The Menninger Clinic and Baylor College of Medicine, Houston, Texas Marcia L. Verduin, MD, Book Editor

Objectives: This study sought to assess the utility of Imagery Rehearsal Therapy (IRT) for nightmares in an inpatient psychiatric setting. Although IRT enjoys a substantial evidence base for efficacy in various populations, data with psychiatric inpatients are lacking. Participants: Participants were 20 adult psychiatric inpatients (11 male, 9 female; mean age=43.4), in an extended stay psychiatric inpatient facility. All participants were diagnosed with multiple, treatment resistant, comorbid conditions, including mood disorders, anxiety disorders, personality disorders, and substance-related disorders. Patients with active psychosis or significant cognitive impairment were excluded. Methods: This was an open trial utilizing a case series design. In addition to routine hospital treatment that included psychotherapeutic and pharmacological interventions, participants received IRT over a span of 3 weeks in 4 small group sessions. Included were education about sleep and nightmares, instruction in writing new dream narratives and practicing guided imagery, and support via further consultation and trouble-shooting. Patients were referred by their psychiatrist or were self-referred, with approval from their treatment teams. Results: Results showed significant aggregate reductions in nightmare frequency and intensity, as well as improvement in sleep overall. Patients also improved on a variety of other symptom measures, including suicidal ideation. No adverse reactions were observed. The present report includes a sampling of individual case vignettes to illustrate variability in treatment response. Conclusions: This study provides preliminary evidence that IRT can be used safely and effectively in a hospital environment to benefit patients suffering from serious mental illnesses, often in the midst of significant life crises. It is not possible in this preliminary study to conclude that IRT specifically (as opposed to other aspects of hospital treatment) produced these outcomes. Larger, controlled trials are needed to establish a causal connection between IRT and nightmare reduction.

Although suicide treatment is an expanding area of research, there is relatively less in the literature with respect to how specific vulnerabilities to suicide are addressed by treatment. Utilizing measures of suicide cognitions, therapeutic alliance, and psychological flexibility, we compared their relative contributions to suicidal ideation during and posttreatment among a group of adult psychiatric inpatients (N = 434). Results revealed that cognitions contributed considerably more unique variance to suicidal ideation than alliance and flexibility at discharge and at 2 weeks postdischarge, and to change in suicidal ideation over the course of treatment. Psychological flexibility explained a small amount of variance at the 6-month time point. Factor level analyses also were conducted, with the unsolvability factor within suicide cognitions accounting for the largest portion of variance at both discharge and 2 weeks postdischarge. Study limitations, implications, and future directions are discussed.

The current study replicates a previously used methodology with a suicidal inpatient sample regarding word counts generated by participants writing about suicidal constructs. Word counts (i.e., the number of written words) on the Suicide Status Form from initial sessions with suicidal inpatients were compared to self-rated suicide risk scores as well as to continuous and repeated measures of hopelessness and suicide ideation assessed over the course of inpatient care. Results showed that higher word counts were associated with initially higher suicide ideation scores that steadily declined over the course of treatment. Lower word counts were associated with lower initial hopelessness scores that increased during treatment before ultimately decreasing. In addition, word count was not found to be a significant predictor of self-rated suicide risk. Clinical implications of these data and future directions are discussed.

While the construct of countertransference has been established in psychodynamic theory since its inception, it has received relatively little attention from cognitive-behavioral theorists. However, it is generally agreed that therapists’ reactions to patients powerfully influence treatment, for better or worse. Suicidal patients in particular are likely to evoke negative reactions in therapists. In this paper, we briefly review the theoretical literature on countertransference, with particular attention to suicidal patients, from standpoints of psychodynamic and cognitive-behavioral theory and research. We argue that the cognitive-behavioral perspective, together with the RAIN model proposed by mindfulness authors (Recognition, Acceptance, Investigation, and Non-Identification), opens avenues to assess, distance from, and perhaps modify cognitions that could lead to counter-therapeutic emotions and behaviors in working with suicidal patients. We conclude that, while work with suicidal patients can be challenging, cognitive-behavioral therapists can potentially improve effectiveness and enhance their own well-being by managing their reactions in a manner consistent with their theoretical orientation.

Recent research by Witte and colleagues (2017) revealed a taxonic structure for classifying suicide risk using a sample of predominantly military outpatients. The authors sought to replicate the Witte et al. (2017) findings using data from a sample of 2,385 psychiatric inpatients who completed measures of suicidal ideation and behavior upon admission to the hospital. The comparison curve fit index values for means above minus below a cut (.80), maximum eigenvalue (.71), and latent mode (.52) showed a similar taxonic structure (i.e., dichotomous rather than continuous). Consistent with Witte et al. (2017), differences between the taxon and complement groups were larger for variables conceptually directly related to suicide risk than to broader constructs such as hopelessness or depression. Support for this categorical distinction among a sample of long-term psychiatric inpatients, who are uniformly high in symptom severity, emphasizes the need for additional research on this high-risk group and development of further assessment methods. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Background: The purpose of the present study was to identify variations in emotional dysregulation patterns among adults diagnosed with borderline personality disorder (BPD), with an eye toward implications for treatment. Methods: Latent profile analysis (LPA) was utilized to classify 156 inpatients with BPD, based on patterns of Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, J Psychopathol Behav Assess 26: 41-54, 2004) subscale scores. Results: Results revealed that a three class solution best fit the sample (Low Impairment, Global Dysregulation, and Emotionally Aware). Further analysis of the classes at admission revealed that the Global Dysregulation group reported significantly higher suicidal ideation than either the Low Impairment or Emotionally Aware groups, and that the Global Dysregulation group reported significantly higher functional impairment than the Low Impairment group. Conclusions: All three groups improved greatly over the course of hospital treatment, although they remained distinguishable at discharge, retaining their positions symptomatically relative to one another. Limitations, implications, and future directions are discussed.

The authors summarize findings from a multiyear research project designed primarily to investigate outcomes of intensive, psychotherapeutic hospital treatment lasting several weeks. Patients are assessed with well-established measures at admission, and their progress is reassessed biweekly up to discharge. A follow-up component was added recently to track outcomes for 1 year after discharge. All inpatient assessments are integrated with clinical care by providing individual results for each time point to the patient and the treatment team. In addition to reporting findings from inpatient treatment, the authors summarize what has been learned about the measures and methodology as well as what the assessments have revealed about psychopathology in these patients. More recently, the outcomes project has included a neuroscience initiative with findings from neuroimaging, genetics, and the microbiome; initial findings are also summarized. The authors conclude with a discussion of their understanding of the basis of the effectiveness of this increasingly rare form of inpatient treatment.

Suicide risk is an inescapable presence in the treatment of people with psychiatric disorders, a fact that applies especially in inpatient psychiatric settings. This article summarizes a several-year research initiative at The Menninger Clinic aimed at better understanding psychological contributors to suicidality and developing more effective clinical interventions. Two areas of research are described, an outcomes arm focused on assessing the feasibility and effectiveness of a suicide-specific intervention (The Collaborative Assessment and Management of Suicidality) and an exploratory arm whose objective is to learn about psychological vulnerabilities that distinguish suicidal from nonsuicidal patients, with an eye toward developing interventions that address such vulnerabilities. The author concludes that, combined with other developments in the field, this body of work strongly supports the view that suicidal patients should be treated with interventions that specifically target vulnerabilities that seem to set the stage for suicidal episodes.

This controlled comparison trial evaluated a suicide-specific intervention, the Collaborative Assessment and Management of Suicidality (CAMS), in an extended-stay psychiatric inpatient setting. Multiple outcomes were examined for 104 patients, half of whom received individual therapy from therapists trained in CAMS. The comparison group was selected from a larger pool through Propensity Score Matching to ensure comparability on age, sex, treatment program, number of prior suicide attempts, and severity of suicidal ideation. Results showed that a) all patients improved significantly across a wide range of measures, including depression, suicidal ideation, functional disability, and well-being; b) these gains were durable over a 6-month post-discharge period; and c) patients treated by a CAMS-trained individual therapist improved significantly more from admission to discharge across all measures. Differences between CAMS and non-CAMS patients were no longer statistically significant at 6-month follow-up, although statistical power was compromised due to attrition. Although replication studies are needed, these findings suggest that interventions specifically tailored for suicidal patients may have advantages compared to usual, intensive inpatient treatment, perhaps by addressing psychological vulnerabilities specific to the population. The lack of significant differences at follow-up suggest that post-treatment contact may be needed to maintain advantages associated with this and similar interventions.

Acute Suicidal Affective Disturbance (ASAD) is a newly proposed diagnostic entity that characterizes rapid onset suicidal intent. This study aims to confirm the factor structure of ASAD among psychiatric inpatients, and to determine the clinical utility of ASAD in predicting suicide attempt status. Overall, 1442 psychiatric inpatients completed a battery of self-report questionnaires assessing symptoms theorized to comprise the ASAD construct. Utilizing these data, a confirmatory factor analysis with a one-factor solution was performed. Regression analyses were employed to determine if the ASAD construct predicted past suicide attempts, and analyses of variance (ANOVAs) were employed to determine if ASAD symptoms differed by the presence and number of past suicide attempts. The one-factor solution indicated good fit: χ2(77) = 309.1, p < 0.001, Tucker-Lewis Index (TLI) = 0.96, comparative fit index (CFI) = 0.97, root-mean-square error of approximation (RMSEA) = 0.05. Controlling for depressive disorders and current symptoms, the ASAD construct significantly predicted the presence of a past suicide attempt. Moreover, ASAD differentiated in the expected directions between individuals with a history of multiple suicide attempts, individuals with a single suicide attempt, and individuals with no history of a suicide attempt. Acute Suicidal Affective Disturbance (ASAD) appears to be a unified construct that predicts suicidal behavior and is distinct from an already-defined mood disorder.

Growing empirical literature in recent years indicates that experiential avoidance plays a role in a wide variety of psychological disorders and psychotherapeutic interventions. This study explored the view of suicidal ideation as a form of experiential avoidance by examining the association between suicidal ideation and therapeutic change in a sample of 189 adult psychiatric inpatients. Results were consistent with predictions, showing a statistically significant association between scores on the Beck Scale for Suicidal Ideation and the Acceptance and Action Questionnaire-II (AAQ-II). It was further shown that change in AAQ-II scores over the course of hospitalization was associated with change in suicidality, independent of changes in depression severity and hopelessness. Moreover, treatment responders (patients whose suicidal ideation scores dropped significantly over the course of treatment) showed greater drops in experiential avoidance relative to nonresponders. These results are consistent with a view of suicidal ideation (and, by extension, suicide) as a form of experiential avoidance and potentially a therapeutic approach that specifically seeks to reduce experiential avoidance.

Thomas E. Ellis, PsyD, ABPP, is a senior staff psychologist at The Menninger Clinic and a professor of psychiatry in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX Marcia L. Verduin, MD, Book Editor

OBJECTIVE:Accurate prediction of suicide remains elusive due to lack of predictive measures. Given the Columbia-Suicide Severity Rating Scale's (C-SSRS) emerging "gold-standard" status for risk assessment, studies are needed to assess its psychometric properties, particularly predictive validity. The current study adds to the limited literature by assessing the C-SSRS's internal consistency, factor structure, concurrent validity, and predictive validity.METHODS:In this longitudinal study of 1,055 adults with DSM-IV diagnoses consecutively admitted to a specialized psychiatric hospital between July 1, 2012, and June 30, 2014, patients completed standardized assessments, including the C-SSRS, at admission and 2, 12, and 24 weeks postdischarge.RESULTS:The C-SSRS evidenced excellent internal consistency (ordinal α = .95). Principal components analysis (PCA) revealed a 2-factor solution, accounting for 65.3% of the variance across items. The severity of ideation and behavioral items loaded onto the first factor, and the intensity of ideation items loaded onto the second factor. The total score, factors, and the most severe ideation single item were moderately correlated with other measures of suicidality (0.27 ≤ r ≤ 0.58; P < .0001). The summary score from the ideation/behavior factor was found to be modestly correlated with any suicide-related behavior within the 6 months following hospitalization. Receiver operator characteristics indicated that the C-SSRS performed adequately in correctly classifying any suicide-related behavior within 6 months of discharge from the hospital (AUC = 0.757, P < .001) with the total score and summary score from the ideation/behavior factor providing the best balance between sensitivity (0.694) and specificity (0.652-0.674).CONCLUSIONS:This study is the first to assess the factor structure of the C-SSRS in a large, high-risk sample. The measure has solid psychometric properties and merits use as a suicide risk assessment measure.

In this study, we set out to extend empirical research on the Life-Death Implicit Association Test (IAT) by administering the measure to an adult psychiatric inpatient population with suicidal ideation. We sought to examine its association with other suicide-relevant measures and to determine whether it adds predictive utility beyond that offered by other measures of suicide risk. The IAT was administered (N = 124) at biweekly intervals as part of an assessment battery at an inpatient facility for complex, treatment resistant psychiatric disorders (average length of stay: approximately 6 weeks). Multiple regression procedures were utilized to examine relationships among the measures and their predictive utility with respect to suicidal ideation at discharge. Consistent with prior research with other populations, significant associations were found between IAT performance and explicit (self-report and interview) measures of suicide risk. Moreover, the IAT was found to predict suicidal ideation at discharge above and beyond number of prior suicide attempts and admission scores on measures of depression, suicidal ideation, and hopelessness. Change in IAT performance over the course of treatment was observed. The IAT shows promise as an addition to explicit measures conventionally used to estimate suicide risk in psychiatric patients. These findings are consistent with a cognitive vulnerability model of suicide risk.

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide-specific interventions may offer benefits beyond conventional care. This naturalistic controlled-comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide-specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.

Background Impaired capacity for emotion regulation is associated with a broad spectrum of psychiatric disturbances; however, little is known about treatment response in emotion regulation functioning among patients with severe mental illness. This study examined treatment response and the role that experiential avoidance plays in mediating the relationship between attachment anxiety/avoidance and change in emotion regulation. Methods Difficulties in emotion regulation were assessed at admission and at discharge, and rates of improvement and deterioration in emotion regulation were calculated. Attachment anxiety and avoidance were assessed in conjunction with experiential avoidance at baseline in a large cohort (N = 493) of adults admitted to a specialized adult psychiatric hospital. Results Inpatient treatment was associated with clinically significant improvement in emotion-regulation capacities for 49 percent of patients completing at least four weeks of treatment. Fifty-six percent of patients attained a status of recovery. Greater attachment avoidance and anxiety were related to positive change in emotion regulation at discharge. Experiential avoidance fully mediated the relationship between insecure attachment and change in emotion-regulation capacities. Conclusions Contrary to expectation, greater attachment insecurity (anxiety and avoidance) as well as greater experiential avoidance predicted improvement in emotion regulation. These counterintuitive findings add to a growing evidence base indicating that severity of psychopathology is associated with greater improvement in hospitalized patients. Results of the mediation analysis suggest that targeting experiential avoidance may be an effective augmentation in the treatment of impaired emotion regulation functioning.

OBJECTIVEThis study examined changes in health-related quality of life in adult inpatients with serious mental illness engaged in a 6- to 8-week intensive treatment program.METHODAdmission and discharge assessment with the MOS 36-item Short-Form Health Survey was completed (June 2010-June 2012) for 410 adults aged 18-68 years. Paired t tests and effect size estimates were calculated for the overall sample, and reliable change index scores and clinical significance were calculated to estimate individual-level response and recovery rates. Hierarchical stepwise regression analyses were conducted to explore patient pretreatment characteristics, including total number of DSM-IV-TR diagnoses, that influence treatment response.RESULTSLarge effect size improvements were demonstrated for the Mental Component Summary score (Cohen d = 1.5), including subjective ratings of vitality (Cohen d = 1.1), social functioning (Cohen d = 1.3), role-emotional functioning (Cohen d = 1.3), and mental health (Cohen d = 1.3). Equivocal findings for change in physical health were demonstrated, with the majority of patients demonstrating no significant change in function (t409 = 0.14, P = .89) but approximately equal numbers of patients demonstrating improvement and deterioration. The pretreatment characteristic of a tendency to be interpersonally distant, cold, and disengaged was predictive of a poorer outcome on Mental Component Summary treatment response (P < .001).CONCLUSIONSIn light of a heavy burden of illness and high psychiatric comorbidity of this sample, treatment response was generally positive for improvement in mental health functioning. This study adds to a growing body of evidence indicating robust treatment response even for those with serious mental illness when treatment is intensive and multimodal.