HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.
Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.
At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.
"That is important, no matter what kind of therapy you do."
Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.
Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.
Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.
A key goal is to work toward "a collaborative relationship that encourages disclosure."
Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."
Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.
Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."
Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."
In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."
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