1st Edition

Treating Suicidal Behavior An Effective, Time-Limited Approach

    Grounded in a comprehensive model of suicidality, this volume describes an empirically supported cognitive-behavioral treatment approach. The clinician is guided to assess suicidal behavior and implement interventions tailored to the severity, chronicity, and diagnostic complexity of the patient's symptoms. Provided are session-by-session guidelines and clear-cut strategies for defusing the initial crisis; reducing suicidal behavior; restructuring suicide-related beliefs; and building interpersonal assertiveness, distress tolerance, problem solving, and other key skills. A special chapter covers risk assessment. Enhancing the book's utility are tables, figures, and sample handouts and forms, some of which may be reproduced for professional use.

    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
    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


    M. David Rudd, PhD, ABPP, is Professor of Psychology and Director of Clinical Training at Baylor University. He also maintains a part-time private practice. Dr. Rudd received his doctorate from the University of Texas at Austin and completed postdoctoral training at the Beck Institute in Philadelphia. He is the author of over 60 articles and book chapters.

    Thomas E. Joiner, PhD, is Professor of Psychology and Director of the Psychology Clinic at Florida State University. He completed his doctoral training at the University of Texas at Austin. Dr. Joiner has authored over 100 articles and book chapters in the areas of depression, eating disorders, and suicidality.

    M. Hasan Rajab, PhD, is Associate Professor in the Department of Psychiatry and Behavioral Science at Texas A&M Health Science Center. Dr. Rajab completed his doctoral training in biostatistics at Texas A&M University. He is the author of several articles addressing a range of issues in methodology and biostatistics.

    Offer[s] clinicians for the first time a flexible and unique therapeutic program that is direct, time-limited, and buttressed by empirical support. Thus, clinicians facing the urgency of suicidal behavior can decide on the content and timing of interventions designed to eliminate suicidal behavior, and assess in an ongoing way the effectiveness of their efforts. Even if not often confronted with suicidal behavior, clinicians who become familiar with the procedures outlined in this manual will gain confidence in their ability to deal with suicidal crises. --From the Series Editor Note by David H. Barlow

    This important book presents a short-term cognitive-behavioral treatment model that will be perused with interest by all contemporary suicidologists. The authors are exemplary scientist-practitioners within the field of psychology. They have produced a noteworthy, clinically useful contribution. --Edwin S. Shneidman, PhD., Professor of Thanatology Emeritus, University of California, Los Angeles

    From premier scholar-clinicians, this remarkable book deftly guides the practitioner through the considerable challenges of working with suicidal patients. It is among the first (and only) comprehensive works of its kind. The authors manage to incorporate the wisdom of empirical science into a realistic and user-friendly practical approach, a rare accomplishment in the contemporary literature. The liberal use of intriguing case examples helps illustrate a broad range of theoretically grounded, intuitively appealing techniques and interventions that are essential to lifesaving clinical work. Written with great clarity, the book will be valuable for everyone from graduate students to mature clinicians. I am certain that the ripple of this book's impact on the field of clinical suicidology will be seen for many years to come. --David A. Jobes, PhD, Department of Psychology, The Catholic University of America; Past President, American Association of Suicidology

    This book fills an important gap in the array of manualized treatment approaches that are currently available. Drawing on extensive research and experience in the treatment of suicidal individuals, the authors have fashioned a flexible, empirically validated, time-limited approach that will be welcomed by therapists of all persuasions. The book provides specific, detailed information on the 'why' and 'how' of a variety of integrated techniques. Replete with assessment forms, charts, and practical guidelines, this book will serve as a basic reference for therapists facing one of the most challenging clinical situations. --George A. Clum, PhD, Department of Psychology, Virginia Polytechnic Institute and State University
    The text has numerous strengths including its theoretically grounded approach towards assessing suicide risk, clear session-by-session outlines of the implementation of both short- and long-term treatment strategies, and rich descriptions of empirical support for the techniques proposed....An exceptional guide to help clinicians effectively and efficiently treat suicidality, and the authors animate the test by providing a multitude of client worksheets, session transcripts, and flow charts. This book will definitely be on my list of recommendations for students and colleagues who want either to build or to strengthen their foundation in conducting cognitive therapy.
    --Cognitive Behavioral Therapy Book Reviews, 7/28/2004ƒƒ
    Provides practitioners with a working manual for dealing with the most serious, complex, and potentially lethal clinical problem found in any treatment and psychiatric rehabilitation setting....Should be on the shelf of all practitioners who interface and treat suicidal individuals.
    --Psychiatric Rehabilitation Journal, 7/28/2004ƒƒ
    A lifeline for both the patient and the therapist....Provides a rich web of techniques, advice, suggestions, and instructions to which the therapist and patient can hold onto in times of a life-and-death crisis without the therapist being overburdened by the sense of responsibility or the patient with uncontrollable anxiety....Very impressive.
    --Death Studies, 7/28/2004ƒƒ
    By incorporating the clinical information contained in this book, clinicians will be better able to decide when and how to effectively intervene in the suicidal syndrome....This book is comprehensive, well-organized, and articulate.
    --Journal of Nervous and Mental Disease, 7/28/2004