Leveraging Alliance-Based Interventions to Address Suicide Risk

Developing and maintaining a therapeutic alliance is key, especially for patients with self-destructive and suicidal behaviors, Eric M. Plakun, MD, told attendees of the 2023 American Psyc

hiatric Association Annual Meeting. Plakun, medical director and chief executive office the Austen Riggs Center, shared his clinical experience and lessons learned in describing the 9 practical principles of the Alliance Based Intervention for Suicide (Table).

9 Principles of ABIS

1. Differentiate therapy from consultation

2. Differentiate lethal from non-lethal self-destructive behavior

3. Explain it is the patient’s responsibility to stay alive as part of the therapeutic alliance

4. Contain and metabolize the countertransference

5. Engage affect

6. Non-punitively interpret the patient’s aggression in the decision to end treatment via their actions

7. Hold the patient responsible for preservation of the therapy

8. Search for the perceived injury from the therapist that may have precipitated the self-destructive behavior

9. Provide an opportunity for repair

First and foremost, set the foundation of the therapeutic relationship by differentiating between consulting and the therapy phase, Plakun commented. The consultant phase allows the patient and clinician to understand and negotiate the terms of an alliance. He might spend a few sessions exploring their background and what may have brought them to care. “I need you alive to do the work,” he tells them. “Can you agree to this? If so, we can see where this takes us.” The self-destructive behavior should also be noted in the contract.

Next, it is important to consider the meanings of any self-destructive behavior as well as their impact on others. Possible meanings include atonement or self-punishment, fusion with another, aggressive assault, marking a boundary, or even a substitute for actual suicide. He spoke of a patient with suicidal ideation and self-cutting behaviors. As part of the initial treatment discussion, her therapist asked her to cease cutting in addition to being safe from suicide. Unfortunately, the patient was using the cutting behaviors as a substitute for suicide, and without that outlet, the patient was lost.

Plakun also detailed the story of “Daisy,” a patient he encountered who had attempted suicide seemingly out of nowhere after a family event. Daisy was raised in the Bible Belt, and she had limited education (ie, high school degree). She reported being unhappy at home as a teen and said she would often go to hang out with friends and others in the woods. Daisy reported being hospitalized in high school following a panic attack. Eventually she moved north, got married; at time of presentation, she had a 14-year-old son. She was place on 150 mg amitriptyline and therapy continued.

Treatment continued and was not remarkable until Plakun the patient was a no-show on Christmas eve—the last day of work for him before a holiday break. This was unusual for Daisy, who never came to the office that day. Instead, Plakun received a call from Daisy’s husband looking for her, as she was late for a date with him. The police were alerted and, shortly thereafter, Daisy was found in a van in a parking lot, somnolent after overdosing on her medication.

Plakun’s initial reactions included fear and being terrified and even angry with the patient. He then pulled in 1 of the ABIS’ principles: to contain and metabolize the countertransference to resume empathetic neutrality; he engaged Daisy in the hospital. “We had an agreement to keep yourself safe,” he said. “You seem to have made a decision to end our work,” he added, referencing the attempt. “I can continue to consult with you, by our commitment to weekly sessions has ended.” Unhappy with this, Daisy explains he was not available when she needed him, so she will find someone else.

Two months later, after trying other clinicians, Daisy returned, and they began to process the events. At that point, Daisy shared new and vitally important information about her previous psychiatric hospitalization: She had been drugged, beaten, and gang raped in one of her outings as a youth. Afraid to discuss this with her religious parents, she kept it to herself. She was later triggered in high school when a boy cornered her to ask her out.

The resulting panic attack landed her in the hospital. As part of outpatient treatment, the therapist asked Daisy to show him the sexual experimentation she had encountered in the woods, which further victimizes Daisy. Scared and ashamed, she considered cutting the therapist, but was unable to do so. Instead, she convinced her family she no longer needed those sessions.

Flash back to present time, and Daisy explained those negative experiences came crashing down on her shortly before the holiday as a result of a few things: Her husband asked her if she was sleeping with Plakun; a seemingly benign comment from Plakun—although they were not making progress about understanding the suicide attempt, they had a good connection, and that Plakun would be unavailable due to a family holiday gathering. Thus, her panic attack.

The benign comment falls in line with another principle, Plakun told attendees, and one that psychiatrists often overlook: consider a perceived injury from the therapist that may have precipitated self-destructive behavior.

Plakun mentioned resources from the Group for the Advancement of Psychiatry as well as the American Psychiatric Association’s Psychotherapy Caucus for clinicians who want to learn more. For those who want to “work at the top of their license,” these psychotherapeutic tools are essential, Plakun noted.

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