Building a Therapeutic Alliance with the Suicidal Patient
There was a think tank-style meeting in Aeschi, Switzerland about what could be done to improve suicide prevention. The meeting spawned others that ran for some time but have unfortunately come to an end. There were a number of things that came from these meetings. From what I can determine by those who went, they were a sort of magical event that doesn’t normally happen. Building a Therapeutic Alliance with the Suicidal Patient is one of the outcomes of these meetings – and it’s a comprehensive look at how to be effective at treating suicidal patients. While it’s aging, it’s aging well. Conceptually, the important points raised in the book remain important to prevention today. To understand why, we need to go to the roots upon which the book is built.
Carl Rogers
The ideas that Carl Rogers shared were radical for his time. He intentionally leveled the playing field between therapists and patients. He suggested that patients were experts in their own lives and that, while therapists brought their own expertise, it wasn’t more important than the patient’s experience. (See A Way of Being.) He also said that therapists should have unconditional positive regard for patients. That is, they should suspend their judgement and remember that their patients are important people, too.
Rogers’ work wasn’t universally adopted in therapy, but thankfully it has reverberated through time.
Motivational and Narrative Interviewing
If you want to find a way to work with difficult patients, substance use disorder (SUD) is a good place to start, because their behaviors are notoriously persistent. Building on Rogers’ work, Miller and Rollnick developed what would be called Motivational Interviewing. It’s a strategy that is widely respected in SUD recovery circles because it works.
While motivational interviewing has specific approaches and techniques, it is consistent with the approach of the Aeschi group – who call theirs a narrative interview – which is quite different than the way that most suicide assessments are done. Instead of reading off a checklist of standard questions, they simply ask the person to tell their story.
Motivational interviewing tools like eliciting, affirmation, and summarizing are good tools in service of the narrative interview to help the patient know that you’re listening and trying to understand.
Letting people tell their story is also consistent with the work of James Pennebaker. He showed the value of creating a narrative and telling a story (or writing it down). (See Opening Up.)
Standards of Care
Every therapist has something they’re doing now. It’s something they were trained in. It’s something that some well-intended person insisted works. However, despite the assurances and the good intentions, a lot of what is done in therapy isn’t supported. The Heart and Soul of Change explains what does work – and, largely, it’s building a therapeutic alliance. Science and Pseudoscience in Clinical Psychology is a bit more critical, highlighting some of the challenges. While many therapists lament poor reimbursement rates and limits to the number of sessions, the simple fact of the matter is that the efficacy of therapies varies wildly.
Screening and Assessment
Before we go further, it’s important to acknowledge that the standard practice today includes two things that have poor predictive capacity for suicide attempts and deaths. They are screening – using any tool – and assessment by even trained clinicians. That is to say that we don’t have any reliable predictor of when someone will die by suicide even when evaluated by a clinician.
This is important, because we have no guarantees and no safety net. When a patient decides to die by suicide, they can. As Craig Bryan points out in Rethinking Suicide, prediction may never be possible. The rapid, event-driven changes in suicidal intensity may be something that we simply need to live with. While it’s essential that clinicians are able to create a therapeutic alliance with the patient, there are no guarantees.
This has important implications, because the death of a patient to suicide is seen as prima facie evidence that the clinician has done something wrong – as if they have the power to prevent a death by suicide. (See The Suicide Lawyers.) But clinicians can’t stop a dedicated patient – even in an inpatient setting. (See Suicide: Inside and Out.)
Disposal
Screening in emergency departments is often seen as a way to dispose of the problematic suicidal patient. Patients with several attempts may earn the derogatory moniker of “frequent flyer.” Emergency room staff believe they are there to treat “real” patients who are experiencing illness or trauma – not patients who are suffering from suicidal ideation and actions. The process of screening patients allows for them to be shuttled off towards inpatient psychiatric commitment – effectively disposing them out of the emergency department. The admission of a serious suicide attempt is often sufficient to proceed to have someone committed.
Commitment laws vary from state to state, but based on the guidelines set by the Supreme Court, a person must be both mentally ill and a danger to themselves or others to qualify for involuntary psychological detention. In Indiana, where I live, the rules around self-harm are codified as gravely disabled. On the mental illness side, it becomes more tenuous. Mental illness diagnoses are based on the DSM-5-TR, but the interrater reliability (the chances two people will get the same answer) is very low. Many believe that if you’re suicidal you must, by definition, have a mental illness – despite evidence to the contrary. (See Myth: Those Who Die by Suicide Had a Mental Illness.) This whole topic is well covered in Your Consent Is Not Required.
Therapy Defection – or Not
What are the set of variables that mediate whether a patient will stay in therapy – and presumably be responsive to the therapy? The answer is one that Marsha Linehan, who was a part of the Aeschi gatherings, recognized in her work with patients with borderline personality disorder. Dialectical behavior therapy (DBT) is based on the notion that a therapist must simultaneously – or at least alternatingly – validate the patient’s current state and thinking while advocating for change. (See Cognitive Behavioral Treatment of Borderline Personality Disorder.)
Directly, the factors that are related to listening and alliance building (such as sensitivity, listening, understanding, attitude and expertise) mattered when it came to keeping patient in therapy.
While the book cites evidence of early alliance had a negative effect. However, this makes sense to me from the perspective that the reported early alliance may be fake. It can be that the patient wants the therapist to approve of them, so they’re answering the alliance questionnaire more positively than is real. When there are stressors to the alliance, it crumbles. Linehan’s approach in DBT of directly moving for change leads to continual testing and refinement of the alliance and assurance that the perception of its stability is supported in fact.
Attachment
The book makes the point in several places that the therapist is fulfilling a role not unlike that of an attachment person (mother or father) by increasing the perceived safety such that the patient feels comfortable exploring on their own. There’s some support for this conceptually from attachment research. In Attachment in Adulthood, it’s explained that children’s attachment can be shifted towards secure with good foster placements. Adults in intimate relationships with a partner who is securely attached move towards secure attachment. So, we know from the attachment research that improving attachment is possible. It’s reasonable to believe that a therapeutic relationship with a clinician can help move people towards secure attachment and the benefits that come with it.
Induction and Promotion of Hope
One of the factors that is consistently correlated with suicidal ideation and attempts is a sense of hopelessness. Most people don’t understand hope. They believe that it’s a feeling, but as Rick Snyder explains in The Psychology of Hope, it’s a cognitive process. It’s the combination of our sense of how to accomplish the change and the willingness to do the work. This is often called willpower and is the subject of a Roy Baumeister’s book, titled Willpower. Marty Seligman in The Hope Circuit reviews the work of his career and reframes his original concept of learned helplessness as a failure to learn hope.
Hope is both an essential tool in fighting suicide and one that is often difficult to induce and promote in people.
Blame and Shame
One of the more common approaches to working with suicidal patients is to blame them or shame them. While this is not a desirable situation, it is unfortunately too common as we see in the emergency room example above. This was the strategy that was used for decades with SUD work. After decades of research on SUD, we discovered that using blame and shame don’t work. It’s not surprising if we look at the work of Bruce Alexander as described in The Globalization of Addiction, which speaks to how the original “rat park” experiments relied on social isolation of the rats – who are social creatures. Chasing the Scream looks not only at the problems with blame and shame but also how we criminalized behaviors that would previously have not been criminal.
The Aeschi approach is structurally designed to avoid the unintentional affliction of blame and shame. Instead, the patient is intentionally validated for their perception of their world.
Fighting the Righting Reflex
Motivational interviewing calls the tendency to “make things right” the righting reflex. It shows up as a desire to tell others what’s right – and it’s nearly universally wrong. In the case of a suicidal patient, it shows up as the desire to correct the desire for suicide. After all, in the therapist’s view, it’s not right. The problem is that this is a severe form of invalidation that can sever any therapeutic alliance that has been generated.
Coherent Narratives
According to Ed Shneidman, a person who could write a meaningful suicide note would not be in the position to complete a suicide. Shneidman was no stranger to suicide notes: his career included extensive work trying to find answers in the notes that suicidal people left behind. In Clues to Suicide, he explains how banal and disconnected they are. He also spoke of cognitive constriction and the inability to fully consider a condition as a part of suicide. It can be that he’s saying the ability to write the note would communicate that the person isn’t in a state of mind consistent with the minds of those who are suicidal.
Sick Cycles
In The Moment It All Starts to Unravel, I share some of the work of relationship experts, including the idea of a sick cycle. It’s a cycle that’s kicked off by one bad behavior that fuels another behavior and so on. Not only does it occur as I explained it in intimate relationships, but it can also occur in any kind of close relationship, particularly when a self-injurious or suicidal behavior occurs.
Experiencing real or imagined threats to the close relationship, the patient engages in self-injurious behavior, which alienates the attachment figure. It may be because they feel betrayed or a lack of control or whatever, but their instinct is to pull back. The patient, rightly, perceives the retreat, which further threatens the attachment – which can lead to further acting out.
When the person in the relationship is the therapist, they’ve got a professional, ethical obligation to stay. However, when the other person is a spouse, a relative, or a friend, the requirement to tolerate the discomfort and continue in the relationship is less strong. Many people who have had chronic suicidality have been in this cycle for a long time. (See Loving Someone with Suicidal Thoughts.)
While therapists have an obligation, it doesn’t make it easy to bear the escalation of patient self-harm intensity nor the implied responsibility to prevent it.
Psychache
Shneidman’s word for mental pain was psychache. (He wrote a whole book on it, Suicide as Psychache.) Referring to the work of Orbach, Mikulincer, Sirota, and Gilboa-Schechtman, the book uses their definition: “Mental pain is an irreversible sense of hurt that arises from the perception of negative changes in the self, which is imbued with extremely negative emotions and cognitions.” They provide an alternative definition from Roy Baumeister’s work as well: “Mental pain as a self-disappointment due to a discrepancy between the ideal and actual selves”
The Unslayable Dragon
It’s described as “the monstrous enemy of the suicidal patient, which cannot be fought alone.” I prefer to think of something more concrete. I see the suicidal state of mind as a dragon that cannot be slain – it can only be subdued for a time. Each battle with the dragon either strengthens it or weakens it.
The goal is to give the suicidal person the tools they need to subdue the dragon in a way that becomes easier for them and further weakens the dragon. Some of the tools may be better armor in the form of protective resources, some may be in better agility by realizing when the dragon is ready to rear its head, and some may be in the form of better weapons to fight with.
The dragon gets stronger when we continue to get triggered.
Making the Implicit Explicit
One of the challenges is that we live in a world where much of what we believe is implicit. We have never tried to articulate it. (See Lost Knowledge for more on implicit and explicit and articulation.) One of the goals of helping anyone is to help them convert their implicit thoughts, feelings, and beliefs into something explicit that can be worked with.
Creating a place of explicit beliefs is core to Building a Therapeutic Alliance with the Suicidal Patient.