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Book Reviews   |    
Treating Suicidal Behavior: An Effective, Time-Limited Approach
Reviewed by Andrew Edmund Slaby, M.D., Ph.D.
Psychiatric Services 2001; doi: 10.1176/appi.ps.52.12.1665
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by M. David Rudd, Thomas Joiner, and M. Hasan Rajab; New York, Guilford Press, 2001, 274 pages, $32

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Despite our growing knowledge of the factors that contribute to self-destructive behavior, the number of persons who die by suicide remains high. The need for a better understanding of how to manage persons who have suicidal behavior is highlighted by the fact that for every suicide completion, there are eight to 25 more attempts.

Clearly, depression, hopelessness, and impulsivity play a role in suicidal behavior. Genetic factors can predispose an individual to neurotransmitter dysfunction during times of stress, which can result in recurrent symptoms of affective illness and other psychiatric disorders that are associated with suicide. Psychopharmacotherapy and electroconvulsive therapy can often effectively mollify if not ameliorate symptoms, but such therapies alone are not enough. Additional interventions should address the skill building and interpersonal change that are required to raise the suicide threshold during times of stress.

Suicidal patients suffer cognitive distortions and a poverty of skills. At their moments of greatest risk, they feel hopeless about the future, unlovable and worthless, and helpless to change their situation enough to make a difference. They often perceive those around them as critical, judgmental, rejecting, or abusive. Lacking in problem solving and interpersonal skills, they focus on their despair.

Although a number of guidelines have been published on the treatment of disorders that are associated with suicide, such as bipolar illness, major depression, schizophrenia, and borderline personality disorder, few authors have systematically enumerated strategies for addressing suicidal ideation itself. In this clearly written and well-documented volume, Rudd, Joiner, and Rajab elaborate an approach to the psychotherapeutic management of suicidal behavior regardless of diagnosis.

The book is divided into two parts; the first provides a theoretical foundation, and the second is an elaboration of specific tasks in assessment and treatment. Research indicates fairly consistently that the most effective interventions for managing suicidal patients in the short term entail cognitive-based therapy in which problem solving is integrated as a core component to reduce depression, hopelessness, and suicidal ideation. Reduction of subsequent suicide attempts and recurrent suicidal ideation requires longer-term treatment in which a variety of modalities are used to target poor stress tolerance, distortions of self-image, anger management, impaired social skills, and dysregulation of emotion.

The authors discuss how to teach patients to effectively solve problems by not avoiding them or responding impulsively to them but by taking a step-by-step approach and by acquiring skills that will increase patients' flexibility, such as emotion regulation and assertiveness. Principles of cognitive therapy are used, such as adopting a present time frame and developing awareness of how individuals actively participate in construction of their reality.

Acutely suicidal patients are often unaware that emotional intensity naturally changes over time and that they may feel better after a while. Their pervasive sense of hopelessness and helplessness overwhelms any sense that they may proactively affect their destiny. Often they cannot see how their behavior may intensify rather than diminish their despair.

The authors emphasize that the therapeutic relationship is a mechanism for modeling support, trust, acceptance, attachment, and, ultimately, separation and growth. For the vast majority of chronically suicidal patients and repeated attempters, interpersonal issues are at the core of their suicidality. The therapeutic alliance is the vehicle for change. The quality of the relationship, the authors emphasize, is the single most significant factor in predicting therapeutic outcome and assessing risk. Without a strong therapeutic relationship, it is unlikely that the patient will invest the energy and endure the pain that are often required for productive change.

At times the attachment in therapy may be all a patient can rely on to survive a particular emotional crisis. The ultimate goal of both brief and longer-term therapy is to raise the threshold of becoming suicidal when the patient is no longer highly symptomatic by instilling hope for the future, improving stress tolerance, enhancing self-image, and improving interpersonal skills.

The authors of this richly illustrated practical manual offer psychiatric clinicians, regardless of professional background, empirically based guidelines to supplement their unique expertise and judgment for the management of acutely and chronically suicidal patients and those who recurrently attempt suicide.

Dr. Slaby is clinical professor of psychiatry at New York University and New York Medical College.

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