Changing the Way People at Risk for Suicide Think: Using CBT to Provide Hope

By Mark Moran

Cognitive-behavior therapy (CBT) can be adapted for patients with suicidal behavior to counteract negative and suicidal thoughts, instill hope, and prevent future crises with the development of a “safety plan” specifically tailored to each patient’s needs, according to Jesse Wright, M.D., Ph.D., Judith Beck, Ph.D., and Donna Sudak, M.D. They were presenters at the session “Cognitive-Behavior Therapy for Reducing Suicide Risk” at APA’s 2021 online Annual Meeting.

Sudak, a professor of psychiatry and vice chair for education at Drexel University, said suicidal patients typically harbor negative thoughts and beliefs about themselves and their place in the world that are activated before making an attempt. These beliefs include that they are hopeless, helpless, and unlovable and that their pain or distress is intolerable, with no way out.

“Problem-solving deficits are significant in patients with suicidal behavior,” Sudak said. “When they encounter problems, they experience anxiety and often avoid solving them. Interpersonal problem solving often is particularly problematic. Thus, frequently suicidal patients see suicide as a desirable solution—a way out.”

She said Aaron Beck, M.D., the father of cognitive-behavior therapy, “was a giant of suicide research.” Beck was the first to outline key risk factors of suicide, developing a suicide intent scale and a scale for suicidal ideation. He identified hopelessness as a key feature of suicide risk.

A landmark 2004 paper in JAMA by Gregory Brown, Ph.D., and colleagues showed that among patients who had attempted suicide, those receiving CBT were 50% less likely to reattempt suicide than participants in the usual care group.

Sudak also introduced research on the effectiveness of a “safety plan” developed by Brown and Barbara Stanley, Ph.D., of Columbia University, which is utilized in CBT for suicide. A safety plan is a written, prioritized list of coping strategies and resources for reducing suicide risk. A 2018 report in JAMA Psychiatry on a large-scale comparative cohort study of safety-planning interventions coupled with structured follow-up reduced the risk of suicidal behavior by 50% and achieved a twofold increase in the odds of treatment engagement over a six-month period.

Beck, who is president of the Beck Institute for Cognitive Behavior Therapy, discussed the specific ways that CBT can instill hope. She said the goal is to help individuals live the life they want, in alignment with their values and aspirations, and strengthen their sense of connection, hope, purpose, empowerment, safety, well-being, competence, and control.

It is critical to motivate patients to recall times when they were living the life they want. Therapists should prompt with these questions: When was the best period of your life? Why was it the best? How long did it last? What were your values, aspirations, achievements, positive qualities, interests, resources? What were your positive relationships like? How did you see yourself, the world and other people, the future? How did you overcome challenges?

“Help patients see that they can affect their well-being,” Beck said. “They can do things to feel better and improve their lives.”

Wright, a professor of psychiatry and director of the University of Louisville Depression Center, described the rationale for safety plans and the way they are implemented in CBT. These are the key points to emphasize with patients:

• Suicide urges fluctuate; a plan to manage them can save your life.
• Personal warning signs will help you know when to use the plan.
• Managing suicidal thinking will keep you alive while you work to solve some of your problems.

A template for developing a safety plan for suicidal patients can be accessed at https://www.appi.org/wright. (Wright is an editor of the American Psychiatric Association Publishing book Learning Cognitive-Behavior Therapy: An Illustrated Guide, Second Edition.)

Steps common to a safety plan include identifying specific activities that can distract the patient during a crisis and people who can provide support, listing personal reasons for living, and restricting access to lethal means. Therapists should collaborate with the patient to write the safety plan and use the patient’s own words.

Safety plans are detailed and specific, Wright said. “When determining items for each step, provide a rationale, ask the patient for ideas and brainstorm further solutions, and remind the patient that the goal is not to feel good but just to get through the crisis,” he said. “Elicit likelihood of follow-through and identify obstacles.” ■