59 Family psychoeducation with suicide attempters

Inappropriate or inadequate treatment in emergency treatment settings frequently leads to failures to adhere to after-care prescriptions and an increase in subsequent suicidality. Working collaboratively with the patient and the family can increase compliance and reduce risk. An intervention based on the family psychoeducation model developed to treat serious mental illnesses is described. A rationale for using this model is presented, which stems from the high rate of mental illness diagnoses in psychological autopsies of completed suicides. Sequential tasks for the clinician are presented. ‘Joining’ as a collaborative technique with both the patient and the family is described. Specific guidelines for the family to reduce potential for further harm are suggested.

Suicidal thoughts, suicide attempts, and completed suicides are all both individual and systemic events. Every completed suicide hurls surviving family and loved ones into a protracted and problematic grieving period (Dunne 1992). In the past quarter century, it has become increasingly apparent that many of these survivors need special attention if they are to successfully negotiate the tasks of grieving. Considerably less is known about the consequences for a family of loved one's repeated attempts to end their own life. During this same time period, it has also become clear that treatment of people with major mental illnesses stands the best chance of a positive outcome if the family is actively engaged in the treatment (McFarlane and Dunne 1991).

As with the trend in physical medicine, in which family members of cancer and heart patients are involved in the after care, family pychoeducation has spread from its original application to people with schizophrenia, to individuals with bipolar disorder, major depression, substance abuse, and persons diagnosed with borderline personality disorder (McFarlane 2002). These studies aptly demonstrate the wisdom of involving families in treatment of these disorders as a means of reducing symptoms and avoiding relapse.

It would then seem natural that suicide prevention, particularly after a suicide attempt, would find increased success if the family of the attempter were involved in after care. Unfortunately, with a very few notable exceptions (Rotheram-Borus et al. 1996; Greenfield et al. 2002), this is not routinely the case. Clinicians in both psychiatric emergency settings, inpatient and outpatient facilities frequently see the family as merely a source of information about things the patient will not discuss or does not remember. They can go so far as to criticise the family for their pre-episode behaviour, for example failing to respond to what now are evident signs of suicidal thinking or ‘early warning signs’.

If the person who attempts suicide is hospitalized, all too often the family is included only in discharge planning as it becomes evident that the patient will be returned to the community with the family acting as the de facto caretakers, providing the majority of the surveillance and monitoring of the patient. They are only infrequently coached about effective ways of performing their role. Keeping the family excluded from the beginning, and then expecting them to implement the after care part of the treatment plan will result in the family's either performing the role poorly or rejecting it with a concomitant increase in suicidal risk. What follows is a rationale for using the family pychoeducation model in preventing future attempts of suicidal people.

It is important at the outset to understand what family pychoeducation is. Anderson and colleagues (1986) view family pychoeducation as a tripartite collaboration among equals, which encompasses the person with the diagnosis, their ‘family’, and the clinician. The word family is placed in quotation marks because it represents, in this context, not merely those individuals who are biological relatives of the patient, but also includes people who have close personal ties to him or her, and who are likely to be sources of support or who will need to change their routine way of relating to the patient to allow for recovery. In this collaboration, each entity has a distinct role to play in the shared enterprise of defeating the illness. Thus, the patient's role is to identify symptoms and sources of stress, and to report them as accurately as possible to the family and clinician. The patient is also expected to report accurately on participation in the after care prescribed, including medications. The family's role is to supplement this reporting by explicating symptoms if the patient fails to identify and to report on prodromal symptoms. The clinician is, at the outset, the educator for the family and the patient in all that is known about the present illness, and what can be done to alleviate it. Additionally, the clinician, as a neutral third party, serves to help resolve conflicts between the patient and the family. Finally, the clinician leads the family and the patient in a highly structured problem-solving exercise directed initially towards symptom reduction, and eventually towards social and vocational rehabilitation.

Anderson et al. place great emphasis on the relationships between, and among, all parties as key to the success of the treatment. They point out that families have to be engaged from a position of collaboration as equal partners with the clinician. This stance is in direct opposition to the more usual hierarchical relationships that typify most people's expectations (and experience) of the mental health system. Likewise, in this endeavour, the clinician must work to gain the patient's trust in order to gain permission to involve the family (if the patient is an adult) and if the patient is to cooperate. The technique of doing this is formally known as ‘joining’ with the family and the patient, and it is accomplished in a prescribed manner through a variety of behaviours on the clinician's part, which are directed at breaking down the traditional ‘doctor–patient’ relationship. It is absolutely essential to the success of this treatment that such joining take place both with the family and with the patient, since, eventually, all parties must be convinced that the clinician is there for them as a powerful ally against the re-emergence of symptoms.

The next step is to provide the family and the patient with as much information about the illness as they can reasonably handle. In this model, the psychobiological underpinnings of the diseases under consideration are usually emphasized over more purely psychological or psychosocial theories. It has been found that a key step in getting the family to collaborate in the treatment is to de-stigmatize the illness, and thereby the family and the patient. This is best accomplished by avoiding blaming the family for the patient's illness, and requires recognizing that even, if eventually, not useful or even harmful, the efforts of the family in the past have been motivated by concern for the patient. Likewise, the patient's past troublesome behaviours are attributed to the illness itself, and not to deliberately hurtful motives. In an atmosphere of increasing trust, both family and patient can join with the clinician in overcoming the illness.

The question of appropriate discharge planning for suicide attempters is one that continues to vex clinicians and other caregivers. On the one hand, attempters are frequently unwilling to admit the seriousness of their situation, and may even be in denial about their lethal intent. They frequently advocate for limited after care as a way of ‘putting all this behind’ them and avoiding the stigma of mental illness. Likewise, they often resist involving their families in treatment, either because they do not want to burden them (feeling too inadequate to deserve special attention) or because they see their family as at least one of the sources of their difficulties. In addition, they often have an acute embarrassment about the attempt and are reluctant to share their feelings and thoughts with other family members. These tendencies increase the further the attempter is from the episode, that is, as they stabilize and begin to recover.

In similar fashion, the families of attempters also frequently advocate for limited after care as a way of avoiding the stigma associated with mental illness and suicide attempts, both for their ill family member and for themselves. Often, they have been burdened by the patient's behaviour prior to the attempts, which frequently include aggression, destructiveness, withdrawal, or acts of physical self-harm. Frequently, they have been the persons directly responsible for maintaining the patient's safety as they moved into a suicidal phase, but before actual suicidal behaviours emerged. Hence, they are often exhausted and demoralized after a suicide attempt is made, and may no longer trust their competence to keep their loved one alive. In some instances, they too are in denial about the seriousness of the attempt, dismissing it as an attention-getting device. And as is true of the patient, the further they are from the episode, the more reluctant they become about being involved.

These factors would argue for prompt and early engagement of the family and the patient in an effort to attach the patient to the appropriate after care following a suicide attempt. It is generally reported that less than one half of all attempters keep their first appointment following discharge from emergency treatment (O'Brien et al. 1987; Sakinofsky and Roberts 1990; Moller 1990). This is a serious treatment failure considering the number of completed suicides who were attempters in the past.

Many health care systems are prohibited from disclosing medical and psychiatric information about an adult patient to anyone without the express permission of the patient, except in instances when the patient is an imminent danger to himself or to others. Unfortunately, all too often clinicians and other care-staff either misinterpret the meaning of these statutes to support not contacting the family, or use them to avoid making the extra effort it takes to get the patient's permission to involve the family. It can be argued that all persons who have made an attempt to end their own lives of sufficient severity as to require emergency treatment are, and remain, for some time thereafter, an imminent danger to themselves, and thus the family can be contacted even absent permission. It is also true that when the clinician takes sufficient time to elaborate the reasons for including the family, most patients eventually agree. Patients' negative attitudes towards involving family can be overcome if the clinician has time to build a relationship with the patient, and to understand the basis of the attitude. The clinician may also need time to convince the patient that family can be helpful for rehabilitation or treatment purposes. In the majority of cases, given sufficient time for this kind of intervention, it is possible to persuade the patient to involve family in the treatment and rehabilitation process without breaking existing rules and laws in the health care systems.

If applied to the treatment of suicide attempters, the family psychoeducational model would require engagement of both the patient and the family at the earliest possible juncture. Rotheram-Borus and colleagues (1996) were able to achieve remarkably high treatment adherence rates in a post-attempt intervention by actually contracting with the patient and the family, while the patient was still in the emergency room (ER). In this instance, the attempters were all adolescents necessitating face-to-face contact with the parents prior to discharge from the ER. This provided an extra bit of leverage and helped the clinician begin the joining process immediately. In the case of adult attempters, no such requirement for family involvement is usually the case. To overcome this disadvantage, it is recommended that the patient be admitted to the general hospital, or to an inpatient psychiatric service for at least 24 hours after presenting to the ER, depending on how much physical harm the attempter has suffered. The following is a series of steps which can ensure maximum safety and aftercare treatment compliance in the event of a suicide attempt.

This allows time for a thorough psychiatric evaluation outside of the time constraints, usually present in emergency room settings, and facilitates efforts to engage the family in aftercare. It also gives time for an assessment of the family as a resource, and the likelihood of providing a safe environment for the patient after discharge. ER staff need to overcome their reluctance to ‘label’ the patient, and insist on a thorough psychiatric exam before discharge. If general hospital admission is required, the family should optimally be contacted by the outpatient clinician who will work with the patient after discharge. Inpatient clinicians can initiate the family contact once the patient is in their care, but every effort should be made to involve the outpatient clinicians as quickly as possible, since it is they who will ultimately have responsibility for the patient's safety and treatment.

The clinician's first task is to join with the patient in such a way as to promote the establishment of trust between them. This, in turn, allows the clinician to recommend engaging the family in the after care planning. To accomplish this, the clinician must negotiate several issues with the patient. First, the patient needs to be educated about suicidal thoughts and behaviours, particularly as they relate to the broad spectrum of mental illnesses. This must be accomplished in the context of joining, in order to establish a collegial rapport and foster trust. Thus, the clinician should blame the illness rather than the patient, while empathizing with the recent feelings of despair and helplessness. The link between these feelings and depression, in particular, should be drawn. It is important for the clinician to validate other common emotions associated with a suicide attempt such as shame, guilt, and anger, and aim to reassure the patient that, with treatment, these emotions need not again overwhelm them. Likewise, the clinician should help the patient turn away from blaming others for his or her actions, suggesting that, ultimately, the blame rests with the illness.

A short explanation of the psychobiology of mental illnesses and their neurological underpinnings should be presented in order to help the patient understand the nature of their illness and the steps needed to recover from it. Next, the clinician must educate the patient that research has clearly demonstrated that patient safety and recovery are most likely achieved when the patient's social network is involved, and it is for that reason that the clinician seeks permission to involve other people, particularly family members.

A further step is to clearly outline to the patient what the intervention would look like—that it is collaboration for safety and recovery, not an opportunity to blame and shame. Next, the clinician should carefully delineate the patient's social network, identifying with the patient who would be likely to participate in such an endeavour and how they may be contacted. It is important that the clinician offers to make the contact, rather than leaving it up to the patient.

Finally, the clinician should begin to reach out to the family as agreed to by the patient. The goals of the initial joining session are to:

Naturally, all this must also be in tune with the physical and psychological condition of the patient as well.

After securing an agreement to after care involving the family, the next step is to contact and join with those family members identified by the patient as important to safety and recovery. If feasible, this should be accomplished during the initial interview, either in person with the people who accompanied the patient to the emergency room, or by phone if necessary. This initial contact with the patient's family represents the first step in joining with them, which is crucial to a successful outcome. It is critical that the clinician approaches the family from a collegial point of view. The failure to engage families in treatment can almost always be attributed to their detection of underlying attitudes of judgement or blame on the part of treatment personnel. In fact, many of the early family-based interventions for attempters suffered from an excessive pathologizing of the family with such family descriptors as ‘disorganized’ (Pfeffer 1990), and ‘unbalanced’ (Frances and Pfeffer 1987).

Here, the goals are similar, and the clinician's approach matches that described in joining with the patient: that is he/she is collegial, frank but optimistic, and supportive of the family's emotional responses to the crisis. The education of the family includes the information shared with the patient about the psychobiology of mental illness, and the relationship between them and suicidal thoughts and behaviours. The clinician helps to de-mystify mental illness and suicide by describing them in objective, non-blaming terms. Prejudices that the family may hold regarding suicide (attention-getting, trying to manipulate us, etc.) are gently challenged.

Next, the clinician must assist the family is making a realistic survey of the safety of the home environment, in terms of access to lethal means, and to develop an action plan to eliminate as many potential sources of self-harm as possible. Following this, the family is helped to recall the days leading up to the attempt in order to expose any prodromal indicators, which had gone undetected at the time or whose meaning was unclear.

Whatever the elements of the after care plan (family psychoeducation, psychotherapy, medication, etc.), the family should be informed about its details and procedures and enlisted to assist in ensuring strict compliance. An action plan, which increases the safety of the patient, is developed. As was true in the case of joining with the patient, the clinician should help the family identify others who might be of assistance in implementing the treatment plan. The clinician must offer round-the-clock accessibility, either to herself or her team in the event of future emergencies. The family should be encouraged to contact the clinician even if they are uncertain about the severity of the situation, since the clinician should be engaged with the family in helping assess what is happening and what action, if any, should be taken.

After care for suicide attempters must address two distinct issues: immediate short-term safety and avoidance of subsequent attempts. Ensuring immediate safety will, particularly, involve the family since, in most cases, they become the after care monitors. Thus, the family needs to be educated about prodromal signs of suicide, as well as being helped to develop communication skills, which will promote confidence and trust. Likewise, they need to be knowledgeable about the ancillary treatment(s) their family member is engaged in (medication, CBT, etc.), so that they can serve as effective observers of treatment compliance. Longer-term objectives include the avoidance of relapse through the development of skills and attitudes, which counter despair and hopelessness. Actively engaging the family with the patient in a psychoeducational setting can be effectively used to accomplish these objectives. The use of problem-solving is especially helpful since it ‘objectifies’ the issues and helps avoid high emotionality and conflict. Family psychoeducation, in this context, may consist of 4–8 meetings with the patient and the family spread out over several weeks, while the patient is simultaneously being seen by an individual therapist. The purpose of these meetings is to assure compliance with all aspects of the after care plan, and to keep the family informed as to the mental status of the patient vis-à-vis current suicide risk. The clinician makes it clear that the material discussed with the family involves issues of safety and not the content of therapy sessions, which do not directly relate to this. If substantial risk remains, the clinician helps the family review the safety plans they have in effect and suggests revisions when necessary or appropriate. The family and the patient should be informed that the early stages of convalescence from a suicide attempt may include the return of suicidal thoughts, so as to normalize the occurrence of such thoughts and prepare everyone for them. At the same time, the clinician holds out the hope that, with continued participation in treatment, the danger will subside and the family can resume normal functioning.

As in most psychoeducational endeavours, clear and consistent guidelines for both the family and the patient help reduce conflict and tension in the early stages of recovery. The family guidelines (see Table 59.1), adapted from McFarlane (2002) and Anderson et al. (1986) are specific to suicide attempts and might be used in addition to whatever other guidelines are suggested by the psychiatric diagnosis.

In the ideal situation, the patient and the family would continue to work together with the clinician to solve problems, the recovery from this episode encounters, and to work proactively to promote a healthy adjustment and avoid future episodes. The clinician takes the lead in helping the patient and the family identify potentially troublesome situations and engages them in formal problem-solving, as described by McFarlane (2002). Initially, the focus will be on issues of safety, but gradually, the focus will shift to resolving issues which impede communication among family members, and which keep recovery moving forward. Directly engaging the family in a collaborative process which taps into their experience with the

patient provides them with knowledge and skills about preventing suicide, increases communication between them and their family member, and greatly enhances the likelihood of after care treatment compliance and the avoidance of subsequent attempts.

Completed suicides of people who have made an attempt in the past suggests a failure in after care, which can often be traced back to the decisions and behaviours of the clinicians and care-staff who handled the initial attempt. Sufficient evidence now exists to demonstrate the efficacy of involving the family in the treatment of a variety of physical and psychiatric disorders, to allow the supposition that involvement of the family after a suicide attempt is likely to reduce not only immediate danger, but also improve after care treatment adherence and reduce the likelihood of subsequent attempts. The family psychoeducation model is a means of involving the family in a way which is respectful of their strengths and sensitive to the needs of the patient. Implementing such an intervention requires the clinician to make an effort to work in a collaborative way, with both the patient and the family, preferably prior to discharge from the emergency treatment setting.