CBT for Preventing Suicide Attempts: A Review

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.

Friday Morning blog

Friday morning blog

I am watching my niece today because it’s Good Friday, a religious Catholic holiday. She has the day off from school, something that I never got when I was in school. Apparently, rules changes concerning religion so any time there is a religious holiday due to whatever domination, the kids have the day off from school.

Next week is April vacation week. I will be watching my niece on Tuesday as well. Today I will be ordering pizza. I don’t know what I will be doing Tuesday. Maybe I will take her to Starbucks with me, if she is willing to go. I was thinking of going today but my ankle is hurting kind of severely. I really don’t want to leave the house.

I woke up to a weird dream. I dreamed that I was in therapy with an older woman. It was our second session and I could barely hear her as she had laryngitis. My former therapist was in the room while we were talking. Then my teddy bear became a male toddler. He had just a diaper on him and was getting cranky because it was wet. I didn’t have another diaper but the therapist did. As I was changing him, he started crapping and it was diarrhea. I cleaned him up and he crapped green shit again. I got it all over myself. There was a shower in the office so I washed him and myself up. I didn’t have another diaper to change him. I felt like a bad father. I had no idea why my teddy bear became a live human. Anyways he walks to a chair and as I am telling him not to sit down, he sits and shit gets all over the chair. I pick him up and then I wake up, shaking my head. Weirdest dream ever.

I just ordered pizza and fries. Should be here in about a half hour or less. I can’t wait. I have been craving pizza all week long. I ordered a large so that my mother can have some, too. I usually order half because no one but me eats cold pizza. I don’t like it reheated. It tastes funny.

I am going to try finishing the CBT book that I started earlier this week after lunch. I should type up what I have written for the blog I am writing. I wrote it in a notebook on Monday. It’s an interesting book and I find it exciting to read because it stimulates my thought process. It’s a short book, only about 8 or 9 chapters and I am in chapter 5 right now. Reading it is not technical, least for me because I have a clinician brain. I am learning as I go as I am more psychodynamically oriented than Cognitive behaviorally. I can’t wait to write up this blog!

For the Love of Espresso

For the Love of Espresso

Yesterday, I made coffee at home and when I poured the half and half, there was shit on top. I asked my mother if it was fine and she said it was “cream”. Coffee tasted okay and I didn’t die as I am living to tell the story. Today, the curdling was worse and I wasted a cup of coffee. I was pissed because the half and half was a new quart that hadn’t been opened yet and had an expiration of Dec 21. I had a Neurontin hangover and I desperately needed coffee. But it was Sunday and there were no direct buses to the Square. I just missed the bus going near the Square, which pissed me off more. I had to wait an hour for the next one. I decided to sojourn in the opposite direction and take the trek to Station Landing, where there was a Starbucks.

I decided just to bring my book with me because I didn’t want to carry anything heavy as that would make the long walk more strenuous. I was feeling pretty good so it wasn’t much difficulty getting to my happy place. I stayed for an hour after having a sandwich and my much desired drink. I read to the point where Lincoln is elected president, South Carolina secedes from the Union and the Lincoln family enters the White House, along with Hay and Nicholay in tow.

It took me fifteen minutes to get back to the train station and to my stop. Not bad for someone who is disabled. Though by the time I was waiting for the bus home, my ankle was starting to throb and increased by the time I got home. I took a pain pill soon as I got into my room. My sister had invited us for dinner and I was just in time. I was kind of hungry from my travels so the timing was perfect. I had half a glass of wine before I realized I had just taken a pain pill. OOPS. I hope it doesn’t cause drowsiness because I don’t want to fall asleep this early. Last night I fought against the drowsiness and couldn’t sleep until nearly 0300. Anxiety from possible pain kept me awake. It was terrible.

I have my first session of CBT tomorrow. I am really nervous as I am more psychodynamic than a cognitive person. To me, this therapy is rigid and I don’t like rigid but, unfortunately, all the current research has lead to say this form of therapy helps those with chronic health conditions so I am giving it a shot against my better judgement. I hope the therapist is willing to work with me and not against me, with the “I know better” attitude. I will be out the door so fast if this is the case. I also hope that the therapist allows my therapist and I to work while doing this as an adjunctive thing. I have mixed feelings about this therapy and the process. I hope it will be a brief therapy, with kind of a relapse therapy sessions available if needed kind of thing. AND it MUST focus more on my pain issues than my depression as the pain is more debilitating me than the depression right now. I also hope the therapist isn’t going to freak out when she finds out about my suicidality. That is another element I am afraid of, being turned down because I am “too sick” for therapy. I don’t know if this therapist is on the up that CBT can actually help suicidal thinking as well. I really hope I don’t have to be the professor either. She is a resident, not a full fledged therapist so we’ll see. If I have to resort to being a suicidologist to her, I will. I have a full library on the subject so I think I know what the hell I am talking about. I just wish I had the time to read Craig Bryan’s book about CBT in suicidality. Damn depression. Maybe I will take it with me and show it to her so to give her background that this isn’t my first therapist and won’t be my last that I have to “train”.

I had to further aggravate my ankle/foot by going downstairs again because I had to use the bathroom. I don’t know who’s brilliant idea it was to have bedrooms upstairs without at least a half bath. Sure it would make the bedrooms smaller but it would be a life saver!

Jar of Frosting

Jar of Frosting

The other day I made pumpkin cupcakes, with the hope of taking them to my therapist today. I have half a jar of cream cheese frosting left over. I think I am going to have it for a snack, along with the cupcakes. I feel totally miserable. My back is still out for whatever reason. And what is worse, is I am out of my regular pain meds. I was supposed to call today to have the appointment moved to Friday as next Tuesday is no good. But after therapy, I just went back to sleep and didn’t get up again until my mother called me for dinner.

I didn’t do anything today. I just rested my back. My sister is going to pick up my prescription at walgreens. I couldn’t go today because I could barely stand up straight, let alone walk to the store and back. I really hate the temperature changes and I know my back is out because it was 70 degrees yesterday and 50 today.

I got the refund from Zipcar for my cancelation. I plan on getting another Zipcar next week so I can see my therapist. I hope to make her the pumpkin fluff I want to try. I just need to get vanilla pudding. I have been feeling paranoid lately so I have been trying to take the trilafon a little more regularly. I forgot to take it this afternoon when I was on the phone with my therapist. I just took it now after dinner, along with three Aleve to see if that helps my back any. The other NSAID that I take doesn’t really help me at all. I have stopped using it. I wish Ketoprofen still worked for me. It worked really well for a while and then stopped for whatever reason. It was really good for back pain.

My therapist talked a lot about food today, even without me bringing it up. I thought it was strange. She felt bad that I didn’t see her today but she understood. I told her I didn’t get much sleep last night because of pain. I don’t think I went to sleep till around 5 and then I woke up around a half hour later to pee. I also was hungry so I had some cupcakes. Then I went back to sleep until my damn mother called me wanting me to put something in the freezer. I was so out of it, I don’t even remember what she wanted me to place in the freezer. Luckily, I woke up a half hour before my therapy appointment.

I told her about the CBT. She is supportive about it and hope that it helps. I told her flat out that it’s my last hope, which I also emailed my psychiatrist at god knows what time in the morning. I know I wrote a blog in the middle of the night to help me sleep. Pain was causing me such havoc. It was more so with my ankle than with my back. My therapist wanted to know why I chose that form of therapy and I told her the research supports it. I found a long PDF about chronic pain and CBT but I couldn’t read it as it was late and I hate reading PDF’s from the computer screen. It was 124 pages so I didn’t want to print it out. I will try reading it later today, if I am up for it. I am still sleepy.

I told her our schedule might have to change when this resident calls me. I don’t know what the availability is. I am hoping it is a day that I don’t have therapy. But we’ll see. I told her I will stress that I want this for chronic pain and not depression. If this resident doesn’t do chronic pain CBT then I will have to look elsewhere, though it will be another setback.