Implementing and Adapting the SAFETY Treatment for Suicidal Youth: The Incubator Model,Telehealth, and the Covid-19 Pandemic

The Safe Alternatives for Teens and Youth (SAFETY) treatment was developed to decrease the risk of repeat suicidal and self-harm behavior in youth presenting with elevated suicide risk. This paper uses case illustrations to demonstrate the SAFETY treatment, building upon the companion paper describing our “incubator” treatment development model and process (Asarnow et al., 2022). As illustrated in the second case illustration, the incubator model approach was particularly useful during the COVID-19 pandemic switch to telehealth. SAFETY specifically targets suicide and self-harm risk reduction using an individually tailored principle-guided approach, grounded in a case conceptualization that identifies cognitive-behavioral processes and reactions that contribute to increased suicide attempt risk and explains the youth’s suicidal/self-harm behavior within the context of his or her broader social systems. The SAFETY treatment has been tested in two treatment development trials, and results support the efficacy of SAFETY for preventing suicide attempts in adolescents presenting with recent self-harm.     

Epidemiology,Risk Factors,and Prevention of Suicidal Thoughts and Behaviour in Prisons: A Literature Review

Suicide is a global public health concern that affects all echelons of society, albeit not equally so. Compared with adults in the general population, incarcerated offenders are at increased risk to consider, attempt, and die by suicide, which represents a substantial burden of morbidity and mortality in prisons worldwide. This review synthesises recent literature pertaining to the epidemiology, risk factors, and prevention of suicidal thoughts and behaviour among prisoners, and outlines a framework which emphasises the interplay between individuals (importation) and their surroundings (deprivation). The available evidence suggests that prison-specific stressors may exacerbate risk of suicide in an already vulnerable population characterised by complex health and social care needs. Emerging data point to differential mechanisms through which prisoners come to think about suicide and subsequently progress to suicidal behaviour. As risk of suicide is determined by a complex web of synergistically interacting factors, its management and prevention demands a cross-sectoral policy and service response that includes targeted interventions aimed at high-risk prisoners in combination with population strategies that promote the health and wellbeing of all people in prison.     

Brief Cognitive-Behavioral Therapy for Suicidal Inpatients

Suicide risk is elevated in psychiatric patients following discharge from inpatient care. Despite this vulnerability, there has been limited research investigating suicide prevention protocols that take into account the unique system characteristics of this setting (e.g., short lengths of stay, crisis stabilization treatment model, multidisciplinary team coordination). Cognitive-behavioral therapy (CBT) has demonstrated efficacy for improving suicide risk in outpatients, but has not been validated with inpatients. The current study was a treatment development and pilot feasibility open trial that modified brief cognitive-behavioral therapy (BCBT) for an inpatient setting (BCBT-I). Key treatment modifications included administering up to 10 sessions (depending on patient length of stay), daily, and in a standardized order, with core crisis management skills introduced during the first three sessions. In addition, coordination with the inpatient treatment team was included in BCBT-I implementation. Six adult inpatients with a recent suicide attempt enrolled and completed an average of 4.67 BCBT-I sessions (SD = 1.36). The treatment was highly acceptable (Client Satisfaction Questionnaire total score M = 3.49, SD = 0.73). Pre- to posttreatment effect sizes demonstrated improvements in suicidal ideation (d = 0.97), depression (d = 1.33), and suicidal implicit associations (d = 1.28). All but one of the participants (83%) completed follow-up assessments 1-, 2-, and 3-months postdischarge. Over follow-up, two participants reported suicidal ideation (both without intent), and none reported suicide attempts, preparatory acts or behaviors, or nonsuicidal self-injury. This study provided preliminary evidence supporting the feasibility of CBT to treat suicidal inpatients. Future research is needed to validate BCBT-I in a larger, randomized controlled trial to determine whether BCBT-I reduces suicide risk beyond that afforded by inpatient treatment alone.     

It is never the right time: How to help a mother to separate from her young child

In this paper I have described a short-psychotherapy treatment with a mother, a 3-year-old girl, and occasionally a father, over the difficulty in separating and settling down at nursery. The mother's unresolved mourning for the early miscarriage of her second baby was one important factor. She held on to the company and comfort provided by the little girl, who had become the vessel of maternal projections. Filled with Poppy's projections, the mother had also felt unable to withstand and process them. Mr Green was a conflictual element in the family, rather than a supportive husband and father, and Poppy's care and problems were left with the mother. Nine sessions unblocked the situation and allowed Poppy to settle down at a private nursery.     

Youth Suicide Intervention Using the Satir Model

Youth suicide is a social issue that needs serious consideration among families, therapists and helping professionals. This article presents an actual case of a youth who completed suicide, and discussion of the hypothetical Satir model treatment of this youth while alive. The Satir model has numerous interventions that have current applications toward dealing with suicidal youth in a humanist and hopeful way, fostering youths' desire to live and to become more positively involved in their lives. In the past, Satir focused on coping stances in communication, and now the coping stances give a deeper understanding into the internal world.     

父母严苛型教养方式与青少年自杀倾向:一个有调节的中介模型

在对西安市四所中学4071名中学生进行问卷调查的基础上,实证研究了父母严苛型教养方式与青少年自杀倾向之间的关系。结果表明:(1)从直接效应上讲,父母严苛型教养方式和个体自身对自杀行为的合理化认知对青少年自杀倾向具有显著的正向预测作用;(2)青少年对自杀行为的合理化认知在父母严苛型教养方式和自杀倾向的相关关系中起部分中介作用;(3)在严苛型教养方式通过自杀行为合理化认知影响自杀倾向的模型中,同伴支持变量不存在显著的调节作用,而教师支持变量在这一模型的直接路径与中介模型后半段均起调节作用。     

Seeking help for non-suicidal self-injury: A social network analysis approach

Individuals who self-injure have consistently reported less perceived social support; yet, little is actually known about the support they seek out from others specifically for non-suicidal self-injury. The goal of this study was to explore characteristics of support networks of those who self-injure. Twenty-three percent reported not seeking support for self-injury, while the remaining reported smaller social networks than typical. Most participants sought help infrequently, and when they did, found supporters to be only moderately helpful. Network characteristics were found to relate to self-injury behavior and patterns emerged regarding supporters in the networks. Implications for advocacy and education are provided.     

Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis

Dialectical Behavior Therapy (DBT) prioritizes suicidal behavior and other self-directed violence as the primary treatment targets, and has been demonstrated to reduce self-directed violence in clinical trials. This paper synthesizes findings from controlled trials that assessed self-directed violence and suicidality, including suicide attempts, non-suicidal self-injury (NSSI), suicidal ideation, and accessing psychiatric crisis services. Eighteen controlled trials of DBT were identified. Random effects meta-analyses demonstrated that DBT reduced self-directed violence (d = -.324, 95% CI = -.471 to -.176), and reduced frequency of psychiatric crisis services (d = -.379, 95% CI = -.581 to -.176). There was not a significant pooled effect of DBT with regard to suicidal ideation (d = -.229, 95% CI = -.473 to .016). Our findings may reflect the prioritization of behavior over thoughts within DBT, and offer implications for clinical practice and future research concerning the implementation of DBT for acute suicidality.     

Integrating the Interpersonal Psychological Theory of Suicide Into the Depression/Suicidal Ideation Relationship: A Short-Term Prospective Study

We examined the hypothesis that depressive symptoms are associated with increased beliefs about perceived burdensomeness and thwarted belongingness identified in the interpersonal psychological theory of suicide and that these beliefs are associated with changes in suicidal ideation. Participants with clinical levels of depressive symptoms (n = 299) were selected from a larger group (n = 508) and completed measures of depressive symptoms, perceived burdensomeness and thwarted belongingness, and suicidal ideation twice over a period of 2 months. Results of a structural equation model found that depressive symptoms were associated with increases in burdensomeness and lack of belonging, which were associated with suicidal ideation. Moreover, this hypothesized integrated model demonstrated a significantly better fit than an alternative model that assumed burdensomeness and lack of belonging were associated with changes in depressive symptoms, which were associated with suicidal ideation. Our findings suggest that the well-established relationship between depressive symptoms and suicidal ideation is associated with changes in beliefs that one is a burden on others and lacks belonging. More generally, these results suggest that it may be fruitful to integrate theories of suicide risk to form a comprehensive model that can inform future research and clinical interventions.     

A Standard of Care for the Assessment of Suicide Risk and Associated Treatment: The Florida State University Psychology Clinic as an Example

The Florida State University has established a set of guidelines to be used as a standard of care for suicide. This standard of care guides therapists through a suicide risk assessment that focuses on key variables related to suicidal behavior that are among the best predictors of completed suicide. This standard of care includes necessary components of suicide risk assessment, critical steps to follow to ensure the safety of suicidal patients, treatment recommendations, and guidelines for minimizing the legal risk of the therapist. Though this standard of care was developed in a research and training clinic, these principles may be applied to all clinicians offering psychological services to patients, regardless of the nature of the clinic or setting.     

The Youth Public Arts Program: Interpersonal and Intrapersonal Outcomes for At-Risk Youth

This article provides the findings of a program evaluation of the Youth Public Arts Program, a long-standing community-based art program that serves at-risk youth in eastern North Carolina. The program evaluation was undertaken to examine the art skills, social and interpersonal skills, and community involvement of the participants. The study included four focus groups and telephone surveys with a total of 38 stakeholders (program participants, parents of participants, program staff, and referral sources). Results indicated that the at-risk youth had gains in both interpersonal and intrapersonal skills, including family relationships, peer relationships, community interaction, increased art skills, confidence, and self-regulation. This article adds to the very limited literature on community-based art programs for youth.     

Illicit Drug Use,Cognitive Distortions,and Suicidal Ideation Among Homeless Youth: Results From a Randomized Controlled Trial

Illicit drug use and cognitive distortions confer significant risks to youth suicidal thoughts and behaviors. However, there has been limited evidence regarding the efficacy of suicide prevention interventions with homeless youth, especially studies testing whether such interventions can reduce the risk for suicidal ideation associated with illicit drug use. Suicidal homeless youth (N = 150) between the ages of 18 to 24 years were recruited from a drop-in center. Youth were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) or TAU alone. Youth reported their illicit drug use, cognitive distortions, and suicidal ideation 4 times over 9 months. A multiple-group multilevel structural equation model showed that higher illicit drug use at baseline predicted a slower reduction in cognitive distortions and suicidal ideation in the TAU group. These associations were not found in the CTSP + TAU group, suggesting an interruption of such risk from illicit drug use. Findings suggest that CTSP can reduce the risk of illicit drug use as a treatment barrier towards cognitive distortions and suicidal ideation among homeless youth, with implications to improve treatment efforts and to reduce premature mortality in a vulnerable population.     

Suicidal Thinking and Perfectionism: The Role of Goal Adjustment and Behavioral Inhibition/Activation Systems (BIS/BAS)

The current study investigated the associations among perfectionism, goal adjustment, behavioral activation sensitivity (BAS), behavioral inhibition sensitivity (BIS), and suicidal thinking. Participants (n = 255) completed the Multidimensional Perfectionism Scale, the BIS/BAS scale, the Goal Adjustment scale, and a measure of suicidal thinking. The findings showed that socially prescribed perfectionism was the only perfectionism dimension associated with suicidal thinking. Goal reengagement (but not goal disengagement) is an important construct in the suicidal process. A series of hierarchical regression analyses showed that goal reengagement moderates and mediates the effect of socially prescribed perfectionism on suicidal thinking. BIS was also associated with suicidal behavior but its effect was mediated via socially prescribed perfectionism. The theoretical and treatment implications of the relationships between socially prescribed perfectionism, goal reengagement, and suicidal thinking and between BIS, socially prescribed perfectionism, and suicidal thinking are discussed. Future research is required to determine whether these relationships are predictive of suicidal thinking and behavior over time.     

Treatment for Deliberate Self-Harm: Integrating Emotion-Focused Therapy

This article proposes that Emotion-Focused Therapy (EFT) can be effectively utilized as a treatment modality for deliberate self-harm or integrated with existing treatment approaches. A brief literature review examines evidence suggesting that attachment and emotion regulation are important etiological variables associated with deliberate self-harm. EFT addresses these variables by emphasizing the importance of the therapeutic relationship and assisting clients in the regulation and transformation of negative, maladaptive emotions. The article describes the basic tenets of EFT, comparing and contrasting this approach with therapeutic models most commonly used in the treatment of deliberate self-harm. Finally, it is recommended that future outcome research utilize randomized clinical trials to evaluate the effectiveness of EFT and compare it with other treatment modalities.     

A Probabilistic and Individualized Approach for Predicting Treatment Gains: An Extension and Application to Anxiety Disordered Youth

The objective of this study was to extend the probability of treatment benefit method by adding treatment condition as a stratifying variable, and illustrate this extension of the methodology using the Child and Adolescent Anxiety Multimodal Study data. The probability of treatment benefit method produces a simple and practical way to predict individualized treatment benefit based on pretreatment patient characteristics. Two pretreatment patient characteristics were selected in the production of the probability of treatment benefit charts: baseline anxiety severity, measured by the Pediatric Anxiety Rating Scale, and treatment condition (cognitive-behavioral therapy, sertraline, their combination, and placebo). We produced two charts as exemplars which provide individualized and probabilistic information for treatment response and outcome to treatments for child anxiety. We discuss the implications of the use of the probability of treatment benefit method, particularly with regard to patient-centered outcomes and individualized decision-making in psychology and psychiatry.     

Emotion Regulation in Youth with Emotional Disorders: Implications for a Unified Treatment Approach

Given the relationship between internalizing disorders and deficits in emotion regulation in youth, the emotion science literature has suggested several avenues for increasing the efficacy of interventions for youth presenting with anxiety and depression. These possibilities include the identification and addition of emotion-regulation skills to existing treatment packages and broadening the scope of those emotions addressed in cognitive-behavioral treatments. Current emotion-focused interventions designed to meet one or both of these goals are discussed, and the developmental influences relevant to the selection of emotion-focused treatment goals are explored using the framework of a modal model of emotion regulation. These various lines of evidence are woven together to support the utility of a novel emotion-focused, cognitive-behavioral intervention, the Unified Protocol for the Treatment of Emotional Disorders in Youth, a transdiagnostic treatment protocol that aims to treat the range of emotional disorders (i.e., anxiety and depression) simultaneously. Avenues for future directions in treatment outcome and assessment of emotion regulation are also discussed.     

Treatment of Comorbid Conduct Problems and Depression in Youth: A Pilot Study

The purpose of this study was to pilot a cognitive behavioral treatment protocol for adolescents with co-occurring conduct problems and depression. A non-concurrent multiple baseline design was used to assess the effectiveness of the intervention. A sample of five adolescents, aged 11 to 14 years, participated; all five families completed the protocol. Results indicated that symptoms of oppositionality were significantly reduced. Moreover, maternal ratings suggested significant improvements in emotion regulation in their children and cohesion in the family. However, symptoms of depression showed little improvement. Results of this study have implications for improving treatment outcomes for youth with these comorbid conditions and may lead to increased conceptual understanding of these comorbid problems.