Case Illustration

Ms. S, a 34-year-old, single African American female with a 10th-grade education, overdosed on her antidepressant medication with a moderate degree of suicide intent and lethality following occupational stressors that led to her job termination. The patient attributed her depressive symptoms to her recurrent poor job evaluations during the past year. In addition, Ms. S had been experiencing significant symptoms of posttraumatic stress disorder (PTSD) due to her history of chronic sexual abuse at the age of 14, and witnessing at the age of 28 the killing of her boyfriend by gang members. Her first and only other reported suicide attempt was at the age of 15, when she confided in her mother about the sexual molestation by the mother's live-in boyfriend. However, her mother reportedly did not believe her daughter's account of the abuse and allowed the perpetrator to remain in the household. The patient had a history of alcohol, marijuana, and cocaine abuse prior to her boyfriend's death 6 years earlier. She has remained clean for the past 5 years. At intake, she presented with severe symptoms of depression and hopelessness (BDI = 41;BHS = 19), and subsequently was diagnosed with MDD, severe, recurrent PTSD, and borderline personality traits.

During the psychoeducation and first therapy session, the patient was informed about the structure and duration of treatment. During the safety planning, Ms. S insisted that she needed help exclusively with her PTSD symptoms; she did not want to talk about her most recent suicide attempt or possible future attempts. The therapist explained the rationale of the current treatment, and provided empathy and direct assistance to Ms. S in obtaining services for all her immediate difficulties, including PTSD symptoms, unemployment, and medication management. The patient was referred to a PTSD treatment program at the University of Pennsylvania, where she was enrolled in a treatment study and received free exposure therapy for her trauma-related symptoms. In addition, Ms. S was assigned a case manager and reconnected with a community psychiatrist she had known previously. Once these arrangements were made, the therapist emphasized the primary goal for Ms. S's treatment at our facility: to decrease the likelihood of future suicidal behavior as a coping response. At this time, Ms. S agreed to share her suicide attempt story with the therapist during an emotionally charged session that was quite distressing for her. Based on the patient's account of internal and external stressors, a cognitive case conceptualization was generated (see Figure 7.2). Three major activating stressors relative to the patient's suicidal behavior were identified: (1) recollection of childhood abuse and activation of core beliefs such as "I am damaged goods"; (2) a conflictual and unsupportive relationship with her mother; and (3) unemployment. At this point, patient and therapist had formed a strong therapeutic alliance, mostly due to the effort put forth by the therapist to help Ms. S with her other problems.

During the middle stages of therapy, the therapist began to teach Ms. S various cognitive-behavioral strategies to increase her overall functioning. Unfortunately, during this time, the patient's cousin committed suicide. Following the suicide, Ms. S refused to attend therapy sessions, ignored all of the therapist's efforts to get in touch with her, and isolated herself in the bedroom at her mother's house. A few weeks later, the patient's mother called our office in a state of crisis and reported that her daughter was experiencing severe symptoms of depression and had expressed a strong desire to kill herself. To maintain patient confidentiality, the therapist asked to speak directly to the patient. Ms. S, crying uncontrollably, reported intense levels of depression and kept asking to be left alone so that she could "end it all." During this crisis call, the patient's brother arrived at the house, and he and the therapist decided that Ms. S should be taken to the emergency department for a psychiatric evaluation. Ms. S was not hospitalized: she later called to thank the therapist for working with her family members to oversee her care on the day of the crisis.

Ms. S returned to therapy shortly after this incident and added her mother and brother to the list of individuals who cared for her safety. She remained compliant with treatment recommendations, learned new skills (e.g., how to communicate better with her mother), and started to look actively for employment. Several therapy sessions were even spent on outlining the steps in the job search process, role-playing job interviews, and problem-solving potential obstacles. The patient's mood dramatically improved as she became more confident with her job search skills; impressively, she began volunteer work at a local church, started to work toward completing her general equivalency degree (GED) requirements, and obtained a part-time paid position. At the time of her therapy termination, Ms. S was still engaged in PTSD treatment. She obtained scores of 0 on both the BDI and the BHS for three consecutive appointments, reported no suicide ideation, and indicated a high commitment to living fully.

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