Many clinicians will be able to share a story similar to this one – you start seeing a new client, and as the therapeutic alliance becomes stronger they disclose to you that they have some very detailed suicidal thoughts, including an idea of how they might die by suicide, perhaps even a date that they are expecting to die by. And even more terrifying might be that they have also started gathering the means for dying by suicide.
As clinicians, we have all been trained on what to do when a client discloses suicidal thoughts and plans. Risk assessment and safety planning to the rescue! We get busy with assessing for risk factors and protective factors, do what we can to convince our client to get rid of the means, and increase social support. We collaborate with our client to create a safety plan, including figuring out distractions that they can engage in to help keep the thoughts at bay, and come up with a backup plan as to what they will do if the urges intensify.
Sounds like best practice, yes? It is the safest, most pragmatic protocol to follow in that current moment, and unfortunately following this procedure is not usually sufficient for getting our clients to want to stay alive in the long term. Why is that? Because completing risk assessments and safety protocols, while vital to keeping the client alive in that moment, do not help the client develop a ‘life worth living’ for the future.
It is common for us as clinicians to get wrapped up in doing an amazing job at a crisis plan and risk assessment, sometimes taking the whole session to do this. This comes from good intentions – we care about our clients and want to do absolutely everything to keep them safe. However, if we consistently give in to the urge to spend the whole session on a crisis plan (or even the majority of the session), this may create a rupture with our clients who are more seasoned in therapy, who have perhaps created so many safety plans with previous therapists that they could wallpaper their bedroom with safety plans. To these clients, creating yet another safety plan often feels patronizing, and may be the reason they choose not to come back for another session.
To clinicians, suicidal ideation is a problem to be tackled in therapy. To our clients, suicide is not the problem, it is the solution to the anguish they are in. Our clients feel like they are living in hell, they are on fire, and they are desperate to find any way to stop the pain. Suicide is an option for escaping the misery they are in.
DBT clinicians take a different slant with regard to how we treat suicidal ideation – while we recognize the importance of risk assessments/safety planning, we will do everything we can to focus our session time on the factors that are causing our clients to be in misery. We focus our attention on the variables that influence their anguish, and consider those variables to be the problems that we need to help our clients find solutions to. This of course, is with the caveat that we will have already created one strong safety plan during the early stages of treatment with our clients (and will update this crisis plan as needed), and we need to know our clients well enough to be confident that we are aware of the current level of risk despite not conducting a lengthy risk assessment every session thereafter.
Once DBT clinicians have a solid understanding of our clients, and one strong crisis plan that both we and our clients are confident in, then future sessions will focus primarily on the variables that are causing our clients to suffer, rather than on the suicidal ideation itself. We use a strategy in DBT called a ‘chain analysis’ that allows us to figure out the variables that led to our clients feeling suicidal, and then we will target our interventions to the variables that influence the suicidality, rather than trying to directly target the suicidal ideation itself.
For example – if my client is feeling suicidal because they are experiencing loneliness, then the problem is the loneliness (and possibly there are other problems that are causing the loneliness, such as difficulty making or maintaining friends, feeling alone even when around others, feeling invalidated by others, etc). The suicidal ideation in this case is not the problem, and therefore, as long as I have reason to believe that my client is not going to act on the suicidal ideation imminently, then I am going to spend the majority of my session treating the loneliness.
The result of this approach is usually that over a series of sessions, the suicidal ideation decreases because the client makes progress on the problems in their lives that are causing them to want to escape the pain. This leads to increased satisfaction in my client’s life, and a decrease in worry for me as my client becomes more stable and less suicidal – a win for all!
Reference:
Linehan, M.M. (1993). Cognitive Behavior Treatment of Borderline Personality Disorder. New York: The Guildford Press.