Cory Newman, PhD - Center for Cognitive Therapy, University of Pennsylvania Perelman School of Medicine
Empirical Support for CBT with Suicidal Patients
There is a growing body of research suggesting that CBT-related approaches that specifically target suicidality lead to a reduction in suicidal behavior, at least during the critical period of time following a suicide attempt when the risk for further attempts is high (see Monti, Cedereke, & Ojehagen, 2003) and up to two years of assessed follow-up. Commonalities among the CBT-based treatment approaches reviewed below are more prominent than their relatively minor procedural and terminology differences. What they have in common is an assessment process that uses empathic interviewing, psychometrically supported measures, and a combination of functional analyses and cognitive conceptualizations in order to understand the chain reaction of external events (precipitants and consequences) and internal reactions (thoughts, feelings, physiological responses, and behaviors) that comprise the suicidal crises. Further, these approaches are alike in that they teach suicidal patients psychological skills such as self-monitoring, reflecting on their intended actions rather than responding reflexively, engaging in constructive actions, rationally responding to combat a sense of helplessness and hopelessness, reaching out to their social supports to counteract a sense of isolation, and contacting mental health professionals (including those by whom they are being treated, and others who are “on call,” such as those in hospitals and on crisis hotlines). These interventions can be used as part of a larger, general package of CBT for the full range of problems that patients bring to treatment, or they can be stand-alone treatments. When they are used as single-contact interventions in emergency departments (Stanley & Brown, 2012) or as brief treatments in inpatient facilities (e.g., Ellis & Ruffino, 2015), they can be learned and applied by well-trained mental health professionals regardless of their self-identified theoretical orientation.
A randomized controlled trial showing the efficacy of a brief Beckian cognitive therapy protocol in reducing suicide attempts in a high-risk population was conducted by Brown, Ten Have, Henriques, Xie, Hollander, and Beck (2005). The 120 patients in this study had presented with a suicide attempt in the emergency department, and were recruited within 48 hours for random assignment either to a treatment-as-usual condition or a 10-session cognitive therapy package (identified as Cognitive Therapy for Suicide Prevention, or CT-SP) in addition to treatment as usual (all of which was conducted post-discharge). Participants in the cognitive therapy group were 50% less likely to re-attempt suicide during follow-up, and they showed significantly lower depression and hopelessness. A very similar version of brief CBT was successfully tested in a military sample of active-duty Army soldiers who had made a suicide attempt within the past month or who had suicidal ideation with intent to die in the past week (Rudd et al., 2015). Half of the cohort (n=76) was randomly assigned to the treatment-as-usual condition, and the other half (n=76) was randomly assigned to brief CBT (12 sessions) plus treatment as usual. Similar to the Brown et al. treatment study (2005), the Rudd et al. (2015) program utilized a CBT approach that specifically focused on the symptoms of suicidality (including the patients’ belief systems pertinent to their thoughts about life and death), as well as on safety planning and relapse prevention. During the two-year follow-up period, those receiving CBT were 60% less likely to make a suicide attempt.
The Collaborative Assessment and Management of Suicidality (CAMS: Jobes, 2006; 2012) is a therapeutic approach that self-identifies as being applicable in conjunction with treatments across the theoretical spectrum but nonetheless borrows heavily from CBT methods. In a non-randomized control comparison study, CAMS was associated with reductions in suicidal ideation in comparison to treatment as usual, and was significantly linked to decreases in emergency department utilization during the 6-month follow-up period (Jobes et al., 2005). In a randomized trial, a brief course of outpatient CAMS was shown to reduce suicidal thinking and general symptom distress significantly, and to increase hopefulness and reasons for living at 12-month follow-up more so than an enhanced care-as-usual approach (Comtois et al., 2011). When provided to hospitalized patients in an individual therapy format, CAMS led to significantly greater improvements on measures specific to suicidal ideation and suicidal cognitions compared to inpatients who did not receive the CAMS interventions (Ellis, Rufino, Allen, Fowler, & Jobes, 2015).
Safety Planning Intervention (SPI: Stanley & Brown, 2012) consists of the same steps as described earlier, but in a condensed, written format that serves as a guide to aftercare and follow-up when suicidal patients exit the emergency department following a single contact. The basic elements of the written SPI are: (1) identifying early warning signs of heightened suicide risk, (2) employing prepared, internal coping strategies, (3) utilizing social settings and contacts to distract from suicidal preoccupation, (4) contacting friends and family members for support in times of crisis; (5) contacting mental health practitioners or agencies, and (6) restricting access to lethal means. Stanley and Brown (2012) report that SPI has been used as part of other evidence-based psychotherapy interventions in clinical trial research.
Another CBT approach that has been applied to suicidal individuals in inpatient settings is Post Admission Cognitive Therapy (PACT: Ghahramanlou-Holloway, Cox, & Greene, 2012). PACT emphasizes helping patients face the stressors that are often encountered following discharge from hospital; stressors that if not managed properly can easily trigger a relapse of suicidal thoughts, feelings, urges and behaviors. Indeed, the period of time when patients are re-acclimating to life outside of the hospital is a period of high risk for another suicide attempt (Ghahramanlou-Holloway, Neely, & Tucker, 2015). PACT has the same treatment objectives as outpatient CBT (e.g., identifying and modifying the cognitive, emotional, and behavioral factors that comprise the patient’s “suicidal mode”), but also helps patients develop the problem-solving skills they will need on the outside. The goals include improving the patient’s self-efficacy in dealing with the demands of their life situation and increasing their compliance with adjunctive medical, social, psychiatric, and substance abuse interventions both during and after hospitalization. In a highly related line of clinical research, a subset of problem-solving that focuses on emotional self-regulation and interpersonal concerns (Emotion-Centered Problem-Solving Therapy: EC-PST, Nezu & Nezu, in press) is also showing promise as a means by which to help highly distressed persons to feel more personally empowered, and to refrain from translating negative affect into self-harm.
It is also important to acknowledge the contribution of dialectical behavior therapy (DBT) to the treatment literature on suicide risk reduction (e.g., Linehan et al., 2006; Linehan et al., 2015). Although DBT is a distinct treatment that involves components of care that are not routinely included in standard CBT packages (e.g., a DBT skills group to go along with individual treatment; regular between-sessions phone contacts), DBT and the CBT approaches mentioned in this review have the same common theoretical roots. Brown et al. (2012) note that their CT-SP treatment and DBT both focus on preventing suicidal behavior by teaching high-risk patients specific coping skills. A noteworthy component of DBT is mindfulness, a self-regulation skill that itself has some empirical support as a method that reduces suicidal behavior in those at risk (see Chesin, Sonmez, Benjamin-Beeler, Brodsky, & Stanley, 2015).
CBT can be applied to suicidal children and adolescents. For example, a randomized controlled trial conducted by Esposito-Smythers and Spirito (2004) on hospitalized adolescents with a substance use disorder and at least one suicide attempt in the previous three weeks showed the superiority of CBT over enhanced treatment as usual on outcomes related to substance use, suicide attempts, emergency department visits, and arrests. The adolescents who received CBT also showed better treatment adherence. Another CBT approach currently being applied to the treatment of suicidal adolescents is the aptly named Treatment of Adolescent Suicide Attempters (TASA: Brent et al., 2009). The authors emphasize the importance of safety planning and increased frequency of therapeutic contact early in treatment. Additionally, a treatment model for young suicidal patients that includes working with the family -- called Safe Alternatives for Teens and Youths (SAFETY) – was shown in a randomized, controlled trial to reduce suicide attempts in adolescents presenting with recent self-harm (Asarnow, Hughes, Babeva, & Sugar, 2017). The authors describe the SAFETY program as a cognitive-behavioral, dialectical behavior-therapy informed family treatment.
Although the studies noted above suggest that even brief CBT interventions for suicidality can be efficacious, a longitudinal approach to the treatment of suicidality may be best. There is evidence that even when patients respond well to treatment they are prone to residual symptoms – including sub-optimally modified dysfunctional beliefs about suicide – that may keep them at elevated risk in the future. Also, in outpatient work with suicidal individuals, spotty attendance and early drop-out from treatment take on added significance. There is evidence that those patients who are most at risk (e.g., having a history of multiple suicide attempts) tend to be least likely to avail themselves of regular therapy sessions (see Berk, Henriques, Warman, Brown, & Beck, 2004; Joiner & Rudd, 2000). Similarly, suicidal patients who opt to discontinue therapy without having a formal concluding session to summarize their gains and formulate a maintenance plan, and/or while still demonstrating hopelessness (e.g., as assessed via their last-completed BHS) are at higher ongoing risk for suicide than those who complete treatment with a better sense of hope and direction (Dahlsgaard, Beck, & Brown, 1998). Thus, therapists cannot remain passive when their suicidal patients are absent from treatment in an unanticipated way. Instead, therapists would do well to try to reconnect with the patients, such as by calling and leaving caring messages that invite the patients to come in for an appointment as soon as possible (Brown et al., 2012). A randomized controlled trial by Motto and Bostrom (2001) also showed that even after therapy is completed, some simple acts of positive outreach (e.g., a birthday card with a pleasant message) can lower suicide risk well after termination.
Concluding Comments
Helping a patient to relinquish suicidal intentions and behaviors is a process. The CBT practitioner makes gradual inroads by establishing a genuinely caring therapeutic relationship, constructing a clear and comprehensive framework for the work of therapy, collaborating with the patient on a treatment plan involving skill-building and safeguarding, and offering a steady flow of words of empathy, support, encouragement, and hope. No single intervention in any given session is likely to put a definitive end to the patient’s risk for suicide. However, each intervention contributes to an incremental lowering of risk, especially if the therapist succeeds in motivating the patient to practice a range of self-help methods between therapy sessions for homework. In sum, the therapist offers the suicidal patient hope and a plan, bolstered by a healthy therapeutic relationship characterized by accurate empathy for the patient’s unique experiences, and ongoing positive reinforcement for learning durable psychological skills.
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Published June 25, 2018
