Hope in Action

Solution-Focused Conversations About Suicide

Heather Fiske

• Publisher: Routledge
• Year: 2012
• eBook ISBN: 9781136915635
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Respectful and effective solution-focused brief therapy (SFBT) for suicidal clients

Few tasks are more important—and daunting—than to help someone who is suicidal to go beyond the darkness of hopelessness to the light of hope. Hope in Action: Solution-Focused Conversations About Suicide is a unique resource providing fresh approaches to treating individuals and families where suicide is an issue. This comprehensive book provides a thorough grounding in using a solution-focused therapy approach to elicit and reinforce hope and reasons for living. Strategies are demonstrated with stories, case vignettes, and transcripts. Special applications include some of the most challenging high-risk clients that therapists treat, including people who make repeated attempts. This powerful resource offers a set of practice principles based on the existing empirical evidence in the context of clinical utility and client expertise.

Hope in Action: Solution-Focused Conversations About Suicide provides case transcripts to help in role-play or rehearsal situations as well as numerous practical tips. The book also provides lists of solution-focused questions for use in various situations, including suicide crisis, the use of anti-depressant medications, facilitation of collaborative working relationships with colleagues as well as clients. Each application chapter gives therapists practical, hands-on tools and uses stories and illustrations to make the book user-friendly. The text also offers a brief appendix on the basic skills of SFBT.

Topics discussed in Hope in Action: Solution-Focused Conversations About Suicide include:

• current knowledge about preventing suicide at the individual level
• helping clients to utilize their strengths even when they are in crisis
• how research in diverse areas supports the solution-focused approach
• effective treatment for couples and families when one member is suicidal
• basic approaches to effective therapy with young children and teens who have attempted suicide
• respectful, effective therapy with people who seem to have adopted being suicidal as their primary coping strategy
• therapeutic tools that help the therapist to stay hopeful about clients and strengthen the therapeutic relationship

Hope in Action: Solution-Focused Conversations About Suicide is a valuable resource for counselors and therapists at every experience level.

PART I:
FOUNDATIONS

Chapter 1

What Works? Building on What We Know to Develop Practice Principles

In this chapter, I propose a series of practice principles for therapeutic talk about suicide. These principles are based on several ways of knowing:

1. The context of clinical experience—what clients teach us about what works

2. The hard-earned wisdom of survivors (people who have been bereaved by suicide) and first voices (people who have lived and struggled with their own suicidal thoughts and actions)

3. The application of solution-focused brief therapy (SFBT) methods, as developed by Insoo Kim Berg, Steve de Shazer, and their colleagues at the Brief Family Therapy Center in Milwaukee (e.g., Berg & de Shazer, 1994; Berg & Dolan, 2001; De Jong &Berg, 2002; de Shazer, 1985, 1988a, 1991a, 1994; de Shazer et al., 2007)

4. What the available literature tells us about what works (see Appendix B for a discussion of the evidence base)

These principles are not rules, guidelines, theories, or “best practices.” “Best practice” in solution-focused therapy is simply what works for a particular client-therapist system. And the current state of empirical knowledge about helpful treatment in suicide intervention is still so limited (Comtois & Linehan, 2006; Hawton, 2000; Heard, 2000; Linehan, 1999a, 2004; Rudd, Joiner, & Rajab, 2001) that our best practice guidelines or standards of care must be regarded as highly tentative works-in-progress. We must be prepared to “take action with imperfect knowledge” (White, 2004). These practice principles are a description of how I take action—how I approach and work with the most critical resources for helping clients who are struggling with suicidal thoughts or behaviors: their own knowledge, capacities, and communications.

Practice Principles for Suicide Intervention

Utilize what the client brings.

Focus on reasons for living.

Make every encounter therapeutic.

Contain crisis.

Tap into hope.

Help the client set constructive goals.

Collaborate with clients and with colleagues.

Work with systems.

Be mindful.

Watch your language!

Evaluate effectiveness.

Do what you can do.

UTILIZE WHAT THE CLIENT BRINGS

The concept and practice of utilization is one of Milton Erickson’s many gifts to the helping field (de Shazer, 1988b). Erickson utilized capacities and beliefs already within the client’s repertoire to build helping interventions. This practice is supported by over forty years of convergent research findings showing that “client factors” make the single most important contribution to positive treatment outcomes, accounting for 40 percent of the variance, compared to only 15 percent accounted for by therapeutic model or technique (Asay & Lambert, 1999; Lambert, 1992; Tallman & Bohart, 1999).

One of my favorite Erickson stories concerns his meeting with an elderly woman (as with any good story, there are numerous versions of this one, e.g., Bertolino & O’Hanlon, 2002, and Gordon & Meyers-Anderson, 1981). This woman lived by herself in an old house. She was in poor health and confined to a wheelchair. Her social world had become increasingly limited, and she seemed despondent and uninterested in life. A relative who lived in another state, concerned about her decline, asked Dr. Erickson to consult, and he made a house call. The woman was polite but clearly reluctant to speak with him, and he resorted to asking for a tour of her home. Their tour was quick: the house was dreary and crumbling, the only signs of life a collection of African violet plants in the back. Dr. Erickson suggested to the woman that if she would agree to do just one thing—something easy for her to do—he would in turn promise to leave and never come back. When she agreed to the bargain, he asked her to find out which families in her community had recently experienced important events—births, deaths, engagements, weddings—and to take such families a small African violet plant. He left and never saw the woman again.

There is, of course, a punch line to this story, a newspaper clipping with the headline “African violet queen dies. Thousands mourn.”

I love the simplicity and richness of this story, how it demonstrates Erickson’s capacity to pay attention to what got the client’s attention, and to utilize what mattered to her. He helped her to take a small step that (1) was within her existing repertoire and (2) made a difference in her life—a difference that made a difference.

Fortunately, in our day-to-day work we rarely have to match Milton Erickson’s perceptive gifts to help people to utilize what they have. People tell us quite openly what is important to them (where they keep their own African violets). Often, they also tell us how to make use of these gifts: how to help them reconnect, or stay connected, with life. Our task, then, is to watch and listen for the African violets. It doesn’t matter where we start, as long as we start with something—anything—that is live and real and meaningful for the individual.

Tips for Utilizing What the Client Brings

• Remember: “If you are going to help people change, first you have to get their attention.” (Berg, 1989; emphasis added)

• To get their attention, focus on whatever is salient, relevant, and important to them.

• Look for ways that you and your clients can

— increase utilization that is already occurring (what they are already doing that works) and

— further utilize whatever matters to them.

FOCUS ON REASONS FOR LIVING

As our grandmothers could have told us, reasons for living are highly potent African violets. Identifying, highlighting, and reinforcing reasons for living is key to engaging in helpful conversations with individuals who are viewing suicide as a solution to their problems. Therefore, “as clinicians we should be unabashed in our active pursuit of reasons for living in the patient’s life” (Jobes, 2006, p. 87).

Ambivalence has long been viewed as a significant aspect of the phenomenology and behavior associated with suicide (e.g., Shneidman, 1993). The person both wants to die and, at the same time, in at least some small, real way, wants to live. Much of our suicide intervention practice has dealt with the wanting-to-die side of this ambivalence, “unpacking” the individual’s views chiefly in terms of achieving a better understanding of reasons for dying. I suggest that we redress this imbalance by allocating at least as much air time to reasons for living.

Research findings support the importance of this shift in balance. For example, “attraction to life” has been shown to be an important variable in suicide risk, adding unique information to that provided by assessing “repulsion toward life” and “attraction toward death” (Muehlenkamp, 2003). Heisel and his colleagues have demonstrated that meaning in life and satisfaction with life are preventive factors for suicidal ideation (e.g., Heisel & Flett, 2000).

In validation work with the Reasons for Living Scale developed by Marsha Linehan and her colleagues, predictive accuracy improved significantly when reasons for living were included in suicide risk evaluation (Linehan, Goodstein, Nielsen, & Chiles, 1983; Strosahl, Chiles, & Linehan, 1992). In addition, just completing Reasons for Living questionnaires stimulated new and useful conversations in the subjects’ therapy relationships, providing new direction and a different kind of “grist for the mill” (Linehan, 1999a).

In practice, taking an interest in the client’s reasons for living means attending to whatever is salient, relevant, and important to the client. Beginning with whatever is “live” for the client, and then following those leads, is the simplest and usually the fastest route to understanding real or potential reasons for living. I try to remember one of my grandmother’s lessons: that African violets can survive even in dark places.

Tip for Focusing on Reasons for Living

Ask yourself:

• Am I spending at least as much of the time I have with this person focusing on reasons for living as on reasons for dying?

• What is relevant, salient, and important to this person?

• Where are the African violets?

MAKE EVERY ENCOUNTER THERAPEUTIC

The modal (most common) number of sessions in any kind of psychotherapy is one (Talmon, 1990). Furthermore, “because of the nature of this [suicidal and self-harming] client group, the likelihood that the first session will also be the last is even greater than across psychotherapy in general” (Callcott, 2003, p. 76). Therefore, we need to maximize the helpful impact of any conversation with a person involved in suicidal thinking, planning, or behavior—that conversation may be our one opportunity to make a difference.

In virtually any text or professional journal article on clinical work with individuals struggling with suicide, the predominant emphasis is on risk assessment. This emphasis reflects suicidology research, which is heavily weighted toward studies of epidemiology and risk factors and, at the practice level, toward risk assessment and prediction.

The plethora of quantitative research findings on hundreds of significant predictors of risk, from gender to family history of depression, can certainly offer some information about where we should direct primary prevention efforts (e.g., Jenkins & Singh, 2000; White & Jodoin, 1998). However, risk prediction research has yet to provide an inventory of useful tools for clinical use with a troubled person (Chiles & Strohsal, 1995; Goldney, 2000; Rudd et al., 2002; Sakinofsky, 2000). “Suicide is notoriously difficult to predict at the level of the individual” (Sakinofsky, 2000, pp. 393-394). The most valid and reliable assessments on two critical dimensions of suicidality, intent (to die) and lethality (of plan and method), are those made by the individuals being evaluated. Professionals can neither agree among themselves nor match the validity and reliability of self-assessment (Furst & Huffine, 1991; Joiner, Rudd, & Rajab, 1999). Nor is a typical risk assessment interview likely to encourage kindling of the “single molecule of hope” (Quinnett, 2000, p. 205), or of the life-saving curiosity about possible change, that can encourage a desperate person to hold on for just a little longer. Furthermore, a “question and answer interview” may “cover our organizational agenda, but risk antagonizing the patient” (Callcott, 2003, p. 76). Chiles and Strosahl (2005) caution:

Going through textbook suicide risk factors for their own sake can be a futile exercise and can be antitherapeutic if the exercise leaves your patient with a sense of not being understood. Be sure to collect information that can be used in a positive set of interventions. (p. 74; emphasis added)

If we spend our precious time with a despairing person conducting a thorough risk assessment—and doing only that—we may miss a valuable and perhaps unique opportunity to be helpful.

My colleague Michael Kennedy is an experienced solution-focused practitioner and teacher who for many years directed a crisis intervention program in the emergency service of a large Toronto teaching hospital. He and his staff often had very limited time (perhaps twenty minutes) in which to meet with a person in crisis, sometimes following a suicide attempt. In that time, they had to collect the information on history, symptoms, mental status, etc., which was required for hospital records, and to decide on diagnostic, referral, and treatment recommendations. Despite these pressures and demands, Kennedy insisted that “every contact can and should be a therapeutic one” (personal communication, October 3, 2002). His message seems critically important to me.

I am also struck by Kennedy’s report that when he approaches clients in a solution-focused way, he typically ends up with all the information about their problems and histories that he needs, but without having subjected his clients to a “problem-saturated” interview. Instead, the data are obtained in the context of a conversation about what changes would be useful, and what strengths and resources of the individual may be helpful in achieving such changes (Mich...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• About the Author
• Contents
• Foreword
• Preface
• Acknowledgments
• Introduction
• Part I Foundations
• Part II Applications
• Appendix A: Solution-Focused Brief Therapy: The Basics
• Appendix B: Notes on the Evidence Base: Toward Communities of Curiosity
• Appendix C: Warning Signs of Imminent Danger for Suicide
• Appendix D: Reflective Questions
• References
• Index