Resolving Therapeutic Dilemmas with Suicidal Clients A Clinical Handbook

by Gregory, Robert J.; Shields, Rebecca J.

• ISBN13: 9781462562671
• ISBN10: 1462562671
• Format: Paperback
• Copyright: 2026-04-24
• Publisher: The Guilford Press
• More Book Details
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Summary

Engaging suicidal clients in treatment and recovery is intense and challenging. Robert J. Gregory and Rebecca J. Shields share principles and techniques grounded in research and extensive front-line experience in this concise, pragmatic guide. The book is uniquely structured around specific dilemmas or sticking points that frequently arise in the treatment of suicidal clients. It provides a roadmap for responding skillfully when a client says, for example, "I just want to die,” “Nothing is going to help,” or “If you discharge me, I’ll kill myself.” Rich clinical vignettes and transcripts illuminate the underlying dynamics of each dilemma and demonstrate effective ways to move through it, regardless of treatment modality.

Author Biography

Robert J. Gregory, MD, is SUNY Distinguished Service Professor in the Department of Psychiatry at the State University of New York Upstate Medical University. He is Founding Director of the Psychiatry High Risk Program (PHRP), a recovery-based outpatient treatment program for suicidal youth and adults, and developer of the PHRP's core treatment modality, Dynamic Deconstructive Psychotherapy. The PHRP has been designated as a best practice in suicide prevention and received a Psychiatric Services Achievement Award (Silver) from the American Psychiatric Association. Dr. Gregory has authored more than 70 articles and book chapters and does trainings nationally and internationally.

Rebecca J. Shields, DO, is a board-certified Child and Adolescent Psychiatrist and Assistant Professor in the Department of Psychiatry at the State University of New York Upstate Medical University. She serves as Co-Director of the Psychiatry High Risk Program (PHRP), where she oversees the adolescent program and provides training and clinical care in the PHRP's core treatment modality, Dynamic Deconstructive Psychotherapy. Dr. Shields has authored articles on recovery-based suicide prevention and the use of Dynamic Deconstructive Psychotherapy with adolescents.

Table of Contents

I. Introduction and Overview
1. Suicide: From Chronic Illness to a Recovery Perspective
2. Introduction to Dynamic Deconstructive Psychotherapy
II. Dilemmas
- Dilemma 1. “I’m just here because of my parents, spouse, etc.” (for clients who are unmotivated to start treatment)
- Dilemma 2. “I just need to be put on the right medication for my ADHD, bipolar, etc.” (for clients who are seeking a quick fix instead of psychotherapy)
- Dilemma 3. “I don’t want to recover; I just want to die.” (for clients who are expressing suicidal intent in session)
- Dilemma 4. “I don’t have anything to talk about.” (for clients who are not actively participating in the treatment)
- Dilemma 5. “You are not qualified to be my therapist.” (for clients who have narcissistic or paranoid personality traits)
- Dilemma 6. “Nothing can help me; I need more help!” (for clients who are hopeless and desperate)
- Dilemma 7. “You don’t really care about me; it’s just your job!” (for clients who have antisocial or dependent personality traits)
- Dilemma 8. “Cannabis is the only thing that helps me.” (for clients who are using substances)
- Dilemma 9. “I want to work toward recovery, but I have a secret stash just in case.” (for clients who are holding onto suicide as a backup option)
- Dilemma 10. “I was too depressed to attend my appointment or do the things you wanted me to.” (for clients who are ambivalent about treatment or recovery)
- Dilemma 11. “I’m coming every week but nothing’s working.” (for clients who feel hopeless that they can get better well into treatment)
- Dilemma 12. “I’m not sure I can keep myself safe, but going to the hospital will just make things worse.” (for clients who feel unsafe but refuse to go to the hospital)
- Dilemma 13. Your client is in the emergency department after taking an overdose. (for clients who recently attempted suicide)
- Dilemma 14. “Why are you so rigid when people may need extra help?” (for clients who violate your boundaries)
- Dilemma 15. “How can you understand me when you haven’t gone through what I have?” (for clients who want a therapist with a similar race, ethnicity, gender, values, or background)
- Dilemma 16. “I thought I was getting better, but now I realize that I’m no better than when we started treatment.” (for clients who were progressing in treatment but are now regressing)
- Dilemma 17. “If you discharge me, I’m going to kill myself.” (for clients who are disengaged from treatment but are threatening suicide if you discharge them)
- Dilemma 18. “I am pregnant!” (for clients or therapists who become pregnant during the course of treatment)
III. Conclusion
Final Reflections
References
Index