The Repetitiously Suicidal Patient: An Intervention Approach for High-Risk Patients

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The Repetitiously Suicidal Patient


An Intervention Approach for High-Risk Patients


There are few greater challenges that you, the therapist, will face than those that occur when caring for patients who engage in repetitious self-harming behaviors. Whether patients engage in repeated sublethal overdosing, chronic self-mutilation, or near-lethal suicide attempts, health care systems have difficulty dealing with these patients. They can be a source of conflicts between providers and may be seen as using more than their fair share of limited health care resources. These individuals can challenge a practitioner’s theoretical and practical assumptions, and they can reveal gaps in service delivery systems.


Repetitiously suicidal patients present in a host of encounters within both the general health and mental health care systems. Emergency department physicians deal with and feel frustrated by these individuals as much as seasoned psychotherapists do. A primary care physician is as likely as an inpatient psychiatrist to feel overwhelmed. In other words, there is something universal about the dilemma presented by this type of suicidal patient. The system response to a chronically suicidal patient often does not work well, partly because of a singular focus on suicide prevention and liability reduction that can limit effective treatment.


Repetitiously self-harming patients often receive a clinical diagnosis of borderline personality disorder, a label that can send chills down the spines of even the most seasoned of therapists. However, we find it limiting to describe these patients in diagnostic terms; it is clinically more useful to describe them in terms of the various skill deficits that limit their functional capacities. They are better thought of as multiproblem patients because of widespread deficiencies in their cognitive, emotional, behavioral, and social functioning. These patients typically have difficulty regulating or tolerating distressing and unwanted emotions, such as depression, anxiety, apathy, boredom, loneliness, guilt, and anger. Their inability to accept distressing, unwanted feelings, thoughts, memories, and urges is a major driver of a plethora of maladaptive coping responses, most of them involving emotional and behavioral avoidance strategies (e.g., drinking, drug use, cutting, suicidal ideation). In our approach, we consider them to be “emotional avoidance machines” because so many of their daily routines are geared to help them avoid distressing, unwanted private experiences.


Not surprisingly, multiproblem patients also experience significant difficulties in social and interpersonal functioning. Relationships of any type can produce complex, and painful, emotional experiences. The multiproblem patient will use the same types of avoidance responses in their relationships as they do when they are alone with their mental pain. Consequently, they have trouble forming and maintaining healthy interpersonal relationships. They also can inject the therapy process with a conflict-laden set of issues around forming and maintaining both casual and intimate adult relationships.


At the level of daily living, multiproblem patients maintain a precarious balance between struggling to control chronic, aversive mental events (e.g., sadness, anxious rumination, self-critical thinking, traumatic memories, suicidal urges) and meeting the minimal requirements for routine social functioning. When internal or external events trigger heightened levels of negative affect, multiproblem patients may exhibit dissociative behavior or frank psychotic symptoms, such as hallucinations and delusional thinking, as well as quasi-psychotic symptoms that are the by-products of substance abuse. The multiproblem patient often engages in a sedentary and/or isolated lifestyle that results in excessive time spent in self-focused attention. At the same time, the patient has difficulty regulating and tolerating the aversive mental states that are the outgrowth of that self-focused awareness. This self-regulatory failure, as well as the extreme coping responses it provokes, is a core feature of the high-risk behavior patterns that therapists must anticipate and address when working with multiproblem patients.


Multiproblem patients are often therapy-wise because they usually have been in and out of therapy multiple times and know all the moves a therapist will typically make. Thus, they can anticipate and perhaps undo the interventions of even the most skilled among us. The number and magnitude of these patients’ behavioral, cognitive, and emotional problems are a source of frustration for therapists and for the people who populate the patient’s social support network. It is difficult to conceptualize a plan of action in therapy when, at any given point in time, the patient exhibits generalized failure in so many areas of functioning. Furthermore, the disruptive presence of high-risk behaviors, the “crisis-of-the-week” syndrome, can undermine the continuity of treatment and challenge the therapeutic relationship. You, the therapist, might feel that the patient has dumped a 10,000-piece jigsaw puzzle on the table and is now asking you to put it back together. Being overwhelmed and not knowing where to begin or how to start, you might feel defeated right at the get-go. To continue the metaphor further, the chaotic nature of this patient’s daily life is akin to getting several hundred pieces in place, just to have the pieces dismantled and rescattered across the table.


Not surprisingly, studies on the effectiveness of outpatient treatment for repetitiously suicidal patients reveal many gaps in our knowledge. On the positive side of the ledger, recent research suggests that acceptance, mindfulness, and value-based interventions can have a positive impact on some of the psychological processes thought to fuel repetitious suicidal behaviors (Gratz and Gunderson 2006; Linehan 1993; Linehan et al. 1991; Strosahl 2004). However, an unacceptably high rate of attrition from therapy has been found, and the best treatments available seem to affect the frequency and lethality of suicide attempts, but not to the point of eliminating suicide attempts altogether. In essence, we would gladly trade all we know for all we do not know about how to help these unfortunate individuals. With this caveat, we describe a set of treatment principles that may lead to a balanced and holistic approach to the treatment of repetitious suicidal behavior.


Suicide, Attempted Suicide, and Parasuicide


Clinical lore suggests that it is possible to distinguish between patients who will ultimately die by suicide, patients who are likely to make suicide attempts with intent to die, and patients who will engage in nonlethal suicidal gestures with no intent to end their lives. This potentially destructive clinical myth deserves more examination because it can result in needless confrontations between therapist and patient, serious ruptures of the therapeutic alliance, and in the worst case, a serious error in the estimation of suicidal risk posed by someone under your care.


The term parasuicide was originally coined by Norman Kreitman (1977), a British researcher and clinician who noted that there seemed to be clinical differences between patients who are attracted to suicidal behavior for reasons other than the purpose of dying and those who are intent on dying, whether or not they succeed. In Kreitman’s approach, the latter group comprises suicide attempters and the former comprises parasuicidal patients. Various speculations have ensued about how these groups might differ. For example, parasuicidal patients are thought to be characterized by use of methods with low potential lethality, such as clearly sublethal drug overdosing, and act in contexts in which discovery is highly likely (i.e., low-risk/high-rescue situations). Conversely, suicide attempters have been described as using more lethal methods, including higher-volume drug overdosing, and as making efforts to elude detection. A major clinical milestone would be achieved if researchers were to isolate the characteristics that differentiate parasuicidal persons from those who make serious suicide attempts; from such findings, clinicians would be able to identify patients most likely to engage in lethal forms of suicidal behavior.


Over time, the clinical utility of the distinction between parasuicide and attempted suicide has not been substantiated. High-intent patients may not be the same as the patients who end up in medical intensive care units. For example, an impulsive overdose of a seemingly safe over-the-counter medication after a traumatic relationship breakup can lead to a life-limiting or life-threatening organ transplant situation or to death, consequences far beyond the person’s original intention. Clinical judgment has not been very accurate in separating these populations. With the exception of perceptions regarding the problem-solving value of suicide and the patient’s ability to tolerate emotional pain, research has revealed very few differences between states of suicidality, even between patients who simply think about suicide and those who engage in some form of suicidal behavior.


In a problem-solving framework, suicidal behavior is a method of controlling or eliminating emotional distress. Many low-intent patients die because they were playing with fire. Their conscious intent to die might well have been low, and perhaps their behavior was an attempt to communicate distress or get someone to help. Conversely, high-intent patients discover that to die by suicide, everything has to work just right and a thousand things can go wrong. Bullets aimed at the heart have missed, hanging ropes have broken, and passersby have discovered and rescued many a near-dead individual. These factors lead to the following conclusion: any form of suicidal behavior can be fatal. Attempting to label patients on the basis of their potential lethality level not only is inaccurate but also can create major intervention errors.


Nevertheless, the concept of parasuicide has heavily influenced the British response to self-poisoning overdoses (which account for approximately 70% of all suicide attempts) and has led to intervention techniques that are certainly consistent with the problem-solving and learning-based framework we have described. For example, alternative treatment, such as short-stay self-poisoning units, have been designed and tested in large-scale naturalistic studies. In this approach, deliberate drug-overdose patients in the in-patient unit are only medically assessed and stabilized; referral and discharge to outpatient therapy are immediate. This strategy basically makes suicidal behavior a nonreinforcing event and forces the individual back to the natural environment, where real-life problem solving can occur. Interestingly, the health care system in the United Kingdom has successfully used this low-intensity approach for decades and has violated some long-standing precepts of U.S. risk management in doing so (see Hawton et al. 1998 for a review).


A Functional Contextual Perspective on Multiproblem Patients


To work effectively with a repetitiously suicidal patient, the therapist needs to place less emphasis on finding a diagnostic label, which can function as an excuse to blame the patient for his or her problems (e.g., “He has a personality disorder and does this to get attention”), and instead put more energy into understanding the psychological functions that support the maintenance of unworkable patterns of behavior. In our view, multiproblem patients exhibit four distinctive types of dysfunctional behavior patterns, which are summarized in Table 7–1.

























Table 7–1Four defining features of multiproblem patients


Pervasive: The same maladaptive responses occur across a broad array of situations.


Example: The patient uses the same basic strategy when dealing with anger (e.g., impulsive action toward self or others) regardless of the situation or context.


Persistent: Dysfunctional responses are consistent over time.


Example: The patient continually enacts behaviors dependent on short-term emotional relief and the rule that emotions are toxic and potentially fatal.


Resistant: Dysfunctional responses do not change despite negative consequences.


Example: Even though the patient’s behavioral response usually results in more difficulties, the patient still enacts that behavioral response in future situations.


Unworkable: The responses move the patient away from valued life outcomes rather than toward those outcomes.


Example: The patient’s behaviors do not align with what the patient values and finds meaningful; rather, they are driven by rules that promote avoidance and short-term relief from emotional distress.


Pervasive Behavior


Patients who are having pervasive life difficulties are not being dysfunctional in just a few discrete situations. Their behavior is ineffective across a broad range of situations. They are caught in the web of an overarching, highly generalized set of beliefs and rules that prevent them from recognizing which responses are likely to work in which life situations. This lack of discrimination results in a narrowing of their behavioral repertoire. For example, the patient has the same basic response to any interpersonal conflict involving anger, no matter what the anger is about, whom it involves, or how intense it is, rather than tailoring the response to better address distinctive, unique, and important features of each situation. One of our patients once remarked in the course of therapy, “I don’t do anger,” thus eliminating what might have been a reasonable response to the behaviors of a number of her acquaintances.


Skills deficits in key areas of personal functioning (e.g., personal problem solving, tolerance for distress, interpersonal effectiveness) can also contribute to narrow response repertoires. The genesis of these problems likely originates in the childhood or adolescent trauma, neglect, and impoverished family environments. Studies have suggested that multiproblem patients tend to have a high incidence of childhood trauma, including physical and sexual abuse (Battle et al. 2004). In addition, adverse childhood experience research shows that these patients tend to come from dysfunctional settings involving problems such as parental mental illness, drug addiction, alcoholism, and domestic assault (Dube et al. 2001). What is being modeled in these environments is a problem-solving approach characterized by impulsive, self-defeating behaviors, with little use of important psychological strategies such as self-reflection, emotion regulation, and acceptance of emotional distress. Thus, the patient leaves adolescence with an unacceptably narrow set of coping responses that must be applied across a broad range of life situations. The patient has the same behavioral response in qualitatively different situations because he or she has learned only one way to respond.


One could imagine that a child who is routinely abused and neglected by parents, siblings, and family members might start to respond with impulsive acting-out behaviors or by passivity and self-isolation just to help ensure his or her own survival. Now, fast forward to adulthood: The same individual has to deal with criticism from a boss or coworker and responds in an impulsive, aggressive fashion or simply walks off the job so as to avoid any more negative feelings. As a result, the individual is fired. This behavioral pattern may have been essential to survival in one context, but when applied indiscriminately across all settings, it is unworkable.


Interestingly, not all individuals with repetitive suicidal behaviors have had childhoods characterized by abuse or adversity. Some studies suggest that up to 25% of adults who meet criteria for borderline personality disorder may not have such environmental influences, suggesting the important role of neurobiology, genetics, and neurodevelopmental factors in the emergence of repetitious suicidal behavior. These findings serve as reminders to approach patients with humility regarding the reasons for their distress and limited coping skills. Remember that your role is not to be a detective or a judge; instead, your responsibility is to appreciate the experience and needs of the patient and to work in the present with him or her, constructively, flexibly, and nonjudgmentally. Regardless of the cause of the behavior, your commitment is to fostering resiliency and the capacity to change that resides within your patient.


Persistent Behavior


A seminal attribute of multiproblem behavior patterns is that they endure for years in the face of continuous negative feedback. Two major mechanisms account for the durability of these problematic behaviors. One is that some high-risk behaviors work in the sense that they temporarily down-regulate powerful, aversive emotional states. The short-term gain of these emotional avoidance strategies outweighs their long-term negative social consequences. Therapists can fail to appreciate the importance of this tradeoff between short-term emotional relief and long-term vitality.


A second mechanism is overidentifying with culturally instilled rules about adverse emotional experiences that paint the experiences as toxic and requiring immediate control or elimination. When followed, these rules more or less demand that the patient engage in immediate extreme measures. It is not unusual to have a multiproblem patient articulate a belief that allowing a forbidden feeling into emotional awareness would be tantamount to dying. These patients are not saying this in a metaphorical sense; it is for them a literal truth.


Resistant Behavior


Another seminal feature of multiproblem behavior patterns is their resistance to negative longer-term consequences. The dysfunctional behavior pattern does not change despite repeated negative results and social pressure to adopt new behavior patterns. This characteristic of multiproblem patients is quite challenging for therapists. The patient’s life is falling apart. The patient is in great emotional pain. Why is the patient unable, or unwilling, to change those patently unworkable behaviors?


Again, the problem is that behavior under the control of arbitrary, culturally instilled rules and mandates, once established and reinforced repeatedly, is impervious to shifting, real-world contingencies. Flexible, effective human responding requires that an individual stay in touch with the contingencies of each particular situation and adapt behavior accordingly.


Unfortunately for them, multiproblem patients live in a mental world that is overrun with simple and inflexible rules; a world that is unfair when following the rules does not work; a world in which the failure of the rule is explained by personal deficiencies and character flaws. Compounding the problem further, these patients do not even know that they are following such rules. Such patients often verbalize these rules in a declaratory, almost defiant fashion, as though there were no other possible options. The following are examples of what you might hear in session:



  • I just need to gain control over the way I’m feeling; then I could live my life the way I want to.
  • If people would stop messing me up, I could move on.
  • I can’t stand how I feel. . . . I’m just exhausted from always trying to feel better.
  • My painful feelings are going to ruin me and I have to eliminate them.
  • The only thing that matters to me is to be able to control the way I feel.
  • I won’t allow myself to feel sad [mad, lonely, bored, guilty] because it is unbearable.

These sample comments demonstrate an important quality of rule following: the patient views the rules as being absolute. These highly generalized rules are strongly shaped by the culture in which we live. Most of us have come into contact with these rules, and to some degree, we can step back, create some perspective, and decide whether or not to follow the rules. A multiproblem patient, however, sees these as absolute mandates for how life is to be lived. This matter is not one of logic; it is a matter of mentally constructed rules gaining dominance over the patient’s direct experience. Because it is more important to follow the rule than to observe how the resulting behavior works, a likely explanation for failure in a situation might be “I don’t have what it takes to do what I have to do. I need more [confidence, support from others, intelligence, willpower] or less [depression, anxiety, self-loathing, anger], and then I will be able to be happy like other people.”


Unworkable Behavior


What do we mean by the term unworkable? Simply put, unworkable behaviors do not promote life outcomes that are consistent with the patient’s values. In contrast, a workable response promotes the person’s sense of vitality, purpose, and meaning. Multiproblem patients are literally and figuratively having the life squeezed out of them. They are simultaneously in intense emotional pain, and, paradoxically, at the same time, they are psychologically numb. If you, therapist, were to ask a multiproblem patient, “What would you be doing in your life if a miracle happened and you suddenly had no more emotional pain to struggle with?” the patient would probably answer, “I don’t know.” This empty destination is eventually reached by those engaged in persistent, excessive, and ineffective rule following. For them, life is about following the rules, not about being present and living a vital life, even if doing so sometimes produces emotional pain. Rather than responding to life’s challenges from a position of personal values and goals, the patient is lost in the haze of rules that promote emotional and behavioral avoidance.


Because following rules makes the patient impervious to contingencies, the patient is left to look for explanations for failure that do not include challenging the actual workability of the rule itself. It is not unusual to hear multiproblem patients emphatically state (as a fact) how frustrating it is that other people can seemingly produce happiness and control their depression, anxiety, flashbacks, and so on. Thus, the patient 1) is not trying hard enough, 2) lacks the necessary willpower or character to make a change, or 3) is inadequate and inept.


All of these explanations generate even more emotional pain and self-loathing. In the end, this self-amplifying process sweeps over the patient’s life space like an avalanche. The human being is buried under the snow, just trying to catch a breath and survive. Your goal is to help the patient free himself or herself from the trap he or she is in by understanding and changing the unworkable rules the patient is following, one by one.


Working With the Multiproblem Patient


Thus far, we have analyzed multiproblem behavior patterns from both functional and behavioral points of view. We as therapists are working with patients who engage in the same unworkable behavior over and over again. They do it because of the dominance of rule following and, often, a lack of specific instrumental skills, particularly those required for emotion regulation and acceptance. Our treatment approach is designed to undermine the patient’s use of high-risk emotional avoidance behaviors, to help the patient understand the costs of following rules that do not work, to encourage the development of responses that are contingency governed, and to begin building patterns of committed action based in personal values. Table 7–2 presents a four-step approach and the key themes to which you will need to attend as treatment unfolds.


























Table 7–2Outline of the acceptance and commitment therapy approach for the repetitiously suicidal client


Step 1: Adopt an accepting, curious, nonjudgmental stance.



  • Reframe the function of high-risk behavior.


  • Study, rather than judge, incidents of high-risk behavior.
  • Normalize impulses to run from emotional pain.
  • Emphasize “response ability” rather than blame.


  • Use the patient’s emotional pain as an opportunity to explore two alternatives: acceptance (willingness) and control (struggle).

Step 2: Focus on workability.



  • Get the patient to notice the rules that drive behavior.
  • Destabilize confidence in the sanctity of rules.
  • Institute workability as a yardstick (what is working and what is not).
  • Help the patient disengage from emotional control rules that seem reasonable but do not work.
  • Encourage stopping what does not work before looking for what does work.

Step 3: Develop self-acceptance, willingness, and present-moment awareness skills.



  • Study the relationship between willingness, suffering, and workability.
  • Reframe avoidance responses as a choice, not a mandate.
  • Find small ways to practice willingness.
  • Use nonjudgmental awareness to help the patient detach from unworkable rules.
  • Practice self-compassion as an alternative to self-loathing.

Step 4: Promote value-based, committed action.



  • Help the patient clarify valued ends in basic sectors of living (values clarification).
  • Help the patient develop value-based goals.
  • Emphasize value-based actions and accumulating small positives.
  • Use acceptance to sustain movement through psychological barriers.
  • Emphasize value-based problem-solving action as a process, not an outcome.

Step 1: Adopt an Accepting, Curious, Nonjudgmental Stance


Your most important immediate priority is to create motivation in the patient to stay in therapy long enough for some benefit to occur. The rate of attrition from treatment in multiproblem patients is very high, and no therapy works when the patient is not attending sessions. Both therapist and patient variables must be controlled. On the therapist’s side, you must repeatedly validate the patient’s sense of emotional desperation and avoid using pathology-based explanations to frame the patient’s behavior. You should emphasize the problem-solving nature of troubling high-risk behaviors—they are one legitimate way of regulating emotional pain. Reframe any high-risk behavior as a choice between making room for negative events and eliminating them. At all times, you must avoid getting into showdowns over the patient’s self-destructive behaviors, both inside and outside of session. You must avoid negative and harmful strategies such as offering moral judgments about high-risk behaviors, lecturing or being condescending to the patient, or taking an overly proscriptive approach. This step is oriented toward forming a collaborative therapeutic relationship, modeling an accepting stance toward the patient’s emotional pain and unworkable responses, and helping the patient see the scope and nature of the real problem.


On the patient’s side, you want to get the patient in touch with the cost of chronic emotional avoidance behaviors, which is the intent of questions such as the following:



  • Tell me, has this (avoidance behavior) affected other goals you have in life?
  • Were there things you dreamed of doing in life that seem far out of reach now?
  • In terms of your personal values, how does this behavior fit in?
  • Is it consistent with what you want to be about as a human being?

The goal is to get the patient thinking about the relationship between personal values and emotional and behavioral avoidance. The patient ultimately has to determine that emotional and behavioral avoidance is not working, even while the mental chatter encouraging avoidance responses continues. This approach will help forestall impulsive actions and set the stage for taking a more deliberate and mindful approach to the problem of what to do about personal pain. At the early stage of treatment, getting in touch with the cost of these behaviors is a significant motivational enhancement strategy.


Step 2: Focus on Workability


An important concept in the acceptance and commitment therapy (ACT) approach is to undermine the patient’s confidence in the accuracy and utility of mental rules. Together, you and your patient are attacking the patient’s story, which is really a patchwork quilt of overlapping rules and associated life experiences. The story comprises the patient’s set of stated reasons for relying exclusively on avoidance behaviors and the patient’s rationale for overfocusing on the short-term benefits of avoidance to the exclusion of examining the long-term downside of these behaviors. The story often contains important clues to the presence of rule following. The patient may tell you a tale of woe that goes back to childhood abuse, broken relationships, unloving parents, or failed life goals. Somewhere in the patient’s story, you will begin to encounter certain assumptions the patient has about how he or she came to such suffering and why emotional avoidance behaviors are a necessary and justifiable response. The underlying theme of the story is often that the patient cannot or will not tolerate a particular type of negative private event (e.g., flashbacks, anger, feelings that are difficult to tolerate). There is a structural similarity in most stories because they serve a basic social purpose: the story will explain the presence of chronically dysfunctional behaviors as well as justify their necessity. Do not challenge the story in terms of its logic; just get a sense of how the various elements of the story pull together to rationalize the necessity of high-risk emotional avoidance behaviors.


The way to effectively maneuver in the context of the patient’s story is to use the concept of workability. Workability is a measure of whether a given response is promoting the patient’s sense of vitality, purpose, and meaning. This concept is not something to argue about with the patient. After all, it is not your life that is being lived here, and the patient may have some very different ideas about what constitutes a workable life. For the most part, the workability question goes something like this:




Therapist: So, as I understand it, you have problem X, then feeling Y, and then you engage in behavior Z as a response to problem X and feeling Y. How is behavior Z working to help promote your becoming a person with a sense of purpose and meaning in life?


Then let the patient answer the question. We use this question over and over again in all sorts of clinical moments. It is a very effective way to get unhooked from a developing therapeutic impasse or confrontation. When you feel stuck or sense that a therapeutic impasse is about to develop, you can always go back and change the conversation to one about workability.


At this point in treatment, it is important to begin calling out the patient’s unworkable change agenda. Your patient is assuming, “To gain control of my life, I must first gain control of my feelings [memories, intrusive thoughts, unpleasant physical sensations].” The problem with this approach, from our perspective, is that the patient is also assuming that to gain control of his or her feelings, he or she must be willing to give up the pursuit of living life in a meaningful way. One can reference the nursery rhyme of the three little pigs as an example: The third pig built the brick house that did indeed keep the wolf out, and his two brothers sought refuge with him. But what did it cost them to stay safe? Their lives await them outside the house, not huddled up inside staying safe from the wolf. Although the wolf has moved on after recognizing that the pigs will not be dinner, the pigs cannot know that the wolf is gone until they venture outside their lair. You can deconstruct any instances of high-risk behavior from exactly this perspective. Again, it is not something to argue about with the patient. You are not playing a game in which you are trying to be right and showing the patient to be wrong. Simply note in a nonjudgmental way that there seems to be a similarity over time and situations in the methods the patient is using to respond to events.


Step 3: Develop Self-Acceptance, Willingness, and Present-Moment Awareness Skills


When the patient begins to spontaneously voice that emotional control strategies do not seem to be working, it is time to pose an alternative. That alternative is to accept distressing, unwanted thoughts, feelings, urges, and memories; to be self-compassionate in times of personal pain; and simultaneously to do what needs to be done to promote a valued, purpose-filled life. There are two important themes in this step of the treatment process.



The first theme is that the willingness to enter into the presence of painful emotions is a choice that is specific to each situation. There is a paradoxical relationship between willingness and emotional suffering. The experience of an unwanted feeling, despite one’s best attempt to avoid it (i.e., being unwilling), is truly traumatic. On the other hand, a distressing, unwanted private experience accepted without struggle is also painful. Pain is a natural component of human existence. It is not toxic in itself. Human organisms are built to feel what they feel, think what they think, and remember what they remember. The destructive component is the avoidance behaviors that develop from following rules that suggest that distressing, unwanted emotional experience is dangerous, toxic, or diminishing.


You can help the patient begin to appreciate this paradox by looking situation by situation at the relationship between levels of willingness, levels of suffering, and life workability. The main thing to realize is that you do not get to willingness and stay there forever, like a trophy hanging on the wall. Willingness and acceptance are ongoing processes. Sometimes we are willing and accepting; at other times we are not. You do not want the patient to co-opt this idea into a rigid rule-following system: “My problem is that I was abused as a child, and I just don’t have enough willingness. What you are telling me is that if I were just more willing to have pain, then my pain would be less.” If the patient says something like this, you should answer with, “Yes, willingness means showing up for whatever is there and allowing it to be whatever it will become, without struggle or defense. But there is no guarantee your pain will go away; it could even get worse, and being willing means you are willing to let that happen as well.”


The second theme in this step of the treatment process is that you must help your patient learn to be present, detached, nonjudgmental, and self-compassionate about even the most painful aspects of personal experience. It is important to use various experiential exercises, metaphors, and mindfulness tactics within each session. You want to teach the patient that there is a position from which the content of private experience is seen for what it is, not what it advertises itself to be. In this detached space, the patient can be aware of, but nonreactive to, mental experiences such as negative emotions, unpleasant thoughts, distressing memories, or disturbing physical sensations.


Another important aspect of nonjudgmental detachment is that it allows the person to avoid impulsively engaging in harsh, negative self-evaluations and creates a space in which the patient can practice softening into pain. Instead of generating a second wave of emotional distress related to harsh, self-rejecting evaluations, the patient can now ask, “If I’m not going to run from the situation, how will I respond to it?” The answer varies from situation to situation, but a general rule might be, “Do what works to promote your sense of moving in the direction of your values.” At this stage, a patient with skill deficits may benefit from learning, for example, personal problem-solving, assertion, interpersonal, and conflict resolution skills. Begin one or more of these traditional skills training interventions as soon as your patient understands that these skills are to be put in the service of approach and resolution, not avoidance and short-term emotional control.


Step 4: Promote Value-Based, Committed Action


As treatment progresses, the patient will be left with the following basic question: “If my life is not going to be about avoiding what I feel, what is it going to be about?” Your goal is to help the patient find the answer to this question. One of our favorite ways of approaching this issue is to ask, “What do you want your life to stand for? Are your behaviors right now consistent with living that type of life?” You are trying to wake up the human being inside and bring out the best that person has to offer. Standing for something in life is very important because it drives emotional acceptance by legitimizing the pain and suffering that are part and parcel of participating in life. We are not teaching the patient to embrace painful material simply for the sake of getting in touch with it. That would be sadistic. Rather, the importance of acceptance is that it allows the patient to move through barriers to value-based action. Instead of using anger as a reason not to perform in a valued way, the patient can make room for anger and behave in a way that is consistent with his or her values as a human being. Valuing is presented as a free human act. The patient gets to choose how to respond because values are not certainties—they are just an assumptive part of the human existence. Value-based action also frees the patient from the hegemony of rule following. This increases the likelihood that the patient will flexibly adapt to changing life circumstances and challenges.


In therapy, it is important to help the patient initiate goals that are based on positive action but limited in scale. There is a quality to value-based problem solving that is measured not by the size or importance of the act but by the freedom the patient has to choose to act. Hence, it is fine to start with seemingly small behavior changes that create an atmosphere of success and promote the patient’s sense of self-efficacy. For example, one of us (J. A. C.) was working with a patient who engaged in cutting herself whenever she became emotionally aroused. The initial goal she agreed to involved waiting for 3 minutes without doing anything when she was emotionally aroused; then she was free to engage in cutting if she wanted to. This seemed more doable to her and taught her some valuable lessons about how to sit still in the initial moments of a painful emotional experience. Over time, your patient will begin to spontaneously initiate valued actions in all sorts of situations. In this case, the patient noticed that over even 3 minutes, she could see a small decrease in the intensity of her feelings, so on her own, she decided to wait 10 minutes before cutting. This had a profound effect on the frequency of her cutting behaviors and dramatically increased her sense of self-control.


Be on the Lookout for Relapse


One thing to watch for at this point is the reappearance of the patient’s story in an insidious form. After all, if the story is one of abuse, neglect, and lack of love leading to a broken human being, the patient might wonder, “What is the significance of ending up with a vital, purposeful life?” Living a purposeful life could require the patient to try to accept that the bad actors in his or her life were not wrong and accordingly should be released from any blame. This can be a heavy load to bear. We have seen more than one patient who, when confronted with the new likelihood of living a meaningful life, relapsed into serious high-risk behavior patterns, missed appointments, or dropped out of treatment. We have also had patients who feel that their only validation in life is having survived trauma. To move beyond the trauma and mere survival to living a more complete life is dangerous in that it is experienced as a negation of the self.


Your patients are attached to their stories and often feel defined by them. As we stated in Chapter 5 (“Outpatient Interventions With Suicidal Patients”), Sigmund Freud was right that sometimes the old ruins tremble again. Normally, as the patient begins to show more psychological flexibility, it is important to talk about how past pain, trauma, blame, and responsibility may interfere with choosing to live according to one’s values. A typical question we might ask is, “Who would be let off the hook of blame if you were to get better and lead a good life?” It is useful to talk about forgiveness in this context, not as an act toward the perpetrator but as an act toward the self. That is what the word forgiveness means in its Latin root—literally, to give oneself the grace that came before the transgression. The task is not about forgetting bad acts or liking the people who performed them; it is about giving oneself permission to move on.


Sep 1, 2019 | Posted by in PSYCHOLOGY | Comments Off on The Repetitiously Suicidal Patient: An Intervention Approach for High-Risk Patients

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