Clinicians' conflicting emotional responses to high suicide-risk patients-Association with short-term suicide behaviors: A prospective pilot study

Suicide Crisis Syndrome: A systematic review

BACKGROUND

The objective of this systematic review is to describe the scientific evidence for the Suicide Crisis Syndrome (SCS), a presuicidal cognitive and affective state consisting of five symptomatic dimensions: entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The aim of this article is to summarize the emerging literature on the SCS and to assess the extent to which a uniform syndrome can be assumed.

METHODS

A systematic literature search was conducted in three different databases (PubMed, PsycInfo, and Google Scholar) using the search terms "Suicide Crisis Inventory," "Suicide Crisis Syndrome," "Narrative Crisis Model of Suicide," and "Suicide Trigger State."

RESULTS

In total, 37 articles from 2010 to 2022 were identified by search criteria. Twenty-one articles published between 2017 and 2022 were included in the systematic review. All but three studies were conducted in the United States and examined clinical samples of adult high-risk psychiatric in- and outpatients. Sample sizes ranged from N = 170 to 4846. The findings confirm the unidimensional structure of the proposed disorder and support the predictive validity for short-term suicidal behavior above and beyond suicidal ideation.

CONCLUSION

Despite the promising predictive validity of the SCS, a precise prediction of future suicidal behavior remains difficult.

The impact of scaffolded and non-scaffolded suicidal virtual human interaction training on clinician emotional self-awareness, empathic communication, and clinical efficacy

BACKGROUND

Clinicians working with patients at risk of suicide often experience high stress, which can result in negative emotional responses (NERs). Such negative emotional responses may lead to less empathic communication (EC) and unintentional rejection of the patient, potentially damaging the therapeutic alliance and adversely impacting suicidal outcomes. Therefore, clinicians need training to effectively manage negative emotions toward suicidal patients to improve suicidal outcomes.

METHODS

This study investigated the impact of virtual human interaction (VHI) training on clinicians' self-awareness of their negative emotional responses, assessed by the Therapist Response Questionnaire Suicide Form, clinicians' verbal empathic communication assessed by the Empathic Communication and Coding System, and clinical efficacy (CE). Clinical efficacy was assessed by the likelihood of subsequent appointments, perceived helpfulness, and overall interaction satisfaction as rated by individuals with lived experience of suicide attempts. Two conditions of virtual human interactions were used: one with instructions on verbal empathic communication and reminders to report negative emotional responses during the interaction (scaffolded); and the other with no such instructions or reminders (non-scaffolded). Both conditions provided pre-interaction instructions and post-interaction feedback aimed at improving clinicians' empathic communication and management of negative emotions. Sixty-two clinicians participated in three virtual human interaction sessions under one of the two conditions. Linear mixed models were utilized to evaluate the impact on clinicians' negative emotional responses, verbal empathic communication, and clinical efficacy; and to determine changes in these outcomes over time, as moderated by the training conditions.

RESULTS

Clinician participants' negative emotional responses decreased after two training sessions with virtual human interactions in both conditions. Participants in the scaffolded condition exhibited enhanced empathic communication after one training session, while two sessions were required for participants in the non-scaffolded condition. Surprisingly, after two training sessions, clinical efficacy was improved in the non-scaffolded group, while no similar improvements were observed in the scaffolded group.

CONCLUSION

Lower clinical efficacy after virtual human interaction training in clinicians with higher verbal empathic communication suggests that nonverbal expressions of empathy are critical when interacting with suicidal patients. Future work should explore virtual human interaction training in both nonverbal and verbal empathic communication.

Relationship Between Clinicians' Inclination Toward Patients at Risk for Suicide (PRS) and Self-reported Countertransference

OBJECTIVES

We investigate the relationship between clinicians' inclination toward treating patients at risk for suicide (PRS), and self-reported countertransference (CT). We consider these observed group differences to explore two competing interpretations for observed CT patterns from a primary study; whether CT patterns are more consistent with defensive attitudes or an adaptative CT montage.

METHOD

We used one-way ANOVA, Tuckey post-hoc, and t-test, to compare clinicians (n = 267) grouped by self-ratings of positive, neutral or non-positive inclination toward working with PRS, with regard to their level of endorsement of the Therapist Response Questionnaire (TRQ) with PRS. We hypothesized that positively inclined clinicians would demonstrate greater CT literacy skills than other clinicians, reflected in lower endorsement of negative/hindering CT and higher endorsement of positive/facilitating CT to PRS.

RESULTS

Compared to non-positively inclined clinicians, positively inclined clinicians endorsed significantly lower levels of two potentially negative/hindering CT dimensions, factor 1: entrapped/rejecting and, factor 5: protective/overinvolvement, and higher levels of the only positive/facilitating CT dimension, factor 2: fulfilled/engaging. Neutral clinicians reported similar CT patterns to positively inclined clinicians.

CONCLUSIONS

Hypothesis of greater CT literacy from positively inclined clinicians appears supported. Observed differences in CT endorsement by inclination group tend to support the CT montage interpretation of our original findings more than the defense mechanism interpretation proposed. Similarities in CT patterns between positively inclined and neutral clinicians suggest that positive inclination to PRS, as assessed in this study, may not be countertransferential per se.

Clinicians' Emotional Reactions toward Patients with Depressive Symptoms in Mood Disorders: A Narrative Scoping Review of Empirical Research

The purpose of this article is to narratively review the empirical literature on clinicians' emotional, cognitive, and behavioral responses (i.e., countertransference) to depressive and other symptoms of patients with mood disorders. Therapist subjective responses (countertransference) can negatively affect both diagnostic and therapeutic processes, especially when they are not recognized and managed promptly. However, at the same time, countertransference recognition, processing, and management can help inform the diagnostic process and improve the therapy process and outcome. In the last couple of decades, the number of studies that empirically explore countertransference toward mood disordered patients, as well as its relationship with various characteristics of both patients and treatment, has increased. Current evidence suggests that patients with depression tend to elicit more positive feelings among clinicians than patients with other severe mental disorders such as borderline personality disorder or schizophrenia. Furthermore, it documents the existence of associations between patients' severity of depressive symptoms and clinicians' subjective reactions, although the results regarding which specific countertransference patterns are evoked in relation to the different phases of the treatment are not entirely consistent. Lastly, growing evidence suggests the presence of clinicians' specific emotional reactions towards patients with suicidal ideation and behavior.

Exploring associations between the Modular Assessment of Risk for Imminent Suicide (MARIS) questionnaire and recent suicidal ideation and behavior among patients admitted at an acute psychiatric inpatient department

PURPOSE

The aim of the present study was to investigate the psychometric validity of the Modular Assessment of Risk for Imminent Suicide (MARIS) questionnaire in relation to recent suicidal ideation and behavior among a sample of patients admitted to an acute psychiatric inpatient department in Norway.

METHODS

The MARIS was completed within the first 24 h after admission by 338 patients and their clinicians. Information on recent suicidal ideation and behavior was extracted from patients' medical charts. Two out of four MARIS modules, the Suicide Trigger Scale Short-Form (STS-SF; modified version), and the Therapist Response Questionnaire Short-Form (TRQ-SF) demonstrated good internal consistency. The relationships between the STS-SF, addressing symptoms of the suicide crisis syndrome, and the TRQ-SF, exploring therapist emotional responses, and recent suicidal ideation was investigated by logistic regression analysis.

RESULTS

In the logistic regression analysis including pre-selected diagnoses, age, and gender as covariates, both STS-SF and TRQ-SF showed significant associations with recent suicidal ideation (inclusive of suicidal behavior in 27% of the patients with suicidal ideation).

CONCLUSION

Both the STS-SF and the TRQ-SF showed concurrent and incremental validity with regard to suicidal ideation. This is the first study showing the cross-cultural validity of the MARIS and supports its clinical utility as a suicide risk assessment tool in inpatient settings. Additionally, this study adds to the literature supporting the value of assessing clinicians' emotional responses to high risk patients.

Military mental health professionals' suicide risk assessment and management before and after experiencing a patient's suicide

OBJECTIVE

This study examines the association between a patient's suicide and the therapist's suicide risk assessment (SRA) and suicide risk management (SRM) of patients, following the occurrence.

METHOD

SRA values range from "absence of suicidality" to "immediate suicidal intent to die". SRM consists of therapists' written recommendations. Rates of the various SRA and SRM values in therapists' evaluations were assessed 6-months prior to the suicide and at the two three- and six-month time-points thereafter.

RESULTS

Of the 150 soldiers who died by suicides, 30 (20%) visited 50 military therapists in the 6 months preceding their deaths. Using Wilcoxon signed rank test, lower SRA rates of "threatens suicide" were found 2 months after a patient's suicide. Regarding SRM, the mean rates for "recommendations for psychotherapy treatment" were higher at the two (p = 0.022) and the 3 month time-points (p = 0.031) after a suicide.

CONCLUSIONS

The SRA findings may indicate therapists' fear of treating suicidal patients, causing them to overlook patients' non-prominent suicide-risk indicators. In SRM, the higher rate of recommendations for additional therapy sessions rather than military release or referrals to other therapists may relate to over-caution and attempts to control the patient's therapy ensuring it's done properly.

Associations between clinicians' emotion regulation, treatment recommendations, and patient suicidal ideation

OBJECTIVE

This study examines how clinicians' emotional responses to suicidal patients and their emotion regulation abilities are related to their treatment recommendations for these patients and to patients' concurrent suicidal ideation and at one-month follow-up.

METHODS

Adult psychiatric outpatients (N = 361) and the mental health professionals evaluating them for treatment (N = 43) completed self-report assessments following their first clinical meeting. Clinician emotion regulation traits, emotional responses to individual patients, and the recommended intensity of treatment were assessed. Patients were assessed for suicidal ideation immediately following the initial meeting and at a one-month follow-up. Moderation and mediation analyses were performed to examine the relationships between study variables.

RESULTS

Patient suicidal ideation at the initial clinical encounter was associated with increased negative emotions in clinicians with lower emotion regulation. Further, recommended treatment intensity was associated with clinicians' negative emotional responses but not with patient suicidal ideation among clinicians with lower emotion regulation.

CONCLUSIONS

Treatment intensification is related to clinicians' emotion regulation abilities. Clinicians' attention to their emotional responses may facilitate improved treatment process and ultimately may improve suicidal outcomes.

The Psychoanalytic Study of Suicide, Part II: An Integration of Theory, Research, and Clinical Practice

In Part I contemporary psychoanalytic concepts about suicide were synthesized with other theories and empirical research findings. Here the focus is on applying those principles and describing an integrative psychodynamic approach to treatment, one emphasizing the therapeutic alliance, unconscious and implicit processes, exploration of fantasy, and use of the therapeutic relationship as an implicitly interpretive vehicle for change. It is "integrative" because it draws on ideas and techniques described in dialectical behavioral therapy (DBT) and cognitive-behavioral therapy (CBT), as well on developmental and social psychology research. Psychotherapy with suicidal patients is inherently challenging, requiring the therapist to bear intense emotional pain while attending to potentially derailing countertransference pressures. The therapist plays an active role in helping the patient navigate affect storms and counter harsh self-attack, and instilling hope that treatment can lead to meaningful change. The integrative psychodynamic approach offers a pathway to a lessening of harsh self-judgment, greater connection with the body, improvement in continuity of experience, positive changes in narrative identity, emergence of the patient's genuine capacities, and more satisfying interpersonal relationships. These changes promote affect tolerance, improve life satisfaction, and decrease the likelihood of suicidal behavior.

Suicide Awareness Training: A Literature Review with Application to Queensland Nurses

Despite decades of strategic intervention, Queensland's suicide rates exceed both national and global rates. This is surely an indicator that not enough is being done to address this cause of death. The authors suggest that this problem may be addressed, in part, by provision of improved suicide awareness training for nurses. The purpose of this review was to support this through examination of the contemporary status of suicide awareness training in Queensland nurses, the efficacy of suicide awareness training in general, and the experiences of nurses, other health professionals, and suicidal patients in healthcare settings. We concluded that while efficacious, suicide awareness training in Queensland nurses is presently inadequate, and that both nurses and patients may benefit from improved suicide awareness training.

Relationship Between Gender and Clinician’s Subjective Experience during the Interaction with Psychiatric Patients

Introduction:

The clinician’s subjective experience can be a valuable element for diagnosis and treatment. A few factors have been recognized that affect it, such as the patient’s personality, the severity of psychopathology, and diagnosis. Other factors, such as patient’s and clinician’s gender, have not been specifically investigated. The aim of this study is to explore the impact of gender differences on the clinician’s subjective experience in a large sample of psychiatric patients.

Methods:

The study involved 61 psychiatrists and 960 patients attending several inpatient and outpatient psychiatric settings. The clinicians completed the Assessment of Clinician's Subjective Experience (ACSE) questionnaire after observing each patient for the first time.

Results:

In multivariate analysis, higher scores on the Difficulty in Attunement (p < 0.001), Engagement (p<0.05), and Impotence (p<0.01) scales were significantly associated with female clinician gender, whereas higher scores on the Tension and Disconfirmation scales were significantly associated with male clinician gender. The scores on all ACSE dimensions were also associated with the severity of psychopathology.

Conclusion:

The findings suggest that clinician’s gender might affect a clinician’s emotional response toward patients. Specific attention to this issue might be useful in clinical situations, not only in terms of promoting gender-balanced teams but also in terms of enhancing self-observation in clinicians evaluating patients for the first time.

Validity of the modular assessment of risk for imminent suicide in predicting short-term suicidality

OBJECTIVE

The Modular Assessment of Risk for Imminent Suicide (MARIS) is a clinical assessment tool, consisting of four modules assessing (1) a pre-suicidal cognitive-affective state (Module 1); (2) patients' attitudes toward suicide (Module 2); (3) clinicians' assessment of suicide risk factors (Module 3); and (4) clinicians' emotional responses to patients (Module 4) that assesses short-term suicide risk. Initial evidence provided evidence for its reliability and concurrent validity. The present study extended these findings by examining the MARIS's predictive validity in relation to suicidal thoughts and behaviors at one-month follow-up.

METHODS

A sample of 1039 psychiatric patients (378 inpatients, 661 outpatients) and their clinicians (N = 144) completed a battery of measures at baseline; 670 patients completed the one-month follow-up assessment.

RESULTS

MARIS total scores predicted suicidal thoughts and behaviors at one-month follow-up, even after controlling for baseline suicidal thoughts and behaviors. Moreover, both Module 1 and the Distress subscale of Module 4 were uniquely associated with suicidal thoughts and behaviors at one-month follow-up, controlling for baseline suicidal thoughts and behaviors. Modules 2 and 3, on the other hand, exhibited poor internal consistency.

CONCLUSION

Overall, both patient- and clinician-rated indices are uniquely predictive of suicidal thoughts and behaviors at one-month follow-up, highlighting the need for integrating clinicians' emotional responses into suicide risk assessment. Pending replication and extension of these findings in external samples, a briefer, two-module version of MARIS (MARIS-2) may be such an integrative, psychometrically sound, and clinically useful instrument that can be utilized to assess short-term suicide risk.

Therapists' emotional state after sessions in which suicidality is addressed: need for improved management of suicidal tendencies in patients with borderline personality pathology

INTRODUCTION

Patient suicidality is a frequently experienced topic for psychotherapists. Especially adolescents with borderline personality pathology (BPP) often exhibit suicidal tendencies. Previous research which examined therapists' countertransference towards suicidal patients suggested that therapists are negatively affected and distressed by them. We hypothesize that this emotional response of the therapists is related to specific sessions in which suicidality came up as a topic. Accordingly, the objective of this study consists in examining therapists' emotional state on a session level of analysis.

METHODS

The sample consisted of N = 21 adolescents (age 13-19 years) with BPD or subthreshold BPD. Therapists' emotional states were measured in n = 418 sessions using the Session Evaluation Questionnaire. Principal component analysis was used to reduce dimensionality of the therapist response. The emotional states were compared depending on whether suicidality has been addressed in the session (SS) or not (NSS).

RESULTS

Two components could be identified. Firstly, therapists were more aroused, excited, afraid, angry and uncertain after SS than after NSS. Secondly, therapists were more aroused, excited, definite and pleased after SS than after NSS.

DISCUSSION

Suicidality does not always have to be a burden for therapists: Both a "distress" and an "eustress" component occur in this context from which the latter is supposed to help clinicians master a difficult situation. Since countertransference feelings are often not fully conscious, it is necessary to do research on therapists' emotional states after sessions in which suicidality is addressed. This is crucial to both prevent the therapeutic process from being endangered and preserve clinicians' mental health. Clinical implications and limitations are discussed.

Behind therapists' emotional responses to suicidal patients: A study of the narrative crisis model of suicide and clinicians' emotions

OBJECTIVE

Clinicians' negative emotional responses to suicidal patients are predictive of near-term suicidality. This study aimed to explore the underlying pathway of this association by investigating the potential relationship between clinicians' emotional responses and the Narrative Crisis Model of suicide, which comprises long-term risk factors (LTRF) of suicidal thoughts and behaviors, Suicidal Narrative, and the Suicide Crisis Syndrome (SCS), a presuicidal affective state.

METHOD

One thousand and One patient participants and 169 clinician participants were recruited. Patients' Suicidal Narrative, SCS, and LTRF were assessed at intake using the Suicidal Narrative Inventory (SNI), the Suicide Crisis Inventory, and a composite score of three separate scales, respectively. Clinicians' emotional responses were measured immediately after patient intake using the Therapist Response Questionnaire-Suicide Form (TRQ-SF).

RESULTS

Multilevel regression analyses, which controlled for clinician differences, found that only patients' SNI total score and perceived burdensomeness subscale score were significantly associated with clinicians' TRQ-SF total score. Furthermore, a higher SNI total score was significantly related to higher distress and lower affiliation scores among clinicians.

CONCLUSIONS

Clinicians appear to respond emotionally to patients' Suicidal Narrative, and thus, future investigation of Suicidal Narrative and its potential to improve imminent suicide risk assessment is warranted.

Countertransference towards suicidal patients: a systematic review

Countertransference towards suicidal patients may blur healthcare professionals’ clinical judgment and lead to suboptimal decision-making. We conducted a systematic review of the quantitative studies on this topic. Following PRISMA guidelines, various databases were searched for studies measuring countertransference in healthcare professionals treating suicidal patients. Two authors independently performed screening and the quality of included studies was formally assessed. Ten studies were identified (3/5/2 of low/intermediate/high quality, respectively). Cross-sectional studies showed evidence for specific and adverse countertransference (e.g., disinterest, anxiety, overwhelming, rejection, helplessness or distress) towards suicidal patients. Furthermore, countertransference was prospectively associated with suicidal behavior and ideation in studies that explored this issue, but the meaning of this association remains to be clarified. Healthcare professionals’ characteristics (e.g. professional background, gender, personality traits) influenced countertransference. Suicidal patients elicit adverse countertransference, which should be addressed in clinical practice and through dedicated training.

How do distal and proximal risk factors combine to predict suicidal ideation and behaviors? A prospective study of the narrative crisis model of suicide

AIM

The Narrative Crisis Model of suicide posits that when individuals with trait vulnerabilities for suicide face stressful life events, they may develop distorted perceptions of themselves and society that culminate in a sense of no future. Referred to as the suicide narrative, these perceptions makes them more likely to experience the Suicidal Crisis Syndrome, an acute affective condition that increases the risk of engaging in suicidal ideation behaviors. The goal of this study was to assess the stage components of this model.

METHODS

The stage components of the NCM were assessed among adult psychiatric inpatients (N = 223; listwise N = 85) aged 18-65 years old and admitted for suicidal ideation or attempts. Suicidal outcomes were assessed at one month follow-up. Structural equation modeling (SEM) was used to assess the model and its prediction of prospective suicidal outcomes.

RESULTS

The model was supported by the SEM and proved to be a good fit for the data. Each temporal stage was significantly predicted by the precedent stage in the model and 13% of the variance in suicidal ideation and behaviors (when assessed conjointly) were explained by the model. When suicidal ideation and attempts were assessed separately, the amount of variance explained was 10.8% for suicidal ideation and 40.7% for suicidal attempts.

DISCUSSION

The progression from trait vulnerabilities to suicidal outcomes proposed by the NCM was supported by our findings. These findings have clinical implications in the assessment and treatment of suicide risk and will need replication with larger samples.

Multi-informant prediction of near-term suicidal behavior independent of suicidal ideation

BACKGROUND

Both the Suicide Crisis Syndrome (SCS) and clinicians' emotional responses to suicidal patients are predictive of near-term suicidal behaviors. Thus, we tested predictive validity of a combination of the proposed Diagnostic and Statistical Manual SCS criteria and the Therapist Response Questionnaire Suicide Form (TRQ-SF) for near-term suicidal behavior.

METHODS

The presence of SCS in adult psychiatric outpatients (N=451) was assessed using relevant items from validated psychometric assessments. Clinicians completed the TRQ-SF immediately after patient intake. Suicide attempts (SA) and a combination of suicide plans and attempts (SPA) were measured at one month follow-up (N=359).

RESULTS

At follow-up nine patients reported having SPA and seven reported SA. Meeting the SCS criteria were associated with near-term SA (χ2=5.987, p<0.01), while high TRQ-SF scores were associated with both near-term SA (χ2=5.971, p<0.05) and SPA (χ2=7.069, p<0.01). Meeting either the SCS or having high TRQ-SF scores, but not both, was associated with near-term SA (χ2=11.893, p<0.01) and SPA (χ2=11.449, p<0.01). Incremental predictive validity over standard suicide risk factors and individual scales was demonstrated in logistic regressions.

CONCLUSIONS

Multi-informant risk assessment not reliant on patient self-reported ideation appear to enhance predictive power of traditional risk assessments in identifying imminent suicide risk.

Occupational Suicide Exposure and Impact on Mental Health: Examining Differences Across Helping Professions

The purpose of the current study was to examine the relationship of suicide exposure with depression, anxiety, and post-traumatic stress disorder across three occupational groups likely to be exposed to suicide (i.e., first responders, crisis workers, mental health professionals). An online survey was completed by 1,048 participants. Results indicated that first responders, mental health professionals, and crisis workers were all exposed to suicide in the routine course of their occupation. Exposure to suicide significantly impacted mental health, specifically on depression, anxiety, and PTSD symptoms. The level of exposure to suicide was associated with higher levels of depression, anxiety, and PTSD.

The model of dynamic balance in therapists' experiences and views on working with suicidal clients: A qualitative study

Working with suicidal clients is frequently referred to as one of the most demanding and anxiety-provoking aspects of therapeutic work. The aim of this study was to obtain an in-depth understanding of therapists' experience in treating suicidal individuals and to develop a theoretical model of it. Eleven psychotherapists (four men and seven women) participated in individual semistructured interviews. The interviews were audiotaped, transcribed and analysed by the principles of grounded theory. We developed a model of dynamic balance in therapists' experiences and views on working with suicidal clients. The model includes six core themes, which represent aspects of therapists' experience and views where a dynamic balance is needed between two different poles. The core themes are as follows: (i) understanding of suicidality: the general versus specific; (ii) the role of alliance: protective factor versus no guarantees; (iii) attitudes: acceptant versus life-oriented; (iv) emotional response: worry versus trust; (v) responsibility: therapist's professionality versus client's autonomy; and (vi) focus: suicidality versus individual as a person. The model takes into account other variables that are relevant to the process and outcomes of the therapy: factors, related to the therapist and the client, as well as system regulations and therapeutic setting. The presented model may be helpful for mental health professionals in reflecting on their experiences of working with suicidal clients, describing the relevant topics and the way they relate to each other.

Differences and similarities in instant countertransference towards patients with suicidal ideation and personality disorders

BACKGROUND

Previous findings showed that suicidal patients elicit mostly negative countertransference such as distress, hopelessness, feelings of inadequacy, and apprehension, and that a concurrent personality disorder is associated with more feelings of entrapment and mistreatment, among other adverse reactions. No studies were however conducted on instant countertransference (iCT), i.e., after a single encounter, for example in an emergency setting. We aimed to evaluate the impact of suicidal ideations, self-harm and presence of personality disorders on instant Countertransference (iCT).

METHODS

Caregivers rated their iCT with two validated and standardized questionnaires after a first emergency or outpatient consultation. Suicidal ideation, self-harm and personality disorders were tested as predictors for iCT in a multivariate and multilevel analysis.

RESULTS

Thirty caregivers rated their iCT towards 321 patients. Personality disorders and suicidal ideation, but neither recent nor past history of self-harm, predicted iCT. Common iCT included tension, lack of self-confidence and feeling of being tied. iCT specifically associated with suicidal ideation included distress, lack of hope, confusion, and sense that the patient's life had little worth. In contrast, iCT towards patients with personality disorders suggested tension in the therapeutic relationship (low affiliation with patient, anger, disappointment, devaluation).

LIMITATIONS

Caregiver's characteristics were not considered in the analysis. Furthermore, while countertransference also includes unconscious phenomena, only conscious iCT was assessed.

CONCLUSIONS

Patients with suicidal ideation and personality disorders elicit common but also specific negative iCT. Mental health institutions need to devote specific resources (such as clinical supervision and training) to help caregivers manage their iCT.

Associations between clinicians' emotional responses, therapeutic alliance, and patient suicidal ideation

BACKGROUND

Mental health clinicians frequently experience intense negative emotional responses to suicidal patients, which have been related to treatment outcome. This study examines the therapeutic alliance as a mediator of the relationship between clinicians' negative emotional responses at the initial encounter and patients' suicidal ideation (SI) concurrently and 1 month later.

METHODS

We assessed 378 adult psychiatric outpatients (62.7% female; mean age = 39.1 ± 14.6 years) and their 61 treating clinicians. Following the initial encounter, self-report questionnaires assessed clinicians' emotional responses to their patients, patients' and clinicians' perception of the therapeutic alliance, and patients' SI. The SI was reassessed 1 month after the initial visit. Multilevel mediation analyses were performed.

RESULTS

Patients' (but not clinicians') perception of the therapeutic alliance mediated the relationship between clinicians' negative emotional responses to patients and patients' SI 1 month following the initial visit (indirect effect estimate = 0.015; p < .001).

CONCLUSIONS

The association between clinicians' negative emotional response and patients' prospective SI appears to be transmitted, at least partly, through the patients' perception of the poorer early quality of the therapeutic alliance. Thus, clinicians' awareness and management of their emotional states appear essential both for the identification of suicidal risk and to enhance therapeutic alliance and treatment outcomes.

The Modular Assessment of Risk for Imminent Suicide (MARIS): A validation study of a novel tool for suicide risk assessment

BACKGROUND

Reliable diagnostic tools for the short-term suicide risk assessment are needed. The recently developed multi-informant Modular Assessment of Risk for Imminent Suicide (MARIS) includes four modules: two are patient-rated and two clinician-rated. The patient-rated modules assess a proposed pre-suicidal cognitive/emotional state (Module 1) as well as patients' attitudes towards suicide (Module 2). The clinician-rated modules assess traditional suicide risk factors (Module 3) and clinicians' emotional responses to the patient (Module 4).

METHODS

With the aim of extending our previous preliminary proof of concept findings, the MARIS was administered to 618 psychiatric patients (167 inpatients, 451 outpatients) and their clinicians (N = 115). Patients were assessed with a battery including the Columbia-Suicide Severity Rating Scale. Four outcomes were considered: lifetime and past month suicidal thoughts and behaviors (STB) (0-10 point scale) and suicidal behaviors (SB) (0-5 point scale). Reliability and concurrent, convergent/divergent and incremental validity were assessed.

RESULTS

Good internal consistency was found for modules 1 and 4 (Cronbach's α: 0.87 and 0.86, respectively) but not for the others. Module 1's total score positively correlated with lifetime STB/SB and past month STB (all p ≤ 0.003). Module 4's total score positively correlated with all four outcomes (all p < 0.001). Modules 1 and 4 showed additional capacity to detect patients' lifetime and past month STB/SB beyond other associated factors.

LIMITATIONS

Lack of prospective assessment. Inpatients were evaluated at discharge, whereas outpatients at intake.

CONCLUSIONS

These findings supported the utility of multiple data sources to identify patients at imminent suicide risk, and in particular clinicians' emotional responses.

Systematic Exploration of Countertransference Phenomena in the Treatment of Patients at Risk for Suicide

Despite its critical role in clinical suicidology, empirical evidence on the nature of countertransference (CT) to patients at risk for suicide (PRS) is lacking. This study aimed to provide a systematic description of CT phenomena to PRS. Psychiatrists, psychologists, and psychotherapists completed the Therapist Response Questionnaire (TRQ) online, with reference to a PRS. Factor analysis (n = 267) yielded a 7-factor structure, including 1) entrapped/rejecting, 2) fulfilled/engaging, 3) aroused/reacting, 4) informal/boundary crossing, 5) protective/overinvolvement, 6) ambivalent/inconsistent, and 7) mistreated/controlling. On average, clinicians reported that CT dimensions tended to not apply to them, except for the positively connoted factor. Our findings suggest that patients at risk for suicide elicit specific dimensions of CT. We offer two alternative interpretations of clinicians' CT endorsement patterns.

Predictive Validity of Proposed Diagnostic Criteria for the Suicide Crisis Syndrome: An Acute Presuicidal State

BACKGROUND

Determining imminent risk of suicide continues to challenge psychiatrists. To this end, we test the clinical utility of a proposed set of diagnostic criteria for the suicide crisis syndrome (SCS) for prediction of imminent suicidal thoughts and behaviors prospectively.

METHOD

One hundred and seventy individuals hospitalized for suicidal thoughts and behaviors (STB) were evaluated within 72 hr of admission with measures assessing symptoms of the proposed SCS, history of STB, current ideation, and depression severity. Four-eight weeks following discharge, STB were reassessed. Associations between SCS and postdischarge attempts were examined using chi-square and logistic regression analyses. The receiver operator characteristic analysis was used to test the optimal number of symptoms required to meet proposed SCS criteria.

RESULTS

The syndrome was maximally informative about short-term risk of postdischarge suicide behavior when all criteria were met. The syndrome conferred a sevenfold increase in risk of postdischarge suicide attempt, and significantly improved prediction by standard risk factors, which was null to limited.

CONCLUSIONS

The SCS diagnostic criteria are supported and appear to describe a clinically meaningful syndrome in a high-risk population. Assessment of SCS may meaningfully improve clinical assessment of imminent suicide risk. Further study is needed to better understand the syndrome and its applicability in low-risk populations.

Determinants and Predictive Value of Clinician Assessment of Short-Term Suicide Risk

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short-term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10-point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire-Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one-month follow-up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow-up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.

Immediate and brief intervention after suicide attempts on patients without major psychiatric morbidity-A pilot study in northern Israel

BACKGROUND

Suicide Prevention is an ongoing task for mental health services. This article describes a pilot program for suicide prevention that took place in two districts in Israel from 2009 to 2012. The program targeted specific population, patients in high-risk for suicide, without major mental illness or previous association with the mental health system. In that group many suicide attempts were due to stressful life events.

METHODS

Patients who performed a suicide attempt or were considered high-risk for suicide were referred to the project. The first contact took place up to 24 h after the referral and included a phone call with suggestion for further intervention. If he was willing, the patient was invited to a serious of 8-12 meetings with a therapist that focused on "crisis intervention" techniques.

RESULTS

212 subjects were referred to the project. Three quarters of the referrals were females. Most of them were of Jewish nationality, however, the percentage of Druze in the program's population was higher than their percentage of general population. Only 137 continued participation after the initial phone call, people of Jewish nationality were more willing to continue the intervention. During the intervention there was a decline in suicide rates in the participating districts.

CONCLUSIONS

The pilot program exhibits promising preliminary results, it is interesting to examine the difference in participation between different ethnic groups. Since the sample size is small, there is a need to continue the program on a larger scale.

Emotional Responses to Suicidal Patients: Factor Structure, Construct, and Predictive Validity of the Therapist Response Questionnaire-Suicide Form

BACKGROUND

Mental health professionals have a pivotal role in suicide prevention. However, they also often have intense emotional responses, or countertransference, during encounters with suicidal patients. Previous studies of the Therapist Response Questionnaire-Suicide Form (TRQ-SF), a brief novel measure aimed at probing a distinct set of suicide-related emotional responses to patients found it to be predictive of near-term suicidal behavior among high suicide-risk inpatients. The purpose of this study was to validate the TRQ-SF in a general outpatient clinic setting.

METHODS

Adult psychiatric outpatients (N = 346) and their treating mental health professionals (N = 48) completed self-report assessments following their first clinic meeting. Clinician measures included the TRQ-SF, general emotional states and traits, therapeutic alliance, and assessment of patient suicide risk. Patient suicidal outcomes and symptom severity were assessed at intake and one-month follow-up. Following confirmatory factor analysis of the TRQ-SF, factor scores were examined for relationships with clinician and patient measures and suicidal outcomes.

RESULTS

Factor analysis of the TRQ-SF confirmed three dimensions: (1) affiliation, (2) distress, and (3) hope. The three factors also loaded onto a single general factor of negative emotional response toward the patient that demonstrated good internal reliability. The TRQ-SF scores were associated with measures of clinician state anger and anxiety and therapeutic alliance, independently of clinician personality traits after controlling for the state- and patient-specific measures. The total score and three subscales were associated in both concurrent and predictive ways with patient suicidal outcomes, depression severity, and clinicians' judgment of patient suicide risk, but not with global symptom severity, thus indicating specifically suicide-related responses.

CONCLUSION

The TRQ-SF is a brief and reliable measure with a 3-factor structure. It demonstrates construct validity for assessing distinct suicide-related countertransference to psychiatric outpatients. Mental health professionals' emotional responses to their patients are concurrently indicative and prospectively predictive of suicidal thoughts and behaviors. Thus, the TRQ-SF is a useful tool for the study of countertransference in the treatment of suicidal patients and may help clinicians make diagnostic and therapeutic use of their own responses to improve assessment and intervention for individual suicidal patients.