CBT for Suicide Prevention

In 1996, Aaron Beck proposed the concept of “modes” to describe the “synchronous interactions” among the cognitive, affective, physiological, motivational, and behavioral systems of personality. To understand the construct of the suicide mode, consider the case of Richard, a 25-year-old graduate student with recurrent depression. Richard discovers shortly after the New Year that he has failed his comprehensive exams. The example below illustrates the full activation of the cognitive, affective, physiological, motivational, and behavioral systems which eventually lead to Richard’s attempted suicide.

Activation of the Suicide Mode

One of Richard’s automatic thoughts is that others will think less of him because of his poor performance. He can visualize himself lowering his eyes while walking through campus to avoid eye contact with his peers and the department faculty. He ruminates on the conditional belief that, “If I have failed my comprehensive exams, this proves that I am not deserving of a doctorate degree.”

Cognitively, his core beliefs of being worthless and a failure have been activated. In terms of affective activation, the recent failure resulted in emotions of shame, embarrassment, worry, and self-hatred. Overall, Richard feels trapped in his body – and becomes agitated and motivated to act in a hostile manner and hurt himself. Physiologically, he is aroused, and motivationally, he begins to think about possible strategies for acting on his suicidal thoughts. Behaviorally, he isolates from his friends and family members. He begins to fixate on postings and pictures of his friends’ Facebook pages, ruminating about congratulatory comments for those who have successfully passed the comprehensive exams. His worry and self-loathing become intolerable.

One night, Richard intentionally plans to drink excessively and crash his car while driving on a secluded road. He is found with extensive injuries in a nearly wrecked car by a highway patrol officer. Following medical hospitalization for his serious injuries, he expresses regret about having survived but has tears in his eyes and a glimpse of hope as his parents enter his hospital room.

Cognitive Behavior Therapy for Suicide Prevention

The goal of cognitive behavior therapy (CBT) for suicide prevention is to de-activate the suicide mode.

  1. The philosophy of the treatment is that suicidal thoughts and/or behaviors must be targeted directly.
  2. The treatment is transdiagnostic. This does not mean that psychiatric diagnoses are neglected; in fact, the cognitive behavioral conceptualization carefully takes into account the role of psychopathology in the trajectory to suicidal behaviors. However, specific psychotherapeutic strategies are tailored to the underlying condition of suicidality, across all psychiatric disorders.
  3. The treatment is adjunctive. This means that the intervention can be added to existing programs of care – for instance, to trauma-focused care, to Alcoholics Anonymous (AA) support groups, to marital therapy, and to psychiatric medication management.
  4. The treatment is guided by a cognitive behavioral case formulation, emphasizes skill building, and teaches relapse prevention.

Empirical Support for CBT for Suicide Prevention

Several studies have provided empirical support for the outpatient CBT protocol to prevent suicide (Brown et al., 2005; Ghahramanlou, Bhar, Brown, Olsen, & Beck, 2012; Rudd et al., 2015). Notably, 50 (Brown et al., 2005) to 60 (Rudd et al., 2015) percent reductions in the suicide re-attempt rates have been reported for high risk suicidal patients. The inpatient adaptation of this protocol, titled, Post Admission Cognitive Therapy (PACT; Ghahramanlou-Holloway, Cox, & Greene, 2012; Ghahramanlou-Holloway, Neely, & Tucker, 2014, 2015) is currently being evaluated in a multi-site randomized controlled trial. The Substance Abuse and Mental Health Services Administration (SAMHSA) has recognized CBT for Suicide Prevention as a “Program with Evidence of Effectiveness” in its National Registry of Evidence-based Programs and Practices.

Training on CBT for Suicide Prevention

Beck Institute for Cognitive Behavior Therapy provides trainings on suicide prevention. The workshops describe the three phases of treatment, and use illustrative case examples, video segments, transcribed psychotherapy sessions, and experiential activities to highlight therapeutic strategies within each phase of treatment. Briefly stated, the early phase of treatment focuses on the suicide narrative, safety planning, and the cognitive behavioral case conceptualization. The middle phase of treatment focuses on skill building with specific emphasis on increasing hope, social support, problem-solving, emotion regulation, and utilization of adjunctive healthcare services. The late phase of treatment focuses on preventing relapse and planning for safety. Booster sessions are offered, depending on the specific needs of each patient.

Overall, patients are taught that suicide can remain an option but not the only solution to one’s life problem(s). 

The suicide mode can in fact be de-activated collaboratively by patients and their treatment providers who learn together (1) to recognize personal warning signs for suicide, and (2) to effectively manage the interplay among the cognitive, affective, physiological, motivational, and behavioral systems.

References

  1. Beck, A. T. (1996). Beyond belief: A theory of modes, personality, and psychopathology. In P. Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 1-25). New York: Guilford.
  2. Brown, G. K., TenHave, T. T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Journal of the American Medical Association, 294(5), 563–570.
  3. Ghahramanlou-Holloway, M., Bhar, S. S., Brown, G. K., Olsen, C., & Beck, A. T. (2012). Changes in problem-solving appraisal after cognitive therapy for the prevention of suicide. Psychological Medicine, 42(06), 1185–1193.
  4. Ghahramanlou-Holloway, M., Cox, D., & Greene, F. (2012). Post-admission cognitive therapy: A brief intervention for psychiatric inpatients admitted after a suicide attempt. Cognitive and Behavioral Practice, 19, 233-244.
  5. Ghahramanlou-Holloway, M., Neely, L., & Tucker, J. (2014). A cognitive-behavioral strategy for preventing suicide. Current Psychiatry, 13(8), 18-25.
  6. Ghahramanlou-Holloway, M., Neely, L., & Tucker, J. (2015). Treating risk for self-directed violence in inpatient settings. In C. J. Bryan (Ed.), A guide to brief cognitive behavioral treatments for suicide risk across clinical settings. New York: Routledge.
  7. Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., … Bruce, T. O. (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.