[Show abstract][Hide abstract] ABSTRACT: This study used a mixed methods approach to examine pathways to suicidal behavior by identifying cognitive warning signs that occurred within one day of a suicide attempt. Transcripts of cognitive therapy sessions from 35 patients who attempted suicide were analyzed using a modified grounded theory approach. Cognitive themes emerging from these transcripts included: state hopelessness, focus on escape, suicide as a solution, fixation on suicide, and aloneness. Differences in demographic and baseline diagnostic and symptom data were explored in relation to each cognitive theme. We propose a potential conceptual model of cognitive warning signs for suicide attempts that requires further testing.
Full-text · Article · Jan 2016 · Archives of Suicide Research
[Show abstract][Hide abstract] ABSTRACT: Objective:
The current study examines the predictive validity of the Beck Depression Inventory (BDI) suicide item for death by suicide and suicide attempts.
The study included 2 samples: (1) 5,200 psychiatric outpatients who were evaluated between 1975 and 1995 and followed prospectively for up to 20 years (all psychiatric diagnoses based on DSM-III and DSM-III-R), and (2) 119 patients who, between 2000 and 2004, participated in a randomized controlled trial of outpatient Cognitive Therapy for Suicide Prevention after a suicide attempt and were followed for 18 months (all psychiatric diagnoses based on DSM-IV-TR). All patients completed structured diagnostic interviews, as well as the BDI and Scale for Suicide Ideation.
Cox regression models demonstrated that the BDI suicide item significantly predicted both deaths by suicide (Wald χ(2)1 = 35.67; P < .001 [N = 5,200]) and repeat suicide attempts (Wald χ(2)1 = 8.82; P < .01 [N = 119]), with each successive rating on the item conferring greater risk. Using receiver operating characteristic (ROC) curves, optimal cutoff scores of 1 and above for suicide and 2 and above for suicide attempts were identified as providing the best balance between sensitivity and specificity.
The BDI suicide item is associated with both risk of repeat suicide attempts and death by suicide. The use of the item as a brief, efficient screen for suicide risk in routine clinical care is recommended. Clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen. Future research examining the item's performance in other at-risk groups (ie, older adults, adolescents, inpatients, etc) is encouraged.
No preview · Article · Dec 2015 · The Journal of Clinical Psychiatry
[Show abstract][Hide abstract] ABSTRACT: Despite the central role of training and consultation in the implementation of evidence-based psychological interventions (EBPIs), comprehensive reviews of research on training have highlighted serious gaps in knowledge regarding best practices. Consultation after initial didactic training appears to be of critical importance, but there has been very little research to determine optimal consultation format or interventions. This observational study compared two consultation formats that included review of session audio and feedback in the context of a program to train clinicians (n = 85) in community mental health clinics to deliver cognitive therapy (CT). A "gold standard" condition in which clinicians received individual feedback after expert consultants reviewed full sessions was compared to a group consultation format in which short segments of session audio were reviewed by a group of clinicians and an expert consultant. After adjusting for potential baseline differences between individuals in the two consultation conditions, few differences were found in terms of successful completion of the consultation phase or in terms of competence in CT at the end of consultation or after a 2 year follow-up. However, analyses did not support hypotheses regarding non-inferiority of the group consultation condition. While both groups largely maintained competence, clinicians in the group consultation condition demonstrated increases in competence over the follow-up period, while a sub-group of those in the individual condition experienced decreases. These findings, if replicated, have important implications for EBP implementation programs, as they suggest that observation and feedback is feasible in community mental health setting, and that employing this method in a group format is an effective and efficient consultation strategy that may enhance the implementation and sustainability of evidence-based psychotherapies.
Full-text · Article · Nov 2015 · Administration and Policy in Mental Health and Mental Health Services Research
[Show abstract][Hide abstract] ABSTRACT: Attentional fixation is a cognitive process characterized by a narrowing of attention on and preoccupation with suicide as the only solution to one’s problems. The present study sought to investigate the experience of attentional fixation on suicide by establishing the psychometric properties of the Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ) in a sample of 64 patients who recently attempted suicide. The AFSEQ evidenced strong psychometric properties, including good internal consistency and construct validity through moderate correlations with measures of suicidal ideation, depressive symptoms, and suicide-relevant cognitive distortions. In addition, an exploratory factor analysis of the AFSEQ identified two factors: Cognitive Dysfunction and Cognitive Stuckness. Results suggest the AFSEQ is a reliable method for assessing the experience of attentional fixation in relation to suicide. We propose future research to further examine attentional fixation as a proximal risk factor for suicidal behavior.
No preview · Article · Aug 2015 · Cognitive Therapy and Research
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to examine influences on the sustainability of a program to implement an evidence-based psychotherapy in a mental health system.
Interviews with program administrators, training consultants, agency administrators, and supervisors (N=24), along with summaries of program evaluation data and program documentation, were analyzed with a directed content-analytic approach.
Findings suggested a number of interconnected and interacting influences on sustainability, including alignment with emerging sociopolitical influences and system and organizational priorities; program-level adaptation and evolution; intervention flexibility; strong communication, collaboration, planning, and support; and perceived benefit. These individual factors appeared to mutually influence one another and contribute to the degree of program sustainability achieved at the system level. Although most influences were positive, financial planning and support emerged as potentially both facilitator and barrier, and evaluation of benefits at the patient level remained a challenge.
Several factors appeared to contribute to the sustainability of a psychosocial intervention in a large urban mental health system and warrant further investigation. Understanding interconnections between multiple individual facilitators and barriers appears critical to advancing understanding of sustainability in dynamic systems and adds to emerging recommendations for other implementation efforts. In particular, implications of the findings include the importance of implementation strategies, such as long-term planning, coalition building, clarifying roles and expectations, planned adaptation, evaluation, diversification of financing strategies, and incentivizing implementation.
[Show abstract][Hide abstract] ABSTRACT: Objective
The onset of psychosis typically occurs during adolescence or early adulthood and can have a detrimental impact on social and cognitive development. Cognitive behavioural therapy (CBT) shows promise in reducing the risk of psychosis. Teaching families to apply CBT with their offspring may bolster therapeutic gains made in time-limited treatment. We developed a comprehensive group-and-family-based CBT (GF-CBT) program that aims to facilitate psychosocial recovery, decrease symptoms and prevent transition to psychosis in youth at risk. GF-CBT is grounded in ecological systems and cognitive theories, resilience models and research on information processing in delusions. The theoretical rationale and description of GF-CBT are presented together with a pilot study that evaluated the program's feasibility and explored participants' outcomes.Methods
Youth ages 16–21 at risk for psychosis and their families participated in an open trial with pre, post and 3-month follow-up assessments conducted by an independent evaluator. The Comprehensive Assessment of At-Risk Mental States was the primary clinical outcome measure.ResultsAll enrolled participants (n = 6) completed GF-CBT and all remitted from at-risk mental state (ARMS). As a group participants showed statistically significant decreases in attenuated psychotic symptoms, negative symptoms, depression, cognitive biases and improvements in functioning. Family members showed significant improvements in use of CBT skills, enhanced communication with their offspring, and greater confidence in their ability to help. Gains were maintained at follow-up.ConclusionsGF-CBT may delay or prevent transition to psychosis in youth at risk, and potentially facilitate recovery from ARMS. More rigorous, controlled research is needed to further evaluate this program.
Full-text · Article · Feb 2015 · Early Intervention in Psychiatry
[Show abstract][Hide abstract] ABSTRACT: Cooperation and conflict may be understood as two sides of the same coin, comprising the social, political, and international sciences on the one hand and, on the other, the murkier nature of human psychology. The authors focus on these concepts by inquiring into the mental mechanisms triggering both cooperative and conflicting approaches in human relations. Exploring a range of different conflict situations, this chapter emphasizes the crucial importance of the meaning people attach to their interpersonal exchanges. Cognitive biases, automatic thoughts, and cognitive distortions (thinking “errors”) are the psychological mechanisms that come into play here, exerting considerable influence on the maintenance of intergroup conflict, its perceptions of interpersonal and social problems, and on adaptive decision-making processes. This chapter shows how cognitive biases can spark violence influencing intercommunication processes and explores their pivotal role in arousing anger, hostility, hatred, and related destructive behaviors. In doing so, it employs the perspective of the cognitive psychotherapy model, highlighting the relevance of the cognitive approach to international relations, mediation, and negotiation processes.
[Show abstract][Hide abstract] ABSTRACT: Policy-makers, payers, and consumers often make decisions based on therapists' reported theoretical orientations, but little is known about whether these labels represent actual or potential skills. Prior to CBT training, therapists (n = 321) reported theoretical orientations. Experts rated CBT competency using the Cognitive Therapy Rating Scale Therapy at pre-, mid-, and post-training. CBT- and non-CBT identified therapists showed equivalent, non-competent baseline CBT skills. CBT-identified therapists showed greater CBT skills at mid-training, but by end of training, groups evidenced equivalent achieved competency. Baseline CBT orientations were neither valid, nor useful markers of later competency. Policy, clinical and research implications are discussed.
Full-text · Article · Dec 2014 · Administration and Policy in Mental Health and Mental Health Services Research
[Show abstract][Hide abstract] ABSTRACT: Although theorists have posited that suicidal individuals are more likely than non-suicidal individuals to experience cognitive distortions, little empirical work has examined whether those who recently attempted suicide are more likely to engage in cognitive distortions than those who have not recently attempted suicide. In the present study, 111 participants who attempted suicide in the 30 days prior to participation and 57 psychiatric control participants completed measures of cognitive distortions, depression, and hopelessness. Findings support the hypothesis that individuals who recently attempted suicide are more likely than psychiatric controls to experience cognitive distortions, even when controlling for depression and hopelessness. Fortune telling was the only cognitive distortion uniquely associated with suicide attempt status. However, fortune telling was no longer significantly associated with suicide attempt status when controlling for hopelessness. Findings underscore the importance of directly targeting cognitive distortions when treating individuals at risk for suicide.
No preview · Article · Aug 2014 · Cognitive Therapy and Research
[Show abstract][Hide abstract] ABSTRACT: To determine the risk factors for suicide, 6,891 psychiatric outpatients were evaluated in a prospective study. Subsequent deaths for the sample were identified through the National Death Index. Forty-nine (l %) suicides were determined from death certificates obtained from state vital statistics offices. Specific psychological variables that could be modified by clinical intervention were measured using standardized scales. Univariate survival analyses revealed that the severity of depression, hopelessness, and suicide ideation were significant risk factors for eventual suicide. A multivariate survival analysis indicated that several modifiable variables were significant and unique risk factors for suicide, including suicide ideation, major depressive disorder, bipolar disorder, and unemployment status. Suicide is the eighth leading cause of death and was responsible for approximately 31,500 deaths in 1997 in the United States according to the most recent mortality statistics available from the National Center for Health Statistics (Hoyert, Kochanek, & Mur-phy, 1999). Given the relative infrequency of suicide, however, the identification of risk factors for suicide has been problematic (Murphy, 1984). Although previous studies have attempted to investigate suicide by studying a more frequent behavior, nonfatal suicide attempts, conclusions regarding the actual risk for suicide are tenuous (Maris, Berman, Maltsberger, & Yufit, 1992). Large samples, a prospective study design, and long-term follow-up are important components that are required for validating potential risk factors. A/though the estimated suicide rate in the general population is 0.01% (Hoyert et al., 1999), the rate among the psychiatric population is approximately 1% (Babigian & Odoroff, 1969; Pokorny, 1964). Several prospective studies have been conducted to identify risk factors in psychiatric populations (for a review, see Mogcicki, 1999). These studies have identified a variety of noso- Gallop for their advice on the epidemiological methods and anal-yses. Correspondence concerning this article should be addressed to Gregory K.
[Show abstract][Hide abstract] ABSTRACT: For over 50 years, Beck's cognitive model has provided an evidence-based way to conceptualize and treat psychological disorders. The generic cognitive model represents a set of common principles that can be applied across the spectrum of psychological disorders. The updated theoretical model provides a framework for addressing significant questions regarding the phenomenology of disorders not explained in previous iterations of the original model. New additions to the theory include continuity of adaptive and maladaptive function, dual information processing, energizing of schemas, and attentional focus. The model includes a theory of modes, an organization of schemas relevant to expectancies, self-evaluations, rules, and memories. A description of the new theoretical model is followed by a presentation of the corresponding applied model, which provides a template for conceptualizing a specific disorder and formulating a case. The focus on beliefs differentiates disorders and provides a target for treatment. A variety of interventions are described. Expected final online publication date for the Annual Review of Clinical Psychology Volume 10 is March 20, 2014. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
Full-text · Article · Jan 2014 · Annual Review of Clinical Psychology
[Show abstract][Hide abstract] ABSTRACT: We investigated the feasibility of implementing a recovery-oriented cognitive therapy (CT-R) milieu training program in an urban acute psychiatric inpatient unit. Over a 1-month period, 29 staff members learned short-term CT-R strategies and techniques in an 8-h workshop. Trainees' perceptions of CT-R, beliefs about the therapeutic milieu, and attitudes about working with individuals with psychosis were evaluated both before the workshop and 6 months after the workshop had been completed. Incidents of seclusion and restraint on the unit were also tallied prior to and after the training. Results indicate that staff perceptions of CT-R and their beliefs about the therapeutic environment significantly improved, whereas staff attitudes towards individuals with psychosis remained the same. Incidents of seclusion and restraint also decreased after the training. These findings provide evidence that CT-R training is feasible and can improve the therapeutic milieu of an acute psychiatric inpatient unit.
No preview · Article · Dec 2013 · Community Mental Health Journal
[Show abstract][Hide abstract] ABSTRACT: Objective:
This study identified modifications to an evidence-based psychosocial treatment (cognitive therapy) within a community mental health system after clinicians had received intensive training and consultation.
A coding system, consisting of four types of contextual modifications, 12 types of content-related modifications, seven levels at which modifications can occur, and a code for changes to training or evaluation processes, was applied to data from interviews with 27 clinicians who treat adult consumers within a mental health system.
Nine of 12 content modifications were endorsed, and four (tailoring, integration into other therapeutic approaches, loosening structure, and drift) accounted for 65% of all modifications identified. Contextual modifications were rarely endorsed by clinicians in this sample. Modifications typically occurred at the client or clinician level.
Clinicians in community mental health settings made several modifications to an evidence-based practice (EBP), often in an effort to improve the fit of the intervention to the client's needs or to the clinician's therapeutic style. These findings have implications for implementation and sustainability of EBPs in community settings, client-level outcomes, and training and consultation.
[Show abstract][Hide abstract] ABSTRACT: Individuals with severe and persistent schizophrenia can present challenges (e.g., difficulties sustaining motivation and conducting information processing tasks) to the implementation of recovery-oriented care. We present a successful application of recovery-oriented cognitive therapy (CT-R), a fusion of the spirit and principles of the recovery movement with the evidence base and know-how of cognitive therapy, that helped an individual with schizophrenia move along her recovery path by overcoming specific obstacles, including a 20-year cycle of hospitalizations (five per year), daily phone calls to local authorities, threatening and berating "voices," the belief that she would be killed at any moment, and social isolation. Building on strengths, treatment included collaboratively identifying meaningful personal goals that were broken down into successfully accomplishable tasks (e.g., making coffee) that disconfirmed negative beliefs and replaced the phone calling. At the end of treatment and at a 6-month follow-up, the phone calls had ceased, psychosocial functioning and neurocognitive performance had increased, and avolition and positive symptoms had decreased. She was not hospitalized once in 24 months. Results suggest that individuals with schizophrenia have untapped potential for recovery that can be mobilized through individualized, goal-focused psychosocial interventions. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
No preview · Article · Sep 2013 · Psychological Services