Menninger suicide research Ellis
Recognizing and addressing unique vulnerabilities of suicidal patients: Suicide research at The Menninger Clinic Thomas E. Ellis, PsyD
Suicide risk is an inescapable presence in the treatment of people with psychiatric disorders, a fact that applies especially in inpatient psychiatric settings. This article summarizes a several-year research initiative at The Menninger Clinic aimed at better understanding psychological contributors to suicidality and developing more effective clinical interventions. Two areas of research are described, an outcomes arm focused on assessing the feasibility and effectiveness of a suicide-specific intervention (The Collaborative Assessment and Management of Suicidality) and an exploratory arm whose objective is to learn about psychological vulnerabilities that distinguish suicidal from nonsuicidal patients, with an eye toward developing interventions that address such vulnerabilities. The author concludes that, combined with other developments in the field, this body of work strongly supports the view that suicidal patients should be treated with interventions that specifically target vulnerabilities that seem to set the stage for suicidal episodes. (Bulletin of the Menninger Clinic, 80[1], 39–52)
The prospect of losing a patient to suicide commonly tops the list of work stressors reported by mental health clinicians (Deutsch, 1984). This worry is especially common in inpatient settings, where a suicidal presentation tends to be more the exception than the rule; indeed, more than half of patients admitted to Thomas E. Ellis is at The Menninger Clinic and Baylor College of Medicine, Houston, Texas. The research described in this article was made possible through the generous support of the Bernice Peltier Huber Charitable Trust, Riverside, California; The Brown Foundation, Houston, Texas; and the Menninger Clinic Foundation, Houston, Texas. Correspondence may be sent to Thomas E. Ellis, PsyD, The Menninger Clinic, 12301 Main St., Houston, TX, 77035; e-mail:
[email protected] (Copyright © 2017 The Menninger Foundation)
Vol. 81, No. 1 (Winter 2017)
39
Ellis
The Menninger Clinic (TMC) report significant thoughts of suicide within one month of admission. One-third (33.8%) report a lifetime history of at least one suicide attempt (A. Madan, personal communication). TMC’s heritage includes pioneering work on the understanding and treatment of suicidal individuals, beginning with Karl Menninger’s (1938) classic volume, Man Against Himself. The current article summarizes more recent efforts at TMC to develop optimal treatment strategies for suicidal patients and to advance the knowledge of psychological processes that create vulnerability to suicide. Begun in 2008, this initiative has explored a framework based on evidence that (a) suicidal individuals are distinguished from other patients by psychological characteristics that increase vulnerability to suicidal episodes, (b) optimal treatment involves methods specifically designed to address these vulnerabilities, and (c) such interventions can be expected to lower future suicide risk compared to patients receiving usual treatments. The suicide research program at TMC has consisted of two main components: outcome research evaluating the Collaborative Assessment and Management of Suicidality (CAMS; Jobes, 2016), and a series of studies exploring psychological vulnerabilities to suicide. Following a brief overview of the research context, each of these will be described here. Evolving models of suicidality Conventional thinking has placed suicide among an assortment of symptoms characterizing various psychiatric disorders, such as depression and borderline personality disorder. This model, while intuitively appealing, begs the question of why only a minority of patients with a given diagnosis dies by, or even seriously considers, suicide. Early insights into the key roles of such psychological characteristics as cognitive rigidity (Neuringer, 1964), hopelessness (Beck, Steer, Beck, & Newman, 1993), and dysfunctional attitudes (Ellis & Ratliff, 1986) began to pave the way for transdiagnostic interventions specifically targeting vulnerabilities to suicide. More recent developments in this arena 40
Bulletin of the Menninger Clinic
Menninger suicide research
include, most notably, Linehan’s work on reasons for living (Ivanoff, Jang, Smyth, & Linehan, 1994), Joiner’s contributions on failed belongingness and perceived burdensomeness (Van Orden et al., 2010), and Rudd’s (2006) work on fluid vulnerability. Particularly notable in the current context are Rudd’s (2006) thoughts on “residual risk,” wherein underlying psychological vulnerabilities can set the stage for future suicidal episodes, even after the patient has recovered from an illness episode. These contributions have naturally led to the development of psychotherapeutic interventions designed to address these vulnerabilities. Such interventions have shown superiority to conventional treatments with suicidal individuals in randomized trials; these include dialectical behavior therapy (DBT; Linehan et al., 2006), cognitive-behavior therapy for suicide (Wenzel, Brown, & Beck, 2009), brief cognitive-behavioral therapy (Rudd et al., 2015), mentalization-based therapy (Bateman & Fonagy, 2009), and Jobes’ Collaborative Assessment and Management of Suicidality (CAMS; Jobes, 2016). It is the last of these that has been the focus of treatment research at TMC. What is CAMS? CAMS is a structured approach to alliance-building, risk assessment, treatment planning, and risk reduction with suicidal patients. It was not designed as a therapy per se so much as a framework or “platform” for treatment, regardless of one’s therapeutic orientation. Central to the model is eschewing control strategies (such as no-suicide “contracts”) in favor of cultivating a spirit of patient–therapist collaboration on tasks such as developing a shared understanding of the suicidal process, developing a stabilization plan, and addressing coping deficits and other vulnerabilities to suicide. While sharing much in common with other suicide-specific interventions, CAMS has unique features as well. Suicidality is viewed fundamentally as a dysfunctional coping response, and thus as a primary problem rather than a mere symptom of an illness; thus, suicidal ideation and behavior are kept at the forefront of therapy. A major agenda item is developing a shared
Vol. 81, No. 1 (Winter 2017)
41
Ellis
understanding of how the suicidal experience unfolds for the patient in terms of typical situational triggers and the contributing cognitions, impulses, behaviors, and emotions. Particular attention is paid to patient-identified suicide “drivers,” that is, problems that induce the individual to consider suicide (Jobes, Comtois, Brenner, Gutierrez, & O’Connor, 2016; Tucker, Crowley, Davidson, & Gutierrez, 2015). Thus, interventions focus on drivers, emphasizing problem-solving to address them, as well as on the development of skills and techniques as alternatives to suicidality as a coping response. Within the CAMS framework, a full range of clinical techniques can be incorporated to develop alternate coping responses, in service of a postsuicidal life defined by purpose and meaning. A variety of interventions are thus used to further these ends; clinicians’ own techniques or others borrowed from DBT, cognitive therapy, psychodynamic psychotherapy, mindfulness, and other approaches may be employed, including coping cards, chain analysis, safety planning, the Hope Kit, and other antisuicide strategies (Linehan, 1993; Wenzel et al., 2009). Multiple clinical trials have provided an evidence base for the efficacy of CAMS (Comtois et al., 2011; Jobes, 2012). CAMS outcome research Our initial work in bringing CAMS to TMC was to establish feasibility and safety by (a) adapting CAMS (previously tested only in outpatient settings) to an in inpatient setting and population and (b) pilot testing to establish safety and acceptability to patients and staff. The one significant adaptation was to regard unit staff (nurses in particular) as the primary locus for risk management and safety measures, while increasing the prominence of case formulation and therapeutic interventions in CAMS, implemented by CAMS-trained therapists (Ellis, Daza, & Allen, 2012). Therapeutic strategies were drawn from a variety of sources, notably DBT (Linehan, 1993), cognitive therapy for suicidality (Wenzel et al., 2009), and mentalizationbased therapy (Allen, Fonagy, & Bateman, 2008). In addition, major emphasis was placed on preparing patients for life after 42
Bulletin of the Menninger Clinic
Menninger suicide research
discharge, through safety planning and cultivation of nonsuicidal coping strategies (Ellis, Daza, & Allen, 2012). Our pilot study, an open trial with 20 patients (Ellis, Green, Allen, Jobes, & Nadorff, 2012), demonstrated safety and feasibility of CAMS in the inpatient environment, acceptability by patients and staff, and significant symptom improvement in a severely ill population. Significant improvement was noted on an array of measures, including depression, hopelessness, suicidal ideation, suicidal cognitions, and factors on the SuicideStatus Form, an instrument specific to CAMS (Conrad et al., 2009). Effect sizes were large, ranging from 0.92 to 2.28. These changes met criteria for statistically and clinically significant changes. Having established feasibility, we next turned our attention to the question of whether the CAMS outcomes were attributable to the CAMS intervention, or perhaps just the result of routine hospital care. Because randomization was not feasible in our setting, we employed Propensity Score Matching (PSM; Austin, 2011) to select a control group that was equivalent on all relevant variables (depression severity, prior suicide attempts, etc.); the groups differed only on whether the patient received individual therapy from a CAMS-prepared therapist. Our first examination of this dataset (Ellis, Rufino, Allen, Fowler, & Jobes, 2015) showed improvement in both groups across a range of measures; however, patients who received CAMS showed significantly greater improvement in suicidal ideation and suicidal cognition at discharge compared to patients who received essentially that same inpatient treatment, although with conventional individual therapy. We later examined an enlarged dataset (N = 104), together with postdischarge follow-up data. Results were consistent with the earlier study, except that the CAMS and treatment as usual groups now differed significantly across all measures, not just suicide-specific measures. These measures included symptom measures of depression, experiential avoidance, functional impairment, and general well-being. Improvement was sustained at 6-month follow-up. Differences between the two groups were no longer significant at follow-up, which is attributable in part
Vol. 81, No. 1 (Winter 2017)
43
Ellis
to diminished statistical power due to attrition and to the fact that the non-CAMS group tended to “catch up” with the CAMS group over time. We interpreted these results as promising, to the extent that CAMS seemed to accelerate improvement over the course of hospitalization, and may have had a protective effect during the high-risk period immediately after discharge (Ellis, Rufino, & Allen, 2017). Vulnerabilities to suicide In light of growing evidence of the viability of suicide-specific therapies, the importance of better explaining how the suicidal process unfolds becomes clear. That is, even if we establish that an intervention such as CAMS “works,” further advancements depend upon understanding what specific psychological vulnerabilities are being affected. To address the important question of why some patients experience reemergence of suicidality even after symptom improvement, Rudd (2005) proposed that suicidal individuals might be characterized by traitlike vulnerabilities that are somewhat independent of symptoms of psychiatric illness, which may increase future vulnerability to suicidality if they are not addressed. This model suggests that, after resolution of the acute symptoms of a suicidal crisis, patients may carry residual risk in the form of persistence of a suicidal belief system, even during noncrisis periods. In addition to the factors proposed by Rudd (self-loathing and unbearability), a variety of psychological vulnerabilities potentially carry risk (Ellis & Rutherford, 2008). Menninger research to date has focused on the following: sleep disturbance, suicide cognitions, experiential avoidance (versus psychological flexibility), and implicit associations. Sleep disturbance Several studies over the past decade have demonstrated an association between sleep disturbance independent of depression per se (Bernert, Joiner, Cukrowicz, Schmidt, & Krakow, 2005; Bernert & Nadorff, 2015). We sought to extend this literature 44
Bulletin of the Menninger Clinic
Menninger suicide research
by examining the relationship between changes in sleep patterns and outcomes among suicidal patients over the course of inpatient treatment (Nadorff, Ellis, Allen, Winer, & Herrera, 2014). We found that individuals whose sleep did not improve over the course of treatment had significantly higher suicidal ideation scores at discharge compared to those whose sleep symptoms improved. This finding held even after controlling for admission scores on sleep quality, depression, and suicidal ideation. These results, combined with earlier findings on sleep and suicidality, suggest that even when depression improves, the failure of sleep to normalize over the course of treatment could constitute a potential risk factor for recurrence of suicidality after treatment. Suicidal cognitions The cognitive model of suicide maintains that various aspects of cognition, including belief systems and cognitive processing issues, powerfully influence emotions and behavior and comprise an important opportunity for therapeutic intervention. The residual risk model further suggests that such cognitive features may exist independent of affective state and may therefore require therapeutic attention distinct from treatments for psychiatric disorders per se. We sought to examine this hypothesis through a psychometric study of the Suicide Cognitions Scale (SCS), which was developed by Rudd and colleagues with the residual risk model in mind (Rudd, 2005). Results were consistent with the model, to the extent that (a) SCS scores were independently correlated with suicidal ideation, after controlling for depression severity and scores on the Beck Hopelessness Scale; and (b) individuals who showed less change in SCS scores over the course of hospitalization exhibited higher suicidal ideation at discharge compared to patients whose SCS scores had improved more (Ellis & Rufino, 2015). Moreover, factor analysis of SCS responses revealed a third factor beyond Rudd’s proposed Unlovability and Unbearability constructs, namely, Unsolvability, the belief that one’s problems cannot be solved, even with assistance. Interestingly, of the three factors, the Unsolvability factor was found to explain by far the greatest portion of variance in suicidal ide-
Vol. 81, No. 1 (Winter 2017)
45
Ellis
ation at discharge (25%), even after controlling for depression and hopelessness. We concluded not only that the SCS is a potentially important measure for assessing and treating suicidal individuals, but also that addressing suicide-related cognitions (a sense of unsolvability in particular) may be an important consideration separate and apart from depression and other affective states. Experiential avoidance Over the past two decades, several “third-wave” behavior therapies, including DBT (Linehan, 1993), Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2012), have highlighted acceptance as a key element in psychotherapy and personal growth (Kahl, Winter, & Schweiger, 2012). The ACT model in particular maintains that experiential avoidance (EA) plays an important role in virtually all forms of psychopathology and is therefore an important target in psychotherapy (Kashdan, Barrios, Forsyth, & Steger, 2006). We therefore set out to explore the role of EA in suicidality, specifically, whether suicide might be conceptualized as an extreme form of EA, and whether EA might therefore be viewed as a cognitive vulnerability to suicide to be targeted in treatment. We therefore administered the Avoidance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) to 189 psychiatric inpatients with histories of significant suicidality. Results showed not only that EA was, indeed, significantly associated with suicidal ideation (independent of depression and hopelessness), but also that change in EA over the course of hospitalization was associated with change in suicidality (again, independent of changes in depression severity and hopelessness; Ellis & Rufino, 2016). Moreover, treatment responders (patients whose suicidal ideation scores dropped significantly over the course of treatment) showed greater drops in EA compared to nonresponders. Implications for treatment are obvious, to the extent that EA becomes a specific target in the treatment of suicidal individuals, with psychological flexibility as an objective.
46
Bulletin of the Menninger Clinic
Menninger suicide research
Implicit associations Recognizing the limitations of patient self-report in the assessment of suicide risk, Mathew Nock has explored options for the measurement of implicit (unconscious) cognitive processes that may be associated with suicidality. The Life-Death Implicit Association Test (IAT; Nock & Banaji, 2007) is a timed task that requires the individual to classify cue words into categories pertaining to life and death, together with the distractor constructs “me” and “not me.” Consistent with predictions, individuals have been shown to classify life and death words into “me” and “not me” categories more quickly depending upon whether or not they are suicidal. To extend this literature, we administered the IAT to 124 psychiatric inpatients at admission, at 2-week intervals, and at discharge. Consistent with prior research with other populations, we found significant associations between IAT performance and explicit (self-report and interview) measures of suicide risk (Ellis, Rufino, & Green, 2016). Moreover, the IAT was found to predict suicidal ideation at discharge above and beyond number of prior suicide attempts and admission scores on measures of depression, suicidal ideation, and hopelessness. Importantly, we also observed IAT performance to change over the course of treatment, suggesting that IAT performance may be more statelike than traitlike. Whether this constitutes a directly modifiable vulnerability is an empirical question that remains to be investigated. Summary and future directions Suicide research at Menninger has contributed to a growing body of evidence for a model of suicidality as (a) related to, but distinguishable from, psychiatric disorders such as depression and personality disorders, (b) characterized by certain psychological vulnerabilities that are not necessarily eliminated when psychiatric disorders are treated and are associated with persistence of suicidality, and (c) one of a class of psychological conditions (such as obsessive-compulsive disorder) that are ideally
Vol. 81, No. 1 (Winter 2017)
47
Ellis
treated with interventions specifically developed to address their distinguishing features. One such suicide-specific intervention is CAMS, which now has been shown to be a feasible, safe, and effective intervention for suicidal individuals that outperforms intensive (and effective) usual care. This finding is noteworthy, given that the CAMS condition differed from usual care only in that the twiceweekly individual therapy was delivered by a CAMS-trained therapist, as well as the fact that comparisons were made with a wide-ranging assortment of measures (not just suicide-specific measures) and with relatively small sample sizes. The body of research on psychological vulnerabilities to suicide has been uniformly consistent with the residual risk model. Indeed, it is becoming increasingly clear that optimal care for suicidal patients must extend well beyond assessment and treatment of illness symptoms such as depression severity to include sleep, experiential avoidance, and other factors that are independent of mood and may, in fact, persist as vulnerability factors unless specifically targeted in treatment. It should be emphasized that to suggest that suicidality should be treated with specific features of suicidality in mind is not to say that conventional treatments are inappropriate or ineffective. To the contrary, our data indicate excellent responses of suicidal patients to intensive treatment, whether or not they receive CAMS. Indeed, conventional treatments offer many of the features one would hope for in treating suicidal individuals; these include restoration of hope, reconnection with caring others, collaborative problem-solving, and attention to selfcriticism and damaged self-esteem. Another “active ingredient” shared by most effective therapies, enhancement of psychological flexibility (the healthy alternative to experiential avoidance), is a strong presence in Menninger therapeutic culture (see Allen, 2017, elsewhere in this issue), with an explicit emphasis on awareness, acceptance, and expression of emotions to enhance coping and facilitate understanding of self and others. However, a suicide-specific approach further enhances treatment of suicidal patients by drawing attention to factors known to be independently associated with suicide risk but that may
48
Bulletin of the Menninger Clinic
Menninger suicide research
not be addressed in more generic interventions, such as sleep disturbance, nightmares, suicide-specific cognitions, stigma associated with suicidality, and others. Attending to these factors may provide advantages over conventional care that improve suicide-relevant outcomes, prevent recurrence, and potentially reduce the needless loss of lives. It is to be hoped that further research in this arena will lead to continued enhancements in treatment strategies and resources for this vulnerable population.
References Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing. doi:10.4088/JCP.09bk05202 Allen, J. G., Fowler, J. C., Madan, A., Ellis, T. E., Oldham, J. M., & Frueh, B. C. (2017). Discovering the impact of psychotherapeutic hospital treatment for adults with serious mental illness. Bulletin of the Menninger Clinic, 81, 1–38. Austin, P. C. (2011). An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behavioral Research, 46(3), 399–424. doi:10.1080/00273171.2 011.568786 Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166(12), 1355–1364. doi:10.1176/appi.ajp.2009.09040539 Beck, A. T., Steer, R. A., Beck, J. S., & Newman, C. F. (1993). Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide and Life-Threatening Behavior, 23(2), 139–145. doi:10.1111/j.1943-278X.1993.tb00378.x Bernert, R. A., Joiner, T. E., Cukrowicz, K. C., Schmidt, N. B., & Krakow, B. (2005). Suicidality and sleep disturbances. SLEEP, 28(9), 1135–1141. Bernert, R. A., & Nadorff, M. R. (2015). Sleep disturbances and suicide risk. Sleep Medicine Clinics, 10(1), 35–39. doi:10.1016/j. jsmc.2014.11.004 Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., … Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised
Vol. 81, No. 1 (Winter 2017)
49
Ellis measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. doi:10.1016/j.beth.2011.03.007 Comtois, K. A., Jobes, D. A., S. O’Connor, S., Atkins, D. C., Janis, K., E. Chessen, C., … Yuodelis-Flores, C. (2011). Collaborative assessment and management of suicidality (CAMS): Feasibility trial for nextday appointment services. Depression and Anxiety, 28, 963–972. doi:10.1002/da.20895 Conrad, A. K., Jacoby, A. M., Jobes, D. A., Lineberry, T. W., Shea, C. E., Arnold Ewing, T. D., … Kung, S. (2009). A psychometric investigation of the Suicide Status Form II with a psychiatric inpatient sample. Suicide & Life-Threatening Behavior, 39(3), 307–320. doi:10.1521/ suli.2009.39.3.307 Deutsch, C. J. (1984). Self-reported sources of stress among psychotherapists. Professional Psychology: Research and Practice, 15(6), 833–845. doi:10.1037/0735-7028.15.6.833 Ellis, T. E., Daza, P., & Allen, J. G. (2012). Collaborative assessment and management of suicidality (CAMS-M): An inpatient adaptation and implementation. Bulletin of the Menninger Clinic, 76(2), 147–171. Ellis, T. E., Green, K. L., Allen, J. G., Jobes, D. A., & Nadorff, M. R. (2012). Collaborative assessment and management of suicidality in an inpatient setting: Results of a pilot study. Psychotherapy, 49(1), 72–80. doi:10.1037/a0026746 Ellis, T. E., & Ratliff, K. G. (1986). Cognitive characteristics of suicidal and nonsuicidal psychiatric inpatients. Cognitive Therapy and Research, 10(6), 625–634. Ellis, T. E., & Rufino, K. A. (2015). A psychometric study of the Suicide Cognitions Scale with psychiatric inpatients. Psychological Assessment, 27(1), 82–89. doi:10.1037/pas0000028 Ellis, T. E., & Rufino, K. A. (2016). Change in experiential avoidance is associated with reduced suicidal ideation over the course of psychiatric hospitalization. Archives of Suicide Research, 20(3), 426–437. doi: 10.1080/13811118.2015.1093983 Ellis, T. E., Rufino, K. A., & Allen, J. G. (2017). A controlled comparison trial of the Collaborative Assessment and Management of Suicidality (CAMS) in an inpatient setting: Outcomes at discharge and sixmonth follow-up. Psychiatry Research, 249, 252–260. doi:10.1016/j. psychres.2017.01.032 Ellis, T. E., Rufino, K. A., Allen, J. G., Fowler, J. C., & Jobes, D. A. (2015). Impact of a suicide-specific intervention within inpatient psychiatric care: The collaborative assessment and management of suicidality. Suicide and Life-Threatening Behavior, 45(5), 556–566. doi:10.1111/sltb.12151 Ellis, T. E., Rufino, K. A., & Green, K. L. (2016). Implicit measure of life/death orientation predicts response of suicidal ideation to treat-
50
Bulletin of the Menninger Clinic
Menninger suicide research ment in psychiatric inpatients. Archives of Suicide Research, 20, 59–68. doi:10.1080/13811118.2015.1004483 Ellis, T. E., & Rutherford, B. (2008). Cognition and suicide: Two decades of progress. International Journal of Cognitive Therapy, 1(1), 47–68. doi:10.1680/ijct.2008.1.1.47 Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford. Ivanoff, A., Jang, S. J., Smyth, N. J., & Linehan, M. M. (1994). Fewer reasons for staying alive when you are thinking of killing yourself: The Brief Reasons for Living Inventory. Journal of Psychopathology and Behavioral Assessment, 16(1), 1–13. doi:10.1007/BF02229062 Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42(6), 640–653. doi:10.1111/j.1943-278X.2012.00119.x Jobes, D. A. (2016). Managing suicidal risk: A collaborative approach (2nd ed.). New York, NY: Guilford. Jobes, D. A., Comtois, K. A., Brenner, L. A., Gutierrez, P. M., & O’Connor, S. S. (2016). Lessons learned from clinical trials of the Collaborative Assessment and Management of Suicidality (CAMS). In R. C. O’Connor & J. Pirkis (Eds.), International handbook of suicide prevention: Research, policy, & practice (2nd ed., pp. 431–449). West Sussex, UK: Wiley-Blackwell. Kahl, K. G., Winter, L., & Schweiger, U. (2012). The third wave of cognitive behavioural therapies. Current Opinion in Psychiatry, 25(6), 522–528. doi:10.1097/YCO.0b013e328358e531 Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behaviour Research and Therapy, 44(9), 1301–1320. doi:10.1016/j. brat.2005.10.003 Linehan, M. M. (1993). Cognitive therapy for borderline personality disorder. New York, NY: Guilford. Linehan, M. M., Comtois, K. A., Murray, A. M., Tutek, D. A., Reynolds, S. K., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757–766. Menninger, K. (1938). Man against himself. New York, NY: Harcourt Brace & Co. Nadorff, M. R., Ellis, T. E., Allen, J. G., Winer, E. S., & Herrera, S. (2014). Presence and persistence of sleep-related symptoms and suicidal ideation in psychiatric inpatients. Crisis, 35(6), 398–405. doi:10.1027/0227-5910/a000279
Vol. 81, No. 1 (Winter 2017)
51
Ellis Neuringer, C. (1964). Rigid thinking in suicidal individuals. Journal of Consulting Psychology, 28(1), 54–58. doi:10.1037/h0045809 Nock, M., & Banaji, M. (2007). Assessment of self-injurous thoughts using a behavioural test. American Journal of Psychiatry, 164(5), 820–823. doi:10.1176/appi.ajp.164.5.820 Rudd, M. D. (2005, April). Individual vulnerability, suicide intent, and residual risk. Paper presented at the 38th Annual Conference of the American Association of Suicidology, Broomfield, CO. Rudd, M. D. (2006). Fluid vulnerability theory: A cognitive approach to understanding the process of acute and chronic suicide risk. In T. E. Ellis (Ed.), Cognition and suicide: Theory, research, and therapy (pp. 355–368). Washington, DC: American Psychological Association. Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., YoungMcCaughan, S., Mintz, J., … Bruce, T. O. (2015). Brief cognitivebehavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry, 172(5), 441-449. doi:10.1176/appi.ajp.2014.14070843 Tucker, R. P., Crowley, K. J., Davidson, C. L., & Gutierrez, P. M. (2015). Risk factors, warning signs, and drivers of suicide: What are they, how do they differ, and why does it matter? Suicide & Life-Threatening Behavior, 45(6), 679–689. doi:10.1111/sltb.12161 Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S., Selby, E. A., & Joiner, T. E., Jr. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. doi:10.1037/a0018697 Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients: Scientific and clinical applications. New York, NY: Guilford.
52
Bulletin of the Menninger Clinic
