The Problem-Solving and Comprehensive Contact Intervention (PS-CCI) is a novel, manual-based intervention for adults presenting to the emergency department for treatment of suicidal ideation, attempts, or both. The purpose of the intervention, developed in 2008, is to facilitate individuals’ transition into outpatient care in order to improve their engagement in outpatient treatment and thereby reduce their risk of future suicidal behavior. Preliminary testing of the intervention occurred between 2008 and 2010.
Suicidal individuals often show cognitive impairments such as poor problem-solving skills and difficulty generating solutions. The PS-CCI addresses these limitations through two main components: a problem-solving interview conducted on admission to the emergency department and follow-up contact across a three-month period.
The problem-solving interview consists of several components: identifying and addressing anticipated barriers to treatment, completing decisional balance worksheets collaboratively to identify pros and cons of attending outpatient treatment and of engaging in suicidal behavior, elucidating and correcting misconceptions about outpatient treatment, and encouraging the client to participate in outpatient treatment.
The first step in conducting the problem-solving interview is to evaluate barriers to engaging in outpatient treatment. Anticipating these barriers and helping clients develop strategies for addressing them if they are encountered can reduce the risk that clients, once engaged in treatment, will decide to withdraw from it when problems arise. Clients receive help with identifying and addressing factors that have served as barriers to receiving treatment in the past and other factors that may be creating barriers to currently engaging in outpatient treatment.
A decisional balance worksheet can help clients who generally struggle with making adaptive decisions to generate meaningful reasons to resist suicidal urges and choose to engage in more adaptive coping behaviors. Clinicians assist clients in developing a list of pros and cons for engaging in and for resisting suicidal behavior. The pros and cons are then reviewed to determine which option best suits the client’s ultimate goals. Clients are instructed that in times of stress, when they are considering engaging in suicidal behavior and are unable to generate reasons to avoid such negative behavior, they should refer to their decisional balance worksheet to remind themselves of meaningful reasons.
Given the cognitive impairments that suicide attempters experience, decisions to attend outpatient treatment may be based on misinterpretations or misconceptions. Thus the next step is to clarify misconceptions about treatment. Psychoeducation is provided regarding the goals of outpatient treatment, what it requires from the client, and the benefits to be gained from participation.
Suicide attempters are unlikely to attend outpatient treatment without encouragement. Developing a decisional balance worksheet focused on attending outpatient treatment can reinforce for clients the importance of attending such treatment and can serve as a reminder in times of stress or doubt about the importance of treatment. Similar to the previously described worksheet, clients develop a list of pros and cons for participating and for not participating in outpatient treatment. The pros and cons are reviewed to determine which option best suits the client’s ultimate goals. Clients are given the original copies of both decisional balance worksheets to review how they will be accessed in times of stress or doubt.
After discharge from the emergency department, individuals receive a phone call and a postcard reminder during the week of their first outpatient appointment. A monthly phone call is then made for three consecutive months. These calls are used to assess factors that have contributed to the patient’s adherence or nonadherence to outpatient treatment and to solve any barriers to treatment that may have developed.
The interactive, personalized aspect of PS-CCI may resonate more concretely with clients than a nonspecific approach in which reasons to refrain from suicidal actions or for engaging in treatment are provided to clients rather than generated by them. Clients raised few concerns regarding their ability to participate in the intervention. However, extended telephone follow-up was difficult because of the nature of this population, which tends to isolate and withdraw from social connections. Although follow-up was completed for most clients, far more attempts than anticipated were needed to reach them.