Outpatient standards of care and the suicidal patient.

This article is a review of the legal and clinical literature on standards of care for nonhospitalized adult suicidal patients. The authors discuss effective assessment, management and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. Through a review of malpractice claims data and through an examination of the clinical literature we detail the essential guidelines for sound assessment, intervention, and management procedures. The authors specifically discuss common failure situations in outpatient care (e.g., problems in pharmacotherapy, the decision to hospitalize, inappropriate and dual relationships, the assessment of imminence and lethality, and so on). Details regarding practical considerations in developing an outpatient standard of care are provided, as are suggestions that such a standard of care must include an ongoing assessment of the therapeutic alliance.     

Case consultation: Mary Catherine.

A case of the attempted suicide of a 66-year-old female is presented. Comment based on the chapters in this volume is presented. Specific topics of demographics, psychiatric-psychological, object relations, the attempt, and concluding comments provide an idiographic illustration of suicidal behavior in an older adult.     

Suicide Prevention in Adolescents (Age 12–18)

The epidemiology of adolescent suicide is summarized with particular emphasis on temporal trends by age and gender. “First-generation” prevention programs, as reviewed and critiqued by the Centers for Disease Control and Prevention, are then examined. In the absence of compelling empirically based behavioral outcome data, selective targeted “second-generation” prevention efforts are then described across the primary-secondary-tertiary continuum. These efforts are focused toward targets of individual predisposition, the social milieu, or proximal agents associated with high risk for suicidal behaviors. Finally, with an eye toward the future, current obstacles and unanswered questions are explored as they relate to opportunities and hopes for change in effecting reduced rates of these behaviors.     

Introduction to Group-Analytic Psychotherapy by S. H. Foulkes

This article will explore special leader issues that emerge in psychodynamically oriented therapy groups with adult children of alcoholics. Particular focus will be on countertransference feelings that get stirred up in group leaders and techniques for dealing with some of these special dilemmas. Specific issues include (a) assumption of sameness between the therapist and the patient (the therapist assuming that he or she “understands” because of having also grown up in an alcoholic family); (b) the “will to restore,” which may be destructive when the therapist, whose own self-esteem is dependent on the patient's progress in therapy, forces a “rush to recovery” on the patient; (c) other personal issues in the life of the therapist that may also resonate with experiences of the patient; (d) “countertransference goodness and availability” as it affects therapists' abilities to set reasonable limits on their patients, as well as reasonable expectations for themselves; and (e) special issues regarding therapist transparency and self-disclosure.     

Prevalence,dynamic risk factors and the efficacy of primary interventions for adolescent dating violence: An international review

Adolescent dating violence is a pressing international issue: yet, there have been few attempts to collate the international evidence regarding this phenomenon. This article reviews contemporary evidence from Europe and North America on prevalence, dynamic risk factors, and the efficacy of intervention programs for adolescent dating violence. Prevalence findings suggest that victimization rates are comparable across Europe and North America. Although individual studies report differing prevalences, the overall hierarchy of violence types – in which psychological/emotional violence is most and sexual violence least prevalent – is consistent across almost all investigations. Four dynamic risk factors for perpetration are identified: peer influence, substance use, psychological adjustment and competencies, and attitudes towards violence. Peer influences and attitudes towards violence appear to be the most extensively evidenced factors in the literature. Nine existing intervention programs are identified, all located within North America. Intervention results are mixed, with some evaluations reporting significant long-term benefits while others report positive intervention effects dissipate throughout follow-up. Tentative analysis suggests that programs focused on behavioral change may elicit sustainable effects more readily. However, this is difficult to ascertain with no data on program repetitions and variations across intervention pedagogy and sample. Concerns with existing research and interventions and possible future directions are discussed.     

Neural and behavioral effects of interference resolution in depression and rumination

Individuals diagnosed with major depressive disorder (MDD) often ruminate about their depression and their life situations, impairing their concentration and performance on daily tasks. We examined whether rumination might be due to a deficit in the ability to expel negative information from short-term memory (STM), and fMRI was used to examine the neural structures involved in this ability. MDD and healthy control (HC) participants were tested using a directed-forgetting procedure in a short-term item recognition task. As predicted, MDD participants had more difficulty than did HCs in expelling negative, but not positive, words from STM. Overall, the neural networks involved in directed forgetting were similar for both groups, but the MDDs exhibited more spatial variability in activation in the left inferior frontal gyrus (a region critical for inhibiting irrelevant information), which may contribute to their relative inability to inhibit negative information.