Brief Ongoing Assessment of Suicide

Following a comprehensive evaluation, the clinician conducts brief ongoing assessments of suicide risk to monitor changes in the patient's overall status. Knowledge about established risk factors helps the clinician make informed judgments about potential risk. Table 7.1 provides a summary of several of these risk factors that are initially assessed during the comprehensive evaluation and subsequently monitored closely during the course of treatment.

During the therapy process, the clinician continues to collect information about the presence and severity of suicide ideation, intent, and planning. Clinicians may continue to administer measures of suicide ideation and hopelessness prior to each therapy session. They may also utilize the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), which is a 21-item self-report depression instrument. The BDI-II has one specific suicide item (i.e., item 9) that directly assesses for suicidal thoughts. This item, in particular, may be used to monitor changes in suicide ideation throughout the course of treatment. A recent study on the predictive validity of the BDI-II indicated that patients with scores of 2 or above on the

TABLE 7.1. Indicators for Determination of Low and High Suicidal Risk

Indicator

Lower risk

Higher risk

Suicide ideation"

SSI item 4 or 5 = 0 or BDI-II

SSI Item 4 or 5 > 0 or BDI-II

Item 9 = 0 or 1

Item 9 > 2

Depression"

BDI-II < 20 (Mild)

BDI-II > 20 (moderate-severe)

Hopelessnessa

BHS < 9 (Mild)

BHS > 9 (moderate-severe)

Reasons for living

Many

None

Access to lethal methods

None

Immediate

Impulse control

Within normal limits

Poor (e.g., anger outbursts)

Treatment compliance

Within normal limits

Poor (e.g., refuses treatment)

Prior suicide attempts

None

One or more prior attempts

Social support

Perception of available support

Perception of poor support

Alcohol/drug abuse

None

Abuse or dependence

Psychosis or mania

None

Symptoms and/or diagnosis

Recent life stressor(s)

None

Severe recent life stressor(s)

Note. BDI-II, Beck Depression Inventory; BHS, Beck Hopelessness Scale; SSI, Scale for Suicide Ideation. For further details about these risk factors, refer to Brown, Beck, Steer, and Grisham (2000).

Note. BDI-II, Beck Depression Inventory; BHS, Beck Hopelessness Scale; SSI, Scale for Suicide Ideation. For further details about these risk factors, refer to Brown, Beck, Steer, and Grisham (2000).

suicide item were 6.9 times more likely to commit suicide than patients who scored below 2 (Brown, Beck, Steer, & Grisham, 2000).

COGNITIVE TREATMENT OF SUICIDE Theoretical Rationale

Beck's cognitive model of depression and emotional disorders serves as the foundation for the intervention presented in this section (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). The model posits that activated maladaptive cognitions in the form of automatic thoughts, assumptions, and core beliefs may result in suicide behavior. More specifically, Beck (1996) proposes a theory of "modes," which refers to structural and operational units of personality that consist of a composite of unified and functionally synchronous cognitive, affective, motivational, and behavioral systems. A "suicide mode" can be activated should the patient, for instance, experience loss-related cognitions (e.g., "I have lost all that is important to me"), suicide-related cognitions (e.g., "Life is no longer worth living"), sad or angry affect, passivity in seeking help, and/or increased impulsivity and motivation to plan and subsequently act upon injuring him/herself.

Cognitive Conceptualization of Suicide

In CT, suicide behavior is targeted directly for clinical intervention and is viewed as a maladaptive coping strategy often utilized presumably to solve extreme psychological distress. Suicidal patients are conceptualized as poor problem solvers. The chronic inability to generate or to consider all alternative options, whether available immediately or possibly in the future, is indicative of the serious hopelessness and helplessness experienced by these patients. In particular, patients with a history of prior attempts may require minimal internal or external triggers to reactivate the "suicide mode"; in cases where the mode is highly accessible in memory, automatic behaviors to self-injure may be likely. Subsequently, from the depressed patient's perspective, suicide is seen as the only option, and even as "a rational course of action" (Beck, 1976, p. 123). The desire to die then outweighs the desire to live.

The stepwise approach to CT is, therefore, first to deactivate the suicide mode; second, to modify its structure and content; and third, to construct and practice more adaptive structural modes (Beck, 1996). Patients are helped to challenge their pessimism and high estimations for future negative outcomes, and to transform hopelessness into hopefulness. Patients are taught problem-solving strategies and are assisted in the development and maintenance of healthy coping strategies, so that suicide behavior is no longer the only available option worth considering. In summary, suicide behavior is viewed as a problematic symptom in and of itself that deserves immediate attention, before other therapeutic goals are addressed. Intervention is aimed at utilizing empirically based strategies that minimize the chance of recurrence of suicidal behavior.

We recommend that the cognitive conceptualization of suicide be shared with the patient at the early phase of treatment, preferably during the first therapy session. The clinician explains the specific treatment goals and rationale. The patient is invited to work collaboratively toward increasing his/her desire to live by exploring new coping options. The maladaptive coping behavior of acting out distressing symptoms no longer remains the only available option.

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