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Treating chronic suicidality in an outpatient setting presents a unique challenge for clinicians, particularly because clients may experience suicidal thoughts on a daily basis with limited time in direct treatment. However, by carefully assessing a client’s history of suicidal behavior, along with their broader socio-cultural environment, outpatient treatment can be highly effective for the right individuals, leading to positive, long-term outcomes.

During a recent collaborative presentation with The Dorm, Mychal Riley, LCSW, Director of the Menninger 360 program, offered his insights on this complex issue, particularly focusing on emerging and young adults with co-occurring disorders. He emphasized that over 60% of Menninger’s clients struggle with suicidality, underscoring the difficulty clinicians often face when working with chronically suicidal individuals—especially in the absence of clear, standardized guidelines.

Key Article Takeaways:

At The Dorm, as an IOP and PHP treatment community*, 36% of clients reported suicidal ideation upon intake.  According to The Dorm’s Outcomes & Impact Report there was a 73% reduction in suicidality and a 89% reduction in psychiatric hospitalizations at discharge.  These significant improvements, paired with Mychal Riley’s reflections, highlight the potential for well-tailored outpatient treatment programs to support young adults with chronic suicidality and offer hope for both clinicians and treatment centers. Watch the full continuing education event on this topic, read the transcript, and explore key highlights in our dedicated library.

Data and Trends in Suicidality

Suicide is a leading cause of death among adolescents and young adults, making it a critical area of focus for clinicians today. To begin his presentation, Riley provides a data-driven overview of suicide trends, noting a concerning increase in suicide rates from 2000 to 2020, despite a slight decline from 2018 to 2020. 

Riley also notes that the most vulnerable groups include non-Hispanic American Indians, Alaska Natives, and sexual minorities, although data on the LGBTQ+ community is incomplete due to underreporting. He also points out that while young adults may not have the highest rates of completed suicides, they do have the highest rates of attempts and emergency room visits.

Case Study: JJ’s Journey

To illustrate the complexities of treating chronic suicidality, Riley introduces a case study of a client named “JJ,” a 20-year-old who had experienced a long history of mental health challenges, beginning therapy at age 10 and experiencing multiple inpatient stays by age 12. Despite efforts to maintain stability in outpatient settings, JJ’s suicidality was exacerbated by significant stressors, such as the loss of a friend and the pressures of college life, and he eventually dropped out and consulted Mychal’s expertise. 

JJ’s case highlights the multifaceted nature of chronic suicidality. They exhibited a range of challenges, including trauma, substance use, emotional sensitivity, and difficulties with attachment and interpersonal relationships. JJ’s diagnosis of borderline personality disorder added another layer of complexity to their treatment. 

Mychal goes on to include JJ’s journey in the following topics of conversation:

Acute vs. Chronic Suicidality

Riley distinguishes between acute and chronic suicidality. Acute suicidality is often linked to reversible factors or stressors, such as substance use or psychiatric disorders, and tends to dissipate when these factors are addressed.

In contrast, chronic suicidality involves a recurring pattern of suicidal thoughts, behaviors, and threats that do not easily resolve with direct intervention. For clients with complex diagnoses, such as borderline personality disorder, repeated hospitalizations may be counterproductive and even increase their sense of hopelessness. 

Removing Stigma and Understanding the Drivers of Suicide

Riley references the work of Dr. Edwin Shneidman, a pioneer in suicidology, who identified key drivers of suicide, including:

• Psychic Pain – “Psychache”: Intense emotional pain that pushes individuals toward suicide as a means of escape.
• Stressors: External pressures that deplete an individual’s coping resources.
• Perturbation: Agitation or discomfort that propels individuals past their fear of death.

Riley also discusses the role of hopelessness, as identified by Aaron Beck, and self-hate, which has been highlighted in studies with air force personnel. These factors can be predictive of suicidal behavior and must be thoroughly assessed to understand a client’s risk.

Risk Factors, Warning Signs, and Protective Factors

Riley explains the importance of distinguishing between risk factors, warning signs, and protective factors:

• Risk Factors: These are stressful events or conditions that increase the likelihood of suicide but are not necessarily predictive. They include prior suicide attempts, psychiatric conditions, substance use, and psychosocial stressors. Sleep hygiene needs to be thoroughly assessed because poor quality sleep exacerbates all other risk factors. 
• Warning Signs: Observable behaviors or changes that indicate a client may be moving closer to suicide. The acronym “IS PATH WARM” helps clinicians remember key warning signs:
  • I Ideation
  • S Substance Abuse 
  • P Purposelessness 
  • A Anxiety 
  • T Trapped 
  • H Hopelessness 
  • W Withdrawal 
  • A Anger
  • R Recklessness 
  • M Mood Change
• Protective Factors: Elements that create barriers to suicide, such as strong support systems, cultural or religious beliefs, and access to mental health care. 

Treatment Planning and Collaboration

Riley emphasizes the need for a collaborative approach in treating chronic suicidality. This includes building a strong therapeutic relationship, using screeners to identify key issues, creating a detailed safety plan, and assessing the client’s willingness to engage in treatment. He highlights the importance of continuously monitoring the client’s progress and adjusting the treatment plan as needed.

“When JJ came to us,” Riley explains, “they were at a stage where, although suicide was still a consideration, they were willing to set it aside temporarily. At that point, their overall suicide risk was somewhat lower. However, several variables were notably high.”

• Psychological Pain: This had been present since JJ was 12 years old. They had found treatment beneficial but experienced a resurgence of pain once they left treatment. We needed to closely monitor this aspect.
• Perturbation: JJ experienced significant discomfort and agitation, particularly around their sense of shame and hopelessness. Their ongoing cycle of treatment and relapse contributed to feelings of inadequacy and frustration.
• Self-Regard and Hopelessness: JJ’s self-regard was deeply tied to their hopelessness. The repeated failures to break the cycle of treatment and relapse made them question their ability to ever change.

As a team, we needed to focus on monitoring JJ’s risk every session and every day. Their ambivalent attachment style was a significant indirect driver, triggering strong emotional responses when discussing future planning, which often led to heightened feelings of shame and hopelessness.

Addressing these issues involved:

• Building Rapport and Collaboration: Establishing a strong therapeutic relationship and collaborating with the client are crucial. This includes conducting a thorough assessment of their psychological state, history of suicide attempts, and current risk factors.
• Using Screeners: Incorporating screeners can be useful. While they are not a substitute for a comprehensive assessment, they can help identify significant issues and inform further evaluation. At our clinic, we use tools like the SPQR, but there are various options available.
• Creating a Safety Plan: Developing a detailed safety plan that includes coping strategies, emergency contacts, and ways to manage crises.
• Assessing Willingness to Collaborate: Evaluating the client’s willingness and ability to work with you on their treatment plan and any restrictions related to means of suicide.

By addressing these components and continuously monitoring JJ’s progress and risk, we aimed to provide a supportive environment and effective intervention strategies to help them navigate their challenges.

Conclusion

Treating chronic suicidality in outpatient settings requires a comprehensive and empathetic approach. By understanding the unique challenges and drivers that each client faces, clinicians can develop tailored treatment plans that address the root causes of suicidality and provide clients with the tools they need to navigate their struggles. Riley’s insights and case study underscore the importance of collaboration, continuous assessment, and the use of evidence-based practices in supporting clients with chronic suicidality.

Thank you Mychal!

This blog post summarizes a continuing education event for professionals hosted by The Dorm, an IOP/PHP treatment community for young adults 18-30 with locations in New York City and Washington, D.C.* Visit our professionals page to stay abreast of future educational sessions.

*In New York State, The Dorm operates as a Group Practice.