Table of Contents

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

About the Author

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.

Reviews

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