Contingent suicidality

[randomdoc1]

We're all familiar with the "admit me to the hospital or I'll kill myself." But what about patients who say they will kill themselves if [insert undesirable event here]? My clinic had a case of a patient with borderline personality disorder, who said she'd kill herself if her (to my understanding well established) business became understaffed and she was unable to find a way to resolve the issue. I was not pleased with how it was handled by her non-prescribing provider. The provider became very anxious and intense countertransference was generated. She initially had strong positive countertransference and allowed exceptions for this patient, not charging for no shows (I did not find out until later). Once the patient voiced contingent suicidality, the provider became extremely anxious and demanded she enroll right away into PHP and made a plan for pt to call intake. That is when the no shows started, prior to that the patient attended therapy religiously. When the ghosting started, the provider nearly called the police for a wellness check. At no point has the patient ever expressed imminent, well solidified plan or even intent. It was a hypothetical situation. She had no access to firearms, substance use, is still raising children who still have much need for her. I told the provider let's just touch base with the patient about follow up first and we were able to reach her via phone. The provider then insisted in order for the relationship to continue, therapy at least must be twice a week. It sounded like it became a power struggle in this situation (provider trying to treat her own anxiety and control the clinical course) and by the time the patient had their third uncharged no show, the therapist was furious. Another detail is that in the treatment plan, the patient was informed from the start that we have no female psychiatrists available in the hours she requested. She agreed to see one of our male providers. She no showed to her first appointment with him. Then agreed to attend the next one. Upon starting the visit she changed her mind, saying she did not like his demeanor and casting him in a way that reminded her of sexual trauma. She said she refuses to do anything that is upsetting to her. Patient proceeded to demand a transfer to a different prescriber blaming the office for not catering to her preferences and she was reminded that from the beginning she was informed of what we had available and we are unable to fulfill her request. At this time she was really starting sound like an entitled, demanding, privileged cluster b pile of _____. So I professionally spoke with her on the phone offering her other resources (had no care in having more of her presence in the office, we're on 5 no shows now with incessant demands). Fortunately we got a correspondence from the patient saying she was grateful for the care and she wishes to cancel all appointments at this office and will continue elsewhere. Correct me if I'm wrong, but from a liability standpoint, that probably really helped for documentation. I think she canceled as a final "eff you [for not giving me the female psychiatrist with evening hours I kept demanding for]".

Regardless, wanted to share this case with colleagues who understand the feeling. But for my own curiosity. what are your takes on this type of contingent suicidality? Her therapist I think misinterpreted as imminent risk, must go to hospital care asap. But I see this as a communication in someone with a personality disorder of how they fantasize about coping with distress. Of course, suicide risk must be assessed, documented and triaged appropriately. But in this case, I did not see anything modifiable by higher level of care and the therapist's approach likely had an adverse outcome. I would not have wanted to continue to have this case in the clinic anyways given she started to unfold being so demanding and boundary pushing. But I think it could have been peacefully concluded without anywhere near as much escalation and the provider did not stay aware of their countertransferance reactions. The trouble first starting with allowing this patient special exceptions on no shows. there was another incident where she put this patient on the schedule of a female prescriber without consulting me first, although I told her as clinic policy no one can add new patients on a psychiatrist's schedule without my approval---the therapist said the acuity warranted it and she'd tell me afterwards. I had her cancel that appointment. And I even told her, this may very likely be a seed of resent the patient will bring up later and I was correct. Also, does anyone know if any literature of these types of scenarios? The only one I found was this link below. Which echoes some of the thoughts I have.

https://ajp.psychiatryonline.org/doi/10.1176/ajp.155.11.1502

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[forchinet121]

So I’m not sure the therapists overreacted to be honest, who knows when her business will become understaffed and then her kill herself? I think getting her into PHP into a higher level of care with increased monitoring is warranted. I think that also sending her for admission to the ER could be reasonable as well given the specific details of her business and how understaffed or likely to be understaffed it is. I agree with the boundaries and everything else you said.

 

[randomdoc1]

So I’m not sure the therapists overreacted to be honest, who knows when her business will become understaffed and then her kill herself? I think getting her into PHP into a higher level of care with increased monitoring is warranted. I think that also sending her for admission to the ER could be reasonable as well given the specific details of her business and how understaffed or likely to be understaffed it is. I agree with the boundaries and everything else you said.

I would agree this would be hard to assess without knowing more details about what is going on with the business. Perhaps I should have been more specific. I think this patient was pretty clear that she had no interest in higher level of care even if it was warranted. But it sounded like more the approach may have been damaging. The continued insistence to adhere to the plan and contacting the patient about when the phone intake was, when they are scheduled to do PHP, etc. The patient did not feel like she was engaged in the medical decision making and she clearly gets very delicate around matters of control. She may very well at least have agreed to therapy twice a week or even higher level of care, if she felt it was more of her decision versus being ordered. And she could probably pick up on the state of alarm in the non-prescribing provider. When she presented the case she sounded nearly frantic. Of note, I have had similar feedback from multiple patients (and their collaborating psychologists and psychiatrists) about similar outcomes with her. So I think it may be a mixed bag on both ends.

 

[Liquid8]

A suicidal threat that is essentially reliant on events outside of anyone’s control isn’t going to change with more frequent appointments, and it feels like the decision to have twice weekly therapy is more about allaying the therapist’s fears as opposed to being of any perceived clinical benefit to the patient. After all, if the patient was the one pushing for it you’d expect them to actually attend.

To me it sounds like the therapist needs support regarding suicide risk assessments and managing their own anxieties. May be worth setting aside some time to explore what was so urgent about the case that they felt the need to break established clinic rules and protocol, and using this as a learning experience for them.

 

[forchinet121]

A suicidal threat that is essentially reliant on events outside of anyone’s control isn’t going to change with more frequent appointments, and it feels like the decision to have twice weekly therapy is more about allaying the therapist’s fears as opposed to being of any perceived clinical benefit to the patient. After all, if the patient was the one pushing for it you’d expect them to actually attend.

To me it sounds like the therapist needs support regarding suicide risk assessments and managing their own anxieties. May be worth setting aside some time to explore what was so urgent about the case that they felt the need to break established clinic rules and protocol, and using this as a learning experience for them.

You’re right it isn’t going to change but the point of the frequent visits would be to monitor the status of the business/SI, I would be wary of scheduling this patient out longer than a week or so given documenting contingent suicidality, I would probably insist on PHP as well to be honest without knowing the specifics and might even consider inpatient admission, again not commenting on the approach the clinician took but rather the treatment options, but I’m pretty inexperienced so open to different opinions/insights

 

[SmallBird]

I agree that the patients behavior could represent the symptoms of her personality disorder and that if the goal is to help he patient then a skilled therapist could work to explore this over time and tolerate this ambiguous statement about safety in the interests of the therapeutic relationship. Tbh though, I haven't got time for this nonsense anymore, and if you have a bad outcome, I don't think there are enough people who are trained in psychodynamics to accept the explanation for why a higher level of care wasn't required. If a patient wants to introduce anxiety into the therapy experience that way I support the therapist setting demands on how he or she would like to manage that.

 

[Fan_of_Meehl]

We're all familiar with the "admit me to the hospital or I'll kill myself." But what about patients who say they will kill themselves if [insert undesirable event here]? My clinic had a case of a patient with borderline personality disorder, who said she'd kill herself if her (to my understanding well established) business became understaffed and she was unable to find a way to resolve the issue. I was not pleased with how it was handled by her non-prescribing provider. The provider became very anxious and intense countertransference was generated. She initially had strong positive countertransference and allowed exceptions for this patient, not charging for no shows (I did not find out until later). Once the patient voiced contingent suicidality, the provider became extremely anxious and demanded she enroll right away into PHP and made a plan for pt to call intake. That is when the no shows started, prior to that the patient attended therapy religiously. When the ghosting started, the provider nearly called the police for a wellness check. At no point has the patient ever expressed imminent, well solidified plan or even intent. It was a hypothetical situation. She had no access to firearms, substance use, is still raising children who still have much need for her. I told the provider let's just touch base with the patient about follow up first and we were able to reach her via phone. The provider then insisted in order for the relationship to continue, therapy at least must be twice a week. It sounded like it became a power struggle in this situation (provider trying to treat her own anxiety and control the clinical course) and by the time the patient had their third uncharged no show, the therapist was furious. Another detail is that in the treatment plan, the patient was informed from the start that we have no female psychiatrists available in the hours she requested. She agreed to see one of our male providers. She no showed to her first appointment with him. Then agreed to attend the next one. Upon starting the visit she changed her mind, saying she did not like his demeanor and casting him in a way that reminded her of sexual trauma. She said she refuses to do anything that is upsetting to her. Patient proceeded to demand a transfer to a different prescriber blaming the office for not catering to her preferences and she was reminded that from the beginning she was informed of what we had available and we are unable to fulfill her request. At this time she was really starting sound like an entitled, demanding, privileged cluster b pile of _____. So I professionally spoke with her on the phone offering her other resources (had no care in having more of her presence in the office, we're on 5 no shows now with incessant demands). Fortunately we got a correspondence from the patient saying she was grateful for the care and she wishes to cancel all appointments at this office and will continue elsewhere. Correct me if I'm wrong, but from a liability standpoint, that probably really helped for documentation. I think she canceled as a final "eff you [for not giving me the female psychiatrist with evening hours I kept demanding for]".

Regardless, wanted to share this case with colleagues who understand the feeling. But for my own curiosity. what are your takes on this type of contingent suicidality? Her therapist I think misinterpreted as imminent risk, must go to hospital care asap. But I see this as a communication in someone with a personality disorder of how they fantasize about coping with distress. Of course, suicide risk must be assessed, documented and triaged appropriately. But in this case, I did not see anything modifiable by higher level of care and the therapist's approach likely had an adverse outcome. I would not have wanted to continue to have this case in the clinic anyways given she started to unfold being so demanding and boundary pushing. But I think it could have been peacefully concluded without anywhere near as much escalation and the provider did not stay aware of their countertransferance reactions. The trouble first starting with allowing this patient special exceptions on no shows. there was another incident where she put this patient on the schedule of a female prescriber without consulting me first, although I told her as clinic policy no one can add new patients on a psychiatrist's schedule without my approval---the therapist said the acuity warranted it and she'd tell me afterwards. I had her cancel that appointment. And I even told her, this may very likely be a seed of resent the patient will bring up later and I was correct. Also, does anyone know if any literature of these types of scenarios? The only one I found was this link below. Which echoes some of the thoughts I have.

https://ajp.psychiatryonline.org/doi/10.1176/ajp.155.11.1502

I'm aware of some case law on contingent threats...for example, a husband says that 'If [he] finds out that his wife and best friend are having an affair, he will kill them both.' In general, I don't think we're liable for contingent threats eventually coming true. I would imagine that similar logic would apply to suicidal threats which are contingent with possible exception of the general issue of foreseeability...if the contingency is imminent and very likely, this may change things? Of course, with the ever worsening zeitgeist of 'Zero Suicide Initiatives' and 'one life lost is too many' pompom waving...all bets may be off.

Edit: I'd also take a closer look at this part..."who said she'd kill herself if her (to my understanding well established) business became understaffed and she was unable to find a way to resolve the issue." If a patient like that said this to me, I'd immediately be compelled to engage in some follow-up questioning regarding:

(1) do you mean that you're extremely concerned that if the business becomes 'understaffed' (whatever the operational definition of that is), then you may be overwhelmed emotionally due to not being able to cope effectively with that contingency? Being extremely concerned about 'losing it' or not being able to cope is fundamentally different than making (perhaps for manipulative reasons) a clear contingent 'threat' of 'I'll kill myself if...'
(2) what is the definition of 'understaffed?' Are we really talking about staffing levels or your perceived lack of coping skills...if the latter, then lets spend the rest of the session working on your coping skills
(3) 'unable to find a way to resolve the issue'...okay, let's review what you have or haven't learned about resolving 'the issue' (assuming we've defined in our therapy what 'the issue' actually is)

By far, the biggest rookie mistake that I see even 'experienced' therapists making time and time again is freaking out and steering the conversations AWAY from vague (or any) threats made by patients for self/other harm. You want to lean INTO them and ask follow up questions to quickly discern if an actual threat is being communicated and does the patient have the intent and ability to carry out the (imminent) threat (some of this might vary with respect to how your state laws surrounding 'dangerous to self/other' patients are defined. But you never just 'pretend like it didn't happen' and steer the conversation away from the vague threat.

 

[Candidate2017]

All things considered, with hindsight supported by subsequent behavior, this seems like the patient merely discharged her anxiety and frustrations on to the "therapist", who buckled from the projective identification. There is something to be said for old school psychiatrists who do not accept split treatment and will fire patients who do therapy with someone else. While outsourcing treatment to therapists (or midlevels) may help a psychiatrist be more productive, the trade off is staff simply are not as skilled and sometimes create problems. More money, more problems.

Then again, if the patient was an actual threat to herself, the therapist should've have locked her up instead of PHP. There is no middle ground if danger is involved. Do or do not.

Before this even became an issue, there were at least a few strong hints that should have screened out this person:
1. A request for a specific gender, by a person whose chief complaint is not related to sexual violence, means this person is incapable or unwilling to deal with half of all humans.
2. No-showing to the initial eval is a hard no.
3. The demand for transfer to another psychiatrist should have triggered automatic discharge. The assumption is all psychiatrists in one's clinic are competent (if not, then fire them), and if a patient rejects your competent psychiatrist, there is absolutely nothing else another competent psychiatrist from your clinic can do for the patient. They are merely trying to split the clinic.

But then again, it depends on your vision of your clinic and how you want to make your money. Some are laissez faire and take everyone, others take everyone with good insurance, others are selective.

Personally, I would fire the therapist. For incompetence, violating your express instructions about scheduling, and for not firing patient after 3 no-shows (which is presume is your policy). Boundaries and processes. There is no problem new under the sun. Every problem that occurs is a result of underlying systemic issues, and will occur again unless the systemic issues are addressed.

 

[ObsequiousAplomb]

I see no reason why a higher level of care would mitigate this risk. I agree with others that contingent threats are great opportunities for exploration in therapy. If the contingent threat were "if Trump/Biden gets reelected I will kill myself' then there's a zero percent chance I would escalate that to a higher level of care. Just as with this scenario, it demonstrates a fantasy for how to address a fear.

 

[randomdoc1]

(1) do you mean that you're extremely concerned that if the business becomes 'understaffed' (whatever the operational definition of that is), then you may be overwhelmed emotionally due to not being able to cope effectively with that contingency? Being extremely concerned about 'losing it' or not being able to cope is fundamentally different than making (perhaps for manipulative reasons) a clear contingent 'threat' of 'I'll kill myself if...'
(2) what is the definition of 'understaffed?' Are we really talking about staffing levels or your perceived lack of coping skills...if the latter, then lets spend the rest of the session working on your coping skills
(3) 'unable to find a way to resolve the issue'...okay, let's review what you have or haven't learned about resolving 'the issue' (assuming we've defined in our therapy what 'the issue' actually is)

By far, the biggest rookie mistake that I see even 'experienced' therapists making time and time again is freaking out and steering the conversations AWAY from vague (or any) threats made by patients for self/other harm. You want to lean INTO them and ask follow up questions to quickly discern if an actual threat is being communicated and does the patient have the intent and ability to carry out the (imminent) threat (some of this might vary with respect to how your state laws surrounding 'dangerous to self/other' patients are defined. But you never just 'pretend like it didn't happen' and steer the conversation away from the vague threat.

Really great insights! My approach would have been:
1--lean into the relationship, strengthen it and try to create a safe experience to have as open of a discussion is possible. This will be your best defense. This situation is delicate. It was clear from the first visit you're walking on egg shells and she can shut down, resist, act out at the slightest hint of anything.
2--let's talk about the circumstance:
-what is objectively happening at the business?
-define unmanageable situation?
-how likely is this going to happen?
-how foreseeable and time frame may this potentially happen?
-should this happen, what are our options before resorting to suicide? What can we do to mitigate the risk of this happening?
3--does this patient actually want to live? How do they feel about their life in general? What keeps them living and what do they live for if anything?
4--how far are we in the suicide planning stages? What method and what alternatives? Do we have a time frame of when this may happen whether this circumstance happens or not?
5--how do the next 1-2 weeks look? How about 4-6 weeks?
6--why aren't we planning suicide today?
7--what does this idea of suicide accomplish for you? What is the role and purpose? What are other ways we can achieve this? Will suicide actually achieve the goals for you or is this a short sighted reaction?

I actually did the general intake on this patient. She presents as high functioning and she had quite future oriented thinking. She does get very touchy about matters of control and wants to call the shots on every detail. I see suicide as her attempt to feel she has the final say in the situation. But she's able to be reasoned with and has shown she was willing to compromise, granted she felt it was her decision and when options are laid out clearly demonstrating potential benefits of each and reducing the absolutist thinking. I've also presented things to her in the light of "hey, if ____ does not work, you do not have to stick with it permanently, but automatically excluding ____ can prematurely lock away things can be really effective, by not even giving it a chance."

This is a quote that really stood out to me:
"Such patients may feel no suicidal intention in the present at all, in part, of course, because the wish has been encapsulated into a particular context set in the future. This suggests that one of the elements of contingent suicidality is its effect as a defense against actual immediate suicide. There is a certain kind of person for whom the idea of suicide is a secret and cherished solution to any difficulty life may throw across his path. Suicide is the ace up his sleeve (revealed to no one), the secret possession of which shapes his response to any and every problem. Such a man confronts his life whispering to himself, “If I can’t find a better job, I’ll kill myself.” If my son won’t confide in me, if my daughter flunks her final exams, if my wife forgets my birthday just one more time—I’ll kill myself…because concealment is so vital to his “advantage,” as he conceives it, and therefore his deviousness and dishonesty so virtually impossible to penetrate, he is, I believe, the most difficult of all potential suicides to treat—or help in any way. (p. 126)"

Other things that did not line up with imminent risk was her affect. It was dulled, but did not have that hopeless rock bottom despair I saw in patients prior to suicide. And of course there's some patients who show no hint of it because they've already decided they will die, why broadcast it so someone can save you? There were definitely days where presentation was perfectly euthymic. And consistently her communications had plans in the future, the booking of appointments, activities with the kids and other plans she was formulating. No indication of preparation for death. Even her demands to change providers.

At the end of the day, it was not clear what the actual acuity of this case was. What I observed starkly contrasted with what the therapist said and the reaction of the therapist. The dynamics sounded so frantic -- and the patient slipping onto a schedule she did not belong to sounded manipulative (consciously or subconsciously).

All things considered, with hindsight supported by subsequent behavior, this seems like the patient merely discharged her anxiety and frustrations on to the "therapist", who buckled from the projective identification.

Those are my thoughts exactly! Why are we giving this patient special exceptions?! That should be the first clue to really step back and look at our reactions and be aware so our clinical judgement does not get too clouded. She was given a psychiatry appointment (with the male psychiatrist) before she started therapy, and as she was in therapy, she was now a cemented established patient. So it was a little harder to back out. Then the therapist flipped and caved and put her on the schedule of a female psychiatrist soon a she spotted a cancellation that was earlier than the intake. But fortunately we now have good documentation that we offered what we could and the patient refused it.

 

[Fluidity of Movement]

[not a doctor]

I'm at crisis text line and we don't even pass off texters to the professionals until after they have Ideation, plan, means, AND timeframe within 48 hours. Hopefully the therapist can recover from this situation and the patient will be ok. Sorry for butting in but these types of threads are really eye-opening and impactful for me.

 

[forchinet121]

[not a doctor]

I'm at crisis text line and we don't even pass off texters to the professionals until after they have Ideation, plan, means, AND timeframe within 48 hours. Hopefully the therapist can recover from this situation and the patient will be ok. Sorry for butting in but these types of threads are really eye-opening and impactful for me.

We don’t know the timeframe as the business can be understaffed at any time (hypothetically) so we would want to hospitalize someone that thinks killing yourself is an appropriate response to understaffed business

 

[Fluidity of Movement]

We don’t know the timeframe as the business can be understaffed at any time (hypothetically) so we would want to hospitalize someone that thinks killing yourself is an appropriate response to understaffed business

I'm just constantly baffled how all of this manages to work as well as it does, when you have a doctor and a therapist trying to work together. It seems like the doctor would fit best taking care of the patient all the way through, but how can they get years and years of talk-therapy training, all while still trying to remain medical experts.

But then when the teamwork and care plans breakdown... it's like trying to square a circle. Respect to you all and hopefully I can figure out the right training for myself in the future.

 

[Fan_of_Meehl]

I'm just constantly baffled how all of this manages to work as well as it does, when you have a doctor and a therapist trying to work together. It seems like the doctor would fit best taking care of the patient all the way through, but how can they get years and years of talk-therapy training, all while still trying to remain medical experts.

But then when the teamwork and care plans breakdown... it's like trying to square a circle. Respect to you all and hopefully I can figure out the right training for myself in the future.

Just a word of clarification: the term 'therapist' is going to be a pretty broad and inexact (and far-spanning) term in the mental health field. The following professionals would/could all be labeled 'therapist':

1) a self-appointed 'therapy coach' without a college degree or licensure or any specialized/supervised training or experience
2) a bachelor's-level 'substance abuse counselor' with a bachelor's degree and state certification
3) a master's-level therapist/counselor with a state license (social worker (LCSW) or master's-level psychologist (MA/MS))
4) a rank-and-file doctoral-level (PhD/EdD/PsyD) psychologist with a state license who completed APA-approved graduate programs and internship
5) #4 with additional post-doctoral training and/or board certification (ABPP) and, say, 30+ years clinical experience
6) an M.D. (psychiatrist) who was well-trained in how to conduct psychotherapy in addition to psychoparmacology
7) an M.D. (psychiatrist) with minimal training/experience/emphasis on evidence-based psychotherapy, per se
8) a pastoral counselor
9) a 'marriage and family therapist'
10) I'm sure there's at least 264 more possibilities

My point being, there's an incredibly broad swath of possible training/qualifications/competencies represented under the moniker of 'therapist' and not all of them, in my opinion, should be considered inferior to a 'doctor' (an inexact term, in itself that can apply to MD/PhD/PsyD/EdD/DNP/XyZD...etc.), however defined.

Not fussing, just trying to shed some light on the fact that 'doctor vs. therapist' is going to be a pretty fuzzy comparison.

 

[mistafab]

I think this case highlights how ongoing supervision is necessary in therapy, that you don't just complete training and are 'done.' Many of the boundary crossings in this case could have prompted a timely/appropriate response that perhaps could have fired the patient or fired the therapist much earlier in the treatment course. The many no-shows essentially cost the clinic hundreds of dollars worth of provider time. As @Candidate2017 pointed out, perhaps this prompts a review about the new patient screening process as well (if you have that control).

Overall, the actual outcome turned out to be fine. Glad this did not blow up dramatically on you. Hopefully the therapist is willing to reflect on the many inappropriate behaviors they engaged in. Otherwise, they may integrate this ugly pattern into their work identity ('I'm the therapist THAT CARES').

 

[Fan_of_Meehl]

I think this case highlights how ongoing supervision is necessary in therapy, that you don't just complete training and are 'done.' Many of the boundary crossings in this case could have prompted a timely/appropriate response that perhaps could have fired the patient or fired the therapist much earlier in the treatment course. The many no-shows essentially cost the clinic hundreds of dollars worth of provider time. As @Candidate2017 pointed out, perhaps this prompts a review about the new patient screening process as well (if you have that control).

Overall, the actual outcome turned out to be fine. Glad this did not blow up dramatically on you. Hopefully the therapist is willing to reflect on the many inappropriate behaviors they engaged in. Otherwise, they may integrate this ugly pattern into their work identity ('I'm the therapist THAT CARES').

Agreed. It's (somewhat) pure speculation on my part but I would guess that the original 'threat' of 'I'll kill myself if my business becomes understaffed' was likely meant as a (not necessarily deliberate) 'power play' on the part of the personality-disordered client to 'shake up' the therapeutic frame and 'knock' the therapist a bit off-balance in the encounter. Unfortunately, it looks like it may have been 'successful' in doing so by eliciting a strong fear/apprehension response in the therapist ('OMG, I don't want this person to kill themselves and have everyone blame me!') which then caused the therapist to 'allow' boundary crossings or otherwise treat the person 'gingerly' in terms of articulating or enforcing boundaries. I would guess that--if this were the case, and if the therapist were to appropriately 'lean into' the apparent threat to clarify what exactly the client meant by it in order to assess if hospitalization were necessary--then the client would likely 'back off' the threat or, even more likely, shift the topic to something else and perhaps try a different gambit. Of course, I'm not saying that we should ever assume that clients like this aren't serious or aren't in serious distress--which would be why I would recommend taking their threats quite seriously and try to immediately and empathically clarify what they are thinking, feeling, and perhaps motivated to do in response to their current state. There are too many variables to make this anything but speculation on my part but I do this because I have seen threats to harm self/others employed in this manner across a number of contexts.

 

[clausewitz2]

Agreed. It's (somewhat) pure speculation on my part but I would guess that the original 'threat' of 'I'll kill myself if my business becomes understaffed' was likely meant as a (not necessarily deliberate) 'power play' on the part of the personality-disordered client to 'shake up' the therapeutic frame and 'knock' the therapist a bit off-balance in the encounter. Unfortunately, it looks like it may have been 'successful' in doing so by eliciting a strong fear/apprehension response in the therapist ('OMG, I don't want this person to kill themselves and have everyone blame me!') which then caused the therapist to 'allow' boundary crossings or otherwise treat the person 'gingerly' in terms of articulating or enforcing boundaries. I would guess that--if this were the case, and if the therapist were to appropriately 'lean into' the apparent threat to clarify what exactly the client meant by it in order to assess if hospitalization were necessary--then the client would likely 'back off' the threat or, even more likely, shift the topic to something else and perhaps try a different gambit. Of course, I'm not saying that we should ever assume that clients like this aren't serious or aren't in serious distress--which would be why I would recommend taking their threats quite seriously and try to immediately and empathically clarify what they are thinking, feeling, and perhaps motivated to do in response to their current state. There are too many variables to make this anything but speculation on my part but I do this because I have seen threats to harm self/others employed in this manner across a number of contexts.

The general DBT approach of responding to statements like this with a calm, inquisitive, and excruciatingly detailed examination of what is going on can be helpful here. You communicate you are actually taking them seriously and aren't dismissive but also if this kind of statement is a bid for more emotive engagement or to get a rise out of you it is not productive. The last thing that someone doing this for other communicative purposes wants to do is engage in a protracted and detailed conversation about it so they will tend to produce this behavior less over time.

 

[Fluidity of Movement]

4) a rank-and-file doctoral-level (PhD/EdD/PsyD) psychologist with a state license who completed APA-approved graduate programs and internship
5) #4 with additional post-doctoral training and/or board certification (ABPP) and, say, 30+ years clinical experience
6) an M.D. (psychiatrist) who was well-trained in how to conduct psychotherapy in addition to psychoparmacology
7) an M.D. (psychiatrist) with minimal training/experience/emphasis on evidence-based psychotherapy, per se

Thank you, I know I want to be a physician but then I know that the psychotherapy training is harder to become competent on. That's why I was thinking maybe try to find the right residency / fellowship but that isn't guaranteed. Then maybe I could work on a LPC / midlevel as an attending, etc.

I doubt I'll ever be as good as #5 but hopefully can reach #6. I'm an older non-trad so reaching 30 years of anything would be a blessing. I know I'm still a long way out but because I'm dealing with SI "patients?" every day it's difficult to "back pocket" these types questions and ultimately I guess fears I have for the future. It's not like I have anyone to mentor me, so I try to learn from reading stuff here.

 

[smalltownpsych]

I would barely blink if I patient told me that. Depending on the therapeutic rapport and what the patient was trying to communicate, I might even laugh about it. Might be a fairly adaptive defense mechanism and if I don’t get that they’re “joking” then I’m not too bright. This one is pretty low on the suicidal risk score from my perspective. Doesn’t mean I would dismiss or ignore it as I always go deeper. Just ask my patients who get annoyed (feel comforted) by me not letting certain things slide.
Agree completely with posts that advocate leaning in and finding out more. In fact, if the patient is truly feeling hopeless and overwhelmed and isn’t sure if they can take one more friggen thing, I want to hear that and respond to that empathically. When they express their pain in a genuine way, then we can work together to come up with a plan to help them through it which rarely involves hospitalization if they are still functioning. Could mean a brief residential stay as that was helpful for a couple of my patients who were functioning but hanging on by a thread more than anything else. Usually it was something that we talked about during a crisis and then after subsequent crises, patient agreed that it would make sense.

 

[whopper]

A major reason why I left my last place of work was because they refused to deal with malingerers, and cluster B manipulation in the ER or inpatient unit. Everyone got admitted unless I was on duty. Also there was a psychiatrist on our staff who saw giving these people a free place to stay as compassionate care. Didn't matter that the crime rate in the unit went up and due to antisocial issues. E.g. patients find the contact info of other patients, call an accomplice in the community, the accomplice looks up their address, then the place is robbed while the patient is in the hospital.

While I was at U of Cincinnati we knew who the malingerers and cluster B manipulators were, and if someone new came in we'd have it figured out usually with the first ER visit or admission. Social workers and psychiatrists documented the way it's supposed to be done. That is write the note so the next clinician knows what's going on. This was not going on where I last worked.

 

[Desired Member]

I would barely blink if I patient told me that. Depending on the therapeutic rapport and what the patient was trying to communicate, I might even laugh about it. Might be a fairly adaptive defense mechanism and if I don’t get that they’re “joking” then I’m not too bright. This one is pretty low on the suicidal risk score from my perspective. Doesn’t mean I would dismiss or ignore it as I always go deeper. Just ask my patients who get annoyed (feel comforted) by me not letting certain things slide.
Agree completely with posts that advocate leaning in and finding out more. In fact, if the patient is truly feeling hopeless and overwhelmed and isn’t sure if they can take one more friggen thing, I want to hear that and respond to that empathically. When they express their pain in a genuine way, then we can work together to come up with a plan to help them through it which rarely involves hospitalization if they are still functioning. Could mean a brief residential stay as that was helpful for a couple of my patients who were functioning but hanging on by a thread more than anything else. Usually it was something that we talked about during a crisis and then after subsequent crises, patient agreed that it would make sense.

When you say residential stay, is that for substance abuse? These are very difficult to find where I practice

 

[smalltownpsych]

When you say residential stay, is that for substance abuse? These are very difficult to find where I practice

There are some treatment centers for just psych stuff. Have to have insurance or cash to pay for it and patient will often need to go out of state depending on where you’re located. Not much like that exists with state funded systems that I know of.