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Book Forum: Assessment and Treatment   |    
Clinical Manual for Assessment and Treatment of Suicidal Patients
HOWARD S. SUDAK, M.D.
Am J Psychiatry 2005;162:1770-1771. doi:10.1176/appi.ajp.162.9.1770
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By John A. Chiles, M.D., and Kirk D. Strosahl, Ph.D. Washington, D.C., American Psychiatric Publishing, 2005, 333 pp., $39.00 (paper).

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This is a provocative book that approaches the evaluation and treatment of suicidal patients from a learning theory perspective: "That suicidal behavior is problem-solving behavior…is the principle underpinning our approaches to both the assessment and treatment of suicidal individuals" (p. xxi). The authors, a psychiatrist and a psychologist, combine cognitive behavior therapy and dialectical behavior therapy techniques, as well as some approaches of their own, to provide an etiological and therapeutic overview of suicide that may be more familiar to psychologists than to psychiatrists (particularly those trained before the teaching of cognitive behavior therapy during psychiatric residencies was required). When heuristic was an "in" adjective, this book would certainly merit such an appellation.

In these days, when a biological model of depression (and suicide) is often overemphasized, it is helpful to find a book that focuses on a more psychological basis for suicide and for psychological treatment of it. This is the book’s strength as well as its shortcoming. It is so devoted to a learning theory approach that other perspectives (including biological as well as other psychotherapies such as interpersonal, psychoanalytic, etc.) are given short shrift. Chronic suicide attempters and suicide completers are not sufficiently dealt with as representing distinct (although overlapping) populations. The authors primarily address chronically suicidal patients who are more apt to suffer from axis II disorders and for whom psychotherapy such as cognitive or dialectical behavior therapy may be indicated as the primary approach. They are less thorough with other groups at higher risk for completion—namely, patients with severe axis I disorders, for whom prompt and adequate pharmacotherapy may be a more appropriate first-line approach. The authors do mention the suicide-reduction effects of lithium and clozapine but are considerably more tepid in their endorsement of other pharmacological agents, such as antidepressants.

I am somewhat concerned by the authors’ explicit wish to "normalize" suicidal behavior. From a public health perspective, we should normalize help-seeking from mental health professionals, not suicidal behaviors, which are better off remaining stigmatized. I realize that Chiles and Strosahl here are referring to individual patients in treatment, where a psychological understanding with a given patient who is suicidal may in effect normalize it, but the point should be clarified.

The value of assessing risk factors is disparaged by the authors because we cannot predict from them who is "at imminent risk" of harming himself or herself and because using them leads to an enormous number of false positives. I agree with both premises but believe that the clinician’s task (as well as the medicolegal standard of care) is to evaluate the risk of suicide and act accordingly. No one expects the clinician to be able to prevent all suicides—the expectation is that he or she evaluate risk appropriately and do what is necessary and possible to prevent harm. If this requires a paternalistic stance rather than a more self-determining approach such as a learning theory model endorses, so be it. The clinical conditions determine what is most appropriate.

The value of inpatient psychiatric care is also questioned by the authors, and, again, this may reflect the issue of discriminating between patients with axis I versus axis II disorders. For the former, inpatient care often is critical. Rather than viewing suicidal behavior as an attempt at problem solving, psychiatrists are more apt to view it as a symptom of a given disease. We protect the patient from the symptom while we treat the underlying disease. In psychiatry, as in medicine in general, if symptoms are severe enough (e.g., a fever of 105°F), we may be forced to attend to them directly (e.g., ice water baths) until the disease (e.g., infection) can be brought under control. Chiles and Strosahl, however, view the disease model as overemphasized because "perhaps as many as 50% of suicidal patients do not meet criteria for any mental disorder."

The book is comprehensive—covering outpatients, inpatients, repetitiously suicidal patients, suicidal emergencies, and special populations—and provides many tables, charts, and appendixes. Each chapter has a Helpful Hints section and its own references and suggested readings. The section dealing with therapists’ feelings toward their suicidal patients and the section on ethical issues are especially worthwhile. There is also a useful chapter authored by Patricia Robinson, Ph.D., devoted to the needs of survivors of suicide—including therapist survivors, an often neglected area. I recommend the book especially to those clinicians who are so wedded to a biological/genetic model that they need to be reminded about learning theory and other psychological perspectives. For those clinicians who de-emphasize the bio in biopsychosocial, however, I am concerned that this work will only reinforce an unfortunate bias.

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