Clinical Impact Statement: Psychologists may often facilitate the treatment of suicidal patients by involving family members or significant others in psychotherapy. This article considers several factors that psychologists need to consider when deciding if or how to involve them in treatment.
Suicides occur from a congruence of many factors including the quality and amount of social support an individual receives. Fortunately, several treatments have strong support for their effectiveness in reducing suicide attempts including cognitive behavior therapy, dialectical behavior therapy, and the collaborative assessment and management of suicide among others (Calati & Courtet, 2016). Whatever intervention psychologists use, however, they need to consider the role of family members or significant others (concerned others) in psychotherapy. Often the involvement of concerned others can make the difference between an effective and futile intervention. But psychologists need to decide carefully if or how to involve concerned others because some might not have the desire or skills necessary to help the patient and others will only be able to help if the psychologist guides them appropriately. This article will first review the importance of social relationships for suicidal patients and then consider when and how to integrate concerned others into treatment.
Interpersonal Relationships and Suicide
Loneliness increases the risk of suicide (McClelland et al., 2020). Married persons have lower rates of suicide than unmarried persons (Øien-Ødegaard et al., 2021). When identifying their reasons for living, suicidal patients often identified their obligations to others, their responsibility to their children, or even their concern for their pets (Bryan, 2021). Interpersonal stressors often precipitate suicide attempts. Stone et al. (2018) identified relationship problems as precipitants in 42% of all suicide attempts. These precipitants could involve the loss of a relationship (e.g., physical relocation, separation, divorce, death), the threatened loss of a relationship, or a decline in the quality of the relationship such as could occur with arguments with loved ones. Suicide notes often reference loneliness (Synnott et al., 2018). Poor relationships involving lack of closeness, hostile or critical comments, or partner abuse may increase the risk of suicide (Kazan et al., 2016). Given the close connection between loneliness, interpersonal strife and suicide, it is not surprising that the interpersonal theory of suicide focuses on relationships including perceived burdensomeness (the perception that “one is a burden to others and that one’s friends, family, or society generally would be improved if the individual were to die;” Tucker et al. 2018, p. 427-428) and thwarted belongingness (“a perception of a lack of desired, reciprocally caring relationships and an unmet desire to belong;” Tucker et al., 2018, p. 427).
Integrating Concerned Others into Suicide Interventions
Given the strong link between social relationships and suicide, it makes sense that psychologists consider involving concerned others into the treatment of suicidal patients. Concerned others can urge patients to get into or to stay in psychotherapy, participate in the development of the patient’s safety plan and lethal means counseling, offer distractions that could help interrupt suicide crisis states, monitor patients who are in a suicidal crisis, provide a sense of belongingness and reasons for living, offer emotional support, give practical assistance, or give feedback on how the patient is progressing in psychotherapy. Patients often indicated that the involvement of others was pivotal in keeping them alive, although some said that it could be harmful as well (Hom et al., 2020).
Whether to Involve Concerned Others in Treatment
Some patients may not wish to involve others for reasons reflecting their misperceptions or distorted beliefs. For example, some patients may not wish to burden others with their problems. This may reflect a sense of perceived burdensomeness, so it is especially important for psychologists to discuss this with their patients as well as other non-rational reasons for rejecting the involvement of concerned others.
At other times patients may not wish to involve family members or others who have shown insensitivity, a lack of concern, or malice toward the patient. In extreme cases they may have harshly criticized, bullied, or physically abused the patient. Or they may endorse stigmas associated with suicide, such as the belief that suicidal persons are selfish or cowardly, or that people should manage their problems by themselves and not go for treatment (Hom et al., 2020). Even well-meaning family members may cause more harm than good if they believe in the tough love approach, overstep their boundaries, or act in hurtful, intrusive, or unwelcomed ways.
As with all major decisions in psychotherapy, psychologists need to consider the perspectives of their patients very highly. Psychologists should overturn the wishes of the patient to involve concerned others only under extreme circumstances, such as when involving them would be the only way to ensure the safety of the patient and other means to ensure safety are not feasible.
How to Involve Concerned Others
If psychologists and patients decide to involve concerned others into psychotherapy, then they may wish to discuss the goals for the meeting before it begins. Psychologists need to orient the concerned others to their role in psychotherapy which is to benefit the patient. If psychologists anticipate that the concerned others will be involved frequently in psychotherapy, then they may wish to describe to all parties how they will manage communications with the concerned other. Psychologists might say, for example, that they accept information from the concerned other if the patient gives consent. But psychologists should not promise that they will always keep all information received as confidential and withhold the source from the patient. Psychologists do not want to be in a situation in which concerned others gave crucial information about the patient and then added the caveat— “but don’t tell him I said so.” Conversely, concerned others should not be in a position where they gave information expecting it to be held in confidence, but then were told that it will not be held in confidence. Many psychologists manage this situation by saying that they will disclose the information only if, on the balance, it is in the patients’ best interest to do so.
When psychologists meet with concerned others for the first time, they may learn that they feel shocked (if they recently learned about the suicidal crisis), traumatized (for example if they saw their loved one attempt suicide), or relieved (that others have identified this as a problem that they have suspected). If their loved one has been suicidal for a long time, they may feel fatigue from dealing with their anxiety or anger. Psychologists may need to balance the acknowledgement of and respect for the emotional state of the concerned other with the need to focus on the wellbeing of their patients.
Bryan and Rudd (2018) suggested that psychologists offer patients the option of having a concerned other discuss their safety plan with them. Safety plans are collaboratively developed and brief interventions that guide patients on how to protect their safety when they fear that they will be entering into a suicide crisis state. Safety plans may include identification of signs warning of an impending suicidal crisis, reasons for living, distracting activities, persons to reach out to for support, lethal means counseling, and crisis response services.
Safety plans reduce suicide attempts by an average of 43% (Nuij et al., 2020). Also, patients tend to find that safety plans helped them. For example, three fourths of respondents found that “doing things with other people” was either “somewhat helpful” or “very helpful” in helping manage their suicidal thoughts (Simon et al., 2016, p. 1027). In addition, safety plans also include contacting others for support if the distracting activities do not reduce the suicidal crisis sufficiently. These may or may not include family members. An equal number of respondents found talking to family members as helpful as found it not helpful for them to manage suicidal thoughts (Simon et al., 2016), but talking to peers also helped many. Safety plans include the option of calling the psychologist or a crisis service so that the concerned others are not the only ones responsible for the patient’s safety.
Lethal means counseling can be part of the safety plan or an activity that is conducted separately. The goal of lethal means counseling is to create a barrier between the patients and their preferred means of suicide. Because suicidal crisis states are usually time limited, by the time the patients have identified another way to kill themselves, the suicidal crisis has passed. Patients almost never substitute other ways to kill themselves (means substitution). Psychologists need to ensure that concerned others cooperate with the lethal means safety plans.
Psychologists could also involve concerned others in psychotherapy in other ways. Although relationships involve many complex issues, often suicidal patients benefit from learning how to express their distress and to inform their concerned others on how they might be helpful. For men, this may mean teaching them to diverge from the cultural stereotype of being independent and self-sufficient (Fogarty et al., 2017). Also, psychologists may need to address other communication issues because even well-meaning family members may come across as overly protective or intrusive, thus creating more friction. Negative communications, such as criticism, withdrawal, or escalating arguments can increase distress and exacerbate the risk of suicide. In a pilot study focusing on marital communication to prevent suicide, the veteran participants reported less suicidal ideation and less perceived burdensomeness (Khalifian et al., 2021).
Finally, if the concerned others are involved consistently in psychotherapy, questions sometimes arise as to how much the psychologist should focus on the wellbeing of the concerned others. Because the psychotherapist may show concern for their feelings and solicit their input it is possible that the concerned others may think of themselves as co-equal patients in the treatment and that the psychologist has fiduciary obligations to them as well as to the identified patient. So, if the course of treatment consistently veers toward the needs of the concerned other at the expense of the patient, then psychologists can gently remind them of their role which is to focus on the needs of the patients and discuss options for them to receive the treatment they need. Psychologists who decide to treat both a suicidal patient and their concerned other at the same time may find themselves in a conflict of interest. For example, the psychologist does not want to be in a position where they are treating a patient who wants desperately for the marriage to succeed while treating the patient’s spouse who is equally desperate for the marriage to end.
- Concerned others can often, but do not always, contribute to effective psychotherapy.
- Psychologists should defer to patient preferences in whether or how to involve concerned others.
- Psychologists should focus on clarifying roles and expectations when involving concerned others in treatment.
Cite This Article
Knapp, S. (2022). Involving concerned others in the treatment of suicidal patients. Psychotherapy Bulletin, 57(3), 27-31.
Bryan, C. J. (2021). Rethinking suicide: Why prevention fails and how we can do better. Oxford.
Bryan C. J., & Rudd, M. D. (2018). Cognitive behavior therapy for suicidal patients. Guilford.
Fogarty, A. S., Spurrier, M., Player, M. J., Wilhelm, K., Whittle, E. L., Shand, F., Christensen, H. & Proudfoot, J. (2018). Tensions in perspectives on suicide prevention between men who have attempted suicide and their support networks: Secondary analysis of qualitative data. Health Expectations, 21 (1), 261-269. http://doi.org/10.1111/hex.12611
Hom, M., Albury, E. A., Christensen, K., Gomez, M. M., Stanley, I. H., Stage, D. R. L., & Joiner, T. E. (2020). Suicide attempt survivors’ experiences with mental health care services; A mixed method study. Professional Psychology: Research and Practice, 51 (2), 172-183. http://doi.org:10.1037/pro0000265
Kazan, D., Calear, A. L., & Batterham, P. J. (2016). The impact of intimate partner relationships on suicidal thoughts and behaviors: A systematic review, Journal of Affective Disorders, 190, 585-598. http://doi.org:10.1016/j.jad.2015.11.003
Khalifian, C. E., Leifker, F. R., Koop, K., Wilks, C. R., Depp, C., Glynn, S., Bryan, C., & Morland, L. A. (2021). Utilizing a couple relationship to prevent suicide: A preliminary examination of Treatment for Relationship and Safety Together. Journal of Clinical Psychology, 78 (5), 747-757. http://doi.org:10.1002/jclp.23251
McClelland, H., Evans, J. J., Nowland, R., Ferguson, E., & O’Connor, R. C. (2020). Loneliness as a predictor of suicidal ideation and behaviour: A systematic review and meta-analysis of prospective studies. Journal of Affective Disorders, 274, 880-896. http://doi.org:10.1016/j.jad.2020.05.004
Nuij, C., van Ballegooijen, W., de Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., . . . & Riper, H. (2021). Safety planning-type interventions for suicide prevention: meta-analysis. British Journal of Psychiatry, 219(2), 419-426. http://doi.org:10.1192/bjp.2021.50.
Øien-Ødegaard, C., Hauge, L. J., & Reneflot, A. (2021). Marital status, educational attainment, and suicide risk: A Norwegian register-based population study. Population Health Metrics, 19(1). http://doi.org/10.1186/s12963-021-00263-2
Simon, G. E., Specht, C., & Doederlein, A. (2016). Coping with suicidal thoughts: A survey of personal experiences. Psychiatric Services, 67(9),1026-1029. http://doi.org/10.1176/appi.ps.201500281
Stone, D. M., Simon, T. R., Fowler, K.A., Kegler, S. R., Yuan, K., Holland, K. M., . . . Crosby, A. E. (2018). Vital signs: Trends in state suicide rates—United States, 1999-2016 and circumstances contributing to suicide—27 states, 2015. Morbidity and Mortality Weekly Report, 67(22), 617-624. http://doi.org:10.15585/mmwr.mm6722a1
Synnott, J., Ioannou, M., Coyne, A., & Hemingway, S. (2018). A content analysis of online suicide notes: Attempted suicide versus attempt resulting in suicide. Suicide and Life-Threatening Behavior, 48(6), 767-778. http://doi.org:10.1111/sltb.12398
Tucker, R. P., Hagan, C. R., Hill, R. M., Slish, M. L., Bagge, C. L. Joiner, T. E., & Wingate, L. R. (2018). Empirical extension of the interpersonal theory of suicide: Investigating the role of interpersonal hopelessness. Psychiatry Research, 259, 427-432. http://doi.org:10.1016/j.psychres.2017.11.005
Vatne, M., Lohne, V., & Nӓden D. (2021). “Embracing is the most important thing we can do”—Caring for the family members of patients at risk of suicide. International Journal of Qualitative Studies in Health and Well-being. 16(1). http://doi.org:10.1080/17482631.2021.199682