Cognitive-behavioral therapists use a variety of techniques in their work with suicidal patients. The choice of technique depends on various factors including the patient’s psychological capacity, the nature of the problem, and the psychological model that the therapist has determined to be most relevant to the patient’s problems.
The cognitive-behavioral formulation is based on information derived from the first assessment. It should be a written explanation of the problem that sheds light on the crucial factors, both cognitive and behavioral, which are thought to play a role in the development and maintenance of the suicidal behavior. It should also reflect the role of external factors, such as family problems or problems with peers, as well as the patient’s views of themselves and of their world. It is possible that the formulation may elucidate various treatment options, but either way, the creation of a formulation is an essential part of cognitive-behavioral therapy with suicidal patients.
Problem-solving is a key ingredient of the cognitive-behavioral approach to suicidal behavior. Although the immediate antecedents of many episodes of suicide are often identifiable in specific cognitions or emotions, the trigger is usually caused by some external problem. These problems are usually interpersonal in nature, and involve both family and peers. Training in problem solving helps patients cope with external challenges, and also provides a useful model for a cognitive-behavioral approach.
At the center of the cognitive approach with suicidal patients are techniques used to elicit, question, and correct distorted conceptualizations and beliefs of the external world. An important emphasis should be given to self-monitoring; the use of a thought diary may aid in verifying links between events, thoughts, and emotions.
Cognitive restructuring also is an important part of therapy. After thoughts have been identified, arguments and evidence supporting and subsequently casting doubts on their reality should be pursued. Finally, patients should reach a reasoned conclusion based on available data, both for and opposed to their beliefs.
Many CBT programs for suicidal patients are based on a system of reward to reinforce desirable behaviors. The reward system may involve relatives as well as friends, but may also involve self-reinforcement, in which patients reward themselves. It has been shown that suicidal behavior can be worsened by inactivity. Therefore, activity scheduling, giving importance to pleasurable activities, is a fundamental process.
Despite all the efforts that have been made during the last century since the publication of the first scientific work by Durkheim (1897), significant progress in this area of clinical intervention has been limited.
Van der Sande et al (1997), in their literature review, discovered that only four studies that applied cognitive-behavioral techniques were useful in preventing future suicide attempts. However, these studies involved very specific populations: women who suffered from borderline personality disorder (Linehan, Heard, & Armstrong, 1993; Linehan, Tutek, Heard, & Amstrong, 1994) and with low lethality; adolescents (Brent, 1997; Rotheram-Borus, Piacentini, Miller, Graae, & Castro-Blanco, 1994) also with low lethality; and young adults at high risk of suicide (Salkovskis, Atha, & Storer, 1990) but with a very small sample size and lax methodology.
On the other hand, Hollon, De Rubeis and Evans (1996), in a more extensive controlled study, found a statistically significant difference when CBT was used as an adjunct to biological treatments, in patients with severe depression, to prevent future relapses. The authors of that study speculated whether CBT, when used as an adjunct to psychopharmacological therapy, could also have a protective effect in decreasing rates of attempted suicide in patients who used more lethal means of suicide.
I believe that an increased focus should be placed on studying suicide as an independent clinical syndrome with its own psychopathology and for which, therefore, corresponding specific therapeutic solutions are needed.
Brent, D. (1997). A Clinical Psychotherapy Trial for Adolescent Depression Comparing Cognitive, Family and Supportive Therapy. Arch Gen Psychiatry, 54(9): 877-885.
Durkheim, É. (1897). Le Suicide – Étude de sociologie. Paris: Les Presses universitaires de France.
Hollon, S. D., DeRubeis, R. J., & Evans, M. (1996). Cognitive Therapy in the Treatment and Prevention of Depression. In P. Salkovskis, Frontiers of Cognitive Therapy. New York: Guilford Press.
Linehan, M. M., Heard, H., & Armstrong, H. (1993). Naturalistic Follow up of a Behavioral Treatment for Chronically Parasuicidal Borderline Patients. Arch Gen Psychiatry, vol.50, pp.971-974.
Linehan, M. M., Tutek, D. A., Heard, H. L., & Amstrong, H. E. (1994). Interpersonal Outcome of Cognitive-Behavior Treatment for Chronically Suicidal Borderline Patients. Am J Psychiatry, 151(12): 1771-6.
Rotheram-Borus, M. J., Piacentini, J., Miller, S., Graae, F., & Castro-Blanco, D. (1994). Brief cognitive-behavioral treatment for adolescent suicide attempters and their families. J Am Acad Child Adolesc Psychiatry, 33(4):508-17.
Salkovskis, P. M., Atha, C., & Storer, D. (1990). Cognitive-Behavioral Problem Solving in theTreatment of Patients who Repeatedly Attempt Suicide. A Controlled Trial. British Journal of Psychiatry, 157: 871-876.
van der Sand, R., Buskens, E., Allart, E., van der Graaf, Y., & van Engeland, H. (1997). Psychosocial Interventions Following Suicide Attempt: A Systematic Review of Treatment Interventions. Acta Psychiatr Scand, 96 (1): 43-50.