Cognitive Therapy for Suicidal Patients: Current Status.

Suicide is the 10th leading cause of death in the United States, with more than 36,000 deaths by suicide per year (Crosby, Ham, Ortega, Parks, & Gfroerer, 2011). The rate of completed suicides has increased steadily over the past decade, and the most recent statistics indicate that the rate of suicide has reached its highest level in the past 15 years (Centers for Disease Control and Prevention [CDC], 2008). Despite the enduring public health significance of suicide, only recently has attention been given to the development of efficacious treatments to prevent suicidal behavior. Traditionally, the approach to treating suicidality was to address the patient’s depression (Ellis, Allen, Woodson, Frueh, & Jobes, 2009; Linehan, 2000). However, this approach is limited because (a) it assumes that all suicidal patients are depressed, which is not always the case; (b) it does not necessarily address the unique psychological mechanisms at work leading up to or during suicidal behavior; (c) it does not necessarily address other modifiable risk factors for future suicidal behavior; (d) it does not necessarily allow for patients to develop strategies that they can use during a future suicidal crisis; and (e) there is no evidence that it is efficacious, as suicidal patients are almost always excluded from randomized controlled trials (RCTs) to evaluate treatments for depression. Thus, beginning in the late 1990s, pioneering work by Aaron T. Beck and Gregory K. Brown was initiated at the University of Pennsylvania to develop a cognitive therapy protocol that specifically targeted suicidal behavior. This treatment protocol was first described in the mid-2000s (Berk, Henriques, Warman, Brown, & Beck, 2004; Henriques, Beck, & Brown, 2003) and subsequently presented in greater detail in a full-length treatment manual (Wenzel, Brown, & Beck, 2009). It was originally developed for patients who recently attempted suicide, but it can also be applied to patients who have experienced a recent episode of acute suicidal ideation that requires intervention. In this article, we view patients as being appropriate for this cognitive therapy protocol if they have experienced a recent suicidal crisis, which is defined as either a suicide attempt or acute suicidal ideation. This treatment protocol’s central feature is that suicidal behavior is viewed as the primary problem rather than as a symptom of a psychiatric disorder. As such, it can be delivered to patients with a wide range of psychiatric disorders. Similar to cognitive therapy protocols for other problems, it targets unhelpful cognitions and maladaptive behavioral patterns, and in this case, the specific cognitions and behaviors that fuel suicidal behavior are the focus of treatment. This treatment protocol also shares many other features with other cognitive therapy protocols, such as an emphasis on problem solving in the here-and-now, collaboration between the patient and therapist, and an organized session structure. It was designed to be a brief intervention (i.e., approximately 10 sessions) that can be administered in concert with other relevant treatments, such as pharmacotherapy, drug and alcohol counseling, and/or group therapy. However, because many suicidal patients present with multiple life problems and chronic emotional distress, it is not expected that patients will no longer need therapy at the end of this brief intervention. Rather, treatment moves from an acute phase, in which the suicide prevention protocol described in this article is delivered, to a continuation phase, where other psychiatric disorders, Axis II clinical presentations, and/or life problems are addressed. The following sections describe the acute phase of treatment for suicidal patients. First, we outline the cognitive model of suicidal behavior that forms the basis of treatment. Next, we describe specific therapeutic strategies that cognitive therapists implement in their sessions with suicidal patients. We also present the primary results from the RCT designed to evaluate the efficacy of this treatment protocol. Finally, we end by highlighting new developments in the field, which center mainly on the adaptation of the cognitive therapy treatment protocol for specific populations and settings.