Managing Suicidal Emergencies: Using Crisis to Create Positive Change

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Managing Suicidal Emergencies


Using Crisis to Create Positive Change


In this chapter we provide tools to manage a suicidal crisis in a way that is collaborative and leads to better health outcomes. We include this chapter on crisis and case management separately because this aspect of work with suicidal patients can be both emotionally exhausting and emotionally challenging. Many providers become ill at ease when dealing with episodically or chronically elevated suicidal behavior. Instead of using the more traditional notion of crisis intervention, with its emphasis on risk management implications, we use the term crisis management to refer to the proactive strategy of planning, in collaboration with the patient, a response to either the immediate suicidal episode or the possibility of recurring suicidal behavior. The crucial goal of this collaborative planning approach is to establish a learning-based framework that rewards value-based problem-solving behaviors and minimizes the short-term reinforcements for suicidality.



The same factors that make suicidal behavior a multidimensional entity add to the complexity of effective crisis management. Some patients will be in the midst of a highly contained suicidal crisis that is clearly the result of specific life stresses (e.g., divorce, discovery of a terminal illness, starting college, death of a spouse, being fired from a job) and that may or may not be associated with a mental health condition. These patients’ premorbid level of functioning will be high, and substantial social support may be available. At the other end of the crisis management continuum, patients may be experiencing chronic suicidal thoughts or engaging in repetitious self-destructive behaviors. Patients in the latter group require a more consistent application of crisis management strategies, although the amount of time and energy spent on this task might vary from week to week or even day to day. In both situations, the significance of any suicidal communications or behavior cannot be downplayed.


These two presenting situations require different clinical responses. For example, it is not productive to view repetitive and intractable ideation as a suicidal crisis per se. For a substantial number of suicidal patients, suicidal ideation is a daily reality, an ever-present symptom. Because suicidal ideation also functions as an emotion regulation strategy, it may not reflect a true desire to die or be a source of extreme distress to the patient because in a paradoxical way it serves to temporarily reduce anxiety about whatever that day’s stressors might be. However, suicidal ideation can generate profound distress for others, including therapists, prescribers, and case managers, and this, in turn, can ratchet up the stakes in interactions with the patient. Patients with chronic suicidal ideation and repetitious suicidal and self-destructive behaviors are often assigned to case management systems. The case manager and therapist must continually balance their crisis intervention response to the recurring suicidal behavior, the ongoing treatment, and the community resource needs of the patient.


In contrast, the patient with no appreciable history of suicidal ideation and no known attempts would be regarded as being in the midst of an acute suicidal crisis. The notion of crisis means that the individual is experiencing a significant upturn in suicidality to levels well beyond the previous typical range of behavior. Yes, a chronically suicidal patient can exhibit a suicidal crisis, but the crisis must entail levels of suicidal ideation or behavior that are significantly increased above the levels typically manifested by the patient.


A core value in treatment is primum non nocere, first do no harm. Using this core value can help inform and shape an appropriate response to heightened suicidality crises that avoids invasive risk-management strategies that might inflict harm on or retraumatize the patient. Using this core value can also aid in viewing each patient holistically, can promote the use of a strengths-based rather than pathology-driven approach, and can help the patient establish feelings of personal safety. Following this basic guidance, it is important for the clinician to carefully attend to the circumstances, concerns, and preferences of individuals in crisis. To the extent possible, engaging patients in mutual decision making regarding the next steps in their clinical care will inspire trust and will lessen feelings of helplessness and loss of control that are common in crisis situations. Such efforts may serve to support patients’ sense of personal responsibility for their well-being and for many, if not all, of the decisions that will be undertaken to address the crisis. Optimal responses to managing crises involve an intention on both sides to use the opportunities inherent within a suicidal crisis to promote a more flexible, adaptive approach to personal problem solving and emotion regulation. In other words, the appearance of suicidality of any kind is an opportunity for positive advances in skill training.


Case management, which we discuss in detail later in this chapter, is best defined as the effective coordination of care through a variety of settings. Many mental health care settings designate an individual as case manager, and this position can be crucial in coordinating the many facets of care a suicidal patient may require. The case manager addresses liability issues, overcomes system-level obstructions, communicates a clear treatment plan, and deals with resistance that other providers may experience in following through with case management strategies. If your facility does not have such a position, get one designated. If that is not possible, then you are the case manager.


One significant and often difficult component of case management is resolution of potential conflicts between the social control goals that may come from immediate family members or the treatment system and the clinician’s sense of what is in the patient’s best interest. Anyone involved in the treatment of a suicidal patient will find some aspect of case management embedded in his or her work.


Remember, whereas crisis management is largely a matter of optimizing the interaction between you and your patient, longitudinal care and active efforts to engage in case management are aimed at influencing others to support your patient. These two missions often converge when patients are less responsive to treatment. Repetitious suicidal patients typically need more instances of crisis management as well as more frequent and active case management. Although there is a tendency to drift away from a problem-solving focus when case management demands intensify, in effective treatment, value-based problem solving and emotional acceptance must be pursued consistently, regardless of recurrent crises or the amount of case management.





Tips for Success


For effective crisis management, you should take mutually agreed-on steps to encourage and reward your patient for engaging in value-based problem solving instead of suicidality.



Separate from crisis management, longitudinal care and case management should involve the coordination of care across treatment settings and providers so that suicidality is responded to in essentially the same way no matter who is involved.



Remember that the fundamental ideas underlying crisis management, longitudinal care, and case management is to first to do no harm to the patient and to maximize opportunities for autonomy and nonsuicidal decision making.


Working Through Suicidal Crises: Five Principles


Whenever a patient needs help with a suicidal crisis, successful intervention relies on the following five principles:



  1. Suicidal behavior is designed to solve specific problems that your patient views as inescapable, interminable, and emotionally intolerable (the three Is introduced in Chapter 3, “A Basic Model of Suicidal Behavior”). Any of us can become suicidal when faced with these conditions. Successful crisis intervention helps the patient work through the suicidal crisis by using both short- and intermediate-term problem-solving strategies.
  2. Your demeanor plays a critical role in accelerating or decelerating the crisis. Validate the emotional pain the patient is experiencing and reframe the pain as a reflection of the patient’s values in life. It is the discrepancy between what the patient is seeking in life and what the patient is getting that is producing the emotional distress of the moment. Approach the suicidal crisis in a direct, matter-of-fact, and candid manner and avoid appearing nervous, scared, or apprehensive about what may happen next. Overwrought emotional responses by the clinician do not usually serve the best interests of the patient.
  3. Suicide is a rare outcome of suicidal crisis. Most of the therapeutic maneuvers that count assume that the patient will be alive tomorrow. The patient should learn from this crisis and should become less vulnerable to subsequent crises through this experience. If your only motive in the therapeutic alliance is to keep the patient alive, a precious opportunity for human growth will be missed. In working with a patient who has a history of recurrent suicidal behavior, you will do little but react to a never-ending stream of suicidal episodes unless your patient is able to grow and learn from each episode.
  4. There is little evidence that any form of crisis intervention, be it counseling, psychopharmacology, or both, will prevent suicide under all circumstances. Real suicidal crises are self-limiting. Few individuals can maintain an acute crisis for more than 24–48 hours without going into an adaptive period of emotional exhaustion. Your treatment should be focused on getting through the next 1 or 2 days while anticipating that the episode will soon give way to the underlying problems that provoked the crisis.
  5. Your intervention should aim to help the patient solve problems constructively and in nonsuicidal ways. Intervention techniques should never reinforce suicidal behavior. Your goal is neither to punish nor to reward suicidal behavior but rather to make it an event with neutral valence. By achieving this neutral valence, the suicidality will lose any advantage it has over other, more adaptive problem-solving strategies.

Strategies for Working Through Escalating Suicidal Behavior


When working with an acutely suicidal person, you can use specific strategies that, when done properly, can defuse a crisis. These techniques, which can be put into play with both new patients and individuals in ongoing therapy, are summarized in Table 8–1.






























Table 8–1What to do when the crisis heats up


Validate the patient’s sense of emotional pain and desperation.


Be calm and methodical—remember functional analysis (see Chapter 5, “Outpatient Interventions With Suicidal Patients”).


Review mental status. Ask about psychotic symptoms and mood or anxiety symptoms.


Assess the immediate potential of substance abuse. Ask about the use of alcohol, prescription medications, and illicit substances.


Assess the patient’s social context. Help the patient generate short-term objectives that identify sources of emotional connection and belonging that can be strengthened in the immediate term.


Be direct in questioning about suicidal behavior. Use evidence-based methods for assessing such behavior.


Always reframe suicidal behavior as problem-solving behavior.


Create a positive action plan.


Review the crisis protocol.


Schedule extra contacts if necessary but beware of reinforcing suicidal behavior—emphasize problem solving, not “feeling better.”


Validate Pain by Connecting It to the Patient’s Experience


The underpinning of suicidal behavior is the patient’s desperate search for any strategy that can control pain that is experienced as intolerable, inescapable, and interminable (the three Is). The pain itself originates in a felt discrepancy between what the patient is seeking in life and the results the patient is getting. The most important thing to remember is that, first off, you need to validate the patient’s feelings of emotional pain and desperation. The best way to validate emotional pain is 1) to state that you can see how much the patient is hurting and 2) to tie the pain to a positive life value the patient wants to pursue. It is very easy to become overfocused on the patient’s pain because this is the reason for the suicidal problem solving. Note, however, that the patient must have some powerful values at stake to be in so much pain. You may need to validate the patient’s emotional pain on several occasions even during a relatively short crisis interaction. You want to make sure that your patient believes that you understand the pain he or she is in and that you are there to help, not to judge. Although the stated goal of crisis management is ultimately to develop a problem-solving set and formulate a new action plan, you need to validate the patient’s difficulties and provide effective support in the context of a therapeutic alliance.


Suicidal crises can escalate when the therapist’s anxiousness to do something leads to disconfirmation of the patient’s pain and distress. The “just do it” motif might work well in the locker room, but it is anathema to a suicidal patient, who may interpret this attitude as an overwhelming injunction. Your patient may well become more suicidal in reaction to such an injunction. With this reaction your patient is saying, “No, you don’t quite understand just how bad I’m really feeling. Let me show you a little more directly!” As frequently as you can, validate your patient’s sense of emotional pain and acknowledge that your patient is considering suicide as an option to stop the pain. At the same time, confidently state your belief that if the two of you work together, better solutions can be found. There are many technical steps that can be taken with a patient who is suicidal, but the emotional tone of the session is the most important mediator of overall success. The patient who feels listened to and accepted is more likely to carry through with a collaborative problem-solving plan.


Keep Calm and Carry On


Throughout the crisis interaction, it is very important to remain calm, direct, and methodical. At the very moment in time when your patient is struggling with basic fears about the ability to control suicidal urges, you, the therapist, are looking relaxed and self-assured. The fact that you are not panicking or shaking with anxiety will be reassuring to your patient. It communicates that you are comfortable dealing with these matters and that you know what you are doing. Your demeanor helps to promote the gathering of certain important pieces of information, such as your patient’s perception of the problems that have precipitated suicidal behavior, the range of problem-solving responses that have been considered, the mood and cognitive factors that will influence short-term problem solving, and features of the situation that indicate heightened risk, such as the availability and lethality of a method of self-injury.


Assess for Psychosis or Signs of Thought Disorder


Part of your assessment of your patient’s problem-solving flexibility and strengths includes monitoring for the presence of psychotic or thought-disordered symptoms. In general, the more disordered a patient’s thinking, the less workable a self-directed problem-solving plan becomes. Seek to verify whether the patient is experiencing command hallucinations or delusions that are producing urges to engage in self-harm. A psychotic illness must always be treated, and clinical intervention must be undertaken immediately when a psychotic symptom is accelerating your patient’s suicidality. A patient with a psychotic illness may benefit from medication and the increased structure of short-term hospitalization or from longer-term hospitalization that targets the underlying psychotic symptoms.


Assess Impairments Due to Mood or Anxiety States


Assessment of mood- and anxiety-related symptoms is an important step in understanding the patient’s crisis. Mood-related symptoms strongly influence a patient’s motivation, attention span, and energy level. A patient who is severely depressed is likely to have trouble following through with a problem-solving plan because of a lack of energy to accomplish it. A patient who is highly anxious and agitated has plenty of energy to expend but may experience trouble maintaining the focus necessary to implement a coping plan. In general, the more serious the mood- or anxiety-related functional impairments are, the more you should focus on developing a simple, short-term coping plan. The goal in such situations is to help your patient weather the storm, and once the storm has subsided, you can move in the direction of solving the patient’s more complex life problems. For example, now is not the time to push a patient to file for divorce from an abusive partner; rather, the immediate focus might be getting the patient to seek safety for a couple of days at a local domestic violence shelter, where there is an atmosphere of trust and safety.


Assess Immediate Potential of Substance Abuse


It is important to assess your patient’s current use or potential for abuse of alcohol, prescription medications, and legal or illicit drugs. Many suicidal people use alcohol or other addictive drugs as a way to regulate emotional pain. If substance use plays a role in precipitating or augmenting suicidality, avoid lecturing or moralizing about the negative effects of substances. Instead, form a problem-solving plan that is incompatible with the passive approach that leads to substance use or misuse. For example, schedule constructive activities during the time your patient is prone to drink, abuse prescription medications, or take illicit drugs or consider follow-up calls at a time when your patient might be tempted to use these short-term fixes. Ask about high-risk times when substances were not used: find out how your patient was able to devise better solutions and then focus on increasing use of these strategies. It is often useful to enlist the aid of others in your patient’s social network to help restrict access to alcohol, prescription medications, and illicit substances and to support or initiate activities that are incompatible with heavy use. If an addiction program is available, encourage your patient to sign up and assist him or her in enrolling.


Assess the Patient’s Social Context


It is important to carefully assess your patient’s significant emotional connections, sources for feelings of belonging, and the quality of any available social supports. The experience of feeling isolated and, very importantly, the experience of an abrupt rupture in one’s sense of belonging (e.g., in a relationship, a family, a community, or, even more abstractly, one’s life) may acutely and significantly increase suicidality. Clarifying the patient’s feelings of connection with others and determining whether any recent shift or disruption has occurred are essential in discerning the drivers that may underlie suicidal behavior. Understanding these aspects of the patient’s situation, moreover, will shed light on the problems that are generating the emotional pain that the patient is attempting to regulate via the use of suicidal and/or self-harming behaviors.


Use Evidence-Based Methods for Assessing Suicidal Potential


Do not assess your patient’s potential for suicidal behavior by limiting yourself to the use of traditional suicide risk-assessment questions. These traditional risk factors have not been shown to be accurate predictors of the risk of suicidal behavior. There are more revealing ways to assess the likelihood that your patient will remain suicidal. These questions are relatively simple to ask and are discussed in greater detail in Chapter 4, “Assessment and Case Conceptualization” (see Table 4–2, “Key Factors That Signal Potential Risk of Suicidal Behavior”).


Probe the patient’s outlook in the following areas:



  • The patient’s belief that suicidal behavior would solve problems
  • The patient’s history of using suicidal behavior as a means of solving problems
  • The nature of the problem that is being solved through suicidal behavior
  • The patient’s ability to tolerate significant emotional pain
  • The patient’s reasons for not dying by suicide, as identified by looking back at other episodes of intense suicidal ideation
  • The patient’s ability to see a future that is positive and life enhancing

Reframe Suicidal Behavior as Problem-Solving Behavior


Reframe suicidal behavior in the problem-solving context so that your patient’s first impression of treatment is oriented toward solving real-life problems. This approach helps remove the stigma of suicidal behavior and gets your patient thinking about symptoms from a different perspective. Work hard to get the message across that suicidal behavior is not a sign of abnormality but rather an outcome of a legitimate problem-solving process. Beyond being an approach that respects the patient’s potential strengths, this tactic in itself will help defuse a suicidal crisis.


Create a Positive Action Plan


The desired outcome of effective crisis management is a short-term plan that has been collaboratively generated by you and your patient. The plan addresses the actions that need to be taken in the succeeding days to solve the problems that precipitated suicidal behavior. A good plan is easy to define: it is concrete, detailed, and within the patient’s ability to achieve.


The two most common mistakes in this endeavor are 1) forming a plan that the patient is unable to accomplish and 2) pushing a plan that is not formed by a collaborative effort. Given the pressure inherent in the crisis situation, you understandably want the outcome to be good; however, beware of your tendency to define good solely by what you think the patient ought to be doing to solve his or her difficulties. Your definition of what is good may not be something that your patient agrees with or is able to do. Keep in mind that it is not necessary to make major changes to solve problems. Achieving a small, positive step can have as much of an impact on one’s outlook as trying to make a heroic change in life. The psychology underlying suicidal behaviors is that the situation is viewed as unchangeable and inescapable. Any positive change can bring these rigid assumptions into question. When you and your patient have developed a workable short-term plan, you have done your best to ensure that your patient will succeed. Tailoring a plan to a patient’s capability is the key to success. If the plan is unachievable, your patient may feel helpless and give up, and thus he or she will have one more failure to deal with. The plan must be seen as achievable and, if successful, as a positive step forward.


Typical goals for the short-term problem-solving plan might include the following:



  1. Decrease your patient’s social isolation.
  2. Increase the patient’s sense of belonging and connection.
  3. Increase pleasant and positive reinforcing events. Avoid activities that trigger unpleasant and negative reinforcing events.
  4. Engage or reengage your patient with an activity in which success is likely.
  5. Increase the patient’s physical activity level through some type of exercise.
  6. Increase the patient’s use of relaxation strategies or self-care behaviors.
  7. Get the patient to engage in coping responses that have worked in previous times of crisis.

Ask the patient the following two key questions regarding each short-term goal:



  1. “If you were able to do _____ in the next few days, would you see that as a sign of progress?”
  2. “Do you think _____ is something that you can actually do in the next few days, given the way you are feeling?”

An isolated person may have a competent social support network but may worry about being a burden and therefore might avoid interaction. In this situation, a short-term behavioral plan might emphasize initiating a social contact with one or more helpful persons but limiting the amount of time spent talking about personal problems. You can also work on ways to get your patient to resume a pleasant activity that has somehow dropped out of the weekly routine. This method may involve scheduling one or two walks in the park over a 5-day period, going to a movie, caring for a pet, or taking an exercise class. It is often useful to look for coping strategies the patient has used in previous times of travail. Did the patient take a nice warm bath each night? Practice meditation or simple relaxation strategies two or three times a day? Call a friend in another city for a daily check-in?


From a strengths-based perspective, you want to look for what the patient already knows how to do. It is easier to reinitiate existing behaviors than it is to learn new behaviors. The scale of these interventions is not large, and the interventions themselves may not directly target suicidal ideation or behavior, mood, or specific cognitions. The important point is to choose interventions that the patient is both able and likely to do. Initially, actually experiencing some level of success is much more important than struggling to solve large problems. Whenever possible, the short-term, positive action plan should be written down and given to the patient to take home. Have the patient post the written action plan in a location he or she visits frequently, such as on the refrigerator door, on a bathroom vanity mirror, or even on a toilet seat.


Schedule Follow-Up Contacts


Depending on your evaluation of the situation, a follow-up contact should be scheduled within the week (or even within 1–2 days if indicated) so you and your patient can assess how the plan is working. This follow-up contact can be a simple phone call or text message at a prearranged time, just to ensure that the plan is being followed and that no unanticipated barriers have surfaced. Be certain that the plan emphasizes problem solving. Of course, the patient should be informed at the initial meeting that he or she can return immediately for care if the plan does not take hold or backfires.


Using Suicidal Crises to Promote Growth


Any patient may again become suicidal during the course of therapy, given the right set of life events or a predisposition to use suicidal behavior as a problem-solving device. Although this possibility may seem obvious, some clinicians may implicitly assume that the act of entering therapy itself should cause suicidal behavior to disappear. This mind-set can be dangerous because clinicians may be unprepared or become angry if suicidal behavior reappears. The art of successful therapy is to collaboratively anticipate and plan for the recurrence of suicidal ideation or behavior at some point during treatment. Coming for treatment is a positive step but should not to be confused with solving real-life problems. Acknowledging this will put your clinician-patient relationship on a realistic level instead of perpetuating an idealized image of therapy that may result in disappointment or an even greater sense of helplessness or inadequacy. Use any recurrence of suicidal behavior as a learning laboratory for practicing acceptance of emotional distress, while remaining in a nonjudgmental state of mind that promotes value-based problem-solving skills. These acceptance- and approach-oriented techniques give the patient the space needed to be forthcoming about sources of emotional pain and all of the various solutions the patient may have contemplated, including suicidal ones.


An Important Agreement: Who Will Do What in the Heat of the Moment?


A powerful strategy for anticipating the potential recurrence of suicidal ideation or a suicide attempt is to discuss this scenario openly with the patient. The goals of this discussion include 1) reaching an agreement about how you will respond to various situations that are commonly encountered in therapy and 2) helping the patient agree to certain ground rules to be followed during a crisis. It is important to get these agreements in place at the start of treatment so that every angle is covered ahead of time and you do not end up having to generate crisis response strategies at 2 A.M. in the midst of a suicidal crisis. The word agreement is the operative term here. You are not making pronouncements to the patient about how things are; you and the patient are negotiating a series of agreements that should pass the following litmus test:



  1. The patient understands the protocol well and agrees to it.
  2. The patient’s and your beliefs and values are consistent with the protocol.
  3. The patient views the protocol as a fair, feasible, and workable arrangement.


One side of this agreement answers the patient’s question, “What are you going to do if I become acutely suicidal?” Your patient may be concerned, for example, that you will use involuntary hospitalization, and therefore he or she may be reluctant to mention anything about a suicidal crisis. Accordingly, you must state your beliefs and values regarding a potential suicidal crisis. Legal, ethical, and moral crosscurrents in this situation can influence the success or failure of therapy. This information should be discussed openly. Any joint action plan must reflect principles that you are willing to follow in the midst of a suicidal crisis.


Using Hospitalization


How, and under what circumstances, you will use hospitalization should be laid out for the patient. You might include discussion of the issues of short-term respite care stays, voluntary admissions for evaluating diagnostic issues, and the use of involuntary admissions. For example, you may present the value of voluntary, short-term, time-out admissions over longer-term, vaguely defined admissions. The goal is to build a scenario in which effective, mutual decision making can occur in the event of a crisis by including your patient in the prospective planning process and thereby maximizing his or her sense of self-control.


Scheduling Additional Sessions


Additional sessions may be needed in the event of a suicidal crisis, and you want the agreement to be clear about the circumstances that might lead to an extra session. The danger is that routinely scheduling additional sessions during a period of heightened suicidality may inadvertently reinforce suicidal problem solving. Realize that paying increased attention in the form of extra hours of face time could actually function as a social reward for engaging in suicidal behavior. This is an ongoing problem with many of the usually unscheduled interventions that occur during periods of elevated suicidal behavior.


In general, it is more helpful to schedule additional sessions when positive problem-solving behaviors are occurring and your patient would benefit from more intense work. If additional contacts are required because of a crisis, try to make the contact as minimally intensive as possible and with a singular focus on coaching and rewarding value-based problem-solving behavior. Consider using techniques such as brief follow-up phone calls rather than face-to-face visits. The ultimate goal of crisis management is to help your patient develop self-sufficiency in crisis—the internal ability to weather the storm and do what matters to promote a sense of vital, purposeful living.


Communicating After Hours


Very early in treatment, establish when and under what conditions you are willing to participate in unscheduled calls, e-mails, texts, or social media contacts from your patient. In general, crisply handling phone calls coupled with turning the context of the phone call into a homework assignment is far more constructive than lengthy, unstructured conversations. In general, you want your patient to contact you at the earliest stages of a suicidal behavior sequence; this usually leads the patient to start thinking about suicide in less intense and definitive terms. By choosing to initiate an interaction with you, the patient builds self-control and a sense of personal responsibility. When your patient adheres to this protocol, you should be available to consult at any hour of the day, or you should have another plan clearly arranged. It is important to remind your patient that clinicians, like all people, have nighttime and after-hours activities that are not part of their daytime work. Agree on the rules beforehand, and let your patient know how you will respond in various situations.


A good strategy is to jointly agree that in situations involving an ongoing suicide attempt, you will undertake an immediate assessment of medical lethality. If you believe the patient is in medical danger, emergency aid will be sent to the location immediately. Indicate that this is not an appropriate time to discuss more effective problem-solving options and reinforce your interest in discussing the situation at the next regularly scheduled session. Encourage your patient to make mental or written notes concerning the handling of this particular crisis and strongly state your belief that there is much to be learned from this situation.


If the patient is sending e-mails or text messages, redirect the interaction to occur in real time by telephone or, when needed, with face-to-face clinical care. If you are involved in after-hours activities when a patient calls, indicate that you are busy and instruct the patient to follow the self-support plan on his or her coping card (see subsection “Developing a Coping Card”) and schedule a time to talk that will work for both of you.



If your patient calls and reports thinking more seriously about making a suicide attempt, engage in a brief problem-solving discussion and help the patient come up with a short-term positive action plan. Again, instruct your patient to make notes to bring to the next session and praise him or her for calling you instead of acting on suicidal impulses. Do not be abrupt or imply that you are punishing your patient because of recurring suicidality.


Many practitioners cringe at the thought of cutting a phone call short, fearing the liability implications if the patient goes on to die by suicide. This dilemma is the result of fears about legal liability hijacking sound clinical decision making. Allowing a suicidal patient to ventilate excessively and talk about the same things over and over again is not going to teach the patient the fundamentals of sound personal problem solving. The issue is to think about what works clinically in this situation, not what alleviates your legal fears. Document the basis of your clinical decisions and the steps you have taken to help the patient.


A more perplexing situation occurs when your patient calls and is suicidal, with the means immediately present, and tells you, “I’m going to do it!” In this case, instruct the patient to remove the means from immediate access, either by turning it over to a friend or otherwise disposing of it. It is helpful to say something like, “I want to help you, but it will be hard for us to talk if you are thinking about killing yourself at the same time. Let’s put that stuff aside so we can work together to sort out what is going on here.” If your patient will not agree to your request, any phone-based problem solving is likely to be a melodrama, and a bad one at that. You have already indicated what your stance is in situations like this; now is the time to follow through.


One problem with agreeing to engage in after-hours communications with certain patients is that, like anyone else, you need time to rest, time away from work, and the ability to pursue other activities. Emotional exhaustion is common among clinicians, and guarding against this occupational risk is an important professional responsibility. A growing body of evidence suggests that mistakes of commission and omission occur as a consequence of clinician burnout. More positively, robust preventive care practices appear to be more common among clinicians with a strong commitment to self-care. Arranging for cross-coverage while off duty is appropriate, for example, and patients should be informed of such arrangements. When your practice includes a large number of at-risk patients, it is particularly important to put such safeguard efforts into place.


Making Random Support Calls and Other Contacts


Ask your patient to allow you to call him or her from time to time just to see how things are going. The strategy behind the random support call is to neutralize the association between escalating suicidal behavior and getting more attention via extra sessions or through after-hours communications when the patient is in crisis. This strategy of unlinking your attention and caring for the patient from the patient’s need to be suicidal can be a precipitant for major positive movement in therapy.


The random support call is usually very short, no more than 2–3 minutes. Do not perform extended therapy on the phone. Random support calls do not have to be made often; one call per month can often have a positive impact. To make this process truly random, you might want to write down dates and draw from them to set up a schedule 3 months in advance. Additionally, an occasional encouraging postcard or letter may be effective in ameliorating suicidality. The essence of the message is, “I care about how you’re doing. I hope the behavioral homework assignment is going well. You were going to pay particular attention to _____. How is that going? I really look forward to seeing you next week. Take care.” In other words, support your patient in whatever activities are occurring that week.


Calls should be made regardless of your patient’s functional status. When your patient is in a crisis, you can add an additional call or two to reinforce the problem-solving strategies that your patient is currently using. Even though your patient is in a crisis, the message should be essentially the same, and the duration of the call should remain short. This strategy creates a new kind of relationship with the patient. The issue of mattering to someone and being understood, of being in relation to another human being who is accepting, can be so central to your suicidal patient’s worldview that a simple 2-minute call may be a major event in treatment.


Developing a Coping Card


The last and most important crisis protocol strategy is to develop a coping card. Coping cards, or crisis cards, have been employed in clinical practice for many years. Although more extensive research is needed, recently, a small randomized controlled study designed to evaluate the effectiveness of using crisis coping cards with frequent suicide attempters demonstrated a reduction in subsequent suicidal behaviors and key symptoms when using cards, compared with usual care (Wang et al. 2016).


Identification of Resources


The first component of the coping card is the identification of resources. The goal is to teach your patient to use existing social support and community resources and to depend on you less as time goes on. Identify one or more competent and supporting persons who can be contacted in the event of a crisis. A competent social supporter is a person who will not lecture, cajole, or moralize about problems but will instead provide emotional validation and a safe atmosphere. Once these social supporters are identified, your patient writes down their names and phone numbers on a card.


Some patients will have trouble identifying a social support group. They may not know many people, or they may hold back because they feel that they are already too much of a burden to others in their life. At these times, consider meeting with your patient and family members or friends who might provide effective support and develop a structure to which all can agree. For example, if long, rambling, and somewhat painful conversations usually take place, suggest a time limit (e.g., 5 minutes) and talking points to be covered in that time frame. The self-support strategies on the coping card (see next subsection) can always be incorporated into the talking points to be covered. Encourage all parties to be creative and to come up with a support solution that is helpful and comfortable for everyone.


It is also important to identify community resources that can be contacted in the event of a crisis. Examples include the local crisis clinic, a mental health center emergency services unit, or a local emergency department social worker. These resources are written down on the card along with corresponding phone numbers.


Development of Self-Support Strategies


The second component of the coping card is the development of self-support strategies. Two to four instructions can be quite helpful. If substance abuse is an aggravating problem, one strategy on the card could be “Don’t drink. If I am drinking, stop drinking.” Simple tactics for affect regulation are useful, such as “Take 10 deep breaths and count to 50” or “Hold steady.” Positive statements that the patient can repeat several times can be useful, such as “I am a strong person and have weathered moments like this before.” Last, and perhaps always, evoke the problem-solving perspective by listing, for example, instruction such as “I need to step back and look at the problem I am having right now.” An example of this component of the coping card is shown in Figure 8–1.



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Figure 8–1 Coping card sample.


With the emergence of e-health, many different applications are now available that purport to foster well-being and reduce negative emotions and behaviors. Artificial intelligence methods have been created to identify risk, such as identifying the repeated use of words suggestive of depression or suicidality by scouring a person’s text and e-mail messages or tracking speech patterns. At this time, very little evidence exists to show the impact of these e-health interventions as a self-support strategy for individuals at risk for suicide. The appropriateness of various e-health approaches for emotional support should be discussed with the patient, as should the risks of using such programs (e.g., insufficiency of confidentiality safeguards, inappropriate use of data, and the threat of cyberbullying, all of which have been reported).



The Coping Card Procedure in Action


Once all feasible social support and community-based resources have been listed and the patient has identified a list of self-support strategies, there is one more name to add to the sequence. The patient’s last point of contact is you, so put your work and home phone number(s) at the bottom of the list. Your patient is to contact all of the listed social supports first and then contact the community resources. If the community resources fail, your patient should then practice the self-support strategies for an agreed-on period of time (30–60 minutes is recommended). If those strategies fail, the patient is to contact you for problem-solving support. The two of you agree that if the patient has followed through with attempts to contact all of the other resources, then you will be as available for personal contact if possible. If your patient has not followed the protocol, then ask the patient, in a direct and supportive way, to proceed through the card and to call back if all attempts at contact fail to ameliorate the crisis. If your patient is unable to follow this procedure, proceed using a brief, focused, problem-solving approach, with the goal of establishing a positive action plan. The agenda for the next session should also include a thorough review of the coping card to see if there might be a better list of resources or if the patient can identify more workable self-care behaviors.


Sep 1, 2019 | Posted by in PSYCHOLOGY | Comments Off on Managing Suicidal Emergencies: Using Crisis to Create Positive Change

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