Box 3: Steps for Creating a Crisis Card 1. Explain the rationale to the client : I’d like us to come up with some steps you can take if you become upset or start thinking about suicide. It can be hard to think clearly when you are having this kind of crisis, so I’d like us to write the steps on this index card (or keep them as a note in your smart phone), and you can pull out these steps when you realize you are thinking about suicide. 2. Brainstorm with the client things that make him or her feel better : Clinicians can ask: What have you found helps you when you feel badly? How have you taken the edge off intense feelings? How do you distract yourself from suicidal thoughts? What helps you feel even a little better? Helpful activities are ones that have worked in the past or require at least one of the following: ○ Attention (e.g., working on a puzzle requires attention; watching television does not require attention). ○ Physical activity. ○ Increased belongingness (e.g., calling a friend, going to a place with people, such as a restaurant or mall). See Appendix A and Resources for other ideas on pleasant events for adults. ○ Step 1: [pleasurable activity or therapy skill]. ○ Step 2: [pleasurable activity or therapy skill]. ○ Step 3: [pleasurable activity or therapy skill]. ○ Step 4: Repeat all of the above. ○ Step 5: If the thoughts continue, get specific, and I find myself preparing to do something, I’ll call (insert number of emergency call person) or 1-800-273-TALK. ○ Step 6: If I still feel suicidal and don’t feel like I can control my behavior, I’ll call 911 or go to the emergency department. Cognitive behavioral therapy 3. List the helpful activities on the card in a step format . Example: When I’m upset and thinking about suicide, I’ll take the following steps:
Cognitive and behavioral therapies (CBT) usually are short- term treatments (i.e., often between six and 20 sessions) that focus on teaching patients specific skills. CBT is different from many other therapeutic approaches because it focuses on how a person's cognitions (i.e., thoughts), emotions, and behaviors are connected and affect one another. Behavior therapists and cognitive-behavior therapists usually focus more on the current situation and its solution, rather than the past. They concentrate on a person’s views and beliefs about their life, not on personality traits. CBT trials with suicidal adults typically find encouraging results and several models share key features, some of which 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 (Bryan et al., 2019). In the case of suicide crises, clinicians using a CBT approach can also incorporate Safety Planning procedures or Crisis Cards into their treatment approach.
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 adolescents and young adults, 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.
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Book Code: SWUS1525
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