Cognitive Therapy for Suicidal Patients (CT-SP)

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 Suicide Prevention (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.

CT-SP Resources:

Brown, G. K., Karlin, B. E., Trockel, M., Gordienko, M., Yesavage, J., & Taylor, C. B. (2016). Effectiveness of cognitive behavioral therapy for veterans with depression and suicidal ideation. Archives of Suicide Research, 20(4), 677-682. doi:10.1080/13811118.2016.1162238

Brown, G. K., Tenhave, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005).  Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial.  Journal of the American Medical Association, 294(5), 563-570. doi:10.1001/jama.294.5.563

Bryan, C. J., Gartner, A. M., Wertenberger, E., Delano, K. A., Wilkinson, E., Breitbach, J., . . . Rudd, M. D. (2012). Defining treatment completion according to patient competency: A case example using brief cognitive behavioral therapy (BCBT) for suicidal patients. Professional Psychology: Research and Practice, 43(2), 130-136. doi:10.1037/a0026307

Guille, C., Zhao, Z., Krystal, J., Nichols, B., Brady, K., & Sen, S. (2015). Web-based cognitive behavioral therapy intervention for the prevention of suicidal ideation in medical interns: A randomized clinical trial. JAMA Psychiatry, 72(12), 1192-1198. doi:10.1001/jamapsychiatry.2015.1880

Henriques, G., Beck, A. T., & Brown, G. K. (2003). Cognitive therapy for adolescent and young adult suicide attempters. American Behavioral Scientist, 46(9), 1258-1268. doi:10.1177/0002764202250668

Leavey, K., & Hawkins, R. (2017). Is cognitive behavioural therapy effective in reducing suicidal ideation and behaviour when delivered face-to-face or via e-health? A systematic review and meta-analysis. Cognitive Behaviour Therapy, 46(5), 353-374. doi:10.1080/16506073.2017.1332095

Mewton, L., & Andrews, G. (2016). Cognitive behavioral therapy for suicidal behaviors: Improving patient outcomes. Psychology Research and Behavior Management,1(9), 21-29. doi:10.2147/PRBM.S84589

Stanley, B., Ph.D., Brown, G., Ph.D., Brent, D. A., M.D., Wells, K., Ph.D., Poling, K., L.C.S.W., Curry, J., Ph.D., . . . Hughes, J., B.A. (2009). Cognitive-behavioral therapy for suicide prevention (CBT-SP): Treatment model, feasibility, and acceptability. Journal of the American Academy of Child & Adolescent Psychiatry, 48(10), 1005-1013. doi:10.1097/CHI.0b013e3181b5dbfe

Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment. Applied and Preventive Psychology, 12(4), 189-201. doi:10.1016/j.appsy.2008.05.001

Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients.  Washington, DC: American Psychological Association.

Wenzel, A., & Jager-Hyman, S. (2012). Cognitive therapy for suicidal patients: Current status. The Behavior Therapist, 35(7), 121.