Cognitive therapy for the suicidal patient: a case study.

TOPIC. The use of cognitive therapy to treat a suicidal patient. PURPOSE. To demonstrate through the use of a case study, the cognitive therapy method in treating a suicidal patient. SOURCE. The author's own clinical work. CONCLUSION. Suicidal people often demonstrate perfectionism, social sensitivity, difficulty problem solving, and hopelessness. Cognitive therapy addresses these problems by helping patients plan activities, track destructive thinking and its impact on feelings and behaviors, and substitute constructive thinking, thus decreasing hopelessness. Key words: Cognitive therapy, depression, suicide Suicide is responsible for more than 31,000 deaths a year, making it the ninth leading cause of death in America (Anderson, Kochanek, & Murphy, 1997). The single most predictive risk factor for a completed suicide is a psychiatric diagnosis. As in the case of depression and panic disorder, cognitive therapy research has made a significant contribution toward understanding the variables in suicide. A task force of the National Institute of Mental Health Center for Studies of Suicide Prevention developed a tripartite classification system in 1973 to describe suicidal behavior--suicide ideation, suicide attempt, and completed suicide (Beck et al., 1973). Within these three processes, the variables of intent, lethality, and method can be assessed so the clinician can evaluate the degree to which a suicidal patient is at risk. There has been much discussion in the literature about the relationship of suicidal intent to degree of lethality in the suicide attempt (Beck, Resnik, & Lettieri, 1986; Riggs, McGraw & Keefover, 1996; Weishar, 1996). This research suggests greater suicidal intent leads to greater lethality of method chosen. If the patient is knowledgeable about the method chosen to end life, the degree of intent is considered to be high, potentially placing the patient at higher risk for completion in a subsequent attempt (Weishaar, 1996). Common assessment tools used in clinical practice for assessing the suicidal patient include: the Beck Depression Inventory (BDI), the Beck Hopelessness Scale (BHS), and the Scale for Suicide Ideation (SSI). The BDI is a 21-item, self-report questionnaire that measures depressive symptoms on a 4-point scale. It targets two important items--hopelessness and suicidal ideation (items 2 and 9). The higher the sum on the scale, the greater the degree of depressive symptoms the patient is experiencing. The BHS is a 20-item, true-false, self-report questionnaire assessing the level of pessimism and hopelessness of the respondent. The SSI is a 19-item, interview-administered inventory that assesses the intensity of and specific attitudes, plans, and behaviors concerning suicidal behavior. Many factors play a role in suicidal ideation and behavior. Hopelessness frequently has been reported to be the most critical psychological variable predictive of suicidal ideation and behavior. Degree of hopelessness, along with a negative self-concept (a variable predictive of suicide independent of hopelessness), compose two of the three components of Beck's negative cognitive triad found operating in depressed individuals (Beck, Steer, Epstein, & Brown, 1990). Cognitive distortions, cognitive rigidity, and dysfunctional assumptions also have been cited as leading to suicidal thinking. Rainier et al. (1987) found that perfectionistic attitudes toward the self and sensitivity to social criticism accounted for independent variance in suicide ideation. In a sample of psychiatric outpatients, four specific dysfunctional attitudes were positively associated with suicidal ideation: feeling vulnerable to becoming depressed, accepting other people's expectations, feeling that it is important to impress others, and being sensitive to the opinions of others (Beck, Steer, & Brown, 1993). Hewitt, Flett, and Turnbull-Donovan (1992) explored three types of perfectionism associated with suicidal threats and impulses: expectation of self (self-oriented), expectations of others (other-oriented), and expectations that others hold for the person (socially prescribed perfectionism). …