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...