CBT for Preventing Suicide Attempts: A Review
I have been reading CBT for Preventing Suicide Attempts edited by Craig Bryan, PhD and these are my thoughts about the book by chapter. I also describe what each chapter is about.
Chapter 1: Deals with the problem of suicide and how it’s on the rise. It also describes the difficulty of knowing what works and what doesn’t. The authors goes on to what the book is about and how CBT has been shown to be useful in some clients with suicide ideation.
Chapter 2: Describes the dreaded nomenclature of suicide attempts, ideas, suicidality, etc. The authors describe how the term SDV (self-directed violence) is a more accurate term and also other terms to decide pathways on treatment protocols. They term the entire suicidality as SDVCS-Self-Directed Violence Classification System. It is used by three large federal organizations- the CDC (Center for Disease Control and Prevention), the VA (Veterans Administration), and the DOD (Department of Defense).
This chapter gives good examples of how different researchers, clinicians, and other professionals can use this classification system. I didn’t review the system pathways and yes/no guidelines because terms don’t mean that much to a suicide attempt survivor writing about my lived experience. I’m either suicidal or I’m not. I don’t need to classify and put myself into a category. But if you are a clinician/researcher or other academic interested in suicide prevention, the nomenclature is pretty good and better than what Silverman et. al. proposed in 2007 a and b (see this blog post on my thoughts about their terms).
Chapter 3 deals with what works and what doesn’t in suicide risk. It talks about studies pertaining to talking therapies and psychopharmalogical treatment of suicidal behaviors. I found this to be more of a review of what I know as of right now in terms of evidence based practices (EBP) and what is not. Some studies were really small and others were large. Most centered around Borderline Personality Disorder (BPD) as that is a high risk group. What I found upsetting is that those with bipolar disorder or those that were psychotic were excluded from most of the studies. As I suffer from psychosis and bipolar disorder, my participation would not be included and I find that disappointing, especially since bipolar disorder and other psychotic disorders such as schizophrenia have a higher incidence of suicide than major depression alone.
Chapter 4 was an eye opening chapter that I really liked. It talked about all of the suicidologists that I have been following for the past eleven years. It discusses different theories and models of suicide and risk assessment. It also discusses protective factors of suicide such as reasons for living/dying. I found this chapter to be really good and a lead off to how all of the things talked about lead to the next chapter, which is a case example.
Chapter 5: In this chapter, a case is described step by step of a suicidal older gentleman and the cognitive steps, consent, etc. are used by a play by play dialogue. Things like safety planning, coping cards, and hope kit are discussed in detail and how to implement them in therapy using cognitive therapy.
Chapter 6 talks about a brief cognitive behavior treatment (BCBT) for inpatient units called PACT (Post Admission Cognitive Therapy). It discusses the criteria for engaging patient, pros/cons of treatment and how not everyone may be suitable for this type of treatment, e.g., those with active psychosis/mania.
It would be good if this could be implemented but as the treatment is 5-6 days and on average most admissions are 3 days, I don’t see how this is to be helpful. Discussion of staff resistance and burnout are also discussed.
Chapter 7: This was very interesting as I’ve never really read about military psychotherapy before. The chapter gives specifics on how to approach a veteran or active military personnel in crisis or dealing with suicidal thoughts. It talks in detail about Brief Cognitive Behavioral Therapy (BCBT) and the steps per session. Not all persons will respond within the 12 sessions. It is individualized for each person. The chapter also talks about hot to discuss lethal means safety and means restriction (see chapt 9 for more information; e.g., gun safety in particular). When the sessions are down to the last two and command of previous exercises are demonstrated to be efficient, end of therapy is initiated. Booster sessions are discussed in case of future crises should happen. I found this therapy to be specific not only for military but can be used for any type of suicidal behavior. It’s a collaboration between therapist and client.
Chapter 8: Emergency departments are the top places suicidal people end up, either with an attempt, ideation, or crisis. Sadly, if the right precautions are not set (e.g., inpatient care or some type of follow up care), individuals are more than likely to die by suicide.
This chapter talks about the challenges and brief interventions that can be initiated so that death by suicide does not occur after a visit. The authors describe specific suicide safety planning that is individualized for that person to help them cope with stress that makes suicide appealing. It also gives crisis numbers, either a trusted person they can talk to in time of need and/or the National Suicide Hotline (1-800-273-8255, text 741741 (US only)). Once a little role play is done and the individual can demonstrate they will use this plan, patients are discharged to follow up outpatient care.
Only trouble I have with this approach is that not all EDs are equipped with mental health professionals and don’t have the 30-45 minutes or so it would take to implement the safety plan, even though it is crucial this should happen.
Chapter 9: As more and more evidence is building that suicidal individuals are seeing a primary care provider prior to death by suicide, it’s become imperative that PCPs have the training to ask patients for means restriction. The author suggests several ways to initiate the conversation and lists steps to do this. If patients are resistant, the use of motivational interviewing techniques are employed. The end result is a means restriction receipt where PCP and patient have agreed to restrict their lethal means. If possible, a supportive person is asked to help secure the means.
Chapter 10: This chapter talks about the use of psychotropic medication and the use of CBT or BCBT in suicidal patients. To date, there has not been studies where therapy and medication has been shown to be effective in reducing suicide risk. It is suggested that despite the thoughts and black box warnings of the FDA, suicide ideation is still likely to occur of not treated or dealt with at the beginning of pharmacological treatment. The author also discusses the risk of substance use and dependence disorders that can increase the risk of a suicide attempt. PTSD has also been discussed as hyperarousal states can increase suicide risk.
Concluding thoughts: Overall, I found this book to be extremely helpful, concise, and important in the prevention of suicide attempts. With the right intervention at the right time, Brief CBT can help decrease the suicide risk and possibly the overall suicide rate.