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Unit 5: Cognitive Behavior Therapy (CBT)

for Suicide Intervention & Prevention



Suicide Intervention and Prevention Strategies - 

A Training Resource

By: Jim Messina


Structure of Cognitive Therapy for Suicidal Clients

1. Structured and time-limited

2. Early, middle and late phases of treatment

3. Important to use a flexible approach

Early Phase of Treatment

 

Goals in Early Phase of Treatment

1. Obtain Informed Consent

2. Engage client in Treatment

3. Conduct a Suicide Risk Assessment

4. Develop a Safety Plan

5. Convey a Sense of Hope

6. Means Restriction Counseling

7. Narrative Description of Recent Suicidal Crisis

8. Treatment Planning

(Wenzel et al., 2009)

 

Engage the Patient in Treatment/Therapeutic Relationship)

VA patients with bipolar disorder: After controlling for current mood state and other

key risk factors for suicide, even minimal improvements in the extent to which the

therapeutic relationship was perceived as collaborative associated with decreases in

suicidal ideation. (Ilgen et al., 2009

 

Conduct a Suicide Risk Assessment

Psychological Assessment:

1. Standard intake information

2. Detailed information re: the circumstances surrounding the recent suicidal crisis

 

Suicide Risk Assessment and Prediction: Challenges

1. Base rates

2. Preventing a specific behavior (Suicide is not a diagnosis)

3. Point prediction

4. Lethality

5. Reliance on self-report

Self-Report Measures of Suicidal Ideation/Behavior Ideation/Behavior

1. Beck Scale for Suicidal Ideation – BSI; Beck & Steer (1991)at: 

http://www.psy-world.com/ssi.htm

 

2. Beck Suicide Intent Scale – SIS; Beck, Schuyler, & Herman (1974) at:  https://deekim.files.wordpress.com/2011/09/becks-suicide-intent-scale.pdf

 

3. Beck Hopelessness Scale – BHS; Beck (1974) at: https://suicideprevention.wikispaces.com/file/view/beckshopelessnessscale.doc

 

4. Columbia-Suicide Severity Rating Scale

– C-SSRS; Posner (2011) at: http://www.integration.samhsa.gov/clinical-practice/Columbia_Suicide_Severity_Rating_Scale.pdf

 

Suicide Risk Assessment via Clinical Interview

Essential, secondary to the limitations of self-report measures

Warning signs

Risk factors

Protective factors

 

Suicide Risk Assessment via Clinical Interview (Rudd, 2006)

1. Previous suicidal thoughts, intent, and behavior

2. Current suicidal thoughts, intent, and behavior

3. Precipitant stressors (acute and chronic)

4. General psychiatric symptoms

5. Impulsivity and self-control

6. Risk and protective factors

7. Use of medications or substances

8. Hopelessness

9. Warning signs

10. Access to lethal means

11. Gain a complete understanding of medical, social and mental health history

12. Utilize empirically supported suicide risk assessment instruments in conjunction with a clinical interview

13. Obtain collateral information from family, friends, work colleagues and medical staff

14. Use a direct/nonjudgmental/collaborative approach

15. Assess risk on an ongoing basis

16. Ask detailed, specific questions

17. Document direct quotes from the patient

18. Need to question about multiple methods since clients will sometimes withhold their accessible method until questioned more thoroughly

 

Assess Nature of Suicidal Thinking & Behaviors (Rudd 2006)

Key: To accurately gauge suicidal intent

Warning signs provide observable markers consistent with potential elevations in intent to die

Important to distinguish among the following:

1. Suicidal thoughts

2. Morbid ruminations

3. Non-suicidal self-directed violence ideation

 

Assessing Suicidal Intent:

Objective Indicators

1. Preparation behavior

2. Rehearsal behavior

3. Stated reasons for living and reasons for dying

4. Perceived lethality of previous suicide attempts

5. Efforts to prevent discovery or rescue in previous suicide attempts

6. Emotional reaction to previous attempts

 

Assessing Impulsivity:

1. Subjective

2.  Objective behavioral markers

3. Substance use

 

Assessing Protective Factors:

1. Accessible and available social support

2. Problem-solving ability

3. Emotional self-control

4. Therapeutic alliance

Each Session Using Cognitive Behavior Therapy Has the Following Components

1. Brief Mood Check

2. Bridge from Previous Session

3. Agenda Setting

4. Review of Homework

5. Discussion of Agenda Items

6. Periodic Summaries

7. Homework Assignment

8. Final Summary and Feedback

 

Mood Check: Watch this Video: 

https://www.youtube.com/watch?v=YWzGmtjBKRA&feature=youtu.be

 

Agenda Setting: Watch this Video: 

https://www.youtube.com/watch?v=KOR2Y1hEBBo&feature=youtu.be

 

During Cognitive Behavior Therapy Session, the Counselor Develops a Narrative

Description of the Suicidal Crisis

 

1. Obtains detailed description of suicidal crisis

2. Constructs timeline

 

Probes for Two Types of Key Automatic Thoughts:

1. Associated with the Reason/Motivation Underlying the Suicidal Crisis

2. Associated with Intent to Die by Suicide

 

Identifies Starting point: Point in time at which the patient experienced a strong emotional reaction to specific events

 

Narrative Description of the Suicidal Crisis: Watch this Video to see how this Narrative Description is developed: 

In Cognitive Behavior Therapy, Crisis Intervention

1. Helps client recognize crisis trigger and help client understand thoughts/ feelings about the trigger

2. Help client act in a way that will deactivate suicidal thoughts

3. Help client gain access to emergency care if the suggested strategies are ineffective

 

Initial Management Post-Suicide Risk Assessment

Match care level to risk level

Secure client’s safety

1. Psychoeducation for client

2. Limit access to means

3. Complete a thorough safety plan

4. Address needs/increase social support

5. Increase coping skills

 

Crisis Intervention: Safety Planning

Developed collaboratively with client

1. Mood regulation techniques

2. Pleasant activities

3. Emergency numbers

 

Six Steps in Safety Planning

Step 1: Warning Signs

Step 2: Internal Coping Strategies

Step 3: Distractions

Step 4: Family/Friends

Step 5: Emergency contacts

Step 6: Safe Environment

 

Implementation of a Safety Plan

1. Review each step and obtain feedback

2. Estimate the likelihood of following through (0-100%)

3. Specify location of safety plan

4. Revise at subsequent meetings as new skills are learned or as the social network is expanded

(Stanley & Brown, 2008); (Wenzel at al., 2009)

 

Promising Means Restriction Intervention

1. Means Restriction–Actual process of limiting/removing access to lethal

means

2. Means Restriction Counseling–Educating client and supportive others about risk

associated with easy availability of means

3. Collaboratively work with client and support person to limit/remove access to means until the suicidal risk has lessened

 

Means Restriction Counseling

1. Describe rationale for means restriction: emphasis on ensuring safety and overcoming suicidality

2. Conduct means restriction counseling: a collaborative plan of how means for suicide will be restricted

3. Implementation of means restriction: The enactment of the agreed-upon measures from the Means Restriction Agreement

a. Means receipt (client and significant other)

b. Crisis support plan (significant other)

(Rudd & Bryan (2011); (Bryan et al., 2011); (Rudd et al., 2015)

 

Means Restriction Counseling: Watch this Video to see how Means Restriction Counseling proceeds: 

https://www.youtube.com/watch?v=FUtdOrmFr38&feature=youtu.be

 

Constructing a Timeline of the Suicidal Crisis

Incorporates…

1. Activating Event

2. Cognitions

• Key automatic thoughts

• Dysfunctional assumptions

• Core beliefs

3. Emotions

4. Behavioral Responses

(Wenzel et al., 2009)

 

Assists in…

1. Developing a cognitive case conceptualization

2. Identifying points for intervention

3. Preparing for the relapse prevention protocol

(Wenzel et al., 2009)

 

Treatment Planning

Purpose: To determine skills deficits which need improvement and dysfunctional beliefs to be modified

1. Developing Treatment Goals

2. Selecting an Intervention Strategy

3. Prevention of future suicidal behavior–Client may be reluctant to establish this as a treatment goal

4. Addressing dispositional vulnerability factors

5. Secondary goals –Approach these in context of recent suicide crises and risk for future suicidal behavior

6. Modifying core beliefs

(Wenzel et al., 2009)

 

Cognitive Case Conceptualization

Goal: To develop a more in-depth understanding of the suicidal crisis

1. Identify: Early experiences, core beliefs, Intermediate beliefs, key automatic thoughts

2. Identify dispositional vulnerability factors which have the potential to…

- Activate suicide-relevant schemas

- Exacerbate suicidal crises

3. Identify suicide-relevant cognitive processes

(Wenzel et al., 2009)

Intermediate Phase of Treatment


Use information from the case conceptualization to generate intervention foci

Examples:

1. Ineffective Coping Strategies

2. Problematic Emotion Regulation

3. Hopelessness

4. Perceived or Actual Lack of Social Support

5. Modifying Core and Intermediate Beliefs

 

Broad Categories of Clinical Focus

1. Behavioral Strategies

2. Coping Strategies

3. Cognitive Strategies

 

Behavioral Strategies

1. Behavioral activation

2. Improving social resources

3. Improving compliance with other services

(Wenzel et al., 2009)

 

Affective Coping Strategies

1. Physical Self-Soothing

2. Sensory Self-Soothing

3. Affective Self-Soothing

4. Cognitive Self-Soothing

(Wenzel et al., 2009)

 

Cognitive Strategies

1. Modifying core beliefs

2. Reasons for living

3. Coping cards

4. Improving problem-solving skills

5. Reducing impulsivity

(Wenzel et al., 2009)

 

Identifying and Modifying Cognitions

There are 3 categories of cognitions counselors are attempting to identify and modify:

1. Core Beliefs

2. Intermediate Beliefs

3.  Automatic Thoughts

(Wenzel et al., 2009)

 

Identification of Core and Intermediate Beliefs

Examine thoughts, looking for common themes


Use the Downward Arrow Technique: 

Client’s first thoughts are usually not therapeutically useful in that they do not describe the implications to the client. Use Downward Arrow Technique to uncover the implications of thought

Ask “What would it mean if….?”

Or “What if it is true that….?”

Or “What about that bothers you?”

Repeat until thought is produced that will benefit from cognitive therapy


Example 1: Downward Arrow Technique

 

Therapist

Client

You mentioned that when your

boyfriend stated he wanted to end

the relationship, you had the thought

that you would be better off ending

your life. Can you explain further

what was going on in you mind at

that time?

I was thinking that without him, I

would have nothing left to live for. He

was such a big part of what made me

happy.

You’d talked about how you have

parents and a sister, a network of

friends, and a promising career. What

makes you feel as though you have

nothing left to live for?

I know that my family love me. But it’s

different now that I’m grown up. And

with my friends…it’s also different. And

I’ve had a hard time keeping a

relationship with a man.

What does not being in a relationship

mean to you?

It means there’s something wrong with

me- like I’m not good enough for

someone to want to stay with me.

What does it mean that someone

doesn’t want to stay with you?

It means that I’m a loser… that I’m

unlovable.
 Example 2:  Downward Arrow Technique
Example 3: Downward Arrow Technique

Identifying Core and Intermediate Beliefs Watch this Video on identifying Core and Intermediate Beliefs and the Downward Arrow Technique:

https://www.youtube.com/watch?v=chszzoN74r4&feature=youtu.be

 

Modifying Core and Intermediate Beliefs Watch this Video on Modifying Core and Intermediate Beliefs:

https://www.youtube.com/watch?v=Yt9ArCO9S4M&feature=youtu.be

 

Possible Interpersonal Therapy (IPT) Themes in Treatment

1. Thwarted Belongingness

  • Marital/relationship conflicts
  • Missing camaraderie of unit

 

2. Perceived Burdensomeness

  • Missing sense of success/mastery
  • Job/financial problems

 

Additional Cognitive Strategies - Coping Cards

1. To address negative automatic thoughts

2. To challenge core beliefs

3. To provide coping strategies in times of distress

4. To address low motivation/low energy

(Wenzel et al., 2009)

Directions: Put Positive Core Belief which are Positive and Emotionally uplifting on 3 by 5 index cards which the client and look at when discouraged, down or feeling like there is nope

 

Additional Cognitive Strategies - Improving Problem-Solving Skills

1. Generate as many solutions as possible

2. Weigh advantages/disadvantages of proposed solutions

3. Consider short/long-term consequences of solutions

4. Use cognitive rehearsal to imagine proposed solutions and their effects

5. Choose a solution

6. Identify discrete steps involved in implementing the solution

7. Consider generalizability to future problems

(Wenzel et al., 2009)

 

Additional Cognitive Strategies - Decreasing Impulsivity

1. Ride out the wave

2. Generate list of advantages/disadvantages of acting on the impulsivity

3. Procrastination

4. Short-term strategies

5. Long-term strategies -Means restriction

(Wenzel et al., 2009)
Clinical Treatment Tools as Resource for CBT 
In planning and delivering CBT 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:

Later Phase of Treatment

 

Later Treatment Phase

1. Review and Consolidation of Skills

2. Relapse Prevention

3. Review of Treatment Goals

4. Additional Treatment Planning

 

Review and Consolidation of Skills

1. A comprehensive review of the skills that were learned and practiced during treatment

2. The client should be able to take a very active role in reviewing and identifying skills

3. Consider generating a coping card listing helpful strategies for future crises

 

Relapse Prevention

Guided Imagery Tasks

1. Preparation Phase

2. Review of Recent Suicidal Crisis

3. Review of Recent Suicidal Crisis with Skills

4. Review of Future Suicidal Crisis

5. Debriefing and Follow-Up

 

Preparation Phase

1. Obtain informed consent

2. Provide rational: by imagining the recent crisis and recalling the pain that was experienced, the client will have the opportunity to assess if the skills learned in treatment can be recalled and applied in a time of emotional distress or crisis

3. Explain main components of the exercise

4. Review timeline of most recent crisis

 

Directions for Review of the Recent Suicidal Crisis

Purpose: To assess whether the client can produce a vivid image of the recent crisis and to help the client access the emotions associated with the crisis

 

Review of the Recent Suicidal Crisis with Skills

1. Lead the client through the recent crisis again, recalling vividly thoughts and emotions

2. Encourage client to imagine using skills learned in therapy to cope with the event

3. The client will say aloud what skills the client would now use at various points to handle the crisis differently

 

Relapse Prevention Exercise Watch a Video of conducting a Relapse Prevention Exercise:

https://www.youtube.com/watch?v=nmQ-88ECbCc&feature=youtu.be

 

Review of Future Suicidal Crisis

1. The counselor develops a realistic scenario of a future suicidal crisis using the patient’s cognitive case conceptualization

2. The client is asked to imagine and describe the sequence of events as they would likely unfold in that scenario, focusing on thoughts, emotions, behaviors, and circumstances eliciting Suicidal Ideations

 

Debriefing and Follow-Up

1. The client summarizes what he/she has learned from the relapse prevention exercises

2. The counselor highlights changes the client made in treatment that were reflected in how he/she handled the imagined suicidal crises.

3. Identify any remaining issues that were elicited in the exercises

4. Assess for suicidal ideation

 

Review of Treatment Goals and Planning

1. Collaboratively evaluate progress made towards

treatment goals

2. Conduct a risk assessment and determine if there is any remaining suicidal ideation, intent, thoughts, plan

3. Based on the risk assessment, conduct treatment planning

 

Special Considerations in CBT Therapy for Suicidal Thoughts and Behaviors

 

Sleep Problems

There is a relationship between insomnia and Suicidal Ideation, even when other factors such as depression are controlled for

Nightmares are associated with Suicidal Ideation, even when controlling for global sleep disruption and depression

 

Treatment of Sleep Problems

1. Minimize sleep disruption

2. Maximize restorative sleep

3. Tailor the following strategies:

- Stimulus control

- Sleep hygiene

- Relaxation techniques

 

Agitation and Hyperarousal

1. Identify Key “warning signs” for suicide

2. Behavioral Interventions

3. Cognitive Interventions

4. Independent of diagnosis of the client: medications - Anti-depressants such as SSRIs are highly recommended

 

Social Support

Belonging/feeling connected to a group is important thus the benefit of client participating in a community based support group also it is important to provide appropriate psychoeducation to the client’s family members so that they can provide appropriate social support as the client progresses in treatment
Note: This Treatment Model is based on the following Treatment Manual: Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients. Washington, DC: American Psychological Association.