despues del intento

413Suicide and Life-Threatening Behavior 35(4) August 2005 2005 The American Association of Suicidology

After the Attempt: Maintainingthe Therapeutic Alliance Followinga Patient’s Suicide AttemptJ. Russell Ramsay, PhD, and Cory F. Newman, PhD

The risk of a patient’s suicide is a prominent occupational hazard for psy-chotherapists. The precise number of patients who attempt suicide while in treat-ment and then resume therapy with the same therapist is not known, but thissituation is a relatively common occurrence in clinical practice. Such scenarios canpose significant challenges to the reestablishment of therapeutic trust and a work-able treatment alliance. The aim of this paper is to identify the challenges facinga clinician treating a patient who resumes therapy following a serious suicide at-tempt, and to offer guidelines for maintaining the viability of the therapeutic alli-ance.

The suicide of a patient is a primary occupa- one in six or seven chance of experiencing apatient suicide (Brown, 1987; Kleespies,tional hazard for psychotherapists. Among

individuals diagnosed with major psychiatric Smith, & Becker, 1990), with 40% of traineeslikely to encounter serious suicidal behaviordisorders, the estimated prevalence of death

by suicide is about 10% to 15% (Brent, Kupfer, by a patient (Kleespies & Dettmer, 2000).The intrusive stress levels reported by psy-Bromet, & Dew, 1988, cited in Bongar,

Maris, Berman, & Litman, 1998; see Bost- chologists who experience a patient suicideare comparable to clinical levels of post-trau-wick & Pankratz, 2000, for a critical analysis

of these statistics). Studies indicate that there matic stress (Chemtob et al., 1988; Hendin,Lipschitz, Maltsberger, Haas, & Wynecoop,is a 22% chance that a psychologist in clinical

practice will experience a patient suicide in 2000).Suicide attempts far outnumber com-the course of a career; this chance is more

than 50% for psychiatrists (Chemtob, Bauer, pleted suicides. Although precise epidemio-logical statistics on suicide attempts in theHamada, Pelowski, & Muraoka, 1989; Chem-

tob, Hamada, Bauer, Torigoe, & Kinney, United States are not kept, it is estimatedthat there are from 765,000 to more than one1988). Even psychologists in training have amillion suicide attempts annually (Crosby,Cheltenham, & Sacks, 1999; Hoyert, Kocha-

J. Russell Ramsay and Cory F. Newman nek, & Murphy, 1999). There are about 10 toare with the Center for Cognitive Therapy at the 25 attempts for each completed suicide withUniversity of Pennsylvania.

between 1% and 4% of adults and betweenWe wish to express our gratitude to Julie2% and 10% of adolescents having made atJacobs, PhD, and to two anonymous peer review-

ers for their helpful comments on an earlier draft least one suicide attempt ( Jamison, 1999;of this article. Moscicki, 1999). For people aged 15 to 24, a

Address correspondence to J. Russell Ram- 100–200:1 ratio of suicide attempts to com-say, PhD, Center for Cognitive Therapy, 3535pletions is estimated. One out of every threeMarket St., #2027, Philadelphia, PA 19104–3309;attempts is serious enough to require medicalE-mail: [email protected]

414 After the Attempt

attention ( Jamison, 1999). Furthermore, lon- have had an inadequate treatment response(Suominen, Isometsa, Henriksson, Ostamo,gitudinal studies indicate that 10% to 15% of

those who attempt suicide will eventually kill & Lonnqvist, 1998).These findings suggest that it is criticalthemselves ( Jamison, 1999).

Thus, the treatment of suicidal ide- for suicidal patients to get back into activetreatment following a suicide attempt. Theyation and behavior are standard features of

clinical practice, though most mental health also raise an important clinical question:How do the therapist and patient most pro-clinicians receive little, if any, formalized

training in treating suicidal patients (Bongar, ductively resume treatment and optimally re-store the therapeutic alliance? The wake of2002; Jobes & Maltsberger, 1995). This in

spite of the fact that leading experts in suicid- the attempt finds the patient facing not onlyemotional distress and ambivalence about theology have compiled treatment guidelines

and standards of care tailored for inpatient “failed” attempt, but also further encroach-ment on his or her privacy, perhaps in thetreatment (Bongar, Maris, Berman, Litman,

& Silverman, 1993; Silverman, Berman, form of hospitalization and/or unwantedfamily involvement. The clinician is con-Bongar, Litman, & Maris, 1994) and outpa-

tient treatment (Bongar, Maris, Berman, & fronted with treating a patient who perhapsremains at high and/or chronic risk for addi-Litman, 1992), spanning different clinical

settings and patient populations (American tional attempts or completed suicide (Holley,Fick, & Love, 1998; Isometsa & Lonnqvist,Psychiatric Association, 2003; Bongar, 1992,

2002; Chiles & Strosahl, 1995; Jacobs, 1999; 1999). The combination of a damaged senseof controllability with a heightened aware-Maris, Berman, & Silverman, 2000).

Even with faithful adherence to the ness of professional accountability can bedaunting, making therapists shy away fromaforementioned guidelines and competent

clinical practice, clinicians are at risk for en- taking such patients back into therapy. Thosetherapists who resume treatment with thesecountering patients’ suicidal behaviors in the

course of their standard practice. As suicide patients may thereafter practice more defen-sively and, in some cases, harbor strong am-attempts far outnumber completed suicides,

therapists who may never experience the bivalent or negative feelings about their pa-tients ( Jobes & Maltsberger, 1995; Maltsbergertrauma of having patients kill themselves are

nonetheless highly likely at some point to en- & Buie, 1974; Rudd & Joiner, 1997). In sum,many issues arise in this context that couldcounter patients who attempt suicide during

the course of active treatment. Many of these conspire to disrupt treatment at a time whenit is highly needed.patients will, after stabilization, plan to con-

tinue in outpatient therapy with the same The primary objective of this paper isto offer clinical guidance for therapists whotherapist. Arguably, there may never be a

more critical time for the patient to be back find themselves faced with the stressful prop-osition of resuming treatment with a patientin treatment with the clinician who knows

him or her best than following a suicide at- who has made a serious suicide attempt. Toaccomplish this objective we will examinetempt; yet, their working relationship may be

significantly strained in the wake of the at- three steps in the process of reestablishing atherapeutic alliance with such a patient. Thetempt. To our knowledge, there have been no

studies of the prevalence of suicide attempt- first step involves the decision of whether ornot, in fact, to agree to continue to treat theers under professional care who resume

treatment with the same clinicians after their patient and, if so, on what terms? Second, wediscuss the issue of addressing with the pa-attempts. There are, however, data to suggest

that patients who eventually commit suicide, tient the mutual rebuilding of trust and con-fidence in the therapeutic relationship. Thewhen compared with matched controls, are

more likely to have left therapy prematurely third step focuses on modifying the treat-ment plan and (perhaps) the composition of(Dahlsgaard, Beck, & Brown, 1998) or to

Ramsay and Newman 415

the treatment team to provide the level of ratively developed, overarching crisis responseplan, run the risk of creating a false sense ofcare and support commensurate with the pa-

tient’s needs. security and could even trigger negative reac-tions by patients (e.g., “If it only took a con-Our goal is to have these guidelines

help practicing psychotherapists regardless of tract to stop my suicidal thoughts, I wouldnot need therapy”) (Rudd et al., 2001). Fur-their particular theoretical orientations. That

said, our particular clinical approach to treat- ther, a mental health clinician claiming he orshe cannot treat suicidal behavior is, as oneing suicidal behavior is grounded in the cog-

nitive therapy model. Cognitive therapy (CT) author wrote, “akin to an internist offeringto perform routine physicals as long as theoriginally confronted suicide as part of the

treatment of depression (e.g., Beck, Rush, patient does not present with a life-threaten-ing illness” ( Jobes, 2000, p. 10). Still, thereShaw, & Emery, 1979) and it has continued

to evolve as a useful and integrative treat- are times when a solid clinical rationale maydictate that the patient no longer shouldment approach for suicidal behaviors (Ellis,

1986; Ellis & Newman, 1996; Rudd, 2000; work with the same therapist, as describedbelow.Rudd, Joiner, & Rahab, 2001). While under-

standing suicidal behaviors (and other behav-iors) via a bio-psycho-social model, cognitive Making an Appropriate Referraltherapists place a premium on understandingeach patient’s unique matrix of beliefs insofar There are times when therapists may

legitimately choose to discontinue their workthat they contribute to the maintenance ofself-destructive impulses. with a given patient following his or her sui-

cide attempt. Based on the ethical principlesoutlined by Thompson (1990), we suggestthe following examples.MEETING EACH OTHER AGAIN

Although the aim of this paper is to 1. A referral to a more experienced cli-nician or intensive treatment pro-discuss guidelines for reestablishing the ther-

apeutic alliance following a patient’s suicide gram is ethically indicated when, forexample, the suicide attempt bringsattempt, many clinicians struggle with the

question of whether to resume treatment with to light new clinical data that changethe diagnostic picture, such as anthese patients at all. Some therapists refuse

to treat suicidal patients, claiming that the emergent manic or psychotic epi-sode, or ongoing substance abuse.treatment of suicidality falls outside the

bounds of their professional competencies The patient’s level of functioningand risk for self-harm may have( Jobes, 2000). Some clinicians consider high

lethality behaviors as violations of the thera- worsened, thus requiring more spe-cialized or comprehensive clinicalpeutic contract in general, or an explicit anti-

suicide contract in particular, and may termi- attention than the current therapist’spractice environment can provide. Ifnate treatment outright with patients who

engage in these activities. Generally speak- a prompt transfer to a more appro-priate treatment setting can be made,ing, a blanket policy of this sort is inadvis-

able. It is our view that the therapist—with this may be advantageous for the pa-tient.few exceptions—should assume that she or

he remains the outpatient therapist of record 2. A transfer to a new clinician is ap-propriate when there is compellingwith all the attendant professional responsi-

bilities, at least until the acute crisis has sub- evidence that the patient’s suicidalbehaviors represent repetitive at-sided and the patient’s condition has been

stabilized for a reasonable period of time. tempts to maintain an unhealthy de-pendency on a given therapist, evenSuicide contracts, in the absence of a collabo-


when insufficient progress is being tient’s questions and concerns can be ad-dressed on the spot to minimize potentialmade and alternative treatments have

been offered. In such cases, it may misinterpretations, including the patient’sview that he or she is being “dumped” orbe argued that a continuing associa-

tion between the patient and the otherwise punished. A final session allows thetherapist and patient the chance to finish ontherapist of record may in fact be

iatrogenic, inasmuch as the auton- a positive note and, if appropriate, to arrangefor specific number of transitional sessionsomy of the patient is not being fos-

tered, and risk remains high. until the patient gets started with a new clini-cian. Nevertheless, even if all of the above is3. Termination of treatment is permis-

sible when the therapist has reason handled well, the patient may still feel aban-doned, especially if this represents a lifelongto feel personally threatened by the

patient. Thankfully, such instances psychological issue.are rare, but when therapists fear fortheir safety, they are within their Updated Ground Rules

for the Resumption of Treatmentethical purview to withdraw fromfurther contact with the patient.Still, it is helpful if they serve as The aforementioned stipulations for

referrals notwithstanding, the clinician whoconsultants and facilitators in sug-gesting more intensive interventions is prepared to continue treatment with the

patient need not feel obliged to resume ther-elsewhere.apy without renegotiating some minimalconditions for doing so. This is an opportu-Weighing the different variables af-

fecting the decision of whether or not to con- nity to revise the ground rules for treatmentin light of the emergency that took place.tinue treating a patient who has attempted

suicide can be difficult. When the issue is not Presumably, the old ground rules were notsufficient to prevent a near catastrophe, andclear-cut, it is prudent to have a formal con-

sultation with a professional colleague (which need to be updated.For example, one of our patients re-is then recorded in the patient’s clinical

chart), who can provide an objective evalua- fused to talk about her experiences years ear-lier as a sexually abused pre-adolescent, stat-tion of the situation. In addition to demon-

strating good professional practice, this sort ing dramatically that such a focus in therapywould drive her to suicide. Based on this as-of peer consultation provides the therapist

with much-needed support and encourage- sertion, the therapist agreed to steer clear ofthis sensitive area, though he asked permis-ment during a stressful time.

When it is determined that a referral sion to revisit the topic at a later date. Thepatient warned him that there would neverto another therapist is clinically indicated and

ethically appropriate, and the therapist does be a time when it would be safe to discuss theincest issue. Some months later, this patientnot feel personally endangered by the pa-

tient, it is preferable that the therapist and attempted suicide without apparent warning.When she was released from the hospital topatient discuss the issues of termination and

referral face to face (perhaps in the presence the outpatient therapist’s care, the therapistused the observation that not talking aboutof the patient’s spouse, parent, or other im-

portant person, with the patient’s permis- the abuse history had not had the intendedeffect of reducing her suicide risk. Conse-sion). This format allows the therapist to

share with the patient his or her professional quently, he proposed that he and the patientneeded to unite forces and treat her suicidal-recommendations and rationale for referrals

to other treatment providers better suited to ity aggressively, including the need for alltopics to be fair game in therapy, includingthe patient’s needs (e.g., “Dr. Smith special-

izes in treating bipolar disorder”). The pa- her abuse history.


The reformulation of therapy ground TABLE 1Clinical Guidelines for Resuming Psychotherapyrules can be done in a constructive, positive

manner, emphasizing the protective value for After a Patient’s Suicide Attemptpatients while also noting the patients’ active

• Confirm that the patient wishes to continueresponsibilities in collaborating with theirtherapy with the same therapist. With few ex-professional and personal caregivers, as wellceptions, be willing to resume treatment.as taking care of themselves. At the same • Review any new clinical information arising

time, therapists may choose to set more strin- from the patients suicide attempt that might ne-gent limits, explaining that certain patient be- cessitate a referral on ethical grounds. If inhaviors deemed to be counter-therapeutic doubt, consult with a professional peer.will have predictable consequences. For ex- • If a transfer of care is ethically indicated, take

appropriate steps to facilitate the patient’sample, in the first session following a pa-smooth transition to a new mental health profes-tient’s alcohol-induced, impulsive suicide at-sional.tempt, the therapist may state that, “If you

• In light of the suicide attempt, clarify and/orcall me while inebriated and suicidal, I willmodify the ground rules for continued therapycall the police first, and talk to you second.”with the patient.When taking such a stance, it is advisable for

• Define the basic expectations for treatment ad-the therapist to adopt a nonpunitive tone and herence and discuss the patient’s and therapist’sto explain her or his therapeutic rationale mutual and distinct responsibilities in psycho-with equanimity. therapy.

An overview of ground rules should • Communicate these guidelines in a positive, col-also include a review of procedures for han- laborative manner.dling cancellations, missed appointments,and unanswered or unreturned phone calls(e.g., in response to pre-arranged phone

cide attempt, the therapist might questioncheck-ins as a means of risk management).the patient’s ability or willingness to commitThe therapist can articulate expectations forto treatment, and to abstain from active sui-regular attendance, including the minimumcidality. At the same time, the patient mayrequirements for being considered “in treat-harbor doubts about whether the treatmentment,” and a patient’s responsibilities for col-in general or the therapist in particular canlaboration with treatment recommendations.be effective. Further, the patient may not be-Clinicians also reaffirm their commitment tolieve that the therapist truly wants to helpthe therapeutic process by highlighting (ver-(e.g., “You must hate me now”), and/or maybally, and documenting in the chart) theirassume that the therapist will recommendavailability for sessions, appropriate proce-hospitalization at the first hint of subsequentdures for between sessions and emergencysuicidality. These thoughts may greatly in-contacts, and realistic expectations for thehibit the patient’s willingness to be forth-length and outcome of therapy. (See Table 1coming.for a summary of clinical guidelines for re-

suming psychotherapy following a patient’sAddress the Issue of Therapeuticsuicide attempt.)Trust Directly

At the outset of the session in whichREBUILDING TRUSTthe therapist broaches the issue of reestab-lishing mutual trust following the patient’sOf course, the agreement to resume

treatment, even under renegotiated terms, suicide attempt, it is helpful if they respect-fully address the following questions: Whybrings to the forefront the issue of trust be-

tween the patient and the therapist. Based on did the patient attempt suicide, and why didshe or he not take the agreed-upon precau-the still fresh experience of the patient’s sui-


tionary steps, such as contacting the therapist “buttons” (e.g., schemas, see Young, 1999) inorder to avoid needlessly pressing them (andbeforehand? The therapist can lay the ground-

work for the discussion by acknowledging the it allows the therapist to recognize his or herown “buttons” related to suicide, e.g., Ruddsensitive nature of the topic, stating that it is

one to be dealt with in a collaborative spirit, & Joiner, 1997). A good case conceptualiza-tion allows the therapist to hypothesize theand expressing the hope that facing it will

allow the patient’s treatment to resume in a reasons for a patient’s suicide attempt in anonjudgmental, clinically astute manner.positive way. Introducing the session agenda

in this manner implicitly demonstrates that Consequently, chances are improved that thepatient will feel understood, will not feelthe therapist will neither deny nor shy away

from the topic of the patient’s suicide at- blamed or shamed, and will be willing tolevel with the therapist about future suicidaltempt.impulses before self-harming actions are taken.

For example, Arnie had been appar-Strive for a Better Understandingof Each Other’s Actions ently doing well in therapy, when he unex-

pectedly tried to asphyxiate himself in his ga-rage. Later, the therapist tried to understandWhen the therapist is committed to

the establishment and maintenance of a col- Arnie’s subjective experience leading up tothe suicide attempt so as to conceptualize thelaborative therapeutic relationship, adverse

events in therapy do not necessarily have to behavior, rather than simply assuming thatArnie had been blithely withholding infor-damage or end a productive course of treat-

ment. For example, circumstances involving mation about his level of risk. Arnie revealedthat his depression had been worseningmisinformation or resistance by the patient

can be treated as a clinical matter and, when steadily over the past few weeks, but “nobodyseemed to notice.” Indeed, a review of his re-handled sensitively and effectively, can bolster

therapeutic trust and bring about positive cent Beck Depression Inventory scores (BDI;Beck, Ward, Mendelson, Mock, & Erbaugh,change in the patient’s beliefs and behaviors

(Newman, 1994). Rather than rebuking the 1961) showed a steady worsening of symp-toms. Unfortunately, his presentation in ses-patient for counter-therapeutic self-destruc-

tive behavior, therapists can try to put the pa- sion—and to the world at large—remainedunchanged, and nobody noticed his decline.tient’s suicidality into the context of a revised

case conceptualization and a better under- The therapist was able to posit that Arnie wasstill ashamed to admit his depressed feelingsstanding of the patient’s unique experience of

and beliefs about suicide (e.g., Jobes, 2000; (something he had acknowledged earlier intreatment), but he hoped that others wouldRudd, 2000).

The case conceptualization is the inte- divine his condition unsolicited. When thisdid not happen, Arnie experienced the activa-grated understanding of the patient’s present-

ing problems, the relevant developmental tion of his schemas of unlovability and aban-donment (cf. Young, 1999), and went to thehistory explaining the etiology of the clinical

issues, and reasonable predictions of appro- extreme of attempting suicide to call atten-tion to the personal misery that “nobodypriate interventions and future functioning

(Beck, 1995; Persons, 1989). When facing cared to notice.” The therapist was also ableto own up to the fact that he had not madeproblematic points in therapy, the case con-

ceptualization is a useful tool for ferreting Arnie’s BDI scores a big issue in previous ses-sions, and perhaps this was an error. Thisout the issues underlying resistance, misper-

ceptions, and strong negative affect the pa- conceptualization was instructive and non-stigmatic, allowing the patient and therapisttient may have about therapy and the alli-

ance. It also allows the therapist to be aware to share responsibility for what had takenplace, and leading to a new agreement—theof and sensitive to the patient’s emotional


therapist would (from now on) always com- help suggestions won’t work for me becauseI’m defective” or “I can’t handle things onment on Arnie’s BDI scores, and Arnie would,

in turn, agree to reveal future suicidal ide- my own and only my therapist’s advice canhelp me”).ation verbally and preemptively.

Similarly, the therapist can go to ex- For example, in the first session afterbeing discharged from the hospital aftertended lengths to help his or her patients get

a better conceptualization of the therapist’s making an impulsive suicide attempt, one ofour patients said that the activating event forbehavior, feelings, and thoughts pertinent to

the suicidal crisis. To this end, the therapist his attempt had been reading a flyer announ-cing a luncheon held at the therapist’s clinic,can use judicious self-disclosure pertinent to

her or his clinical decision-making and emo- sponsored by a pharmaceutical company.The therapist gently and persistently in-tional reaction to the suicide attempt. The

goals are to improve the patient’s under- quired about the meaning of the luncheonfor the patient. What slowly unfurled was astanding of the therapist’s intentions, and

perhaps to provide crucial feedback about the series of mistrustful interpretations and be-liefs that culminated in the patient’s judg-effects of the patient’s suicidal behavior on

others. While doing so, the therapist can ment that, “My therapist is a puppet of thepharmaceutical industry who will eventuallymaintain an empathic stance regarding the

patient’s thoughts and feelings, while still giv- refer me for medication management only.He does not care about me and he cannot being frank, straightforward feedback.

For example, following Arnie’s return trusted.” The upshot of the session was thatthe patient had felt abandoned by previousto treatment, his therapist acknowledged that

he was now more wary—perhaps even fright- helping professionals and felt particularlyvulnerable, even as he had been makingened—about the patient’s condition. He ex-

plained how unsettling it was not to be able progress in therapy and was developing trustin the therapist. The conceptualization of theto fully trust Arnie’s condition at face value.

As the therapist noted, “I would much rather patient’s beliefs (i.e., schemas) about vulnera-bility, abandonment, and mistrust (and theirhave a solid, unshakeable confidence in your

ongoing recovery from depression than cast relation to suicidal thoughts) set the stage forthese themes to be the thrust of subsequenta suspicious eye about how you’re really do-

ing at every appointment, but that may be sessions.In other cases, however, there may bethe safest way to proceed, at least until you

feel comfortable enough to wear your true stronger negative affect directed by the pa-tient toward the therapist (e.g., “You don’temotions and intentions on your sleeve.”

Some patients readily express their seem to have a clue as to how to help me”),either explicitly or implicitly. The therapistopinions about the treatment relationship,

the therapy process, and factors contributing may have to draw on strong empathic listen-ing and communication skills to handle criti-to the recent suicide attempt. These factors

can often be understood as mistrust of self- cal feedback or outright expressions of anger.In yet other cases, the therapist may have tohelp techniques (e.g., “I just knew that calling

up a friend or writing out my thoughts would be sensitive to contradictions or nonverbalcommunication that might suggest ambiva-not have made any difference”) or mistrust of

therapy support (e.g., “I did not page the on- lence or outright hostility toward the thera-pist. Finally, the therapist would do well tocall therapist because I did not want to talk

with someone who does not know me”). Re- bear in mind that patients may feel easilyashamed in such situations, thus, it is impor-inforcing the importance of making use of

available therapeutic resources and exploring tant to communicate in a way that allows thepatient to “save face.” (See Table 2 for a sum-the source of mistrust might reveal deeper

beliefs that could affect therapy (e.g., “Self- mary of clinical guidelines for addressing the


TABLE 2 coping skills. The revised case conceptualiza-tion also can highlight the changes in the pa-Clinical Guidelines for Addressing the Issue

of Trust in Psychotherapy After a Patient’s tient’s belief system that need to be made inorder to reduce the risk for future suicideSuicide Attempt(e.g., “Even if I cannot reach my therapist in

• Explicitly discuss the issue of trust in therapy a crisis, I have the skills to manage it, andduring a session following the patient’s suicide to wait safely until tomorrow’s session”). Theattempt. therapist can encourage the patient to make• Set the stage for discussing trust issues by ac-

a fresh start in therapy, utilizing past prob-knowledging it may be a difficult topic to ex-lems in therapy as useful learning experi-plore.ences, and the therapist and patient can move• Share and elicit feedback from the patient aboutforward with renewed energy and hope.his/her views of the therapeutic alliance.

• Maintain a nondefensive tone when dealing withthe patient’s expressions of mistrust and general Deconstructing the Suicide Attemptnegative feedback.

• To increase understanding, revise the case con- The recent suicide attempt offers anceptualization by incorporating clinical data aris- opportunity to explore the patient’s expecta-ing from the most recent suicide attempt. tions for what his or her completed suicide

• Explain the clinical rationale for the therapist’s would have achieved. The patient’s responsesactions prior to, during, and after the patient’soften are along the lines of “I wanted to es-emergency.cape my problems,” “I wanted people to see• Reframe patient’s mistrustful interpretations ofhow sorry they would be when I was gone,”the above.or “I wanted to make the pain stop.” The• Regularly monitor the status of the therapeutic

alliance. therapist and patient can reframe the pa-tient’s expectations into therapeutic goalssuch as, “I want to solve some of my prob-lems,” “I want to have better relationships

issue of trust in psychotherapy following a with others,” and “I want to feel better.” Al-patient’s suicide attempt.) ternative strategies that do not require the

extreme behavior of suicide can be fashionedfor obtaining such ends. What’s more, the re-

REFORMULATING alization that the actual outcome of suicideTHE TREATMENT PLAN would not necessarily bring about the pa-

tient’s desired results creates cognitive disso-nance that might weaken a suicidal impulsePart of the process of resuming a pro-

ductive course of therapy involves spelling (Ellis & Newman, 1996; Freeman & Rein-ecke, 1993).out a revised treatment plan, updated in light

of the suicide attempt and its signal that Such explorations of the patient’s be-liefs set the tone for subsequent clinical in-something more and/or different is needed in

therapy. The new treatment plan should terventions (e.g., Jobes, 2000; Rudd, 2000).The stressful life circumstances the patientmake overt use of the revised case conceptu-

alization, demonstrating how the suicide at- faces can be acknowledged, but the patient’sinference that “my problems are too over-tempt could be accounted for by the patient’s

unique psychological vulnerabilities. Further, whelming for me to handle” can be gentlyquestioned. Simply listing out the distinctit can include interventions that will most

likely help the patient make the changes that problems the patient faces can help to decat-astrophize them, as each problem can beare most needed, such as increasing self-effi-

cacy, hopefulness, trust in benevolent others, framed in specific behavioral terms (coupledwith coping options) rather than as a general-and a willingness to invest in the learning of


ization. For example, there is a palpable dif- invested in supporting the patient’s well-being. It is clinically advantageous to elicitference between “I’m on the verge of losing

my job and going broke” and “My boss their support, as they may be more likely tobe on the scene to help the patient during aseemed concerned about the amount of time

I took off from work (for my hospitalization) crisis. Therapists can encourage patients toprovide written consent to involve such per-and I don’t know what to tell him because

I’m afraid he’ll fire me.” sons in their treatment, with specific parame-ters collaboratively negotiated in session.The patient’s reasons for dying are of-

ten cognitively well rehearsed. The interven- The participation of the patient’s significantothers provides another source of observa-tion of formulating reasons for living may

modify hopeless attitudes and be a protective tional data about the patient’s functioningand follow-through on therapeutic recom-factor against further suicidal acts (Ellis &

Newman, 1996; Linehan, Goodstein, Niel- mendations. As we try to make clear to pa-tients, identifying the need for and request-sen, & Chiles, 1983; Malone et al., 2000). In

addition to the assessment and therapeutic ing appropriate assistance are adaptive copingskills in line with the goals of therapy.benefits of compiling such a list (e.g., Jobes

& Mann, 1999), patients should be encour- The inclusion of significant others inthe treatment team might be a suggestionaged to maintain a copy of it for reference

as a coping strategy when they encounter a welcomed by the patient; however, it is im-portant to be mindful of the patient’s rela-recurrence of suicidal thoughts and hopeless-

ness about the future. tionship with her or his support system andto determine whether the members’ partici-pation would indeed support the patient’sExpanding the Treatment Teamwell-being or would, instead, jeopardize it. Insome cases, the patient’s experience of theThe reworking of the treatment plan

may well reveal that outpatient psychother- family involves memories of abuse or otherdysfunctional behaviors from which the pa-apy alone is insufficient to help the patient

achieve his or her treatment objectives; addi- tient is trying to gain distance. It is importantto thoroughly explore the pros and cons fortional professional services may be needed.

The treatment team approach is prudent including specific individuals in treatmentand to proceed with this plan only with theclinical practice when the patient has diverse

clinical needs, each requiring specialized at- patient’s explicit permission (short of an emer-gency).tention (Bongar, 2002). If the patient has not

already been assessed for medications, a psy- The appropriate role of a willing sup-port person needs to be clearly delineated. Aschiatric referral may be indicated. There may

be other therapeutic services such as group the goal for treatment is to help the patientdevelop skills for handling his or her life andtherapy, day hospital programs, case manage-

ment, vocational rehabilitation, and 12-step emotions, it would be counter-therapeutic ifthe patient continues to expect that othersprograms that help spread out the clinical re-

sponsibilities and provide appropriate com- will be responsible for his or her behavior.The scope of the support person’s involve-prehensive care. Maintaining open lines of

communication among these professionals ment (e.g., frequency of sessions attended,duration of participation) can be negotiatedfurther promotes the sense of teamwork and

collaboration, and reflects good risk manage- with the help of the patient. In the absenceof an acute crisis, patients determine howment.

Another potential source of aid comes much of their clinical information should beopenly disclosed to the support persons, asfrom members of the patient’s personal sup-

port system. These individuals may have fre- the latter do not have carte blanche access toconfidential data without the patients’ explicitquent contact with the patient and may be


permission. At the same time, it may be em- guidelines for reformulating a treatment planfollowing a patient’s suicide attempt.)phasized that it can be advantageous to treat-

ment if patients’ important others provide in-formation pertinent to their care, such as thepatient’s level of functioning between ses- FUTURE DIRECTIONSsions and medication compliance.

By including significant others into the Researching the role of the therapeuticalliance after a patient’s attempt suffers all theteam, clinicians help to engender the good

will sense that “we are all in this together.” challenges of suicidological research in gen-eral: suicidal behavior has a relatively lowThe patient’s important others get the op-

portunity to see the therapist as a real person base rate, is difficult to predict and, conse-quently, much research is conducted onlywho is acting professionally and who is sin-

cerely trying to help. Such a scenario is far after the attempted or completed suicide.The first step in this area of research wouldmore favorable than when the patients’ fam-

ily members view the therapist as an anony- be to collect data regarding the frequencywith which suicide attempters resume ther-mous figure, knowledge of whom is gained

only via the patient’s report (e.g., Bongar, apy with the same therapists. Surveys of prac-ticing clinicians and of suicide attempters2002). The notion of teamwork notwith-

standing, it should be documented in the would yield more precise epidemiologicaldata regarding the occurrence of suicide at-clinical record and made explicitly clear dur-

ing a session and in the presence of other tempts in the course of active psychotherapy.To gather data on the prophylactic ef-available treatment team members, particu-

larly support persons, that the patient is ulti- fects of the therapeutic alliance on suicidalbehavior would require ongoing assessmentmately responsible for using the therapeutic

supports and following through on treatment of relationship factors and risk factors for sui-cide throughout treatment, such as usingrecommendations (e.g., Ellis & Newman,

1996). (See Table 3 for a summary of clinical both patient and therapist assessments of thealliance and their correlation with suicidalsymptoms. Even more useful would be tohave these sessions recorded (video and/oraudio) to allow for the assessment (via codingTABLE 3by raters) of crucial factors affecting theClinical Guidelines for Reformulating a Treatmenttreatment alliance. Clinical trials for de-Plan After a Patient’s Suicide Attemptpressed and/or suicidal patients can readily

• Use the revised case conceptualization to update incorporate these measurements. Data of thisthe treatment and safety plans. sort would allow researchers to (1) compare

• Review the events leading up to the suicide at- patients who attempt suicide during thetempt for lessons to be learned that could in- course of treatment with those patients whoform ongoing clinical safeguards and interven- do not on measures of the treatment alliance;tions.

and (2) determine relationship factors, if any,• Review the effects of the suicide attempt on thethat differentially predict a patient’s responsepatient’s subjective reasons for living and dying.to the resumption of therapy with the same• Identify the residual problems the patient is fac-therapist after an attempt.ing after the suicide attempt and use a problem-

solving approach to address them. The aim of this paper has been to pro-• Consider the additional therapeutic and support vide clinically useful guidelines for resumingservices that might be required to promote the psychotherapy with a patient who has at-patient’s safety and improved functioning. tempted suicide during the course of treat-

• Coordinate efforts with the other members of ment. Although this aspect of psychotherapythe treatment team, ideally with the full partici- has received little attention in the literature,pation of the patient. it is one that appears highly relevant for


many practicing clinicians. We have outlined tention to these matters will help clinicianseffectively face the stressful proposition ofclinical strategies pertinent to resuming treat-

ment, reestablishing a sense of mutual trust resuming therapy with patients who have re-cently made a serious suicide attempt, and toin the therapeutic relationship, and reformu-

lating the treatment plan. We hope that at- reduce the risks for both parties.

REFERENCES

American Psychiatric Association. (2003). G., Torigoe, R. Y., & Kinney, B. (1988). Patientsuicide: Frequency and impact on psychologists.Practice guideline for the assessment and treat-

ment of patients with suicidal behaviors. American Professional Psychology: Research and Practice, 19,416–420.Journal of Psychiatry, 160(Suppl.), 1–117.

Beck, J. S. (1995). Cognitive therapy: Basics Chiles, J. A., & Strosahl, K. (1995). Thesuicidal patient: Principles of assessment, treatment,and beyond. New York: Guilford.

Beck, A. T., Rush, A. J., Shaw, B. F., & and case management. Washington, DC: AmericanPsychiatric Press.Emery, G. (1979). Cognitive therapy of depression.

New York: Guilford. Crosby, A. E., Cheltenham, M. P., &Sacks, J. J. (1999). Incidence of suicidal ideationBeck, A. T., Ward, C. H., Mendelson,

M.,Mock, J., & Erbaugh, J. (1961). An inventory and behavior in the United States, 1994. Suicideand Life-Threatening Behavior, 29, 131–140.for measuring depression. Archives of General Psy-

chiatry, 4, 561–571. Dahlsgaard, K. K., Beck, A. T., &Brown, G. K. (1998). Inadequate response toBongar, B. (Ed.). (1992). Suicide: Guidelines

for assessment, management & treatment. New York: therapy as a predictor of suicide. Suicide and Life-Threatening Behavior, 28, 197–204.Oxford University Press.

Bongar, B. (2002). The suicidal patient: Ellis, T. E. (1986). Toward a cognitivetherapy for suicidal individuals. Professional Psy-Clinical and legal standards of care (2nd ed.). Wash-

ington, DC: American Psychological Association. chology: Research and Practice, 17, 125–130.Ellis, T. E., & Newman, C. F. (1996).Bongar, B., Maris, R.W., Berman, A. L.,

& Litman, R. E. (1992). Outpatient standards of Choosing to live: How to defeat suicide through cogni-tive therapy. Oakland, CA: New Harbinger.care and the suicidal patient. Suicide and Life-

Threatening Behavior, 22, 453–478. Freeman, A., & Reinecke, M. (1993). Cog-nitive therapy of suicidal behavior. New York: Springer.Bongar, B., Maris, R.W., Berman, A. L.,

& Litman, R. E. (1998). Outpatient standards of Hendin, H., Lipschitz, A., Maltsberger,J. T., Haas, A. P., & Whynecoop, S. (2000).care and the suicidal patient. In B. Bongar, A. L.

Berman, R. W. Maris, M. M. Silverman, E. A. Therapists’ reactions to patient suicides. AmericanJournal of Psychiatry, 157, 2022–2027.Harris, & W. L. Packman (Eds.), Risk management

with suicidal patients (pp. 4–33). New York: Guil- Holley, H. L., Fick, G., & Love, E. J.(1998). Suicide following an inpatient hospitaliza-ford.

Bongar, B., Maris, R.W., Berman, A. L., tion for a suicide attempt: A Canadian follow-upstudy. Social Psychiatry and Psychiatric Epidemiology,Litman, R. E., & Silverman,M.M. (1993). Inpa-

tient standards of care and the suicidal patient. 33, 543–551.Hoyert, D. L., Kochanek, K. D., &Mur-Part I: General clinical formulations and legal

considerations. Suicide and Life-Threatening Behav- phy, S. L. (1999). Deaths: Final data for 1997. Na-tional Vital Statistics Report, 47. Hyattsville, MD:ior, 23, 245–256.

Bostwick, J. M., & Pankratz, V. S. National Center for Health Statistics.Isometsa, E. T., & Lonnqvist, J. K.(2000). Affective disorders and suicide risk: A re-

examination. American Journal of Psychiatry, 157, (1999). Suicide attempts preceding completed sui-cide. British Journal of Psychiatry, 173, 531–535.1925–1932.

Brown, H. N. (1987). The impact of sui- Jacobs, D. G. (Ed.). (1999). The Harvardmedical school guide to suicide assessment and interven-cides on therapists in training. Comprehensive Psy-

chiatry, 28(2), 101–112. tion. San Francisco: Jossey-Bass.Jamison, K. R. (1999). Night falls fast: Un-Chemtob, C. M., Bauer, G. B., Hamada,

R. S., Pelowski, S. R., &Muraoka,M. Y. (1989). derstanding suicide. New York: Knopf.Jobes, D. A. (2000). Collaborating to pre-Patient suicide: Occupational hazard for psycholo-

gists and psychiatrists. Professional Psychology: Re- vent suicide: A clinical-research perspective. Sui-cide and Life-Threatening Behavior, 30, 8–17.search and Practice, 20, 294–300.

Chemtob, C. M., Hamada, R. S., Bauer, Jobes, D. A., &Maltsberger, J. T. (1995).


The hazards of treating suicidal patients. In M. Newman, C. F. (1994). Understanding cli-Sussman (Ed.), A perilous calling: The hazards of ent resistance: Methods for enhancing motivationpsychotherapy practice (pp. 200–214). New York: to change. Cognitive and Behavioral Practice, 1, 47–69.Wiley. Persons, J. B. (1989). Cognitive therapy in

Jobes, D. A., & Mann, R. E. (1999). Rea- practice: A case formulation approach. New York:sons for living versus reasons for dying: Examin- Norton.ing the internal debate of suicide. Suicide and Life- Rudd, M. D. (2000). The suicidal mode:Threatening Behavior, 29, 97–104. A cognitive-behavioral model of suicidality. Suicide

Kleespies, P. M., & Dettmer, E. L. and Life-Threatening Behavior, 30, 18–33.(2000). The stress of patient emergencies for the Rudd, M. D., & Joiner, T. (1997). Coun-clinician: Incidence, impact, and means of coping. tertransference and the therapeutic relationship: AJournal of Clinical Psychology, 56, 1353–1369. cognitive perspective. Journal of Cognitive Psycho-

Kleespies, P.M., Smith,M. R., & Becker, therapy: An International Quarterly, 11, 231–250.B. R. (1990). Psychology interns as patient suicide Rudd, M. D., Joiner, T., & Rajab, M. H.survivors: Incidence, impact, and recovery. Profes- (2001). Treating suicidal behavior: An effective, time-sional Psychology: Research and Practice, 21, 257–263. limited approach. New York: Guilford.

Linehan, M. M., Goodstein, J. L., Niel- Silverman, M. M., Berman, A. L.,sen, S. L., & Chiles, J. A. (1983). Reasons for Bongar, B., Litman, R. E., & Maris, R. W.staying alive when you are thinking of killing (1994). Inpatient standards of care and the suicidalyourself: The reasons for living inventory. Journal patient. Part II: An integration with clinical riskof Consulting and Clinical Psychology, 51, 276–286. management. Suicide and Life-Threatening Behav-

Malone, K. M., Oquendo, M. A., Haas, ior, 24, 152–169.G. L., Ellis, S. P., Shuhua, L., & Mann, J. J. Suominen, K. H., Isometsa, E. T., Hen-(2000). Protective factors against suicidal acts in riksson, M. M., Ostamo, A. I., & Lonnqvist,major depression: Reasons for living. American J. K. (1998). Inadequate treatment for major de-Journal of Psychiatry, 157, 1084–1088. pression both before and after attempted suicide.

Maltsberger, J. T., & Buie, D. H. (1974). American Journal of Psychiatry, 155, 1778–1780.Countertransference hate in the treatment of sui- Thompson, A. (1990). Guide to ethical prac-cidal patients. Archives of General Psychiatry, 30, tice in psychotherapy. New York: Wiley Intersci-625–633. ence.

Maris, R. W., Berman, A. L., & Silver- Young, J. E. (1999). Cognitive therapy forman, M. M. (Eds.). (2000). Comprehensive textbook personality disorders: A schema-focused approach (3rdof suicidology. New York: Guilford. ed.). Sarasota, FL: Professional Resource Press.

Moscicki, E. K. (1999). Epidemiology ofsuicide. In D. G. Jacobs (Ed.), The Harvard medical

Manuscript Received: November 7, 2003school guide to suicide assessment and intervention (pp.40–51). San Francisco: Jossey-Bass. Revision Accepted: December 20, 2004

despues del intento

Documents