Practice recommendations for suicidal patients

Working with suicidal patients is often diffi cult and psychologically draining.
More often than not the clinician is working at two levels at once. Suicidal
patients almost always have an underlying psychological or psychiatric disorder
which fi nds expression in suicidal behavior. Hence the clinician must
treat the underlying emotional, cognitive, or perceptual dysfunction. At the
same time, the clinician must monitor and address self-destructive thoughts
and behaviors while working with a patient who may not share the goal of
getting better, or even remaining alive. It’s important to acknowledge and
monitor one’s countertransference when working with acutely or chronically
suicidal patients (Maltsberger & Buie, 1974). It’s also important to assess if
one possesses the skills and temperament to work with these individuals.
If not, one should sensitively arrange for a suicidal student to be followed by
a more suitable clinician. At the very least, clinicians working with suicidal
cases should regularly seek consultation, supervision and support from other
clinicians. There is no place for complacency when working with self-destructive
patients.
Another issue is the false reassurance provided by suicide or safety “contracts.”
Although I can support the value of such contracts on occasion, their
effectiveness is possible only within the context of a strong therapeutic relationship
and overall safety plan, including such key components as a crisis
intervention plan (Berman et al., 2006). In the absence of a good therapeutic
relationship and overall safety plan, a suicide contract is of limited usefulness
or is worthless and may even be potentially damaging in legal cases.
Rudd et al.’s (1999) review of the treatment literature provides a useful
set of practice recommendations that make intuitive and clinical sense. For example, the clinician should provide information pertaining to the limits
of confi dentiality in relation to clear and imminent suicide risk, and offer a
detailed review of available treatment options. The clinician should routinely
monitor, assess, and document a patient’s initial and ongoing suicide risk,
and document interventions for maintaining outpatient safety until suicidality
has clinically resolved.
It is important to ensure the appropriate standard of care to students seeking
psychological help (Bongar, 2002; Bongar et al., 1998). Key to the appropriate
care of at-risk students is full documentation, frequent consultation with
clinical and administrative peers, and adherence to established college policies
and protocols—for example, regarding parental notifi cation or required
evaluations for returning to a residence hall following a hospitalization.