A cognitive-behavioral strategy

for preventing suicide

Consider a 3-phase course of CBT to put distance
between a patient and repeat suicide attempts,
in outpatient and inpatient settings

M
Marjan Ghahramanlou-Holloway, PhD
Associate Professor
any mental health practitioners have had training in cogni-
Department of Medical and Clinical Psychology tive-behavioral therapy (CBT)—short-term, evidence-based
Department of Psychiatry psychotherapy for treating a variety of psychiatric conditions
Director
Laboratory for the Treatment of Suicide-Related (eg, posttraumatic stress disorder) and medical comorbidities (eg, insom-
Ideation and Behavior nia)—but only some are knowledgeable about how to best use CBT with
Laura L. Neely, PsyD a suicidal patient. This article provides a clinician-friendly summary of
Psychologist a 10-session evidence-based outpatient1-3 and an adapted 6 to 8 session
Associate Director
Laboratory for the Treatment of Suicide-Related
inpatient4,5 cognitive-behavioral protocol (known as Post-Admission
Ideation and Behavior Cognitive Therapy [PACT]) that is designed to help patients who have
Jennifer Tucker, PhD suicide-related thoughts and/or behaviors.
Postdoctoral Fellow
Laboratory for the Treatment of Suicide-Related
Ideation and Behavior
3 phases of CBT for suicide prevention
Uniformed Services University of the Health Sciences An average of 9 hours of individual CBT for the prevention of suicide
Bethesda, Maryland
has been reported to reduce the likelihood of repeat suicide attempts in
Disclosures approximately 50% of patients.1 Here, we introduce you to 3 phases of
Support for research on inpatient cognitive-behavioral therapy
for the prevention of suicide provided to Principal Investigator, CBT for preventing suicide—phases that are the same for outpatients or
Dr. Ghahramanlou-Holloway by the Department of Defense, inpatients. Our aim is to help you become familiar with CBT strategies
Congressionally Directed Medical Research Program
(W81XWH-08-2-0172), Military Operational Medicine Research that can be adapted for your treatment setting and used to intervene with
Program (W81XWH-11-2-0106), and the National Alliance for vulnerable patients who are at risk for suicidal self-directed violence. A
Research on Schizophrenia and Depression (15219).
thorough assessment of the patient’s psychiatric diagnosis and history,
presenting problems, and risk and protective factors for suicide must be
ALICIA BUELOW FOR CURRENT PSYCHIATRY

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 under-

Current Psychiatry
Vol. 13, No. 8 19
 Table 1

Objectives of cognitive-behavioral therapy for preventing suicide

Objectives Description
Provide psychoeducation To educate the patient about the association between one’s suicidal
thoughts, urges, and feelings, and subsequent behaviors
Reduce suicide risk factors To reduce the severity of established suicide risk factors (depression,
hopelessness, suicidal ideation, etc.)
CBT for Enhance effective coping To enhance effective coping, emotion regulation, and problem-
preventing suicide solving skills, such that suicide is no longer viewed as the only
solution to one’s life problems
Minimize social isolation To help the patient gradually establish a new social support network
or more adaptively use an existing social support network
Increase medical adherence To increase use of, and adherence to, adjunctive medical care,
including mental health and treatment for substance-related
disorders
Plan for safety To prepare patients, family members, and friends to implement
emergency safety plan procedures if suicidal urges recur
Clinical Point
Some persons might
experience a chronic Box
Theoretical basis for preventing
state of suicide Prompting a patient to tell his suicide with CBT
mode activation and, suicide storya Aaron Beck, in 1979, 6 proposed that a per-
therefore, remain son’s biopsychosocial vulnerabilities can

at elevated risk of ‘P lease tell me about what happened on

the day of your suicide attempt as if
it were a story with a beginning, a middle,
interact with suicidal thoughts and behaviors
to produce a state that Beck labeled the “sui-
suicide and an end. I would like to hear about the cide mode.” Once produced, a suicide mode
circumstances, thoughts, feelings, and can become activated by cognitive, affective,
actions that resulted in your decision to
attempt suicide.”
motivational, and behavioral systems.
The frequency and severity of suicide
aPhase I
mode activation can increase over time,
especially for persons who do not have
protective factors and those who have a his-
standing how best to deactivate the wish to tory of self-directed violence—in particular,
die through the process of psychotherapy. attempted suicide. Moreover, some persons
might experience a chronic state of suicide
Phase II. The patient is assisted with modify- mode activation and, therefore, remain at
ing underdeveloped or overdeveloped skills elevated risk of suicide. Once a suicide-
that are most closely associated with the risk specific mode is activated, the person con-
of triggering a suicidal crisis. For example, a siders suicide the only option for solving his
patient with underdeveloped skills in regu- life problems. Suicide might be considered a
lating anger and hatred toward himself is rational decision at this point.6
taught to modulate these problematic emo- The hypothesized mechanism of action
tions more effectively. In addition, effective associated with CBT for preventing suicide
problem-solving strategies are reviewed and can be described as:
practiced. • deactivation of the suicide mode
Discuss this article at • modification of the structure and con-
www.facebook.com/ Phase III. The patient is guided through a tent of the suicide mode
CurrentPsychiatry
relapse prevention task. The purpose of this • construction and practice of more
exercise is to 1) highlight skills learned dur- adaptive structural modes to promote a
ing therapy and 2) allow the patient to prac- desire to live.
tice effective problem-solving strategies that The underlying philosophy of this inter-
Current Psychiatry
are aimed at minimizing the recurrence of vention is that the suicide mode occurs inde-
20 August 2014 suicidal self-directed violence. pendently of psychiatric diagnoses and must
 Figure 1

Timeline of a suicide attempta

Event
Drug relapse

Thoughts
“I am a failure. I will never be clean.”

Emotions
Shame
Hopelessness

Behaviors
Steals money
Buys more drugs

Suicide mode
“I can no longer do this to my family.
They would be better off without me.”
Clinical Point
Suicide attempt
The underlying
Reaction to attempt
Regrets surviving philosophy of this
intervention is that
aPhase I
suicide mode occurs
independently of
be targeted directly; treatment therefore is mize the risk of drop-out, practitioners
psychiatric diagnoses
transdiagnostic.7 In other words, instead of are encouraged to establish a strong, early and must be targeted
addressing a symptom of a psychiatric disor- therapeutic alliance with the patient.
der, treatment directly targets suicide-related Showing genuine empathy and provid-
ideation and behaviors (Table 1). ing a safe, supportive, and nonjudgmental
Using that framework, psychiatric diag- environment are instrumental for engag-
noses are conceptualized in terms of how the ing patients in treatment. The practitioner
associated symptoms contribute to the acti- listens carefully to the patient’s narrative,
vation, maintenance, and exacerbation of the provides periodic summaries to check on
suicide mode. accurate understanding, and keeps inter-
ruptions to a minimum.

Protocol for preventing suicide Collaboratively generate a safety plan.

The outpatient protocol1-3 comprises 10, A crisis response plan or safety plan—an
45- to 50-minute weekly individual psy- individualized, hierarchically arranged,
chotherapy sessions, with an allowance written list of coping strategies to be
for booster sessions (as needed), until the implemented during a suicide crisis—is
patient is able to complete the relapse pre- developed as soon as possible. Guidance
vention task in Phase III. The inpatient on how to develop a structured safety plan
protocol4,5 comprises 6, 90-minute individ- has been provided by Stanley and Brown.8,9
ual psychotherapy sessions, with an allow- Practitioners must ensure that the safety
ance for 2 booster sessions (as needed) plan contains contact information that the
during the inpatient stay and as many as 4 patient can use to reach the practitioner,
telephone booster sessions after discharge. the clinic, the on-call provider (if available),
the local 24-hour emergency department,
and the 24/7 National Suicide Prevention
Phase I: Tell the suicide story Lifeline (800-273-TALK [8255]). Discussion
Engage the patient in treatment. To of how to limit access to lethal means also Current Psychiatry
increase adherence to treatment and mini- is important. Vol. 13, No. 8 21
continued
 Table 2

Sample cognitive-behavioral conceptualization

Concept Example
Relevant childhood data Invalidating family environment
Domestic violence
Core beliefs “I am unlovable.”
CBT for “I am worthless.”
preventing suicide Intermediate beliefs “If I disappoint people, they will leave me.”
“If I try a new strategy in my life, I will fail.”
Compensatory strategies Adheres superficially to treatment because of fear of disappointing the
provider
Avoids giving feedback to provider due to anxiety about being
abandoned
Activating event Appointment with provider and disclosure about recent challenges in
maintaining safety
Clinical Point
Automatic thoughts “I have messed up again. There is no hope for me. I cause problems for
Check on everyone, including my therapist.”

the patient’s Meaning of automatic “I am unlovable—I am worthless. I am a burden to others.”

thoughts
willingness to follow
Emotions Embarrassed, guilty, worried, agitated
the safety plan and
Behaviors Leaves apologetic suicide note on provider’s voice mail
help him overcome and attempts suicide
perceived obstacles Source: Adapted from Beck JS. Cognitive behavior therapy: Basics and beyond, 2nd ed. New York, NY: Guilford Press; 2011
in implementation

Because safety planning is a collaborative This activity gives the patient an opportu-
process, it is imperative that practitioners nity to disclose details surrounding his sui-
check on the patient’s willingness to follow cidal thoughts and actions, and might allow
the safety plan and help him overcome per- for a cathartic experience through storytell-
ceived obstacles in implementation. Copies ing. As practitioners listen to the suicide
of the plan can be kept at different locations narrative, they collect data on the patient’s
and shared with family members, friends, or early childhood experiences (typically,
both with the patient’s permission. suicide-activating events), associated auto-
matic thoughts and images, emotional
Develop a cognitive-behavioral concep- responses, and subsequent behaviors.
tualization. The cognitive-behavioral con- Based on this information, a cognitive-
ceptualization is an individualized map behavioral case conceptualization diagram
of a patient’s automatic thoughts (eg, “I (Figure 1, page 21, and Table 2) is generated
am going to get fired today”), conditional collaboratively with the patienta and used to
assumptions (“If I get fired, then my life personalize treatment planning.
is over”), and core beliefs (“I am an utter
failure”) that are activated before, during, Phase II: Build skills
and after suicidal self-directed violence. To Build skills to prevent episodes of sui-
develop that conceptualization, the patient cidal self-directed violence. Information
is asked to tell a story about his (her) most obtained from the conceptualization is used
recent suicidal crisis (the Box, page 20, offers to generate an individualized cognitive-
a sample script) and to describe reactions to behavioral plan of intervention. The over-
having survived a suicide attempt. (Note: all goal is to determine skill-based problem
Current Psychiatry
Patients who report regret after an attempt aJudith Beck offers sample case conceptualization diagrams in

Cognitive behavior therapy: Basics and beyond, 2nd ed. New York,
22 August 2014 are at greatest risk for dying by suicide.10) New York: Guilford Press; 2011.
 Table 3

Skill-deficit domains, with examples of underdeveloped

and overdeveloped skillsa
Skill-deficit domain Underdeveloped skill Overdeveloped skill
Coping strategies, self-efficacy, Self-soothing Self-blame
problem-solving
Regulation of emotions Modulating emotional intensity Dissociation
Hopelessness Optimism Catastrophizing
Reasons for dying > reasons for living
Social support Assertive communication Social avoidance
Acquired capability for suicidal self- Inhibition of impulsive urges to Pain endurance
directed violence and motivation kill oneself
to repeat
Adherence to medical and psychiatric Ability to provide feedback on Missing medical and
treatment medication side effects psychiatric appointments
Phase II
a Clinical Point
Constructing
a hope box allows
areas that are associated with the most recent maladaptive thoughts, especially during the patient to work
episode of suicidal self-directed violence. extreme distress, by being reminded of pre- on modifying his
Practitioner and patient collaboratively vious successes, positive experiences, and problematic core
identify skills that are underdeveloped and reasons for living. The process of construct-
ones that are overdeveloped so that they ing a hope box allows the patient to work
beliefs, such as
can be addressed systematically. In gen- on modifying his problematic core beliefs worthlessness and
eral, based on our clinical experience with (eg, worthlessness, helplessness, incapable helplessness
suicidal patients, we recommend focusing of being loved).
on skills captured within ≥1 of the deficit It can be helpful to have the patient con-
domains in Table 3. Explanation of the vari- struct his hope box during a session, to ensure
ous cognitive-behavioral strategies used in that everything that is put in the box is truly
this phase of treatment is beyond the scope helpful and personalized. Items included
of this article, but 2 activities that highlight vary from patient to patient, and might con-
the clinical work conducted in this phase sist of pictures of loved ones, a favorite poem,
are described in the following sections. We a prayer, coping cards (see next section), or
selected those activities because they are all of these. For example, one of our patients
easy to implement and, we have found, chose to include a picture of herself in her
receive overall patient acceptability. early 20s as a reminder of a positive, fulfill-
For a detailed understanding of strate- ing time in her life; this gave her hope that it
gies used in Phase II of CBT for preventing is possible to experience those feelings again.
suicide, see Related Resources (page 28). Bush et alb at the National Center for
In addition, the book Choosing to live: How Telehealth and Technology have developed
to defeat suicide through cognitive therapy11 a Virtual Hope Box, a free mobile applica-
can serve as a self-help guide for patients tion for tablets and smartphones (compatible
to follow through with CBT skill-building with Android and iOS operating systems)
strategies. that patients can use under the guidance of
their practitioner.
Sample activity #1: Construct a ‘hope
box.’ One activity that you can use to help Sample activity #2: Generate coping
a patient cope with suicide-activating core cards. Effective problem-solving skills can
beliefs (eg, “My life is worthless”) involves be promoted by having the patient construct
construction of a so-called hope box. The coping cards—wallet-size cards generated Current Psychiatry
box helps the patient directly challenge his bwww.t2.health.mil/apps/virtual-hope-box Vol. 13, No. 8 23
 Figure 2 actions and reducing the likelihood of acting
on suicidal urges. The brief guidance pro-
Sample coping card to motivate vided below will familiarize you with each
a patienta of the relapse prevention steps, which may
When I feel down and don’t want to do be completed in multiple sessions.
anything, I …
put on my gym shoes STEP 1: Provide psychoeducation
CBT for  alk a quarter mile outside (approximately
w Explain the difference between a lapse and a
10 minutes)
preventing suicide relapse. In general, you want the patient to
s top and rate how healthy I feel understand that, although suicidal thoughts
(on a scale of 1 to 10)
might persist and recur over time, suicidal
practice my breathing
self-directed violence must be prevented.
decide whether to keep walking or
Describe the purpose of the relapse preven-
to go back home
tion task (ie, to minimize the chance that
record my activity in my daily exercise log
suicidal thinking and actions will recur);
give myself a pat on the back for taking a
walk address questions and concerns; and obtain
Clinical Point take a shower and relax permission to begin the procedure. Assure
the patient that this is a collaborative activity
For patients with aPhase II
and you will be in the room to ensure com-
suicidal self- fort and safety.
directed violence,
relapse prevention collaboratively in session. Coping cards are STEP 2: Retell the suicide story
is directed at note cards that a patient keeps nearby to Ask the patient to imagine the chain of
cope better during a difficult situation. They events, thoughts, and feelings that led to
identifying triggers provide an easily accessible way to jump- the most recent episode of suicide ideation
for suicidal actions start adaptive thinking during a suicidal or suicidal self-directed violence. Tell the
crisis. The patient is encouraged to use cop- patient that you want him to construct a
ing cards to practice adaptive thinking even movie script to describe the chain of events
when not in a crisis. that resulted in the suicide crisis—but to do
There are 3 kinds of coping cards: so slowly, taking enough time to describe the
• place a suicide-relevant automatic details of each scene of the movie.
thought or core belief on one side of the card;
on the other side, place an alternative, more Step 3: Apply CBT skills
adaptive response Ask the patient again to take you through
• write a list of coping strategies the sequence of events leading to the most
• write instructions to motivate or “acti- recent episode of suicide ideation or suicidal
vate” the patient toward completing a spe- self-directed violence. This time, however,
cific goal (Figure 2). direct him to use the skills learned in ther-
apy to appropriately respond cognitively,
affectively, and behaviorally to move further
Phase III: Prevent relapse away from the suicide outcome.
Complete relapse prevention task. If the patient is moving too fast or neglect-
Relapse prevention is a common CBT strat- ing important points, stop and ask about
egy that aims to strengthen self-management alternative ways of thinking, feeling, and
to minimize likelihood of returning to a pre- behaving. Use as much time as needed until
viously stopped behavior. For patients who the patient is able to demonstrate solid learn-
present only with suicidal thoughts, relapse ing of at least several learned CBT strategies
prevention is directed at identifying trig- to prevent suicidal self-directed violence.
gers and minimizing the occurrence and/
or intensity of such thoughts in the future. Step 4: Generalize learning to prepare for future
For patients who present with suicidal self- suicidal crises
Current Psychiatry
directed violence, relapse prevention is In this stage—given your knowledge of the
24 August 2014 directed at identifying triggers for suicidal patient’s psychosocial history, cognitive-
 Table 4

Post-Admission Cognitive Therapy (PACT): Delivering the intervention

to inpatients
Phase of treatment Therapeutic goals
Phase I Build therapeutic alliance
Sessions 1 and 2 Provide psychoeducation
(≤90 minutes/session) Collaboratively plan for safety
Listen to suicide narrative
Assess readiness for change
Develop suicide mode conceptualization
Phase II Review assessment and case conceptualization data to identify primary
Sessions 3 and 4 problem area(s) most closely associated with the suicide-related event
(≤90 minutes/session) leading to psychiatric hospitalization; tailor intervention to the specific needs
of the patient
• Coping strategies, self-efficacy, problem solving
• Emotion regulation
• Hopelessness, reasons for dying > reasons for living
• Perceived or actual lack of social support or inadequate use of existing
Clinical Point
social support
Debrief the patient by
• Capability for self-harm and motivation to repeat
• Compliance-related problems associated with medical and psychiatric providing a summary
care
of the skills he has
Phase III Provide psychoeducation on relapse prevention and its purpose
Sessions 5 and 6 Collaboratively generate a relapse prevention plan
learned in therapy,
(≤90 minutes/session) Have the patient imagine a future suicidal crisis and demonstrate effective and congratulate him
problem-solving
for completing this
Phase IV Continue to practice learned skills such as emotion regulation
Booster sessions Review bibliotherapy homework progress (Choosing to Live)
final therapeutic task
(before discharge); Review and update relapse prevention plan as needed
≤2 sessions Update safety plan as needed before discharge
Sessions 7 and 8 Promote self-care
Provide information on aftercare booster sessions’ purpose and frequency
Promote linkage to outpatient aftercare
Problem-solve potential obstacles with aftercare
Phase V Review objectives of telephone contact
Telephone booster Discuss patient’s transitional challenges and adjustment
sessions Update safety plan as needed
(after discharge); Utilize motivational interviewing strategies to promote linkage to aftercare
≤4 sessions
Continue to practice learned skills, such as emotion regulation
Session 9 Identify specific treatment goals to work on until the next call
(within 7 days) Remind the patient about the number of telephone sessions remaining
Schedule the next call
Sessions 10-12
Provide information about case management and emergency numbers as
(within 12 weeks)
needed

behavioral conceptualization, and suicide Step 5: Debrief and summarize lessons learned
mode triggers—you collaboratively create Debrief the patient by providing a sum-
a future scenario that is likely to activate mary of the skills he has learned in
suicidal self-directed violence. Question the therapy, congratulate him for complet-
patient about possible coping strategies, pro- ing this final therapeutic task, and assess
vide helpful feedback, guide him through overall emotional reaction to this activity.
each link in the chain of events, and pro- Remind him that mood fluctuations and
pose additional alternative strategies if he future setbacks, in the form of lapses, are
is clearly neglecting important points of the expected. Give him the option to request Current Psychiatry
intervention. booster sessions and make plans for next Vol. 13, No. 8 25
continued on page 28
 Post-Admission Cognitive
Related Resources Therapy (PACT)
• Academy of Cognitive Therapy. www.academyofct.org.
An inpatient cognitive-behavioral pro-
• National Suicide Prevention Lifeline. www.suicide
preventionlifeline.org.
tocol for the prevention of suicide,
• Wenzel A, Brown GK, Beck AT. Cognitive therapy for suicidal adapted from the efficacious outpatient
patients: scientific and clinical applications. Washington, DC: model, is being evaluated at the Walter
American Psychological Association; 2009.
Reed National Military Medical Center,
CBT for Bethesda, Maryland, and Fort Belvoir
preventing suicide continued from page 25 Community Hospital, Fort Belvoir,
steps in accomplishing general goals of Virginia. The inpatient intervention is
therapy. called PACT; components are summarized
Treatment can be terminated when the in Table 4 (page 25).
patient is able to complete the relapse preven-
References
tion task. If he is not ready or able to complete 1. Brown GK, Ten Have T, Henriques GR, et al. Cognitive
this exercise successfully, you can extend therapy for the prevention of suicide attempts: a
randomized controlled trial. JAMA. 2005;294(5):563-570.
treatment. The duration of the extension is
2. Brown GK, Henriques GR, Ratto C, et al. Cognitive
Clinical Point left to the practitioner’s judgment, based therapy treatment manual for suicide attempters.
Philadelphia, PA: University of Pennsylvania; 2002
on the overall treatment plan. Brown and
Treatment can be (unpublished).
colleagues2 have reported a maximum num- 3. Berk MS, Henriques GR, Warman DM, et al. A cognitive
terminated when ber of 24 outpatient sessions (for patients who therapy intervention for suicide attempters: an overview
of the treatment and case examples. Cogn Behav Pract.
the patient is able to need additional booster sessions); based on 2004;11(3):265-277.

complete the relapse clinical experience, it is reasonable to assume 4. Ghahramanlou-Holloway M, Cox D, Greene F. Post-
admission cognitive therapy: a brief intervention for
prevention task that it would be highly unlikely for a patient psychiatric inpatients admitted after a suicide attempt.
Cogn Behav Pract. 2012;19(2):233-244.
not to meet treatment objectives after a
5. Neely L, Irwin K, Carreno Ponce JT, et al. Post Admission
methodical course of outpatient CBT. Cognitive Therapy (PACT) for the prevention of suicide
in military personnel with histories of trauma: treatment
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Bottom Line
Cognitive-behavioral therapy for preventing suicide is an efficacious protocol for
reducing the recurrence of suicidal self-directed violence. Post-Admission Cognitive
Therapy is the adapted inpatient treatment package. You are encouraged to gain
additional training and supervision on the delivery of these interventions to your
Current Psychiatry
28 August 2014 high-risk suicidal patients.