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Suicide and Life-Threatening Behavior 45 (1) February 2015 © 2014 The American Association of Suicidology DOI: 10.1111/sltb.12114

Family Centered Brief Intensive Treatment: A Pilot Study of an Outpatient Treatment for Acute Suicidal Ideation TRENA T. ANASTASIA, PHD, TERRESA HUMPHRIES-WADSWORTH, PHD, CAROLYN M. PEPPER, PHD, AND TIMOTHY M. PEARSON, PHD

Family Centered Brief Intensive Treatment (FC BIT), a hospital diversion treatment program for individuals with acute suicidal ideation, was developed to treat suicidal clients and their families. Individuals who met criteria for hospitalization were treated as outpatients using FC BIT (n = 19) or an intensive outpatient treatment without the family component (IOP; n = 24). Clients receiving FC BIT identified family members or supportive others to participate in therapy. FC BIT clients had significantly greater improvement at the end of treatment compared to IOP clients on measures of depression, hopelessness, and suicidality. Further research is needed to test the efficacy of FC BIT. In 2007, there were 34,598 documented deaths by suicide in the United States. Suicide is the tenth leading cause of death in the United States with 11.3 deaths per 100,000 (CDC, 2005-2010). Suicide death rates vary by region, with Alaska and the upper western states having the highest rates (McIntosh, 2010). These states are sparsely populated and underserved by mental health providers (e.g., Size, 2002). Inpatient psychiatric facilities in particular are rare or require significant travel time. Current suicide treatment protocols have changed in TRENA T. ANASTASIA, QDG Consulting, Fort Collins, CO, USA; TERRESA HUMPHRIESWADSWORTH, Associates in Counseling and Therapy Services, Cody, WY, USA; CAROLYN M. PEPPER and TIMOTHY M. PEARSON, University of Wyoming, Laramie, WY, USA. This research was funded in part by the Wyoming Department of Health and the Substance Abuse and Mental Health and Services Administration (Garrett Lee Smith Suicide Prevention Initiative). Address correspondence to C. M. Pepper, University of Wyoming, Dept. of Psychology 3415, 1000 E. University Ave., Laramie, WY 82071;; E-mail: [email protected]

response to both managed care and empirical studies. Three- to four-day hospital stays with outpatient follow-up are the new standard, as opposed to extended hospitalization (Jobes, Rudd, Overholser, & Joiner, 2008). In addition, there has been a shift toward identifying warning signs of suicide, including hopelessness, rage, reckless behavior, a feeling of being trapped, increased substance abuse, social withdrawal, anxiety/agitation, dramatic mood change, and/or feelings of purposelessness (Rudd et al., 2006). Effective treatment procedures include developing new cognitive and behavioral skills for the patient and formulating plans if suicidal thoughts resurface, which rely on patient input (Jobes et al., 2008). The prevailing suicide theories suggest there should be a role for family and important others in suicide treatment. Theories around social integration, psychache, burdensomeness, alienation, and hopelessness demonstrate the need to build connections throughout the recovery process (Beck, Steer, Kovacs, & Garrison, 1985; Hassan, 1998; Joiner, 2005; Shneidman, 1998). A few youth program models recognize the impor-

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tance of building connections within families (Diamond et al., 2010; Kerfoot, Harrington, & Dyer, 1995; Piacentini, Rotheram-Borus, & Cantwell, 1995). These programs seek to decrease stress on patients by reducing familial conflicts, strengthening family coping mechanisms, and reframing interactions to make the family a supportive element in the youthful patient’s life. Traditionally, treatment for suicidal ideation has required the individual with the fewest resources to make the most change. In addition, the supportive others who have worried intensely about the individual find relief in hospitalization, believing that care is now out of their hands and that their loved one would not be released from the hospital unless he/she was well. However, individuals released from hospitalization are still in need of help. Supportive others are exhausted from caregiving and in need of support themselves. Using findings in the literature, a treatment program that capitalizes on the importance of supportive others in the treatment of suicidal patients was developed to reduce the burden on the individual and provide assistance to the exhausted support system. In developing the treatment protocol, 11 goals were established: (1) avoid hospitalization and associated stigma; (2) reduce relapse; (3) strengthen the natural support system; (4) improve “family” functioning; (5) reduce anxiety; (6) decrease depression/dysphoria; (7) decrease stigma of seeking treatment; (8) decrease or eliminate suicidal ideation; (9) decrease hopelessness; (10) shorten recovery time; and (11) reduce costs associated with out of area treatment (Humphries-Wadsworth, 2012). Family Centered Brief Intensive Treatment (FC BIT) is an intensive outpatient treatment for the client and his/her family (one or more supportive others identified by the client) that is used as an alternative for patients who qualify for hospitalization due to suicidal ideation. FC BIT is based on systemic family therapy. In working with patients with suicidal ideation, the goal of FC BIT is to stabilize the individual and start the client on the path to long-term

79 wellness while also keeping him/her in the community. The initial session is attended by the client and family or friends. The primary goals of the session, aside from orientation to the therapy, are to assess level of suicidality and work with the individual and supportive others to collectively develop a safety plan. A case worker is often included in the therapy to assist with connecting to community resources. Subsequent sessions of FC BIT occur with the client and his or her family/supportive others (SO) at least three times per week for up to a maximum of 15 sessions per week. Locations for individual sessions are flexible and occur in a combination of agency-based or community-based locations such as the client’s home, school, or workplace to maximize community integration and to access services for both the client and their family/ supports. Each subsequent session includes an assessment of the client’s suicidality and a review of progress made on the plan developed in the initial session. Another goal of these sessions is to provide family/ SO therapy to increase appropriate connectivity, communication, problem solving, and perceived support within the system. A secondary goal of subsequent sessions is to increase linkages with community supports via the case manager, as needed. The current investigation was a pilot study of FC BIT therapy for patients who qualified for admission to inpatient hospitalization based on their level of suicidality. Intensive outpatient therapy (IOP) without the family component served as a comparison treatment. The study was conducted in a small city in a rural area of the U.S. Mountain West region.

METHODS

Participants Participants included qualified suicidal patients (n = 46) who received either FC BIT therapy (n = 19) or intensive outpatient

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therapy (IOP; n = 24). No incentives were provided to the clients to allow for data inclusion. Three patients did not complete treatment. Patients were assessed as suicidal based on treatment as usual (TAU) screening by a trained therapist, and all were candidates for hospitalization based on TAU standards. Only participants who completed both preand post-test measures were included in the analyses. Due to missing data, numbers for specific analyses vary. The sample was 67.4% female with an average age of 35.5 (SD = 14.5) ranging from 12 to 63. Ten patients were aged 18 or younger. The group mostly identified as White (90.7%), with the remainder identifying as Hispanic. Measures The Beck Depression Inventory-Second Edition (BDI-II; Beck, Steer, & Brown, 1996) was used to measure levels of depressive symptoms. This self-report measure consists of 21 questions rated on a 0–3 scale. The BDI-II has excellent internal consistency (a = .92), test–retest reliability of .93, and construct validity correlations with older versions of the BDI of .93 (Beck et al., 1996). The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) was used to measure level of anxiety symptoms. The BAI consists of is 21 items rated on a 0–3 scale. The BAI has excellent internal consistency with psychiatric outpatients (Cronbach’s a = .92) and has adequate test– retest reliability of .75 (Beck et al., 1988). The Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974) consists of 20 true or false items designed to measure positive and negative beliefs about the future. Adequate internal reliability has been reported for the BHS across diverse clinical and nonclinical populations, with Kuder-Richarson-20s (KR-20) typically in the .80s and correlations with clinical ratings of hopelessness in the 0.70s (Beck & Steer, 1993). The Depression Hopelessness Suicide Screening Form (DHS; Mills & Kroner,

2004) is 39-item self-report measure. In a sample of male offenders in a medium-security institution, the measure demonstrated good internal consistency (Cronbach’s a = .87) and support for concurrent and construct validity (Mills & Kroner, 2004). The Daily Living Activities Inventory-20 (DLA-20) was used to measure functioning. This measure was designed as an assessment of DSM-IV Axis V Global Assessment of Functioning (GAF). High scores are indicative of higher functioning. The scale has demonstrated adequate internal consistency, interrater reliability, and criterion-related validity (Scott & Presmanes, 2001). This measure was re-administered at 90 days or treatment completion, whichever occurred first. Procedures After the initial mental health assessment to determine appropriate treatment protocol was completed, all patients completed the psychological inventories (BDI-II; BAI; BHS; DHS, and DLA-20) prior to the initial clinical assessment interview. Psychological instruments were administered at 2-week intervals throughout treatment. During the first 4 years of implementation, individuals presenting with acute suicidal ideation who met criteria for hospitalization were treated on an outpatient basis utilizing the Family Centered Brief Intensive Treatment (FC BIT) model or intensive outpatient therapy (IOP) without the family component depending on which therapist they were assigned. For FC BIT, clients identified family members or supportive others to participate in therapy. The IOP therapy was conducted by one therapist who followed the guidelines for FC BIT therapy with the exception of including family members or supportive others in the treatment. The IOP treatment was also administered on an outpatient basis with similar amounts and frequency of treatment. Clients received the FC BIT or IOP program until they reached a criterion

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where they were qualified for transfer to regular weekly outpatient treatment. Qualifications for discharge from the FC BIT program were: suicidal ideation was absent or low and has remained at a manageable level for 2 or more weeks, an increase in coping and/or problem solving was consistently demonstrated, decreased hopelessness, decreased need for three sessions a week for more than 2 weeks, increased perceived connectivity, and consensus by ALL participants to a change in treatment course.

RESULTS

Participants in the FC BIT and the IOP groups did not differ on baseline clinical measures. However, the FC BIT group was more racially diverse, v2 (df = 1) = 5.57, p = .018. Trends suggested the FC BIT group had a greater proportion of men, v2 (df = 1) = 3.40, p = .065, and that the FC BIT group was younger than the IOP group, t(41) = 1.84, p = .075. The two treatments were conducted to criteria described earlier. On average, the FC BIT treatment ended approximately 4 weeks earlier than the IOP treatment, t(26) = 3.05, p = 005. The groups were compared on outcome measures using repeated measures ANOVAs comparing treatment group (IOP or FC BIT) across time (pre- and post-test), examining the Group X Time Interaction (See Table 1). Strength of association indices (g2p ) is reported along with interpretations (i.e., .01 ≥ small, .06 ≥ medium, and .14 ≥ large; Sink & Stroh, 2006). Across all outcome measures, results indicated greater reductions in symptoms for the FC BIT group. A main effect was found for change in BDI, F(1, 26) = 76.58, p = .001, g2p = .75 (large effect), indicating improvement for both groups. A significant Group X Time interaction indicated greater reductions on BDI scores for the FC BIT group compared to the IOP group, F(1, 26) = 12.08, p = .002, g2p = .32

81 (large). Similarly, a main effect indicated significant reductions in BHS scores for both groups, F(1, 24) = 31.47, p = .001, g2p = .57 (large), with a significant interaction indicating greater reductions for the FC BIT group compared to the IOP group, F(1, 24) = 12. 05, p = .002, g2p = .33 (large). Main effects indicated improvements for both groups on BAI scores, F(1,19) = 56.11, p = .001, g2p = .75 (large), with a significant interaction showing greater improvement for the FC BIT group, F(1,24) = 7.82, p = .012, g2p = .29 (large). The same pattern was found for DHS with significant main effects, F(1,17) = 33.38, p = .000, g2p = .66 (large), and a significant interaction effect, F(1,17) = 6.89, p = .018, g2p = .29 (large). Finally, for GAF scores, a main effect of time was found demonstrating improvement across time, F(1, 31) = 28.24, p = .000, g2p = .48 (large), with a significant interaction indi-

TABLE 1

Means and Standard Deviations for Outcome Variables Pre-test M (SD) BDI FC BIT (n = IOP (n = 12) BHS FC BIT (n = IOP (n = 12) BAI FC BIT (n = IOP (n = 13) DHS FC BIT (n = IOP (n = 13) GAF FC BIT (n = IOP (n = 16)

Post-test M (SD)

14) 38.87 (10.13) 15.33 (10.91) 34.08 (15.36) 23.92 (14.34) 14) 15.43 ( 4.22) 11.58 ( 6.19)

7.64 ( 6.25) 9.75 ( 7.67)

8)

27.75 ( 8.40) 9.38 (6.46) 23.68 (14.05) 15.31 (12.47)

6)

31.67 (4.13) 25.92 (7.73)

16.50 (9.81) 20.23 (10.05)

17) 40.53 (14.78) 64.00 (15.93) 38.44 (7.46) 40.38 (7.80)

Note. BDI, Beck Depression Inventory; BHS, Beck Hopelessness Scale; BAI, Beck Anxiety Inventory; DHS, Depression Hopelessness Suicidality Scale. For all measures except GAF, higher scores indicate higher symptom levels.

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cating greater improvement for the FC BIT group, F(1, 31) = 20.28, p = .000, g2p = .40 (large). DISCUSSION AND FUTURE DIRECTIONS

Although both treatments were effective, the addition of the family-centered therapy components of the FC BIT treatment produced superior outcomes compared to the IOP. The consistent pattern of findings indicated that the FC BIT treatment produced lower scores on depression, anxiety, suicidality, and hopelessness. Clients in the FC BIT treatment also had better overall functioning compared to patients in the IOP post-treatment. This study can be viewed as a naturalistic study as the therapists did not follow standardized treatment manuals over a prescribed duration of sessions. The FC BIT and IOP treatments were conducted until patients met discharge criteria. On average, FC BIT patients reached the criteria 4 weeks earlier than the IOP group, suggesting that FC BIT treatment is more efficient. A chart review shows that only one FC BIT client has received any acute treat-

ment after completing the program. That individual checked him/herself into an inpatient unit for one night 2 years after completing FC BIT. Prior to receiving FC BIT, this individual had been in acute inpatient treatment on average every 6 months over a 7-year period. Further follow-up studies are needed. One weakness of the study was that all clients in the IOP group had the same therapist; thus, the differences between the groups could be a therapist effect. However, a subsequent investigation of the discharge charts of this therapist indicated that other clients on this therapist’s caseload improved at rates comparable to other therapists at the treatment site. These results must be viewed as preliminary as patients were not randomly assigned to treatment group. FC BIT appears to be an effective hospital diversion program. When compared to individually oriented intensive outpatient treatment, it is more effective at reducing depression, hopelessness, suicidality, and anxiety while improving patient functioning. In addition, this promising outpatient treatment avoids the prohibitive costs of hospitalization for suicidal patients.

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Family centered brief intensive treatment: a pilot study of an outpatient treatment for acute suicidal ideation.

Family Centered Brief Intensive Treatment (FC BIT), a hospital diversion treatment program for individuals with acute suicidal ideation, was developed...
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