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Unit 4: Brief Cognitive Behavior Therapy (BCBT) for Suicide Intervention & Prevention

Suicide Intervention and Prevention Strategies - 

A Training Resource

By: Jim Messina

What works in Treating Clients to Prevent Suicidal Thinking and Actions

What works?


1. Theoretical models easily translated to clinical work

2. Treatment fidelity

3. Adherence

4. Emphasis on skills-building

5. Personal responsibility

6. Easy access to treatment and crisis services

 

1. Theoretical models easily translated to clinical work

  • Well-defined and theoretical models embedded in empirical research
  • Identify thoughts, emotional processing, and associated behavior responses
  • Clients can easily understand why they have tried or are thinking about suicide


2. Treatment fidelity

  • Clinician training to competence with supervision
  • Manual-driven
  • Clear sequence or hierarchy of treatment targets
  • Suicidal behaviors is central treatment focus independent of psychiatric condition


3. Adherence

  • Specific interventions and techniques to target poor adherence and motivation
  • Clear directions about what to do if nonadherence emerges


4. Emphasis on skills-building

  • Identification of skills deficits with opportunity for skills building and practice
  • Clear understanding of “what is wrong” and “what to do about it”


5. Personal responsibility

  • Emphasis on client self-reliance and self-management
  • Clients assume high level of responsibility for their care, including crisis management


6. Easy access to treatment and crisis services

  • Clear plan of action for emergencies
  • Dedication of time to practicing skills necessary to identify true crisis, using crisis plan, and using external support services judiciously
 (Rudd, Williamson, & Trotter, 2009).

Brief Cognitive Behavioral Therapy (BCBT) 

 

Phase I:

Crisis management, distress tolerance


Phase II:

Cognitive restructuring of suicidal belief system, problem solving, cognitive flexibility


Phase III:

Relapse prevention


How Brief Cognitive Behavioral Therapy differs from Treatment as Usual 

Treatment as Usual 

• Suicide as symptom of psychiatric diagnosis

• Focus on psychiatric diagnosis

• Emphasizes external sources of self-management including hospitalization

• Clinician responsibility for preventing suicide

 

Brief Cognitive Behavioral Therapy

• Suicide as problem distinct from psychiatric diagnosis

• Focus on suicide risk

• Emphasizes internal sources of self-management to minimize hospitalization

• Shared client-clinician responsibility for preventing suicide


Based on Clinical Trials of BCBT

- BCBT contributes to 60% reduction in suicide attempts as compared to TAU
- No differences between treatments are found in terms of emotional distress
- Gains occur with an average of 12 outpatient hours of contact and reduced use of hospitalization


(Bryan, Gartner, Wertenberger, Delano, Wilkinson, Breitbach, Bruce, & Rudd, 2012).


In engaging sucidal clients use the Motivational Interviewing Model of Developing Discrepancy by them challenging the Pros and Cons of Changing:
BCBT Phase 1 - Crisis Management & Distress Tolerance

Primary Tasks
1. Describe treatment
2. Conduct assessment of index suicidal episode
3. Educate patient about suicidal mode
4. Develop crisis response plan
5. Develop treatment plan and obtain commitment
6. Emotion regulation skills training


Emotion Regulation Strategies
1.  Means restriction counseling
2.  Relaxation training
3.  Mindfulness training
4.  Reasons for living list
5.  Survival kit
6.  Sleep hygiene / stimulus control


Help the cleint to learn how to relax, be mindful of the good that life has to offer so as to grow into a survival rationale to keep on living:

BCBT Phase II: Cognitive restructuring of suicidal belief system, problem solving, cognitive flexibility


Primary Tasks
1. Review and rehearse emotion regulation strategies in order to generalize across
situations
2. Target core beliefs and behaviors that contribute to the suicidal mode
3. Undermine shame and guilt
4. Teach clients how to consider alternatives to learned behavioral and cognitive
patterns


Phase II Strategies
1.  ABC worksheets
2.  Challenging beliefs worksheets
3.  Behavioral activation
4.  Coping cards
Phase II Treatment Tools

1. ABC's Decision Making
1. ABC Worksheets
You can download ABC Worksheets from: 
2. Challenging Thoughts Worksheets
You can download Challenging Unhealth Thoughts Worksheets from:
3. Behavioral Activation Worksheets
You can download Behavioral Activation Worksheets from:
  1. Behavioral Activation Worksheet at: http://www.getselfhelp.co.uk/docs/BehaviouralActivation.pdf
  2. Behavioral Activiation Daily Diary Worksheet at: http://www.getselfhelp.co.uk/docs/BACEdiary.pdf
  3. Behavioral Activation Weekly Schedule Worksheet at: http://www.therapistaid.com/worksheets/schedule-behavioral-activation.pdf
  4. Handout: Positive Steps to Wellbeing at: http://www.therapistaid.com/worksheets/positive-steps-to-wellbeing.pdf
  5. Positive Experience Worksheet-Having Client Identify when functioned positively at: http://www.therapistaid.com/worksheets/positive-experiences.pdf
4. Coping Cards
To assist client to continue to remind self to work at thinking, feeling and behaving positively so as to get back on track, have client put positive statements about self on 3 by 5 index cards to keep in their pockets for when they are feeling down, blue or hopeless.
To help them work at identifying Positive Statements About themselves have them use the following worksheepts:
  1. My Strengths and Qualities Worksheet at: http://www.therapistaid.com/worksheets/schedule-behavioral-activation.pdf
  2. Positive Experiences: To identify when Client experienced positive qualities to be recorded and reminded of at: http://www.therapistaid.com/worksheets/positive-experiences.pdf
  3. Positive Activirty Identification Worksheet to help client idenfity positive activities which can be recorded on Coping Cards to remind Client of something they might want to engage in at the moment to turn  negative thinking around at: http://media.psychology.tools/worksheets/english_us/activity_selection_en-us.pdf

The Goal of Use of Coping Cards is to help the clients to IMPROVE Through Imagering, Meaning. Prayer, Relaxation, One thing at a time so as to gain meaning and value from current life circumstances, 
Clinical Treatment Tools as Resource for BCBT 
In planning and delivering BCBT with your clients who are experiencing suicideal ideation and behaviors, you may need additional tools to help you Assess, Treat, and Provide Homework assignments. You can get such tools on the Clinical Treatment Tools section of this website at:  

On this site you can get:

BCBT Phase III: Relapse Prevention


Primary Tasks
1. Conduct relapse prevention task repeatedly
2. Review index suicidal episode several times until patient demonstrates ability to
problem solve
3. Develop hypothetical future crises and conduct imaginal exposure with patient
imagining effective use of problem solving skills


Relapse Prevention Tasks
1.  Educate client about relapse prevention task
2.  Answer questions and address concerns
3.  Instruct client to remain in present tense
4.  Prompt client during task to increase emotional vividness and specificity
5.  As client demonstrates competency, increase complexity and difficulty of task
6.  Process task following completion


Teach clients about how to resist and avoid the urge to go backwards and to act on such urges through learning to surf their urges:

BCBT Final session
1. Review treatment log contents
2. Determine final “lesson learned” for treatment log
3. Educate client on follow-up procedures as needed
4. Provide client with token of treatment completion (e.g., coin, certificate, etc.)
Note: This unit on Brief Cognitive Behavior Therapy (BCBT) for Suicide Intervention and Prevention is based on the following book: Bryan, C.J. (Ed). (2015). Cognitive Behavioral Therapy for Preventing Suicide Attempts: A Guide to Brief Treatments Across Clinical Settings (Clinical Topics in Psychology and Psychiatry). New York: Rutledge. 

The BCBT Model is based on this Treatment Manual: Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients. Washington, DC: American Psychological Association.This book functions as the Treatment Manual for BCBT and CBT for Suicide Intervention and Prevention.