Implicancias del estudio

A major part of the formula for success with the repetitiously suicidal patient is to develop an effective approach to ongoing self-destructive behavior. To ac-complish this task, you must effectively manage how adjunctive and ancillary services are delivered to your patient. In working with the chronically suicidal patient you often wear many hats: clinician, case manager, advocate, and care coordinator. The more you plan these roles, the less likely there is to be con-fusion and a critical change of course during a crisis.

The Therapeutic Management of Chronic Crisis

A well-known feature of repetitiously suicidal patients is the capacity to slip in and out of crisis: the crisis-of-the-week syndrome. With some regularity,

you are presented with a crisis by the patient that invites diversion from the treatment plan. These crises often occur in association with suicidal or self-destructive behavior. To some extent, these crises are the hallmark of the early phase of treatment. You need to assimilate these events into the flow of therapy without losing continuity or placing yourself and your patient in a confrontational or adversarial position.

Many of the important components of a behaviorally based crisis man-agement protocol are discussed in Chapter 7 (“Managing Suicidal Emergen-cies”). The repetitious suicide attempter requires special attention to and stringent application of these principles. The reason is simple. You are going to be confronted with more suicidal behavior, and you need to have a very potent yet flexible plan of attack. The issue of the patient’s engaging in sui-cidal behavior or experiencing severe crisis needs to be addressed at the outset of treatment. You need to be able to predict these events. You need to make very clear your particular stance with respect to intervening in suicidal behav-ior. The ground rules about after-hours phone contact and scheduling extra sessions in relation to suicidal behavior must be clear and mutually accept-able. You must work together to develop a crisis card so your patient can be-gin learning to activate natural social supports. Encourage your patient to make therapeutic contacts before engaging in any self-destructive behavior.

Create a structure in which you and your patient can effectively deal with the chaos and distress that often go along with suicidal behavior. The structure allows you both to hark back to earlier agreements as a guide to managing your way through these difficult times.

A well-prepared crisis protocol will answer nearly all the questions in ad-vance. The existence of the protocol creates a higher level of comfort in the midst of suicidal behavior and generally promotes healthy interventions. The patient who is scared but locked-in on suicidal behavior is drawn to a calm and purposeful clinician. An effective crisis plan can provide an experiential demonstration that selecting alternatives to uncontrolled self-destructive be-havior can be rewarding. Assimilation of crisis is a major case management strategy. Many events that trigger suicidal crises in the chronically suicidal pa-tient are small in scale and are better thought of as the straw that broke the camel’s back. If the suicidal response is taken off center stage, the patient may discover straightforward and effective ways of solving the specific event.

When the suicidal behavior itself becomes the focus of attention, then it is

very difficult to solve primary problems—the problems that have pushed sui-cidality to the forefront.

Beware of Magical Assumptions

The clinician often communicates overtly or covertly an expectation that the patient’s suicidal and self-destructive behavior will either disappear or rapidly diminish as a simple consequence of entering treatment. In this scenario, it is assumed that the “magic” of therapy will immediately effect a change in the patient’s suicidal behavior independent of the therapeutic approach. Conse-quently, a recurrence of suicidal behavior is viewed as a signal that treatment is failing. Negative therapeutic processes can result from this error (e.g., resis-tance interpretations, anger and confrontation, and ultimatums). The major philosophical cornerstone of effective case management is to use the suicidal crisis as an opportunity to promote growth in the patient. It is easy for the clinician’s patience to wear thin when the covert expectation of decreased sui-cidal behavior is continually being violated. The act of planning and fre-quently reaffirming the crisis management plan in collaboration with the patient will help neutralize this potentially destructive dynamic.

Case Management in the Community

Case management activity is an essential ingredient of effective treatment of chronically suicidal patients. It is important to conduct case management at key points of contact, particularly with emergency department providers, who may not have the necessary clinical skills to independently implement an effectual treatment response to a repetitiously suicidal patient. Because sui-cidal behavior is potentially life threatening and raises legal liability issues, it is imperative that your case management plan be as specific and concrete as possible. For example, most emergency departments have rotating shifts of personnel, which means that the repetitious suicide attempter may not see the same medical provider despite repeated contacts. The case management plan needs to transfer easily from one shift to another. Thus it must be written in the patient’s chart in concise and concrete language. The plan should identify who the patient is, the nature of the patient’s suicidal behavior, a rationale for the management plan, and the specific steps providers are to take in the event that they come into contact with the patient after a suicide attempt.

Figure 6–1 presents a sample emergency department case management plan for a repetitious drug overdose patient. The goal of the management plan is to limit psychotherapeutic interaction with the patient after an index sui-cide attempt, in that such interaction is a powerful reinforcement of suicidal behavior. Conversely, more attention, caring, and support are made available if the patient presents to the emergency department before engaging in the self-destructive behavior. The most difficult part of forming such plans is to get health care providers to understand the rationale for, and importance of, stabilizing and then discharging a repetitious attempter after an index epi-sode. This idea is both new and scary to most health and mental health pro-fessionals, who often believe this approach flies in the face of risk manage-ment rules. The tendency is to hold the patient until manage-mental health personnel eliminate all suicidal ideation or secure a no-suicide contract and then to dis-charge the patient. This method results in a tremendous amount of interper-sonal attention, which can promote a positive view of suicidal behavior in your patient.

Case management plans frequently require repeated contacts with both medical and mental health personnel at key contact sites. The need for re-peated contact is especially prominent when the patient tests the case man-agement plan by increasing suicidal behavior and presentations for care.

Providers become uncertain and worried about legal liability. In such cases, it is important to teach providers about the learning theory concepts of extinc-tion and spontaneous recovery. Extincextinc-tion means that when suicidal behavior is neither positively nor negatively reinforced, it will gradually decrease in fre-quency. However, well-learned behaviors undergoing extinction can sponta-neously reappear at an even higher frequency for short periods. Suicide attempting may initially increase but will gradually decrease as the extinction plan is consistently followed.

When spontaneous recovery occurs with a suicidal patient, medical or men-tal health personnel often are caught off guard. Spontaneous recovery is a crit-ical point in determining the overall integrity of the case management plan.

The more participating providers know what to expect in terms of the suicidal patient, the easier it is to draw attention to the fact that predicted events are occurring. This approach provides the reassurance needed for providers to drop their own biases about how to treat suicidal patients and can allay risk management concerns.

Someone Has to Be in Charge

A final critical feature of effective case management is identification of a single provider who makes the final decision about the patient’s care. This individ-ual also handles all psychotherapeutic transactions with the patient. This in-dividual ordinarily is the patient’s primary therapist. The goal of all such funneling actions is to restrain providers at other contact points from deliver-ing uncoordinated treatment—often treatment that is incompatible with the approach being followed by the primary therapist. This aspect of treatment is especially critical when a behavioral model is being followed and when rein-Figure 6–1. Management protocol for S.L., a repetitious drug overdose patient.

TO: MSWs, RNs, MDs, Consulting RNs, Medical Clinics, Emergency Centers

RE: Protocol for S.L.

As most of you know, S.L. has made multiple medication overdoses. None of these attempts have been lethal, few have been serious. We are trying to modify her behavior without reinforcing it and without teaching her to be more lethal. We request that when she presents to you with an overdose, you respond in the following manner:

1. Assess medical danger.

2. Treat her medically, as necessary.

3. Provide S.L. with a meal, but otherwise limit interaction to the bare minimum. Provide no positive or negative feedback. No punishments, no lectures. Your contact with S.L. should be a noninteractive event.

4. Send S.L. home after treatment and a meal.

5. All therapeutic interactions are to be with N.S., S.L.’s primary therapist only.

For further concerns or questions, please contact N.S. If N.S. is not available, contact O.S., the clinical backup in this case.

Thank you for your help with this difficult client.

forcements of the suicidal behavior are the all-important issue. In return for keeping interventions within set boundaries, the primary therapist needs to respond promptly to requests for help by participants in the case management plan. If the primary therapist is going on vacation, other members of the case management network need to be aware of the absence so they do not expect help that cannot be delivered. Case management plans often fall apart during a therapist’s absence, insofar as the patient may interpret the therapist’s depar-ture as a form of abandonment and go into crisis.

When the various treatment entities properly funnel decisions to the pri-mary clinician, the clinician is able to extend a wider umbrella of protection for the patient if the patient complies with the behavioral treatment plan. In other words, you can control the reinforcements offered at a wider variety of contact points (i.e., hospital emergency departments, primary care clinics, and community mental health center emergency teams). When the system works, the patient does not have two sets of response rules applied with regard to suicidal potential. This plan allows the clinician and patient to work with a consistent crisis management model.

To Hospitalize or Not to Hospitalize?

Many suicide attempters admitted to an inpatient psychiatric facility have a history of at least one previous suicide attempt. As “dangerousness to self ” in-creasingly becomes a reason for hospitalization, inpatient staff may feel that they are dealing with a revolving door filled with repetitious suicide attempt-ers. These admissions raise the question of how hospitalization should or can support the treatment process for the repetitious patient. Of all the subpop-ulations of suicidal patients, this one is probably the most difficult to deal with effectively during an inpatient admission. The patient is often not well liked by hospital staff and tends to be at disproportionate risk of a discharge against medical advice. The patient may be given the diagnosis of borderline personality disorder before the first intake interview, because repetitious sui-cidal behavior itself is strongly related to such a diagnosis. In the era of man-aged health care, few inpatient units can offer the long-term treatment programs that even begin to address the many cognitive and emotional needs of a multiproblem patient with borderline personality disorder.

An equally important consideration is that the repetitiously suicidal

pa-tient is often dumped into the inpapa-tient system by a frustrated clinician who just wants the patient to go away. When we talk about a therapist “cracking”

in the moment of truth, this type of dumping is one of the cardinal manifes-tations. The clinician is tired of the patient and hands over care to an inpa-tient staff that then may be negatively disposed toward the painpa-tient because of the dump and the out-of-control gestalt that develops around poor planning.

Consequently, the suicidal patient can evoke a high level of hostility and con-frontation during even a brief hospital stay. This patient may well receive less preferred and less intensive forms of treatment available on the unit. The pa-tient may be given a medication regimen that has little chance of succeeding.

Diagnostic and treatment disputes often erupt between treatment team mem-bers (i.e., “splitting”) and are blamed on the patient rather than on the real culprits: interpersonal conflicts, disciplinary jealousies, and turf struggles among members of the treatment team.

Even when none of the negative consequences occurs, consider also the possible reinforcing effects of the hospitalization per se on the individual’s sui-cidal problem-solving potential. The patient is removed from a stressful envi-ronment and is exposed to a highly structured setting in which all basic needs are met. Positive caring and attention are forthcoming from the unit staff.

The individual feels looked after and supported because of the suicidality, and, accordingly, the behavior is reinforced. In all, hospitalization potentially offers negative and positive reinforcement scenarios. Given the frequent use of hospitalization for suicidal persons, this reinforcement may be a factor in the relatively high risk of suicidal behavior in the United States.

There are certainly circumstances in which a patient is bound and deter-mined to land in some type of intensive care facility. The clinician cannot ig-nore this possibility in effective treatment planning. It is therefore critical to attempt to develop alternatives to traditional inpatient treatment in the event the patient ends up in that part of the treatment system. This plan may in-volve contracting with a local hospital to allow the patient to elect a 72-hour voluntary time-out with an automatic prearranged discharge plan. If the local community has an acute care crisis facility, the patient can be directed to seek admission to that facility with prearranged, short-term problem-solving goals.

Your goal is to eliminate the reinforcement potential from any intensified treatment and, as soon as possible, get the patient back into the natural envi-ronment and in the right mind-set to solve problems.

Continuity in case management is particularly critical during the transi-tion between inpatient and outpatient mental health treatment. When a sui-cidal outpatient enters a psychiatric hospital in the context of a suicide attempt, there is an even greater need to coordinate in a way that supports the basic outpatient treatment plan. The reason is simple: Psychiatric units can deliver an enormous array of services in a very condensed time. If these ser-vices are not synchronized with the outpatient treatment regimen, long-term treatment can suffer. Psychiatric inpatient staffs have their own way of dealing with suicidal patients and often do not coordinate with the outpatient system.

Coordination usually occurs at the initiative of the primary therapist. Because the very act of admission to a hospital is a potent reinforcement of suicidal behavior, the primary therapist must make efforts to arrange for appropriate treatment at likely inpatient sites.

It is important to provide a sound rationale to attending psychiatrists to gain support for a treatment plan that may be different from the usual milieu plan of the unit. For example, if the plan calls for automatic discharge within 48–72 hours and a minimum of psychotherapeutic contact, the responsible physicians need to understand why that is the best way to care for the patient.

The primary therapist needs to initiate the dialogue about how best to coor-dinate the interface between outpatient and inpatient care. There are myriad reasons why this type of coordination and planning may not happen, and it is sometimes particularly difficult to effectively work together with the repe-titiously suicidal patient. To deal with coordination of care, try to establish a consistency of purpose with at least one inpatient psychiatric site, and direct the patient to that site in the event of a suicidal crisis. Discourage admissions to hospitals where the staff seems unwilling or unable to coordinate care. Hos-pitalizations are helpful when they reinforce your long-term strategy, but they are harmful when they subvert it. In Chapter 8 (“Hospitals and Suicidal Be-havior”) we discuss additional aspects of hospitalization and provide inpatient treatment techniques.

Helpful Hints

• The repetitiously suicidal patient differs in degree, not kind, from ep-isodic and more functional patients.

• The mechanisms of repetitious suicidal behavior are the dominance of ineffective rule-governed responses, emotional avoidance, lack of behavioral flexibility, and specific skill deficits.

• The goals of treatment of the repetitiously suicidal patient are the same as those in treatment of the acutely suicidal patient: teach ac-ceptance and tolerance of emotional pain and problem-solving skills.

• Building patterns of committed, valued action that are the antithesis of the suicidal lifestyle is the ultimate goal of treatment.

• With the repetitious patient, the therapist must reconcile polarities that develop over who is in control.

• Effective treatment avoids confrontations with the patient over a va-riety of issues related to ongoing suicidal behavior.

• The repetitiously suicidal patient typically needs ongoing intermittent crisis and supportive care because beliefs and behavior are very slow to change.

• In case management, it is important to establish an open, direct dia-logue with the patient about how suicidal behavior will be responded to in the course of therapy.

• Intersystem case management is a basic therapeutic function and re-quires collaboration with emergency departments, crisis units, and in-patient psychiatric units.

• In general, inpatient hospitalization is not helpful for the repetitious patient; consider using short-stay, acute care alternatives.

References

Kreitman N: Parasuicide. New York, Wiley, 1977

Liberman RP, Eckman T: Behavior therapy vs insight-oriented therapy for repeated suicide attempters. Arch Gen Psychiatry 38:1126–1130, 1981

Linehan MM, Armstrong HE, Suarez A, et al: Cognitive-behavioral treatment of chron-ically parasuicidal borderline patients. Arch Gen Psychiatry 48:1060–1064, 1991 Strosahl K, Chiles JA, Linehan M: Prediction of suicide intent in hospitalized parasui-cides: reasons for living, hopelessness, and depression. Compr Psychiatry 33:366–

373, 1992

Selected Readings

Beck A, Freeman A: Cognitive Therapy of Personality Disorders. New York, Guilford, 1990

Evans J, Williams JMG, O’Loughlin S, et al: Autobiographical memory and problem solving strategies of parasuicide patients. Psychol Med 22:399–405, 1992 Farmer RDT: The differences between those who repeat and those who do not, in The

Suicide Syndrome. Edited by Farmer R, Hirsch S. Cambridge, UK, Cambridge

Suicide Syndrome. Edited by Farmer R, Hirsch S. Cambridge, UK, Cambridge