According to the World Health Organization, almost one million people die by suicide every year, which is a global mortality rate of 11.4 per 100,000. In the United States, an average of one person dies by suicide every 12.3 minutes with suicide being the tenth leading cause of death in the U.S. (CDC, 2016). In addition, it is important to remember that suicides have consistently been underreported for a variety of reasons. Experts have estimated that suicide incidence may be 10-15% higher than officially recorded.
The military reflects an important subset of the U.S. population. Rising suicide rates among Service members and Veterans over the past decade have raised public and professional concerns. Suicide is the second leading cause of death in the U.S. military. According to the calendar year 2014 Department of Defense Suicide Event Report (DoDSER) annual report, the standardized suicide rate was 19.9 per 100,000 for the Active component. For the Selected Reserves component, the rates were 21.0 per 100,000 for the Reserves and 19.4 per 100,000 for the National Guard. In addition, a recent report published by the Office of Suicide Prevention (2016) revealed that Veterans account for 18% of all deaths by suicide among U.S. adults, with the Department of Veterans Affairs estimating that 20 Veterans die by suicide each day.
Many behavioral health providers have had training in cognitive-behavioral therapy (CBT), but few are knowledgeable about how to best use CBT when working with a suicidal patient. Cognitive Therapy for Suicidal Patients (CT-SP) is an evidence-based, manualized cognitive-behavioral treatment for adults with suicidal ideation and behaviors. Although this treatment protocol was initially developed for individuals who recently attempted suicide, the protocol can also be applied to individuals with acute suicidal ideation.
CT-SP is based on Dr. Aaron Beck’s cognitive-behavioral model. According to this theory, an individual’s biopsychosocial vulnerabilities can interact with suicidal thoughts and behaviors to produce a “suicide mode.” Suicide is distinct from any medical or mental health conditions and can occur in the context of many diagnoses. Accordingly, treatment directly targets suicide-related thoughts and behaviors and is considered transdiagnostic in nature.
Like other CBT treatments, CT-SP is structured and time-limited. CT-SP is typically conducted in a 10-session protocol (approximately 50 minutes in length per session) and follows a session structure consistent with a typical CBT session. CT-SP generally includes three broad phases: an early phase, an intermediate phase, and a later phase.
The early phase of treatment focuses on treatment engagement, risk assessment, and crisis management. Treatment begins with the therapist completing a thorough suicide risk assessment, in addition to gathering other relevant information. Crisis intervention strategies, such as developing a Safety Plan and conducting Means Restriction Counseling, are also completed during this phase. Finally, the therapist guides the patient in obtaining a detailed narrative timeline of the most recent suicidal crisis. A cognitive-behavioral case conceptualization is generated collaboratively with the patient and used to create an individualized treatment plan based on the idiographic needs of the patient.
During the intermediate phase of treatment two main types of strategies are implemented. First, behavioral strategies are implemented to help the patient develop cognitive, behavioral, and affective copings skills. Examples include relaxation training, activity monitoring, and increasing social resources. Secondly, cognitive strategies are implemented to help modify unhelpful beliefs associated with the risk of triggering a suicidal crisis. Patients are educated about the cognitive model and are taught ways to evaluate their thoughts and beliefs, to include modifying core beliefs and identifying reasons for living.
The final phase includes several relapse prevention exercises intended to consolidate skills learned during therapy. The main component of the relapse prevention exercises is a guided imagery task, in which the patient is directed to implement skills learned during therapy in response to imaginal exposure of past and potential future suicidal crises. Once the patient is able to demonstrate generalization of skills learned, a debriefing and summary of skills learned is conducted. At this time, the provider will conduct a thorough risk assessment and offer additional treatment session or referrals as clinically indicated.