Cory Newman, PhD - Center for Cognitive Therapy, University of Pennsylvania Perelman School of Medicine
Suicide is a significant public health problem both at home and abroad, and therefore is an area of major importance for mental health intervention. Cognitive-behavioral interventions that specifically target suicidality are showing promise in significantly reducing potentially lethal self-directed violence in patients at high risk.
When patients present with suicidal ideation, intent, and/or recent self-harming behaviors, the clinician conducts a comprehensive suicide risk assessment (Bryan, 2015; Wenzel, Brown, & Beck, 2009). An assessment includes interviewing patients about their suicidal thoughts, observing their behavior directly, obtaining information from other pertinent sources (e.g., medical records, verbal reports from others, family history), and using psychometrically sound assessment inventories (several of which appear in Box 1).Box 1. Inventories to Assess Suicidality
The Beck Scale for Suicide Ideation (BSSI: Beck, Kovacs, & Weissman, 1979): The BSSI is an interview-based instrument that addresses multiple factors pertinent to a patient’s suicidality. The BSSI includes a section that inquires about the patient’s worst past episode of suicidality. This adds important information, as there is evidence that future risk for suicide is significantly linked to past severity of suicidality, even if the patient’s current risk level is low (Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999; Joiner, Steer, Brown, Beck, Petit, & Rudd 2003).
The Beck Hopelessness Scale (BHS: Beck, Weissman, Lester, & Trexler, 1974): The BHS is a 20-item “true-false” self-report inventory that assesses patients’ views of their future, with such items as, “I might as well give up because there is nothing I can do about making things better for myself.” Hopelessness has been shown to be a mediator between depression and suicidality, and has predictive validity for deaths by suicide (Brown, Jeglic, Henriques, & Beck, 2006).
The Beck Depression Inventory-II (BDI-II: Beck, Steer, & Brown, 1996): This 21-item self-report measure of the severity of depression contains items pertinent to hopelessness (#2) and suicidality (#9). When patients fill out the BDI-II at each session, therapists can eyeball these two scoring items for a quick, concise understanding of the patients’ current level of suicide risk, and can ask the patients to discuss their inventory responses as part of the session agenda.
The Columbia-Suicide Severity Rating Scale (C-SSRS: Posner et al., 2011): The C-SSRS is an interview-based scale measuring patients’ past and current suicidal ideation and behavior. It addresses the four constructs of severity, intensity, behavior, and lethality.
The Suicide Cognitions Scale (SCS: Bryan et al., 2014): The SCS is an 18-item self-report instrument. Patients rate their strength of belief in each item on a 0-5 Likert-type scale. The two main constructs underlying the items are the suicidal schemas of unbearability and unlovability.
If a patient presenting for treatment has previously engaged in self-directed violence, the clinician inquires about the patient’s level of intent (e.g., impulsive versus planned; communicating the need for help versus wanting to die), degree of lethality of the method used (e.g., taking several pills or superficially cutting one’s wrist, versus trying to hang oneself), presence and extent of actual physical injury, whether or not the suicide attempt was interrupted (and by whom), and situational context and triggers. It is also important to determine if the current suicide attempt was the first time or the latest in a historical pattern, as patients who have a history of multiple suicide attempts are particularly at risk (Joiner & Rudd, 2000).
It is also advisable to construct a chain analysis that includes the sequence of events precipitating the suicide attempt, the patient’s resultant thoughts, emotions, and behaviors, as well as the consequences (Brown, Wright, Thase, & Beck, 2012). This process assists in providing patients with valuable psycho-education about their vulnerabilities and related targets for intervention. In terms of ongoing treatment, therapists can explain to their patients that they will ask about their suicidal ideation, intentions, and behaviors as a routine part of each session, because they will need to be vigilant for emergent recurrences of increased risk.
Unlike the more traditional syndromal model that viewed patients’ suicidality as secondary to their psychiatric diagnoses, current cognitive-behavioral approaches directly assess and target the suicidality as a primary issue. Therapists examine the antecedent and consequent contextual influences as well as the patient’s belief systems that interact to initiate and maintain suicidal feelings and behaviors (Clemans, 2015). For example, the therapist may hypothesize that a patient receives negative reinforcement for cutting herself in that she provides herself with a temporary distraction from her emotional pain that she considers much worse. She may also receive some positive reinforcement for her self-harming behaviors when people close to her increase their demonstrations of care and concern. In another case, the therapist posits that the patient’s suicidal ideation and intent are congruent with his stated self-punitive belief “I am a bad person who doesn’t deserve to live.” When other people (including the therapist) give this patient support and positive feedback, he has great difficulty believing it, thus he appears to be unresponsive to help. Exploring such factors contributes greatly to the formulation of a cognitive-behavioral case conceptualization (see Kuyken, Padesky, & Dudley, 2009) that can increase the practitioner’s accurate empathy, and guide the construction of a treatment plan for the suicidal patient.
Cognitive Vulnerabilities Associated with Suicidality
A CBT approach to the assessment and treatment of suicidality pays close attention to the cognitive characteristics associated with suicide risk. For example, hopelessness has been found to be a significant factor in differentiating non-suicidal persons from those who are potentially at elevated risk for suicide (Beck, Brown, Berchick, Stewart, & Steer, 1990; Beck, Steer, Beck, & Newman, 1993; Beck, Steer, Kovacs, & Garrison, 1985; Brown, Beck, Steer, & Grisham, 2000; Brown, Jeglic, Henriques, & Beck, 2006; Smith, Alloy, & Abramson, 2006).
In addition to general hopelessness, there are specific beliefs that have been found to be related to suicide risk. For example, suicidal patients have a tendency to believe that they are unlovable, that their problems are unsolvable, that their pain is unbearable, and/or that they are a burden to others (Ellis & Rufino, 2015; Joiner et al., 2009; Peak et al., 2015).
Cognitive rigidity or inflexibility has also been identified as a characteristic in suicidal thinking (Miranda, Gallagher, Bauchner, Vaysman, & Marroquín, 2012; Miranda, Valderrama, Tsypes, Gadol, & Gallagher, 2013). Suicidal persons are prone to evaluating themselves and their lives in all-or-none terms. For example, situational self-reproach becomes blanket self-condemnation, and/or an adverse event seems inexorable and devastating.
Perfectionism is also a cognitive risk factor for suicide (Flett, Hewitt, & Heisel, 2014; O’Connor, 2007). “Morbid” perfectionism goes way beyond just a stubborn desire to get things right. It entails a patient’s internal demand to have things be “just so,” and to be punitive toward oneself, excessively concerned about others’ negative judgments, and angry at the world if things turn out differently. Within this mindset, the minor setbacks of everyday life become triggers for emotional crises, and larger disappointments become reasons to want to die (e.g., “If I don’t pass the Bar Exam this time, I will kill myself”).
It should be noted that the term “interventions” does not just mean “techniques,” as interventions are intertwined with and highly dependent upon the quality of the therapeutic relationship and case conceptualization (see Newman, 2015). Similarly, the term “interventions” goes beyond what transpires in the therapist’s office. It also refers to the patient’s homework assignments, in which they practice in everyday life what they learned in their CBT sessions. Homework assignments can also include self-help readings that supplement and are congruent with the treatment (e.g., Choosing to Live: How to Defeat Suicide Through Cognitive Therapy, Ellis & Newman, 1996). Several major areas of intervention are described below.
Safety Planning – “Safety planning” refers to formal methods for keeping suicidal patients safe between therapy sessions (Stanley & Brown, 2012; Wenzel et al., 2009). Safety planning entails the implementation of good, standard risk management methods, including identifying, promoting, and utilizing the patients’ interpersonal and intrapersonal resources. The typical components of outpatient risk management include increasing the frequency of sessions, scheduling between-session phone contacts, making arrangements for the patient to spend time in public places around other people (e.g., cafés, bookstores, parks, sporting or community events, malls) and/or with selected others who can provide some measure of oversight (e.g., friends, family, support group cohorts), and doing advance problem-solving to reduce the likelihood of the patient’s being in situations that might increase risk. The risk management methods above involve a strong interpersonal component, in which the patient is prepared to reach out to (and spend time with) others. Patients should have ready access to important contact information, including phone numbers for their practitioners and suicide hot lines. The interpersonal part of the safety plan can also be utilized to enact a lethal means restriction – that is to say that important people in the patient’s life are enlisted to help remove whatever poses a potential danger to the patient. For example, a trusted family member can take possession of the patient’s firearm(s) for safe storage (see Simon, 2007), or a person in the patient’s household can take charge of doling out the patient’s medications in small increments to lower the risk of deliberate overdose. When patients do not wish to give up their instruments of self-harm (e.g., firearms, razors, pills), the risk of a power struggle can be lowered by adopting a therapeutic negotiating style known as motivational interviewing (Miller & Rollnick, 2002), which can be utilized to take steps toward reducing access to lethal means (Britton, Bryan, & Valenstein, 2016).
The intrapersonal piece in safety planning has to do with the patient learning to spot early warning signs of increasing suicidality and being ready and agreeable to use the full array of self-help coping skills he or she is learning in CBT. The key self-help skills, which can be used at times of acute need as well as throughout a course of treatment and beyond, are described below.
Building Psychological Self-Help Skills – In order to help patients make therapeutic gains that will be well-maintained for the long term, CBT helps patients develop and practice durable psychological skills. Some of these interventions include, (1) developing hopefulness and reasons for living, (2) rationally responding to suicidogenic beliefs, (3) constructing a compassionate narrative of one’s own life, (4) creating a “hope kit,” (5) improving problem-solving, (6) engaging in activities that bring a sense of accomplishment and enjoyment, and (7) preparing for potential high-risk situations to prevent relapse (see Ellis & Newman, 1996; Wenzel et al., 2009).
Developing Hopefulness and Reasons for Living – CBT therapists validate their patients’ experiences of subjective emotional pain, but also invite them to consider ways in which this pain may be eased within the scope of an improved life and a more hopeful future. A simple, straightforward technique that can be very enlightening is discussing and writing the pros and cons of dying by suicide versus investing in living (Ellis & Newman, 1996; Jobes, 2006; Brown et al., 2012). This method gives patients overt permission to identify the “advantages” of suicide that they have already been dwelling upon, and to talk about the topic openly with the therapist (see Figure 1). Often there are obvious cognitive biases that are identified in the course of fleshing out the “pros of dying” (e.g., “My family will be better off if I kill myself”), and these beliefs can be subjected to rational responding (see below). Meanwhile, the therapist engages the patient in a process of considering the advantages of investing in life going forward, something that the patient may have been discounting or neglecting. A further application of this technique involves discussing the pros and cons of the patient’s living versus dying for the patient’s loved ones. Doing so often motivates patients to think about the well-being of their family and other important people in their lives as a deterrent to suicide.
Figure 1. Advantages/Disadvantages Analysis
Rationally Responding to Suicidogenic Beliefs – Suicidal patients are taught to identify their beliefs that potentially support their suicidal feelings and intentions, and to use cognitive restructuring techniques (see Newman, 2015) in an attempt to modify these dangerous beliefs. Many suicidal patients evince rigid, maladaptive beliefs that are not easy to relinquish. However, therapists try to create “reasonable doubt” in the minds of such patients about their notions (for example) that death is the only “solution” to their problems, or that they are so bad that they “deserve” to die. Rational responding is not the same thing as “thought replacement.” The more apt description is that rational responding plants seeds of hope that can sprout over time with the help of a strong therapeutic relationship. Patients are taught that it is not necessary for them to fully believe their own rational responses – it is progress in itself if they can simply generate more hopeful, more constructive beliefs that can be tested, or if they are willing to partially believe their therapist’s attempts at hopeful reframing. Even tentatively believed rational responses can gain greater acceptance over time, as other interventions take hold.
Constructing a Compassionate Narrative of One’s Own Life – In order to gain a broader perspective on their lives, to escape the “time trap” of being unduly focused on the pain of the moment, to improve specific autobiographical recall, and to imagine a better future, suicidal patients are encouraged to write a compassionate narrative of their lives. It is best if this technique is done in stages, across sessions, so that it can grow into a detailed, thorough story, and so that it can become a useful, ongoing homework assignment. An additional narrative can be added that describes positive possibilities for the future. For example, the patients can be asked to list three positive and/or interesting things they might experience each year going forward – things that they would miss if they were to die by suicide (see Ellis & Newman, 1996).
Creating a “Hope Kit” – A hope kit (see Wenzel et al., 2009) is a compilation of positive memorabilia that patients can store in a shoebox, a phone app, or a computer file. Once patients do the work of putting a hope kit together (an excellent homework assignment), they can continue to add to it as new events come up that serve as reminders about what is valuable in their lives. The contents of hope kits typically include such items as photos of happier times and events, birthday and greeting cards that the patient has received over the years, personal archives that represent success experiences (e.g., awards, certificates, congratulatory notes), and mementos from favored activities (e.g., trips, clubs, organizations). Additionally, patients can add emotionally significant and meaningful things they have produced, such as artwork, crafts, and writings, including the best examples of previous therapy homework assignments. Consistent with the information used in a safety plan, the hope kit can also include a list of important people in the patient’s life along with their contact information. The main purpose of the hope kit is to produce evidence that suicidal patients do indeed have important attachments to life, and to remind them why their existence is worth preserving and nurturing.
Improving Problem-Solving – Suicidal patients sometimes feel overwhelmed by life’s problems (and/or by their perceptions of life’s problems) and see no way out other than escaping from life itself. This is where therapists need to teach their patients basic problem-solving skills, including describing problems objectively, brainstorming solutions, weighing pros and cons, implementing chosen methods, evaluating the outcomes, and beginning the process with another problem (Nezu, Nezu, & D’Zurilla,2013). Even when patients have bona fide crises and hardships, therapists offer empathy along with a lesson in the benefits of doing “damage control” to begin to turn things around for the better. There is evidence that the subset of problem-solving known as social problem-solving (also called emotion-centered problem solving, see Nezu & Nezu, in press) – which pertains to interpersonal and emotional self-regulation skills – is particularly germane to suicidality in that deficiencies in this area are a risk factor (Nezu, Nezu, Stern, Greenfield, Diaz, & Hayes, 2017; Woods, 2018). Such findings suggest that treatment should teach patients to view their negative emotions and interpersonal concerns as problems that can be addressed constructively and with self-efficacy, rather than as indicators of uncontrollable, intolerable misery.
Engaging in Activities for Accomplishment and Enjoyment – Therapists help their patients brainstorm a list of activities in which to engage, particularly those that have the potential to be enjoyable and/or to provide a sense of accomplishment. Sometimes an excellent source of ideas for this list comes from a review of the things that the patient used to do and/or has been meaning to do. Deeply depressed patients are prone to minimizing the meaning or importance of such activities, and often assume that taking part in the activities will fail to make them feel better anyway. Practitioners of CBT encourage patients to increase their level of activity step by step as a therapeutic experiment to test hypotheses about the potential impact. When patients begin to do positive, constructive things, it often improves their morale, provides some hope, and helps in the process of connecting with others and/or solving problems. All of this serves as a counterweight to suicidality.
Preparing for Potential High-Risk Situations to Prevent Relapse – The skills described above require regular practice to minimize the risk of relapsing into suicidal crises. This involves such methods as reviewing and documenting the patient’s self-help strategies (e.g., drawing from earlier homework assignments), updating the safety plan to incorporate new material (e.g., new activities, additional people to contact), and organizing and assembling “coping cards” that contain the best of the patient’s rational responses to the re-emergence of old stress reactions. Coping cards can be index cards, or memos on the patient’s phone or other digital device. A particularly powerful relapse prevention method is the guided imagery exercise described by Green and Brown (2015), in which the therapist instructs the patient to imagine anticipated situations in the future that could have the potential to trigger suicidal ideation and intentions. Patients then have to provide a detailed account of the coping methods they would use in such situations. This method serves as an important measure of the patient’s preparedness for the maintenance and ending phases of a treatment trial.
Published June 25, 2018