Description of the Cognitive Protocol

The cognitive protocol for treatment of suicidal behavior (Brown, Henriques, Ratto, & Beck, 2002) comprises one 60- to 90-minute psychoeducation session and approximately 10 (45- to 50-minute) weekly psychotherapy sessions. During the psychoeducation session, patients are informed that the offered treatment is short term and time limited. Patients are provided with a copy of Choosing to Live: How to Defeat Suicide through Cognitive Therapy (Ellis & Newman, 1996). Treatment is initiated with patient consent and following the psychoeducation session. For patients who have recently experienced a suicide attempt or an interrupted suicide attempt, it is recommended that the first treatment session be scheduled within 72 hours after the attempt or discharge from the hospital.

The cognitive protocol for the treatment of suicide aims to accomplish the following main objectives: (1) decrease patients' severity of depression, hopelessness, and suicide ideation; (2) increase problem-solving and coping skills, especially relative to the problems and stressful life events that preceded and triggered the most recent suicidal behavior; (3) increase patients' gradual establishment and adaptive use of a broad social support network; (4) increase patients' use of and compliance with adjunctive medical, substance abuse, psychiatric, and social interventions; (5) educate patients about the interconnection between feelings, thoughts, and behaviors, so that they fully understand the conceptualization involving the cognitions associated with their suicidal behavior; and (6) prepare patients, family members, and/or friends in implementation of emergency procedures in cases where suicidal behavior may recur.

Treatment is terminated when the patient is able to complete a task of relapse prevention with his or her therapist. In cases where the patient is not ready to complete this exercise successfully, treatment is extended to accommodate the patient. A termination checklist may be used to determine whether a patient is ready to end treatment. For instance, consistently reduced scores on self-report measures such as the BDI-II and the BHS; evidence of improved problem-solving skills; homework compliance; engagement in adjunctive medical, psychiatric, and chemical dependence treatment services; and development of a social support system are all factors that may be considered in assessment of patient readiness for termination.

The remainder of this chapter outlines the stages of CT and its main elements for individuals with suicidal behavior. The intervention is flexible and should not be followed strictly in its sequence of presentation at the expense of therapeutic rapport and clinical judgment. The challenge is for the therapist to develop an individualized cognitive conceptualization of the patient for the purposes of treatment planning. An active and directive role is encouraged, with particular attention paid to collaborative work with the patient. We generally conceptualize therapy in three stages: (1) the early phase of treatment (Sessions 1-3) whose aims are to engage the patient, to plan for patient safety, and to develop an initial cognitive conceptualization based on a review of the patient's suicide history or, if applicable, the most recent incident of suicide behavior; (2) the middle phase of treatment (Sessions 4-7) whose aims are to teach various cognitive and behavioral strategies to reconstruct patient's problematic coping style, to build a social support network, and to increase participation in adjunctive medical and psychiatric services; and (3) the final phase of treatment (Sessions 8-10) whose aims are to assess formally the patient's increased cognitive-behavioral skills through a relapse prevention task.

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