Comprehensive Safety Planning
Initial Steps in Therapy
- Formulating a safety plan is a primary task undertaken early in therapy.
- The plan includes a detailed list of alternatives the client can resort to when experiencing suicidal urges.
Elements of the Safety Plan
- Providing the client with emergency crisis line numbers.
- Offering contacts of healthcare professionals, including the therapist.
- Encouraging the client to engage in activities that serve as distractions.
- Identifying individuals in the client’s life who represent safe points of contact.
- Suggesting public places where the client can be around others, thereby reducing the likelihood of engaging in self-harm.
DBT Approach
- The therapist may share their personal contact information when the client needs assistance applying DBT skills, explicitly stating it’s not a crisis line substitute.
- DBT involves actively coaching clients through skill application challenges, reinforcing the importance of a safety plan.
Intervention to Remove Access to Means
Proactive Measures
- A critical intervention involves inquiring about and then working towards the removal of the client’s access to means of suicide.
- Strategies may include disposing of items that could be used for self-harm or placing them beyond easy reach, such as giving them to a trusted person or locking them away.
- Collaborating with pharmacies to dispense medication in limited quantities to prevent overdose is an effective risk mitigation strategy.
Enhancing Client Commitment to Treatment
Obtaining a verbal commitment from the client to stay alive is essential, as research indicates that such commitments can improve adherence to behavioral change. The therapist navigates the commitment-building process to keep the client engaged in treatment and life itself.
Strategies for Commitment in DBT
The-Foot-in-the-Door Technique
The foot-in-the-door technique starts with modest requests and escalates them gradually. The therapist may begin by asking the client to consider removing suicide as an option during the treatment duration.
Example With Sophia
- The therapist asks, “Sophia, would you be willing to set aside thoughts of suicide for the duration of our treatment sessions?”
- Upon agreement, the therapist reinforces the commitment by citing studies where skill utilization improved post-treatment and suggests a longer-term commitment.
After the initial agreement, the therapist introduces evidence from follow-up studies demonstrating sustained skill improvement over the years. Then proposes a more extended commitment, seeking to secure a two-year commitment to life from the client as part of fully engaging in the treatment process.
The Door-in-the-Face Technique
Start with a significant request, such as a lifelong commitment to abstaining from suicide, then adjust to more immediate and achievable goals based on the client’s response. This approach is used with clients who may resist making significant commitments from the outset.
The Therapeutic Commitment Dance
Therapy is similar to a dance, incorporating various techniques tailored to each client’s situation. While securing a commitment does not guarantee adherence, it significantly enhances the probability of clients following through with treatment. Unlike a no-suicide contract, the focus here is on constructing detailed safety plans and asking for verbal commitments.
The process involves not just obtaining commitments but also preparing for potential setbacks. Acknowledging that individuals may face recurring suicidal urges, the strategy includes preemptive planning for such instances. Troubleshooting these commitments is a crucial step; it is essential to strategize for the re-emergence of suicidal thoughts. The ultimate goal is to equip clients with the tools and plans to navigate future crises effectively.