Contributions of Cognitions, Psychological
Flexibility, and Therapeutic Alliance to Suicidal
Ideation in Psychiatric Inpatients
Although suicide treatment is an expanding area of research, there is rela-
tively less in the literature with respect to how speciﬁc vulnerabilities to suicide
are addressed by treatment. Utilizing measures of suicide cognitions, therapeu-
tic alliance, and psychological ﬂexibility, we compared their relative contribu-
tions 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 ﬂexibil-
ity 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 con-
ducted, 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.
Recent years have seen concerning trends in
rates of suicide in the United States, with
age-adjusted rates increasing 24% between
1999 and 2014 (Curtin, Warner, & Hede-
gaard, 2016). Clinical researchers have
therefore redoubled efforts to address sui-
cide risk among individuals with mental
health disorders, and major advances are
being seen (Ellis & Goldston, 2012). Thera-
pies with proven impact on suicidal behav-
iors via randomized trials include Dialectical
Behavior Therapy (Linehan et al., 2015) and
Mentalization-Based Therapy (Bateman &
Fonagy, 2008, 2009). More so, a growing
empirical literature also supports therapies
developed speciﬁcally to address suicidality.
These include Cognitive Therapy for Suici-
dal Patients (CT-SP; Wenzel, Brown, &
Beck, 2009), Brief Cognitive Behavioral
Therapy (brief CBT; Rudd et al., 2015), and
the Collaborative Assessment and Manage-
ment of Suicidality (CAMS; Jobes, 2016).
CT-SP applies the fundamentals of
cognitive therapy, but targets suicidal
behavior as the primary focus of treatment,
in contrast to conventional therapies that
approach suicide secondarily as a symptom
of a psychiatric disorder (Berk, Henriques,
, The Menninger
Clinic and University of Houston–Downtown,
Houston, TX, USA; T
College of Medicine and The Menninger Clinic,
Houston, TX, USA.
This research was supported in part by a
grant from the Hogg Foundation for Mental
Health. Opinions, interpretations, conclusions,
and recommendations are those of the authors
and are not necessarily endorsed by the Hogg
Foundation for Mental Health. The authors also
thank the Bernice Peltier Huber Charitable
Trust and the Menninger Clinic Foundation for
their support of this research.
Address correspondence to Thomas E.
Ellis, The Menninger Clinic, 12301 Main Street,
Houston, TX 77035; E-mail: tellis@menninger.
Suicide and Life-Threatening Behavior 48 (3) June 2018 271
© 2017 The American Association of Suicidology