Perspectives of suicidal veterans on safety planning: Findings from a pilot study


Aims: Individual interviews were conducted and analyzed to learn about the engagement of suicidal veterans in safety planning.

Method: Twenty suicidal veterans who had recently constructed safety plans were recruited at two VA hospitals. In semistructured interviews, they discussed how they felt about constructing and using the plan and suggested changes in plan content and format that might increase engagement.research blog (5)

Results: The veterans’ experiences varied widely, from reviewing plans often and noting symptom improvement to not using them at all and doubting that they would think of doing so when deeply depressed.

Conclusion: The veterans suggested ways to enrich safety planning encounters and identified barriers to plan use. Their ideas were specific and practical. Safety planning was most meaningful and helpful to them when they experienced the clinician as a partner in exploring their concerns (e.g., fear of discussing and attending to warning signs) and collaborating with them to devise solutions.


Kayman, J. D., Goldstein, F. G., Dixon, L., & Goodman, M. (October 27, 2015). Perspectives of suicidal verterans on safety planning: Findings from a pilot study. The Journal of Crisis Intervention and Suicide Prevention, 36, 371-383.

RCT of a Brief Phone-Based CBT Intervention to Improve PTSD Treatment Utilization by Returning Service Members

Worried about their reputation and career prospects, returning service members with PTSD may avoid seeking treatment. research blog (1)In a randomized controlled trial, the authors examined engagement in treatment and symptoms among veterans with PTSD who received a brief phone-based intervention to discuss why they had avoided treatment. Veterans who received a call entered treatment sooner and experienced more immediate reductions in PTSD symptoms than veterans who received usual care. By six months, differences between the two groups had faded, suggesting that adding a second phone call might be warranted.


Many service members do not seek care for mental health and addiction problems, often with serious consequences for them, their families, and their communities. This study tested the effectiveness of a brief, telephone-based, cognitive-behavioral intervention designed to improve treatment engagement among returning service members who screened positive for posttraumatic stress disorder (PTSD).



Service members who had served in Operation Enduring Freedom or Operation Iraqi Freedom who screened positive for PTSD but had not engaged in PTSD treatment were recruited (N=300), randomly assigned to either control or intervention conditions, and administered a baseline interview. Intervention participants received a brief cognitive-behavioral therapy intervention; participants in the control condition had access to usual services. All participants received follow-up phone calls at months 1, 3, and 6 to assess symptoms and service utilization.



Participants in both conditions had comparable rates of treatment engagement and PTSD symptom reduction over the course of the six-month trial, but receiving the telephone-based intervention accelerated service utilization (treatment engagement and number of sessions) and PTSD symptom reduction.



A one-time brief telephone intervention can engage service members in PTSD treatment earlier than conventional methods and can lead to immediate symptom reduction. There were no differences at longer-term follow-up, suggesting the need for additional intervention to build upon initial gains.


Stecker, T., McHugo, G., Xie, H., Whyman, K., & Jones, M. (January 01, 2014). RCT of a brief phone-based CBT intervention to improve PTSD treatment utilization by returning service members. Psychiatric Services (washington, D.c.), 65, 10, 1232-7.

Reducing Clinician Stress When Treating Traumatized, Suicidal Clients

Marjan G. Holloway, Ph.D., Beck Institute Faculty



Marjan G. Holloway, Ph.D.

As an educator, I have noticed that two subgroups of clients are highly likely to activate anxiety and other types of emotional distress (e.g., professional burnout) among clinicians.  The first subgroup consists of traumatized clients and the second subgroup consists of suicidal clients.  When working with clients who are traumatized and suicidal, the potential for therapy-interfering emotions such as excessive worry and therapy-interfering behaviors such as avoidance on the part of the clinician notably increases.  These problematic emotional and behavioral reactions often stem from a series of maladaptive clinician cognitions, as described below.

  1. All-or-None Thinking (Example: “After months of therapy, nothing has changed.”)
  2. Catastrophic Thinking (Example: “If I ask too many questions about the traumatic event, the client will deteriorate, fall apart, and may even become suicidal.”)
  3. Labeling (Example: “This client is resistant to change – wants to remain a victim.”)
  4. Personalizing (Example: “As an incompetent therapist, it’s my fault that the client remains symptomatic.” )

We have all been there.  I recall my excitement after having received a new client referral in the early years of my practice.  This excitement quickly transformed to anxiety, indecisiveness, and self-doubt as I learned about this particular client’s history of multiple lifetime traumas and suicidal behaviors.  I was terrified to accept the case as a newly licensed psychologist and I frankly questioned my ability to work effectively with the client (even after years of solid clinical training).  Not surprisingly, I avoided taking the case.  To address my sense of responsibility and guilt, I started to call other community clinicians and colleagues in private practice to find a good referral source.  Very quickly, I discovered that other clinicians, regardless of their seasonality, were similarly not available to accept a “complex” trauma case who was also considered at high risk for suicide.  As I listened to the justifications provided by these clinicians, I had an opportunity to examine my own beliefs about the client.  I realized that these beliefs – along with my negative emotions – were dictating my decision to avoid.

During an upcoming 2016 Beck Institute Workshop on CBT for PTSD, I plan to review two evidence-based CBT interventions for trauma: Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick & Schnicke, 1996).  While each intervention has a different theoretical underpinning and technical approach, both emphasize the following:

  • The importance of having the client understand (i.e., “digest”) the traumatic event
  • The importance of having the client understand that the memory of the traumatic event, by itself, is not dangerous and therefore, not to be avoided

By repeated exposure to the memories associated with the traumatic event and/or repeated examination of the impact of the traumatic event, the traumatized client can gain a sense of control and mastery over the traumatic memories.

To date, there is no scientific evidence to suggest that asking about trauma-related and/or suicide-related content exacerbates psychiatric symptoms.  CBT clinicians can learn to effectively manage their own anxiety and emotional distress, while working with this highly vulnerable client population, by engaging in the following recommended activities:

  • Gaining continuing education in evidenced-based CBT for PTSD
  • Being mindful of their own therapist maladaptive emotions, cognitions, and/or behaviors
  • Seeking peer consultation and/or supervision, as needed
  • Listening carefully to the trauma/suicide narratives of their clients in order to construct meaningful cognitive behavioral conceptualizations for treatment planning
  • Paying close attention to self-care and early signs of professional burnout

Working with traumatized clients is certainly not easy.  However, we as CBT clinicians have the responsibility to intervene, rather than to avoid.  Prolonged Exposure and Cognitive Processing Therapy are two CBT-oriented treatment packages that are evidence-based.  Gaining familiarity and future competency in delivering these interventions will certainly prove to be beneficial to your clients and to you.


Recommended Resources

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide. New York, NY: Oxford University Press.

Ghahramanlou-Holloway, M., Neely, L., & Tucker, J. (2014). A cognitive-behavioral strategy for preventing suicide. Current Psychiatry, 13(8), 18-25.

Resick, P. A., & Schnicke, M. K. (1996). Cognitive processing therapy for rape victims. Newbury Park, Sage Publications.


Mobile Apps to Consider

PE Coach


Provider Resilience

Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up


research blogObjective: The authors evaluated the effectiveness of brief cognitive-behavioral therapy (CBT) for the prevention of suicide attempts in military personnel.

Method: In a randomized controlled trial, active-duty Army soldiers at Fort Carson, Colo., who either attempted suicide or experienced suicidal ideation with intent, were randomly assigned to treatment as usual (N=76) or treatment as usual plus brief CBT (N=76). Assessment of incidence of suicide attempts during the follow-up period was conducted with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation with intent to die during the past week and/or a suicide attempt within the past month. Soldiers were excluded if they had a medical or psychiatric condition that would prevent informed consent or participation in outpatient treatment, such as active psychosis or mania. To determine treatment efficacy with regard to incidence and time to suicide attempt, survival curve analyses were conducted. Differences in psychiatric symptoms were evaluated using longitudinal random-effects models.

Results: From baseline to the 24-month follow-up assessment, eight participants in brief CBT (13.8%) and 18 participants in treatment as usual (40.2%) made at least one suicide attempt (hazard ratio=0.38, 95% CI=0.16–0.87, number needed to treat=3.88), suggesting that soldiers in brief CBT were approximately 60% less likely to make a suicide attempt during follow-up than soldiers in treatment as usual. There were no between-group differences in severity of psychiatric symptoms.

Conclusions: Brief CBT was effective in preventing follow-up suicide attempts among active-duty military service members with current suicidal ideation and/or a recent suicide attempt.


Rudd, M. D. (January 01, 2015). Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up. American Journal of Psychiatry, 172, 5, 441-449.


Cognitive–behavioral therapy for late-life anxiety: Similarities and differences between veteran and community participants

New Study (1)Abstract:

Cognitive–behavioral therapy (CBT) is an evidence-based treatment for anxiety; however, a growing body of research suggests that CBT effect sizes are smaller in Veteran samples. The aim of this study was to perform secondary data analyses of a randomized controlled trial of CBT for late-life generalized anxiety disorder compared with treatment as usual (TAU) in a Veteran (n = 101) and community-based (n = 122) sample. Veterans had lower income and less education than community participants, greater severity on baseline measures of anxiety and depression, poorer physical health, and higher rates of psychiatric comorbidity. Treatment effects were statistically significant in the community sample (all ps < 0.01), but not in Veterans (all ps > 0.05). Further analyses in Veterans revealed that poorer perceived social support significantly predicted poorer outcomes (all ps < 0.05). Our results underscore the complexity of treating Veterans with anxiety, and suggest that additional work is needed to improve the efficacy of CBT for Veterans, with particular attention to social support.

Barrera, T. L., Cully, A. J., Amspoker B. A., Wilson, L. N., Kraus-Schuman, C., Wagener, D. P., Calleo, S. J., Teng, E. J., Rhoades, H. M. & Mosozera, N. (2015)9. Cognitive–behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants  Journal of Anxiety Disorders, Volume 33, Issue null, Pages 72-80

Workshop Participant Spotlight – Amanda May, LLMSW

Amanda, a recent graduate of University of Michigan (but a Spartans fan!) attended the Beck Institute CBT for a PTSD workshop, taught by Dr. Aaron Brinen. She traveled from Michigan with 8 other trainees from Henry Ford Health System. At HFHS, Amanda is a clinical therapist for adults and teenagers; she also runs a substance abuse group. DSC_0328

The group from HFHS had the opportunity to travel to Philadelphia and attend training at Beck Institute, because their organization recently learned that they will be providing services to first responders in the Detroit area. The CBT for PTSD workshop was the perfect fit.

When she learned she would have the opportunity to attend a workshop at Beck Institute, Amanda was thrilled because she learned and loved CBT in graduate school. “And let’s be honest, the Beck Institute is prestigious.” Other than meeting Dr. Aaron Beck, and learning more about prolonged exposure therapy, Amanda most appreciated that “Dr. Brinen is amazing with talking about difficult topics and keeping us engaged.”

Effects of Psychotherapy on Trauma-related Cognitions in Posttraumatic Stress Disorder: A Meta-Analysis

New Study (1)Abstract

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria for posttraumatic stress disorder (PTSD) incorporate trauma-related cognitions. This adaptation of the criteria has consequences for the treatment of PTSD. Until now, comprehensive information about the effect of psychotherapy on trauma-related cognitions has been lacking. Therefore, the goal of our meta-analysis was to determine which psychotherapy most effectively reduces trauma-related cognitions.

Our literature search for randomized controlled trials resulted in 16 studies with data from 994 participants. We found significant effect sizes favoring trauma-focused cognitive-behavioral therapy as compared to nonactive or active nontrauma-focused control conditions of Hedges’ g = 1.21, 95% CI [0.69, 1.72], p < .001 and g = 0.36, 95% CI [0.09, 0.63], p = .009, respectively. Treatment conditions with elements of cognitive restructuring and treatment conditions with elements of exposure, but no cognitive restructuring reduced trauma-related cognitions almost to the same degree. Treatments with cognitive restructuring had small advantages over treatments without cognitive restructuring.

We concluded that trauma-focused cognitive-behavioral therapy effectively reduces trauma-related cognitions. Treatments comprising either combinations of cognitive restructuring and imaginal exposure and in vivo exposure, or imaginal exposure and in vivo exposure alone showed the largest effects.


Diehle, J., Schmitt, K., Daams, J.G., Boer, F., & Lindauer, R.J. (2014). Effects of psychotherapy on trauma-related cognitions in posttraumatic stress disorder: a meta-analysis. Journal of  Traumatic Stress, 27(3), 257-264. doi: 10.1002/jts.21924.

Core Beliefs and Assumptions in Posttraumatic Stress Disorder: A Case Example

Norman Web

Norman Cotterell, Ph.D.  Clinical Coordinator, Beck Institute for Cognitive Behavior Therapy

Posttraumatic Stress Disorder (PTSD) refers to a problematic and prolonged response to traumatic events. Ehlers and Clark (2000) note its puzzling nature, identified by both inattention and hyper-arousal, by memories that won’t go away and others that cannot be found, and by both recklessness and an excessive desire for safety. Rothbaum (2006) describes it as a failure of natural recovery.

Mike, a 49 year old production packer, was involved in an accident and suffered 3rd degree burns on the back of his right hand. He is right handed. He remembers watching the machine coming down on his hand. He remembers in vivid detail the smell of burning flesh. 

Mike’s initial response is matter-of-fact. He tells his wife, “Everything is fine.” He makes it through surgeries and skin grafts without much overt difficulty. But he doesn’t own up to any emotional distress. So he misses out on the emotional support that could have helped him process the trauma. Why does he fail to reveal his feelings? One key belief he holds is, “If I reveal any vulnerability, people will lose faith in me and view me as weak.”

Shortly after the medical procedures are finished, Mike experiences cognitive intrusions: flashbacks and nightmares. While these intrusions are distressing, what is more distressing is the special meaning he puts to them. “[They show] I can’t control my own mind.” Dissociative amnesia is further evidence to Mike of his loss of control.

His perceived loss of control leads to Mike’s experiencing intense and distressing negative emotions. He feels highly anxious, sad, and ashamed. “I should be able to cope. I’m weak.” The experience of negative emotion, too, leads Mike to feel out of control. His core beliefs — “I’m out of control. I’m helpless. I’m weak. I can’t function” — become fully activated. He sees himself as being in grave danger, not from an external threat, but from one that he cannot escape. No matter where he goes, his mind goes with him. Mike adopts a battlefield mentality. He is alert, on-guard, aggressive, unable to sleep. Because he views this extreme mentality as unwarranted(“It’s only a burned hand!“) — he takes these symptoms as proof of his weakness.

Mike also engages in extensive behavioral avoidance. He believes he must avoid all that he loves, or risk tainting it with insanity. He also engages in emotional avoidance through the use of alcohol. But avoidance fuels his belief of weakness. He is in a double bind: “If I avoid, I’m in control, I can function. But If I avoid, it means I’m helpless, defective, out of control. But if I don’t avoid, I’m in danger.”

To summarize, when individuals develop PTSD, they put dysfunctional meanings to their symptoms: intrusions, cognitions, emotions, avoidance, and arousal, among others. Their dysfunctional behaviors and the intensity of their emotions are understandable once we grasp the assumptions they are making. Their assumptions make sense once we comprehend the core beliefs that have become activated. The trauma itself doesn’t directly lead to PTSD; rather it is the meanings they attribute to the trauma, to their cognitive, emotional, physiological, and behavioral symptoms, and to their changed circumstances that are more closely tied to the development of the disorder.


Learn to treat clients with PTSD in our CBT for PTSD workshop.



Ehlers, A. & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder, Behaviour Research and Therapy 38, 319-345.

Foa, E.B., Hembree, E.A., & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD. Oxford: Oxford University Press.

Morris, D. (2015). The Evil Hours. New York: Houghton Mifflin Harcourt.

Resick, P. A. (2001). Cognitive therapy for posttraumatic stress disorder. Journal of Cognitive Psychotherapy, 15(4), 321 – 329.

Rothbaum, B.O. (2006). Virtual Vietnam: Virtual Reality Exposure Therapy. (2006). In M. Roy (Ed.), Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. Amsterdam: IOS Press.

US Dept of Veteran’s Affairs: How common is PTSD? PTSD: National Center for PTSD. (n.d.). Retrieved May 26, 2015, from

Trauma-Focused Cognitive Behavior Therapy

New StudyThis study aimed to gain an understanding of the aspects of trauma-focused cognitive behavioral therapy (Trauma-Focused-CBT) for post-traumatic stress disorder (PTSD) that service-users find important in contributing to their improvement. Nine people (5 females and 4 males, mean age 53 years old who had received on average 12 sessions of Trauma-Focused-CBT) who reported a significant reduction in their symptoms following treatment of PTSD took part in semi-structured interviews. Interpretative phenomenological analysis identified five themes: Living with Symptoms before Therapy; Feeling Ready for Therapy; Being Involved; Bringing About Therapeutic Change; and Life After Therapy. This study contributes towards a clearer understanding of the aspects of the Trauma-Focused-CBT process that service-users found important in aiding their improvement. In particular, it highlights the central role that participants attributed to their own involvement in the therapeutic process and how much they valued this. Limitations and future directions are discussed.

Lowe, C., & Murray, C. (2014). Adult service-users’ experiences of trauma-focused cognitive behavioural therapy. Journal of Contemporary Psychotherapy, 44, 4, 223-231.

Guest Blogger Dr. Judith Beck: Helplessness

I recently presented a Master’s Clinician Class at the Anxiety and Depression Association of America. My topic was cognitive conceptualization of personality disorders. I asked for a volunteer to describe a case so as a group, we could conceptualize the client, using the Cognitive Conceptualization Diagram (Beck, 2005).ADAA 2015 Registration I have changed certain details to protect the client but his difficulties are fairly typical of someone with avoidant personality disorder.

Joe is a 52 year old man who developed PTSD 32 years before, following a series of traumatic incidents. For a long time, he lived with his family and led a fairly reclusive life. He then moved into subsidized housing which he dislikes.

Joe has been in and out of therapy for many years with many therapists. Although he no longer displays symptoms of PTSD, and hasn’t for a long time, he suffers from dysthymia. His anxiety is fairly low as he avoids situations that could lead to distress. He hasn’t had a job since he developed PTSD and has made only half-hearted attempts to secure one. He does have a few friends, “drinking buddies,” but isn’t particularly close to any of them. His relationships with his family are somewhat strained.

When the therapist listed Joe’s automatic thoughts in situationsADAA 2015 with Cindy Aaronson, PhD where he either felt some (mild) distress or acted in a dysfunctional way (using avoiding something), it became clear that Joe has very strong core beliefs of helplessness. Many patients have a belief in one of the three subcategories of helplessness; Joe seems to have core beliefs of being ineffective in all three.

When Joe discusses his future, he says, “My crummy apartment is preventing me from living my life.” When he considers doing his therapy homework, he thinks, “I won’t be able to do it right.” This represents the subcategory of believing one is ineffective in getting things done.

When Joe imagines going to session without having done his homework, he thinks, “She [his therapist] will be mad if I don’t do it.” When they discuss fixing up his apartment, he thinks, “I don’t want to talk about this. It will be too upsetting.” This represents the subcategory of believing one is ineffective in being able to protect oneself, in this case, in being emotionally vulnerable.

When Joe discusses his past, he thinks, “I’ve wasted so many opportunities. I’m a loser.” When Joe fails to protest a teasing insult from his buddy, he thinks, “I should have said something. I’m a wimp.” This represents the subcategory of being ineffective as compared to others.

Joe’s sense of helplessness has led to extensive behavioral avoidance. He procrastinates, avoids doing homework or cleaning up his apartment. It has led to extensive social avoidance. He avoids intimacy in relationships. And it has led to extensive cognitive and emotional avoidance. He over-intellectualizes, changes the subject in therapy, and avoids even thinking about upsetting topics. And he fails to take responsibility for improving his life, blaming his mother, PTSD, and his living situation for holding him back.

Clients’ emotional and behavioral reactions always make sense once we understand what they are thinking. And the patterns or themes in their thinking always make sense once we understand the fundamental ways they view themselves, other people, and their worlds.


Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York: Guilford Press.