Middle Phase of Treatment Sessions

The therapeutic work completed during the middle phase of treatment is grounded in the generated cognitive conceptualization. The primary focus is on helping the patient to develop adaptive cognitive and behavioral skills to better manage future suicidal behavior.

Objective 1: Modifying Negative Suicide-Relevant Automatic Thoughts and Core Beliefs

Once the patient's automatic thoughts and core beliefs in relation to his/her suicidal behavior are identified, the therapist first assists the patient in evaluating these cognitions and, second, in modifying them. Patients are initially taught to evaluate their automatic thoughts by gaining an understanding of their most commonly utilized cognitive distortions. A Dysfunctional Thought Record can be used to teach the patient about more effective responses to daily distortions in the form of automatic thoughts. Emphasis is placed on the impact of these cognitive distortions on the accompanying emotional, physiological, and behavioral reactions.

The next step is to educate the patient about his/her core beliefs. What is important for the patient to understand at this stage is that such beliefs are generally rooted in childhood events, not in absolute truth, and can be tested, as well as changed. The therapist hopes that modification of core beliefs results in a lower likelihood of future suicidal behavior. To accomplish this goal, cognitive restructuring techniques such as Socratic questioning, cognitive continuum, historical tests of core beliefs, behavioral experiments, and/or restructuring early memories may be used to help the patient to devise more positive, realistic, and functional core beliefs.


An activity that helps the patient challenge his/her suicide-activating core beliefs, such as "My life is worthless," or automatic thoughts, such as "I have no reason to live," involves the construction of a hope box. The purpose of the hope box is to help patients directly challenge their maladaptive thoughts by being reminded of previous successes, positive experiences, and current reasons for living, especially at times of extreme distress. The process of constructing the hope box allows patients to work actively on modifying their core beliefs that they are worthless, helpless, and/or unlovable. Patients are encouraged to decorate the hope box with inspiring words and pictures. Items included in the box vary depending on each patient and may consist of pictures of loved ones, a favorite poem, a religious prayer, and/or coping cards. One of our patients, for instance, chose to include a positive work evaluation letter and a picture of herself in her early 20s as a reminder of a very positive and fulfilling time in her life.

Objective 2: Teaching Problem-Solving Skills

Depressed individuals with suicidal behavior usually face daily stressors, in addition to other, more challenging problems. The therapist, during the early stages of treatment, starts to gain an understanding of these problems. The therapist's task at the middle stage is to educate the patient about the direct relation between one's life-problems and perceived inability to solve these problems, and his/her subsequent suicidal behavior. The ultimate goal is to prepare the patient to react differently to future life stressors by learning effective problem-solving strategies. Once this goal is accomplished, the patient no longer relies solely on suicidal behavior as the only preferred means of dealing with problematic situations.

Teaching problem-solving skills comprises the following steps: (1) identifying and listing problems, (2) prioritizing problems, (3) connecting problems in living to suicidality, (4) assessing the functionality and adaptiveness of responses, (5) generating alternatives and plans, (6) weighing pros and cons of proposed solutions, (7) working out discrete tasks to achieve the goal, and (8) reviewing the consequences of the chosen solution(s).


Therapist and patient collaboratively create a problem list, then rank-order these problems based on their level of impact on the patient's past and/or present suicidal behavior. Once a problem list is generated, each problem is examined. Although the patient is asked to understand that therapy cannot aim to fix each problem, he or she learns that various options are available to start a process of resolving each problem. The therapist can model, as well as direct the patient to implement, effective problem-solving strategies. For instance, for a patient who is unemployed, one strategy may be to refer him/ her to a community job-counseling program or even to review the patient's résumé in session.

Objective 3: Developing Healthy Behavioral Coping Skills

Individuals with suicidal behavior are likely to have low distress tolerance and poor affective regulation. One goal of therapy is to help these individu-

als develop healthy coping skills, so that their chances of relying on self-injury and suicidal behavior are minimized. Patients are taught to engage in a variety of activities, such as progressive muscle relaxation, controlled breathing exercises, a regular exercise regimen, and/or distraction in the form of self-soothing strategies, such as taking a bath, imagining a positive scene, or listening to a favorite piece of music.

The development and continual practice of healthy coping strategies are important steps in teaching a patient to "procrastinate" relative to their suicidal impulses, which generally occur in waves. A diagram of a patient's mood and suicidality over time that visually illustrates his/her gradual or sudden increase and subsequent decrease in impulsivity may help the patient understand the one need to "ride out" suicidal urges. Simple coping strategies or delay tactics may include taking a nap, going for a walk, making a phone call, cleaning one's home, or visiting a friend. Another important delay tactic is to remove immediate access to lethal means by safeguarding one's environment. As therapy progresses, the patient can be prepared further to implement long-term coping strategies (e.g., completing college course work to increase job opportunities) in addition to these short-term strategies.


Coping cards are small, wallet-size cards generated collaboratively in session. They provide the patient an easily accessible way to "jump-start" adaptive thinking during a suicidal crisis. The patient is encouraged to use the coping cards to practice adaptive thinking even when not in crisis. Three types of coping card may be constructed. One way is to place each suicide-relevant automatic thought or core belief on one side of the card and the alternative, more adaptive response on the other. Another way is to write down a list of coping strategies. Still another way is to write a list of instructions to motivate or "activate" the patient toward completing a specific goal.

Objective 4: Increasing Social Support and Compliance with Adjunctive Services

An important goal of therapy is to increase patients' social support networks. A common observed core belief in patients with suicidal behavior is that "no one cares." For patients who already have an existing network of supportive friends, family members, or coworkers, the goal is to increase their perception of social support and to practice communication skills that make future social support likely. Patients may be encouraged, for instance, to share their safety plan with a family member in session or to ask a specific person for assistance with a therapeutic task (e.g., removing lethal means from the premises). For those patients who truly lack an existing social support network, the goal is to establish gradually an adaptive network of accessible social support. Connecting patients to people and resources in the community is a great way to accomplish this task. One patient treated at our program, for instance, currently has developed a relationship with two case managers, several addiction counselors, and two therapists. These newly formed relationships have reinforced the notion that he has a team of professionals "watching out for him."

Another important therapeutic goal is to increase the patient's compliance with adjunctive medical, psychiatric, and chemical dependence treatment services. As mentioned previously, patients with suicidal behavior are likely to experience a host of life problems that are more adequately addressed by a comprehensive range of services. A patient is taught that such services can begin to make a difference only if he/she demonstrates a clear commitment to adhere to treatment recommendations. Of course, this task is not easy, and the therapist's role is to provide encouragement, support, and guidance through this process.


The patient is helped to generate a comprehensive list of individuals within his/her circle of social support. This list can include members, friends, coworkers, other patients (e.g., Alcoholics Anonymous [AA] or Narcotics Anonymous [NA] sponsor), and/or treatment providers who care. Next, the patient outlines the potential contributions each ofthese individuals may be asked to make to assist with his/her therapeutic progress. The patient is asked to keep track of positive interactions with each of these individuals and to involve each appropriate person in one aspect of his/her treatment process.

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