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Suicidal Behavior

By
Richard McKeon PhD

Course Outline

Over 30,000 Americans and almost one million persons worldwide die by suicide each year, making it one of the leading causes of death throughout the lifespan. Suicide attempts outnumber deaths by suicide by a ratio of at least 25 to 1 and those who attempt suicide are at high risk of later death by suicide or of additional suicide attempts. Suicide risk is one of the most frequent reasons for admissions to inpatient psychiatric units. All of these facts make the treatment of those at risk for suicide a pressing priority. Research over the past two decades has led to the development of excellent empirically supported treatment methods. This book aims to increase clinicians’ access to empirically supported interventions for suicidal behavior, with the hope that these methods will become the standard in clinical practice.

About Authors

Richard McKeon PhD, MPH received his doctorate in Clinical Psychology from the University of Arizona, and a Master’s of Public Health in Health Administration from Columbia University. He has spent most of his career working in community mental health, including 11 years as Director of a psychiatric emergency service and four years as Associate Administrator/Clinical Director of a hospital-based community mental health center in Newton, New Jersey. He established the first evidence-based treatment program for chronically suicidal borderline patients in the state of New Jersey utilizing Marsha Linehan’s Dialectical Behavior Therapy. In 2001, he was awarded an American Psychological Association Congressional Fellowship and worked for United States Senator Paul Wellstone, covering health and mental health policy issues. He spent five years on the Board of the American Association of Suicidology as Clinical Division Director and has also served on the Board of the Division of Clinical Psychology of the American Pychological Association. He is currently a public health advisor on suicide prevention for the Substance Abuse and Mental Health Services Administration where he coordinates suicide prevention activities. He also serves as Co-Chair of the Federal Working Group on Suicide Prevention.

Learning Objectives

After completing this course you’ll be able to:

  1. List the risk factors for suicide.
  2. Describe the NSSP and list one of the critical objectives.
  3. State the percent of suicides in the U.S. that are associated with mental illness or substance abuse disorders.
  4. Define a suicide attempt, according to Silverman et al., 2007b.
  5. Compare an aborted suicide attempt and an interrupted suicide attempt.
  6. Discuss the reliance on an individual’s self-reporting, regarding his intent to do self-harm or a suicidal attempt.
  7. Compare suicidality and self-harm.
  8. State the ratio of female and male suicide deaths in older adults.
  9. Compare the methods of suicide among males and females.
  10. State the ratio of suicide to suicide attempts between young adults and older adults.
  11. State the percent of students, grade 9-12, who had seriously considered suicide in the previous 12 months. (Table 5)
  12. State the percent of former or current U.S. military personnel who die by suicide.
  13. Discuss the “course” of suicide.
  14. Discuss the work of Thomas Joiner (2005) regarding desensitization.
  15. State the two most significant comorbidities which impact suicide.
  16. List the various drugs present at the time of suicide, according to the National Violent Death Reporting System.
  17. Discuss the longitudinal study done in New Zealand regarding pathways to suicide.
  18. Discuss methods of assessment regarding suicide.
  19. Compare suicide of identical and non-identical twins, according to Roy, Rylander, and Sarchiapone (1997).
  20. Discuss the genetic contribution to suicide.
  21. Discuss the research of Shneidman.
  22. Define cognitive sensitization, according to Beck.
  23. Discuss suicidal desire and suicidal capacity according to Joiner.
  24. Discuss the link between mental illness and suicide.
  25. Define social isolation and social connection.
  26. Describe risk.
  27. Discuss the data from England regarding suicide following discharge from the hospital.
  28. Discuss the findings of JCAHO regarding critical incidents.
  29. State the first phase of treatment according to Linehan and Rudd et al.
  30. Discuss the goal of therapy according to Linehan (1993).
  31. Discuss the value of telephones and hotlines.
  32. List two services therapists can rely on being available in hospital EDs.
  33. Discuss social isolation and the remarks of Joiner (2005).
  34. Describe a no-suicide contract.
  35. List the four types of skills taught in Dialectical Behavioral Therapy and briefly describe each.
  36. Describe bibliotherapy.
  37. Describe non-demanding brief caring letters as described by Motto and Bostrum, 2001.
  38. Discuss re-evaluation of the treatment plan after suicide.
  39. Discuss balancing validation and problem solving of DBT.
  40. Discuss the high risk adolescent population according to D’Augelli et al.,2005.
  41. Discuss the findings of the Institute of Medicine after acute treatment for suicidal patients.
  42. Describe “therapy interfering behavior” according to Linehan, 1993.
  43. Compare suicide rates among various ethnic and cultural groups.

Course Contents

  1. Description
    • 1.1 Terminology
    • 1.2 Definition
    • 1.3 Differential Diagnosis
    • 1.4 Epidemiology
    • 1.5 Course and Prognosis
    • 1.6 Comorbidities
    • 1.7 Assessment Procedures
  2. Theories and Models of Suicidal Behavior
    • 2.1 Neuropsychiatric Theories
    • 2.2 Psychological Theories
  3. Risk Assessment and Treatment Planning
    • 3.1 Assessing Suicide Risk and Protective Factors
    • 3.2 Estimating Suicide Risk Level
    • 3.3 Resolving Contradictory Risk Factors
    • 3.4 Understanding the Time Dimension of Suicide Risk
    • 3.5 Documenting Suicidal Risk
  4. Treatment
    • 4.1 Methods of Treatment
    • 4.1.1 Multiphase Models
    • 4.1.2 Orientation and Engagement
    • 4.2 Crisis Intervention and the Management of Acute Risk
    • 4.2.1 Assuring Telephone Accessibility After Hours
    • 4.2.2 Suicide Prevention Hotlines
    • 4.2.3 Emergency Appointment Capability
    • 4.2.4 Use of the Emergency Department
    • 4.2.5 Psychiatric Emergency Services
    • 4.2.6 Involuntary Hospitalization and the Use of the Police
    • 4.2.7 Use of Mobile Outreach Services
    • 4.3 Safety Planning
    • 4.3.1 Involving Family and Friends
    • 4.3.2 Means Restriction
    • 4.3.3 Safety Planning Versus No-Suicide Contracts
    • 4.4 Treatment Techniques
    • 4.4.1 Skills Training
    • 4.4.2 Self Monitoring/Homework Assignments
    • 4.4.3 Cognitive Interventions
    • 4.4.4 Exposure Treatment
    • 4.4.5 Reducing Perceived Burdensomeness
    • 4.4.6 Failed Belongingness
    • 4.4.7 Bibliotherapy
    • 4.4.8 Outreach and Follow-up
    • 4.4.9 Postvention
    • 4.5 Mechanisms of Action
    • 4.6 Efficacy and Prognosis
    • 4.7 Variations and Combinations of Methods
    • 4.7.1 Variations and Combinations of Methods
    • 4.7.2 Working With Families
    • 4.7.3 Treatment of Adolescents
    • 4.7.4 Individual and Group Treatment
    • 4.8 Problems in Carrying Out the Treatments
    • 4.8.1 Problems in Communication and Information Gathering
    • 4.8.2 Problems in Continuity of Care
    • 4.8.3 Problems in Initial Risk Assessment
    • 4.8.4 Problems in Collaboration
    • 4.9 Multicultural Issues
  5. Case Vignette
  6. Case Example
  7. Further Reading
  8. References
  9. Appendices: Tools and Resources

Feedback

“We are entering a “no nonsense” period of suicidological theorizing and practice, with a substantial emphasis on empirical roots. In these exciting times, Richard McKeon is an indispensable intellectual guide. I was thrilled to read his Suicidal Behavior which spells out, kurz und klar, an easily digestible point of view as to what suicide really is. Get this book!”

– Edwin S. Shneidman, PhD
Professor of Thanatology Emeritus, University of California, Los Angeles and Founder of the American Association of Suicidology

“This important book represents a key resource on suicidal behavior for mental health clinicians, from those in training to senior experts…this concise and authoritative text will increase the ability of clinicians to understand suicidal behavior. Application of these principles has the potential to save lives.”

– Dale E. McNiel, PhD
Professor of Clinical Psychology, University of California, San Francisco and Chief Psychologist, Langley Porter Psychiatric Hospital and Clinics

“Books describing theory and research about suicide are plentiful, but guidebooks providing clinicians with specific, useful counsel on working with suicidal individuals are rare. Richard McKeon has written just such a volume.”

– Thomas E. Ellis, PsyD, ABPP
Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine and Associate Director of Psychology, The Menninger Clinic, Houston, TX