General Clinical Recommendations

Three clinical issues are reviewed to maximize the effectiveness of the cognitive intervention presented later in this chapter: (1) patient therapy attendance and compliance, (2) a "team" approach to intervention, and (3) attention to sociocultural factors in treatment engagement.

Effective strategies to engage patients in treatment, as well as to increase overall therapy attendance and compliance, need to be implemented. Patient attrition from psychotherapy is a documented problem in suicide attempters (i.e., only 20-40% of patients continue with outpatient treatment following their psychiatric hospitalization; O'Brien, Holton, Hurren, & Watt, 1987).

Therapy compliance can decrease due to factors such as shame about the suicide attempt; stigma and negative, culturally based attitudes about mental health services; poor economic resources; and chronic substance use (Berk, Henriques, Warman, Brown, & Beck, 2004).

When a patient drops out of psychotherapy, especially during the early stages, he or she is not likely to benefit from the delivery of treatment. Because the original reason for referral often has not been addressed, one may even expect that the patient's psychological difficulties, if left untreated, may worsen over time. Therefore, we recommend the implementation of a psychoeducation session before formal onset of CT. During this session, the therapist can directly assess the patient's attitudes and expectations about treatment and readiness for change. The major aims of psychoeducation are threefold: (1) to educate the patient about the nature and rationale for treatment, and his/her role as a participant in CT; (2) to educate the patient about the high attrition rates and the common reasons for treatment failure and/or dropout; and (3) to educate the patient about potential barriers to treatment and to provide the problem-solving skills and resources to address these difficulties.

Management and treatment of suicidal patients require time, effort, careful consideration of complex clinical factors, and decisions about hospitalization and/or breach of patient confidentiality. We advocate a "team" approach to intervention for two reasons: (1) to collaborate with other professionals to maximize quality patient care, and (2) to create a support network for all team members, so that issues such as patient safety, crisis management, and countertransference may be more effectively addressed. Decisions about patient care should be made in collaboration with all other providers (e.g., psychiatrist, substance abuse counselor, social worker) to best serve the needs of the patient.

A final recommendation is for clinicians to pay close attention to factors such as socioeconomic class, religion, culture, and the extent of perceived and actual social support available to the patient. The socially and economically disadvantaged tend to experience long-standing, multiple chronic stressors; consequently, mental health care may be perceived as a low priority. Although the CT protocol presented here is a manualized treatment package, we emphasize the importance of clinician flexibility and consideration of individual factors that may present as treatment obstacles. For instance, following a recent psychoeducation session with a Moslem female suicide attempter with a history of childhood sexual abuse, forced genital mutilation, and subsequent discomfort with male authority figures, a decision was made to assign the case to a female therapist to ensure the patient's early compliance and continuation with treatment. In the case of a patient who could not attend therapy due to transportation difficulties, phone sessions and financial assistance with transportation were considered.

The following clinical practices may increase overall treatment compliance: (1) reminder phone calls, (2) flexible scheduling, (3) willingness to conduct phone sessions, (4) a team approach to tracking the patient and encouraging treatment compliance, and (5) frequent problem-solving sessions to address difficulties in transportation, child care, housing, medication adherence, and follow-up. Although it is understandable that an outpatient therapist may not have the ability to provide all these support services, it is highly recommended that he/she take a more active and directive role in coordinating efforts with an existing case manager or medical provider to increase patient engagement in treatment.

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