Late Phase of Treatment Sessions 810

Formal assessment of how well the patient has learned cognitive-behavioral skills is warranted at the final stage of treatment and is accomplished by the patient's completion of a guided imagery exercise, the relapse prevention task (RPT). The purpose of the RPT is twofold. The first aim is to activate images, thoughts, and feelings associated with previous, or the most recent, suicidal behavior in a safe therapeutic environment. The second aim is to evaluate treatment progress by directly assessing the patient's ability to respond adaptively to this activated state. A decision to terminate treatment is appropriate following the successful completion of RPT.

The RPT is completed in five stages. In the first stage, the therapist describes the purpose of this activity and obtains patient feedback and consent to begin the procedure. The patient is informed that because detailed imagery and discussion of previous suicidal behavior may activate strong physiological and emotional responses, full debriefing follows to ensure comfort and safety prior to each session's termination. In the second stage, the patient is asked to imagine the chain of events, thoughts, and feelings leading to his/her most recent suicidal behavior. Basically, the patient is being asked again to share his/her suicide story. The therapist guides the patient through this imagery exercise, scene by scene, using all senses to construct a detailed sequence of events and their meaning to the patient on the specific day of the suicidal behavior. The third stage of the RPT is similar to the second stage. The patient is again taken through the sequence of events leading to the most recent suicidal behavior, but this time he/she is asked to respond actively to maladaptive thoughts and images. The therapist stops the patient as needed and directly questions him/her about alternative ways of thinking, feeling, and behaving. This stage can be repeated if necessary, until the patient is able to demonstrate solid learning of the cognitive-behavioral strategies taught in treatment.

During the fourth stage of RPT, the therapist uses the generated cognitive case conceptualization and overall knowledge about the patient's history and existing situation to create a future scenario that is likely to activate suicidal behavior. The patient is then taken through another imagery exercise, this time, one that involves a future suicidal crisis. The therapist questions the patient about possible coping strategies, provides positive feedback, and proposes additional alternative strategies. The fifth and final stage of RPT involves debriefing the patient. The therapist provides a summary of learned skills in therapy, praises the patient for his/her completion of this final therapeutic task, and assesses his/her overall emotional reaction to this activity. The patient is reminded that mood fluctuations and future setbacks are to be expected. One therapeutic activity may involve the collaborative creation of a coping card that lists a series of strategies for addressing future setbacks instead of automatic reliance on "catastrophic" and "all-or-none" thinking. The patient is given the option of requesting future booster sessions. The necessity and structure of these sessions may be discussed prior to therapy termination.

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