Office Hours Recap: Providing support for those who have difficulty engaging in therapy

A clinician shared a challenging situation: She is working with someone who comes faithfully to sessions, but is struggling to identify treatment goals and reasons for living. This person’s suffering is related to symptoms linked to bipolar disorder as well as multiple relational and socio-economic challenges.

Together we walked the SafeSide Framework, shared experiences and identified strategies to try. But here was our biggest takeaway: The idea that everyone must have a “treatment goal” can be artificial. In the end we need to meet people where they are, and "put ourselves in the space of the client” because while our systems and structures may tell us they need a “treatment goal” the bigger mission is always around offering connecting and healing, in whatever form fits for where that person is in their journey.

Here are strategies we brainstormed together.

Connect: Start with empathy and understanding. Look at what stands out to you as unique or special about this person, and highlight their strengths and protective factors and reflect that back to them, because they may not be able to see it. Then start to unpack the person’s stressors, symptoms, past suicidal actions and long-term risk factors. Demonstrate your commitment, show interest - this can provide a corrective validating experience.

Example: Let this person share information about things they are passionate about. Respond with curiosity and ask them about their engagement in those activities regularly, even if it seems unrelated to addressing the drivers of suicide. So if video games are what they love, learn about them. Let them teach you about them - this is how we “put ourselves in the space of the client”. Acknowledge their strengths and connection seeking, like continuing to attend sessions when so many other relationships have been difficult for a long time.

Assess: Risk status and risk state can be especially helpful in informing what next steps to take in this complex situation because rather than seeing the person by their diagnosis or their socioeconomic stressors, it places them in context.  Explore available resources and identify foreseeable changes that could quickly increase the person’s risk. Let them know that you are asking so that you can plan, identify supports and be better prepared if things get worse for them.

Example: 

• Risk state: The risk status is about the same as other people with similar mental health issues being seen in a community setting.
• Risk state: The suicidal thinking is more frequent than it has been in the last few years because of all the stressors, so risk state is higher than it has been.
• Available resources: There are a couple but could use more. Could there be family members the individual is not engaging with or is there potential for support in the online community they are connected to?
• Foreseeable changes: The person can identify two things that could make things worse if they happen. This could be a future loss, a financial challenge. Reassure them you are asking so that you can develop a plan together. If the person can’t see into the future like that, you can suggest a couple or even ask a family or support person what they think would be helpful to have a plan for.

Respond: Develop contingency plans for foreseeable changes and rely on mini-interventions to provide in-the-moment relief. Discuss evidence-based treatments that are available and help them determine if they may be a fit.

Example: Contingency plans for a future loss or challenge are specific. Who would they call? What actions would they take? How could they be sure someone was aware they were struggling? This includes exploring with the person if they could let these people know they are part of this plan.

Extend: Use caring contacts to help bridge the gap in between sessions.

Example: Write one or two sentences on the card such as “We haven’t had an appointment lately. I hope you are doing well”. This small act of sending cards regularly has been shown to reduce suicide behavior.

Overall, the meeting highlighted that while systems and settings may view treatment engagement as having suicide-specific treatment goals, a compassionate, individualised approach means meeting them where they are and staying open to taking steps towards connection and feeling better, whatever that looks like for that person.

Note: This is one of the recaps from our monthly Office Hours sessions where SafeSide members can ask questions and share their experiences. Members also have access to Community of Practice with the full library of recaps, newsletters and resources.