion of time a person spends in direct contact with a health professional is minute. We can make the most of our direct encounters by following best practices for connection, assessment and respond described in Chapters 5, 6, and 7. But ultimately, we must also consider how to extend the impact of our interventions beyond our healthcare environment into the lives and networks of the people we serve.
A Introduction
The proportion of time a person spends in direct contact with a health professional is extremely small. We can make the most of our direct encounters by following best practices for connection and assessment and responding, as described in Chapters 5, 6, and 7. But ultimately, we must also consider how to extend the impact of our interventions beyond our healthcare environment into the lives and networks of the people we serve.
B Principles
Extending care means thinking:
Beyond the individual, to their network of family, friends, and other supports
Beyond direct interactions within healthcare facilities
Beyond the person’s enrolment in a program or clinic or their episode of care
A set of key practices, service design, and systems structures that exemplify the extend mindset include ensuring:
Input and clear roles for family and other supports
Caring contacts to extend impact and intervention
Proactive follow-up assessments and support
Continuity and alternatives in suicide crisis care
Patient Perspective
Words matter. As a patient, I don’t want you to think of your job as “monitoring” or “transitioning” me. It feels more respectful to communicate that you and your organization understand that my life extends beyond when I’m with you, and that you’re interested in how your assessments and responses fit, and extend into, my life.
C Input and Clear Roles for Family and Other Supports
Planning with Families and Support Persons
The primary goal in involving support persons is to extend the core task of connection outwards. This means collaborating as early and as frequently as is possible with family, service providers, and other central supports around a shared goal of recovery.1
Chapter 7 emphasized the importance of developing safety plans that address the specific needs and situation of the person being cared for. A vital element in safety planning involves drawing on professional and personal support persons who can provide resources in times of difficulty. But these other people also need their own plans. In extending care, a key goal is to integrate contact with third parties into planning and to help them develop the skills needed to motivate and engage with these people – not as an afterthought but as central elements in the process.
At ABC Health, mental health treatment plans are updated every 90 days. Coincident with this update, policy also requires updating contacts, persons involved in support plans, and their specific roles. If the person has declined contact with outside individuals, this decision is revisited.
Having a routine for updating and revisiting who is important and available in a person’s life can make an enormous difference in the connection between clinician and patient and in the quality of care it is possible to deliver.
Awareness of the central people in an at-risk person’s life, and the development of support plans in collaboration with them, should be core elements in care routines that are regularly updated. This provides an opportunity to hear about new potential resource individuals, as well as to learn about the disappearance of other individuals from a patient’s life. Instead of relying on chance, making a concerted effort to stay abreast of a patient’s evolving circumstances helps to embed shared plans and the roles of support persons in routine care.
Clinicians can draw on a range of practices, skills, and attitudes to facilitate productive engagement with a patient’s wider support network.
The Family Support Plan
One important practice for engaging families around safety planning is the development of a family support plan. Family support plans present the content of a patient’s safety plans from the point of view of one or more family members or other central support persons. The development of these plans involves taking each of the elements of a personal safety plan and reformulating them so that the support person knows exactly what they should do to provide support when needed. This might involve ensuring the removal of lethal means or specifying tasks or timetables for monitoring the person they are supporting. But it can also involve explaining when and how they can connect with the professional care team if it looks to the support person that the safety plan may not be working as is intended.
For example, a common element in safety planning2 involves identifying social strategies for distraction and support. In the case of a young person, an important element in developing such strategies would be to determine what role their parents would play (e.g., reminding the young person of steps they need to take, or driving them toward certain behaviors or goals). In an ideal world, these plans will have been developed with family input and involvement, but even when time or circumstances do not permit extensive upfront involvement, developing a family support plan over time should be part of routine care.
Youth Special Focus: Availability of Alcohol
In the USA, alcohol is often implicated in youth suicide, with some studies suggesting it may even be involved in the majority of cases. Alcohol can play a role in disinhibiting suicidal behavior even for young people who have not previously abused alcohol or other substances. For these reasons, educating parents about securing alcohol is a top priority. Families can often misdirect their safety planning toward objects such as sharp kitchen utensils (a rarely used means of suicide) while ignoring open liquor cabinets or fridges of beer in the basement. Many safety planning documents for youth do not explicitly address alcohol in the home, so it might be up to you to add this element to your routine practice.
Meeting Common Challenges in Working with Family
The challenges to involving family members in safety planning can differ significantly across care settings.
In youth-serving settings, approaching family members as potential assets and involving them at every step of the way is second nature. Thinking in terms of family systems is part of the job, so suicide risk should be approached in the same way. In acute services, by contrast, getting families involved is often difficult. Most inpatient hospitals have mechanisms for connecting with families, but it can be hard to involve them in a meaningful way unless family members are quick to respond, highly cooperative, and eager. Even when family members are keen to help, the pace of inpatient care and the need to stabilize and discharge patients quickly make it difficult to engage with family at a deep level.
Health and behavioral health settings fall somewhere in between. Professionals in these areas generally welcome family involvement, and it may even be a requirement when youth or vulnerable individuals at risk for suicide are involved. However, barriers can still arise in dealing with the broader care team, with collaborating providers, and sometimes from the person themselves.
There is no “silver bullet” solution to these challenges. What is important is to cultivate a mindset that treats extending care beyond individuals, episodes, and institutions as a standard. In developing such a mindset, it will be useful to consider a number of common barriers and to reflect on potential methods for overcoming them.
1. The first challenge is to recognize that family members struggle as well, and that they are not always equipped to help or easy to get along with. Making family members part of the team is an attractive ideal, but sometimes the reality is that a family member’s own struggles make them unavailable or even counterproductive.
2. The second challenge is that some youth and adults do not want their families – or anyone else – involved and informed about their situation or care. These two challenges can feel particularly difficult to navigate in certain cases, as when there is a legal requirement to inform and involve family.
Three basic principles provide invaluable starting points in these situations:
Assume good intentions
Widen the circle
Widen the options
When I’m invited to consult in situations with very severe suicide risk, it often happens that family members are described to me in a very negative light. It is natural for staff to feel angry when it seems like parents or other family members are working against the goals the care team is striving toward. One strategy that has helped me is to ask staff members to make a family tree-or genogram showing at least one generation above the “difficult” family member. We almost always find the same thing – significant levels of trauma. The recognition that the family member has their own suffering – and simply coming to know them a little more as an individual rather than an obstacle – makes all of us begin to soften a bit. When you can see that these challenging behaviors developed for understandable reasons, it can make the behaviors easier to work with and around.
Assuming that family members have good intentions may sound obvious, but it often takes commitment and effort. When family members present challenges, it helps to remember that nobody chooses to be disorganized, socially difficult, or drug addicted. Similarly, challenging or confrontational interaction styles are usually manifestations of a misdirected effort to have fundamental needs met. Once a positive mindset toward family members has been established, it is then possible to work together to find strengths and to capitalize on what they can offer to the process, rather than focusing on what they lack.
Assuming good intentions does not mean shying away from real family issues, as these can be important to tackle for someone at risk of suicide. Developing a set of feasible, acceptable, and convenient options for addressing structural and relational problems in the family will often be an important part of planning.
Prompting questions can be used to help uncover support persons who might not be immediately obvious. A young person could be asked:
“Think about your bigger family – people you don’t live with or maybe you don’t even see very often. Who’s someone you look up to or like to be around, or you think is cool?”
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