Atlas›Domain II · Behavioural & cognitive›Guide 135
Guide II-135

Teachable Moment Brief Intervention

O'Connor, Comtois2015
A 34 · L 56 · M 109 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the single-session TMBI as described by O'Connor, Comtois et al. (2015, General Hospital Psychiatry 37:427–433), which was built on a treatment manual developed at a US Level 1 trauma centre (the authors' University of Washington affiliation suggests Harborview [uncertain]). It is supplemented by the 2018 Vanderbilt pilot RCT (O'Connor et al., Gen Hosp Psychiatry), in which psychiatry, social work and counselling staff delivered the same manual on medical/surgical and inpatient psychiatry units, and by O'Connor's conference description. The TMBI manual itself is not publicly available and is not drawn on. The step-level detail below therefore comes from the published descriptions plus clearly marked synthesis. [source: O'Connor et al. 2015 via PMC4558367; O'Connor et al. 2018 abstract; MDedge report] [uncertain: manual not seen]

The TMBI is a brief, single-session, collaborative psychological intervention. It is delivered at the bedside to people admitted to an acute medical or surgical setting (including ICU) after a medically serious suicide attempt. It adds to usual consultation-liaison care rather than replacing it. Its model of change is the teachable moment. The idea is adapted from McBride, Emmons and Lipkus's (2003) smoking-cessation model, in which a health-threatening "cueing event" briefly opens a person to change. The attempt and its medical aftermath can heighten emotion, sharpen how the person perceives the risks of continuing and the possible gains of changing, and bring clarity to their self-concept and social roles. The clinician uses this window. Together, clinician and patient work out, without shaming, why the attempt happened and what it cost and gained. They then turn what they find into a crisis plan and into motivation to engage with ongoing treatment. [source: O'Connor et al. 2015] In O'Connor's words, the aim is to help patients "wrap their head around what happened in a nonshaming way at a sensitive time." [source: MDedge report of O'Connor's AAS presentation]

Lineage: the collaborative stance comes from CAMS (Jobes 2006; Comtois et al. 2011), and the functional assessment from DBT's functional analysis of self-directed violence (Linehan 1993). The 2015 paper does not list motivational interviewing as part of the TMBI's basis; the codebook's "motivational elements" are not confirmed in the primary paper. [source: O'Connor et al. 2015] [uncertain]

2. Framework

Format. One individual session at the bedside. In the 2015 trial it lasted a mean of about 44 minutes (SD ~13); O'Connor describes 30–45 minutes as typical. [source: O'Connor et al. 2015; MDedge] Settings:

  • medical/surgical floor or ICU during the acute admission (2015, 2018);
  • inpatient psychiatry units (2018).

[source: O'Connor et al. 2015; 2018 abstract; NCT02414763 summary via plaintrial.com]

Who delivers it. Originally, the developer, a clinical psychologist. In the 2018 pilot, staff trained on the manual from psychiatry, social work and counselling, who achieved similar adherence ratings. [source: 2018 abstract] Fidelity was checked by a second clinician (in 2015, the second author, K. A. Comtois) reviewing audio-recorded sessions against an adherence measure. [source: 2015] Formal training requirements are not published. [uncertain]

Place in the care pathway. Usual care (psychiatric consultation, risk assessment, diagnosis, disposition planning, possible psychiatric admission, community clinic referral) continues alongside. The developers observed that usual care concentrated on keeping the patient safe and managing risk in the short term. It did not intervene directly on the specific drivers of the attempt, such as perceived burdensomeness, isolation or emotion dysregulation. The TMBI is meant to fill that gap. [source: 2015] O'Connor calls it a "drop in the ocean" of the treatment the person will later need. [source: MDedge]

Session structure. The published sequence of components is as follows. [source: 2015; MDedge]

  1. Rapport building. Goal: a collaborative, non-shaming working relationship.
  2. Functional assessment of the attempt. Goal: the patient discovers the specific factors that led to the attempt and why it made sense at the time.
  3. Review of what was lost and gained. This includes the medical, financial, practical and social repercussions, and what the person has learned. Goal: sharper perception of risks and of the positive outcomes of change.
  4. Self-concept and social role. Goal: awareness of how the attempt affected supports, roles and plans for the future.
  5. One-page worksheet and crisis response plan. Goal: a written summary of the factors identified, short-term coping strategies, and longer-term treatment planning.
  6. Linkage discussion. Goal: commitment to outpatient mental health care, and to inpatient psychiatric care where appropriate.

Intended endpoint of the session. The patient moves toward:

  • deciding to reject suicide and actively address the problems behind the attempt;
  • more hope, self-acceptance and insight;
  • readiness to engage in forthcoming treatment and to reconnect with supports.

[source: 2015]

Criteria for starting. The patient must be medically able to take part. In the trials, timing was adjusted around imminent surgery or altered mental status, and patients who were too cognitively impaired were excluded. The session took place the same day as the research baseline interview, before discharge. [source: 2015] Being referred by the psychiatric consultation service after a confirmed suicide attempt was the entry route. [source: 2015]

Criteria for moving between components. None are published. [uncertain] Working rules [synthesis]:

  • Move from rapport to the functional assessment once the patient is willing to talk about the attempt in their own words.
  • Move to loss/gain once a coherent, patient-endorsed account exists of what led up to the attempt and what it was meant to achieve.
  • Move to the crisis plan once at least one modifiable driver has been named.
  • Move to linkage once the plan contains something the patient endorses as useful.
  • If time or the patient's stamina runs short, compress the earlier steps rather than drop the crisis plan and the linkage discussion.

Follow-up. The trials' 1-, 3- and 12-month contacts were research assessments, not part of the intervention. [source: 2015; 2018; NCT02414763]

3. Guiding principles

  • Use the window. Practical meaning: deliver the session during the admission, while the attempt is fresh and its consequences are visible; do not defer it to outpatient care. [source: 2015; MDedge]
  • Collaborative, not expert-led (from CAMS). Practical meaning: the patient is the authority on their own attempt. You guide discovery rather than lecture about why people attempt suicide. [source: 2015]
  • Overtly non-shaming. Practical meaning: name the attempt plainly and without judgement, and never moralise. The 2015 paper calls the stance "overtly non-shaming". [source: 2015; MDedge]
  • The attempt had a function (from DBT). Practical meaning: validate both the internal and the external motivations, and accept that death may not have been the only goal. Ask what the attempt was meant to solve. [source: 2015]
  • Context first. Practical meaning: understand the attempt within the person's circumstances. O'Connor: it is "all about the context." [source: MDedge]
  • Honesty about consequences, without judgement. Practical meaning: review real costs (injury, bills, hospitalisation, missed obligations) alongside what the attempt gained, and do not catastrophise or minimise. [source: 2015]
  • Target the drivers, not just safety. Practical meaning: aim at the factors behind the suicidal thinking (for example burdensomeness, isolation, emotion dysregulation), which usual care rarely addresses directly. [source: 2015]
  • Turn insight into a written plan. Practical meaning: end with a one-page record of the drivers and a crisis response plan the patient keeps. [source: 2015]
  • Bridge to treatment. Practical meaning: the session is a beginning, and its job is to raise readiness for the treatment that follows and to connect the patient to it. [source: 2015; 2018; MDedge]
  • Adjunct to usual care. Practical meaning: coordinate with the consultation-liaison team, which retains responsibility for risk assessment, legal holds and disposition. [source: 2015] [synthesis: the division of responsibility is inferred]
  • Deliverable across disciplines with fidelity. Practical meaning: follow the manual's component order and check adherence through recorded or observed review. [source: 2018 abstract; 2015]

4. Intervention inventory

The published sources name six components (rapport, functional assessment, loss/gain review, self-concept/social role, worksheet plus crisis response plan, linkage). Below, validation is given its own entry because the paper treats it as a distinct function. A preparation step is added, built from the trials' procedures and marked as such. The papers do not give scripted steps. The step lists below are the published component content (tagged [source]) expanded into in-session actions; anything beyond what the papers state is tagged [synthesis]. All example language is illustrative and is not the manual's wording.

4.1 Bedside readiness check and framing (pre-session)

  • Purpose / when: Before starting, confirm that the patient can take part, that the timing fits around medical care, and that the consultation-liaison team is aligned. In the trials, sessions were timed around imminent surgery and altered mental status, and patients too cognitively impaired to take part were not enrolled. [source: 2015]
  • Steps:
    1. Check with the primary team and nurse:
      • level of sedation, pain control and delirium screen;
      • any planned procedures;
      • the expected discharge date.
      [synthesis]
    2. Confirm with the psychiatric consultation service that risk assessment and disposition are being handled by them, and agree how you will pass on any new risk information. [synthesis]
    3. Arrange privacy: ask visitors to step out, close the curtain or door, and silence the TV. Ask whether a sitter or security officer is required to stay, and position yourself so you can talk at eye level. [synthesis]
    4. Introduce yourself and your role. Explain that this is a one-time conversation of about 30–45 minutes, separate from the risk assessment, about making sense of what happened and planning next steps. Obtain the patient's agreement. [source: session length, 2015/MDedge] [synthesis: wording of the framing]
  • Example language (illustrative): "I'm not here to decide where you go after the hospital; the psychiatry team does that. I'm here, if you're willing, to spend about half an hour helping you make sense of what happened and figure out what might help from here."
  • Watch for:
    • drowsiness, confusion or fluctuating attention (defer the session);
    • severe pain or nausea;
    • a hostile or tearful refusal (respect it and offer a later time);
    • an imminent discharge (prioritise and compress the session; see 5).
    [synthesis]

4.2 Rapport building

  • Purpose / when: Opens every session. It establishes the CAMS-style collaborative relationship that the rest of the session depends on. [source: 2015] The paper names this component but does not describe how it is done. [uncertain]
  • Steps: [synthesis, consistent with the CAMS stance cited in 2015]
    1. Start with the person, not the attempt: ask how they are feeling physically, what the admission has been like, and what they have been told.
    2. Acknowledge the strain of the situation: being in hospital, possibly under a hold, possibly having had several people ask about the attempt already.
    3. Ask permission to talk about the attempt, and make clear that you want to understand it, not judge it.
    4. Signal shared work: "we" language, sitting alongside rather than over the bed, and offering the patient control over pace and what to discuss.
  • Example language (illustrative): "A lot of people have probably asked you the same questions since you got here. I'd like to do something a bit different: really understand how things got to that point, from your side. Would that be OK?"
  • Watch for: Rapport is sufficient when the patient begins telling the story in their own words, with some detail, rather than answering in a yes/no style. Signs it is not yet there: guarded answers, "I already told the doctor," or minimising ("it was stupid, it's done"). [synthesis]

4.3 Functional assessment of the attempt (guided discovery)

  • Purpose / when: This is the core component. The clinician leads the patient through a discovery process that identifies the specific factors behind the attempt and how the attempt made sense to them at the time. It draws on DBT's functional analysis of self-directed violence, and it is explicitly not a psychoeducational talk in which the therapist is the expert. [source: 2015; MDedge: what drove the attempt and why it seemed to make sense]
  • Steps: The 2015 paper does not list the categories of the functional analysis. [uncertain] The sequence below follows the standard DBT functional-analysis structure (Linehan 1993), adapted to a single bedside session. [synthesis]
    1. Choose the target. The target is the attempt itself. Ask the patient to describe it, then go back in time.
    2. Vulnerabilities: what had been building over the preceding days and weeks. For example, sleep, substance use, pain, conflict, losses, finances, isolation, feeling a burden.
    3. Prompting event: what happened on the day that set things moving.
    4. Links in the chain: ask in order about thoughts, emotions, body sensations, actions and the actions of other people, up to the point of the decision.
    5. The point of decision: what the patient was thinking when suicide seemed like the answer, and what the patient hoped would happen. This includes outcomes other than death, such as relief, escape, stopping the pain, or communicating something.
    6. Immediate aftermath: what happened next and how they came to be in hospital. Keep means detail to what is needed to understand the sequence. Do not elicit method specifics beyond that.
    7. Summarise the chain back in the patient's words and ask them to correct it.
    8. Mark modifiable points. Note the two or three links where something different could have changed the outcome. These feed the worksheet and plan (4.7, 4.8).
  • Example language (illustrative):
    • "Let's slow it down. Going back a few days before, what was already weighing on you?"
    • "And when that text came in, what went through your mind?"
    • "At that moment, what were you hoping would happen?"
  • Watch for:
    • Working: the patient starts to see a sequence they had not seen before ("I didn't realise how much the drinking set it up"), names their own drivers, and the account becomes more specific.
    • Not working: the patient gives a one-line explanation ("I just snapped"); gently ask for more detail.
    • Acute distress while recounting: see 5. The papers do not discuss this. [synthesis]

4.4 Validating the function of the attempt

  • Purpose / when: Runs through the functional assessment. It validates both the internal motivations (for example, ending unbearable emotion) and the external ones (for example, escaping a situation, affecting others), and it acknowledges that death may not have been the only aim. The purpose is to reduce shame and to make the attempt understandable, and therefore changeable. [source: 2015]
  • Steps: [synthesis]
    1. When the patient names a motivation, reflect that it made sense given what they were facing.
    2. Separate the need from the behaviour: the need was valid, and the method carried enormous costs.
    3. If the patient expresses mixed aims ("I wanted to die, but I also wanted them to see"), validate the mixture without forcing them to choose one.
    4. Avoid both shaming ("how could you") and endorsing suicide as a reasonable solution.
  • Example language (illustrative): "Given how trapped you felt, it makes sense you were desperate for a way out. What I'd like us to look at is whether there are other ways out that don't cost you this much."
  • Watch for:
    • Visible relief or less defensiveness after validation shows it is working.
    • If the patient hears validation as permission ("so you agree it was the only option"), clarify that you understand the need, not the solution. [synthesis]

4.5 Loss/gain review (what was lost, what was gained, what was learned)

  • Purpose / when: After the functional assessment. This is a non-judgmental review of what the attempt cost and what it gained, to heighten the patient's perception of risk and of the positive outcomes of change. [source: 2015] O'Connor also describes asking what the patient has learned. [source: MDedge]
  • Steps:
    1. Ask what the attempt achieved, including any short-term relief or changes in how others responded. [source: 2015 — gains]
    2. Review the costs, letting the patient generate them first and then prompting for any that are missing. The costs listed in the paper are:
      • physical injury or impairment;
      • medical bills;
      • the likelihood of (psychiatric) hospitalisation;
      • time away from work, school, caregiving and other community obligations.
      [source: 2015]
    3. Include social costs and gains: how relationships were affected. [source: 2015]
    4. Ask what the patient takes from this: what they now know about themselves and their situation. [source: MDedge]
    5. Summarise the balance in the patient's own words. [synthesis]
  • Example language (illustrative):
    • "What, if anything, did the attempt change for you?"
    • "And what has it cost: your body, money, time, the people around you?"
    • "Looking at all of that, what do you take away from it?"
  • Watch for:
    • Working: the patient describes the costs as reasons to do things differently. Hope or determination statements count here, such as "I don't want to put my kids through that again."
    • Risk signals: the patient says the gains were real and there were no costs, or says the only problem is that they survived. Treat this as active risk: flag it to the consult team and see 5. [synthesis]
    • Shame spiral: the cost review is turning into self-attack ("I'm such a burden, look at the bills"). Pause and re-validate (4.4). [synthesis]

4.6 Self-concept and social role exploration

  • Purpose / when: Follows the loss/gain review. It aims to heighten awareness of how the attempt has affected the person's view of themselves, their support network and their plans for the future. This draws on the third mechanism of the teachable-moment model, clarity about self-concept and social role. [source: 2015] The paper's example is a patient who saw his family in tears after a self-inflicted injury and concluded he had made the wrong choice. [source: 2015]
  • Steps: [synthesis, built on the stated aim]
    1. Ask how the people close to them have responded since the attempt: visits, calls, conversations.
    2. Ask which roles matter to them (parent, partner, worker, friend, carer, member of a faith community), and how the attempt and recovery affect those roles.
    3. Ask about plans and goals for the future that existed before the attempt, and which of them are still wanted.
    4. Gently explore beliefs about being a burden or not belonging. The 2015 paper names burdensomeness and isolation as typical unaddressed drivers. Test those beliefs against what has actually happened since admission.
    5. Link any identified role or relationship to a reason for staying alive and engaging in treatment. The 2015 trial measured reasons for living as an outcome, but linking them to the session in this way is synthesis.
  • Example language (illustrative):
    • "You said you thought everyone would be better off. What have you noticed in how your sister has been since she got here?"
    • "Who do you want to be for your kids over the next year?"
  • Watch for:
    • Working: the patient revises a belief about being a burden, or names a person or role they want to stay alive for.
    • Caution: family responses may have been angry or rejecting. Do not over-sell reconnection; acknowledge the hurt and look for any other source of belonging. [synthesis]

4.7 One-page worksheet of identified factors

  • Purpose / when: Toward the end of the session. It records, on a single page, the factors the patient identified as underlying their suicidal ideation and attempt, so the insight leaves the room with them. [source: 2015] The worksheet itself has not been published. Its layout is unknown and it is not reproduced here. [uncertain]
  • Steps: [synthesis]
    1. Write the drivers from 4.3–4.6 in the patient's own words. These include the vulnerabilities, the prompting event, the key thoughts and feelings, and what the attempt was meant to achieve.
    2. Ask the patient to check and edit the list, and to star the factors they most want to work on.
    3. Note which items will go to the crisis plan (short-term) and which to treatment (longer-term).
    4. Give the patient the original or a copy, and with consent share it with the next provider.
  • Example language (illustrative): "Let's get down on paper what we've worked out together, in your words, so you and whoever you see next don't have to start from scratch."
  • Watch for: The patient recognises the list as theirs and, ideally, corrects your wording. A list the patient merely tolerates suggests the functional assessment was clinician-driven; revisit it briefly. [synthesis]

4.8 Crisis response plan (short-term coping and longer-term treatment planning)

  • Purpose / when: Completed on the same one-page worksheet. It turns the identified factors into a plan with two parts: short-term coping strategies for future crises, and longer-term treatment planning. [source: 2015] The paper does not specify the plan's headings. [uncertain]
  • Steps: The structure below follows common crisis-response and safety-planning practice; it is not taken from the TMBI manual. [synthesis]
    1. Warning signs. Using the chain from 4.3, name the personal warning signs: thoughts, feelings, situations or behaviours that came before the attempt.
    2. Self-coping. List two or three things the patient can do alone to get through the urge or the emotion, chosen to target the specific links in their chain. For example, if alcohol was a vulnerability, plan for reducing or avoiding it during crises.
    3. People and places. List people and places that help with distraction or support, and who they could tell about the plan.
    4. Professional and crisis contacts. Include the follow-up clinic, the after-hours line, the national crisis line (988 in the US) and emergency services.
    5. Lethal-means counselling. Discuss storage away from the home or locked storage of firearms, and limiting medication supplies, with family involvement where appropriate. This is standard post-attempt practice and is not described as a TMBI component; keep the discussion to storage and removal. [synthesis]
    6. Longer-term targets. Note which drivers from the worksheet need ongoing treatment, such as depression, substance use, relationship conflict or emotion regulation.
    7. Rehearse briefly: "If the same thing happened next month, what's the first thing you'd do?"
  • Example language (illustrative): "If you start noticing that 'nothing's going to change' feeling again, what's one thing you could do in the first ten minutes?"
  • Watch for:
    • Working: the strategies are specific, matched to the patient's own chain, and judged by the patient as doable.
    • Weak: a plan that is generic or clinician-written; a patient who cannot name a single contact; a patient who rejects every option. Any of these leads into 4.9 and needs flagging to the team. [synthesis]

4.9 Linkage discussion

  • Purpose / when: This closes the session. It discusses connecting to outpatient mental health care and, when appropriate, engaging in inpatient psychiatric care to resolve the problems underlying the attempt. It aims at readiness to engage in forthcoming treatment and reconnection with supports. [source: 2015] In the 2018 pilot, the TMBI group were more likely to maintain a positive trajectory in motivation and engagement with mental health services. [source: 2018 abstract]
  • Steps:
    1. Connect the starred drivers on the worksheet to what treatment can offer. [synthesis]
    2. Elicit the patient's own reasons for engaging and their concerns about engaging (cost, stigma, past bad experiences, transport). [synthesis]
    3. If psychiatric admission is planned, frame it as continuing this work rather than as a punishment. [source: 2015, inpatient care as appropriate] [synthesis: framing]
    4. Agree the concrete next step: the named service, how the referral will be made, and who will make the first contact. Coordinate with the consult team's disposition plan. [synthesis]
    5. Close by summarising what the patient discovered, and thank them. [synthesis]
  • Example language (illustrative):
    • "Of everything on this sheet, what would you most want help with once you're out of here?"
    • "What might get in the way of you getting to that first appointment?"
  • Watch for: Commitment talk about specific services and willingness to sign releases show it is working. If the patient says yes to everything but seems flat, check what they actually intend. [synthesis]

5. Handling problems

The published sources record only a few practical difficulties:

  • discharge before the session could happen;
  • cognitive impairment;
  • a participant too distressed by the baseline interview to continue;
  • a referred patient later judged not to have made a suicide attempt;
  • patients who regretted surviving;
  • low baseline readiness, which the authors describe as the teachable moment being "under-stimulated".

[source: 2015] How the developers handled these in session is not described. Everything below that goes beyond those facts is [synthesis].

  • Medically unfit, sedated or delirious.
    • [source: 2015] Defer the session, as the trials did around surgery and altered mental status.
    • [synthesis] Recheck daily with nursing staff. If the patient is lucid only for short windows, split the session into two short visits: rapport plus functional assessment, then plan plus linkage. Keep the component order. Splitting the session is a departure from the single-session format; note it.
  • Imminent discharge.
    • [source: 2015] Patients were lost when discharged before consent.
    • [synthesis] Find out the discharge plan early. If only 15–20 minutes are available, compress the session: a brief functional assessment, then the worksheet, crisis plan and linkage. Do not drop the crisis plan or the linkage discussion.
  • Too distressed or overwhelmed while recounting the attempt.
    • [source: 2015] One trial participant was too distressed by the baseline interview to continue.
    • [synthesis] Slow the pace, shift from detail to summary, and offer grounding (orient to the room, breathing at the patient's own pace). Offer to stop. If the patient stops, close with at least a minimal crisis plan and tell the consult team and nurse. Do not push through to finish the chain.
  • The patient wishes they had died, or is angry at being saved.
    • [source: 2015] At least one such patient was enrolled; the authors suspect others declined. Handling is not described.
    • [synthesis] Validate the anger and despair without arguing. Explore what death was meant to solve (4.3, 4.4). Look for even small ambivalence ("part of you agreed to talk to me"). Treat ongoing intent as current high risk and inform the consult team the same day, since it bears on observation level and disposition. Lower the goal to understanding plus a minimal plan rather than "rejecting suicide".
  • The patient denies or minimises the attempt ("it was an accident", "I just wanted to sleep").
    • [source: 2015] One participant was later judged not to have made an attempt, so the classification itself can be wrong.
    • [synthesis] Do not argue about the label. Run the functional assessment on "what happened that day" and the loss/gain review on the event, and ask the consult team to reassess intent if your account differs from the chart.
  • Low readiness, flat or perfunctory engagement.
    • [source: 2015] The authors note wide variation in readiness at baseline.
    • [synthesis] Spend longer on the cost review and on self-concept and social role (4.5, 4.6), the components meant to stimulate the teachable moment. Ask scaling questions about how important change is and how confident the patient feels; these are borrowed from MI and are not listed as TMBI components. Accept a small commitment, such as one appointment.
  • Shame and self-attack. [synthesis] This is common during the cost review. Return to validating the function of the attempt (4.4). Separate the person from the act. Point out that being able to look at it at all is a strength.
  • Rupture: "You're just another person asking the same questions", suspicion that the session affects the legal hold, or feeling interrogated. [synthesis]
    • Name it and apologise for adding to the burden.
    • Clarify what you do and do not decide.
    • Hand back control ("we can stop or go at your pace").
    • Shift from questions to reflections.
  • Privacy problems: visitors, roommates, sitters, staff interruptions. [synthesis]
    • Negotiate privacy before starting.
    • If a sitter must stay, acknowledge them openly.
    • Pause when staff interrupt and resume with a one-line summary.
    • With consent, family can be brought in for the crisis-plan and means-safety portion only.
  • Ongoing or newly disclosed risk during the session. The 2015 paper places risk assessment and disposition with usual consultation-liaison care. [source: 2015] [synthesis]
    • Pass any new intent, plan, access to means or new information to that team the same day.
    • Do not let the TMBI stand in for a risk assessment.
    • Include lethal-means counselling (storage and removal) in the plan.
  • Non-adherence after discharge. [synthesis] The TMBI as published has no follow-up contacts; the trial calls were research assessments. Strengthen the hand-off instead:
    • a booked appointment rather than a phone number;
    • consent to share the worksheet;
    • where your service allows, a caring-contact or follow-up call.
    Caring contacts are a separate intervention, not part of the TMBI.
  • Cognitive or communication limits (brain injury after hanging or overdose, intubation recently removed, interpreter needed). [synthesis] Use shorter questions, written prompts and more time. Use a professional interpreter rather than family members.
  • Interventionist fidelity and comfort. [source: 2015; 2018] Adherence was monitored through review of recorded sessions. [synthesis] Get supervision from someone experienced in CAMS or DBT. Watch for drifting back into a risk-assessment interview or into psychoeducation, which the developers contrast with the TMBI's discovery stance.

Sources

Sources:

Articles and books cited:

  • O'Connor SS, Comtois KA, Wang J, Russo J, Peterson R, Lapping-Carr L, Zatzick D. (2015). The development and implementation of a brief intervention for medically admitted suicide attempt survivors. General Hospital Psychiatry, 37(5), 427–433. doi:10.1016/j.genhosppsych.2015.05.001
  • O'Connor SS, McClay MM, Choudhry S, Shields AD, Carlson R, Alonso Y, Nicolson SE. (2018). Pilot randomized clinical trial of the Teachable Moment Brief Intervention for hospitalized suicide attempt survivors. General Hospital Psychiatry. doi:10.1016/j.genhosppsych.2018.08.001 (abstract only)
  • McBride CM, Emmons KM, Lipkus IM. (2003). Understanding the potential of teachable moments: the case of smoking cessation. Health Education Research, 18, 156–170. (cited, not drawn on)
  • Jobes DA. (2006). Managing Suicidal Risk: A Collaborative Approach. Guilford. (cited, not drawn on)
  • Linehan MM. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford. (cited, not drawn on)

[uncertain] Not drawn on:

  • the TMBI treatment manual, worksheet and adherence measure (unpublished);
  • the full text of the 2018 paper;
  • the registry records for the VA adaptation (NCT03533075) and the inpatient-setting trial (NCT03600532).
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