suicide risk including behavioral activation, emotion regulation, cognitive restructuring, enhancing problem-solving skills, and improving interpersonal effectiveness (Bryan et al., 2019). In the case of suicide crises, clinicians using a CBT approach can also incorporate Safety Planning procedures or Crisis Cards into their treatment approach. Mood graphing can also be a useful strategy. Having patients record their mood at several points throughout the day can provide patients and clinicians with information for their ongoing assessment and about the outcomes of various interventions. Finally, some clinicians have used a hope kit to facilitate reasons for living when patients are feeling suicidal (Denneson et al., 2019). To make a hope kit, patients fill a small box with items that lead to positive feelings, instill hope, and take the edge off a suicidal crisis. Examples of items in the hope kit include pictures of the patient with loved ones, awards from school, and cards or letters from important people. Patients are instructed to place the hope kit in a prominent area, such as in the case of adolescents, a desk in their bedroom. Simply viewing the hope kit on a regular basis may help prevent a crisis once the adolescent realizes it contains concrete evidence of reasons for living. Recent research advances have pioneered the use of Dialectical behavior therapy Dialectic behavior therapy (DBT; Linehan, 1993) is one of the most commonly used psychotherapeutic techniques for recurrent suicidal behavior. DBT is based on concepts from cognitive behavioral therapy, and it has been used mostly in patients with borderline personality disorder, but increasing evidence suggests it may be useful to people with a variety of different diagnoses (DeCou, Comtois, & Landes, 2019). Furthermore, DBT is one of the few treatments for suicidal individuals with solid data supporting its use in both adults and adolescents (DeCou et al., 2019; McCauley et al., 2018; Rathus, Berk, Miller, & Halpert, 2020). The roots of dialectical behavior therapy (DBT) lie in Marsha Linehan’s work with chronically suicidal adult patients. She originally attempted to use cognitive behavioral strategies with these individuals, only to discover that those approaches simply did not work well. The population with which she was working felt misunderstood and invalidated. Cognitive behavioral therapy’s exclusive focus on change often pushed individuals into feeling emotionally overwhelmed, and they would frequently shut down. Conversely, focusing on acceptance also had its limitations. Individuals would feel extreme hopelessness or even rage at the clinician for failing to appreciate their emotional suffering and for treating it as inconsequential. As a result, Linehan (1993) developed DBT as a model that would balance and synthesize the opposing tensions between acceptance and change, good and bad, positive and negative. An important dialectical idea is that each position contains within it its own opposition. As Miller, Rathus, and Linehan (2007) describe it, “dialectic refers to change by persuasion and by making use of the oppositions inherent in the therapeutic relationship, rather than by formal impersonal logic” (p. 39). The therapy involves balancing problem solving and validation. Dialectic behavior therapy promotes the belief in one's own ability to succeed, the ability to emotionally self-regulate, and interpersonal effectiveness. It has repeatedly been shown to reduce the recurrence of suicidal behaviors in affected patients when compared to standard treatment for both adults (DeCou
digital hope kits through the use of smartphone apps (Bush et al., 2015). In addition to more general CBT approaches to suicide, some suicide-specific CBT protocols have been created, such as CBT for Suicide Prevention (CBT-SP; Bryan, 2019). CBT-SP can be used with adults and adolescents and includes: ● Cognitive restructuring strategies, such as identifying and evaluating automatic thoughts from cognitive therapy. ● EEmotion-regulation strategies, such as action urges and choices, emotions thermometer, index cue cards, mindfulness, opposite action and distress tolerance skills from DBT (discussed below. ● Other CBT strategies, such as behavioral activation and problem-solving strategies. Thus, although CBT-SP contains many elements of traditional CBT, it also focuses on some key issues involved in suicidal behavior that might not be addressed outside the context of suicidal behavior, especially with regard to emotion-regulation skills. In the case of adolescents and young adults, suicidal crises occur within an environment that may include problematic relationships, abuse, family dysfunction or poor school performance, CBT-SP includes family interventions if needed. role of emotional dysregulation and impulsivity in suicide. DBT therapists would respond to the patient by first assessing the patient’s suicide intent. As in other therapies, if intent was high, the therapist would engage the patient in revisiting her commitment to refrain from life-threatening behaviors and review plans for safety. If the patient is safe to proceed with therapy, the DBT therapist might explore whether and how her suicidal ideation is an expression of her distress. The DBT therapist might use an intervention method called “extending,” wherein they take the patient extremely seriously, possibly more seriously than the patient, and might wonder aloud about hospitalization with the expectation that the patient would back away from expressing suicidality in order to get a more desirable response, such as the therapist understanding her distress. This would allow the therapist to take the dialectic stance of validating the patient’s experience while engaging her in problem solving and developing a plan for using previously-taught skills. et al., 2019) and adolescents (McCauley, Berk, Asarnow, Adrian, Cohen, et al., 2018). The DBT perspective emphasizes the DBT involves a pretreatment stage and four additional stages, each with its own intervention targets. The pre-treatment phase aims to forge a mutual commitment to eliminate suicidal behavior and entails an intensive approach with weekly individual therapy and skills- training groups. Stage one focuses on: (a) decreasing behaviors that are life-threatening, interfere with therapy, and diminish quality of life, and (b) increasing behavioral skills. Stage two addresses decreasing post- traumatic stress. Stage three aims at increasing respect for self and achieving individual goals. Finally, stage four focuses on resolving a sense of incompleteness and finding freedom and joy. DBT skills are divided into several modules, including core mindfulness, emotion regulation, interpersonal effectiveness, distress tolerance, and walking the middle path. DBT therapists meet weekly with other DBT providers in consultative groups to help one another maintain a validating and “dialectic” stance toward their patients. The dialectic stance involves balancing validation strategies with change interventions.
CLINICAL DECISION-MAKING CONCERNS AND DOCUMENTATION
When mental health providers are dealing with individuals who are suicidal, it is imperative that they be aware of the legal implications related to the seriousness of suicidal thoughts. There are times when clients will need to be protected from themselves through hospitalization. At times, hospitalization even may be involuntary. It is critical that clinicians be aware
of the need for professional documentation of their decision- making process when dealing with clients who are at risk for suicide. The following section reviews various issues related to commitment and documentation issues.
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