Mark J. Goldblatt

Common factors in empirically supported treatments of borderline personality disorder.

In this article, we examine the manuals of empirically supported psychotherapies for borderline personality disorder (BPD) by comparing their common and specific treatment strategies. We compare these treatments using a previously constructed scale of treatment interventions. Individual psychotherapies for BPD have several common strategies: clear treatment framework, attention to affect, focus on treatment relationship, an active therapist, and exploratory and change-oriented interventions. Use of interpretations, supportive interventions, designating treatment targets, attention to patient functioning, multimodal treatment, and support for therapies varied across the psychotherapies. We discuss these findings in the context of clusters of BPD symptoms, reports regarding overlap in treatment interventions used by various psychotherapies, and the effectiveness of specific treatment strategies.

Strategies in treatment of suicidality: identification of common and treatment-specific interventions in empirically supported treatment manuals.

OBJECTIVE Many reports of treatments for suicidal patients claim effectiveness in reducing suicidal behavior but fail to demonstrate which treatment interventions, or combinations thereof, diminish suicidality. In this study, treatment manuals for empirically supported psychological treatments for suicidal patients were examined to identify which interventions they had in common and which interventions were treatment-specific. METHOD Empirically supported treatments for suicidality were identified through a literature search of PsychLit and MEDLINE for the years 1970-2007, employing the following search strategy: [suicide OR parasuicide] AND [therapy OR psychotherapy OR treatment] AND [random OR randomized]. After identifying the reports on randomized controlled studies that tested effectiveness of different treatments, the reference list of each report was searched for further studies. Only reports published in English were included. To ensure that rated manuals actually correspond to the delivered and tested treatments, we included only treatment interventions with explicit adherence rating and scoring and with adequate adherence ratings in the published studies. Five manualized treatments demonstrating efficacy in reducing suicide risk were identified and were independently evaluated by raters using a list of treatment interventions. RESULTS The common interventions included a clear treatment framework; a defined strategy for managing suicide crises; close attention to affect; an active, participatory therapist style; and use of exploratory and change-oriented interventions. Some treatments encouraged a multimodal approach and identification of suicidality as an explicit target behavior, and some concentrated on the patient-therapist relationship. Emphasis on interpretation and supportive interventions varied. Not all methods encouraged systematic support for therapists. CONCLUSION This study identified candidate interventions for possible effectiveness in reducing suicidality. These interventions seem to address central characteristics of suicidal patients. Further studies are needed to confirm which interventions and which combinations thereof are most effective.

Suicide Fantasy as a Life-Sustaining Recourse

The suicide literature tends to lump all suicidal ideation together, thereby implying that it is all functionally equivalent. However obvious the claim that suicidal ideation is usually a prelude to suicidal action, some suicidal daydreaming tends to inhibit suicidal action. How are we to distinguish between those daydreams that augur an impending attempt from those that help patients calm down?

Hospitalization of the suicidal patient

The safety needs of the suicidal patient are of the utmost importance. Decisions concerning the admission of such patients into the hospital are often difficult, and clinicians usually are anxious and ambivalent during this process. In this era of decreased resources, when clinicians are increasingly aware of suicidal danger and of safety requirements, it is even more critical that the inpatient psychiatric unit be used judiciously. There are risks and benefits involved in the use of a psychiatric inpatient program, and there are risks and benefits to not using such a facility. Development of safe treatment plans for suicidal patients is reviewed in the context of the psychodynamic formulation and therapeutic alliance.

Suicide and trauma: A case discussion

In this paper we explore the relationship between trauma and suicidal thoughts and behaviour. This exploration has a double perspective: a deeper understanding of trauma can illuminate the dynamics of suicidality; and the psychotherapeutic study of suicidal people increases our understanding of the impact of trauma. This discussion addresses three particular configurations: (a) the impact on the individual of the suicide of a close person; (b) the traumatic dimension of suicidal behaviour on the self; and (c) the impact of childhood traumatic experiences on the subsequent development of suicide. We describe the psychotherapy of a suicidal man, who had suffered many losses including that of his mother to suicide, as the basis for commentary by three discussants. The paper concludes that the approach linking trauma with suicide is a fruitful one and further study is recommended.

Traumatic subjective experiences invite suicide

The overwhelming events that lead to posttraumatic stress disorders and similar states are commonly understood to arise from noxious external events. It is however the unmasterable subjective experiences such events provoke that injure the mind and ultimately the brain. Further, traumatic over-arousal may arise from inner affective deluge with minimal external stimulation. Affects that promote suicide when sufficiently intense are reviewed; we propose that suicidal crises are often marked by repetitions (flashbacks) of these affects as they were originally endured in past traumatic experiences. Further, recurrent overwhelming suicidal states may retraumatize patients (patients who survive suicide attempts survive attempted murders, albeit at their own hands). We propose that repeated affective traumatization by unendurable crises corrodes the capacity for hope and erodes the ability to make and maintain loving attachments.

Does treatment with antidepressant medication increase suicidal behavior

Suicidal ideation and behavior are commonly associated with psychiatric conditions, in particular the affective disorders. Patients diagnosed with Major Depression carry an estimated lifetime risk of suicide ranging from 15-30%. In recent years increasing attention has been paid to the psychobiology of suicide. Serotonin, an indolamine neurotransmitter, has been implicated as playing a role in suicidal behavior, especially in depressed patients. Treatment of depressive episodes with antidepressant medication has greatly improved the prognosis for survival through the suicidal period and recovery from the depressive episode. However, there has been considerable debate about the significance of reports that antidepressants may, on occasion, adversely affect depressed patients. Recently this has received much attention in the United States of America, particularly involving the antidepressant fluoxetine. In this paper we briefly outline previous studies on the role of serotonin in suicidal behavior in depression; and review the debate about antidepressants adversely affecting suicidal behavior. Possible mechanisms involving effects on the serotonergic system that could account for some of these adverse reactions are discussed, and a contextual framework is developed for interpreting clinical data on this important phenomenon.

Comparison of Journals of Suicidology

BACKGROUND Three English-language journals deal explicitly with suicide phenomena. To the best of our knowledge, no previous study has analyzed the subject content of these three journals. AIMS To review the abstracts of the three suicide-related journals in order to clarify the subjects of the papers. METHODS We examined all abstracts of every paper published in Crisis: The Journal of Crisis Intervention and Suicide Prevention, Archives of Suicide Research, and Suicide and Life-Threatening Behavior for the 5 years between 2006 and 2010, and categorized each paper by subject. RESULTS We found that the journals were similar with respect to subject allocation. Most papers dealt with epidemiological issues (32.7-40.1% of abstracts); prevention (5.8%-15.3%) and research (8.3%-10.6%) were next best represented subjects. Clinical papers comprised from 2.8% to 8.2% of the studies published. CONCLUSIONS English-language suicide journals publish a preponderance of epidemiological studies. Clinical studies are relatively underrepresented.

Self-Harming Behavior and Suicidality: Suicide Risk Assessment

The patient who is discussed in this article represents some of the difficulties regularly faced by clinicians dealing with suicidal patients, such as how to assess the real risks involved when a patient denies any plans to kill herself. The case consultants emphasize the importance of a thorough suicide risk assessment, and the importance of considering a broad overview of the patient’s presentation. Protective factors, such as the patient’s stated reasons for living, which are usually ties to loved ones or work, are not enough. Similarly, the patient’s denial of current suicidal ideation does not necessarily mean that there is no further risk for suicide. The complexity of this evaluation and the tensions that it balances require knowledge, training, skill, and time. Short circuiting this process leads to unnecessary risk taking with potentially lethal consequences. Modern psychiatric inpatient stays put pressure on the clinician to discharge patients in a very short period of time, often prematurely. Consideration of the points raised by these consultants can help in this complicated assessment.

Postdischarge suicide: A psychodynamic understanding of subjective experience and its importance in suicide prevention

Recent discharge from a psychiatric inpatient facility is associated with a high risk of suicide. There are multiple factors that may contribute to this increase in risk. Psychodynamic considerations about the patients subjective experience of suicidality, hospitalization, and discharge are often overlooked but are critical to understanding this phenomenon. Qualitative research has begun to provide empirical support for the importance of the psychological aspects of discharge, and the heightened state of vulnerability that patients experience during this time. Review of the literature and careful consideration of clinical experience is helpful in elucidating this experience in a way that can inform effective treatment. This article integrates a psychodynamic understanding of suicidality in the postdischarge period with a review of empirical research and formulates clinical recommendations for suicide prevention.