Treating Suicidal Behavior

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 The Robert O. Lawton Distinguished Professor of Psychology 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.

• I. Establishing a Foundation for Treatment1. What Do We Really Know about Treating Suicidality?: A Critical Review of the LiteratureThe Available Literature: A Limited DatabaseA Critical Review of Intervention Studies: Do Simple Procedural Changes Make a Difference?Implications for Clinical PracticeA Critical Review of Treatment Studies: An Emerging Trend for Cognitive Behavioral TherapyImplications for Clinical PracticeThe Therapeutic Relationship in Treating Suicidality: Attachment, Hope, and SurvivalImplications for Clinical PracticeUnanswered Questions: The Challenge Awaits Us2. A Cognitive-Behavioral Model of SuicidalityExisting Theoretical Models of Suicidal Behavior: A Brief OverviewStatic and Dynamic Variables Predicting SuicidalityApplication of Theory and Empirical Findings in Treatment: The Problem of Limited Clinical RelevanceBasic Assumptions of Cognitive Theory and Therapy: Implications for SuicidalityThe Essential Requirements for a Cognitive-Behavioral Model of Integrating Empirical Findings and Ensuring Clinical RelevanceThe Suicidal Mode as a Cognitive-Behavioral Model of Suicidality: An Elaboration and Specific Application of Beck's Theory of Modes and PsychopathologyDefining the Suicidal Mode: Characteristics of the Various SystemsCompleting the Suicidal Mode: Individual Case ConceptualizationImplications of the Suicidal Mode for the Organization, Content, and Process of TreatmentTheoretical Flexibility of the Suicidal Mode for Psychotherapy IntegrationThe Therapeutic Relationship in Cognitive-Behavioral Therapy: Three Fundamental Assumptions3. An Overview of the Treatment ProcessCompleting the Clinical Picture: Understanding Severity, Chronicity, and Diagnostic ComplexityIdentifying Treatment ComponentsAn Overview of the Goals for Each Treatment ComponentAn Overview of the Steps in Treatment PlanningUnderstanding the Treatment Process: Treatment Components and Corresponding LevelsDefining the Component LevelsSymptom Management ComponentCycling through Components and LevelsThe Role of MedicationsSkill-Building ComponentPersonality Development ComponentVariation in Therapist RoleA Clinical Example of Acute Suicidality: The Case of Mr. EMonitoring the Treatment ProcessProcess Tasks and MarkersProvocations and Resistance in the Therapeutic Relationship: How a Clear Organizational Framework HelpsQuantifying Change: How to Measure and Monitor Change in TreatmentTreatment Withdrawal and NoncomplianceEnsuring Treatment FidelityTermination: When, Why, and HowInterpersonal Process Groups and Booster SessionsThe Role of the Treatment TeamThe Need for Long-Term Care in a Time-Limited WorldII. Assessment and Treatment4. Treatment Course and Session-by-Session GuidelinesThe Beginning of Treatment: Sessions 1-4Sessions 5-10: Symptom Management, Cognitive Restructuring, Reducing and Eliminating Suicidal BehaviorsSessions 10-19: Emphasis on Skill BuildingSessions 19-20: A Shift Toward Personality Development and Longer-Term Treatment5. The Evaluation Process and the Initial InterviewsRisk Assessment Goals: The Importance of Establishing a Baseline for Ongoing MonitoringTreatment Conceptualization and Consent: Setting the StageThe Use and Role of Psychometric TestingEstablishing the Therapeutic Relationship6. Assessing Suicide RiskDistinguishing between Risk Assessment and Prediction: Defining the Nature of Clinical ResponsibilitiesThe Importance of Precise Terminology: Saying What We Know and Knowing What We SayEssential Components of a Clinical Risk Assessment InterviewTips on Eliciting Information on Intent and Self ControlRisk Categories: Baseline, Acute, Chronic High Risk, and Chronic High Risk with Acute ExacerbationRating Severity: A Continuum of SuicidalityClinical Documentation and the Process of Risk: The Concept of Risk MonitoringThe Role of Chronicity and Time in Risk AssessmentClinical Decision Making, Management, and TreatmentOngoing Monitoring of Treatment Outcome and EvaluationThe Persistence of Suicidal Thoughts: A Potentially Misleading Marker of Treatment Outcome7. Crisis Intervention and Initial Symptom ManagementKeys Tasks of Crisis InterventionEnsuring the Patient's SafetySelf-Monitoring during CrisesTeaching the Patient to Rate Discomfort: A Self-Monitoring TaskCompleting the Suicidal Thought RecordDepicting the Suicidal Cycle: The Suicidal Mode in ActionUsing Mood GraphsImproving Distress Tolerance and Reducing Impulsivity: The Importance of Repeatedly Emphasizing That Bad Feelings Do Not Last ForeverTargeting Source Hopelessness: A Different Kind of Problem SolvingSymptom Matching: Improving Level of Functioning over the Short TermThe Importance of Structure: Providing a Crisis Response Plan8. Reducing and Eliminating Suicide-Related BehaviorsIdentifying Behavioral Targets in Treatment: Understanding the Suicidal ModeDistinguishing between Suicidal Acts and Instrumental BehaviorsDealing with Mixed MessagesIdentifying the Suicidal CycleThe Process of Behavioral Change: Reducing and Eliminating Suicidal BehaviorInhibiting the Suicidal Cycle during Crisis States: Late-Cycle InterventionSubstitute Behaviors and Purposeful Hypervigilance:Early-Cycle InterventionShaping Behavior: A Process of Gradual ChangeExposure-Based Strategies: Role Playing, Cue Exposure, and Behavioral RehearsalContingency Management and Treatment SuccessTargeting Treatment DisruptionsProvocation(s): The Currency of Interpersonal Relatedness in SuicidalityHandling Provocation in TreatmentThe Evolution of Hope and the Elimination of Suicidal Behavior: A Few Concluding Words9. Cognitive Restructuring: Changing the Suicidal Belief System and Building a Philosophy for LivingPrivate Meaning and the Suicidal Belief System: The Role of Automatic Thoughts and Intermediate and Core BeliefsA Straightforward Strategy for Cognitive ChangeDealing with Poor Motivation and Treatment NoncomplianceBuilding a Philosophy for Living: Change and Acceptance as New RulesPrevailing, Facilitating, and Compensatory Modes in Chronic Suicidality: Developing Adaptive Modes and Acknowledging Personal Qualities and CharacteristicsThe Therapeutic Belief System: Therapy-Specific BeliefsOutlining the Therapeutic Belief SystemThe Therapeutic Belief System of the Therapist Treating Suicidality: Monitoring Thoughts, Feelings, and Behaviors in TreatmentEvaluating the Relationship: Patience, Determination, and Consistency10. Skill Building: Developing Adaptive Modes and Ensuring Lasting ChangeConceptualizing Skill Deficits in Cognitive-Behavioral Therapy for SuicidalityTargeting Skill DeficitsA Model for Problem Solving: Learning to Identify, Evaluate, and Pursue Alternatives to SuicideEmotion Regulation Ability: The Art of Feeling Better When SuicidalSelf-MonitoringDistress ToleranceInterpersonal Skills: Learning to Be Assertive, Attentive, and ResponsiveAnger Management: Early Identification, Appropriate Expression, and the Importance of Empathy, Acceptance, and ForgivenessSkill Building and Personality Change: One and the Same?Changing Interpersonal Process: Integrating Group TreatmentEpilogue

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. BarlowThis 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 AngelesFrom 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 SuicidologyThis 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