Chris Aiken, MD.
Editor-in-Chief of The Carlat Psychiatry Report. Practicing psychiatrist, Winston-Salem, NC.
Dr. Aiken has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
What can you do—beyond prescribing medications—to help your patients who have suicidal ideation? There are many strategies that you can teach your patients, even in the context of brief psychopharm visits. In this article, I’ll describe eight behavioral strategies that your patients are likely to find helpful. They are adapted from cognitive behavioral therapy for suicide prevention (CBT-SP), a modified form of CBT designed for patients who’ve made a recent suicide attempt, regardless of their diagnosis. CBT lowers the risk of repeated attempts by 50% compared to treatment as usual, according to a meta-analysis of 12 controlled trials. That’s impressive, though the caveat is that most of those “treatment as usual” groups did not receive comparable levels of regular psychotherapy (Gøtzsche PC et al, J R Soc Med 2017;110:404–410).
Actively prevent dropouts Premature dropout is a significant risk for suicidal patients. Many decline outpatient care (30%–50%), and over a third who attend treatment drop out within 3 months (Michel K et al, Int J Environ Res Public Health 2017;14:243). Unstable social supports, poverty, younger age, impulsivity, and substance abuse are among the factors contributing to these high rates. This risk needs to be addressed early, with an open discussion of obstacles that could prevent the patient from returning. Find out the best ways to reach patients if they miss an appointment, and try to conduct missed sessions by phone.
Communicate hope Even when the patient’s struggles seem insurmountable, maintain an attitude of hope. However, there’s no need to be a Pollyanna. Instead of convincing patients that a positive outlook is more realistic, which can be invalidating, focus on the pragmatic value of hope. Patients are more likely to find solutions when they approach problems from an optimistic stance.
A safety plan In working with suicidal patients, it helps to assume that they won’t be able to think clearly when a crisis strikes. Thus, written reminders are critical, particularly a safety plan. At a minimum, the plan should include phone numbers of social supports, emergency numbers for mental health providers, and contacts for a 24-hour emergency behavioral health center and a suicide hotline. For a downloadable safety plan template, see: https://tinyurl.com/yd65jrt8
Empathic assessment Successful therapies for suicide evaluate the risk collaboratively, inviting the patient to weigh in on the assessment and problem-solve methods of risk reduction. Avoid controlling and judgmental attitudes; approach the assessment with a wish to understand how it feels to walk in the patient’s shoes. When patients feel understood, their connection to therapy grows, often forming a counterweight to suicidal impulses.
Problem solving People who attempt suicide tend to have poor problem-solving skills. In CBT-SP, suicide is viewed as an understandable but ultimately harmful attempt to solve a problem. A major focus of CBT-SP is to improve problem-solving skills. For example, patients can list their problems and prioritizes those that are most amenable to change. From there, the pros and cons of different solutions are weighed—with an emphasis on flexibility and acceptance, as the available solutions are usually less than perfect.
Distress tolerance Suicidal impulses are surprisingly brief. Most pass after minutes or hours, and very few continue beyond a day (Hawton K, Crisis 2007;28:4–9). Distress tolerance skills can help patients ride out these painful waves unharmed. Cognitive abilities are distorted during a suicidal crisis, so the best skills are simple, easy, and physical: deep breathing, guided meditation, aromatherapy, exercise, a warm bath, music, engaging a pet, or being in nature. Distraction techniques also work, like puzzles or word games. Apps to teach these skills include Stress Free, Panic Relief, and Breathe2Relax. Practice is critical. By using distress tolerance skills in everyday life, patients gain confidence that they can endure suffering without resorting to suicide.
Coping cards During a suicidal crisis, thoughts are forceful, quick, and extreme. Coping cards help patients slow down and consider alternatives. On the front of the card is a negative thought that tends to come up in a crisis, such as “This will never get better.” On the other side is a more adaptive response, like “I’ve made it through situations that seemed hopeless before.” Patients make these cards when they are thinking clearly, and refer to them when a major stress has narrowed their perspective.
Hope box This final tool wraps everything up in one place. It’s an actual box that patients make to store all of the life-saving information they’ve gained in therapy but are likely to forget in a crisis. Coping cards, emergency plans, names and numbers of supportive people, and reminders of distress tolerance skills are all inside. Also in the box is a list of reasons to live and sensory reminders of those reasons, like pictures of family or pets, sentimental gifts, letters from friends, or spiritual texts. Reminders of past achievements, like awards, can counter thoughts of helplessness. A free app that keeps all this together is called Virtual Hope Box—I recommend patients use both the virtual and the real option.
TCPR Vertict: Suicidal patients can evoke strong emotions, from anxiety to aversion. Clinicians may feel they are charged with an impossible task: to predict and prevent a self-inflicted death. CBT-SP shifts the focus toward matters that are more within the therapist’s—and patient’s—control. It empowers patients to manage their problems more effectively. Instead of using safety contracts to dissuade them from what they shouldn’t do, it emphasizes what they can do during a crisis. To learn more, a good text is Brief Cognitive-Behavioral Therapy for Suicide Prevention by Craig Bryan and David Rudd. For patients, the standard workbook is Choosing to Live by Thomas Ellis.