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Focus on the Current Hazard and Crisis. The interview needs to focus on clarifying the hazard and crisis. Clients who digress need frequent direction toward what is pertinent to the current situation. Assess the lethality of suicidal intent as rapidly as possible.
When a client presents many problems, the caregiver helps to focus on the worst problem. When the client is confused, the care-giver helps with the one problem that can be dealt with in that session. For example:
Client: I just don't know where
to begin. My daughter is pregnant and not married, I have a retarded son, my car
doesn't work, and I don't have any food.
Make Sure the Client Gains a Clear Perception of the Hazard and Crisis. The client needs you to restate the problem, showing how you perceive and evaluate the situation. It is essential to repeat this within a common frame of reference until the client hears and understands you. Be empathetic and reflective about the client's internal turmoil, but help put this turmoil into perspective.
Reduce Any Immediate Danger. Using short, clear commands, direct the client to remove or destroy any method available by which to carry out the suicidal plan:
want you to put the gun down so we can talk."
Alternatively, direct the client to separate himself from the method:
"I want you to leave the gun
where it is and go over to your friend's apartment."
Have the client repeat, "I promise not to do anything self-destructive intentionally or unintentionally until I talk to you first by phone or in person." The client must repeat your exact words-a shrug, a mumbled "m-m-hm" or other gesture of assent is not acceptable. The time limit of the contract must be specific and must be clearly stated by the client.
When the client is unable to make the statement as described, the caregiver directs the client as follows: "Qualify the statement any way you wish, but repeat it as I give it to you." A client who is unable to make this contract is really telling you that safety provisions will be necessary-hospitalization, perhaps, or some other alternative must be considered.
Evaluate the Client's Need for Medication. When internal turmoil is severe, the client may need medication to reduce stress, promote sleep, or make it possible to think clearly. This medication must be prescribed by a physician who is aware or should be made aware of the suicidal crisis. It is wise to ask the physician to prescribe small, nonlethal amounts of medication and to ask a relative or friend to keep the bottle and dispense as needed. Bear in mind that although medication can provide great benefit, your decision to resort to it can also be interpreted by the client as your permission to commit suicide.
The same client may say, "They gave me the pills because they wanted me to die." As a safeguard against such a possibility, medicalion must be controlled and the client be made to understand that no one has given permission to use the medication self-destructively. In any event it is rare that medication alone has solved a suicidal crisis.
Evaluate the Client's Need for Someone Present. The client who indicates an inability to control suicidal impulses, who discloses a specific and imminent plan, or who cannot promise to avoid self-destructive behavior may be saying, "I need someone to protect me from myself." Before considering hospitalization, the caregiver may realize that this client is afraid of being alone and for the time being needs to stay with someone else. The caregiver actively helps the client to solve the problem and find someone whom he can stay with for a few days. If no such person can be found, hospitalization must be considered. In no case should the caregiver ever invite a client to become a houseguest, even as a last resort! Once the caregiver exchanges the therapeutic role for the role of host, it becomes, at the very least, infinitely harder to reach the goal of mobilizing the client's own resources.
Mobilize the Client's Internal and External
Resources. Success in reducing suicidal lethality hinges on getting the
client back into a network of resources where personal feelings of isolation and
worthlessness diminish. Conversely, when lethality is not immediately reduced,
the availability of these resources may give the client the support and hope needed
to continue even for a little longer. Caregivers are advised to seek out these
resources for the client, particularly in response to the client's feeling that
no one cares. Several approaches may be considered in mobilizing these resources
and involving others in the client's therapy.
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