Cognitive Behavioral Therapy Approaches for Chronic Suicidality.

This review provides an overview of research evidence from the past 5 years concerning cognitive behavioral therapy for suicide prevention. The authors then discuss the clinical implementation of this approach in patients with chronic suicidal behavior.

Psychodynamic Therapy: An Overview for Trainees and Their Teachers: Part 2-The Therapeutic Stance.

This second column in a series on psychodynamic therapy (PDT) offers an overview of concepts related to the therapeutic stance of PDT. It reviews resistance, components of the therapeutic relationship, and elements that constitute the therapeutic stance of PDT.

Afterword to "Through The Valley of the Shadow of Death. Journey Through Major Mental Illness as Experienced by a Mental Health PhD Candidate".

The author describes her struggle with depression and borderline personality disorder, self-harm, and suicidality. She first reviews the long years during which she did not respond to any of the numerous antidepressant medications that were prescribed. She then describes how she finally achieved healing and good functioning as a result of long-term caring psychotherapy in the context of a strong therapeutic relationship in combination with medications that were found to be effective for her symptoms.

Psychodynamic Therapy: An Overview for Trainees and Their Teachers: Part 1-The Basics.

This first column in a series on psychodynamic therapy (PDT) offers an overview of the basics required to understand and master the provision of PDT. It offers a way of understanding what patients struggle with when viewed through a psychodynamic lens and then examines evidence-based core elements of psychotherapy and PDT.

Psychotherapy and Artificial Intelligence.

This column explores the challenges involved in providing psychotherapy through artificial intelligence. It reviews artificial intelligence's capacity across schools of therapy to address relevant issues related to privacy, the use of technical interventions, and the therapeutic relationship.

Afterword to "When the Supervisor Needs a Supervisor: A Case-based Guide for Developing Psychotherapy Supervisors".

Supervision of psychotherapy is recognized as fundamental for attaining competency in psychotherapy. However, there is a lack of training in "best practices" of supervisory skills, and some supervisors may lack contemporary knowledge to support supervisees adequately. Training program leadership challenged by limited time and resources to provide supervisors with the necessary education and support can benefit from additional resources for developing psychotherapy supervisors. The authors present 3 core elements of navigating supervisory challenges: training, open dialogue in supervision, and a formal program-level process. Common issues in psychotherapy supervision are then presented in a case-based format. Reflection questions are included to provide an opportunity to consider a personal approach to the case, while specific guidance based on the literature addresses critical aspects of the case examples. Complex supervisory conflicts can challenge programs, but they are normative to the learning process and promote growth in our supervisors.

Finding Psychodynamic Psychiatry's Lost Generation.

This paper describes forces that have adversely affected the place of the psychodynamic perspective within psychiatric practice and training over the last generation. One effect of these forces has been to create a lost generation of psychiatrists with little knowledge or experience with psychodynamic treatment. The article addresses opportunities to reverse some of the detrimental effects of recent changes. The Residency Review Committee's introduction of a requirement that residents achieve a measurable level of competence in five schools of psychotherapy represents a major opportunity to influence psychiatric training and practice. The past and present work of the Committee on Psychotherapy by Psychiatrists (COPP) is summarized, including efforts to integrate and revise the five existing core competencies in psychotherapy into a "Y"-shaped model in a way that secures the future of psychodynamic therapy training in residencies. One existing unusual training opportunity with a central psychodynamic focus is described.

Afterword: Beyond Diagnosis to Mourning and the Meaning of Symptoms.

Reports of destructive behavior by military personnel after demobilization have become more frequent; however, the pathways that might lead these individuals to commit such acts are not clear enough. This column presents the case of a retired soldier who reported the onset of pyromania after military service, and the relationship between dissociation and reenactment of the trauma is discussed. The main conclusions are that psychotherapy of traumatized patients should focus on helping them create a verbal representation of the trauma and that integrating ceremonies and rituals into treatment is a possible and significant option.

A Verdict Overturned: Are We at Our Wit's End?

Despite the 2008 Mental Health Parity and Addiction Equity Act, access to psychotherapy through health insurance is quite limited. The 2019 landmark verdict in Wit v. United Behavioral Health offered hope of change. This column describes the recent overturning of the verdict in Wit v. United Behavioral Health, efforts by the Plaintiffs' attorneys to pursue a review by the entire 29-member United States Court of Appeals for the Ninth Circuit of the puzzling decision apparently based on a misunderstanding of the arguments of the case, and steps forward to implement the mental health parity law.

Do Patients With Treatment-resistant Disorders Recover?

This column describes the challenge posed by patients with treatment-resistant disorders. It then reviews a recently published study demonstrating that with adequate treatment and enough time-over a decade-even patients with conditions that were previously considered treatment-resistant and who have high degrees of comorbidity, suicide risk, and a significant number of prior hospitalizations can achieve full recovery in terms of measures of psychodynamic conflicts, symptoms, and overall functioning. These areas of improvement converge and thus appear to be linked, suggesting the transdiagnostic relevance of psychodynamic measures.

Medications, Genes, Environmental Stress, and Pursuit of Recovery.

This column summarizes the findings of 2 recent studies of interest to psychotherapists. One study reports that the use of antidepressant medication is not associated with long-term improvement in health-related quality of life, while the other finds that psychotic experiences in adolescents are more closely associated with environmental experiences than with genetic risk. The column discusses the implications of these studies for psychotherapists and for the field at large.

Afterword to "Working on the Frontlines From Home: Residents' Experiences With Telepsychiatry During the COVID-19 Pandemic".

The coronavirus disease 2019 (COVID-19) pandemic thrust health care professionals around the globe to the frontlines to care for those affected by this medical crisis. While many surgical and procedural medical subspecialties experienced drastic declines in patient visits during this time, the demand for psychiatric services was more stable. In response to statewide stay at home orders, third-year residents in the psychiatry outpatient clinic described in this article quickly transitioned to telepsychiatry to continue providing care to their patients. While providing care from home, these residents experienced a number of challenges that serve as important lessons for enhancing competence in telepsychiatry services.

Another Step Toward Implementing Mental Health Parity.

This column describes a recent $14.3 million settlement in a case brought against United Behavioral Health by the Department of Labor and New York State Attorney General Letitia James. United Behavioral Health agreed to stop 2 practices that were in violation of the Mental Health Parity and Addiction Equity Act. One of the practices involved systematic underpayment of nonphysician therapists and the other involved systematic use of targeted utilization review to end behavioral treatment after 20 sessions in a year.

Improving Access to Psychotherapy: Implications of Wit Versus United Behavioral Health.

This column summarizes the verdict in the federal class action known as Wit v United Behavioral Health (UBH)/Optum, highlighting the verdict's implications for increasing access to care, implementing the mental health parity law, and reducing health disparities. Achieving these results requires recognition of the verdict as more than simply a nice news story, but as a decision that actually offers individual clinicians, their professional organizations, as well as patients, families, and their consumer organizations, a powerful tool for implementing change if they take up the task of learning how to use it. The verdict applies to outpatient treatment, including psychotherapy, along with 2 other levels of care: intensive outpatient programs and residential treatment.

Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients.

This column explains the value of developing routine medical necessity letters to help patients maximize the likelihood of securing insurance approval for medically necessary services for the treatment of mental and substance use disorders, including psychotherapeutic treatment. The structure proposed for such medical necessity letters is based on the terms of the Mental Health Parity and Addiction Equity Act and the landmark verdict in the federal class action known as Wit v. United Behavioral Health/Optum.

The Mental Health Crisis in America: Recognizing Problems; Working Toward Solutions: Part 2. Offering Hope Through Engagement.

This column is the second in a series summarizing the 2-day Centennial Conference of the Austen Riggs Center. The conference framed problems in access to care and in the nature of the care being provided that are part of a mental health crisis in America, and then worked to propose solutions. This column addresses problems with the nature of care provided, proposing psychodynamic perspectives that offer hope through engagement. Such approaches play a role in "bending the curve" to improve mental health outcomes.

The Mental Health Crisis in America: Recognizing Problems; Working Toward Solutions: Part 3. Access to Care.

This column is the third in a series summarizing the 2-day Centennial Conference of the Austen Riggs Center. The conference framed problems in access to care and in the nature of care provided that are part of a mental health crisis in America and then worked to propose solutions. This column addresses problems with access to care and summarizes the conference's closing keynote by Peter Fonagy, PhD, OBE, addressing issues both of access to care and of the nature of care provided. These issues play roles in ultimately "bending the curve" to improve outcomes for those struggling with mental and substance use disorders.

Psychotherapy in the Post-COVID-19 Era.

This column anticipates challenges likely to be faced by psychotherapists and their patients after the coronavirus disease 2019 (COVID-19) pandemic subsides. It looks beyond the current impact of loneliness, isolation, thwarted belongingness, and loss toward the longer term impact of moral injury and blocked opportunities for mourning.

The Mental Health Crisis in America: Recognizing Problems; Working Toward Solutions: Part 1. Defining the Crisis.

This column is the first in a series summarizing the 2-day Centennial Conference of the Austen Riggs Center. The conference framed problems in access to care and in the nature of care provided that are part of a mental health crisis in America, and then worked to propose solutions. This column focuses on framing the problems and on beginning to address what it might take to "bend the curve" in mental health outcomes.

Improvement and recovery from suicidal and self-destructive phenomena in treatment-refractory disorders.

Long-term data about recovery from suicidal and self-destructive phenomena are limited. We examined these phenomena in a naturalistic, follow-along study of 226 adults with treatment-refractory disorders admitted at the Austen Riggs Center. Follow-along interviews systematically rated suicidal ideation, suicide attempts, self-mutilation, and other self-destructive phenomena. We identified vital status in 98.7%, finding 1 death by suicide. Among 79 who made at least 1 suicide attempt in the 6 months before admission, 61 (77.2%) were estimated to be free of suicidal acts by a median of 7.18 years. Self-mutilation and other self-destructive phenomena showed slightly longer times to recovery. Among 156 individuals with suicidal ideation, 79 (50.6%) attained sustained recovery at a median of 8.69 years. On average 2.9 to 5.2 years were required from the last observed self-destructive event to attain sustained recovery. Most participants showed significant improvement in suicidal phenomena, whereas between 50.6% and 77.2% attained sustained recoveries.