Brief Cognitive-Behavioral Therapy for Suicide Prevention
294
Brief Cognitive-Behavioral Therapy for Suicide Prevention
294eBook
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Overview
Product Details
| ISBN-13: | 9781462536689 |
|---|---|
| Publisher: | Guilford Publications, Inc. |
| Publication date: | 06/13/2018 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 294 |
| File size: | 3 MB |
About the Author
M. David Rudd, PhD, ABPP, is President of the University of Memphis, where he is also Distinguished University Professor of Psychology. He is Co-Founder and Scientific Director of the National Center for Veterans Studies at the University of Utah. Dr. Rudd is a Fellow of the American Psychological Association, the International Academy of Suicide Research, and the Academy of Cognitive and Behavioral Therapies, and has been elected a Distinguished Practitioner and Scholar of the National Academies of Practice in Psychology. He previously served as chair of the Texas State Board of Examiners of Psychologists, president of the Texas Psychological Association, president of the American Association of Suicidology, and a member of the American Psychological Association’s Council of Representatives. Dr. Rudd’s research focuses on the treatment of suicidal patients. He has published over 200 scientific articles and numerous books on the clinical care of suicidal individuals, and is considered an international leader in suicide prevention.
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CHAPTER 1
Why Brief Cognitive-Behavioral Therapy to Prevent Suicide?
In 2014, more than 41,000 individuals died by suicide in the United States (Centers for Disease Control and Prevention, 2016). From 1970 to 2000, the U.S. general population suicide rate declined approximately 20% from an estimated 13.2 per 100,000 to 10.4 per 100,000. Around the turn of the century, however, this downward trend reversed and the suicide rate steadily increased to 13.4 per 100,000 in 2014. Though suicide rates have increased across most demographic subgroups, the most pronounced increase has occurred among middle-aged (i.e., 45–64 years) white men. Similar trends have been observed globally, although differences by age groups have been noted (Chang, Stuckler, Yip, & Gunnell, 2013). In Europe, for instance, suicides increased most dramatically among young men ages 15 to 24 years. For each death by suicide, there are an estimated 10 to 30 suicide attempts (Centers for Disease Control and Prevention, 2016). In light of these trends, there has been increased interest in identifying and developing interventions and prevention strategies that reduce death by suicide and suicidal behavior more generally.
Within the United States, research focused on the understanding and treatment of suicidal individuals began in earnest during the 1950s, driven in large part by Edwin Schneidman and Norman Farberow, both clinical psychologists, and Robert Litman, a psychiatrist, at the Los Angeles Suicide Prevention Center. Although the number of suicide researchers has since grown rapidly, it was not until the 1990s that clinical researchers, both within the United States and around the world, started to apply rigorous scientific methods to develop and critically evaluate the efficacy of treatments for reducing suicide ideation and preventing suicide attempts. Despite these efforts, the suicide rate of the U.S. general population started to rise in 1999 and in 2014 reached its highest point in nearly 30 years (Centers for Disease Control and Prevention, 2016).
Traditional approaches to treating suicidal patients have largely been influenced by a risk factor model of suicide, which seeks to understand suicidal thoughts and behaviors by identifying and describing their correlates. For example, several well-established correlates of suicidal thoughts and behaviors include male gender, white or Caucasian race, age above 45 years, and psychiatric diagnoses (Franklin et al., 2017). Within the general category of psychiatric diagnoses, mood disorders and substance abuse disorders have traditionally been implicated (Kessler, Borges, & Walters, 1999; May & Klonsky, 2016; Nock et al., 2008).
The risk factor model does not necessarily propose any specific underlying process or cause for suicidal behavior, but rather assumes that it is the accumulation of multiple risk factors that contributes to suicidal thoughts and behaviors. Treatment informed by this model aims to reduce these risk factors under the assumption that doing so will reduce the incidence and/or severity of suicidal thoughts and behaviors. Countering this assumption are the results of a recent meta-analysis of 50 years of research studies in which the risk factor model was found to have relatively little impact on suicide prevention or the development of effective treatments (Franklin et al., 2017). The utility of the risk factor model of suicide has increasingly been called into question.
The psychiatric syndromal model, in which suicidal thoughts and behaviors are conceptualized as symptoms of psychiatric illness, is a specific subcategory of the more general risk factor model. From this perspective, suicidal thoughts and behaviors are described and organized according to observable characteristics and surface features of the behaviors (e.g., method, lethality, and intent), similar to the syndromal classification schemes commonly used in the mental health and medical professions (e.g., the World Health Organization's International Classification of Diseases, the American Psychiatric Association's Diagnostic and Statistical Manual). In the medical field, a syndrome is reclassified as a disease once the characteristics and surface features of the syndrome are linked to their underlying processes and causes. As applied to suicide, the psychiatric syndromal model implicates the central role of psychiatric illness when treating suicidal patients: that is, treat the psychiatric illness and suicide risk will resolve. By extension, if a suicidal patient is diagnosed with depression, then the clinician should treat the depression to prevent suicide attempts; if a suicidal patient has posttraumatic stress disorder, however, then the clinician should treat the trauma. Although the psychiatric syndromal model has predominated in our clinical understanding of suicide for decades and is the perspective from which most clinicians approach the treatment of suicidal patients, accumulating evidence has failed to support the effectiveness of this conceptual framework (e.g., Tarrier, Taylor, & Gooding, 2008). This may be due in part to the fact that most psychiatric disorders are correlated with suicidal thoughts but not suicidal behaviors(Kessler et al., 1999; May & Klonsky, 2016; Nock et al., 2008). This suggests that treatments that prioritize psychiatric disorders may not be sufficiently specific to the mechanisms that give rise to suicidal behavior. As a result, they reduce psychiatric symptoms but not the risk for suicide attempts.
A third general framework for understanding suicidal behaviors is the functional model. According to this model, suicidal thoughts and behaviors are conceptualized as the outcome of underlying psychopathological processes that specifically precipitate and maintain suicidal thoughts and behaviors over time (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). From this perspective, suicidal thoughts and behaviors are not the result of any particular psychological process per se (e.g., psychiatric illness); rather, they are the result of how the psychological process is experienced by the individual within the context of his or her personal history, immediate environment, and behavioral responses. Clinically, the functional model suggests that the primary target of treatment with suicidal individuals is not the psychiatric illness itself, but rather it is the context that surrounds the emergence and maintenance of suicide risk over time.
To highlight the differences between these models, consider two separate women diagnosed with major depression secondary to marital problems. Both individuals have comparable levels of depression severity, but one of these women (Patient A) makes a suicide attempt following an argument with her partner, whereas the second woman (Patient B) experiences suicide ideation following a similar argument but does not make a suicide attempt. According to the risk factor and the psychiatric syndromal models, the suicidal symptoms experienced by both women are explained in part by underlying depression. There is no clear explanation for why only one of these two women made a suicide attempt, but both models would generally presume that, since Patient A made a suicide attempt but Patient B did not, Patient A must have a greater number of risk factors than Patient B. The risk factor model would suggest that the differential risk factor profiles for both women would need to be identified in order to develop a treatment plan for each. These treatment plans would generally seek to reduce or eliminate each woman's risk factors. The psychiatric syndromal model would take a similar, albeit more focused approach: the indicated treatment approach for both women should focus on reducing depression. Because Patient A made a suicide attempt, the psychiatric syndromal model would presume she has a more severe clinical profile overall as compared to Patient B. Patient A might therefore be more likely than Patient B to receive treatment in an inpatient setting because she is more likely to be seen as requiring a higher level of care.
In contrast to these two approaches, the functional model would assume that the suicidal symptoms experienced by both women are explained only in part by their depression; a more complete explanation is provided by considering their depression within the context of each woman's history and the circumstances surrounding the emergence of their suicidal episodes. To understand why Patient A made a suicide attempt but Patient B did not, we would therefore seek to identify differences in how the two women responded to the argument with their spouses across several domains: cognition (e.g., Why does she think the argument happened? What does she believe the argument says about her relationship and/ or her as a person?), emotion (e.g., Which emotions did she experience?), behavior (e.g., What actions did she take after the argument? How did she attempt to manage her emotions?), and somatic (e.g., What bodily sensations did she experience during and after the argument?). In short, Patient A made a suicide attempt not because she was depressed, but rather because she experienced the argument in a way that was shaped by previous life experiences and a general deficiency in effective self-regulation and coping. Outpatient treatment for Patient A is therefore likely to be different from treatment for Patient B, and would focus on these deficits in self-regulation and coping instead of focusing exclusively on depression.
The superiority of treatment approaches based on the functional model relative to treatment approaches based on a risk factor or psychiatric syndromal model are now well established empirically. In a meta-analysis of 24 studies investigating treatment effectiveness for suicide ideation and suicide attempts, for instance, treatments that directly targeted suicidal thoughts and behaviors as the primary outcome (i.e., a functional approach) contributed to statistically significant and larger improvements in suicide risk relative to treatments that primarily targeted psychiatric diagnosis (Tarrier et al., 2008). In light of such studies, the general consensus among suicide researchers is that the treatment of suicidal individuals should focus directly on suicide risk itself as opposed to psychiatric diagnosis. Unfortunately, despite the scientific evidence that supports this perspective, the majority of mental health professionals continue to be influenced heavily by the psychiatric syndromal model of treatment, a situation that is due in large part to insufficient education and training for clinicians in newer and better models of care (Schmitz et al., 2012).
THE EVOLUTION OF COGNITIVE-BEHAVIORAL THERAPY TO PREVENT SUICIDE ATTEMPTS
Although clinical suicide researchers as a whole hail from a remarkably diverse range of disciplines (e.g., psychology, social work, psychiatry, sociology) and clinical traditions (e.g., biomedical, psychodynamic, cognitive-behavioral, interpersonal), the most significant advances in the development of effective treatments for suicidal patients have arguably come from the cognitive-behavioral tradition. This is not to say that important knowledge has not been gained from clinical researchers trained in different theoretical perspectives and traditions, but rather that cognitive-behavioral models may "fit" more readily with the functional approach to conceptualizing suicide. Indeed, the functional model's emphasis on understanding the contextual antecedents and consequences of suicidal thoughts and behaviors (e.g., thoughts, emotions, and behavioral responses) parallels the core conceptual principles of cognitive-behavioral theory.
When considering treatment efficacy for suicidal behaviors in general, it should first be noted that no treatments have been shown to prevent suicide death. This is due in large part to the very high cost that would need to be incurred to conduct and implement such a study; death by suicide occurs with such infrequency that it would require a very large sample of participants to examine death as an outcome. To put this in perspective, across two studies of brief cognitive-behavioral therapy (Brown, Ten Have, et al., 2005; Rudd et al., 2015), only 3 out of a total of 272 participants died by suicide during the study period. In other words, only 1% of patients died by suicide. This low base rate is quite notable when one considers that approximately 90% of the participants in these two studies had made at least one suicide attempt during their lives (in most cases, the suicide attempt was within the past month), which means these participants were very high risk. Researchers would therefore need to enroll a very large number of high-risk individuals (over 1,500) into a study to show that a treatment could reduce the risk for death by suicide by half. Tragically, the cost of conducting such a large-scale study, which would necessitate the collaborative participation of multiple research sites, is much higher than what many funding agencies would consider practical.
Because death by suicide is not (yet) a feasible outcome for the purposes of research, treatment efficacy studies typically use proxies for suicide death that occur with greater frequency, such as suicide attempts and suicide ideation. Studies that evaluate the effects of treatment on suicide attempts as the primary outcome are generally considered to be more rigorous and informative than studies that consider treatment effects on suicide ideation, whereas studies that evaluate the effects of treatment on psychiatric diagnoses and other suicide risk factors are generally considered to be the least informative. This is because suicide attempts are a much closer approximation to suicide death than suicide ideation or psychiatric diagnosis (one must make a suicide attempt in order to die by suicide) and because suicide attempts are a stronger risk factor for later death by suicide than suicide ideation and psychiatric diagnosis. For example, in the classic meta-analysis of 249 studies investigating suicide as an outcome of psychiatric illness, Harris and Barraclough (1997) found that individuals with a history of suicide attempt had a standardized mortality ratio of approximately 40, which means that individuals who have attempted suicide are 40 times more likely to die by suicide than individuals with no such history. By comparison, the standardized mortality ratios for psychiatric disorders commonly associated with suicide were much lower: 20 for major depressive disorder, 19 for substance use disorder, 15 for bipolar disorder, and 8.5 for schizophrenia. Suicide attempt is therefore considered to be the best available proxy for suicide death.
Another important consideration with respect to treatment efficacy is the nature of the control or comparison treatment condition, without which it is not possible to determine if a treatment is effective. Because it is unethical to nottreat acutely suicidal individuals, studies of suicidal patients must include an active treatment as the control condition. The most common control condition in treatment studies to prevent suicide attempts is treatment as usual, also known as usual care. Treatment as usual entails standard mental health treatment delivery as it is typically provided by mental health professionals. In most studies, treatment as usual generally entails some combination of individual psychotherapy and psychotropic medications, and may also include group therapy, substance abuse counseling, and case management. In essence, clinicians providing treatment as usual are simply asked to do whatever it is they would normally do with a suicidal patient; they are not asked to change anything about how they conduct treatment. Treatments are only considered to be "effective" for preventing or reducing risk for suicide attempts if they reduce the risk for suicide attempts relative to another active treatment approach that is widely used by mental health clinicians. In other words, an effective treatment is one that has "beaten" another form of treatment in a head-to-head comparison. To date, cognitive-behavioral therapies have garnered the most consistent evidence of efficacy, indicating they have outperformed other forms of therapy in numerous studies.
Brief cognitive-behavioral therapy (BCBT) to prevent suicide is best understood as the "next step forward" in the development and refinement of the cognitive-ehavioral model that been successfully used by clinical researchers over the course of several decades. To date, approximately 30 clinical trials testing the efficacy of cognitive-behavioral therapies to reduce suicide risk have been conducted with varying outcomes (Tarrier et al., 2008). One of the first treatments to demonstrate efficacy for reducing the risk of suicide attempts was dialectical behavior therapy (DBT; Linehan, 1993). Based on the biosocial model of suicide, DBT is a multimodal, structured cognitive-behavioral therapy that entails psychoeducational skills training groups, individual psychotherapy, between-session phone consultation for patients, and regularly occurring clinician supervision. The efficacy of DBT and modified versions of DBT have been replicated in several clinical trials, making it "the most thoroughly studied and efficacious psychotherapy for suicidal behavior" (National Action Alliance Clinical Care & Intervention Task Force, 2012, p. 17). DBT entails training in emotion regulation, distress tolerance, problem solving, and cognitive reappraisal skills, accomplished with a range of cognitive-behavioral interventions such as cognitive restructuring, exposure, and behavioral rehearsal (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).
Results of the first randomized clinical trial of DBT (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) indicated that patients receiving DBT were 32% less likely to engage in self-directed violence1 during the 12-month follow-up period than patients receiving treatment as usual (64% in DBT vs. 96% in treatment as usual). Among those patients in DBT who did engage in self-directed violence, the total number of self-directed violence episodes was significantly fewer than for patients in treatment as usual (1.5 episodes in DBT vs. 9.0 episodes in treatment as usual during the 12-month follow-up), and the medical lethality of their behavior was significantly less severe. In terms of treatment utilization, patients in DBT were significantly more likely to start individual therapy than patients in treatment as usual (100% in DBT vs. 73% in treatment as usual) and were significantly more likely to remain in therapy for an entire year (83% in DBT vs. 42% in treatment as usual). Patients in DBT also had significantly fewer psychiatric hospitalization days during the 12-month follow-up than patients in treatment as usual. In terms of depression, hopelessness, and suicide ideation severity, however, patients in DBT and treatment as usual improved to a comparable degree.
(Continues…)
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Table of Contents
I. Background and Conceptual Foundation1. Why Brief Cognitive-Behavioral Therapy to Prevent Suicide?
2. Conceptualizing Suicide: The Suicidal Mode
3. Core Principles of Treatment with Suicidal Patients
4. Suicide Risk Assessment and Its Documentation
5. Monitoring Treatment Progress
6. An Overview of Brief Cognitive-Behavioral Therapy
II. The First Session
7. Describing the Structure of Brief Cognitive-Behavioral Therapy
8. Narrative Assessment
9. Treatment Log and Case Conceptualization
10. Crisis Response Plan
III. Phase One: Emotion Regulation and Crisis Management
11. Treatment Planning and Commitment to Treatment Statement
12. Means Safety Counseling and Crisis Support Plan
13. Targeting Sleep Disturbance
14. Relaxation and Mindfulness Skills Training
15. Reasons for Living List and Survival Kit
IV. Phase Two: Undermining the Suicidal Belief System
16. ABC Worksheets
17. Challenging Questions Worksheets
18. Patterns of Problematic Thinking Worksheets
19. Activity Planning and Coping Cards
V. Phase III: Relapse Prevention
20. Relapse Prevention Task and Ending Treatment
Appendix A. Patient Forms and Handouts
A1. The Suicidal Mode
A2. Patient Information Sheet about Brief Cognitive-Behavioral Therapy (BCBT) to Prevent Suicide Attempts
A3. Treatment Plan Template
A4. Commitment to Treatment Statement
A5. Means Safety Plan
A6. Crisis Support Plan
A7. Improving Your Sleep Handout
A8. ABC Worksheet
A9. Challenging Questions Worksheet
A10. Patterns of Problematic Thinking Worksheet
Appendix B. Clinician Tools
B1. Fidelity Checklists
B2. Suicide Risk Assessment Documentation Template
B3. Crisis Response Plan Template
B4. Possible Warning Signs
B5. Common Self-Management Strategies
B6. Relaxation Script
B7. Mindfulness Script
Interviews
Clinical psychologists, psychiatrists, clinical social workers, counselors, and psychiatric nurses. May serve as a supplemental text in graduate-level courses.