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The Hazard. When the client's perception of the hazard (defined in Chapter 3 as a clinical characteristic) is clarified, it may be possible to mobilize his or her internal strengths to manipulate, decrease, or eliminate the hazard. The threat of the hazard may be minimized when its limits are clearly outlined.
The Crisis. The crisis (also defined in Chapter 3 as a clinical characteristic) usually becomes less threatening as the client is safely surrounded and supported by persons who care and understand the former's internal turmoil. It is important that the client be made to feel confident that he or she will be helped and protected even in the event of losing control.
Significant Others. These persons need help in finding out what the client needs and learning how to direct their energies toward supporting the suicidal individual. The caregiver must decide which significant others will be able to be helpful and assist these significant others to plan for their own support so that they will not be drained by the client. Strengthen the communication between the client and these significant others. Support their relationships by directing both client and significant others toward exchanging messages of care and concern. Teach them to ask directly for what they want.
Priorities in the Organization of Resources. Organize a resource network so that the client will have direction and priorities. Make sure the client knows what resources to use first and how to make use of them. At first, the caregiver may need to contact outside resources for the client and arrange for the support being sought. The caregiver must be alert to all cues from the client which show the client's readiness to take over. The caregiver's messages must always reflect this eventually: "I will help you get started so that you can do more on your own. I will respect and care about you as you return to independence." The caregiver who consistently does everything for the client is headed for disaster by creating a totally dependent client. Even in an emergency, caregiver's must direct clients to do as much as they can for themselves (eg, first-aid measures). In areas where the client cannot be independent, caregivers use authority and direction. Unfortunately, many clients remain suicidal for fear that by surrendering their suicidal intent they risk losing the caregiver's care and concern.
The caregiver's attention to internal resources of the client is paramount to effective therapy. Confused, disoriented clients need assistance in structuring their day. Frequently the client needs help even to make a "do list" of what is to be done in what order and at what time of day. Simple chores often taken for granted by the caregiver (shower, hair wash, laundry, meal planning) can be overwhelming to a client until the first "do list" is launched. Simple lessons in problem solving, with the client providing the data and the caregiver helping to set priorities, are important in strengthening the client's internal resources. Often, the client has solved a problem of this kind but needs support from the caregiver. A pat on the back or a smile of encouragement may be all that is required to set the plan in action.
Harnessing Coping Devices That Have Not Disintegrated. Ask the client to search for any coping devices that may have worked in the past. Encourage problem solving that applies previous coping strategies to the current hazard. The client should also be encouraged to visualize some coping strategy that might work and to anticipate the consequences. The most important resource a client can have is the belief, "I can help myself." Let the client choose a coping strategy that will fit his or her lifestyle but at the same time make sure there are three choices for the solution of any problem. Having only two choices makes a client feel boxed in.
There are five common ways of harnessing the client's coping devices.
ASSIGN STRUCTURED TASKS. Give the client tasks to do and assist in the structuring of the client's time, ie, "Go to the market now; call your mother at 10 A.M., and then do your homework." Depending on the client's needs, the caregiver will determine how detailed the directions must be, and how simple the tasks.
CONTINUE ACTIVITIES. Daily activities need to be continued as much as possible. An immobilized client may actually require a firm command to initiate any activity. However, too much activity can be just as harmful as too little. The caregiver's goal is to assist the client in successfully modifying an exhausting schedule and to help set realistic priorities for a daily regimen of purposeful activity.
DIRECT THE CLIENT TO PLANNED AND ORGANIZED ACTION. It may be wise to structure an entire day. Conversely, it may only be necessary to work with what the client says must be done. The client may then be able to decide personally what to do first.
Alternatively, the client may have to be directed specifically to contact certain community resources for therapy, money, or housing or directed specifically to certain activities, such as keeping a journal or diary, expressing inner feelings through painting, sculpture, or pottery making, or making social contacts with others.
EXPLORE ALTERNATIVE SOLUTIONS WITH THE CLIENT. When the client is locked into a situation ("I have to kill myself-you see, I can't live with my husband and I can't live without him so I have to die") the caregiver explores alternatives together with the client. The alternatives may seem limited in the client's perception. The caregiver can offer other choices and can involve significant others in the search for still other possibilities. The goal here is to get the client out of the corner into which he has boxed himself.
It may also be wise to help the client perceive the secondary benefits arising from putting oneself into such a position-whether in the form of attention, help, affection, or empathy from those who respond to the dilemma.
TEACH PROBLEM-SOLVING TECHNIQUES TO THE CLIENT. Ask the client how he/she thinks the problem could be solved. Remember that the client needs at least three viable alternatives to avoid feeling boxed in by rigid either-or solutions. The consequences of each possible solution should be discussed. When no choice seems desirable, the client may have to choose the most palatable one. As a client once said, "I felt I was caught between a rock and a hard place. Now I see I have three choices-a rock, a hard place, and a bed of nails. Looking at it this way, the hard place doesn't seem so bad." In the final step of problem solving, the caregiver, looking back at the problem and the process, encapsulates what the client has learned from the process that will be of help in the future, what coping device has been reaffirmed or developed that will help in dealing with future hazards. Spelling this all out reinforces positive aspects of the transaction.
The techniques of intervention discussed here present a range of approaches suitable to the needs of a suicidal person. Table 5 will assist the caregiver in correlating the appropriate intervention approaches with the lethality of risk assessed. It is important to note that the caregiver does not change the intervention techniques used, but rather changes their relative importance and the amount of directive guidance that must be provided as the degree of risk varies from low to high.
Hatton, Corrine, Valente, Sharon, Rink, Alice, & Edwin Shneidman, Suicide:
Assessment and Intervention, Appleton-Century-Crofts: New York, 1977.
Reflection Exercise #5
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