Clinical Manual for Assessment and Treatment of Suicidal Patients

Front Matter\r......Page 0
Cover\r......Page 1
Title Page\r......Page 4
Copyright Information\r......Page 5
Contents......Page 6
Contributor......Page 20
Preface......Page 22
1 Introduction: The Dimensions of Suicidal Behavior......Page 24
Can Suicide Be Predicted?......Page 29
The Role of Psychiatric Diagnosis......Page 30
Demographic Factors......Page 32
Personality and Environmental Characteristics......Page 33
The Role of Biochemistry......Page 35
Helpful Hints......Page 36
Selected Readings......Page 37
2 The Clinician’s Emotions, Values, Legal Exposure, and Ethics: Global Issues in the Treatment of Suicidal Patients......Page 40
Emotions and “Hot Buttons” Exercise......Page 41
Evaluation of Responses......Page 43
Morals- and Values-Based Stances on Suicide......Page 46
Consequences of Suicidal Behavior Questionnaire......Page 49
Reasons for Living Inventory......Page 51
Legal and Risk Management Issues......Page 52
From Adverse Event to the Courtroom......Page 53
Malpractice Claims......Page 55
The Process of Discovery......Page 57
The Civil Trial......Page 58
Characteristic Claims in Wrongful Death Suits......Page 59
The Search for the Elusive Standard of Care......Page 62
What Is the Standard of Care for the Treatment of Suicidal Patients?......Page 63
Conduct a Competent Clinical Assessment and Document the Plan......Page 64
Reassess Suicidal Behavior Over Time......Page 66
Do Not Be Fooled by Suicide Prevention Measures......Page 67
Reduce Policy- and Procedure-Driven Services......Page 68
Never Alter the Clinical Record After the Fact......Page 69
Never Second-Guess a Decision......Page 70
Ethical Issues in the Treatment of Suicidal Patients......Page 71
Ethical Guidelines for the Treatment of Suicidal Patients......Page 72
Helpful Hints......Page 75
Selected Readings......Page 76
3 A Basic Model of Suicidal Behavior......Page 78
The Role of Problems......Page 79
The Role of Emotional Control and Avoidance......Page 81
The Role of Learning and Reinforcement......Page 82
The Role of Short-Term Versus Long-Term Consequences......Page 83
Instrumental Versus Expressive Functions......Page 84
The Basic Formula for Suicidal Crisis: The Three Is......Page 86
The Patient’s Relationship to Suffering......Page 88
Helpful Hints......Page 89
Selected Readings......Page 90
4 Assessment of Suicidal Behavior and Predisposing Factors: Blending Your Assessment With Treatment......Page 92
Prediction of Suicidal Behavior: Clinical Lore Versus Clinical Research......Page 93
Risk Prediction Systems......Page 94
Assessing Suicidal Behavior......Page 96
Prevention-Focused Assessment......Page 101
Treatment-Focused Assessment......Page 102
Using Self-Monitoring to Study Suicidal Behavior......Page 105
Prescribing Self-Monitoring Tasks......Page 106
Collaboration in Data Collection......Page 107
Using Self-Report Inventories......Page 108
Assessing Predisposing Factors......Page 109
Thinking Style......Page 110
Social Behavior......Page 111
Behavior Change Skills......Page 112
Life Stress......Page 113
Predisposing Factors Assessment Tool......Page 114
Helpful Hints......Page 115
References......Page 116
Selected Readings......Page 117
5 Outpatient Interventions With Suicidal Patients......Page 118
An Overview of Treatment Philosophies......Page 119
Reconciling Opposites: A Key to Managing Suicidal Behavior......Page 121
The Main Objectives......Page 123
Validation of Emotional Pain......Page 125
The Problem-Solving Framework......Page 126
Ending the Initial Session......Page 128
The Early Phase of Treatment......Page 129
Assaulting the Stigma......Page 131
Self-Monitoring......Page 132
Trigger Situations......Page 133
The Personal Scientist......Page 135
Three Clinical Pitfalls of the Early Phase of Treatment......Page 136
Session Logistics and Course of Treatment......Page 137
The Intermediate Phase of Treatment: Developing Acceptance of Feelings and a Commitment to Act......Page 138
Recontextualization......Page 139
Comprehensive Distancing......Page 141
Personal Problem-Solving Skills......Page 142
Interpersonal Effectiveness......Page 143
Three Clinical Pitfalls of the Intermediate Phase of Treatment......Page 144
Session Scheduling and Course of Treatment......Page 145
The Termination Phase of Treatment: Building the Future......Page 146
Shaping a Positive Future......Page 147
Putting a New Frame on Terminating Treatment......Page 148
Clinical Pitfalls of the Termination Phase of Treatment......Page 151
Helpful Hints......Page 152
Selected Readings......Page 153
6 The Repetitiously Suicidal Patient: Evaluation, Psychotherapy, and Basic Case Management......Page 154
Suicide, Attempted Suicide, and Parasuicide......Page 156
Pervasiveness of Maladaptive Behavior......Page 158
Persistence of Dysfunctional Behavior......Page 160
Resistance to Change......Page 161
Behavior That Is Self-Defeating......Page 163
See the World Your Repetitiously Suicidal Patient Sees......Page 164
A Basic Treatment Approach......Page 165
Phase One: Create a Humanizing Clinical Foothold......Page 166
Phase Two: Attack the Rationale for, and the Workability of, Suicidal Behavior......Page 168
Phase Three: Substitute Acceptance and Willingness for Emotional Control......Page 170
Phase Four: Develop Expanding Patterns of Committed Action......Page 171
Three Therapy Process Issues With the Repetitiously Suicidal Patient......Page 172
Allow Your Patient “to Be”......Page 174
Steal the Point of Resistance......Page 175
Make Suicidal Impulses an It......Page 176
Suicidal Feelings Are Your Friends......Page 177
Dealing With Downers......Page 178
The Moment of Truth: The First Crisis in Treatment......Page 181
Resistance: An Overused Interpretation......Page 183
Sample Dialogue: Accepting and Working With Suicidal Communication......Page 184
Providing Crisis and Social Support......Page 186
The Therapeutic Management of Chronic Crisis......Page 187
Case Management in the Community......Page 189
Someone Has to Be in Charge......Page 191
To Hospitalize or Not to Hospitalize?......Page 192
Helpful Hints......Page 194
References......Page 195
Selected Readings......Page 196
7 Managing Suicidal Emergencies: More on Crisis and Case Management......Page 198
We Are All Case Managers......Page 199
Working Through Suicidal Crises: Five Principles......Page 200
Working Through Escalating Suicidal Behavior: Strategies......Page 201
The Positive Behavior Action Plan......Page 203
The No-Suicide Pact: Who Is the Beneficiary?......Page 205
The Emotional Tone of the Intervention......Page 206
Suicidal Behavior Protocols......Page 207
Scheduling Additional Sessions......Page 208
Receiving Telephone Calls......Page 209
Making Random Support Calls......Page 210
Identification of Resources......Page 211
Growing Through Suicidal Behavior......Page 212
To Hospitalize or Not to Hospitalize: That Is the Question......Page 214
Emphasizing Responsibility and Self-Control......Page 215
Case Management: Crisis Intervention at the System Level......Page 216
The Concept of Funneling: Someone Has to Be in Charge......Page 217
Qualities of the Effective Case Manager......Page 218
During Crisis......Page 221
Selected Readings......Page 222
8 Hospitals and Suicidal Behavior: A Complex Relationship......Page 224
Does Hospitalization Prevent Suicide?......Page 226
Latrogenesis: The Unintended Side Effects......Page 227
Will I Get Sued if I Do Not Hospitalize?......Page 229
When Hospitalization Goes Sour......Page 230
When Should You Hospitalize a Patient?......Page 232
Short-Term Sanctuary......Page 233
Reshaping Suicidal Behavior: Planned Hospitalization......Page 234
Targets for a Short-Term Hospital Stay......Page 235
The Trouble With Discharge......Page 238
Component 1: An Emergency Center......Page 239
Component 3: A Brief-Stay Inpatient Service......Page 241
Component 5: A Crisis Stabilization Outpatient Program......Page 242
Keep All the Doors Open......Page 243
Selected Readings......Page 244
9 Working With Special Populations: Substance-Abusing, Psychotic, Young, and Elderly Patients......Page 246
Medications and the Suicidal Patient: They Don’t Work if You Don’t Take Them, and They Don’t Work if You Take Them All at Once......Page 247
Antianxiety Agents......Page 248
Antidepressant Medications......Page 250
Antipsychotic Medications......Page 252
Polymedication Regimens......Page 254
Case Management in Microcosm: The Prescribing Physician–Therapist–Patient Triangle......Page 257
Substance Abuse and Suicide: The Patient Who Is Left Out in the Cold......Page 259
The Substance-Abusing Suicidal Patient......Page 260
Alcohol on Breath: AOB in the Clinic......Page 263
The Inpatient Substance Abuse Unit......Page 264
The Special Case of Schizophrenia......Page 266
The Young: Working With Suicidal Children and Adolescents......Page 268
An Adolescent Suicidal Behavior Scenario......Page 269
Family Evaluation Is a Must: Therapy May Be a Bust......Page 270
The Forgotten Many: Suicidal Behavior in the Elderly......Page 272
Helpful Hints......Page 275
Selected Readings......Page 276
10 Suicidal Patients in General Health Care......Page 278
Develop Quick, Effective Screens for Suicidality......Page 281
Four Indicators to Look For......Page 282
The Role of Diagnostic Screening......Page 283
After Detection, Assign an Urgency Level......Page 285
Target 1: Validate Emotional Pain......Page 286
Target 2: Discuss Ambivalence and Provide Encouragement to Come Down on the Side of Life......Page 287
Target 3: Create a Positive Action Plan......Page 288
Target 4: Develop a Crisis Management Plan......Page 289
Target 6: Arrange Telephone Follow-Up......Page 290
Target 7: Initiate Appropriate Medication Treatment......Page 291
Helpful Hints......Page 293
Selected Readings......Page 294
11 Understanding and Providing Care to the Survivors of Suicide......Page 296
Clinical Characteristics of Survivors of Suicide......Page 299
A Three-Stage Model for Intervening With Survivors of Suicide......Page 308
Stage 1: Awareness of a Story and Acceptance of the Impact of the Story......Page 312
Stage 2: Reforming the Story and Creating More Behavioral Flexibility......Page 314
Stage 3: Applying the New Story to the World......Page 316
Group Treatment of Survivors of Suicide......Page 318
Treating Survivors of Suicide in Primary Care Settings......Page 319
References......Page 323
Selected Readings......Page 325
III. Suicide Is Not a Moral or Ethical Issue......Page 328
V. Suicide Has Intrinsic Positive Value......Page 329
Appendix B: Consequences of Suicidal Behavior Questionnaire......Page 330
Survival and Coping Beliefs......Page 334
Fear of Social Disapproval......Page 335
Moral Objections......Page 336
Appendix D: Suicidal Thinking and Behaviors Questionnaire......Page 338
Appendix E: Malpractice Management Assessment......Page 340
A......Page 342
C......Page 343
D......Page 345
E......Page 346
H......Page 347
M......Page 349
P......Page 350
R......Page 352
S......Page 353
W......Page 356