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Psychotherapy Articles

Using Self-determination Theory to Inform Interventions for Suicidal Patients

Consider this example: A psychologist sought consultation because her patient was not responding adequately to treatment. The consultant asked her three questions: Have you built a connection with your patient? Does your patient feel a sense of control and engagement in psychotherapy? Is your patient building the skills to handle their emotions and life difficulties?

The consultant derived these three questions from self-determination theory (SDT), which identifies three basic needs or intrinsic motivators of human behavior which are: connectedness to others, autonomy, and mastery. Connectedness or relatedness to others “involves the need to feel connected with and significant to others” (Ryan et al., 2011, p. 230). This involves both a sense of being cared for by others and a sense that one can contribute to the well-being of others. Autonomy “describes actions that are self-endorsed and volitional rather than controlled or compelled” (Ryan et al., 2011, p. 230). It does not refer to being isolated or separate from others but instead indicates having a sense of control over one’s choices. Mastery or competence “concerns the psychological need to experience confidence in one’s capacity to affect outcomes” (Ryan et al., 2011, p. 230). It is a belief that one can take actions that are likely to reach one’s goals. Internal motivation for treatment improves when patients believe the treatment will meet their needs.

One can see the importance of self-determination in the World Health Organization’s (2022) definition of mental health, which includes developing connections, making decisions, and coping with life stressors. Patients feel better when these intrinsic needs are met and worse when these needs are thwarted.

Psychotherapists can consider these needs or motivators when working with any patient, although they appear especially important for suicidal patients. Psychotherapists can use these three questions to monitor their patients’ engagement in psychotherapy in addition to understanding their suicidal patients and helping them identify treatment goals.

Suicidal patients often experience frustration with these three intrinsic drives. Admittedly, suicidal thoughts and behaviors arise from the complex interaction of genetic, life history, psychological, and environmental factors, and there may not be one pathway to a suicide attempt for all people. Nonetheless, certain beliefs increase the risk that a person will have suicidal thoughts or attempt suicide, such as perceived burdensomeness (a sense that others would be better off if they were dead), thwarted belongingness (a feeling that one does not belong or is not accepted by a valued social group), or entrapment (a sense that their pain is unbearable and they have no options available to end intolerable life situations). Furthermore, suicidal patients often ruminate or feel intrusive, repetitive, and negative thoughts they cannot control.

As found in the research by Tucker and Wingate (2014), the basic needs identified by SDT appear linked to the beliefs and experiences that could lead a person to consider suicide. For example, perceived burdensomeness and thwarted belongingness may represent a frustration of the need for connectedness; internal entrapment may represent the perception of a lack of autonomy or choices in one’s life; and rumination appears to represent a lack of mastery over one’s emotions (emotional self-regulation). Conversely, those with their intrinsic needs met may be more likely to believe their life is worth living. One effective intervention with suicidal patients is to help them identify their reasons for living, many of which appear to be linked to meeting their intrinsic needs.

Specific Steps Using Self-Determination Theory

Just as the causes of suicidal ideation are complex and multifaceted, interventions can also be multidimensional and personalized. The effective treatment of suicidal patients often requires psychotherapists to make many decisions regarding the optimal intervention for their patients. Nonetheless, regardless of their theoretical orientations or the location where they deliver services, psychotherapists can incorporate insights from SDT to inform their approach in making these decisions.

Can I Help My Patient to Connect with Others?

Loneliness, the perceived discrepancy between perceived and desired social connections, is associated with various psychological and physical limitations. Loneliness has an impact on health comparable to the effects of smoking, high cholesterol, and lack of physical activity. Relationship quality is related to all-cause mortality and morbidity (Holt-Lunstad et al., 2017). In contrast, strong social networks are associated with well-being (Murthy, 2023). Social relationships provide emotional comfort when people are distressed, material assistance when needed, information or advice on handling life difficulties and distractions, and opportunities for joint relaxation and entertainment.

Persons with suicidal thoughts often feel a lack of connectedness to others. They may experience perceived burdensomeness or thwarted belongingness (Tucker & Wingate, 2014). Furthermore, relationship losses often precede suicide attempts. In contrast, maintaining a solid social network is a protective factor against suicide and is linked to good mental health (Stone et al., 2018).

Effective psychotherapists build relationships with their patients and help them feel comfortable and secure in psychotherapy. They approach their patients with a compassionate and curious mind without judgment and validate their experiences (understanding how they came to have suicidal thoughts without endorsing suicide as a goal; Schechter & Goldblatt, 2011). A good relationship early on in psychotherapy is associated with fewer subsequent suicidal thoughts and attempts (Huggett et al., 2022).

In addition to building a good treatment relationship, psychotherapists frequently help their suicidal patients build or repair relationships with others. Loneliness may have different causes, and the interventions need to vary accordingly. For example, some patients may misinterpret or overreact to minor social offenses and need cognitive therapy to address dysfunctional interpretations of social interactions. Some may need relationship counseling to mend or strengthen relationships with others. Still, others may need opportunities to engage in social activities like social clubs or churches (Mann et al., 2017).

Can I Promote My Patient’s Autonomy?

People like to have choices in their lives. Nevertheless, when patients feel entrapment, they perceive they have no options left to them and can do nothing to end their unbearable pain except to kill themselves. In addition, one significant factor that keeps people from seeking treatment for suicidal thoughts is the fear that their autonomy will be taken away if they reveal their suicidal thoughts. They may fear that they will be forced to go into a hospital against their will or that their psychotherapists will disclose confidential information about them without their consent (Hom et al., 2017). Even if they enter psychotherapy, these fears may keep them from revealing their suicidal thoughts thoroughly.

Although respecting autonomy is important when treating all patients, it becomes especially important when treating suicidal patients. Psychotherapists can respect patient autonomy by listening carefully to their patients, explaining the nature and anticipated course of treatment clearly to them, collaborating with them throughout treatment as much as clinically indicated, and soliciting their feedback concerning their progress and perceptions of the psychotherapy process (Joiner et al., 2009; Knapp, 2024). This may involve, for example, adapting treatment according to the patient’s characteristics, needs, and preferences. Treatments that incorporate patient preferences tend to result in better outcomes than treatments that do not (McAleavy et al., 2018; Norcross & Cooper, 2021).

The informed consent process, for example, can respect patient autonomy if it is used to ensure that patients understand what treatment will involve, what is expected of them, and how they expect their psychotherapist to act. Also, good psychotherapists see the informed consent process as part of treatment by conveying faith in the patient that they have the power and agency to effect positive change. As Jobes (2023) tells his patients, “The answers to your struggles exist within you—we will find these answers together as treatment partners” (p. 64). Psychotherapists should also be entirely transparent about what they are doing and why. For example, before starting a new activity, they may engage in mini-informed consent sessions to explain the purpose and rationale of the activity (Bryan & Rudd, 2018).

Additionally, psychotherapists can respect patient autonomy by involving patients in as many treatment decisions as clinically possible. For example, psychotherapists can include patients in every step of developing a safety plan, including identifying their reasons for living, the options for distracting them from their suicidal thoughts, and whom to contact if they are feeling depressed. As O’Connor (2021) has stated, “A safety plan is someone else’s plan, it is not your plan” (p. 198).

Finally, psychotherapists can ask patients about their perceptions of their treatment progress and the acceptability of the psychotherapy processes. For example, Bryan and Rudd (2018) suggest that psychotherapists ask their patients to rate their perception that they would follow the plan on a 10-point scale when developing crisis plans. Even though patients were involved in the plan’s development, it gave them a second opportunity to consider its overall value and ways to improve it.

Can I Improve My Patient’s Sense of Mastery or Competence?

Although the exact nature of the suicidal experience will vary from patient to patient, some thoughts and feelings commonly occur among patients with suicidal thoughts (Rogers et al., 2023). These include, but are not limited to, hyperarousal behaviors, such as insomnia, nightmares, or agitation, or self-disapproving emotions, such as self-disgust or shame. These intense negative emotions often lead to entrapment or a pervasive belief that one can do nothing to end their unbearable pain. Nonetheless, gaining a sense of control over one’s emotions may help reduce the patient’s sense of entrapment. Of course, no one can have control over all of life’s circumstances. They cannot control whether a factory stays open or closes, whether they or their loved one has a severe health concern or other factors related to their well-being. However, entrapment often limits their ability to identify what they can control. Psychotherapists can help their patients gain a sense of agency to influence events under their control and moderate their reactions to circumstances beyond their control.

Treatments may include cognitive reappraisals of these events, self-compassion-focused meditations, mindfulness training, psychoeducation on sleep hygiene, relaxation training, or medications to reduce emotional arousal or depression. Patients will develop more confidence in managing their emotions as their emotional arousal declines. Although patients may still have stressful life events, they are not seen as catastrophic. And while patients may continue to have unpleasant feelings, they can begin to see them as transitory or tolerable.

Practice Implications When Utilizing Self-Determination Theory

Suicide becomes less likely when patients learn to meet their needs. Psychotherapists can use the insights from SDT to help their patients formulate treatment goals, identify effective interventions, and rethink psychotherapy if patients appear stuck and are not making adequate progress. Specifically, psychotherapists can:

  • Connect with their patients in psychotherapy and help them create or maintain connections where they feel cared for by others and can reciprocate care for others.
  • Respect patient decision-making throughout psychotherapy and help patients identify and implement their options and choices.
  • Help patients develop the ability to monitor and regulate their emotions and thoughts and gain some mastery of these skills.

 

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Samuel Knapp is a retired psychologist who formerly worked as the director of professional affairs for the Pennsylvania Psychological Association.

Cite This Article

Knapp, S. (2024, April). How self-determination theory can inform interventions for suicidal patients. Psychotherapy Bulletin, 59(2). 31-35.

References

Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive behavior therapy for suicide prevention. Guilford.

Holt-Lunstad, J., Robles, T. F., & Sbarra, D. A. (2017). Advancing social connection as a public health priority in the United States. American Psychologist, 72(6), 517-530.

Hom, M.A., Stanley, I. H., Podlogar, M. E., & Joiner, T. E. (2017). “Are you having thoughts of suicide?” Examining experiences with disclosing and denying suicidal ideation. Journal of Clinical Psychology, 73(10), 1382-1392.

Huggett, C., Gooding, P., Haddock, G., Quigley J., & Pratt, D. (2022). The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review. Clinical Psychology and Psychotherapy, 29(4), 1203-1235.

Jobes, D. A. (2023). Managing suicide risk: A collaborative approach (3rd ed.). Guilford.

Joiner, T. E., Van Orden, K. A., Witte, T. K., & Rudd, M. D. (2009). The interpersonal theory of suicide: Guidance for working with suicidal clients. American Psychological Association.

Knapp, S. (2024). Listen, explain, collaborate, evaluate: Why promoting autonomy helps suicidal patients. Ethics and Behavior, 34(1), 18-27.

Mann, F., Bone, J. K., Lloyd-Evans, B., Frerichs, J., Pinfold, V., Ma. R., Wang, J., & Johnson, S. (2017). A life less lonely: The state of the art in interventions to reduce loneliness in people with mental health problems. Social Psychiatry and Psychiatric Epidemiology, 52(6), 627-638.

McAleavey, A. A., Xiao, H., Bernecker, S. L., Brunet, H., Morrison, N. R., Stein, M., & Beutler, L. (2019). An updated list of principles of change that work. In L. Castonguay, M. L. Constantino, & L. E. Beutler (Eds.), Principles of change: How psychotherapists implement research in practice (pp. 13–37). Oxford.

Murthy, V. H. (2023). Our epidemic of loneliness and isolation: The US Surgeon General’s advisory on the healing effects of social connection and community. [Web article]. Retrieved from https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf

Norcross, J., & Cooper, M. (2021). Personalizing psychotherapy: Assessing and accommodating patient preferences. American Psychological Association.

O’Connor, R. (2021). When it is darkest. Random House.

Rogers, M. L., Jeon, M. E., Zheng, S., Richards, J. A., Joiner, T. E., & Galynker, I. (2023). Two sides of the same coin? Empirical examination of two proposed characterizations of acute suicidal crisis: Suicide crisis syndrome and acute suicidal affective disorders. Journal of Psychiatric Research, 162,123-131.

Ryan, R. M., Lynch, M. F., Vansteenkiste, M., & Deci, E. L. (2011). Motivation and autonomy in counseling, psychotherapy, and behavior change: A look at theory and practice. The Counseling Psychologist, 39(2), 193-260.

Schechter, M.A., & Goldblatt, M. J (2011). Psychodynamic therapy and the therapeutic alliance: Validation, empathy, and genuine relatedness (pp. 91–107). In K. Michel & D. A. Jobes (Eds.), Building a therapeutic alliance with the suicidal patient. American Psychological Association.

Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R., Yuan, K., Holland, K. M., Ivey-Stephenson, A., & 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.

Tucker, R. P., & Wingate, L. R. (2014). Basic need satisfaction and suicidal ideation: A self-determination perspective on interpersonal suicide risk and suicidal thinking. Archives of Suicide Research, 18(3), 282-294.

World Health Organization. (June 17, 2022). Mental health. [Web article]. Retrieved from https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response

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