Understanding Therapists' Work With Suicidal Patients: An Examination of Qualitative Data

Long-Term Use and Application of Systematic Tailored Assessment for Responding to Suicidality (STARS) Protocol Following Original Training

BACKGROUND

Understanding the use of Systematic Tailored Assessment for Responding to Suicidality protocol (STARS-p) in practice by trained mental health practitioners over the longer- term is critical to informing further developments. The study aim was to examine practitioners' experiences of STARS-p and factors associated with its use in practice over a 12-24-month period after training.

METHOD

Practitioners who undertook the STARS-p training completed an online survey 12-24 months post training. The survey focused on the frequency of use of STARS-p (in full and each section) as well as perceptions about STARS-p applied in practice. Analyses included correlations, logistic regression and content analysis.

RESULTS

67 participants (81% female, Mage = 43.2, SD = 10.3) were included in the analyses. A total of 80.6% of participants had used the entire STARS-p at some time-point in their practice and less than half (44.7%) frequently used the entire STARS-p (all components in one administration). Parts A, B and C were used frequently in suicide risk assessment (SRA) by 84%, 71% and 82% of participants, respectively. Use of the entire protocol and different sections was most related to male gender, perceived ease of administration and confidence in the use of the protocol. Qualitative results revealed three main themes.

CONCLUSIONS

STARS-p as a whole or its parts, is frequently used. Advantages of, and barriers to, using STARS-p in practice can inform further developments of STARS-p and STARS training.

Costs, benefits, and cost-benefit of Collaborative Assessment and Management of Suicidality versus enhanced treatment as usual

Suicide rates have been steadily increasing in both the U.S. general population and military, with significant psychological and economic consequences. The purpose of the current study was to examine the economic costs and cost-benefit of the suicide-focused Collaborative Assessment and Management of Suicidality (CAMS) intervention versus enhanced treatment as usual (ETAU) in an active duty military sample using data from a recent randomized controlled trial of CAMS versus ETAU. The full intent-to-treat sample included 148 participants (mean age 26.8 years ± 5.9 SD years, 80% male, 53% White). Using a micro-costing approach, the cost of each condition was calculated at the individual level from a healthcare system perspective. Benefits were estimated at the individual level as cost savings in past-year healthcare expenditures based on direct care reimbursement rates. Cost-benefit was examined in the form of cost-benefit ratios and net benefit. Total costs, benefits, cost-benefit ratios, and net benefit were calculated and analyzed using general linear mixed modeling on multiply imputed datasets. Results indicated that treatment costs did not differ significantly between conditions; however, CAMS was found to produce significantly greater benefit in the form of decreased healthcare expenditures at 6-month follow-up. CAMS also demonstrated significantly greater cost-benefit ratios (i.e., benefit per dollar spent on treatment) and net-benefit (i.e., total benefit less the cost of treatment) at 12-month follow-up. The current study suggests that beyond its clinical effectiveness, CAMS may also convey potential economic advantages over usual care for the treatment of suicidal active duty service members. Our findings demonstrate cost savings in the form of reduced healthcare expenditures, which theoretically represent resources that can be reallocated toward other healthcare system needs, and thus lend support toward the overall value of CAMS.

Impact of Systematic Tailored Assessment for Responding to Suicidality (STARS) Protocol Training on Mental Health Professionals' Attitudes, Perceived Capabilities, Knowledge, and Reluctance to Intervene

BACKGROUND AND AIMS

Systematic Tailored Assessment for Responding to Suicidality (STARS) protocol and associated training were developed with the key objectives of supporting clinicians to conduct a suicide enquiry, obtaining a comprehensive account of psycho-social factors contributing to suicidality, and collaboratively developing a safety plan with clients. STARS training aims to address knowledge, attitudes and capabilities that influence intervention behavior/skills. This study aimed to examine associations between clinician characteristics and pre-training competencies in suicide risk assessment (SRA), as well as the impact of STARS training workshop on clinician competencies; and to determine the predictors of SRA training outcomes.

METHOD

Australian mental health professionals working with suicidal persons who undertook the STARS 2-day face-to-face workshop between 2018 and 2020 completed an online survey at pre- and post-training. Of the 222 participants who completed the pre-training questionnaire, 144 (64.9%) also completed the post-training questionnaire. Participants were mostly female (75.7%), had completed a university degree (86.4%), had <10 years of experience in suicide prevention (71.7%), and were allied and mental health professionals (78.1%). We used linear mixed-effects regression for statistical analyses.

RESULTS

STARS participants who reported higher perceived capability at baseline had significantly greater formal and informal training, more years of experience in suicide prevention, and were more likely to have experienced client suicide and/or suicide attempt and to report fewer SRA related fears. We found overall significant positive impacts of STARS training on clinician competencies (attitudes, perceived capability, declarative knowledge) from pre- to post-training. The most distinct changes following STARS training were for perceived capability and declarative knowledge. Participants who had more positive attitudes after training were significantly more likely to have had less prior supervision/mentoring. Reluctance to intervene was not found to significantly change after training.

CONCLUSIONS

We found evidence that attitudes, perceived capability and declarative knowledge changed positively from pre- to post-STARS training among mental health professionals. Underpinned by the minimum standardized SRA competencies, STARS training may be critical for informing evidence-based knowledge and skills in SRA and safety planning.

Handling suicidal crises in psychodynamic psychotherapy: A process case study

The core characteristics of patients with a borderline personality disorder (BPD) affect the therapeutic relationship and frequently lead psychodynamic therapists to adapt interventions to manage crises. This study aims to increase knowledge of how such crises affect the therapeutic process. Using her therapist's notes, combined with the Psychotherapy Process Q-Set, we studied the therapeutic process of the first 44 therapy sessions of a female BPD patient with many depressive-like symptoms, including a disruptive period that included hospitalization. We found marked differences between different phases of therapy (before a crisis, acute disorganization, hospitalization, and back to the consulting room). The analysis suggests that a crisis and hospitalization may occur without necessarily damaging the therapeutic process. The therapist's ability to tolerate aggression, to explore and contain suicide wishes and behaviors, and to flexibly adapt techniques to patient needs, are among the therapeutic attitudes and behaviors that can help restore an effective psychodynamic process.