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Suggestions for handling suicidal crises (largely from Marsha Linehan)
Jim Pretzer · 11/24/01 at 9:25 PM ET
The following suggestions are largely adapted from Marsha Linehan’s suggestions for handling suicidal crises which appear in the “Therapists’ Survival Guide: Suicide Crisis Protocol” distributed by the Behavioral Technology Transfer Group http://www.behavioraltech.com:
- Promptly assess risk for immediate suicide or serious injury. (Do not hesitate to ask directly about suicidality if you are concerned. Take seriously any hints about suicidality and any actions which may be preparations for suicide.)
- Immediately explore the problem. (What precipitated the crisis? Summarize the problem. How would suicide “solve” the problem?)
- Focus on solving the immediate problem. (Explicitly instruct NOT to commit suicide. Emphasize that suicide is not an effective solution. Identify and reinforce adaptive responses. Give advice and make direct suggestions. Draw on the client’s skills and past successes.)
- Generate hope. (Identify believable solutions for the current problem. Generate hopeful statements. Get the patient to spell out clear reasons for living.)
- Pay attention to affect. (Focus on current emotion. Validate emotions and soothe them. Try cognitive restructuring and cheerleading. Coach the patient in coping effectively with the emotions. Encourage affect tolerance.)
- Reduce environmental risk factors. (Remove lethal means or get patient to do so. Dismantle any preparations for suicide. Remove or counteract suicidal models/images. Increase social support, including support from you. Minimize stressful events & demands.)
- Reduce behavioral risk factors. (Increase activity level. Block maladaptive responses. Address the function of current suicidal ideation.)
- Get a commitment to a plan of action. (Ask explicitly for a commitment to a specific plan. Sell the action plan. Ask for a lot, settle for less if you must. Ask for a bit more than the patient agrees to easily. Remind the patient of any prior commitments. Highlight their freedom to choose suicide while stressing the negative consequences of choosing suicide.
- Troubleshoot the action plan. (Identify potential problems that may arise in the next few hours/days. Identify solutions to potential problems. Revise the action plan as needed. Anticipate possible crises and plan how to hendle them.)
- Reassess suicide risk and commitment to the action plan before ending the intervention.
Overall: Be flexible, be more active when suicide risk is high, base non-conservative interventions on failure of conservative interventions, be honest about the reasons for your responses.
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