Empirically-Based Outpatient Treatment for a Patient at Risk for Suicide: The Case of "John"

Abstract

Emerging research has provided empirical support for a number of cognitive-behavioral strategies designed to reduce suicidal behaviors. In this case study of "John," I describe the application of a combination of these strategies in treating a suicidal patient who recently returned from stressful military duty in Iraq. Focusing on assisting the patient to develop problem-solving and distress tolerance skills, treatment was centered in a collaborative model emphasizing the importance of the therapeutic relationship and involvement of social support networks. Interventions were guided by continual monitoring of suicidal symptoms and general distress level using standardized outcome measures, including Lambert's Outcome Questionnaire (OQ-45) and Jobes' Suicide Status Form (SSF). The treatment involved 21 sessions and resulted in eventual resolution of the suicidal crisis and in significantly reduced emotional distress.Key words: case study; suicidal behavior; empirically-supported treatment; therapeutic relationship; standardized outcome assessment ___________________________________________________________________________ CASE CONTEXT AND METHODWorking with suicidal patients is often an anxiety-provoking clinical activity that is commonly addressed with one of two extreme approaches: (1) an overly-cautious approach that overestimates suicide risk; or (2) an underestimation of suicide risk due to a dismissive attitude or inept assessment (Wingate, Joiner, Walker, Rudd, & Jobes, 2004). The former approach has undesirable consequences, including inappropriate deprivation of patients' rights and misuse of limited clinical resources. The latter approach, by contrast, jeopardizes patient safety and increases provider liability. Research has shown that behavioral health clinicians tend to follow the "better safe than sorry" approach, and overestimate suicide risk (Joiner, Rudd, & Rajab, 1999). Many clinicians assume that hospitalization is the "gold standard" for treatment of suicidal patients. A common clinical belief held by behavioral health professionals is that intensive inpatient care is the most effective strategy for reducing suicide risk. In fact, no clinical trial of inpatient hospitalization has ever been found to be efficacious for reducing suicidal behaviors (see . The persistence of this myth, in combination with a shift over the past few decades in the health care system away from inpatient psychiatric services (Goldney, 2003), has contributed to considerable challenges for the outpatient behavioral health practitioner. Because outpatient treatment is currently the most likely -and most available -method for treating suicidal patients (Goldney, 2003), and the criteria for admission into the dwindling number of institutionalized treatment programs continually becomes harder to meet, it is imperative that clinicians become comfortable delivering services on an outpatient basis. Furthermore, it is imperative they do so in a way that is consistent with empirically-supported practices and standards of c...

The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence‐Based Clinical Approach to Suicidal Risk

“…Since CAMS was purposely developed to be a “nondenominational” approach, there is no required theoretical orientation to use and a wide range of cross‐theoretical interventions can be imported into this therapeutic framework. In this regard, a number of different uses and adaptations of CAMS and related research are now seen in the professional literature that are independent of the work of the Catholic University Suicide Prevention Lab (e.g., Bryan, 2007; Ellis, Daza, et al., 2012; Pisani, Cross, & Gould, 2011; Zerler, 2009). While a number of CAMS‐relevant initiatives are underway, this article will close with a discussion of four current and emerging next‐step projects that are emblematic of CAMS‐related activities and where CAMS as a clinical intervention is going in the years ahead.…”

Evaluación e intervención en crisis: retos para los contextos universitarios

“…También es importante indagar sobre factores protectores como el soporte social, las habilidades de solución de problemas, la historia de habilidades de afrontamiento, la participación activa en el tratamiento, la presencia de esperanza, los niños en el hogar, el embarazo, el compromiso religioso, la satisfacción vital, el contacto con la realidad, el miedo a la desaprobación y el miedo al suicidio o a la muerte (Bryan, 2007).…”

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Conducting suicide research in naturalistic clinical settings

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