The Prediction and Prevention of Suicide
Dr. Maor Katz, the founder of the Feeling Good Institute in Mt. View, California, asked if we’d do a show on the Prediction and Prevention of Suicide, so his staff could learn about the unique approach I have developed. Dr. Fabrice Nye and I were delighted to devote today’s show to this topic.
Suicidal thoughts and urges are very common among depressed patients. The vast majority of depressed individuals have thoughts of suicide from time to time, and some struggle with serious suicidal urges. The experts tell us that 10% to 15% of chronically depressed individuals do eventually commit suicide, even if they are receiving treatment for depression. It is hard for me to believe that suicide is that common, but even if it is only 2% or 3%, that’s still very significant, especially if you have a large clinical practice and you treat lots of depressed individuals.
Suicide attempts are shocking and devastating for the patient, for the family, and for the therapist as well. The loss of a patient through suicide is the dark side of our profession. The loss of life is a horrible and unnecessary tragedy, since the feelings of hopelessness that trigger suicidal urges are always the result of cognitive distortions; the belief that you are hopeless and cannot improve is never valid. Yet, the depressed patient does not realize this, and sometimes turns to suicide as the only way out of his or her suffering.
Sadly, clinicians’ capacity to assess suicidal urges in patients they are treating is very poor. In fact, in a research study I did, experts estimated how suicidal patients were feeling at the end of a several hour diagnostic interview at the Stanford Hospital. The patients recorded how suicidal they were actually feeling at the exact same time. Surprisingly, the patients’ and experts’ assessments were not significantly correlated. In other words, the experts accuracy in detecting suicidal fantasies and urges was zero. that’s one reason so many patients in treatment do commit suicide–because the therapist simply did not realize the patient was feeling that way.
In this podcast, I describe how you can solve this problem with the use of the EASY Diagnostic System and a systematic suicide interview, if needed, at the initial evaluation, and the use of the Brief Mood Survey at all subsequent sessions, with no exceptions.
In this podcast, I focus on two things. First, how can the clinician identify and evaluate a new (or old) patient who is struggling with suicidal thoughts and fantasies and determine if the patient is at risk for a suicide attempt? Second, how can the therapist make the patient accountable and guarantee that the patient will not now, or ever, make a suicide attempt?
The “defensive psychotherapy” I recommend will sound unfamiliar and maybe even shocking to many therapists but can save lives and make your practice far more peaceful and rewarding. The approach to the suicidal patient involves Paradoxical Agenda Setting techniques, including the Gentle Ultimatum, Sitting with Open Hands, and Fallback Position.
I hope you enjoyed today’s podcast on a very serious topic!
Therapy 101 for clinicians with no empathetic skills! Apparently only a sociopathic-like approach can out manouver patients with Borderline Personality Disorders.
Hi ron, I didn’t quite “get” your comment, but it is true that empathy skills are vital in the treatment of individuals with Borderline Personality Disorder, along with Paradoxical Agenda Setting skills. It can be challenging for therapists to treat this diagnosis, but in a large study at my clinic in Philadelphia, we reported in a research journal that the 28% of our patients with this diagnosis at intake recovered from depression at nearly the same rate as patients without this diagnosis, which was encouraging. The treatment of individuals with BPD was what led, in part, to the evolution of TEAM-CBT. Thanks for your comment, and feel free to share your thinking any time! Appreciate the chance for dialogue. david
I’ve just listened to this episode and found it really interesting and useful but I have a few questions. Firstly, how is your requirement that the patient agree to not make any suicide attempts for the rest of their life any different to a ‘suicide contract’ which you mention are not effective? Also, you talk about doing this assessment at the intake and making non-attempts a condition of therapy. If the patient/client agrees to this, why then do you continue to monitor suicidal thoughts in each session in the BMS? Presumably because the agreement is no guarantee of cessation of thoughts. Surely if you’ve told them it’s a condition of therapy with you to not make any attempts then they’d be likely to not tell you about them even if they occurred, and don’t see how setting the initial ground rule resolves the problem. And lastly, when suicidal thoughts, urges, or fantasies do come again in the BMS how do you handle it then? Do you tell them you’ll end therapy, say “but you promised”?
Looking forward to your reply.
Michelle (Australia-based psychologist)
Thanks, Michelle. I have scheduled your email for an upcoming ask david episode, and will use your first name unless you prefer that i use some other name. Here is a brief reply. Most patients with borderline personality disorder will become enraged by the gentle ultimatum at the initial evaluation, and if they decide this is not the type of therapy they want, so be it. The techniques I use will not be effective with patients who continue to threaten suicide. TEAM therapy requires TEAM work. Most, nearly all, patients will “get it” and will decide to continue with the therapy. They can have suicidal thoughts and urges, and we can work on them together in therapy. However, it is important that they therapist and patient be protected, in a safe environment. If the patient starts threatening to make a suicide attempt, then they will need another form of more intensive treatment like hospitalization of day care intensive outpatient treatment, options I cannot personally provide for them. I monitor suicidal urges before and after each session to protect the patient and to protect myself as well. Thanks! PS the suicide contract is an agreement not to attempt suicide “while we are working together.” This is very weak, as the patient can suddenly decide he or she is dropping out of therapy and making a suicide attempt. My contract is more demanding, and intentionally so. They must also agree to do psychotherapy homework, too. Some patient want to make the therapist a hostage with suicide threats, which can and so work as a form of manipulation and hostility. Then the therapist is in an almost constant state of agitation, anxiety, and frustration. david
Thank you for this amazing content.
Let’s assume the patient says “Well, I will not agree to your Gentle Ultimatum. I prefer to have my options open to me. And I may choose death.”
How the other kind of treatment shall proceed? How do you treat this kind of patient? I’m just interested as I have never encountered such a situation. Is there any other way to save this person’s life?
Or maybe you just leave it as it is because “you can’t save them all”?
KB, You can search my website for suicide and find my podcast(s) on this exact topic. Thanks! dvid
I think you are listening to my podcast on suicide. I tell the patient that I cannot safely or ethically work with him or her as a voluntary outpatient without giving up the plan ever to commit suicide ever. If they can make this commitment, I can help them and work with them. If they wish to keep the suicide option on the table, they will need a more intense form of therapy. Hospital, day treatment, or whatever. The Hippocratic Oath says, “Do no harm.” Treating patients with a treatment that will likely lead to their death is clearly harmful! Hope that’s that podcast that explains all of this. d
Thank you for your response. I did not expect to get any! And I certainly did not expect to get it that quickly 😉 I’m glad you chose to respond.
Alright, here comes the question: So let’s assume the patient gets to the place where he/she cannot commit suicide f.e psychiatric hospital. What methods a therapist can use in his/her work with a patient that says:
“I want to die. Thank you for your help but I choose death. I really love your hard work but the moment I leave this hospital I will kill myself. But I truly appreciate your effort! It’s not for me. I prefer NOT to face my problems and so I will pursue death option. You can sit here and talk to me all you want, but I will NOT change my opinion. And I won’t even do any experiments that you propose.”
I have read most of your books (apart from the newest one which is not available in my country) and I think I’m up to date with your podcasts. I just have never heard what could be a CBT method for the patient that is 100% resistant and a) unwilling to do homeworks b) unwilling to combat negative thoughts c) unwilling to even talk to the therapist d) constatly trying to kill oneself
Please accept my apologies if I’ve missed this valuable piece of information in any of your materials.
Thanks, in the case of suicide we are dealing, not so much with therapeutic issues, but with legal and administrative issues. I would suggest you consult with colleagues at the hospital to find out what their policies are, as well as your malpractice insurance carrier. They will usually provide free legal consults for what to do.
Good question, and I hope my answer is helpful for you.
PS I do not, for the most part, try to help people against their will. You can, of course, empathize, and this patient is likely quite angry, as well as hopeless, but this is a legal issues since, at least in the United States, there is a high likelihood of a lawsuit when a patient commits suicide. So “defensive driving” is indicated.