CLINICAL INTERVIEWING - PART 7

262 Structuring and Assessment mary of suicide intent levels and Putting It in Practice 9.2 for a comprehensive suicide assessment checklist). CRISIS INTERVENTION WITH SUICIDAL CLIENTS The following guidelines, although not foolproof, provide basic ideas about how to handle yourself and your client during a suicide crisis. They are consistent with Shneid-man’s (1996) advice for therapists working with suicidal clients: “Reduce the pain; re-move the blinders; lighten the pressure—all three, even just a little bit” (p. 139). Listening and Being Empathic The first rule of working therapeutically with suicidal clients is to listen closely to their thoughts and feelings. Often, suicidal clients feel isolated, and, therefore, it is impera-tive to establish an empathic connection with them. They may have never openly dis-cussed their depressive or suicidal thoughts and feelings with another person. Conse-quently, let them know you truly hear how miserable and desperate they are feeling (Shneidman, 1980, 1996). Obviously, when clients begin discussing suicide, expressions of shock or surprise should be avoided. This is easier said than done, but you must deal with clients’ thoughts and feelings in a matter-of-fact manner; this suggests to clients that you have dealt with such issues previously, and reassures them that their experiences are not completely unusual. In some situations, you may want to be openly reassuring and sup-portive, even acknowledging that suicidal urges are sometimes a natural response, by saying something like the following: “You’ve told me about some of the difficult experiences you’ve had recently-losing your wife, your job, and your good health. It’s not unusual for you to con-sider killing yourself. Many people you’re your situation might think about whether life is still worth living.” Establishing a Therapeutic Relationship As you make efforts to empathize with your client, you also should work on establish-ing a therapeutic relationship. As a professional, it’s your job to side with life. Continue to be empathic, but also let your client know your professional stance: “Right now it probably doesn’t feel like your life is worth much, but I want to let you know that things can, and probably will, get much better for you. It’s a fact that just about everyone who gets depressed also gets over it and then feels much better. And you can accelerate the ‘getting better’ process by involving yourself in therapy.” Research indicates that people who are depressed or in a mood characterized by psy-chological or emotional discomfort have difficulty remembering positive events or emotions (Blaney, 1986; E. Clark & Teasdale, 1982; Eich, 1989). You can help clients focus on positive events and past positive emotional experiences, but also remain em-pathic with the fact that it is not easy for most depressed and suicidal clients to recall anything positive. On the other hand, too often interviewers become uniformly negative and problem- Suicide Assessment 263 focused when working with depressed and suicidal clients (J. Sommers-Flanagan, Rothman, & Schwenkler, 2000). This makes it all the more important for interviewers to weave comments about current resources, strengths, and reasons for living into in-terviews with suicidal clients. If nothing else, you will be able to further assess your client’s level of depression and suicidality by observing his or her responses to your ef-forts to integrate positive content into the interview. Finally, suicidal clients may find it difficult to attend to what you are saying. Speak slowly and clearly, occasionally repeating key messages, when working with clients who are depressed and suicidal. Identifying Alternatives to Suicide The primary thought disorder in suicide is that of a pathological narrowing of the mind’s focus, called constriction, which takes the form of seeing only two choices; either some-thing painfully unsatisfactory or cessation of life. (Shneidman, 1984, pp. 320–321) Suicide is, in fact, a possible alternative to life. It is fruitless to debate with clients about whether suicide is a philosophically acceptable course of action. (We’ve tried that our-selves.) Instead of arguing with clients about whether they should commit suicide, help them identify options in addition to suicide. Encourage suicidal clients to examine the question “Why commit suicide now?” Talk about the fact that there’s no rush. An individual can always commit suicide later, after other life options have been explored. In fact, because suicide is a permanent choice, all other options should be explored first. The key here is that if you get your clients reinvolved with life, they often reap natural rewards and gratifications that even-tually reduce the desire to commit suicide. Usually, suicidal clients suffer from mental constriction; they are unable to identify options to suicide. As Shneidman (1980, p. 310) suggests, help your clients “widen” their view of life options. They need to take off their mental blinders and see that sui-cide is not the only alternative. Shneidman (1980) writes of a case in which he goes through a list of alternatives with a pregnant suicidal teenager in an effort to remove her mental blinders. This is a prac-tical and concrete approach that can be used with clients to enhance the working rela-tionship and at the same time open their minds to constructive alternatives. Get out a pencil and paper to brainstorm alternative actions with regard to a specific life dilemma. Encourage clients to contribute to the list, but have plenty of your own to of-fer. After all alternatives are listed, ask your clients to rank the alternatives in order of preference. There is always the possibility that clients will decide suicide is the best choice (at which point you have obtained very important assessment information). On the other hand, it is surprising how often suicidal clients discover other, more prefer-able, options through Shneidman’s method. Separating the Psychic Pain from the Self Rosenberg (1999, 2000) described a helpful cognitive reframe intervention for use with suicidal clients. Specifically, she states: “The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self” (p. 86). This technique can help suicidal clients because it provides much needed empathy for the clients’ psychic pain, while at the same time helping them see that they wish for the pain to stop existing, not for the self to stop ex-isting. 264 Structuring and Assessment Similarly, Rosenberg (1999) recommends that therapists help clients reframe what is usually meant by the phrase “feeling suicidal.” She notes that clients benefit from see-ing their suicidal thoughts and impulses as a communication about their depth of feel-ing, rather than an “actual intent to take action” (p. 86). Once again, this approach to intervening with suicidal clients can decrease clients’ needs to act, partly because of the elegant cognitive reframe and partly because of the empathic message by the therapist. Establishing Suicide-Prevention Contracts Many writers and clinicians recommend establishing suicide-prevention contracts (Davidson, Wagner, & Range, 1995; Drye, Goulding, & Goulding, 1973). Although most clinicians we know use verbal suicide-prevention contracts, contracts may be for-mally written as well. The typical contract is a verbal agreement between client and therapist (or interviewer), sometimes sealed with a handshake. The agreement often sounds something like this: Interviewer: “You’ve said that sometimes you feel an urge to kill yourself. The possibility of your taking your own life during an especially bad moment con-cerns me. Can you promise me that if the urge to kill yourself wells up inside you, and you’re afraid you’re going to lose control, you’ll call me first? We can talk things over and hopefully you’ll be able to regain control.” Client: “Okay. Yeah, I can call you if I start to feel out of control.” Interviewer: “Fine, then. Let’s set up your next appointment time.” Before reading on, stop and reread the previous suicide-prevention contract state-ment. Think about what is wrong with this agreement where the therapist tells the client to “call me first” in case of strong suicidal impulses. First, although as a professional helper you may feel completely committed to your clients, you may not want to deal with client crises at any time, night or day. But that is exactly what might happen with the preceding offer. Second, you may not be able to respond to your client immediately. For example, you may not be home, or you may be at home dealing with a smaller cri-sis of your own. Therefore, if you enter into a suicide contract like the one described, be sure to provide your client with alternative telephone numbers (e.g., the local suicide hotline) in case you are unavailable when the suicidal urges occur. Third, what if your client simply calls you as his or her final act? For example: “Doc, I was calling because you said to call if I felt out of control. Well, I just wanted to say good-bye; I promised I would. Don’t feel bad. You’re a good coun-selor, but I gotta do this. No other way. Good-bye.” Instead of the traditional “call me if you feel out of control” contract, Mahoney (1990) recommends making an agreement with clients to meet face-to-face before fol-lowing through with suicide impulses. Although this approach has several advantages, it also may be difficult for severely suicidal clients to honestly agree to such a contract. To avoid having clients feel pressured into establishing a suicide-prevention contract with you, give them an opportunity to decline your contract offer (e.g., “I want you to agree to this contract only if you really believe you can follow through with it.”). In ad-dition, when establishing a suicide contract with clients, be sure to acknowledge that you cannot always be available to them. Suicide-prevention contracts (even contracts that specify only telephone contact) probably decrease suicide risk in most cases because they constitute a lifeline between Suicide Assessment 265 client and interviewer. Consequently, to be most effective, you should establish a solid therapeutic relationship before entering into a suicide-prevention contract. In many cases, even a single interview can be adequate for establishing the type of relationship necessary to make a suicide-prevention contract effective. If it does not seem you are relating well enough to a particular client to establish a suicide contract, it may mean the client is severely suicidal and that more immediate intervention is warranted. Suicide-prevention contracts also help evaluators assess client self-control and in-tent. If clients agree to a suicide-prevention contract, they probably have some control and have only low to moderate intent. Clients with low self-control or high intent often will not agree to a suicide contract. However, as emphasized by Simon (1999, 2000), in terms of liability, a suicide prevention contract is not an adequate substitute for a com-prehensive suicide risk assessment. Becoming Directive and Responsible When clients are a clear danger to themselves, in our culture and by our laws, it be-comes the interviewer’s responsibility to intervene and provide protection. For many counselors and psychotherapists, this means taking a much more directive role than usual. You may have to directly tell the client what to do, where to go, whom to call, and soforth. It also may involve prescriptive therapeutic interventions, such as strongly urg-ing the client to get involved in daily exercise, consistent recreational activity, church activities, or whatever seems preventative based on the individual client’s needs. Clients who are severely or extremely suicidal (see Table 9.1) may require hospital-ization. If you have such a client, be positive and direct regarding the need for and po-tential benefit of hospitalization. Clients may have stereotyped views of what life is like inside a psychiatric hospital. Statements similar to the following may help you begin the discussion. “I wonder how you feel (or what you think) about the possibility of staying in a hospital for a while, until you feel safer and more in control?” “I think being in the hospital may be just the right thing for you. You can rest and workon feeling better. And the staff members at the hospital are great. They’ll be there to talk with you, but they’ll also leave you alone and let you rest.” “Some people feel uncomfortable about staying in a hospital. I think you should give it a try and see if it helps. If it doesn’t help, you can check out in a few days or a week. My opinion is that life can be better for you, but that you need to take some steps to help make that happen. Going into the hospital is one of those steps: It’s a chance to be in a safe place while you focus on yourself and how you can feel better.” Linehan (1993, 1999) has discussed a number of directive approaches for reducing sui-cide behaviors based on her dialectical behavior therapy work with chronically para-suicidal borderline clients. For example, she advocates: • Emphatically instructing the client not to commit suicide. • Repeatedly informing the client that suicide is not a good solution and that a bet-ter one will be found. • Giving advice and telling the client what to do when/if he or she is frozen and un-able to construct a positive action plan. 266 Structuring and Assessment Making Decisions about Hospitalization and Referral Whenusing interview methods to conduct a suicide assessment, most professionals fol-low procedures similar to those described in this chapter. However, oncethe assessment is completed, there is still the question of how to proceed with the client’s professional care. The first question to be addressed in the decision-making process is: How suicidal is the client? Suicidality can be measured along a continuum from nonexistent to extreme. Clients with mild to moderate suicide potential can usually be managed on an outpa-tient basis. Obviously, the more frequent and intense the ideation and the more clear the plan (assess using SLAP), the more closely the client should be monitored. We recommend making verbal suicide-prevention contracts with clients who are a mild to moderate suicide risk. We also recommend discussing suicide as one of many alterna-tives. However, we are less directive with and take less responsibility for mild to mod-erately suicidal clients than for severely to extremely suicidal clients. If moderately suicidal clients fit into several important high-risk categories, we sometimes treat them as severely suicidal. For example, imagine a 55-year-old de-pressed male who presents with a consistent suicide ideation and a vague plan. The man is socially isolated and has increased alcohol use since the onset of his depression. De-pending on a number of clinical issues, this client might be a good candidate for psy-chiatric hospitalization (a strategy usually reserved for severely or extremely suicidal clients). This would especially be true if he had made a previous suicide attempt. Severely and extremely suicidal clients warrant swift and directive intervention. If possible, such clients should not be left alone while you consider intervention options. Instead, inform them in a supportive but directive manner that it is your professional re-sponsibility to ensure their safety. Such actions may include contacting the police or a county or municipal mental health professional. Unless you have special training and it is the policy of your agency, never transport a severely or extremely suicidal client to a psychiatric facility on your own. Suicidal clients have jumped from moving vehicles, at-tempted to drown themselves in rivers, and thrown themselves into freeway traffic to avoid hospitalization and accomplish their suicidal goal. Regardless of whether they suc-ceed during such an attempt, the attempt itself is traumatic to both client and interviewer. There are several reasons why hospitalization may not be the best option for mod-erately or severely suicidal clients (although it is probably always the best option for ex-tremely suicidal clients). For some clients, hospitalization itself is traumatic. They ex-perience deflated self-esteem and may regress to lower functioning, becoming cut off from more socially acceptable support networks. Severely suicidal clients who are em-ployed and have adequate social support networks may, in some instances, be better off without hospitalization. In such cases, you might increase client contact, perhaps even meeting for brief sessions every working day. Regardless of how suicidal a client seems on a given day, interviewers and therapists should consistently check with clients to determine whether suicidal status has changed. Do not assume that because your client was only mildly suicidal yesterday, he or she is still only mildly suicidal today. PROFESSIONAL ISSUES When working with suicidal clients, it is your responsibility to be a competent and caring professional who lives up to professional standards of practice. Meeting pro- ... - tailieumienphi.vn