Keri E. Cannon and Thomas J. Hudzik (eds.)Suicide: Phenomenology and Neurobiology10.1007/978-3-319-09964-4_14

14. Cognitive Therapy with Suicidal Patients

Michael E. Thase¹

(1)

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania and Philadelphia Veterans Affairs Medical Center, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA

Michael E. Thase

Email: thase@mail.med.upenn.edu

Abstract

Cognitive Therapy is both the best-studied time-limited psychotherapy for treatment of depressive disorders and one of the few forms of psychotherapy that has been specifically adapted for treatment of acutely suicidal individuals. In Cognitive Therapy for Suicide Prevention the primary targets for intervention are hopelessness, suicidal ideations, and the behaviors that have been associated with suicide attempts in the past. Acute suicidal risk is mitigated by collaboratively developing a safety plan and hopelessness explicitly counteracted by identifying and strengthening reasons for living and social support. In the one controlled study conducted to date, patients randomly allocated to Cognitive Therapy for Suicide Prevention were significantly less likely to make another suicide attempt than were those receiving usual care.

14.1 Introduction

Cognitive Therapy, which was developed more than 30 years ago by Aaron T. Beck and colleagues (Beck 1976; Beck et al. 1979), is the best-studied time-limited treatment for depression (Cuijpers et al. 2008). In Cognitive Therapy, the therapist helps the depressed patient learn to identify and modify the automatic negative thoughts that can trigger and sustain dysphoric mood states. Grouped within a broader class of interventions known as Cognitive Behavior Therapy (CBT), treatment also usually incorporates behavioral activation and other related interventions to address maladaptive behaviors and improve coping skills. For the purposes of this chapter, these terms will be used interchangeably. As most depressed patients have some thoughts about hopelessness, death, and/or suicidal ideations, it is common to therapists to address these symptoms, typically beginning within the first few minutes of the very first session. Nevertheless, in conventional Cognitive Therapy hopelessness and suicidal ideations are but one of the constellation of signs and symptoms of the depressive syndrome. A more focused intervention—Cognitive Therapy for Suicide Prevention (Wenzel et al. 2009)—was therefore developed specifically to treat individuals in suicidal crises. Cognitive Therapy for Suicide Prevention focuses on suicidal ideations and suicidal behaviors as the principal targets of therapy. Thus, in Cognitive Therapy of Suicide Prevention, the therapist helps the patient to recognize the various triggers and risk factors that are proximally related to suicidal ideation or behavior and then to practice specific coping and problem-solving strategies that are intended to prevent or attenuate subsequent suicidal crises. This chapter will provide an overview of Cognitive Therapy for Suicide Prevention, as well as a brief summary of the results of research using this approach to treatment.

14.1.1 Methods of Cognitive Therapy for Suicide Prevention

As briefly described below, Cognitive Therapy for Suicide Prevention consists of four phases: (a) the early phase of treatment, (b) the cognitive case formulation, (c) the middle phase of treatment, and (d) the later phase of treatment.

14.1.1.1 Early Phase of Treatment

The first phase of Cognitive Therapy for Suicide Prevention is the most important because it is focused on ensuring patient safety and because it sets the tone for all that follows. Like other forms of Cognitive Therapy, the therapist fosters a “collaborative empirical” atmosphere and is entrusted to engage the patient into a psychoeducational treatment process. Without overpromising (i.e., Cognitive Therapy doesn’t help everyone), the therapist engenders a cautiously optimistic attitude, drawing upon the knowledge that this approach to treatment has helped many people in similar or even worse circumstances. Beyond starting to teach about therapy and how it helps to prevent suicide, the therapist must conduct an assessment of suicide risk and develop a Safety Plan in the initial session. Consistent with the psychoeducational nature of therapy, the therapist teaches the patient about the limits of privacy and confidentiality, the potential risks, and benefits of treatment, provides an overview of the methods used in therapy. If the patient has a past treatment history, it is helpful discuss what aspects of therapy were—and were not—helpful in the past. It is the therapist’s responsibility to obtain the patient’s commitment to give treatment a chance to work, including agreement to consistently attend sessions, actively participate, and complete homework assignments.

The assessment suicide risk includes both narrative and psychometric sources, as well as information from tools such as the Beck Hopelessness Scale. Mindful of the time available and multiple competing priorities, it is almost always helpful for the patient to have the opportunity to tell his or her own story. Most patients will describe a suicidal crisis that has been provoked or at least temporally preceded by an adverse life event. Enculturation to Cognitive Therapy methods typically begins seamlessly as the therapists asks about the patient’s reactions—thoughts, feelings, and actions—that accompanied the life event and subsequent crisis.

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