The Suicidal Crisis. Clinical Guide to the Assessment of Imminent Suicide Risk

CHAPTER 1: INTRODUCTION AND OVERVIEW

1. The Ticking Time Bomb of the American Suicide Epidemic
2. What is Imminent Suicide
3. Long-Term vs. Imminent Suicide Risk: Who vs. When
4. Lack of Tests for Suicide Prediction
5. The Problem of “Non-Disclosure”
6. The Suicide Crisis Syndrome
7. The Narrative Crisis Model of Suicide
8. One-Informant vs. Multi-Informant Suicide Risk Assessments
9. Using Clinicians' Emotions in Suicide Prevention
10. Risk Stratification vs. Clinical Judgment
11. How to Use the Suicidal Crisis
12. A Roadmap for Comprehensive Assessment
13. References

CHAPTER 2: PSYCHOLOGICAL MODELS OF SUICIDE
with Olivia Lawrence and Shira Barzilay

1. Introduction
2. Historical Perspective
3. Shneidman's Theory of Psychache
4. Suicide as Escape from Self
5. The Cry of Pain/Arrested Flight Model
6. Cognitive Vulnerability Model
7. Fluid Vulnerability Model
8. Beck's Diathesis-Stress Model
9. Mann's Stress-Diathesis Model
10. Joiner's Interpersonal Model
11. O'Connor's Integrated Motivational-Volitional Model of Suicide
12. Klonsky's Three-Step Theory of Suicide
13. Summary
14. References

CHAPTER 3: THE NARRATIVE-CRISIS MODEL OF SUICIDE

1. Introduction
2. Trait vs. State Risk Factors
3. Static vs. Dynamic Risk Factors
4. The Narrative Crisis Model Overview
5. The Long-Term Risk Component
6. Stressful Life Events
7. The Suicidal Narrative Subacute Component
8. The Suicidal Crisis
9. Model Flexibility: Narrative-Driven vs. Crisis-Driven Suicidal Behaviors
10. Conclusion
11. References

CHAPTER 4: LONG-TERM OR CHRONIC RISK FACTORS

1. Demographics
1.1. Gender and Age
1.2. Sexual Orientation and Identity
1.3. Race, Ethnicity, and Geographical Region
2. Psychological Factors
2.1. Impulsivity
2.2. Hopelessness and Pessimism
2.3. Perfectionism
2.4. Fearlessness and Pain Insensitivity
2.5. Attachment Style
3. Historical Factors
3.1. History of Mental Illness
3.2. History of Suicide Attempts
3.3. Suicide in the Family
3.4. Suicide Exposure and Practicing
3.5. Childhood Trauma
3.6. Parenting Style
4. Social Factors
4.1. Cultural Attitudes and Immigration Status
4.2. Moral, Philosophical and Religious Objections
4.3. Suicide Clusters
5. COVID-19 Pandemic
6. Case Examples
6.1. Case 1: High Risk for Imminent Suicide
6.2. Case 2: Moderate Risk for Imminent Suicide
6.3. Case 3: Low Risk for Imminent Suicide
7. Test Case 1
8. References

CHAPTER 5: STRESSFUL LIFE EVENTS
with Olivia Lawrence, Inna Goncearenco, Ehsan Moazen-Zadeh and Kimia Ziafat

1. Introduction
2. Adults
2.1. Work and Financial Hardship
2.1.1. Economic Hardship
2.1.2. Business or Work Failure
2.1.3. Loss of Home
2.2. Relationship Conflict
2.2.1. Romantic Rejection
2.2.2. Intimate Relationship Conflict
2.2.3. Parents in Conflict with Children
2.3. Serious Medical Illness
2.3.1. Recent Diagnosis
2.3.2. Prolonged and Debilitating Illness
2.3.3. Acute and Chronic Pain
2.4. Serious Mental Illness
2.4.1. Recent Diagnosis
2.4.2. Recent Hospitalization
2.4.3. Recent Suicide Attempt
2.4.4. Attempt Lethality
2.4.5. Illness Exacerbation and Acute Episodes
2.4.6. Medication Changes: Initiation, Discontinuation, and Non-adherence
2.5. Recent Substance Misuse
2.5.1. Drug and Alcohol Use Disorder
2.5.2. Acute Alcohol Intoxication and Recent Drug Use
2.5.3. Alcohol and Drug Withdrawal.
3. Adolescents
3.1. Children in Conflict with Parents
3.2. Ongoing Childhood and Adolescent Abuse and Neglect
3.3. Bullying
4. Internet and Social Media
4.1. Screen Time
4.2. Internet Addiction
4.3. Cyberbullying
5. COVID-19 Pandemic
6. References

CHAPTER 6 SUICIDAL NARRATIVE

1. The Seven Stages of the Suicidal Narrative
1.1. Stage 1: Unrealistic Life Goals
1.2. Stage 2: Entitlement to Happiness
1.3. Stage 3: Failure to Redirect to More Realistic Goals
1.4. Stage 4: Humiliating Personal or Social Defeat
1.5. Stage 5: Perceived Burdensomeness
1.6. Stage 6: Thwarted Belongingness
1.7. Stage 7: Perception of No Future
2. Constructing the Suicidal Narrative
3. Probing the Suicidal Narrative: an Interview Algorithm.
4. Case Examples
4.1. Case 38: High Risk for Imminent Suicide
4.2. Case 39: Moderate Risk for Imminent Suicide
4.3. Case 40: Low Risk for Imminent Suicide
4.4. Test Case 2
5. References

CHAPTER 7: SUICIDE CRISIS SYNDROME

1. Distinction Between Chronic Long-Term Suicide Risk and Acute Short-Term Suicide Risk
2. Suicide Warning Signs
3. Suicidal Ideation and Intent
3.1. Suicidal Ideation
3.2. Suicide Intent and Plan
4. Suicide Crisis Syndrome
4.1. SCS Diagnostic Structure
4.2. Clinical Utility of SCS
4.3. Suicide Specific Modifiers for SCS
4.3.1. Suicidal Ideation as a Modifier
4.3.2. Suicidal Behavior Disorder as a Modifier
4.3.3. Acute Suicidal Affective Disturbance as a Modifier
4.3.4. The Argument in Support of the Three Modifiers
5. Suicide Crisis Syndrome Criteria and Symptoms
5.1. Criterion A: Frantic Hopelessness/Entrapment
5.2. Criterion B1: Affective Disturbance
5.2.1. Emotional Pain
5.2.2. Rapid Spikes of Negative Emotions
5.2.3. Extreme Anxiety
5.2.4. Acute Anhedonia
5.3. Criterion B2: Loss of Cognitive Control
5.3.1. Ruminations
5.3.2. Cognitive Rigidity
5.3.3. Failed Thought Suppression
5.3.4. Ruminative Flooding
5.4. Criterion B3: Hyperarousal
5.4.1. Agitation and Irritability
5.4.2. Hypervigilance
5.4.3. Insomnia
5.5. Criterion B4: Acute Social Withdrawal
5.6. SCS Assessment Algorithm
5.6.1. The Full SCS Assessment
5.6.2. The One-Minute Assessment
6. Case Examples
6.1. Case 38: High Risk for Imminent Suicide, continued
6.2. Case 39: Moderate Risk for Imminent Suicide, continued
6.3. Case 40: Low Risk for Imminent Suicide, continued
6.4. Test Case 3
7. References

CHAPTER 8: EMOTIONAL RESPONSE TO SUICIDAL PATIENTS IN THE ASSESSMENT OF IMMINENT SUICIDE RISK
with Benedetta Imbastaro, Olivia Lawrence, and Inna Goncearenco.

1. Introduction
1.1. The Need for New Approaches in Risk Assessment
2. Clinician's Emotional Responses to Suicidal Patients and their Underlying Mechanisms
2.1. Experimental Evidence for Clinician's Emotional Responses
2.2. Clinicians' Defense Mechanisms in Psychotherapy with Suicidal Patients
2.3. Clinicians' Pattern of Emotional Response
3. Relevance Of Clinician Emotional Response in Clinical Practice
3.1. A Predictive Factor in Suicide Risk Assessment
3.2. How to Appraise the Emotional Response
4. A Practical Method for Assessing One's Emotional Response
5. Case Examples
5.1. Case 52: High Risk for Imminent Suicide - Reaction Formation
5.2. Case 53: High Risk for Imminent Suicide - Repression and Denial
5.3. Case 54: Low Risk for Imminent Suicide
6. Conclusion
7. References

CHAPTER 9: CONDUCTING SHORT-TERM RISK ASSESSMENT INTERVIEWS

1. Comprehensive Short-term Risk Assessment Outline
2. Suicidal Ideation and Intent: Self-report and its Limitations
3. Development and Use of Suicide Risk Assessment Instruments
3.1. The SAD PERSON scales
3.2. Columbia Suicide Severity Rating Scale (C-SSRS)
3.3. Suicide Tracking Scale (STS)
3.4. The Suicide Crisis Inventories (SCI)
3.5. The Suicide Crisis Syndrome Checklist (SCS-S)
3.6. The Modular Assessment of Risk for Imminent Suicide (MARIS)
4. Risk Assessment Interview Strategies
4.1. Comprehensive Interview
4.2. The Brief MARIS Interview
4.3. Expanded MARIS interview
5. The Case of Eerie Calm
6. Appendix A: The Suicide Crisis Inventory-2 (SCI-2)
7. Appendix B: The Modular Assessment of Risk for Imminent Suicide (MARIS-2)
8. Appendix C: SCS Checklist (SCS-C)
9. References

CHAPTER 10: THE NARRATIVE CRISIS MODEL OF SUICIDE AS A FRAMEWORK FOR SUICIDE PREVENTION
with Inna Goncearenco, Lakshmi Chennapragada, Ehsan Moazen-Zadeh and Megan L. Rogers, PhD.

1. Introduction
2. Overview of the NCM
3. Empirical Support for the Narrative Crisis Model of Suicide
4. Utilizing the Narrative Crisis Model as a Framework for Clinical Intervention
4.1. Lethal Means Counseling
4.2. Treatment of the Suicide Crisis Syndrome
4.2.1. Step 1: Pharmacological or Non-Pharmacological Somatic Treatment
4.2.2. Step 2: Safety Planning
4.3. Treatment of the Suicidal Narrative
4.3.1. Collaborative Assessment and Management of Suicidality
4.3.2. Cognitive Behavioral Therapy for Suicide Prevention
4.3.3. Attempted Suicide Short Intervention Program
4.4. Stress Management
4.4.1. Dialectical Behavior Therapy
4.4.2. Mindfulness-Based Stress Reduction
4.4.3. Emotion Regulation Therapy
4.4.4. Attachment-Based Family Therapy
4.5. Digital Interventions
4.6. Long-Term Risk Factors/Trait Vulnerabilities
4.7. Cultural Considerations
4.7.1. African American
4.7.2. Hispanic
4.7.3. American-Indian/Alaskan Native
4.7.4. Asian American
4.7.5. Cultural Competence
5. Implications for Future Research and Clinical Practice
6. Conclusions
7. References

Most people who die by suicide see a clinician prior to taking their lives. Therefore, one of the most difficult determinations clinicians must be able to make is whether any given patient is at risk for suicide in the immediate future. The Suicidal Crisis, Clinical Guide to the Assessment of Imminent Suicide Risk, is the first book written specifically to help clinicians evaluate the risk of such imminent suicidal behavior.

The Suicidal Crisis is an essential work for every mental health professional and for anyone who would like to have a framework for understanding suicide. Written by master clinician Dr. Igor Galynker, the book presents methods for a systematic and comprehensive assessment of short-term suicide risk and for conducting risk assessment interviews in different settings.

Dr. Galynker describes suicide as an attempt of a vulnerable individual to escape an unbearable life situation, which is perceived as both intolerable and inescapable. What sets the Suicidal Crisis apart from the other books of its kind is its sharp focus on those at the highest risk. It presents a wealth of clinical material within the easy-to-understand and intuitive framework of the Narrative-Crisis model of suicidal behavior. The book contains sixty individual case studies of actual suicidal individuals and their interviews, detailed instructions on how to conduct such interviews, and risk assessment test cases with answer keys. A unique feature of the book, not found in any other book on suicide, is a discussion of how clinicians' emotional responses to acutely suicidal individuals may help identify those at highest risk.

In this timely, thorough, and well-written monograph, Dr. Galynker provides a method for understanding the suicidal process and of identifying those at the highest risk for taking their lives. Any clinician who works with suicidal individuals-and anybody who knows someone who has considered suicide-will find the book an essential and illuminating read.

Dr. Igor I. Galynker is a clinical and research psychiatrist with broad interests in suicide prevention, bipolar disorder, behavioral addictions, and the role of family in psychiatric illness. He has published extensively on these topics in professional journals and in the lay press and has authored an acclaimed book on family involvement in psychiatric treatment.