Working With the Suicidal Client Who Also Abuses Substances

Substance use disorders and suicidal thoughts and behaviors commonly co-occur in adolescent and adult psychiatric populations and are often functionally interrelated. Although the evidence base for treatment of this population is sparse, integrated cognitive behavioral treatment (CBT) protocols, or those that rely heavily on CBT techniques, hold promise. In this paper, we provide an overview of the evidence-based literature for interventions that target suicidal behavior and substance use disorders with adults and adolescents. We then discuss the manner in which these behaviors may be functionally interrelated and offer a conceptual framework (S-O-R-C) to guide case conceptualization and treatment planning for clients with co-occurring suicidality and substance use disorders. Next, we provide a case example of a client with suicidal behavior and an alcohol use disorder and demonstrate how to apply an integrated CBT treatment protocol to this case. This case example is followed by a more general discussion about the potential advantages of integrated CBT protocols for suicidality and substance use disorders, guidelines for prioritizing treatment targets and skill selection for each individual client, and other important treatment considerations. We conclude with recommendations for future research in this area.     

Working With Suicidal Clients: Not Business as Usual

In this introduction to a special series of articles on working with suicidal clients, we note that much of the recent growth in theory and research pertaining to suicidal individuals has been contributed by cognitive-behavioral theorists and researchers. This work has established that suicidal people manifest important cognitive vulnerabilities that can be addressed in therapeutic interventions specifically designed for them. Studies to date have produced outcomes that support this framework. We provide brief previews of the collection of articles that follow, which cover safety planning, protocols for evaluating risk, the utility of health behavior theory for informing treatment, mindfulness-based approaches for suicidality, developmental and family considerations, intensive inpatient CBT for individuals in the military, integrated interventions for substance abuse and suicidal behaviors, and coping with the impact of client suicide. We conclude that clinicians are now in a position to begin moving beyond a “therapy as usual” mindset in working with suicidal clients.     

Ethical Guidelines for Counselors Working With Older Adults

Counselors working with older adults may encounter situations that are not directly addressed by the ethical standards of the American Counseling Association (1995). After an extensive review of the literature, the Standards Committee of the Association for Adult Development and Aging (1998) identified 3 areas of concern: older adults with cognitive impairments, older adults who are the victims of abuse, and older adults with a terminal illness. This article examines the unique needs of older adults with these concerns and proposes guidelines for counselors working with such clients.     

Consultation and the Suicidal Patient

This paper presents an argument for a paradigm shift in the way that mental health professionals approach their work with psychiatric patients in the midst of a suicidal crisis and suggests that the time has come to discuss a standard of care based on integration of detected risk factors, effective education and training in suicidology, and most importantly, the routine use of consultation and teamwork. Also proposed is a workable model for the use of consultation that has a number of major components: quality education in suicidology, the training and availability of appropriate consultants, clinical teamwork, and the recognition by training programs and clinical institutions that it is necessary to routinely consider a consultative risk management approach for work with suicidal patients.     

Ethical Considerations for Therapists Working With Demographically Similar Clients

The increasing emphasis on multicultural competence within psychotherapy continues to highlight the need for being sensitive to key differences between therapist and client. However, this attunement to the psychotherapeutic impact of therapist–client differences may obscure the equally critical need to evaluate ethical problems associated with therapist–client similarities. It will be argued that therapists treating clients who are demographically similar to themselves encounter a unique set of ethical challenges that warrant careful consideration and caution precisely because of therapist–client matching. The extant research on matching therapists and clients based on demographic similarities is discussed, with a particular emphasis on psychotherapeutic outcomes and client preferences. Attention then turns to the nonrational heuristics and biases that can often cloud therapists’ ethical decision making regarding the appropriate uses versus contraindications for demographically matching therapists and clients. Within the discussion of nonrational heuristics and biases, suggestions are offered for managing related challenges for ethical decision making.     

The CAMS Approach to Working with Suicidal Patients

The Collaborative Assessment and Management of Suicidality (CAMS) is a novel clinical protocol designed to quickly identify and effectively engage suicidal outpatients in their own clinical care. The CAMS approach emphasizes a thorough and collaborative assessment of the patient's suicidality that then leads to problem-solving treatment planning that is coauthored by the clinician and the patient. This approach is specifically designed to launch a strong therapeutic alliance creating an effective treatment trajectory. The CAMS approach is designed to modify and change clinician behaviors in terms of how they initially identify, engage, conceptualize, assess, treatment plan, and manage suicidal outpatients. Critically, however, CAMS does not usurp clinical judgment or dictate treatment modality. Preliminary research has shown that CAMS leads to faster resolution of suicidality and may decrease nonmental health medical utilization. Given the challenges of clinical work with suicidality, increased concerns about malpractice liability, and the decreased use of inpatient hospitalization, CAMS provides a potentially important new approach to working with suicidal individuals on an outpatient basis.     

Therapeutic Practices and Ethical Beliefs of Professionals Working With Adolescents in Residential Treatment

The authors investigated dual relationships between 2 groups of staff (direct care and professional) and adolescent clients in 2 residential treatment programs. Staff were surveyed on their behavior and corresponding ethical beliefs regarding interactions they believed to be acceptable with minor clients specifically at termination of the treatment program. Direct care staff were more likely than were professional staff to have inconsistencies in behaviors and ethical beliefs. The American Counseling Association's (1995) Code of Ethics would prohibit some of the staff beliefs regarding acceptable behavior. Both groups were uncertain about the ethical appropriateness of certain interactions with adolescent clients. Implications are discussed.     

Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients

Suicide is the 10th leading cause of death in the United States and the second cause of death among those ages 15–24 years. The current standard of care for suicidality management often involves an involuntary hospitalization deemed necessary by the attending psychiatrist. The purpose of this article is to reexamine the ethical tradeoffs inherent in the current practice of involuntary psychiatric hospitalization for suicidal patients, calling attention to the often-neglected harms inherent in this practice and proposing a path for future research. With accumulating evidence of the harms inherent in civil commitment, we propose that the relative value of this intervention needs to be reevaluated and more efficacious alternatives researched. Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive hospitalization of suicidal individuals to those who lack decision-making capacity.     

Behavioral Risk Assessment of the Guarded Suicidal Patient

Psychiatrists and other mental health professionals are trained to assess patients by direct observation and examination. Short inpatient length of stay, brief outpatient visits, emergency room evaluations, and other time‐limited clinical settings require rapid assessment of suicide risk. Recognition of behavioral suicide risk factors can assist in the early identification of the guarded suicidal patient, thus avoiding total reliance on the patient's reporting.     

Ethical Guidelines for Counselors When Working With Clients With Terminal Illness Requesting Physician Aid in Dying

In 2005, the American Counseling Association (ACA) introduced a new ethical standard for counselors working with clients with terminal illness who are considering hastened death options. The authors’ purpose is to inform counselors of the Death With Dignity Act and explore relevant ethical guidelines in the ACA Code of Ethics ( ACA, 2005 ).     

Using the Linehan Risk Assessment and Management Protocol With a Chronically Suicidal Patient: A Case Report

The Linehan Risk Assessment and Management Protocol (LRAMP) is an empirically supported, comprehensive framework used to assess suicide risk and protective factors, and provide a guide for the therapist to consider reasonable options for intervening on suicidal behavior. This protocol includes a structured checklist for assessing, managing, and documenting suicide risk. It also structures the documentation to clearly describe the presentation, assessment, in-session interventions, decision-making process, and follow-up to other members of the treatment team. This paper describes a case in which the LRAMP was used to guide the assessment, intervention, and documentation of the suicidal behavior of a patient, “Ann,” being treated with outpatient Dialectical Behavioral Therapy in a community mental health clinic. Each section of the LRAMP is discussed as it was used with this complex patient, who had history of high utilization of acute psychiatric services. Application of the LRAMP included the assessment of risk and protective factors, and the use of an individualized crisis plan that engaged the patient, her family, the therapist, and the clinical team, to decrease acute risk, continue outpatient treatment, and avoid inpatient hospitalization. The considerations for documenting clinical decision-making with chronically suicidal patients are discussed.     

Ethical Challenges and Legal Issues for Mental Health Professionals Working With Family Caregivers of Individuals With Serious Mental Illness

Mental health professionals frequently work with family caregivers in the provision of psychotherapy services to individuals with serious mental illness. To address the need for ethical guidelines for working with family caregivers, an analysis of relevant ethical and legal issues is provided within the context of dynamic mental health care and legal systems. When working with family caregivers, practitioners utilize the American Psychological Association’s Ethics Code (2010), legal codes, and a complex decision-making plan; identify and communicate ethical obligations to family caregivers; consider the unmet needs of this population; avoid harm resulting from multiple relationships; and balance ethical duties of beneficence and respect for autonomy.     

Cultural Competence When Working With American Indian Populations: A Couple and Family Therapist Perspective

This article focuses on treating the underrepresented American Indian and Alaska Native population in therapy. The lack of literature on this topic may impede the ability of couple and family therapists (CFTs) to work effectively with members of this group. Issues such as the underutilization of therapy, dropout rates, culturally syntonic joining and assessment, religion, and spirituality are discussed. In addition, potential boundary issues of gift giving and community integration are explored. Finally, cultural strengths are addressed so they may be clinically integrated with this unique population.     

Patient and Family Descriptions of Ethical Concerns

Abstract

Ethically challenging situations routinely arise in the course of illness and healthcare. However, very few studies have surveyed patients and family members about their experiences with ethically challenging situations. To address this gap in the literature, we surveyed patients and family members at three hospitals. We conducted a content analysis of their responses to open-ended questions about their most memorable experience with an ethical concern for them or their family member. Participants (N?=?196) described 219 unique ethical experiences that spanned many of the prevailing themes of bioethics, including the patient-physician relationship, end-of-life care, decision-making capacity, healthcare costs, and genetic testing. Participants focused on relational issues in the course of experiencing illness and receiving medical care and concerns regarding the patient-physician encounters. Many concerns arose outside of a healthcare setting. These data indicate areas for improvement for healthcare providers but some concerns may be better addressed outside of the traditional healthcare setting.     

On Replacing the Ethical Principle of Autonomy With an Ethical Principle of Accordance

The author defines and critiques the ethical principle of autonomy. As a concept, autonomy is most aligned with paradigms of counseling that focus on the individual as a psychological entity with moral agency. It is less consistent with frameworks that focus on relationships philosophically and in practice. Autonomy is paradoxical, because it is a consensually defined principle imposed on counseling practice while denying counselors a choice in its application. The author suggests accordance as an alternative ethical principle. Accordance is consistent with relational paradigms of practice and the other relationship‐focused ethical principles in counseling. Accordance fully contextualizes individual responsibility and choice.     

Evaluations of Rebuttal Analogy Users: Ethical and Competence Considerations

Recent theorizing and research concerning the pragmatics of analogy in persuasion posits that it serves two communicative functions. Specifically, rebuttal analogy instrumentally functions as argument and also as a social attack device used to demean the competence or character of opponents. The study reported here empirically investigated message receivers' perceptions of rebuttal analogy users. Participants were exposed to one of four messages employing rebuttal analogy or to one of the same four messages with a nonanalogy version of the rebuttal argument. As anticipated, the findings revealed that participants perceived the communicator employing rebuttal analogy as less ethical and less competent than communicators using nonanalogy counterparts. These results are discussed and future research is proposed.     

Ethical Challenges in the Treatment of Individuals With Intellectual Disabilities

The effective provision of psychotherapy services to individuals with intellectual disability requires consideration of ethical issues related to clinical competence, access to services, obligations to multiple parties, guardianship, and appropriate assessment practices. This article provides an overview of major ethical considerations with guidance for clarifying and resolving common ethical concerns. Psychologists are encouraged to expand access to psychotherapy services for this population while maintaining awareness of potential modifications, training needs, and boundaries of professional competence. The authors provide recommendations and resources for effective and ethical treatment of psychotherapy clients with intellectual disabilities.     

The Countertransference Experiences of Pregnant Counselors Working With Sex Offenders

Using a phenomenological approach, the authors explored the lived experiences of female counselors who were pregnant during the course of providing clinical services to sex offenders. Themes included awareness of countertransference, emotional distress, safety concerns, and clinical objectivity.     

艾滋病防控中获取患者信息的伦理问题刍议

当前艾滋病获取患者信息中,存在公私观念上的摩擦、相关规定与环节存在疏漏、对信息弱势群体关照不足的伦理难题。问题背后包含着患者为了公共健康的伦理目的却又失去伦理关系的风险,“失德”名声带来的耻感与歧视,遵守政策规范却缺少应有的尊重与保护等矛盾。问题的解决需要在文化背景和利益关系下思量个人身心秩序与社会整体秩序间如何权衡,结合历史、理论与现实维度提出路径。“信”的建立是关键所在,包括公共卫生部门公信力的树立和相应制度措施建设,同时在信息活动中需要给“私”以合理地位,并注重艾滋病治疗相关医学信息的宣传。     

Predicting Suicidal Tendencies Among High Risk Youth With the General Theory of Crime

This study examines whether suicidal tendencies among a group of juveniles who have come to the attention of Child Protective Services can be predicted by self-control theory. Using data from the National Survey of Child and Adolescent Well-Being, we find that self-control predicts suicidal tendencies. In addition, the effect of self-control remains significant even when controlling for the juveniles’ depression and previously reported suicidal thoughts and behaviors. This study lends further support to the claim that self-control serves as a general explanation for a wide range of problematic outcomes. In addition, these findings provide caseworkers with another tool for assessing the risk of suicide among high risk youth.