---

---

“Organized around real-world therapeutic dilemmas, this book is a valuable reference and guide for clinicians and graduate students across disciplines who seek to deepen their understanding of client-centered, recovery-focused care for those navigating suicide risk. Readers will benefit from the actionable tools and compelling clinical vignettes, and from the emphasis on therapist self-awareness, alliance repair, and fostering authentic engagement—critical competencies for effective suicide treatment. Blending clinical wisdom with empirical rigor, this book will inspire and facilitate discussions around complex and nuanced decision making, risk assessment, alliance management, and client ownership of recovery.”

—Jennifer J. Muehlenkamp, PhD, Department of Psychology, University of Wisconsin–Eau Claire


“This 'must-read' book addresses the practical problems, countertransferences, and pressures that busy clinicians struggle with when working with suicidal patients. It provides solutions and—perhaps more important—hope and optimism. The book is organized around 18 scenarios that are familiar to all experienced clinicians, and suggests pragmatic techniques for helping patients move from simply managing their painful symptoms to recovery.”

—Richard F. Summers, MD, Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania


“This unique book succeeds in offering an accessible, evidence-based framework for understanding and intervening with clients with suicidal ideation. Regardless of one's theoretical orientation, the tools and principles provided in this book are practical, adaptable, and deeply human. Clinicians are equipped with clear strategies to engage suicidal clients meaningfully and effectively. This book is essential reading for all professionals—from trainees to seasoned clinicians—seeking to expand their therapeutic toolkits and offer hope to clients in their darkest moments.”

—Patrick Luyten, PhD, Faculty of Psychology and Educational Sciences, University of Leuven, Belgium; Research Department of Clinical, Educational and Health Psychology, University College London, United Kingdom


“This book is a unique, important, and remarkably impactful contribution to the area of clinical practice that is arguably the most anxiety provoking for providers. Clinicians are often at a loss for how best to respond when a client experiencing a suicidal crisis voices unshakable hopelessness, despair, or rage. Gregory and Shields offer specific, expert guidance founded in an empirically informed model, vast experience, and clinical wisdom. The book helps clinicians develop and refine critical skills for facing the most challenging clinical scenarios. Not only will this book calm clinicians' anxiety, it also will improve the quality of care and help save lives.”

—M. David Rudd, PhD, ABPP, Distinguished University Professor of Psychology and President Emeritus, The University of Memphis

---

Table of Contents

I. Introduction and Overview

1. Suicide: From Chronic Illness to a Recovery Perspective

2. Introduction to Dynamic Deconstructive Psychotherapy

II. Dilemmas

- Dilemma 1. “I’m just here because of my parents, spouse, etc.” (for clients who are unmotivated to start treatment)

- Dilemma 2. “I just need to be put on the right medication for my ADHD, bipolar, etc.” (for clients who are seeking a quick fix instead of psychotherapy)

- Dilemma 3. “I don’t want to recover; I just want to die.” (for clients who are expressing suicidal intent in session)

- Dilemma 4. “I don’t have anything to talk about.” (for clients who are not actively participating in the treatment)

- Dilemma 5. “You are not qualified to be my therapist.” (for clients who have narcissistic or paranoid personality traits)

- Dilemma 6. “Nothing can help me; I need more help!” (for clients who are hopeless and desperate)

- Dilemma 7. “You don’t really care about me; it’s just your job!” (for clients who have antisocial or dependent personality traits)

- Dilemma 8. “Cannabis is the only thing that helps me.” (for clients who are using substances)

- Dilemma 9. “I want to work toward recovery, but I have a secret stash just in case.” (for clients who are holding onto suicide as a backup option)

- Dilemma 10. “I was too depressed to attend my appointment or do the things you wanted me to.” (for clients who are ambivalent about treatment or recovery)

- Dilemma 11. “I’m coming every week but nothing’s working.” (for clients who feel hopeless that they can get better well into treatment)

- Dilemma 12. “I’m not sure I can keep myself safe, but going to the hospital will just make things worse.” (for clients who feel unsafe but refuse to go to the hospital)

- Dilemma 13. Your client is in the emergency department after taking an overdose. (for clients who recently attempted suicide)

- Dilemma 14. “Why are you so rigid when people may need extra help?” (for clients who violate your boundaries)

- Dilemma 15. “How can you understand me when you haven’t gone through what I have?” (for clients who want a therapist with a similar race, ethnicity, gender, values, or background)

- Dilemma 16. “I thought I was getting better, but now I realize that I’m no better than when we started treatment.” (for clients who were progressing in treatment but are now regressing)

- Dilemma 17. “If you discharge me, I’m going to kill myself.” (for clients who are disengaged from treatment but are threatening suicide if you discharge them)

- Dilemma 18. “I am pregnant!” (for clients or therapists who become pregnant during the course of treatment)

III. Conclusion

Final Reflections

References

Index

---

About the Authors

Robert J. Gregory, MD, is SUNY Distinguished Service Professor in the Department of Psychiatry at the State University of New York Upstate Medical University. He is Founding Director of the Psychiatry High Risk Program (PHRP), a recovery-based outpatient treatment program for suicidal youth and adults, and developer of the PHRP's core treatment modality, Dynamic Deconstructive Psychotherapy. The PHRP has been designated as a best practice in suicide prevention and received a Psychiatric Services Achievement Award (Silver) from the American Psychiatric Association. Dr. Gregory has authored more than 70 articles and book chapters and does trainings nationally and internationally.

Rebecca J. Shields, DO, is a board-certified Child and Adolescent Psychiatrist and Assistant Professor in the Department of Psychiatry at the State University of New York Upstate Medical University. She serves as Co-Director of the Psychiatry High Risk Program (PHRP), where she oversees the adolescent program and provides training and clinical care in the PHRP's core treatment modality, Dynamic Deconstructive Psychotherapy. Dr. Shields has authored articles on recovery-based suicide prevention and the use of Dynamic Deconstructive Psychotherapy with adolescents.

---

Audience

Clinical psychologists, psychiatrists, clinical social workers, counselors, and psychiatric nurses.