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Cognitive Therapy for Adolescent and Young Adult Suicide Attempters

Gregg Henriques, , Aaron T. Beck, and Gregory K. Brown, American Behavioral Scientist 2003 46: 1258 DOI: 10.1177/0002764202250668 The online version of this article can be found at: http://abs.sagepub.com/content/46/9/1258

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ARTICLE

Cognitive Therapy for Adolescent and Young Adult Suicide Attempters

GREGG HENRIQUES AARON T. BECK GREGORY K. BROWN
University of Pennsylvania

Although there is a large and increasing literature on biological, psychological, and social characteristics of suicidal behavior, there is a relative lack of information dealing specifically with how to treat suicidal adolescents and young adults. A 10-session cognitive intervention for older adolescents and young adults who have attempted suicide is described in detail. A novel element of the therapy is that the treatment can be applied to individuals exhibiting suicidal behavior, regardless of psychiatric diagnosis. Information is provided about how to structure therapy sessions and how therapy progresses through the early, middle, and later stages. New, specific strategies are offered for helping suicidal individuals learn to cope more adaptively with crises and distress. Keywords: cognitive therapy; suicide attempters; adolescents; depression

Currently the third leading cause of death for 15- to 24-year-olds, suicidal behavior in adolescents and young adults is a serious public health problem. Yet, despite the prevalence of the problem and in contrast to the large and growing literature on assessment and risk of suicide, there is little information about the practical aspects involved in treating suicidal patients (Ellis, 2001). Only in the past decade have specific interventions been developed for suicidal adolescents and young adults (see Jobes, Luoma, Jacoby, & Mann, 1998; Miller, Rathus, Linehan, Wetzler, & Leigh, 1997; Rudd, Joiner, & Rajab, 2001). In this article, we describe a brief cognitive intervention developed for treating suicidal behavior in older adolescents and young adults that provides practioners with a specified conceptual framework and a varied set of interventions that can be practically employed by mental health professionals working with this difficult-to-treat population. A key, novel element of the intervention is that suicidal behavior is regarded as the primary problem, in contrast to traditional approaches that conversely view suicidal behavior as a symptom of some other underlying condition. Another central philosophical element that guides the intervention is the notion that the suicidal behavior is both understandable
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given the patients frame of reference and ultimately disadvantageous to the patient. The efficacy and effectiveness of the intervention is currently being evaluated in a randomized controlled clinical trial.

THE COGNITIVE INTERVENTION FOR SUICIDE ATTEMPTERS The intervention presented here was born out of the cognitive model of emotional disorders in general and depression in particular, as well as the large empirical literature linking hopelessness with suicidal behavior (e.g., Beck, Steer, Kovacs, & Garrison, 1985). In accordance with cognitive theory, the central feature of the intervention is the identification of proximal thoughts and associated core beliefs that were activated just prior to the patients suicide attempt. With the particular cognitive components identified, cognitive and behavioral strategies are applied to help individuals develop more adaptive ways of thinking about their situation and more functional ways of responding during periods of acute emotional distress. The focus of the therapy is on reducing suicidal behavior and key elements of the intervention including (a) developing specific ways to address hopelessness and target suicidal behavior, (b) developing effective ways for engaging patients quickly in the treatment to reduce dropout, (c) increasing adaptive use of other health services, and (d) increasing the adaptive use of social support. The intervention is a 10-session protocol with specific strategies developed for the early, middle, and late phases of the treatment. The therapist plays an active and directive role in working with the patient in a collaborative manner to explore the individuals perceptions, interpretations, and explanations related to suicidal behavior. The structure of the therapy sessions consists of agenda setting; checking symptoms such as mood, suicidal ideation, and behavior; monitoring use of substances; monitoring compliance with other treatments; building bridges between past sessions with a particular focus on beliefs related to the suicide attempt; making capsule summaries; eliciting feedback throughout the session; and assigning homework. Below, we describe the main strategic elements as they might occur in a typical course of therapy. We would like to underscore the importance of using a flexible approach in implementing the procedures described here. Under optimal circumstances, patients are motivated for treatment, attend each session on time, and complete all their homework assignments. However, we have found that these optimal circumstances are uncommon. In making clinical decisions, the therapist is encouraged to individualize therapy to the styles, capacities, and needs of patients, as opposed to just getting through the material. At the same time, we would like to emphasize the danger in becoming wrapped up in the magnitude of the individuals difficulties and losing sight of the primary focus on curbing suicidal behavior. Maintaining an empathic, validating position

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while at the same time keeping the focus on the problem at hand is where much of the art of the clinician comes into play.
EARLY PHASE OF TREATMENT (SESSIONS 1-3)

The main goals in the early phase of treatment are to (a) engage the patient in treatment, (b) have the patient tell their story about the suicide attempt, (c) assess the patient for risk of suicidal behavior, (d) develop a safety plan for suicidal emergencies, (e) orient the patient to the cognitive model, (f) begin to develop a cognitive conceptualization of the suicide attempt, (g) begin to develop a problem list and goals for the therapy, and (h) convey a sense of hope to the patient. Engaging the patient in treatment. Before therapy with suicidal patients is possible, it is necessary to increase the likelihood that they attend subsequent sessions. Yet, historically, providing effective interventions for suicide attempters has been problematic precisely because they are difficult to engage in treatment. There are many reasons for this difficulty, including very low economic resources (making things like transportation difficult), chaotic life styles, beliefs that treatment is futile or unnecessary, severe depression, alcohol or drug abuse, avoidant coping styles, poor self-management skills, shame about the suicide attempt, stigma associated with receiving treatment or help, and cultural issues that may affect patients beliefs about and behaviors toward the use of physical health and mental health services. Because of these factors, the therapist must adopt a proactive stance in engaging the patient in therapy. This requires a shift in the traditional mind-set of clinicians that the responsibility for getting to therapy lies solely with the patient. Simply scheduling an appointment with a patient for a specific hour a week or even several days in advance is usually inadequate. Reminder calls within 24 hours of the scheduled appointment, discussion about the types of factors that would prevent the patient from attending, and a strategy for contact if the individual does not show up for the appointment are recommended. Having funds available for helping patients with transportation, child care, and emergency food money is also useful. If, despite these efforts, patients continue to not show up, we recommend conducting a session on the phone, with an item on the agenda being a discussion about the patients difficulties attending therapy and a specific plan for attending the next session and what to do in the event that the patient misses that session. History of suicidal behavior: Telling their story. One task of the early sessions is helping patients tell their story. The therapist asks the patient to talk about the events that led up to the suicide attempt and the details of the suicide attempt itself. While doing so, the therapist listens and questions the patient in an empathic way to elicit the life problems, thoughts, images, and feelings that led

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to the attempt. There are several important reasons for having patients describe details about the suicide attempt. First, it gives them a chance to feel heard. It is often the first time they have had the chance to discuss their innermost, desperate thoughts with another person. In so doing, the sharing of the story facilitates rapport building and helps patients engage in treatment. This intervention also facilitates the development of a conceptualization of the individuals suicidality and an assessment of future risk. Assessment of suicide risk. Because suicide attempts constitute a significant risk of suicide, a thorough assessment of suicidal thoughts and behaviors is an essential component of the initial evaluation. The patients account of his or her most recent suicide attempt is a valuable source of information that allows the therapist to conceptualize the patients suicidal behavior and begin to assess current and future risk for suicide. In addition to the standard evaluations of suicidal ideation, intent, plan, and access to lethal means, we strongly recommend that clinicians consider as indicators of heightened risk the severity of the depression and hopelessness, recent major losses or stressors, the history of suicidal behavior, unemployment status and other economic factors, and whether the individual has a substance abuse/dependence disorder. Constant monitoring of suicidal ideation should be conducted both clinically and by self-reported levels of hopelessness and depression, particularly items 2 and 9 of the BDI-II. Developing a safety plan. Because it is often difficult for patients to problem solve effectively when they are suicidal, a safety plan is developed and tailored for each patient. The safety plan is a hierarchically arranged written list of coping strategies, developed collaboratively by the patient and therapist, which the patient can do if a crisis situation arises. At a minimum, the safety plan should include the telephone numbers of (a) social supports, (b) the therapist, (c) the oncall therapist, (d) a local 24-hour emergency psychiatric center, and (e) other local support services that handle emergency calls. It should clearly communicate to patients that appropriate professional help is accessible in a crisis and, when necessary, make clear to patients how that help can be accessed. As described below, during the middle phase of therapy, the patient and therapist collaboratively work to develop specific coping strategies, such as coping cards, relaxation techniques, social supports, and the construction of a hope kit that can all be incorporated into a safety plan. Introduction of the cognitive model. A major goal of cognitive therapy is to help patients learn to become their own therapists. To do this, patients are explicitly taught about the relationship between interpretations and explanations, feelings, and behavior. Bibliotherapy also can be useful and literate patients can be provided with pamphlets on coping with depression and a book called Choosing to Live: How to Defeat Suicide Through Cognitive Therapy (Ellis & Newman, 1996). This self-help book is a useful companion guide for working with

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patients who are contemplating suicide and reading chapters of it often serves as an appropriate homework assignment. Therapists might focus patients attention on parts of the book that are most relevant and/or ask the patients themselves to point out relevant sections and discuss them in the next session. Developing a cognitive case conceptualization. Another advantage in having patients tell their story is that it can be used to develop a cognitive conceptualization of the suicide attempt. In developing the cognitive conceptualization, the therapist is assessing patientsresources, distal/developmental causes, proximal stressors, maladaptive information processing and dysfunctional core beliefs, and deficits in problem solving. A major focus of the intervention is the specific beliefs associated with the suicide attempt. For example, many patients justify their suicidality through hopeless cognitions, such as Things will never improve. The intervention is structured to identify these specific cognitions and to target them explicitly. A cognitive conceptualization diagram is developed that depicts relevant early experiences, identified or hypothesized core beliefs, conditional beliefs that set the stage for particular compensatory behavioral strategies, activating events that tend to precipitate suicidal impulses, and negative suicidal thoughts that ultimately result in the suicide attempt. The conceptualization serves to provide a cognitive road map of the patients psychopathology and organizes large amounts of data into a coherent whole. Therapists complete and amend the diagram as data are gathered throughout the course of treatment. Teaching problem solving and developing a problem list. Given the relationship between problem-solving deficits and suicidal behavior (e.g., Salkovskis, Atha, & Storer, 1990), both modeling and teaching problem-solving strategies to suicidal patients are highly recommended. By asking patients about problems that may have triggered their suicide attempt, the discussion can usefully identify and elaborate on the relationship between life problems and mental health problems. Furthermore, therapists emphasize the connection between the problems the patient was having and the suicide attempt. The goal of suicide is usually to escape from pain that an individual believes is unbearable and unending or to change something in the environment. This conception allows one to see the suicidal behavior as an attempt to solve ones problems, which in turn makes it easier to evaluate the functionality of the behavior. It is also recommended that the therapist and patient work to develop a Problem List, which clearly identifies the areas on which the patient needs to work. The problems are then prioritized and some basic framework is established for addressing them. It is important to note that suicidal patients are often faced with multiple, longstanding problems and it is likely that many of the problems on the list will not be addressed in the context of a brief therapy. This reality can be turned to a benefit because it provides the impetus for prioritizing the problems the individual is facing. Such a process can be an excellent learning experience

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for tackling difficult, multifaceted concerns. The list also can function as a guide or prompt for suggesting homework assignments that serve as steps that can be taken toward reaching some of the goals. Transforming hopelessness into hope. At the most basic level, the task of the therapist is to join with the patient and instill hope. Through first empathizing with why the patient has come to see the situation as hopeless and then validating the patients experience, the therapist helps the patient see that even in the worst of situations, hoping smart is a more functional way of responding to adversity than hopelessness and despair. Change is always a possibility and it is always possible that things could get better. This does not mean that the therapist adopts a Polyanna-ish attitude. Instead, the therapist recognizes that by becoming hopeless one inevitably gives up power and the possibility to change; thus, the more functional approach is to retain a realistically optimistic orientation toward life and its inherent difficulties and promise.
THE MIDDLE PHASE OF TREATMENT (SESSIONS 4-7)

The middle phase of treatment consists of a focus on developing new skills for reacting to distressing situations with a focus on cognitive restructuring and behavioral change. The treatment becomes increasingly focused on the individuals core beliefs associated with the suicide attempt and develops specific ways of dealing with them. Changing maladaptive beliefs and automatic thoughts. One of the fundamental tenets of the cognitive model is that there is an interrelationship among thoughts, feelings, and behaviors. If patients can begin to change the way they perceive themselves, the world, and their future, they will likely begin to change the way they feel and behave. To facilitate the identification of the relationship among thoughts, feelings, and behavior, patients can be instructed to note when their mood shifts (e.g., when they become sad, angry, anxious, suicidal) and ask themselves, What went through my mind? and can be assigned to keep a log of situations that elicit negative thoughts, the content of the thoughts, the emotion associated with them, and any behavioral impulses they may have. After the patients are able to see the relationship among thoughts, feelings, and behaviors, the therapist teaches them techniques to develop adaptive alternatives to these thoughts. We have found the development of coping cards to be particularly useful in helping patients to identify and develop more adaptive responses to their dysfunctional thinking. Coping cards are small cards that the patient can carry around with them. The patient and therapist collaborate in discovering key cognitions that are salient when the individual becomes suicidal. These thoughts are placed on one side of the card; on the other side of the card, alternative, adaptive responses to the thoughts are listed. For example, one patient had the thought, My situation is hopeless and will never get better; this

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belief was placed on one side of the card, with the adaptive responses she generated: Although I am overwhelmed now, I know this is temporary, I have solved problems that initially looked unsolvable before, and Getting hopeless does not help, I need to consult with someone who can help me look at my situation objectively, on the other side of the card. Emergency numbers also can be placed on the card. Construction of a Hope Kit. We have found that a particularly helpful intervention is to suggest that patients make a Hope Kit. Many patients report that when they are in an emotionally charged state they have difficulty recalling reasons to live or coping statements that were devised in prior sessions. The kit serves as a memory aid to be used at a time of crisis. The kit is a box in which they put items that remind them of reasons to live. For example, one patients kit was comprised of pictures of her dog, a handmade finger painting that her younger sister had made for her, an award from school, a letter from a friend, a passage from the Bible, a prayer card, and a coping card made in session. She decorated the box with inspiring words and pictures on the outside of the box. She then put the kit in a conspicuous place in her home with the strategy that she could use it in a time of crisis. She reported that putting the time and effort into making the kit and deciding which items to place in the box solidified her thinking regarding her reasons to live. Building affective coping skills. A range of affective regulation strategies can be taught to patients with the goal of increasing distress tolerance. This serves the purpose of enabling patients to better regulate their emotionality without resorting to self-injury and suicide. Physical self-soothing or exercise can be very useful. Patients also can be taught progressive muscle relaxation and controlled breathing exercises to decrease the physiological arousal associated with distressing emotions. Patients can be taught distraction techniques to counteract their volatile emotions and desires to flee from situations by focusing their attention on any of a number of neutral or positive thoughts. They can try to recall positive memories or imagine a pleasant scene. These self-soothing strategies should be made explicit and worked into the patients crisis plan. Such strategies can come early in the arranged list so that when an individual begins to feel overwhelmed, she can first take a bath, paint her nails, take a walk, and so on as ways of distracting, calming, and delaying an emotional crisis. Addressing impulsivity. Many patients who make suicide attempts are impulsive individuals. These patients can be taught to procrastinate around their suicidal impulses. Explaining that suicidal urges typically occur in waves can be very helpful, often with the aid of a diagram charting the individuals mood and suicidality across time. A mood diagram can be a strong visual tool demonstrating that the individual is not constantly suicidal. With such tools, the patients can learn to ride out the suicidal urge, because the intensity will eventually decrease.

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Strategies to deal with suicidal impulses include sleeping, talking or visiting with someone, calling their therapist, or engaging in ordinary tasks (e.g., cleaning, singing to the radio). In addition to these short-term strategies for delaying suicide, long-term strategies are also suggested. Patients should be urged to reflect on the things that they have been meaning to do with their life that they have either not started or not completed. A potential homework assignment could be to ask the patient to generate a list of these items and write down all of the reasons why these tasks have been important. Another useful problem-solving strategy to address problems of impulsivity is to help patients distinguish between short-term and longterm solutions. Impulses can be thought of as short-term solutions and the therapist and patient can engage in discussions about the pros and cons of constantly adopting short-term solutions at the expense of long-term ones. Another delay tactic includes encouraging patients to safeguard their environment to make it more difficult (i.e., less convenient) to kill themselves. Patients should be encouraged to dispose of any extraneous lethal means at their disposal. By making their environment one in which it is difficult to attempt suicide, the patient will buy time to safely get through low periods. Increasing social support. A general goal of therapy with suicidal patients is the gradual establishment of an adaptive network of accessible social support. For some, this simply means turning their attention toward the people who are most caring in their lives and who would be glad to help. Family resources are particularly important to explore with adolescent and young adult suicide attempters and we have noted that some patients who attempt suicide underutilize their family resources. Many patients who have attempted suicide report that no one cares and they are all alone. Detailed questioning often reveals that many patients have family members who do care and make efforts to be involved in the patients life. One method that we have found helpful to understanding and capitalizing on the patients family resources devotes one or two sessions to a family meeting. The family meeting helps the therapist determine how much a patients belief that he or she is alone is true versus how much it is a distortion. Increasing compliance with adjunctive health and social services. People who attempt suicide frequently face numerous psychiatric, substance abuse, and physical health problems as well as social and economic problems. It is therefore likely that they can benefit from a range of psychiatric, substance abuse, physical health, and social services. Yet, compliance with these services among suicide attempters is often poor. Consulting with appropriate professionals and services is central to working effectively with this patient population in so far as the types of problems patients present are unlikely to be addressed by one service alone. Therefore, integration of services and inclusion of adjunctive services often may be key to treatment success.

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LATER SESSIONS

Relapse prevention task for coping with suicidal thinking. When the therapist believes that the patient has made gains in therapy, a formal assessment of increased cognitive-behavioral skills is indicated. A guided imagery relapse prevention task (RPT) can serve as an endpoint assessment. The objective is to prime, in session, as many of the thoughts, images, and feelings associated with prior suicide attempts as possible and to determine if the patient is able to respond to problems in an adaptive way. The RPT consists of five stages. The first stage is describing the task, which consists of imagining both past and possible future sequences of events that result in the patient becoming suicidal. The therapist might provide the rationale to patients that by imagining the suicide attempt and reliving the pain and distress they experienced, they will be able to see if they are able to recall the coping strategies discussed in therapy. The imagery exercise serves as a chance to practice coping in imagination, which might help coping in real-life situations. The therapist should forewarn patients that they may have a strong emotional response to this experience but that it is to be expected, and there will be time to talk through it before they leave. In the second stage, the therapist has the patient imagine the sequence of events and concomitant thoughts and feelings that led up to the suicide attempt. The therapist sets up the scene, reviewing the situational and personal triggers associated with previous attempts. Next, the patient is asked to describe the scene. For example, the therapist might ask patients to describe everything that they see, hear, smell, and feel. Afterward, patient and therapist collaboratively summarize the sequence of events and their meaning to the patient. The third stage involves using the same format as before but this time responding to maladaptive thoughts and images with the tools learned in therapy. This step aims to test whether the patient can, in imagery, produce alternative ways of responding. In the fourth stage of the relapse prevention task, the therapist uses the patients conceptualization to develop a scenario that the patient might face in the future that would likely lead to suicidal thinking. The therapist first clarifies the nature of the task and then uses guided imagery to direct the patient through a possible sequence of events and concomitant thoughts and feelings. Once the patient can imagine a distressing sequence of events to the point where the person reports imagining becoming suicidal, the therapist then asks the patient to imagine how he or she might proceed to cope with such a situation. As the patient generates possible solutions and activates learned coping strategies, the therapist praises the patient for adaptive responding but also proposes additional challenges. The additional challenges are done to evaluate the depth and flexibility of the patients adaptive responding. The final stage involves debriefing patients. After the relapse prevention task is given, patients are then asked to return to the therapy session and describe how

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they feel. Any suicidal ideation activated by the task is explored, and the patient remains in the session until all such thoughts have subsided.
ANTICIPATING LAPSES AND CONSIDERING THE MAINTENANCE OF TREATMENT GOALS

High rates of chronic stressors and low resources for solving complicated problems among suicidal patients may make relapse of psychopathology likely. The therapist needs to check the patients expectations for what is considered to be satisfactory maintenance of gains. The therapist should prepare the patient for mood fluctuations and setbacks. The therapist must caution patients against catastrophic and all-or-nothing thinking, explaining that if they suffer a setback, it does not mean that they are back to square one. It is also helpful to ensure that patients explore what is realistic to expect in terms of normal mood fluctuations. Some patients become alarmed when they feel sad or hopeless and believe it is a signal of an impending spiral of depression. The therapist should look for this tendency and address it as it occurs in session.
CONCLUSION

Although suicidal behavior represents a serious mental health problem, few psychosocial interventions have been developed specifically to target it. Fewer still have been empirically demonstrated to reduce future suicidal behavior and those that have been conducted have a host of methodological problems (see Rudd et al., 2001, for a review). We have detailed a cognitive intervention that focuses specifically on suicidal behavior regardless of other diagnoses and outlined a set of interventions for suicidal individuals. Although the trial is ongoing and the patient population on which this intervention is being examined is an extremely difficult to treat population, evidence is emerging that the intervention is having a positive impact on reducing subsequent suicidal behavior. As of this writing, 20 of the 60 individuals (33.3%) randomized to the Enriched Care Condition have made 34 subsequent suicide attempts in the follow-up period, whereas 10 of the 59 individuals (16.9%) randomized to the Cognitive Therapy Condition have made 17 subsequent suicide attempts. This difference is statistically significant and suggests that the treatment is reducing the subsequent repeat attempt rate by approsimately 50%.

REFERENCES
Beck, A. T., Steer, R. A., Kovacs, M., & Garrison, B. (1985). Hopelessness and eventual suicide: A 10-year prospective study of patients hospitalized with suicidal ideation. American Journal of Psychiatry, 42, 559-563.

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Ellis, T. (2001). Psychotherapy with suicidal patients. In D. Lester (Ed.), Suicide prevention: Resources for the millennium. Philadelphia: Brunner-Routledge. Ellis, T. E., & Newman, C. F. (1996). Choosing to live: How to defeat suicide through cognitive therapy. Oakland, CA: New Harbinger. Jobes, D. A., Luoma, J. B., Jacoby, A. M., & Mann, R. E. (1998). Manual for the collaborative assessment and management of suicidality (CAMS). Unpublished manuscript, The Catholic University of America, Washington, DC. Miller, A. L., Rathus, J. H., Linehan, M. M., Wetzler, S., & Leigh, E. (1997). Dialectical behavior therapy for suicidal adolescents. Journal of Practical Psychiatry and Behavioral Health, 3, 78-86. Rudd, M. D., Joiner, T., & Rajab, M. R. (2001). Treating suicidal behavior. New York: Guilford. Salkovskis, P. M., Atha, C., & Storer, D. (1990). Cognitive-behavioural problem solving in the treatment of patients who repeatedly attempt suicide: A controlled trial. British Journal of Psychiatry, 157, 871-876. GREGG HENRIQUES is a research assistant professor in the Department of Psychiatry at the University of Pennsylvania. His primary responsibility is directing several treatment outcome studies on suicide attempters and borderline personality disorder. He has a diversity of theoretical and empirical research interests, which range from developing a unified theoretical framework for psychology to exploring treatment outcomes for suicide attempters. AARON T. BECK, professor of psychiatry at the University of Pennsylvania, is a graduate of Brown University (1942) and Yale Medical School (1946). Best known as The Father of Cognitive Therapy, he is the recipient of numerous awards and honorary degrees and is the only psychiatrist to receive research awards from the American Psychological Association and the American Psychiatric Association. He is the author or coauthor of more than 400 articles and 15 books, with his most recent book being Prisoners of Hate: The Cognitive Basis of Anger, Hostility and Violence. He is president of The Beck Institute of Cognitive Therapy. His areas of special interest and research are the psychopathology of psychiatric disorders, the prediction of suicide, and cognitive therapy for depression, anxiety, suicidal behavior, obsessive-compulsive disorder, addiction, schizophrenia, and the personality disorders. GREGORY K. BROWN is an assistant professor in the Department of Psychiatry at the University of Pennsylvania. His research interests include investigating the effectiveness of cognitive therapy for suicide attempters and for suicidal patients with borderline personality disorder. He also participates in other multisite clinical trials regarding the development and implementation of clinical practice guidelines for managing elderly suicidal patients in primary care settings.

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