Objective 3 Developing a Cognitive Case Conceptualization for Suicide Behavior

The "cognitive case conceptualization" is an individualized cognitive map of the current automatic thoughts, conditional assumptions, and core beliefs activated before, during, and after suicidal behavior. It is based on collected data about the patient's early childhood experiences, typical activating events, associated automatic thoughts, emotional responses, and subsequent behavior. Figure 7.2 illustrates a completed cognitive case conceptualization diagram for a depressed suicide attempter. We recommend that a cognitive case conceptualization diagram be generated collaboratively with the patient in session. Because the diagram is based on a series of hypotheses, its content should be refined periodically as needed during the course of treatment.

An important clinical task during this early phase of treatment is to provide patients an opportunity to "tell their story" about the most recent suicidal behavior and the specific events leading up to it. This activity is helpful for three reasons: First, this may be the patient's first chance to disclose the details surrounding his/her suicide behavior. By providing the patient with a supportive and nonjudgmental environment, the patient's storytelling can be cathartic. The therapist's ability to communicate empathy and discuss freely or to hear about the details of the suicidal behavior builds a strong alliance with the patient. Second, the patient's suicidal behavior story provides a wealth of information for the purposes of cognitive case conceptualization and treatment planning. For instance, one can collect data about the events surrounding the patient's suicidal behavior and suicide-related beliefs, problem-solving abilities, and implemented compensatory strategies. Third, during the process of generating a cognitive case conceptualization, the patient is educated about the interrelatedness of thoughts, feelings, and behaviors that serves as the foundation for CT. A frequent review of the generated diagram allows the patient to see the patterns of association between specific situational problems and subsequent suicidal behavior. At this point, therapist and the patient can develop a suicide-related problem list, prioritize the problems, and develop a plan for addressing each.

• University of Pennsylvania Hospital—Psychiatry Emergency Evaluation Center (PEEC)

• National Hopeline Network (24-hour service, 7 days a week)

Starts with machine saying you're going to be redirected to local call center

Therapist and Case Manager Contact Numbers

Therapist's Name Address Line 1 Address Line 2 PHONE: (555) 555-5555

Case Manager's Name Address Line 1 Address Line 2 PHONE: (555) 555-5555

When I notice the following signs:

Having flashbacks, feeling depressed, feeling like I was nothing or nobody—like there is no space here for me in this world, that I would be better off dead . . .

That lead to:

Me staying up all night, obsessing, crying, thinking about hurting myself . . .

I plan to do the following:

1. Get out of the house

3. Call my grandmother

4. Listen to the new country music CD I bought

When others notice the following signs:

I am not talking, I go to my room and I lock the door, I stay in my room for 2 days—not coming out at all, turning my phone off . . .

I would like them to:

Come and talk to me and INSIST to stay until they figure out what is wrong with me.

1. My sister can call and leave a message.

2. My husband can give me a hug.

I am in serious trouble when I or others notice that:

I have psychiatric medications in my possession and I start to count the number of pills I have.

When I am in serious trouble:

I will try to use my safety plan. If this plan does not work, then I will call my therapist (Jane 555-555-5555) or my case manager (Sam 555-555-5555). In case of an emergency, I will call the Psychiatric Emergency Room (555-555-5555) to be evaluated for possible hospitalization. I can also call 911.

Patient Signature:

Date:

Therapist Signature:

Date:

FIGURE 7.1. Sample safety plan.

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RELEVANT CHILDHOOD DATA

Childhood Verbal, Physical, and Sexual Abuse by Stepfather Mother did not believe patient's report of abuse.

CORE BELIEFS

"I am damaged goods." "I am unlovable and shameful."

CONDITIONAL ASSUMPTIONS Negative Assumptions

"If I don't protect myself, then I will be taken advantage of." "If I withdraw, then no one else can hurt me."

COMPENSATORY STRATEGIES Affective Feeling Sad, Feeling Angry Cognitive "Nothing will change."—Suicide Ideation Behavioral Isolation, Crying, Anger Outbursts, Impulsivity

Situation 1

Situation 1

Situation 1

Argument with Mother

Job Rejection

Bounced Check

i

Automatic Thought

Automatic Thought

Automatic Thought

"She is still blaming me for what happened."

"I can't take this anymore."

"1 can't even do my own checkbook."

1

Meaning of AT

Meaning of AT

Meaning of AT

I am still unlovable even by my own Mom.

I am worthless.

1 am a failure.

1

1

1

Emotion

Emotion

Emotion

Sadness, Anger

Frustration, Hopelessness

Anger, Irritation

1

1

1

Behavior

Behavior

Behavior

Isolates herself in bedroom.

Gives up on applying to future job opportunities.

Argues with bank manager, cuts herself to relieve tension.

FIGURE 7.2. Cognitive Case Conceptualization Diagram.

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