CBT for Suicidal Cognitions and Behaviors

By Milton Spett

            On January 23 Amy Wetzel described her empirically-supported, 10-session “Cognitive Therapy for Suicidal Cognitions and Behaviors” to 68 NJ-ACT members. Her basic point is that the suicidality is a specific problem that requires a specific treatment. Although most suicidal patients are depressed, treating their depression is not the most effective treatment for their suicidality. Cognitive therapy for suicidality can be implemented in addition to other treatments suicidal patients are receiving.

Developing a Safety Plan

The first step in any safety plan is to remove whatever means the patient is likely to choose for a suicide attempt -- guns, pills, etc. This may require the patient agreeing to contact a friend or family member who can be trusted to remove the means for a suicide attempt.

            A no-suicide contract is not a safety plan. In a no-suicide contract the patient agree not to attempt suicide. But a safety plan is a written, prioritized list of coping strategies and resources the patient will use during a suicidal crisis. A safety plan has six components. Patients are instructed to first try component 1. If this doesn’t work, they should attempt component 2, then component 3, etc.

            1. Recognizing the warning signs. The patient identifies warning signs including thoughts, images, moods, and/or behaviors. For example social isolation, racing thoughts, crying, intense anger, or the thought “I am a failure.”

            2. Identifying individual coping strategies. This is a list of meaningful and/or pleasurable activities the patient can engage in without contacting another person.

            3. Socializing with family or friends. The patient lists several people, along with their phone numbers, in case the patient cannot reach the first person on the list.

            4. Asking family or friends for help. At this stage the patient not only contacts family members or friends, but also describes the suicidal crisis and asks for help.

            5. Seeking professional help. For example, contacting the therapist or the National Suicide Prevention Lifeline (800-273-TALK).

            For each item on the safety plan, the patient and therapist should discuss potential obstacles to implementing that component and ways to overcome those obstacles. The written safety plan should be easily accessible in time of crisis, and revised and improved as treatment progresses.

Case Conceptualization

            During assessment, construct a sequenced time line that indicates all internal and external events leading up to recent suicidal crises. For example the activating event could be criticism from the patient’s father, which leads to anger, which leads to the patient storming off, which leads to the automatic thought “I can’t take this anymore,” which leads to depression, which leads to the automatic thought “I want to die,” which leads to the suicide attempt.            These time lines enable the patient and therapist to understand the sequence of events that culminated in the suicide attempts, and develop alternative thoughts and behaviors for breaking this sequence in the future.

            Wenzel pointed out that after a failed suicide attempt, the patient’s thought “I regret that I didn’t die” strongly predicts future suicide attempts.

Treatment Interventions

            Wenzel emphasized that therapists should always follow up on missed sessions with a phone call, a telephone session, or an extra therapy appointment. As in DBT, after addressing life-threatening behaviors, treatment should focus on therapy-interfering behaviors. This begins with assessing the factors provoking non-compliance, and problem-solving ways to counteract these factors.

            Wenzel’s treatment includes self-soothing behavioral interventions such as exercise, muscle relaxation, distraction, and mindfulness. Cognitive interventions include modifying suicidal beliefs, discussing reasons for living and reasons for not living, a list of the patient’s accomplishments, and “Coping Cards.” Coping Cards have automatic suicidal thoughts on one side, and competing, adaptive thoughts on the other.

            The “Coping Box” is an affective intervention which includes materials that increase the will to live. The coping box can include items such as pictures of loved ones, letters from loved ones, prayer cards, and it can also include Coping Cards. Tech savvy the patient can put their coping cards or boxes on their smart phones.

            Relapse Prevention. The patient visualizes the internal and external events that led up to recent suicidal crises, and cognitive and behavioral techniques that might have averted these crises. The patient also visualizes events that could lead to future suicidal crises, and ways to cope with these events.

            Outcome. Research has compared treatment as usual (TAU) with Wenzel’s cognitive therapy plus TAU. 42% of the patients in the TAU group made one or more subsequent suicide attempts, compared with only 24% in the cognitive therapy plus TAU group. But note that this research was performed by Wenzel and her colleagues, and the cognitive therapy plus TAU group received more hours of therapy than the TAU group.

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