Developing an effective relationship with the person at risk of suicide is fundamental to their safe and effective care (Gilburt et al 2008). Responding effectively and engendering someone’s trust requires us to be calm, compassionate, focused and non-judgemental. How we react non-verbally and the way we express things (the language we use) are as important as what we say. Guidelines for supporting individuals at risk of suicide emphasise the importance of developing a trusting working relationship from the outset, treating the person with respect, listening (Michail 8c Mughal 2018; NCCMH 2018) and being consistent. Research suggests the power of the therapeutic relationship to mitigate suicidal distress comes from its potential to foster feelings of hopefulness, connectedness and being cared for (Collins 8c Cutcliffe 2003; Cooper et al 2011). Cole-King and Lepping (2010) describe a model of care she calls suicide mitigation which is an active process to try to prevent suicide. It starts from the assumption that suicidal thoughts need to be taken seriously and met with compassion and understanding on every occasion in order to engage positively with the person. For the many suicidal individuals ambivalent about their wish to die, compassionate engagement can be the tipping point back to safety. A compassionate approach is also critical to facilitating patients disclosing risk.

Health care professionals who are empathetic and compassionate encourage patients to disclose their concerns, symptoms and behaviour, and are ultimately more effective at delivering care (Larson 8cYao 2005). Conversely, negative reactions can cause a patient to feel that the clinician is hostile, unsympathetic and uncaring, putting the therapeutic relationship at risk (Thompson 2008). Health care staff may have negative reactions to self-harming behaviour which is detrimental to the patients immediate safety and longer-term recovery (Royal College of Psychiatrists 2010) and can lead to frustration and/or resentment towards the patient. Suicidal patients have well-tuned “radar” which can detect a clinician’s attitude. Compassionate care must also be competent care, and the establishment of a therapeutic alliance and trusting relationship between clinician and patient must be matched by a comprehensive and skilled risk assessment (Cole-King et al 2013).

Goodpractice point

The quality of the therapeutic relationship makes it possible for the patient to disclose suicidal thoughts. All suicidal thoughts, however “minor”, require a response that needs to be compassionate, proportionate and timely.

A positive therapeutic relationship is not only the context in which suicide prevention takes place but also a protective factor in its own right. Everyday aspects of good clinical care, such as listening to patients and treating their feelings with compassion and respect, are disproportionately important for patients who are feeling suicidal. CMH (2019)

The first aim when delivering an SFI is to engage the person who is struggling with persistent suicidal thoughts and to work alongside them as they make changes to reduce their suicide risk. If someone is especially ambivalent or hopeless, we may need to ask them to commit to taking suicide offthe table (Jobes 2016) or commit to a delay (Sudak Sc Rajyalakshmi 2018). This is not the same as a “no self-harm contract” but is rather a “middle way”. It can also be thought of as shaping the person’s willingness to consider other solutions to their problem(s), a strategy in DBT known as “foot-in-the-door”. Many people who are suicidal have significant psychosocial problems and experience relief when they think about dying as they see it as an escape from overwhelming stress or distress. Resolving these underlying psychosocial problems takes time. This presents what is known in DBT as a dialectic. The person may feel they can’t give up suicide as a solution until their problems are resolved and we can’t address their problems very effectively whilst their risk of suicide is the highest priority. Personal disclosure can be helpful here, especially if you have already established a trusting relationship, you can explain, with radical genuineness (Linehan 1993) that you are unlikely to be at your best in helping them address their problems if you are less worried they may die.

An SFI involves ten key elements: [1]

  • • “leaning in” to address suicide risk and change and leaning back to emphasise choice;
  • • continuous assessment of risk;
  • • using validation, metaphors and similes;
  • • identifying and working with ambivalence;
  • • an individualised (personal) formulation of the key factors driving and maintaining suicidal intent;
  • • supporting the person whilst they start to make changes to increase safety and reduce suicidality;
  • • shaping and pacing behavioural change. Practising active change between sessions;
  • • identifying and addressing obstacles to change and regularly reviewing and adjusting safety plans;
  • • modelling flexibility and willingness, e.g. see family members if that could be helpful.

The “safety plan” in particular is regularly reviewed via collaborative attempts at discovering what works rather than prescribing a fixed plan. It is a collaborative rather than a formulaic, “off-the-peg” or instructional approach which, unfortunately, we can get pulled into doing when we are under time pressure to agree a risk plan.

Metaphors are especially helpful when we need to have difficult conversations and to summarise a meaning you want to convey and use again without a long explanation (see Stoddard & Afari 2014).They become a shorthand not just for conveying the issue itself but also validating and/ or normalising it. They are especially helpful when we have a rift or rupture in the therapeutic alliance such as “I feel we aren’t quite on the same page at the moment. Does it feel like that to you?”Jobes (2016) suggests a helpful metaphor of asking someone to “take suicide off the table” when they are suicidal, to enable a period when you can both work together at finding other solutions. He describes the CAMS intervention as going on a journey together and needing to both be in the car with seat belts done up (not the car door ajar). Similarly, when asking someone to surf suicidal urges, rather than making it sound as if you are trivialising suicidal urges, a metaphor can convey your request compassionately such as “surfing the wave”. This implies that waves go up and down without your having to spell out that suicidal urges pass and fluctuate in intensity. It is important to notice how metaphors are received and if they make sense to someone, especially if they have a different cultural or ethnic background or if you are not speaking in their first language.

Other ways to engage patients in treatment include instilling hope, demonstrating confidence that their problems can be addressed using this framework, and showing a willingness to talk about suicide and other difficult issues that patients are experiencing. Psychoeducation can also be helpful and validating. It may be appropriate at some point to explain to patients in simple ways how, for example:

  • • we don’t problem-solve well when we are under stress or depressed as our thinking can become constricted and attention impaired.
  • • suicidal thinking can be reinforced as it presents the sense of an escape from our problems and pain; offering a sense of control.

See suicide.

  • [1] creating a therapeutic relationship with the client; being bothcompassionate and forthright;
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