Does suicidal history enhance acceptance of other suicidal individuals?

Suicide is stigmatized, so suicidal people may be especially hard to accept. To see if moderately suicidal outpatients were more accepting of a suicidal person than never-suicidal or severely suicide outpatients, 105 respondents completed measures of suicidality, depression, acceptance, and empathy. A curvilinear ANCOVA was nonsignificant, but a linear ANCOVA significantly adjusted for depression, and indicated, unexpectedly, that net of depression, never-suicidal people were more accepting of a suicidal person than moderately or severely suicidal people. Empathy and acceptance were moderately related. An implication is that social support for suicidal individuals might best be obtained from those who were never suicidal themselves.

No-suicide contracts among college students

This study evaluates the use of 3 no-suicide contracts that differed in length from 1 to 9 sentences, and in specificity from indicating that clients will talk to a friend or therapist to a clear outline of persons and interventions to be used if they feel suicidal. Of the sample of 112 college students, 40% admitted to suicidal ideation and 54% reported some form of previous counseling. Students read all 3 contracts and rated them on how well they helped stop suicidal thoughts, communicated that the therapist cared, strengthened resistance to suicide, lessened depression, gave hope, encouraged cooperation with therapy and empowered, and how much they were complicated, short, or unrealistic. Regardless of gender, ethnicity, history of counseling, or prior suicidal ideation, students rated the more detailed contract best overall. Although other groups may respond differently, for college students, a specific, detailed no-suicide contract is best.

Is training in psychology associated with increased responsiveness to suicidality?

Training is associated with improved responses to suicidal individuals, but it is not clear whether any training helps or whether the training needs to be in psychology. The authors compared beginning and advanced psychology graduate students and practicing psychologists to nursing graduate students. A total of 139 participants in these 4 groups read a vignette about Pat, who had either contemplated suicide or never contemplated suicide, then completed questions about how they would respond to a distressed telephone call from Pat, how suicidal they thought Pat was, and how good a no-suicide contract would be for Pat. Advanced students and psychologists were more helpful in their responses than beginning graduate students, who were more helpful than nursing graduate students. However, all participants noticed whether Pat had contemplated suicide, and all were faintly positive about no-suicide contracts.

Writing projects: lessening undergraduates' unique suicidal bereavement

To assess if writing projects lessen undergraduates' grief following a loved one's suicide, 40 students whose loved one died by suicide in the past 2 years wrote on four occasions over 2 weeks about profound topics (e.g., events and emotions surrounding the death) or trivial topics (e.g., description of the previous meal). All participants completed pre- and posttest measures of grief and self-reported health visits, and 75% completed the same measures at 6-week mailed follow-up. As expected, individuals in the profound condition reported less grief associated with suicide at follow-up than those in the trivial condition. However, the trivial and profound groups were not significantly different in general grief or health visits. Writing about grief associated with the suicide of a loved one appeared to reduce suicidal grief associated with this event. However, this benefit did not extend to general grief or physical health.

Does writing about the bereavement lessen grief following sudden, unintentional death?

Writing about traumatic events produces improvement in an array of areas including physical and psychological functioning. To see if these improvements extended to improved bereavement recovery after the accidental or homicidal death of a loved one, 64 undergraduates (51 women, 13 men) began, and 44 completed, a writing project. At pretest, they completed measures of depression, anxiety, grief, impact, and non-routine health visits. Then, they were randomly assigned to write about either the bereavement experience (profound condition), or innocuous topics (trivial condition). They wrote for 15 minutes a day for four days, then completed the same measures a second time (posttest). Six weeks later, they were mailed the same measures again (follow-up). A 2 (CONDITION: Profound versus Trivial) x 3 (Time: Pre-, Post-, or Follow-up) MANOVA yielded a significant main effect for time, but no main effect for condition and no interaction. Follow-up ANOVAs indicated that, across conditions, from pretest to follow-up testing participants reported less anxiety and depression, less impact, greater grief recovery, but about the same health center visits. A 2 (CONDITION) x 4 (Writing Day) MANOVA and follow-up tests indicated that those in the profound condition reported less subjective distress from Day 1 to Day 3, compared to those in the trivial condition. Combined with Kovac and Range (1999), present results suggest that writing projects may be more beneficial to those experiencing the unique bereavement of suicidal death, rather than those experiencing the nonintentional death of a loved one by accident or homicide.

Are teachers of children and young adolescents responsive to suicide prevention training modules? Yes

Both before and after a 1-hour suicide prevention training module, 75 elementary teachers-in-training read a 4-sentence vignette about a suicidal student ("Pat"), then completed 8 questions about their responses. Compared with pretraining, at post-training these teachers were more likely to say that they would send or escort Pat to the counselor's office, use written or verbal no-suicide agreements, call Pat's parents, believe Pat to be serious rather than simply seeking attention, and feel comfortable handling a similar situation. Increased proactive attitudes after one hour of training imply that teachers would benefit from periodic suicide awareness and prevention training modules.

Gender, culture, and suicidal behavior: a feminist critique of theories and research

Suicide research has developed historically from philosophical roots in logical positivism and structural determinism. Thus, much suicide research has been based on assumptions of cause-and-effect relationships, reductionistic analysis, and the individual as the primary unit of analysis. In counterpoint, six guiding themes define feminist research (Worell & Etaugh, 1994). The present manuscript traces these six themes, illustrating them with suicide research projects. By challenging scientific tradition, focusing on women, considering power, recognizing gender constructs, maintaining awareness of the power of language, and promoting active, practical applications, researchers can combine traditional and alternative methodologies to make suicide research more robust.

Content analysis of previously suicidal college students' experiences

To ascertain actual helpful and unhelpful remarks received from others, 40 previously suicidal students answered open-ended questions about their experiences and completed the Suicidal Behaviors Questionnaire (SBQ). Respondents were still moderately suicidal on the SBQ, even though their most recent suicidal episode was an average of 3 years earlier. Respondents reported that family, friends, and personal resources were most helpful in keeping them alive. Those who told someone about their suicidal ideas or plans reported helpful remarks ("The situation is not worth dying for") that appeared to be empathic and thoughtful. Those who told no one about their suicidal ideas or plans, speculated helpful remarks that also appeared to be empathic and thoughtful. In contrast, unhelpful remarks (e.g., "You are stupid") appeared to be simplistic and thoughtless. Implications are that those who are suicidal should be careful in choosing person(s) in whom they confide, and training modules that give examples of actual helpful remarks might be useful for students.

Type and severity of child abuse and college students' lifetime suicidality

OBJECTIVE

The present study compared reported histories and severity of child sexual abuse, child physical abuse, and both, in college men and women.

METHOD

Four hundred and eighty-six consenting undergraduates completed measures of suicidality, sexual abuse (SA), and physical abuse (PA). Based on their responses, they were categorized into 12 mutually exclusive groups: no PA/no SA (n = 234), moderate PA/no SA (n = 78), severe PA/no SA (n = 34), no PA/mild SA (n = 21), moderate PA/mild SA (n = 12), severe PA/mild SA (n = 5), no PA/moderate SA (n = 20), moderate PA/moderate SA (n = 15), and severe PA/moderate SA (n = 10).

RESULTS

Participants who reported both severe sexual and severe physical abuse reported more lifetime suicidality than participants who reported either mild sexual and/or physical abuse. Those who reported sexual abuse involving invasive sexual acts such as rape, and physical abuse involving behaviors that resulted in physical injury to the child, were more suicidal than those who reported less severe abuse. In addition, although combined sexual and physical abuse correlated with increased suicidality, unexpectedly, there was no interaction. Finally, women students endorsed more reasons for living than men and about the same level of suicidal ideas and global suicidality, despite a greater likelihood of having been abused.

CONCLUSIONS

The absence of an interaction between sexual and physical abuse suggests that this increased suicidality is additive rather than multiplicative. An implication is that college counseling personnel need to be aware of the suicidal risk of women and men students reporting either sexual or physical abuse.

Twenty suicide assessment instruments: evaluation and recommendations

Twenty relatively new suicide assessment instruments can be grouped into the following categories: (a) clinician-rated suicide instruments, (b) self-rated suicide instruments, (c) self-rated buffers against suicide, (d) instruments focused on children and adolescents, and (e) special purpose scales. The present review describes these instruments, giving the potential clinician or researcher information about their psychometric properties, strengths, and weaknesses. They vary in length and the age group for which they are designed, but most are reliable and have some psychometric evidence of validity. Of the 20, most highly recommended are Beck's Scale for Suicide Ideation series, Linehan's Reasons for Living Inventory, and Cole's self-administered adaptation of Linehan's structured interview called the Suicidal Behaviors Questionnaire.

Suicidality, hopelessness, and attitudes toward life and death in clinical and nonclinical adolescents

To see if hopelessness and four attitudes (attraction to life and death and repulsion by life and death) account for the development of suicidality in children, 15 adolescent psychiatric inpatients and 84 middle and high school students, average age 15.2 years, took a four-item version of the Suicidal Behaviors Questionnaire, the Hopelessness Scale for Children (HSC), and the Multi-Attitude Suicide Tendency Scale for Adolescents (MAST-A). Profiles on the four attitudes differentiated adolescents at risk for suicide from those not at risk. Suicidality was negatively related to Attraction to Death and positively related to Repulsion by Life, Attraction to Death, Repulsion by Death, and hopelessness. Hopelessness was negatively related to Attraction to Life, and positively related to Repulsion by Life and Repulsion by Death. The best predictors of suicidality were hopelessness and Repulsion by Life. Results imply that reducing feelings of rejection by their families might lessen suicidality in adolescents.

Family environment, attitudes toward life and death, depression, and suicidality in elementary-school children

This study examines whether perception of family environment, attitudes toward life and death, and depression predict suicidality in elementary-school children. Seventy-eight participants ages 8 to 13 recruited through an elementary school and a university were assessed for attitudes toward life and death, depression, suicidality, and family environment. A regression equation indicated that depression and attraction to life were the only variables accounting for variance in suicidality (49%). Family environment variables were moderately correlated with depression, indicating that family environment may play a role in the development and maintenance of depression, of which suicidality is a symptom. Concurrent treatment of family issues may not only ameliorate children's symptoms, but also provide a critical sense of support that may decrease the likelihood that these children will become suicidal in the future.

Reasons for living and coping abilities among older adults

Older adults have successfully resisted inclinations to commit suicide; however, little research has focused on their ability to cope or their reasons for living. In the present study, seventy-nine (fifty-five women, twenty-two men, two unknown) older adults (M = 60.6 years) recruited from churches, retirement groups (n = 22), and relatives of college psychology students (n = 57), completed the Reasons for Living and the Cope inventories. Overall coping was significantly positively correlated with total reasons for living, r(78) = .19, p < .05, although the low correlation suggests that the constructs are moderately unique. Further, coping was positively correlated with two RFL subscales, Survival and Coping Beliefs, r(78) = .27, p < .01, and Child-Related Concerns, r(78) = .28, p < .01. Women were higher than men in total reasons for living, t(75) = 2.16, p < .05, but not significantly different in coping abilities. Older women may underrate their ability to cope. An implication is that suicide prevention strategies should target men and bolster their cognitive deterrents to suicide.

The escape theory of suicide and perfectionism in college students

A preliminary model of the escape theory of suicide was tested in 168 college students (52 males, 116 females), who completed self-report measures of self-oriented, other-oriented, and socially prescribed perfectionism, negative life stress, depression, hopelessness, anxiety, reasons for living, and suicidal behaviors. A path analysis provided only partial validation for the model and accounted for 26% of the variance in suicidal behaviors. None of the three dimensions of perfectionism significantly accounted for any additional variance in suicidal behaviors above and beyond the other variables used in the study. Socially prescribed perfectionism was the only dimension of perfectionism that showed a statistically significant bivariate correlation with suicidal behaviors. The path analysis indicated that this correlation was an indirect effect through reasons for living. Depression was a better predictor of suicidal behaviors than hopelessness. Perhaps one reason for these equivocal results was the limited amount of variability in suicidal behaviors in this nonclinical sample.

The escape theory of suicide in college students: testing a model that includes perfectionism

A model of the escape theory of suicide was tested, using the following measures: the Life Experiences Survey, the Socially Prescribed Perfectionism subscale, the Self-Rating Depression Scale, the Hopelessness Scale, the Reasons for Living Inventory, and the Scale for Suicide Ideation. College students (N = 114) completed all of these measures, and results were correlated. LISREL path analysis failed to validate the proposed model. All proposed paths were significant, except for the reciprocal path proposed between negative life events and socially prescribed perfectionism. Two residual paths were also significant: from socially prescribed perfectionism to suicide ideation, and from hopelessness to suicide ideation. A revised model constructed from these significant paths had a good overall fit, which suggests that an interactional model is more appropriate than a linear one.

Psychometric properties of the Suicidal Behaviors Questionnaire

In order to assess the reliability and validity of Cole's (1988) four-item version of the Suicidal Behaviors Questionnaire (SBQ), 57 clinical outpatients completed it and the Reasons for Living Inventory (RFL), and 86 undergraduates completed it and the Scale for Suicide Ideation (SSI). Two weeks later, 30 undergraduates completed the SBQ again. Cronbach alphas were moderate (clinical sample = .75; nonclinical sample = .80). Test--retest correlations were also significant (r = .95). The SBQ and SSI were significantly correlated (r = .69). The SBQ and RFL were also significantly correlated (r = -.34), although modestly. In view of its moderate to strong reliability, its construct and fact validity, its ease of administration and scoring, and its brevity, the SBQ is recommended as a brief screening instrument for suicidality for researchers and clinicians.

Childhood sexual abuse and current suicidality in college women and men

In previous research, adults who reported childhood sexual abuse have been more suicidal than nonabused adults, but no research has examined their cognitive deterrents to suicide. Strict definitions of sexual abuse in these studies have excluded (a) unwanted sexual experiences with peers, and (b) exploitive experiences not involving genital contact (i.e., unwanted sexual invitations or suggestions, unwanted exposure to others' genitals via exhibitionism, unwanted kissing or hugging in a sexual way). The present study compared suicidal behavior and cognitive deterrents to suicide in 266 college students using both a strict and a liberal definition of sexual abuse. Both women and men abused by adults or peers were more suicidal as adult college students than were women and men with no such history. Women reported similar degrees of suicidality as men, but greater survival and coping beliefs and more fear of suicide. Those whose sexual abuse involved touching were more suicidal, and felt less able to cope, and less responsibility for their families, than nonabused adults. Implications are that adults who experienced childhood sexual abuse that involved touching are more suicidal and have less cognitive deterrents to suicide than adults who have not, regardless of whether they are men or women or whether they were abused by adults or by peers.

Clinicians' attitudes toward no-suicide agreements

Though no-suicide agreements are widely used and often recommended for suicidal patients, their sparse empirical support leads to questions regarding their use with patients of various ages. To answer this question, 46 licensed psychologist members of a Southern state psychology association answered questions regarding their beliefs and attitudes about no-suicide agreements. Such agreements were considered more appropriate for adults or adolescents than children. They were judged highly appropriate with moderately suicidal patients and were expected to help patients postpone suicide until after a crisis had past and to help reduce clinicians' anxiety.

Suicidality in college women who were sexually and physically abused and physically punished by parents

In order to ascertain if physically abused, sexually abused, physically punished, and nonabused/nonpunished women students reported different levels of suicidality, 182 women completed measures of suicidality, sexual abuse, physical abuse, and physical punishment. Women who reported sexual abuse were more suicidal than all other groups, and those physically abused were more suicidal than those nonabused/nonpunished. In a multiple regression, sexual abuse accounted for the most variance in suicidality (15%). Apparently women who report sexual or physical abuse, but not ordinary physical punishment alone, are at greater risk for suicide.

Hope, hopelessness, and suicidality in college students

To estimate the associations among measures of hope, hopelessness, and suicidality, 206 undergraduates completed the Reasons for Living Inventory, the Hopelessness Scale, and the Hope Scale. As expected, significant correlations indicated that, as hope increased, hopelessness decreased. Those who scored as relatively more suicidal had relatively fewer feelings of total hope (Agency and Pathways) and more hopelessness. Further, scores on three Reasons for Living scales (Coping Beliefs, Family Responsibility, and Child Concerns) were significantly correlated in expected directions with hope and hopelessness scores. A stepwise multiple regression indicated that scores on Survival, Coping Beliefs and the Hope subscale Agency accounted for 37% of the total variance in suicidality. Apparently in unscreened college students, survival and coping beliefs and hope rather than hopelessness or other reasons for living are most related to suicidality. An implication is that facilitating college students' hopefulness may bolster their survival and coping beliefs and discourage development of suicidal thoughts or actions.

Mood influences on reasons for living in older adolescents

Suicide is a major public health problem of the current period, particularly among young people, and is the second leading cause of death among the 15- to 24-year-old age group (Rudd 1989). Moreover, the suicide rate among the nation's youth has increased dramatically in the last two decades, an increase that amounts to having tripled in the years 1956 to 1975 (Holinger 1982).

A factor analysis of six commonly used instruments associated with suicide using college students

Determined whether six commonly used inventories which are associated with suicide (Hopelessness Scale, Zung Self-Rating Depression Scale, Scale for Suicide Ideation, Reasons for Living Inventory, Suicide Probability Scale, and the Suicide Ideation Questionnaire) overlap; all six were given to 308 undergraduates. A principal components factor analysis yielded four factors with Eigenvalues greater than 1.00. These four factors were labeled Suicidal/Negative Ideas, Reasons for Living, Self-Doubt, and Suicide Desire. Each scale or subscale had a factor loading of .4 or greater on one factor. Only the Survival and Coping Beliefs subscale of the Reasons for Living Inventory and the Suicide Ideation Questionnaire loaded on two factors. Thus, each of these six instruments accounts for unique variance in suicidality. A suicide screening battery that includes all six inventories would take approximately 20 min for college students to complete, and would be valuable in identifying different aspects of suicidality.

Life satisfaction and death anxiety in elderly nursing home and public housing residents

To compare life satisfaction and death anxiety in older adults, 30 elderly residents of a public housing apartment complex and 20 nursing home residents completed the Death Anxiety Scale, the Philadelphia Geriatric Center Morale Scale, and a structured interview. Nursing home residents more frequently reported that in five years they expected to be dead, whereas public housing residents more frequently reported that in five years they would be doing about the same thing or nothing. The two groups did not differ on their reported death anxiety or life satisfaction. However, across both groups, those reporting higher life satisfaction also reported lower death anxiety and a more positive attitude toward growing older. It appears that, for the elderly individuals in this study, place of residence was not related to their expression of life satisfaction or death anxiety.

Students' attitudes toward hypothetical chronically and acutely mentally and physically ill individuals

To assess attitudes toward chronically and acutely mentally and physically ill individuals, 106 undergraduates read one of four vignettes describing a hospitalized individual, with each vignette divided along the factors of diagnosis (schizophrenia or cancer) and chronicity (acute or chronic). Then they completed the Community Acceptance Scale and responded to 19 rationally derived paired adjectives. A series of 2 × 2 univariate analyses indicated that individuals with diagnoses of schizophrenia were viewed significantly more pejoratively than individuals with diagnoses of cancer. Similarly, individuals with chronic courses of treatment were viewed significantly more negatively than individuals with acute courses of treatment. Surprisingly, however, no univariate interactions reached statistical significance. Findings suggest that the lack of acceptance of the chronically mentally ill individual is a function of the devaluation associated with psychiatric diagnosis.

Perception of behavioral contagion of adolescent suicide

In order to assess perceptions of behavioral contagion of suicide (what people thought a disturbed adolescent would do if the teen knew about a suicide in the community), and to assess actor-observer differences in such perceptions, 142 college students were asked to view a videotaped vignette of a distressed high school student, and then to assess her potential for committing suicide, running away, entering therapy, or abusing alcohol. Subjects who were told that the teenager knew of two recent suicides in the community (contagion group) rated the young woman as more likely to commit suicide or run away than did the subjects who were not told of the suicides (noncontagion group). Subjects who were instructed to imagine that they were the teenager (actors) blamed situational factors, and in particular the teen's parents, more for her distress than did subjects who were instructed just to rate the teenager on the videotape (observers). Contagion/actors rated suicide as more likely than did any other group. Apparently, people believe that behavioral contagion occurs when a suicide is reported, and they especially perceive themselves to be influenced by such information.

Factor structure of Calhoun's Youth Suicide Scale

To assess the factor structure of Calhoun's Youth Suicide Scale (YSS), 191 consenting undergraduates in one sample and 240 consenting undergraduates in a second sample wee given the YSS during class. From the second sample, 152 subjects also took the YSS a second time about 1 month later. In the first sample, three factors, which accounted for 50.0% of the variance, emerged. They were: How the Parents were Viewed (in terms of psychological disturbance, likability, and blame); Expected Responses to the Bereaved Family (terms of tension and sympathy); and Empathy with Parents (whether the newspaper was viewed as correct in reporting the cause of death, how long parents were expected to grieve, and whether parents were expected to be liked). In the second sample, the same three factors emerged (accounting for 55.5% of the variance), with the exception of one item on Factor 3: expecting to like the parents. Congruence coefficients between the three factors in the two samples were .98, .94, and .78, respectively. Reliability correlations on individual items ranged from a low of .30 to a high of .61. These results indicate that the YSS is valid, stable, and moderately reliable for assessing reactions to youth suicide; thus, it would be a viable instrument for use in future research on reactions to suicide.

Community responses following suicide, homicide, and other deaths: the perspective of potential comforters

To determine whether actual responses of potential comforters in the community differ according to cause of death, 83 college students participated in a structured, individual interview. They were asked demographic questions about themselves, the bereaved, and the deceased, and then about various aspects of how they, and others in the community, responded to the death. Students were grouped by their reports of the cause of death (suicide, homicide, accident, natural anticipated death, or natural unanticipated death). When the death was by suicide or homicide, others were perceived as relatively less supportive of the bereaved person. When the death was by suicide, respondents themselves tended more to blame the bereaved person. When the death was by homicide, the bereaved person was perceived as reacting relatively worse. Potential comforters were relatively more shocked when the death was by homicide or accident.

Gestalt dialogues as a treatment for mild depression: time works just as well

In a treatment analogue design, 44 moderately depressed volunteer subjects were divided randomly into four groups: attention-placebo; Gestalt empty chair dialogues designed to be personally relevant and high in affect; dialogues designed to be personally irrelevant and neutral in affect; and groups in which strong affect was encouraged, but no dialogues enacted. Groups met 1 hour per week for 4 weeks. Each group was pretested, post-tested, and follow-up tested with an abbreviated MMPI, the Depression Adjective Check List, and experimenter questionnaires. A series of 4 X 3 ANOVAs indicated significant main effects for time across all dependent variables. Also, anxiety and social introversion decreased over time in all groups. No other main or interactional effects were significant. These results suggest that mild depression, as well as anxiety and social introversion, dissipated over time and remained lower regardless of whether the subject had any treatment.

Cultural and emotional components of loneliness and depression

The relation between loneliness and depression and the distinction between emotional and social loneliness were examined by administering the University of California, Los Angeles (UCLA) Loneliness Scale, the Belcher Extended Loneliness Scale (BELS), the Beck Depression Inventory, and self-report questions about social and emotional loneliness to the following four groups: foreign (Chinese-descent) students in American universities, Chinese students in Taiwanese universities, American students in American universities, and depressed American clients. Depressed clients reported not only more depression but also more overall loneliness than did any of the other groups; they also were more likely to report emotional loneliness or both emotional and social loneliness than were the other three groups. Foreign students, in contrast, reported more social loneliness than did Taiwanese students. Results substantiate the view that loneliness is not a unitary concept and suggest that the UCLA Loneliness Scale and the BELS emphasize emotional rather than social loneliness and that emotional loneliness is a greater component of depression than is social loneliness.

The effects of patients' fee payment source on the duration of outpatient psychotherapy

Investigated the effects of fee payment source alone, as well as in combination with selected demographic factors (race, sex, education, and socioeconomic status), on the duration of outpatient psychotherapy. One hundred and sixty outpatients receiving treatment at a medical center based community mental health center served as Ss. These Ss were divided into four groups: Medicaid, insurance, insurance plus self-payment, and scaled self-payment only. Univariate results indicated that patients who paid a scaled fee had significantly more sessions than those whose fee was paid by Medicaid. Multivariate results, however, indicated that education and sex, which were highly correlated with fee payment source, accounted for most of the variance in treatment duration.

Predicting psychotherapy duration from therapists' sex, professional affiliation, democratic values, and community mental health ideology

Analyzed therapists' scores on the Community Mental Health Ideology (CMHI) and Democratic values scales and their sex and professional affiliation to predict the number of psychotherapy visits of 166 outpatients. A step-wise multiple regression indicated that all variables taken together accounted for 3% of the variance in treatment duration. A four-way analysis of variance revealed only a significant main effect for the CMHI scale. Thus, low-scoring CMHI therapists had significantly more therapy sessions with their clients than high-scoring CMHI therapists. The latter may emphasize briefer treatment approaches that stress outside resources and primary prevention.