After the Attempt: Maintaining the Therapeutic Alliance Following a Patient's Suicide Attempt
We wish to express our gratitude to Julie Jacobs, PhD, and to two anonymous peer reviewers for their helpful comments on an earlier draft of this article.
Abstract
The risk of a patient's suicide is a prominent occupational hazard for psychotherapists. The precise number of patients who attempt suicide while in treatment and then resume therapy with the same therapist is not known, but this situation is a relatively common occurrence in clinical practice. Such scenarios can pose significant challenges to the reestablishment of therapeutic trust and a workable treatment alliance. The aim of this paper is to identify the challenges facing a clinician treating a patient who resumes therapy following a serious suicide attempt, and to offer guidelines for maintaining the viability of the therapeutic alliance.
The suicide of a patient is a primary occupational hazard for psychotherapists. Among individuals diagnosed with major psychiatric disorders, the estimated prevalence of death by suicide is about 10% to 15% (Brent, Kupfer, Bromet, & Dew, 1988, cited in Bongar, Maris, Berman, & Litman, 1998; see Bostwick & Pankratz, 2000, for a critical analysis of these statistics). Studies indicate that there is a 22% chance that a psychologist in clinical practice will experience a patient suicide in the course of a career; this chance is more than 50% for psychiatrists (Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989; Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988). Even psychologists in training have a one in six or seven chance of experiencing a patient suicide (Brown, 1987; Kleespies, Smith, & Becker, 1990), with 40% of trainees likely to encounter serious suicidal behavior by a patient (Kleespies & Dettmer, 2000). The intrusive stress levels reported by psychologists who experience a patient suicide are comparable to clinical levels of post-traumatic stress (Chemtob et al., 1988; Hendin, Lipschitz, Maltsberger, Haas, & Wynecoop, 2000).
Suicide attempts far outnumber completed suicides. Although precise epidemiological statistics on suicide attempts in the United States are not kept, it is estimated that there are from 765,000 to more than one million suicide attempts annually (Crosby, Cheltenham, & Sacks, 1999; Hoyert, Kochanek, & Murphy, 1999). There are about 10 to 25 attempts for each completed suicide with between 1% and 4% of adults and between 2% and 10% of adolescents having made at least one suicide attempt (Jamison, 1999; Moscicki, 1999). For people aged 15 to 24, a 100–200:1 ratio of suicide attempts to completions is estimated. One out of every three attempts is serious enough to require medical attention (Jamison, 1999). Furthermore, longitudinal studies indicate that 10% to 15% of those who attempt suicide will eventually kill themselves (Jamison, 1999).
Thus, the treatment of suicidal ideation and behavior are standard features of clinical practice, though most mental health clinicians receive little, if any, formalized training in treating suicidal patients (Bongar, 2002; Jobes & Maltsberger, 1995). This in spite of the fact that leading experts in suicidology have compiled treatment guidelines and standards of care tailored for inpatient treatment (Bongar, Maris, Berman, Litman, & Silverman, 1993; Silverman, Berman, Bongar, Litman, & Maris, 1994) and outpatient treatment (Bongar, Maris, Berman, & Litman, 1992), spanning different clinical settings and patient populations (American Psychiatric Association, 2003; Bongar, 1992, 2002; Chiles & Strosahl, 1995; Jacobs, 1999; Maris, Berman, & Silverman, 2000).
Even with faithful adherence to the aforementioned guidelines and competent clinical practice, clinicians are at risk for encountering patients' suicidal behaviors in the course of their standard practice. As suicide attempts far outnumber completed suicides, therapists who may never experience the trauma of having patients kill themselves are nonetheless highly likely at some point to encounter patients who attempt suicide during the course of active treatment. Many of these patients will, after stabilization, plan to continue in outpatient therapy with the same therapist. Arguably, there may never be a more critical time for the patient to be back in treatment with the clinician who knows him or her best than following a suicide attempt; yet, their working relationship may be significantly strained in the wake of the attempt. To our knowledge, there have been no studies of the prevalence of suicide attempters under professional care who resume treatment with the same clinicians after their attempts. There are, however, data to suggest that patients who eventually commit suicide, when compared with matched controls, are more likely to have left therapy prematurely (Dahlsgaard, Beck, & Brown, 1998) or to have had an inadequate treatment response (Suominen, Isometsä, Henriksson, Ostamo, & Lönnqvist, 1998).
These findings suggest that it is critical for suicidal patients to get back into active treatment following a suicide attempt. They also raise an important clinical question: How do the therapist and patient most productively resume treatment and optimally restore the therapeutic alliance? The wake of the attempt finds the patient facing not only emotional distress and ambivalence about the “failed” attempt, but also further encroachment on his or her privacy, perhaps in the form of hospitalization and/or unwanted family involvement. The clinician is confronted with treating a patient who perhaps remains at high and/or chronic risk for additional attempts or completed suicide (Holley, Fick, & Love, 1998; Isometsä & Lönnqvist, 1999). The combination of a damaged sense of controllability with a heightened awareness of professional accountability can be daunting, making therapists shy away from taking such patients back into therapy. Those therapists who resume treatment with these patients may thereafter practice more defensively and, in some cases, harbor strong ambivalent or negative feelings about their patients (Jobes & Maltsberger, 1995; Maltsberger & Buie, 1974; Rudd & Joiner, 1997). In sum, many issues arise in this context that could conspire to disrupt treatment at a time when it is highly needed.
The primary objective of this paper is to offer clinical guidance for therapists who find themselves faced with the stressful proposition of resuming treatment with a patient who has made a serious suicide attempt. To accomplish this objective we will examine three steps in the process of reestablishing a therapeutic alliance with such a patient. The first step involves the decision of whether or not, in fact, to agree to continue to treat the patient and, if so, on what terms? Second, we discuss the issue of addressing with the patient the mutual rebuilding of trust and confidence in the therapeutic relationship. The third step focuses on modifying the treatment plan and (perhaps) the composition of the treatment team to provide the level of care and support commensurate with the patient's needs.
Our goal is to have these guidelines help practicing psychotherapists regardless of their particular theoretical orientations. That said, our particular clinical approach to treating suicidal behavior is grounded in the cognitive therapy model. Cognitive therapy (CT) originally confronted suicide as part of the treatment of depression (e.g., Beck, Rush, Shaw, & Emery, 1979) and it has continued to evolve as a useful and integrative treatment approach for suicidal behaviors (Ellis, 1986; Ellis & Newman, 1996; Rudd, 2000; Rudd, Joiner, & Rahab, 2001). While understanding suicidal behaviors (and other behaviors) via a bio-psycho-social model, cognitive therapists place a premium on understanding each patient's unique matrix of beliefs insofar that they contribute to the maintenance of self-destructive impulses.
MEETING EACH OTHER AGAIN
Although the aim of this paper is to discuss guidelines for reestablishing the therapeutic alliance following a patient's suicide attempt, many clinicians struggle with the question of whether to resume treatment with these patients at all. Some therapists refuse to treat suicidal patients, claiming that the treatment of suicidality falls outside the bounds of their professional competencies (Jobes, 2000). Some clinicians consider high lethality behaviors as violations of the therapeutic contract in general, or an explicit anti-suicide contract in particular, and may terminate treatment outright with patients who engage in these activities. Generally speaking, a blanket policy of this sort is inadvisable. It is our view that the therapist—with few exceptions—should assume that she or he remains the outpatient therapist of record with all the attendant professional responsibilities, at least until the acute crisis has subsided and the patient's condition has been stabilized for a reasonable period of time. Suicide contracts, in the absence of a collaboratively developed, overarching crisis response plan, run the risk of creating a false sense of security and could even trigger negative reactions by patients (e.g., “If it only took a contract to stop my suicidal thoughts, I would not need therapy”) (Rudd et al., 2001). Further, a mental health clinician claiming he or she cannot treat suicidal behavior is, as one author wrote, “akin to an internist offering to perform routine physicals as long as the patient does not present with a life-threatening illness”(Jobes, 2000, p. 10). Still, there are times when a solid clinical rationale may dictate that the patient no longer should work with the same therapist, as described below.
Making an Appropriate Referral
There are times when therapists may legitimately choose to discontinue their work with a given patient following his or her suicide attempt. Based on the ethical principles outlined by Thompson (1990), we suggest the following examples.
- 1
A referral to a more experienced clinician or intensive treatment program is ethically indicated when, for example, the suicide attempt brings to light new clinical data that change the diagnostic picture, such as an emergent manic or psychotic episode, or ongoing substance abuse. The patient's level of functioning and risk for self-harm may have worsened, thus requiring more specialized or comprehensive clinical attention than the current therapist's practice environment can provide. If a prompt transfer to a more appropriate treatment setting can be made, this may be advantageous for the patient.
- 2
A transfer to a new clinician is appropriate when there is compelling evidence that the patient's suicidal behaviors represent repetitive attempts to maintain an unhealthy dependency on a given therapist, even when insufficient progress is being made and alternative treatments have been offered. In such cases, it may be argued that a continuing association between the patient and the therapist of record may in fact be iatrogenic, inasmuch as the autonomy of the patient is not being fostered, and risk remains high.
- 3
Termination of treatment is permissible when the therapist has reason to feel personally threatened by the patient. Thankfully, such instances are rare, but when therapists fear for their safety, they are within their ethical purview to withdraw from further contact with the patient. Still, it is helpful if they serve as consultants and facilitators in suggesting more intensive interventions elsewhere.
Weighing the different variables affecting the decision of whether or not to continue treating a patient who has attempted suicide can be difficult. When the issue is not clear-cut, it is prudent to have a formal consultation with a professional colleague (which is then recorded in the patient's clinical chart), who can provide an objective evaluation of the situation. In addition to demonstrating good professional practice, this sort of peer consultation provides the therapist with much-needed support and encouragement during a stressful time.
When it is determined that a referral to another therapist is clinically indicated and ethically appropriate, and the therapist does not feel personally endangered by the patient, it is preferable that the therapist and patient discuss the issues of termination and referral face to face (perhaps in the presence of the patient's spouse, parent, or other important person, with the patient's permission). This format allows the therapist to share with the patient his or her professional recommendations and rationale for referrals to other treatment providers better suited to the patient's needs (e.g., “Dr. Smith specializes in treating bipolar disorder”). The patient's questions and concerns can be addressed on the spot to minimize potential misinterpretations, including the patient's view that he or she is being “dumped” or otherwise punished. A final session allows the therapist and patient the chance to finish on a positive note and, if appropriate, to arrange for specific number of transitional sessions until the patient gets started with a new clinician. Nevertheless, even if all of the above is handled well, the patient may still feel abandoned, especially if this represents a lifelong psychological issue.
Updated Ground Rules for the Resumption of Treatment
The aforementioned stipulations for referrals notwithstanding, the clinician who is prepared to continue treatment with the patient need not feel obliged to resume therapy without renegotiating some minimal conditions for doing so. This is an opportunity to revise the ground rules for treatment in light of the emergency that took place. Presumably, the old ground rules were not sufficient to prevent a near catastrophe, and need to be updated.
For example, one of our patients refused to talk about her experiences years earlier as a sexually abused pre-adolescent, stating dramatically that such a focus in therapy would drive her to suicide. Based on this assertion, the therapist agreed to steer clear of this sensitive area, though he asked permission to revisit the topic at a later date. The patient warned him that there would never be a time when it would be safe to discuss the incest issue. Some months later, this patient attempted suicide without apparent warning. When she was released from the hospital to the outpatient therapist's care, the therapist used the observation that not talking about the abuse history had not had the intended effect of reducing her suicide risk. Consequently, he proposed that he and the patient needed to unite forces and treat her suicidality aggressively, including the need for all topics to be fair game in therapy, including her abuse history.
The reformulation of therapy ground rules can be done in a constructive, positive manner, emphasizing the protective value for patients while also noting the patients' active responsibilities in collaborating with their professional and personal caregivers, as well as taking care of themselves. At the same time, therapists may choose to set more stringent limits, explaining that certain patient behaviors deemed to be counter-therapeutic will have predictable consequences. For example, in the first session following a patient's alcohol-induced, impulsive suicide attempt, the therapist may state that, “If you call me while inebriated and suicidal, I will call the police first, and talk to you second.” When taking such a stance, it is advisable for the therapist to adopt a nonpunitive tone and to explain her or his therapeutic rationale with equanimity.
An overview of ground rules should also include a review of procedures for handling cancellations, missed appointments, and unanswered or unreturned phone calls (e.g., in response to pre-arranged phone check-ins as a means of risk management). The therapist can articulate expectations for regular attendance, including the minimum requirements for being considered “in treatment,” and a patient's responsibilities for collaboration with treatment recommendations. Clinicians also reaffirm their commitment to the therapeutic process by highlighting (verbally, and documenting in the chart) their availability for sessions, appropriate procedures for between sessions and emergency contacts, and realistic expectations for the length and outcome of therapy. (See Table 1 for a summary of clinical guidelines for resuming psychotherapy following a patient's suicide attempt.)
| • Confirm that the patient wishes to continue therapy with the same therapist. With few exceptions, be willing to resume treatment. |
| • Review any new clinical information arising from the patients suicide attempt that might necessitate a referral on ethical grounds. If in doubt, consult with a professional peer. |
| • If a transfer of care is ethically indicated, take appropriate steps to facilitate the patient's smooth transition to a new mental health professional. |
| • In light of the suicide attempt, clarify and/or modify the ground rules for continued therapy with the patient. |
| • Define the basic expectations for treatment adherence and discuss the patient's and therapist's mutual and distinct responsibilities in psychotherapy. |
| • Communicate these guidelines in a positive, collaborative manner. |
REBUILDING TRUST
Of course, the agreement to resume treatment, even under renegotiated terms, brings to the forefront the issue of trust between the patient and the therapist. Based on the still fresh experience of the patient's suicide attempt, the therapist might question the patient's ability or willingness to commit to treatment, and to abstain from active suicidality. At the same time, the patient may harbor doubts about whether the treatment in general or the therapist in particular can be effective. Further, the patient may not believe that the therapist truly wants to help (e.g., “You must hate me now”), and/or may assume that the therapist will recommend hospitalization at the first hint of subsequent suicidality. These thoughts may greatly inhibit the patient's willingness to be forthcoming.
Address the Issue of Therapeutic Trust Directly
At the outset of the session in which the therapist broaches the issue of reestablishing mutual trust following the patient's suicide attempt, it is helpful if they respectfully address the following questions: Why did the patient attempt suicide, and why did she or he not take the agreed-upon precautionary steps, such as contacting the therapist beforehand? The therapist can lay the groundwork for the discussion by acknowledging the sensitive nature of the topic, stating that it is one to be dealt with in a collaborative spirit, and expressing the hope that facing it will allow the patient's treatment to resume in a positive way. Introducing the session agenda in this manner implicitly demonstrates that the therapist will neither deny nor shy away from the topic of the patient's suicide attempt.
Strive for a Better Understanding of Each Other's Actions
When the therapist is committed to the establishment and maintenance of a collaborative therapeutic relationship, adverse events in therapy do not necessarily have to damage or end a productive course of treatment. For example, circumstances involving misinformation or resistance by the patient can be treated as a clinical matter and, when handled sensitively and effectively, can bolster therapeutic trust and bring about positive change in the patient's beliefs and behaviors (Newman, 1994). Rather than rebuking the patient for counter-therapeutic self-destructive behavior, therapists can try to put the patient's suicidality into the context of a revised case conceptualization and a better understanding of the patient's unique experience of and beliefs about suicide (e.g., Jobes, 2000; Rudd, 2000).
The case conceptualization is the integrated understanding of the patient's presenting problems, the relevant developmental history explaining the etiology of the clinical issues, and reasonable predictions of appropriate interventions and future functioning (Beck, 1995; Persons, 1989). When facing problematic points in therapy, the case conceptualization is a useful tool for ferreting out the issues underlying resistance, misperceptions, and strong negative affect the patient may have about therapy and the alliance. It also allows the therapist to be aware of and sensitive to the patient's emotional “buttons”(e.g., schemas, see Young, 1999) in order to avoid needlessly pressing them (and it allows the therapist to recognize his or her own “buttons” related to suicide, e.g., Rudd & Joiner, 1997). A good case conceptualization allows the therapist to hypothesize the reasons for a patient's suicide attempt in a nonjudgmental, clinically astute manner. Consequently, chances are improved that the patient will feel understood, will not feel blamed or shamed, and will be willing to level with the therapist about future suicidal impulses before self-harming actions are taken.
For example, Arnie had been apparently doing well in therapy, when he unexpectedly tried to asphyxiate himself in his garage. Later, the therapist tried to understand Arnie's subjective experience leading up to the suicide attempt so as to conceptualize the behavior, rather than simply assuming that Arnie had been blithely withholding information about his level of risk. Arnie revealed that his depression had been worsening steadily over the past few weeks, but “nobody seemed to notice.” Indeed, a review of his recent Beck Depression Inventory scores (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) showed a steady worsening of symptoms. Unfortunately, his presentation in session—and to the world at large—remained unchanged, and nobody noticed his decline. The therapist was able to posit that Arnie was still ashamed to admit his depressed feelings (something he had acknowledged earlier in treatment), but he hoped that others would divine his condition unsolicited. When this did not happen, Arnie experienced the activation of his schemas of unlovability and abandonment (cf. Young, 1999), and went to the extreme of attempting suicide to call attention to the personal misery that “nobody cared to notice.” The therapist was also able to own up to the fact that he had not made Arnie's BDI scores a big issue in previous sessions, and perhaps this was an error. This conceptualization was instructive and non-stigmatic, allowing the patient and therapist to share responsibility for what had taken place, and leading to a new agreement—the therapist would (from now on) always comment on Arnie's BDI scores, and Arnie would, in turn, agree to reveal future suicidal ideation verbally and preemptively.
Similarly, the therapist can go to extended lengths to help his or her patients get a better conceptualization of the therapist's behavior, feelings, and thoughts pertinent to the suicidal crisis. To this end, the therapist can use judicious self-disclosure pertinent to her or his clinical decision-making and emotional reaction to the suicide attempt. The goals are to improve the patient's understanding of the therapist's intentions, and perhaps to provide crucial feedback about the effects of the patient's suicidal behavior on others. While doing so, the therapist can maintain an empathic stance regarding the patient's thoughts and feelings, while still giving frank, straightforward feedback.
For example, following Arnie's return to treatment, his therapist acknowledged that he was now more wary—perhaps even frightened—about the patient's condition. He explained how unsettling it was not to be able to fully trust Arnie's condition at face value. As the therapist noted, “I would much rather have a solid, unshakeable confidence in your ongoing recovery from depression than cast a suspicious eye about how you're really doing at every appointment, but that may be the safest way to proceed, at least until you feel comfortable enough to wear your true emotions and intentions on your sleeve.”
Some patients readily express their opinions about the treatment relationship, the therapy process, and factors contributing to the recent suicide attempt. These factors can often be understood as mistrust of self-help techniques (e.g., “I just knew that calling up a friend or writing out my thoughts would not have made any difference”) or mistrust of therapy support (e.g., “I did not page the on-call therapist because I did not want to talk with someone who does not know me”). Reinforcing the importance of making use of available therapeutic resources and exploring the source of mistrust might reveal deeper beliefs that could affect therapy (e.g., “Self-help suggestions won't work for me because I'm defective” or “I can't handle things on my own and only my therapist's advice can help me”).
For example, in the first session after being discharged from the hospital after making an impulsive suicide attempt, one of our patients said that the activating event for his attempt had been reading a flyer announcing a luncheon held at the therapist's clinic, sponsored by a pharmaceutical company. The therapist gently and persistently inquired about the meaning of the luncheon for the patient. What slowly unfurled was a series of mistrustful interpretations and beliefs that culminated in the patient's judgment that, “My therapist is a puppet of the pharmaceutical industry who will eventually refer me for medication management only. He does not care about me and he cannot be trusted.” The upshot of the session was that the patient had felt abandoned by previous helping professionals and felt particularly vulnerable, even as he had been making progress in therapy and was developing trust in the therapist. The conceptualization of the patient's beliefs (i.e., schemas) about vulnerability, abandonment, and mistrust (and their relation to suicidal thoughts) set the stage for these themes to be the thrust of subsequent sessions.
In other cases, however, there may be stronger negative affect directed by the patient toward the therapist (e.g., “You don't seem to have a clue as to how to help me”), either explicitly or implicitly. The therapist may have to draw on strong empathic listening and communication skills to handle critical feedback or outright expressions of anger. In yet other cases, the therapist may have to be sensitive to contradictions or nonverbal communication that might suggest ambivalence or outright hostility toward the therapist. Finally, the therapist would do well to bear in mind that patients may feel easily ashamed in such situations, thus, it is important to communicate in a way that allows the patient to “save face”. (See Table 2 for a summary of clinical guidelines for addressing the issue of trust in psychotherapy following a patient's suicide attempt).
| • Explicitly discuss the issue of trust in therapy during a session following the patient's suicide attempt. |
| • Set the stage for discussing trust issues by acknowledging it may be a difficult topic to explore. |
| • Share and elicit feedback from the patient about his/her views of the therapeutic alliance. |
| • Maintain a nondefensive tone when dealing with the patient's expressions of mistrust and general negative feedback. |
| • To increase understanding, revise the case conceptualization by incorporating clinical data arising from the most recent suicide attempt. |
| • Explain the clinical rationale for the therapist's actions prior to, during, and after the patient's emergency. |
| • Reframe patient's mistrustful interpretations of the above. |
| • Regularly monitor the status of the therapeutic alliance. |
REFORMULATING THE TREATMENT PLAN
Part of the process of resuming a productive course of therapy involves spelling out a revised treatment plan, updated in light of the suicide attempt and its signal that something more and/or different is needed in therapy. The new treatment plan should make overt use of the revised case conceptualization, demonstrating how the suicide attempt could be accounted for by the patient's unique psychological vulnerabilities. Further, it can include interventions that will most likely help the patient make the changes that are most needed, such as increasing self-efficacy, hopefulness, trust in benevolent others, and a willingness to invest in the learning of coping skills. The revised case conceptualization also can highlight the changes in the patient's belief system that need to be made in order to reduce the risk for future suicide (e.g., “Even if I cannot reach my therapist in a crisis, I have the skills to manage it, and to wait safely until tomorrow's session”). The therapist can encourage the patient to make a fresh start in therapy, utilizing past problems in therapy as useful learning experiences, and the therapist and patient can move forward with renewed energy and hope.
Deconstructing the Suicide Attempt
The recent suicide attempt offers an opportunity to explore the patient's expectations for what his or her completed suicide would have achieved. The patient's responses often are along the lines of “I wanted to escape my problems,”“I wanted people to see how sorry they would be when I was gone,” or “I wanted to make the pain stop.” The therapist and patient can reframe the patient's expectations into therapeutic goals such as, “I want to solve some of my problems,”“I want to have better relationships with others,” and “I want to feel better.” Alternative strategies that do not require the extreme behavior of suicide can be fashioned for obtaining such ends. What's more, the realization that the actual outcome of suicide would not necessarily bring about the patient's desired results creates cognitive dissonance that might weaken a suicidal impulse (Ellis & Newman, 1996; Freeman & Reinecke, 1993).
Such explorations of the patient's beliefs set the tone for subsequent clinical interventions (e.g., Jobes, 2000; Rudd, 2000). The stressful life circumstances the patient faces can be acknowledged, but the patient's inference that “my problems are too overwhelming for me to handle” can be gently questioned. Simply listing out the distinct problems the patient faces can help to decatastrophize them, as each problem can be framed in specific behavioral terms (coupled with coping options) rather than as a generalization. For example, there is a palpable difference between “I'm on the verge of losing my job and going broke” and “My boss seemed concerned about the amount of time I took off from work (for my hospitalization) and I don't know what to tell him because I'm afraid he'll fire me.”
The patient's reasons for dying are often cognitively well rehearsed. The intervention of formulating reasons for living may modify hopeless attitudes and be a protective factor against further suicidal acts (Ellis & Newman, 1996; Linehan, Goodstein, Nielsen, & Chiles, 1983; Malone et al., 2000). In addition to the assessment and therapeutic benefits of compiling such a list (e.g., Jobes & Mann, 1999), patients should be encouraged to maintain a copy of it for reference as a coping strategy when they encounter a recurrence of suicidal thoughts and hopelessness about the future.
Expanding the Treatment Team
The reworking of the treatment plan may well reveal that outpatient psychotherapy alone is insufficient to help the patient achieve his or her treatment objectives; additional professional services may be needed. The treatment team approach is prudent clinical practice when the patient has diverse clinical needs, each requiring specialized attention (Bongar, 2002). If the patient has not already been assessed for medications, a psychiatric referral may be indicated. There may be other therapeutic services such as group therapy, day hospital programs, case management, vocational rehabilitation, and 12-step programs that help spread out the clinical responsibilities and provide appropriate comprehensive care. Maintaining open lines of communication among these professionals further promotes the sense of teamwork and collaboration, and reflects good risk management.
Another potential source of aid comes from members of the patient's personal support system. These individuals may have frequent contact with the patient and may be invested in supporting the patient's well-being. It is clinically advantageous to elicit their support, as they may be more likely to be on the scene to help the patient during a crisis. Therapists can encourage patients to provide written consent to involve such persons in their treatment, with specific parameters collaboratively negotiated in session. The participation of the patient's significant others provides another source of observational data about the patient's functioning and follow-through on therapeutic recommendations. As we try to make clear to patients, identifying the need for and requesting appropriate assistance are adaptive coping skills in line with the goals of therapy.
The inclusion of significant others in the treatment team might be a suggestion welcomed by the patient; however, it is important to be mindful of the patient's relationship with her or his support system and to determine whether the members' participation would indeed support the patient's well-being or would, instead, jeopardize it. In some cases, the patient's experience of the family involves memories of abuse or other dysfunctional behaviors from which the patient is trying to gain distance. It is important to thoroughly explore the pros and cons for including specific individuals in treatment and to proceed with this plan only with the patient's explicit permission (short of an emergency).
The appropriate role of a willing support person needs to be clearly delineated. As the goal for treatment is to help the patient develop skills for handling his or her life and emotions, it would be counter-therapeutic if the patient continues to expect that others will be responsible for his or her behavior. The scope of the support person's involvement (e.g., frequency of sessions attended, duration of participation) can be negotiated with the help of the patient. In the absence of an acute crisis, patients determine how much of their clinical information should be openly disclosed to the support persons, as the latter do not have carte blanche access to confidential data without the patients' explicit permission. At the same time, it may be emphasized that it can be advantageous to treatment if patients' important others provide information pertinent to their care, such as the patient's level of functioning between sessions and medication compliance.
By including significant others into the team, clinicians help to engender the good will sense that “we are all in this together.” The patient's important others get the opportunity to see the therapist as a real person who is acting professionally and who is sincerely trying to help. Such a scenario is far more favorable than when the patients' family members view the therapist as an anonymous figure, knowledge of whom is gained only via the patient's report (e.g., Bongar, 2002). The notion of teamwork notwithstanding, it should be documented in the clinical record and made explicitly clear during a session and in the presence of other available treatment team members, particularly support persons, that the patient is ultimately responsible for using the therapeutic supports and following through on treatment recommendations (e.g., Ellis & Newman, 1996). (See Table 3 for a summary of clinical guidelines for reformulating a treatment plan following a patient's suicide attempt.)
| • Use the revised case conceptualization to update the treatment and safety plans. |
| • Review the events leading up to the suicide attempt for lessons to be learned that could inform ongoing clinical safeguards and interventions. |
| • Review the effects of the suicide attempt on the patient's subjective reasons for living and dying. |
| • Identify the residual problems the patient is facing after the suicide attempt and use a problem-solving approach to address them. |
| • Consider the additional therapeutic and support services that might be required to promote the patient's safety and improved functioning. |
| • Coordinate efforts with the other members of the treatment team, ideally with the full participation of the patient. |
FUTURE DIRECTIONS
Researching the role of the therapeutic alliance after a patient's attempt suffers all the challenges of suicidological research in general: suicidal behavior has a relatively low base rate, is difficult to predict and, consequently, much research is conducted only after the attempted or completed suicide. The first step in this area of research would be to collect data regarding the frequency with which suicide attempters resume therapy with the same therapists. Surveys of practicing clinicians and of suicide attempters would yield more precise epidemiological data regarding the occurrence of suicide attempts in the course of active psychotherapy.
To gather data on the prophylactic effects of the therapeutic alliance on suicidal behavior would require ongoing assessment of relationship factors and risk factors for suicide throughout treatment, such as using both patient and therapist assessments of the alliance and their correlation with suicidal symptoms. Even more useful would be to have these sessions recorded (video and/or audio) to allow for the assessment (via coding by raters) of crucial factors affecting the treatment alliance. Clinical trials for depressed and/or suicidal patients can readily incorporate these measurements. Data of this sort would allow researchers to (1) compare patients who attempt suicide during the course of treatment with those patients who do not on measures of the treatment alliance; and (2) determine relationship factors, if any, that differentially predict a patient's response to the resumption of therapy with the same therapist after an attempt.
The aim of this paper has been to provide clinically useful guidelines for resuming psychotherapy with a patient who has attempted suicide during the course of treatment. Although this aspect of psychotherapy has received little attention in the literature, it is one that appears highly relevant for many practicing clinicians. We have outlined clinical strategies pertinent to resuming treatment, reestablishing a sense of mutual trust in the therapeutic relationship, and reformulating the treatment plan. We hope that attention to these matters will help clinicians effectively face the stressful proposition of resuming therapy with patients who have recently made a serious suicide attempt, and to reduce the risks for both parties.
