A cognitive-behavioral strategy for preventing suicide

Many mental health practitioners have had training in cogni­tive-behavioral therapy (CBT)—short-term, evidence-based psychotherapy for treating a variety of psychiatric conditions (eg, posttraumatic stress disorder) and medical comorbidities (eg, insom­nia)—but only some are knowledgeable about how to best use CBT with a suicidal patient. This article provides a clinician-friendly summary of a 10-session evidence-based outpatient^1-3 and an adapted 6 to 8 session inpatient^4,5 cognitive-behavioral protocol (known as Post-Admission Cognitive Therapy [PACT]) that is designed to help patients who have suicide-related thoughts and/or behaviors.

3 phases of CBT for suicide prevention
An average of 9 hours of individual CBT for the prevention of suicide has been reported to reduce the likelihood of repeat suicide attempts in approximately 50% of patients.¹ Here, we introduce you to 3 phases of CBT for preventing suicide—phases that are the same for outpatients or inpatients. Our aim is to help you become familiar with CBT strategies that can be adapted for your treatment setting and used to intervene with vulnerable patients who are at risk for suicidal self-directed violence. A thorough assessment of the patient’s psychiatric diagnosis and history, presenting problems, and risk and protective factors for suicide must be completed before treatment begins.

Phase I. The patient is asked to tell a story associated with his (her) most recent episode of suicidal thoughts or behavior, or both. This narrative serves as 1) a foundation for planning treatment and 2) a model for understanding how best to deactivate the wish to die through the process of psychotherapy.

Phase II. The patient is assisted with modify­ing underdeveloped or overdeveloped skills that are most closely associated with the risk of triggering a suicidal crisis. For example, a patient with underdeveloped skills in regu­lating anger and hatred toward himself is taught to modulate these problematic emo­tions more effectively. In addition, effective problem-solving strategies are reviewed and practiced.

Phase III. The patient is guided through a relapse prevention task. The purpose of this exercise is to 1) highlight skills learned dur­ing therapy and 2) allow the patient to prac­tice effective problem-solving strategies that are aimed at minimizing the recurrence of suicidal self-directed violence.

Theorectical basis for preventing suicide with CBT
Aaron Beck, in 1979,⁶ proposed that a per­son’s biopsychosocial vulnerabilities can interact with suicidal thoughts and behaviors to produce a state that Beck labeled the “sui­cide mode.” Once produced, a suicide mode can become activated by cognitive, affective, motivational, and behavioral systems.

The frequency and severity of suicide mode activation can increase over time, especially for persons who do not have protective factors and those who have a his­tory of self-directed violence—in particular, attempted suicide. Moreover, some persons might experience a chronic state of suicide mode activation and, therefore, remain at elevated risk of suicide. Once a suicide-specific mode is activated, the person con­siders suicide the only option for solving his life problems. Suicide might be considered a rational decision at this point.⁶

The hypothesized mechanism of action associated with CBT for preventing suicide can be described as:
• deactivation of the suicide mode
• modification of the structure and con­tent of the suicide mode
• construction and practice of more adaptive structural modes to promote a desire to live.

The underlying philosophy of this inter­vention is that the suicide mode occurs inde­pendently of psychiatric diagnoses and must be targeted directly; treatment therefore is transdiagnostic.⁷ In other words, instead of addressing a symptom of a psychiatric disor­der, treatment directly targets suicide-related ideation and behaviors (Table 1).

Using that framework, psychiatric diag­noses are conceptualized in terms of how the associated symptoms contribute to the acti­vation, maintenance, and exacerbation of the suicide mode.

Protocol for preventing suicide
The outpatient protocol^1-3 comprises 10, 45- to 50-minute weekly individual psy­chotherapy sessions, with an allowance for booster sessions (as needed), until the patient is able to complete the relapse pre­vention task in Phase III. The inpatient protocol^4,5 comprises 6, 90-minute individ­ual psychotherapy sessions, with an allow­ance for 2 booster sessions (as needed) during the inpatient stay and as many as 4 telephone booster sessions after discharge.

Phase I: Tell the suicide story
Engage the patient in treatment. To increase adherence to treatment and mini­mize the risk of drop-out, practitioners are encouraged to establish a strong, early therapeutic alliance with the patient. Showing genuine empathy and provid­ing a safe, supportive, and nonjudgmental environment are instrumental for engag­ing patients in treatment. The practitioner listens carefully to the patient’s narrative, provides periodic summaries to check on accurate understanding, and keeps inter­ruptions to a minimum.

Collaboratively generate a safety plan. A crisis response plan or safety plan—an individualized, hierarchically arranged, written list of coping strategies to be implemented during a suicide crisis—is developed as soon as possible. Guidance on how to develop a structured safety plan has been provided by Stanley and Brown.^8,9