Treating Suicidal Behavior An Effective, Time-Limited Approach
By M. David Rudd Thomas Joiner M. Hasan Rajab
The Guilford Press Copyright © 2004 The Guilford Press
All right reserved. ISBN: 1-59385-100-6
Chapter One An Overview of the Treatment Process
When faced with a suicidal patient, the practicing clinician is often left wondering, "What exactly do I do with this patient? How frequently, in what manner, and in what order do I address the myriad presenting problems? What symptoms do I target, and for how long?" Building on the empirical findings reviewed in Chapter 1 and the theoretical foundation provided in Chapter 2, this chapter offers an organizational framework to assist in the weighty task of treating suicidal patients. We have four goals for this chapter. First, we want to provide a clinically accessible summary of treatment tasks (i.e., the content of therapy) consistent with existing standards of care and supported by empirical findings. Second, we offer an organizational framework for treatment planning, one that incorporates the various treatment tasks discussed in Chapter 2 and complements the conceptual model offered. Third, we emphasize the varied roles, tasks, demands, and potential limitations of psychotherapy with suicidal patients. And finally, we discuss the complicating role of time and chronicity in treatment planning. Our treatment approach iscognitive-behavioral in the truest sense: cognitive restructuring and skill building go hand in hand. One cannot be done without the other. Skill building is simply a series of behavioral experiments, each providing a critical opportunity for cognitive restructuring and lasting change. Accordingly, the treatment agenda includes a range of cognitive and behavioral tasks.
This chapter provides a flexible, comprehensive, and thorough template for treatment planning, clinical risk assessment, patient management, and on-going monitoring. Although the framework offered is most consistent with the theoretical model reviewed in Chapter 2, it is flexible enough to be applied to other theoretical orientations. This is a function of its focus on concrete treatment tasks, as well as the inherent flexibility of cognitive-behavioral theory (e.g., Alford & Beck, 1997). Consistent with the discussion of emerging trends in psychotherapy integration offered by Norcross (1997), the integrative approach described is organized around identifiable problem areas, treatment goals, and related tasks that are uniform across suicidal patients, irrespective of diagnosis (both Axis I and II) and specific symptomatic presentation.
Completing the Clinical Picture: Understanding Severity, Chronicity, and Diagnostic Complexity
Inordinate time constraints in time-limited care demand structure and organization in the treatment process, in planning, in day-to-day application, and in monitoring outcome. In Chapter 2, we discussed six fundamental questions about the patient's suicidality that enable us to articulate the suicidal mode. We wanted to know about the patient's history (i.e., predisposing vulnerabilities), stressors that may have precipitated the suicidal crisis (i.e., triggers), the nature of suicidal thinking (i.e., suicidal belief system), feelings (i.e., affective system), physical symptoms (i.e., physiological system), and suicide-related behaviors (i.e., behavioral system). To complete the treatment planning process, it is critical to think about and be able to answer a few additional probing clinical questions. There are three primary features of the patient's presentation: (1) severity, (2) chronicity, and (3) diagnostic complexity. These characteristic features influence treatment goals, how they are organized and targeted (e.g., what is addressed first, second, third and how much time is devoted to each), and determine the actual duration of treatment itself. The additional questions we need to consider include the following:
What is the relative severity of dysfunction or disturbance evidenced by the patient? In other words, can he or she be managed in outpatient psychotherapy or is a more intensive intervention required first such as hospitalization or day treatment? Is the immediate risk for suicide too high to allow for outpatient treatment? If the patient is at high risk but can be treated on an outpatient basis, do special considerations need to be made such as daily monitoring or a suicide watch at home?
How chronic is the disturbance? That is, how long has the patient been struggling with suicidality? How many suicide attempts has he or she made, if any? In other words, we want to make sure we distinguish between ideators, single attempters, and multiple attempters. How complex a behavioral picture is presented? Is the suicidality compounded by other self-destructive and self-defeating behaviors (e.g., self-mutilation, substance abuse, aggressiveness, and sexual acting out) that will also need to be targeted?
How complex is the diagnostic picture presented by the patient in terms of both Axis I and Axis II comorbidity? In all likelihood, the more complex the behavioral picture, the more complex the diagnostic picture and vice versa.
What are the associated domains (i.e., nature) of disturbance? That is, how is the patient actually impaired? What symptoms, deficient skills, and/or maladaptive personality traits are present?
Depending on the answers to these questions and the patient's suicidal mode, we can start to organize the treatment agenda and determine what goals are important and reasonable within a time-limited framework. From the outset, however, it is critical to recognize that those with severe, complex, and chronic suicidality will most likely require longer-term care. Although the treatment agenda will be the same, it will simply take longer. The duration of care, in most cases, will be complicated by frequent relapses and recurrent crises for those evidencing chronic suicidality. The same organizational framework can be applied but the patient's progression through the various levels of treatment will be slower. As discussed in later chapters, this is a part of the informed consent process that needs to be emphasized when treatment goals are identified, expectations created, and a prospective time line established. This is particularly important for the patient, but it is also an issue for insurance carriers and managed care entities.
Identifying Treatment Components
In accordance with the recent trend in psychotherapy (e.g., Layden, Newman, Freeman, & Morse, 1993; Lerner & Clum, 1990; Linehan, 1993; Linehan et al., 1991; Rudd, Rajab, et al., 1996), suicidality can be viewed as a general construct (see Figure 3.1), with three discernible domains, components, or visible manifestations of psychopathology consistent with lower-order factors:
1. Symptoms (i.e., depression, anxiety, hopelessness, suicidal ideation, anger, guilt, panic, etc.).
2. Identifiable skill deficits (i.e., problem solving, emotion regulation, distress tolerance, interpersonal skills, and anger management).
3. Maladaptive personality traits (i.e., consistent with personality disorders as defined by DSM-IV and influencing both self-image and the nature of interpersonal relationships with family and friends).
Most traditional treatment approaches have focused on symptoms and personality traits, often struggling to integrate the role of deficient skills in a theoretically coherent manner. The most recent approaches have differed, however, emphasizing the three component parts noted previously (e.g., Linehan, 1993; Rudd, Rajab, et al., 1996). These three domains are the essence of what is targeted via psychotherapy, comprising the content of treatment. Consistent with the notion of the suicidal mode, each domain is the observable consequence of an active mode.
The emergence of managed care entities in the mental health landscape mandate shorter-term, targeted, and symptom-focused treatment. The suicide-specific approaches that have emerged over the last decade are empirically grounded, with identifiable and quantifiable treatment targets. As a result, they are more easily adapted for short-term treatment. Shorter-term and symptom- focused treatment does not, by any means, suggest less effective treatment. As is evident in our previous discussion of the suicidal mode and the interactive and interdependent nature of the modal systems, the more superficial symptoms are related to associated skill deficits and underlying core personality disturbance. All are a part of an active suicidal mode and targeted to some degree during the course of treatment, regardless of duration, and most often in simultaneous fashion. As is apparent from several of the studies reviewed in Chapter 1, brief treatment can and does having lasting impact. The end result is, ideally, more efficient and effective treatment and a more precise understanding and measurement of treatment outcome, both in terms of direct and indirect markers of suicidality (see Chapter 4 for a detailed discussion of direct and indirect markers of suicidality). As noted previously, however, those evidencing severe, complex, and chronic suicidality will require longer-term care. One of the benefits of using the treatment-planning framework offered is that it makes it easier to negotiate with insurance companies for additional sessions. Clinicians will be able to discuss in clear and concrete terms what has and has not been accomplished in treatment. They will be able to offer a coherent explanation as to why treatment is going to take considerably longer, that is, that the patient's problems are the result of a complex and chronic diagnostic picture compounded by recurrent, severe episodes of suicidality. In essence, the suicidal mode is more active, stable, and easily accessible.
The content of treatment is more readily accessible and quantifiable as a result of these suicide-specific approaches (as illustrated in Figure 3.1). We can discuss more clearly and cogently what we are actually doing in therapy, what we are working on specifically, and the types of change we expect to occur. We can articulate where we are in the treatment process (i.e., what component(s) of treatment we are targeting). We can also monitor and measure this change over time. As discussed later, this conceptualization has led to the identification of treatment tasks that provide a foundation for psychotherapeutic integration and a coherent organizational framework for the treatment of suicidality in a managed care environment.
An Overview of the Goals for Each Treatment Component
As summarized previously, empirically based approaches have incorporated three treatment components that target (1) symptoms, (2) deficient skills, and (3) maladaptive personality traits. Couched within the theoretical model of the suicidal mode, these three components form the foundation of our treatment approach (see Figure 3.4 for a summary). In other words, the patient's symptoms, deficient skills, and maladaptive traits are the observable consequences of the active suicidal mode, as well as the facilitating modes during periods in which the suicidal mode is inactive. The general goal is not just to deactivate the suicidal mode but to help the patient develop more adaptive modes, making it much more difficult to activate or trigger the suicidal mode in the future. That is, we want to raise the patient's threshold for becoming suicidal. When the patient is no longer highly symptomatic, is making use of improved skills, is more hopeful about the future, has a restructured suicidal belief system, has an improved self-image, and is functioning better in relationships, a new and more adaptive mode has been developed. Adaptive modes need to be accessible during periods of acute stress and crisis. Although each treatment component cuts across multiple systems of the suicidal mode, each has discrete, identifiable goals along with specific treatment targets. As discussed in more detail later, each treatment component is addressed simultaneously, with varying degrees of time and intensity depending on the specifics of the clinical situation.
Goals for Symptom Management
The goals for the symptom management component, focus specifically on acute symptomatology and immediate day-to-day functioning. Among the goals are the following:
Resolve any immediate crisis.
Reduce suicidality, including diffusing suicidal thoughts and related behaviors.
Instill a sense of hopefulness regarding both the immediate future and the treatment process.
Reduce overall symptomatology.
Goals for Skill Building
Goals for the skill-building component revolve around skill identification, development, and refinement. The task, for the most part, is to identify the patient's current level of functioning, associated skill level, and deficient areas to target and to pursue accordingly. Among the goals are the following:
Identify current skill level across targeted areas of problem solving, emotion regulation, self-monitoring, distress tolerance (i.e., impulsivity), interpersonal assertiveness, and anger management.
Improve the patient's general level of functioning, that is, return to premorbid level or better.
Help the patient develop and refine basic skills in the areas identified as deficient.
Goals for Personality Development
The goals for the personality development component are much broader in focus and, accordingly, are likely to be longer term. Specifically, the goals target three areas: self-image disturbance, developmental trauma, and interpersonal functioning including relationships with family and friends. This component targets more enduring psychopathology, and, naturally, it will be a particularly important aspect of treatment for those evidencing chronic suicidality. Among the goals are the following:
Improve the patient's overall self-image and sense of esteem (e.g., address persistent sense of self-loathing, guilt, shame, hatred, inadequacy, or incompetence).
Help the patient resolve internal conflicts, developmental trauma, and underlying core issues (e.g., early sexual, emotional, or physical abuse).
Help the patient improve the quality and nature of his or her interpersonal relationships, including those with both family and friends (e.g., improved intimacy as well as accessibility and quality of support).
An Overview of the Steps in Treatment Planning
As illustrated in Figure 3.2, treatment planning can be summarized in five sequential steps. These steps are straightforward and relatively simple. The first step is to complete the initial interview(s) and related history.
Excerpted from Treating Suicidal Behavior by M. David Rudd Thomas Joiner M. Hasan Rajab Copyright © 2004 by The Guilford Press. Excerpted by permission.
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