First Session Intervention in Self-Injurious Crisis

Suicidal or self-injurious crisis intervention might just be one of the most sensitive ones out there. This is because the pressure a therapist feels in these circumstances is huge. Hence, today's article will focus on the first session because the possibility of suicide is greater there.
First Session Intervention in Self-Injurious Crisis

Last update: 03 June, 2021

The World Health Organization (WHO) lists suicide, a self-injurious crisis, as the leading cause of violent death worldwide. many more than those by other types of homicide, even war murders. The number of suicides was nearly double the number of deaths due to traffic accidents. This is an important topic that we’ll discuss in today’s article.

Although you may not be aware of it, suicide is the second leading cause of unnatural death among 15 to 25-year-olds. Therefore, it’s an epidemic that specifically threatens public welfare along with all the psychopathology that comes with it. Thus, suicide crisis intervention is a tool for its preservation.

Myths and prejudices about suicide and the fear of a hypothetical call effect make it so that suicide seldom makes the headlines of newspapers or news programs in proportion to its prevalence. As a result, education about suicide is scarce and myths usually fill the void.

Believing such myths in suicidal crisis intervention is a mistake that needs correction. This is because of the impact on the individual who attends therapy and their subsequent prognosis.

“I didn’t want to wake up. I was having a much better time asleep. And that’s really sad. It was almost like a reverse nightmare, like when you wake up from a nightmare you’re so relieved. I woke up into a nightmare.”

-Ned Vizzini-

A distressed woman.

The suicidal self-injurious crisis and the first session

First of all, it’s important to know that discussing suicide doesn’t increase its possibility. One should never be afraid to ask specific questions about suicidal ideation or self-injurious behavior.

In fact, assessment tools such as the BDI-II (Beck, Steer, Brown, Sanz, & Vázquez, 2011) ask explicit questions. These aren’t only about suicidal intent but also attempts to establish its actual levels. Thus, therapists, as well as a standardized measurement tool, must be able to assess freely, without fear of reinforcing these ideas.

The assessment must be exhaustive, especially regarding social and environmental support, the presence of any medical condition, history of previous psychopathology and family, previous suicide attempts, and suicidal ideation (method, planning, and intentionality). Then, they must use all of this information as a basis to assess the need for hospital admission.

However, either there isn’t always the possibility of admission or the suicide attempts aren’t so pressing. Thus, a therapist has 50-minute sessions to work with a self-injurious client and motivate them to stick to the therapy.

Alternative behaviors and stimulus control

The first measure is related to the number of sessions with a client. Psychological therapy usually takes place weekly. You must increase the number of sessions to at least two per week after the first session in which you determine you’re dealing with a self-injurious client. This way, your client will only have to spend two or three days without therapeutic support.

In addition, it’s too hasty to expect the client to develop coping strategies during a self-injurious crisis. You both must work in the therapeutic alliance two days a week until they attain a greater degree of autonomy and introduce some of the tasks described below.

You can’t pretend proper emotional management on the part of a client during the first session, as they haven’t worked on it yet. Thus, the goal isn’t to avoid suicidal ideation at the moment of a crisis but to provide them with a list of alternative behaviors they can put into practice when they’re highly distressed.

Alternative behaviors

Taking a shower, listening to music, reading, going for a walk, or talking to a friend or close person about something other than their discomfort can prove helpful. They may seem like rather banal actions but will force the person to leave the house and establish a stimulus control with behaviors incompatible with suicide. Talking to a friend can be decisive for a person thinking about going through with their self-injurious plans during moments of crisis.

It’s important to make a list of these alternative behaviors during the first session and to check if the patient is putting them into practice. Evaluate why they aren’t if that’s the case.

Reasons for living and life memories in the face of a self-injurious crisis

Cognitive restructuring after the first session is necessary to identify and point out those reasons that are reasons for living. However, propose a simple list, given that the first session will be insufficient to establish an effective Socratic dialogue. Have them include photographs if possible, as these can motivate alternative behaviors to suicide.

The goal of the list of reasons to live is for the client to keep it handy and doesn’t have to elaborate it during critical moments, where the negative worsens and they forget the positive. This and other measures must always be followed by a well-thought-out evaluation. This is because it’ll give you clues about the quantity and quality of the possible things that must be part of this list.

Thus, skip this step if the client indicates they have no friends, pets, family, or hobbies. Instead, some mobile apps, such as Prevensuic, have tools like “Reasons to live” or “My life photos”. These may be helpful for implementing it during the session.

A therapist and a patient.

Does a non-suicide contract work?

This type of contract must be written by hand and it’s between the client and their therapist. It’s only valid until the following session. For example, the client must promise not to attempt suicide in the next three days (at least). This is because it’s when the next session will take place. Then, they’ll renew the contract in that session by signing it again. The signature of the contract will disappear as the sessions go by and cease to be necessary, assuming the suicidal thoughts will progressively become less pronounced.

Therefore, there must be activities to provide the client with resources against suicidal ideation from the very first session. Having lists and documents that validate the suicidal crisis and take it seriously is the beginning of a therapeutic alliance. That is a connection that must be nuclear for the therapeutic development and improvement of the client’s state of mind.

The tasks carried out in the next sessions will have to be more specific and powerful. However, offering alternative behaviors, stimulus control, tools derived from positive psychology, and contracts are all relevant. Especially for a person who thinks suicide is the only option.

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  • Chiclana, C. y Giner, L. (2011). Protocolo diagnóstico del paciente con riesgo de suicidio. Protocolos de práctica asistencial, 10(85), 5777- 5781.