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Cognitive Behavioral Therapy forSuicide PreventionGregory K. Brown, Ph.D.VA/DoD Clinical Practice Guideline for SuicidePrevention Webinar SeriesApril 27, 2021Penn Center for the Prevention of Suicide

Disclaimer and Disclosure Dr. Brown’s views and opinions expressed in thispresentation do not necessarily state or reflect those ofthe United States Government including the Departmentof Veterans Affairs and the Department of Defense. Dr. Brown receives royalties from the ResearchFoundation for Mental Hygiene for the commercial useof the Columbia Suicide Severity Rating Scale.1

Learning Objectives1. Describe the general approach, rationaleand evidence supporting CognitiveBehavioral Therapy for Suicide Prevention(CBT-SP)2. Describe specific cognitive and behavioralstrategies for reducing risk3. Describe a competency-based training forlearning CBT-SP2

VA/DoD Clinical Practice Guidelinefor the Assessment and Management ofPatients at Risk for Suicide (2019)Strong recommendation for“using cognitive behavioraltherapy-based interventionsfocused on suicideprevention for patients witha recent history of selfdirected violence to reduceincidents of self-directedviolence” (p 27).3

Conceptual Underpinnings of CBT-SP Suicidal behavior is viewed as the primaryproblem rather than a symptom of a disorder Cognitive therapy for suicide prevention is viewedas an adjunctive treatment Suicidal behavior is viewed as a problematiccoping behavior Treatment is brief and focused (10 to 16 sessions)4

Suicidal Thoughts and Behaviorsas Primary TargetsBrown et al. (2005). JAMA, 295, 563-570.5

Survival Functions for Repeat Suicide Attemptby Study ConditionCT-SP was associatedwith a 50% reduction insuicide attempts in asevere sample with ahigh rate of repeatattempts.Cumulative Survival1.00.9CT-SP0.80.7*p .05Control0.60.50182364546728DaysSource: Brown et al. (2005). JAMA, 294, 563-370.6

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Brief Cognitive-Behavioral TherapySoldiers in briefCBT wereapproximately60% less likely tomake a suicideattempt duringfollow-up thansoldiers intreatment asusual.Source: Rudd, Bryan, et al. (2015).AJP, 172, 441-449.8

Cognitive Therapy for Suicide Prevention Initial Phase Informed Consent Motivational Enhancement Suicide Risk Assessment and Narrative Timeline Interview Safety Planning Intervention (Stanley & Brown, 2012) Reasons for Living & Dying and Hope Kit Treatment Goals and Case ConceptualizationMiddle Phase Cognitive & Behavioral Strategies Case Management StrategiesFinal Phase Skill Consolidation Relapse Prevention Task Treatment PlanningWenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitivetherapy for suicidal clients: Scientific and clinical applications.Washington, DC: APA Books.9

Problems with Treatment Engagement Individuals hospitalized for suicide attemptsoften do not attend outpatient treatment.Potential reasons include: Poor economic resources or practical barriers Negative attitudes toward treatment– Feels hopelessness about getting better, won’t behelpful Culturally-based beliefs about mental healthtreatment (e.g., don’t talk about things like that; helpshould be found within family/church/community, etc.) Mistrust of mental health treatment– Belief is common and valid among Black,Indigenous, people of color (BIPOC) populationsdue to discrimination and racism10

Assess Treatment Expectations Assess attitudes and expectations fortherapy: “What do you expect therapy to be like?” “Do you think therapy will be helpful?” “How willing are you to attend a few therapysessions to see if it would be helpful?” Discuss previous experiences in therapyand how it contributed to any negativeattitudes and expectations: “What happened the last time you went to therapy?How was it helpful? How was it unhelpful?”11

Address the Risks of Treatment Possibility of emotional discomfort Discuss potential strategies that can beimplemented should the client feel upsetfollowing a treatment session Potential negative effects of breachingconfidentiality Collaborate around involving others (includingemergency services) as a general rule Keep clients informed if confidentiality isbroken in emergency situations where youwere not able to discuss this first12

“Case Management” during CBT-SP Go the “extra mile” and reach out to patientsBe flexible in scheduling appointmentsMake reminder and check-in callsSend birthday and holiday cardsDiscuss cases in regular team meetings;frequent use of consultation (“huddles”) toreceive support13

Narrative Interview of Suicidal Crisis Obtain a detailed description of a suicidal crisis(e.g., recent attempt or recent moment whensuicidal ideation increased) Patients are asked to recall the suicidal crisis inas much detail as possible, including theactivating events and reactions to the events. Construct a timeline that indicates the majorexternal events and cognitive, emotional, andbehavioral factors proximal to the crisis Forms the basis of the case conceptualization Understand that suicidal thinking and behavior“makes sense” to the individual in the contextof his or her history, vulnerability, andcircumstances.14

Timeline of Suicide Attempt: ExampleDISTALACTIVATINGEVENT4.5 months ago,wife moves toMichigan w/ kidsKEY AUTOMATICTHOUGHTSWhat do you dowhen everythingis starting to fallapart?AFFECTIVERESPONSEAngerKEY AUTOMATICTHOUGHTSACTIVATINGEVENT”I never thought itwould come tothis.“Commander laidinto me andcalled meirresponsibleBEHAVIORALRESPONSEHad a few beers15

Timeline of Suicide Attempt: ExamplePROXIMALACTIVATINGEVENTArgued with wifeon EHAVIORPut gun to chinand call from afriend interruptedthe attemptTold friendeverything; wentto his place andtaken to clinicoffice.KEY AUTOMATICTHOUGHTS(MOTIVATION)KEY AUTOMATICTHOUGHTS(SUICIDE INTENT)I can’t take thisanymore. I don’tknow what to do.I’m helpless.“”Maybe it wouldbe easier if Iended it.Everything wouldbe fixed.REACTION TOSUICIDALBEHAVIORI don’t want to die16

CBT-SP Focuses on Modifiable Risk Factors Case Conceptualization and Selection of CBTStrategies: Each treatment session addresses thoughts,beliefs, and behaviors that are most proximallyrelated to the suicidal crisis and contribute to andmaintain hopelessness. Select CBT-SP strategies that are perceived byboth the clinician and patient to be the mosthelpful in preventing a future suicidal act.17

Hope Kit Identify and discuss reasons fordying and reasons for living Construct a Hope Kit or Survivor Kitto create a representation ofreasons for living Pictures Letters Poetry Prayer Card Coping Cards Meaningful mementos or tokens18

Common CBT-SP Strategies Behavioral Activation Used to increase meaningful or purpose-drivenactivities, strengthen or enhance reasons forliving, increase social connectedness, etc. Cognitive Restructuring Used to help individuals to identify and evaluatesuicide-related thoughts; increase cognitiveflexibility. Coping Cards Used to remind individuals of importantconclusions from therapy that can be easily usedin a crisis.19

Thought Record ExampleDate Situation12/18Automatic FeelingsThoughtsAlternativeResponseOutcomeWhat eventled to theunpleasantemotion?Whatthoughtswent throughyour mind?Whatemotionswere youfeeling?Use questions toWhatevaluate the thought. emotion doyou feel now?What will youdo?Checked themailNothing butbillsNo holidaycardsNo onewould careif I wasdead (95%)Sad (80)Lonely (90)Not many peoplesend cards anymore.It doesn’t meanpeople don’t care. Igot a call from mycousin the other dayand Carlene invitedme to Christmasdinner. They wouldtake it really hard if Ikilled myself becausethey really do care.I believe theoriginalthought 20%now.Not so down,actually, moreoptimistic(50)Still a littlelonely (30)I’ll call afriend andmake plans.20

Sample Coping Card Automatic Thought: “It’s too much; it’sover, there’s nothing you can do about it.” Adaptive Response: “Things have beenbad before. You always come out of itbetter in the end.”21

Common CBT-SP Strategies Planful Problem Solving Used to help individualsbrainstorm andevaluate potentialsolutions to solveproblems withoutresorting to suicide. Examine Pros and Cons Used to help individualsresolve ambivalenceand make importantdecisions.Locking firearm in safe andgiving key to KeatsProsConsStaying on trackin treatment; If Ikill myself,treatment won’thelpI would be givingin to what otherstell meIt would makemy family feelbetterI won’t have it forprotectionIt might make itmore “out ofsight, out ofmind”22

Review and Consolidate Skills Reviewing coping skills: “Which skills were most helpful in reducing your suicidalideation and desire for suicidal behavior?” “What have you learned through this experience?” “What further goals do you have for yourself?” If the patient has difficulty generating a list ofspecific CBT coping strategies, then they maynot be ready for the later phase of treatment Preparation for the Relapse Prevention Task23

Relapse Prevention Task Goals Rehearse coping with future crises. Assess treatment progress. Determine if additional sessions are alCrisiswith 4

Age-adjusted Suicide Rates, by Sex: US, 1999-2019Hedegaard et al. NCHS Data Brief. 2021 Feb;(398):1-8.25

Suicide Rates for Females by Age Group: US, 1999-2019Hedegaard et al. NCHS Data Brief. 2021 Feb;(398):1-8.26

Suicide Rates for Males by Age Group: US, 1999-2019Hedegaard et al. NCHS Data Brief. 2021 Feb;(398):1-8.27

Risk Factors for Suicide Among Older Adults Older adults have a lower lifetime prevalence ofsuicide attempts than younger adults Suicidal ideation is a major risk factor for death bysuicide for older adults Older adults often experience significant loss (e.g.,death of partner, medical problems, independence,etc.) that increases risk Older men are often reluctant to disclose suicidalideation to others Older men are likely to engage in “passive” suicidalbehavior (e.g., failing to take prescribed medications)28

Adapting CBT-SP for Older Men Greater focus on reducing suicidal ideation Treatment length was extended from 10 sessionsto 16/20 sessions to address persistent ideation Pacing was slower. Take your time! Used whiteboards to stay on the agenda andprevent drift Used worksheets and forms with LARGE FONTS Used post-it notes; laminate important informationsuch as Coping Cards Provided written summary of the session andwritten homework assignment with rationale(reminders)29

Cognitive Therapy for Suicidal Older MenAssessed for Eligibility(N 332)Baseline Assessment(N 110)Randomization(N 95)Cognitive Therapy16 Sessions(N 46)Follow-up Assessments1, 3, 6, 9, 12 months(N 34 completed 12M)Case Management16 Telephone Sessions(N 49)Follow-up Assessments1, 3, 6, 9, 12 months(N 42 completed 12M)NIMH: R01MH086572-1A2, PI: Brown GK; ClinicalTrials.gov: NCT0153548230

Cognitive Therapy for Suicidal Older MenInclusion Criteria:1. Suicidal desire or intent in the past month (SSI Items 4 or 5 0)2. Male gender3. 50 years of age or older4. English speaking5. Able to provide informed consent6. Able to attend the study assessment and therapy sessions7. Provide at least 2 verifiable contacts for tracking purposes8. Cognitive Functioning: MMSE 24 and EXIT-25 14Exclusion Criteria:1. Needed priority treatment for a substance use disorder or PTSD2. Taking antidepressant medication for less than four weeks orchange in antidepressant medicationNIMH: R01MH086572-1A2, PI: Brown GK; ClinicalTrials.gov: NCT0153548231

Demographics Mean age 60.68 (SD 5.68; Range 50-80) Race: 51.6% Black 41.1% White 1.1% Asian/Pacific Islander 1.1% American Indian 5.3% Other Ethnicity: 0% Hispanic/Latinx 95% were VeteransNIMH: R01MH086572-1A2, PI: Brown GK; ClinicalTrials.gov: NCT0153548232

Columbia Suicide Severity Rating ScaleSeverity of Ideation Scale:Worst Point Since Last Assessmentb -0.05; p .02; 95% CI: -0.10 to -0.01NIMH: R01MH086572-1A2, PI: Brown GK; ClinicalTrials.gov: NCT0153548233