This manual provides an empirically supported approach to treating suicidality that is specifically tailored to today's managed care environment. Structured yet flexible, the model is fully compatible with current best practice standards. The authors establish the empirical and theoretical foundations for time-limited treatment and describe the specific tasks involved in assessment and intervention. The book then details effective ways to conduct a rapid case conceptualization and outpatient risk assessment, determine and implement individualized treatment targets, and monitor treatment outcomes. Outlined are clear -cut intervention techniques that focus on symptom management, restructuring the patient's suicidal belief system, and building such key skills as interpersonal assertiveness, distress tolerance, and problem solving. Other topics covered include the role of the therapeutic relationship, applications to group work and longer-term therapy, the use of medications, patient selection, and termination of treatment. Illustrated with helpful clincial examples, the book also features dozens of tables, figures, and sample handouts and forms.
I. Establishing a Foundation for Treatment 1. What Do We Really Know about Treating Suicidality?: A Critical Review of the Literature The Available Literature: A Limited Database A Critical Review of Intervention Studies: Do Simple Procedural Changes Make a Difference? Implications for Clinical Practice A Critical Review of Treatment Studies: An Emerging Trend for Cognitive Behavioral Therapy Implications for Clinical Practice The Therapeutic Relationship in Treating Suicidality: Attachment, Hope, and Survival Implications for Clinical Practice Unanswered Questions: The Challenge Awaits Us 2. A Cognitive-Behavioral Model of Suicidality Existing Theoretical Models of Suicidal Behavior: A Brief Overview Static and Dynamic Variables Predicting Suicidality Application of Theory and Empirical Findings in Treatment: The Problem of Limited Clinical Relevance Basic Assumptions of Cognitive Theory and Therapy: Implications for Suicidality The Essential Requirements for a Cognitive-Behavioral Model of Integrating Empirical Findings and Ensuring Clinical Relevance The Suicidal Mode as a Cognitive-Behavioral Model of Suicidality: An Elaboration and Specific Application of Beck's Theory of Modes and Psychopathology Defining the Suicidal Mode: Characteristics of the Various Systems Completing the Suicidal Mode: Individual Case Conceptualization Implications of the Suicidal Mode for the Organization, Content, and Process of Treatment Theoretical Flexibility of the Suicidal Mode for Psychotherapy Integration The Therapeutic Relationship in Cognitive-Behavioral Therapy: Three Fundamental Assumptions 3. An Overview of the Treatment Process Completing the Clinical Picture: Understanding Severity, Chronicity, and Diagnostic Complexity Identifying Treatment Components An Overview of the Goals for Each Treatment Component An Overview of the Steps in Treatment Planning Understanding the Treatment Process: Treatment Components and Corresponding Levels Defining the Component Levels Symptom Management Component Cycling through Components and Levels The Role of Medications Skill-Building Component Personality Development Component Variation in Therapist Role A Clinical Example of Acute Suicidality: The Case of Mr. E Monitoring the Treatment Process Process Tasks and Markers Provocations and Resistance in the Therapeutic Relationship: How a Clear Organizational Framework Helps Quantifying Change: How to Measure and Monitor Change in Treatment Treatment Withdrawal and Noncompliance Ensuring Treatment Fidelity Termination: When, Why, and How Interpersonal Process Groups and Booster Sessions The Role of the Treatment Team The Need for Long-Term Care in a Time-Limited World II. Assessment and Treatment 4. Treatment Course and Session-by-Session Guidelines The Beginning of Treatment: Sessions 1-4 Sessions 5-10: Symptom Management, Cognitive Restructuring, Reducing and Eliminating Suicidal Behaviors Sessions 10-19: Emphasis on Skill Building Sessions 19-20: A Shift Toward Personality Development and Longer-Term Treatment 5. The Evaluation Process and the Initial Interviews Risk Assessment Goals: The Importance of Establishing a Baseline for Ongoing Monitoring Treatment Conceptualization and Consent: Setting the Stage The Use and Role of Psychometric Testing Establishing the Therapeutic Relationship 6. Assessing Suicide Risk Distinguishing between Risk Assessment and Prediction: Defining the Nature of Clinical Responsibilities The Importance of Precise Terminology: Saying What We Know and Knowing What We Say Essential Components of a Clinical Risk Assessment Interview Tips on Eliciting Information on Intent and Self Control Risk Categories: Baseline, Acute, Chronic High Risk, and Chronic High Risk with Acute Exacerbation Rating Severity: A Continuum of Suicidality Clinical Documentation and the Process of Risk: The Concept of Risk Monitoring The Role of Chronicity and Time in Risk Assessment Clinical Decision Making, Management, and Treatment Ongoing Monitoring of Treatment Outcome and Evaluation The Persistence of Suicidal Thoughts: A Potentially Misleading Marker of Treatment Outcome 7. Crisis Intervention and Initial Symptom Management Keys Tasks of Crisis Intervention Ensuring the Patient's Safety Self-Monitoring during Crises Teaching the Patient to Rate Discomfort: A Self-Monitoring Task Completing the Suicidal Thought Record Depicting the Suicidal Cycle: The Suicidal Mode in Action Using Mood Graphs Improving Distress Tolerance and Reducing Impulsivity: The Importance of Repeatedly Emphasizing That Bad Feelings Do Not Last Forever Targeting Source Hopelessness: A Different Kind of Problem Solving Symptom Matching: Improving Level of Functioning over the Short Term The Importance of Structure: Providing a Crisis Response Plan 8. Reducing and Eliminating Suicide-Related Behaviors Identifying Behavioral Targets in Treatment: Understanding the Suicidal Mode Distinguishing between Suicidal Acts and Instrumental Behaviors Dealing with Mixed Messages Identifying the Suicidal Cycle The Process of Behavioral Change: Reducing and Eliminating Suicidal Behavior Inhibiting the Suicidal Cycle during Crisis States: Late-Cycle Intervention Substitute Behaviors and Purposeful Hypervigilance:Early-Cycle Intervention Shaping Behavior: A Process of Gradual Change Exposure-Based Strategies: Role Playing, Cue Exposure, and Behavioral Rehearsal Contingency Management and Treatment Success Targeting Treatment Disruptions Provocation(s): The Currency of Interpersonal Relatedness in Suicidality Handling Provocation in Treatment The Evolution of Hope and the Elimination of Suicidal Behavior: A Few Concluding Words 9. Cognitive Restructuring: Changing the Suicidal Belief System and Building a Philosophy for Living Private Meaning and the Suicidal Belief System: The Role of Automatic Thoughts and Intermediate and Core Beliefs A Straightforward Strategy for Cognitive Change Dealing with Poor Motivation and Treatment Noncompliance Building a Philosophy for Living: Change and Acceptance as New Rules Prevailing, Facilitating, and Compensatory Modes in Chronic Suicidality: Developing Adaptive Modes and Acknowledging Personal Qualities and Characteristics The Therapeutic Belief System: Therapy-Specific Beliefs Outlining the Therapeutic Belief System The Therapeutic Belief System of the Therapist Treating Suicidality: Monitoring Thoughts, Feelings, and Behaviors in Treatment Evaluating the Relationship: Patience, Determination, and Consistency 10. Skill Building: Developing Adaptive Modes and Ensuring Lasting Change Conceptualizing Skill Deficits in Cognitive-Behavioral Therapy for Suicidality Targeting Skill Deficits A Model for Problem Solving: Learning to Identify, Evaluate, and Pursue Alternatives to Suicide Emotion Regulation Ability: The Art of Feeling Better When Suicidal Self-Monitoring Distress Tolerance Interpersonal Skills: Learning to Be Assertive, Attentive, and Responsive Anger Management: Early Identification, Appropriate Expression, and the Importance of Empathy, Acceptance, and Forgiveness Skill Building and Personality Change: One and the Same? Changing Interpersonal Process: Integrating Group Treatment Epilogue
