A cognitive-behavioral strategy for preventing suicide

There are 3 kinds of coping cards:
• place a suicide-relevant automatic thought or core belief on one side of the card; on the other side, place an alternative, more adaptive response
• write a list of coping strategies
• write instructions to motivate or “acti­vate” the patient toward completing a spe­cific goal (Figure 2).

Phase III: Prevent relapse
Complete relapse prevention task. Relapse prevention is a common CBT strat­egy that aims to strengthen self-management to minimize likelihood of returning to a pre­viously stopped behavior. For patients who present only with suicidal thoughts, relapse prevention is directed at identifying trig­gers and minimizing the occurrence and/ or intensity of such thoughts in the future. For patients who present with suicidal self-directed violence, relapse prevention is directed at identifying triggers for suicidal actions and reducing the likelihood of acting on suicidal urges. The brief guidance pro­vided below will familiarize you with each of the relapse prevention steps, which may be completed in multiple sessions.

Step 1: Provide psychoeducation
Explain the difference between a lapse and a relapse. In general, you want the patient to understand that, although suicidal thoughts might persist and recur over time, suicidal self-directed violence must be prevented. Describe the purpose of the relapse preven­tion task (ie, to minimize the chance that suicidal thinking and actions will recur); address questions and concerns; and obtain permission to begin the procedure. Assure the patient that this is a collaborative activity and you will be in the room to ensure com­fort and safety.

STEP 2: Retell the suicide story
Ask the patient to imagine the chain of events, thoughts, and feelings that led to the most recent episode of suicide ideation or suicidal self-directed violence. Tell the patient that you want him to construct a movie script to describe the chain of events that resulted in the suicide crisis —but to do so slowly, taking enough time to describe the details of each scene of the movie.

Step 3: Apply CBT skills
Ask the patient again to take you through the sequence of events leading to the most recent episode of suicide ideation or suicidal self-directed violence. This time, however, direct him to use the skills learned in ther­apy to appropriately respond cognitively, affectively, and behaviorally to move further away from the suicide outcome.

If the patient is moving too fast or neglect­ing important points, stop and ask about alternative ways of thinking, feeling, and behaving. Use as much time as needed until the patient is able to demonstrate solid learn­ing of at least several learned CBT strategies to prevent suicidal self-directed violence.

Step 4: Generalize learning to prepare for future suicidal crises
In this stage —given your knowledge of the patient’s psychosocial history, cognitive- behavioral conceptualization, and suicide mode triggers —you collaboratively create a future scenario that is likely to activate suicidal self-directed violence. Question the patient about possible coping strategies, pro­vide helpful feedback, guide him through each link in the chain of events, and pro­pose additional alternative strategies if he is clearly neglecting important points of the intervention.

Step 5: Debrief and summarize lessons learned
Debrief the patient by providing a sum­mary of the skills he has learned in therapy, congratulate him for complet­ing this final therapeutic task, and assess overall emotional reaction to this activity. Remind him that mood fluctuations and future setbacks, in the form of lapses, are expected. Give him the option to request booster sessions and make plans for next steps in accomplishing general goals of therapy.

Treatment can be terminated when the patient is able to complete the relapse preven­tion task. If he is not ready or able to complete this exercise successfully, you can extend treatment. The duration of the extension is left to the practitioner’s judgment, based on the overall treatment plan. Brown and colleagues2 have reported a maximum num­ber of 24 outpatient sessions (for patients who need additional booster sessions); based on clinical experience, it is reasonable to assume that it would be highly unlikely for a patient not to meet treatment objectives after a methodical course of outpatient CBT.

In cases in which goals of treatment have not been met, consultation with colleagues, review of adherence problems, and consid­eration of obstacles for treatment efficacy would be recommended.

A checklist can be used to determine whether a patient is ready to end treatment. Variables that can be considered in assessing readiness for termination include:
• reduced scores on self-report measures for a number of weeks
• evidence of enhanced problem-solving
• engagement in adjunctive health care services
• development of a social support system.