Staff Perspective: Exploring a Suicide-Specific Couple-Based Intervention

Staff Perspective: Exploring a Suicide-Specific Couple-Based Intervention

Dr. Marjorie Weinstock

While I’ve written numerous blogs about military couples, one of my other professional interests is suicide prevention. Since September is Suicide Prevention Awareness Month, I thought suicide prevention would be a good topic for my blog post this month. So, when I recently ran across Khalifan and colleagues’ (2022) article “Utilizing the couple relationship to prevent suicide: A preliminary examination of treatment for relationships and safety together” I was intrigued!

Watch a recording of the CDP Presents webinar: "Dyadic Interventions - Involving Significant Others in Suicide Prevention"

The DoD/VA Clinical Practice Guidelines for the Assessment and Management of Patients at Risk for Suicide recommends using cognitive-behavioral based interventions specifically focused on suicide prevention to treat individuals with suicidal thoughts and behaviors (VA/DoD, 2019). However, we also know that key theories of suicide have identified a connection between suicidal thoughts and behaviors and interpersonal difficulties (Joiner, 2005; Klonsky & May, 2015). Relationship problems is a common psychosocial stressor for Service members, and DoD data indicate that family/intimate relationship stressors is the most common type of stressor reported in Service members who have attempted or died by suicide (DoD, 2022). To date, interventions for treating suicidal thoughts and behaviors have been individually focused, so the idea of a couple-oriented cognitive-behavioral treatment is very exciting. The abstract of the article by Khalifan et al. (2022) indicates that it’s a description of a preliminary investigation of the first comprehensive couple-based treatment for suicide, so before reading further, I decided to take a step back to learn more about the treatment itself.

As described by the developers (Kahlifan et al., 2021), “Treatment for Relationships and Safety Together” (TR&ST) was created by integrating Brief Cognitive Behavioral Therapy (BCBT; Bryan & Rudd, 2018) with cognitive-behavioral therapy couple skills (Epstein & Baucom, 2014). BCBT is an individual therapy designed to reduce the probability of suicidal behavior, while cognitive-behavioral couple therapy takes a problem-solving approach to working with couples by identifying problems and encouraging both partners to be actively involved in improving them. TR&ST builds upon the foundation of BCBT, adding couple skills to make the treatment more dyadically focused. As the authors note, there is a precedence for integrating cognitive-behavioral couple skills into individual interventions, such as with Cognitive-Behavioral Conjoint Therapy for PTSD (Monson & Fredman, 2012).

TR&ST consists of 10 90-minute sessions that are organized into four phases: (1) emotion regulation, (2) self-awareness and communication skills, (3) cognitive skills, and (4) relapse prevention. I want to briefly summarize what occurs in each of these phases:

  1. Emotion regulation: In this phase, the focus is on providing a cognitive-behavioral conceptualization of both suicide and relationship distress (as well as their reciprocal influences). As in BCBT, one of the initial interventions in this phase is developing a crisis response plan for the suicidal patient; however, in TR&ST a crisis support plan is also created for the partner. Examples of other additions to this phase of treatment include psychoeducation about conjoint time-0uts and conjoint activity planning.
  2. Self-awareness and communication skills: In this phase, the focus shifts toward teaching skills to improve dyadic communication, such as the speaker-listener technique and how to use mindfulness during interpersonal interactions. This phase of the treatment is unique to TR&ST.
  3. Cognitive skills: The third phase includes cognitive interventions that are designed to address not only maladaptive thinking patterns that maintain suicidality, but also those that maintain relationship dysfunction.
  4. Relapse prevention: Similar to BCBT, TR&ST ends with a set of relapse prevention exercises for suicidal crises. There is an additional focus in TR&ST, however, on the conjoint construction of values and creating a life worth living.

Now that I’ve shared a brief summary of TR&ST, I want to circle back to the article that initially caught my eye. Khalifan et al. (2022) conducted a preliminary investigation of this treatment with five couples (N=10) who participated in 10 weekly conjoint therapy sessions. All five couples included a veteran who reported suicidal ideation at baseline and their partner. Couples completed measures of relationship functioning, perceived burdensomeness, thwarted belongingness, and suicidal ideation at baseline, mid-treatment, and post-treatment. Results indicated that the treatment was not only feasible to deliver, but that both veteran and partner functioning improved, and veteran perceived burdensomeness, thwarted belongingness, and suicidal ideation all decreased.

While this preliminary investigation only looked at a few couples, a larger clinical trial is currently underway. This clinical trial consists of two phases: (1) treatment refinement with 12 couples, and (2) a pilot RCT comparing TR&ST to treatment as usual. As a psychologist with an interest in both military couples and suicide prevention, I was excited to learn about the development of TR&ST, and I look forward to seeing the results of the clinical trial when they’re published!

Watch a recording of the CDP Presents webinar: "Dyadic Interventions - Involving Significant Others in Suicide Prevention"

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Marjorie Weinstock, Ph.D., is a Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.


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Veterans Health Administration and Department of Defense. (2019). VA/DoD clinical practice
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