CBT trials with suicidal adults typically find encouraging results (Ougrin et al., 2015). Several models, which share key features, have been studied and are described below (e.g., Asarnow et al., 2017; Bryan, 2019; Lee, Bryan, & Rudd, 2020; Singer, O’Brien, & LeCloux, 2017). The central premise of cognitive theory is that the meaning people assign to environmental stimuli significantly shapes subsequent affect, and affect is in turn associated with their behavioral responses (Asarnow et al., 2017). Several empirically-based suicide cognitive constructs are identified through assessment, including hopelessness, heightened impulsivity, information-processing biases, problem- solving deficits, and dysfunctional attitudes. Behavioral approaches vary; however, they focus mostly on how some thoughts or behaviors may accidentally be “rewarded” within one’s environment, contributing to an increase in the frequency of these thoughts and behaviors. Behavior therapies can be applied to a wide range of psychological symptoms to adults, adolescents, and children. Although behavioral therapies are different from disorder to disorder, a common thread is that behavioral therapists encourage patients to try new behaviors and not to allow negative “rewards” to dictate the ways in which they act. Once cognitive constructs are identified, a comprehensive behavioral chain analysis is conducted to specify antecedents and consequences of suicidal thoughts and behaviors. CBT includes several strategies to reduce suicide risk including behavioral activation, emotion regulation, cognitive restructuring, enhancing problem-solving skills, and improving interpersonal effectiveness (Brent et al., 2011). CBT also contains techniques designed to reduce suicide risk when crises emerge (Lee et al., 2020). Clinicians help suicidal individuals elicit social support from others and discuss the significance of reducing periods of isolation when feeling depressed or suicidal. In lieu of the “no-suicide” contracts described previously, CBT clinicians implement commitment- to-treatment statements. These statements may help patients feel more connected to their clinician, thus increasing a sense of belongingness. CBT clinicians use crisis cards, but they must provide more than just emergency numbers. Similar to safety planning intervention, crisis cards highlight mood regulation techniques, pleasant activities, and emergency numbers in the event that other techniques fail to reduce suicidal symptoms. Using this technique, clinicians assist patients to match protective behaviors with feelings, thoughts, or nonprotective behaviors that might activate a suicidal crisis. For example, agitation may be met with relaxation and/or exercise. Dialectical behavior therapy Dialectic behavior therapy (DBT; Linehan, 1993) is one of the most commonly used psychotherapeutic techniques for recurrent suicidal behavior. DBT is based on concepts from cognitive behavioral therapy, and it has been used mostly in patients with borderline personality disorder, but increasing evidence suggests it may be useful to people with a variety of different diagnoses (DeCou, Comtois, & Landes, 2019). Furthermore, DBT is one of the few treatments for suicidal individuals with solid data supporting its use in both adults and adolescents (DeCou et al., 2019; McCauley et al., 2018; Rathus, Berk, Miller, & Halpert, 2020). The roots of dialectical behavior therapy (DBT) lie in Marsha Linehan’s work with chronically suicidal adult patients. She originally attempted to use cognitive behavioral strategies with these individuals, only to discover that those approaches simply did not work well. The population with which she was working felt misunderstood and invalidated. Cognitive behavioral therapy’s exclusive focus on change often pushed individuals into feeling emotionally overwhelmed, and they would frequently shut down. Conversely, focusing on acceptance also had its limitations. Individuals would feel extreme hopelessness or even rage at the clinician for failing to appreciate their emotional suffering and for treating it as inconsequential. As a result, Linehan (1993) developed DBT as a model that
Loneliness may be addressed with behavioral activation with an interpersonal focus, such as calling a friend. Each suicidal crisis trigger is then written on a card with an identified protective symptom-matching technique to be used when the trigger occurs. Thorough assessment aids in the creation of symptom- matching hierarchies (Chu et al., 2015). See Box 3 above for a sample format of a crisis card. Mood graphing can also be a useful strategy. Having patients record their mood at several points throughout the day can provide patients and clinicians with information for their ongoing assessment and about the outcomes of various interventions. Finally, some clinicians have used a hope kit to facilitate reasons for living when patients are feeling suicidal (Denneson et al., 2019). To make a hope kit, patients fill a small box with items that lead to positive feelings, instill hope, and take the edge off a suicidal crisis. Examples of items in the hope kit include pictures of the patient with loved ones, awards from school, and cards or letters from important people. Patients are instructed to place the hope kit in a prominent area, such as in the case of adolescents, a desk in their bedroom. Simply viewing the hope kit on a regular basis may help prevent a crisis once the adolescent realizes it contains concrete evidence of reasons for living. Recent research advances have pioneered the use of digital hope kits through the use of smartphone apps (Bush et al., 2015). In addition to more general CBT approaches to suicide, some suicide-specific CBT protocols have been created, such as CBT for Suicide Prevention (CBT-SP; Bryan, 2019). CBT-SP can be used with adults and adolescents and includes: ● Cognitive restructuring strategies : Such as identifying and evaluating automatic thoughts from cognitive therapy. ● Emotion-regulation strategies : Such as action urges and choices, emotions thermometer, index cue cards, mindfulness, opposite action and distress tolerance skills from DBT (discussed below). ● Other CBT strategies : Such as behavioral activation and problem-solving strategies. Thus, although CBT-SP contains many elements of traditional CBT, it also focuses on some key issues involved in suicidal behavior that might not be addressed outside the context of suicidal behavior, especially with regard to emotion-regulation skills. In the case of youth and adolescents, suicidal crises occur within an environment that may include problematic relationships, abuse, family dysfunction or poor school performance, CBT- SP includes family interventions if needed. would balance and synthesize the opposing tensions between acceptance and change, good and bad, positive and negative. An important dialectical idea is that each position contains within it its own opposition. As Miller, Rathus, and Linehan (2007) describe it, “dialectic refers to change by persuasion and by making use of the oppositions inherent in the therapeutic relationship, rather than by formal impersonal logic” (p. 39). The therapy involves balancing problem solving and validation. Dialectic behavior therapy promotes the belief in one’s own ability to succeed, the ability to emotionally self-regulate, and interpersonal effectiveness. It has repeatedly been shown to reduce the recurrence of suicidal behaviors in affected patients when compared to standard treatment for both adults (DeCou et al., 2019) and adolescents (McCauley, Berk, Asarnow, Adrian, Cohen, et al., 2018). The DBT perspective emphasizes the role of emotional dysregulation and impulsivity in suicide. DBT therapists would respond to the patient by first assessing the patient’s suicide intent. As in other therapies, if intent was high, the therapist would engage the patient in revisiting her commitment to refrain from life-threatening behaviors and review plans for safety. If the patient is safe to proceed with therapy, the DBT therapist might explore whether and how her suicidal ideation is an expression of her distress. The DBT therapist might use an intervention method called “extending,” wherein they
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