Cognitive Behavior Therapy for Suicide Prevention (CBT-SP):

Treatment Model, Feasibility and Acceptability

Barbara Stanley, PhD
1
, Gregory Brown, PhD
2
, David Brent, MD
3
, Karen Wells, PhD
4
, Kim
Poling, LCSW
3
, John Curry, PhD
4
, Betsy D. Kennard, PsyD
6
, Ann Wagner, PhD
5
, Mary Cwik,
PhD
7
, Anat Brunstein Klomek, PhD
1
, Tina Goldstein, PhD
3
, Benedetto Vitiello, MD
9
,
Shannon Barnett, MD
7
, Stephanie Daniel, PhD
8
, and Jennifer Hughes, BA
6
1
Columbia University-New York State Psychiatric Institute
2
University of Pennsylvania
3
The University of Pittsburgh and Western Psychiatric Institute & Clinic
4
Duke University
5
National Institute of Mental Health
6
University of Texas Southwestern Medical Center in Dallas
7
J ohns Hopkins University
8
University of North Carolina at Greensboro
9
National Institute of Mental Health
Abstract
ObjectiveTo describe the elements of a manualized cognitive behavior psychotherapy for suicide
prevention (CBT-SP) and to report its feasibility in preventing the recurrence of suicidal behavior in
adolescents who have recently attempted suicide.
MethodCBT-SP was developed using a risk reduction, relapse prevention approach and
theoretically grounded in principles of cognitive behavior therapy, dialectical behavioral therapy and
targeted therapies for suicidal, depressed youth. CBT-SP consists of acute and continuation phases,
each lasting about 12 sessions, and includes a chain analysis of the suicidal event, safety plan
development, skill building, psychoeducation, family intervention, and relapse prevention.
ResultsCBT-SP was administered to 110 depressed, recent suicide attempters aged 1319 years
(mean 15.81.6) across five academic sites. Twelve or more sessions were completed by 72.4% of
the sample.
ConclusionsA specific intervention for adolescents at high risk for repeated suicide attempts
has been developed and manualized, and further testing of its efficacy appears feasible.
Keywords
Suicide; psychotherapy; depression; adolescents
Corresponding Author: Barbara Stanley, Ph.D., Department of Psychiatry, Columbia University College of Physicians & Surgeons,
NYSPI Unit 42, 1051 Riverside Drive, New York, New York 10032, Phone: 212 543-5918, Fax: 212 543-6946, [email protected].
Clinical Trials Registry Information: Treatment of Adolescent Suicide Attempters (TASA); http://clinicaltrials.gov; NCT00080158
Disclosure: Dr. Wells receives speaking fees fromthe REACH Institute. The other authors report no conflicts of interest.
This article is the subject of an editorial by Dr. Garry Walter in this issue.
NIH Public Access
Author Manuscript
J Am Acad Child Adolesc Psychiatry. Author manuscript; available in PMC 2010 October 5.
Published in final edited form as:
J Am Acad Child Adolesc Psychiatry. 2009 October ; 48(10): 10051013. doi:10.1097/CHI.
0b013e3181b5dbfe.
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Introduction
The Surgeon Generals Call to Action to Prevent Suicide (USPHS, 1999) emphasized the need
for more effective suicide prevention strategies This need is particularly pressing in
adolescents, with nearly 9% reporting a suicide attempt in the prior year.
1
Furthermore, suicide
is the third leading cause of death for adolescents in the U.S. Intervening with adolescents who
recently attempted suicide or engaged in self- injury is vital because these behaviors are
predictive of future suicidal behavior and risk of repetition is highest in the first 36 months
post-attempt.2

7 Prior suicidal behavior elevates the risk for subsequent death by suicide 10
60 fold.7
10
Moreover, adolescents with depressive disorders and a history of suicidal behavior
are a particularly high risk group for repeated and completed suicide.
58,11
Despite this public health problem, there are no empirically supported individual
psychotherapies for adolescents shown effective in reducing suicidal behavior through
randomized controlled trials (RCT).
12
Importing empirically-supported treatments for
depressed adolescents to suicidal adolescents may not be appropriate because the trials in which
efficacy was established excluded suicidal teens. In an effort to target the suicidal adolescent
population, Dialectical Behavioral Therapy was adapted (DBT-A).13 DBT-A employs
individual therapy and group skills training and targets suicidal behavior. A quasi-experimental
investigation of DBT-A vs. usual care in suicidal adolescents with borderline personality
disorder features reported that in the DBT-A group, although not statistically significant, fewer
subjects made suicide attempts, fewer subjects were hospitalized, and the completion rates for
treatment were higher. However, this was not an RCT and focused only on adolescents with
borderline symptoms.
Family, group-oriented and brief, adjunctive psychosocial intervention models have been
tested in suicidal adolescents. Wood, Trainor, Rothwell, Moore, and Harrington (2001)
evaluated the efficacy of developmental group therapy for adolescents with self-injury
behavior, using problem solving and cognitive behavior therapy, DBT, and psychodynamic
group psychotherapy strategies.
14
Patients attended six acute group sessions organized
around specific themes (i.e., relationships, school problems and peer relationships, family
problems, anger management, depression and self-harm, hopelessness and feelings about the
future), followed by weekly group therapy. The experimental treatment, compared to routine
care, showed a reduction in episodes of self-harm, time to first repetition of self-harm was also
delayed and school attendance was improved. There was no differential treatment effect on
depression, suicidal ideation, or global outcome.
Multisystemic therapy (MST), a family-based treatment developed for antisocial behavior and
delivered in the natural environment, was associated with fewer suicide attempts but not greater
reductions in suicidal ideation, hopelessness or depression.
15
However, the results are difficult
to interpret because about 50% of teens receiving MST required emergency hospitalization
and, thus, the hospitalization itself may have been responsible for the lower suicide attempt
rate. Cotgrove et al. (1995) found that permitting adolescents to rehospitalize themselves on
demand was associated with a nonsignifcant reduction in suicide attempts at one year follow-
up.16 A post-hoc analysis seemed to indicate that open access was protective only for those at
low or moderate risk for suicide re-attempt. Of those given open access, 11% requested
hospitalization.
Other randomized controlled trials with high risk adolescents that have tested efficacy of a
cognitive behavioral family intervention in the emergency department or outpatient family
therapy have not been successful in reducing or preventing suicidal behavior.17

18 Rotheram-
Borus et al.(2000) reported that, while 18-month follow-up re-attempt rates and suicidal
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ideation were not different between the two groups, there was a non-significant trend for a
lower re-attempt rate in the experiemental group (8.7% vs. 14.6%).17 Harrington et al. (1998)
compared a 5-session home-based family intervention plus routine care to routine care alone
for adolescent who made suicide attempts.18 Although the experimental intervention was no
better than routine care for reducing ideation or reattempts, among the non-depressed subgroup,
the home-based treatment reduced suicidal ideation more than usual care. King et al. (2006)
developed a novel intervention in which suicidal adolescents identified adults in their life who
would be a source of ongoing support.19 Although there was no main effect for suicide ideation
or attempts, females in the study intervention group reported greater decreases in suicide
ideation than females in the control group.
The lack of empirically-based psychotherapies is further complicated by the high rate of
treatment refusal and drop out by adolescents.
17
While adolescents are difficult to engage and
retain in treatment, suicidal individuals, irrespective of age, also refuse or drop out of treatment
very quickly.
20
The task of engaging and retaining patients who are both adolescent and suicidal
is daunting.
In summary, there is a need for empirically supported, individual psychotherapies developed
for suicidal adolescents to prevent recurrence of suicidal behavior. Interventions that aim to
reduce the severity of established risk factors for suicidal behavior such as depression, suicide
ideation and impulsivity may be beneficial. Such interventions are likely to be most effective
if they target these prominent risk factors that exist during acute suicidal crises. The focus of
this manuscript is to describe the elements of a newly developed manualized psychotherapy,
Cognitive Behavior Therapy-Suicide Prevention (CBT-SP), that takes a risk reduction, relapse
prevention approach and is aimed expressively at reducing risk for future suicidal behaviors
in suicidal adolescents. This treatment was developed in the context of a multisite study,
Treatment of Adolescent Suicide Attempters (TASA), designed to prevent reoccurrence of
suicide attempts in depressed, suicidal adolescents. We report on treatment retention, patient
acceptability, and frequency of the use of treatment modules in adolescents who received CBT-
SP as part of a multisite feasibility study.
Method
CBT-SP Treatment Description
OverviewCognitive Behavior Therapy-Suicide Prevention (CBT-SP) is a manualized
cognitive behavioral treatment for adolescents who recently attempted suicide (90 days).
Although CBT-SP was implemented with suicide attempters, the theoretical approach and
strategies may also apply to adolescents who experience episodes of acute suicide ideation (as
opposed to chronic, unremitting ideation) in which precipitants can be identified. The primary
goals of this intervention are to reduce suicidal risk factors, enhance coping and to prevent
suicidal behavior. Adolescents who make suicide attempts, or who have acute or persistent
suicide ideation, typically have multiple psychiatric and environmental problems.
9
CBT-SP is
narrow in focus and is not designed to address all of the adolescents problems. This approach
recognizes that the teen may need further treatment. Instead, it focuses on developing skills
(cognitive, behavioral and interactional skills) that will enable the adolescent to refrain from
further suicidal behavior. Thus, CBT-SP is designed to help adolescents use more effective
means of coping when faced with their stressors and problems that trigger suicidal crises.
Parents meet with the therapist for family sessions focused specifically on suicide risk reduction
strategies.
CBT-SP is based on a stress-diathesis model of suicidal behavior.
21
Theoretically, the diathesis
for suicidal behavior includes a combination of factors, such as sex, religion, familial and
genetic components, childhood experiences and psychosocial support system. In this model,
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stressors trigger suicidal behavior in the context of an individual who possesses the diathesis.
Stressors include a variety of psychosocial events, such as interpersonal conflict, work or
school-related difficulties. CBT-SP acts to modify reactions to stressors both acutely and
chronically in the context of vulnerability (i.e. positive diathesis).
A central focus of CBT-SP is the identification of proximal risk factors and stressors, including
emotional, cognitive, behavioral and family processes active just prior to and following the
adolescents suicide attempt or recent suicidal crisis. These processes include deficits in the
adolescents abilities or motivations to cope with suicidal crises. For example, such deficits
may include the inability to regulate emotions, the inability to resolve problems, the inability
to tolerate distress, the inablity to address negative thoughts or beliefs such as hopelessness or
worthlessness. These risk factors are identified by conducting a detailed chain analysis of the
sequence of events, and their reactions to these events, that led to the suicidal crisis. A core
feature of the treatment is the development of an individualized case conceptualization that
identifies problem areas to be targeted and the specific interventions to be employed during
periods of acute emotional distress.
Individual and family treatment strategies are selected based on their relevance from the
perspective of the therapist, patient, and family for risk reduction for each adolescent. In
particular, strategies are chosen collaboratively between therapist and patient with particular
consideration for those strategies that are most likely to have an impact on reducing suicide
risk and those that bolster already-existing strengths. These strategies may include a variety of
CBT techniques already described in the literature. CBT-SP treatment was informed by several
sources and includes cognitive restructuring strategies such as identifying and evaluating
automatic thoughts from Cognitive Therapy,
2229
emotion regulation strategies such as action
urges and choices, emotions thermometer, index cue cards, mindfulness, opposite action, and
distress tolerance skills from Dialectical Behavior Therapy, as well as other CBT strategies
such as behavioral activation and problem-solving strategies.
3031
Family issues are addressed to the extent that they are viewed by the patient, family and
clinician to be relevant to the case conceptualization and the prevention of a future suicide
attempts. CBT-SP also recognizes that suicidal crises occur within the context of the
adolescents environment and these factors contribute to suicide risk. Specifically, such factors
may include problematic peer or romantic relationships, physical, verbal or sexual abuse,
dysfunctional family beliefs, high family expectations and low reinforcement, or poor school
performance. Thus, CBT-SP also incorporates specific family therapy techniques to address
these contextual concerns.
2526
CBT-SP consists of acute and continuation phases, both of which are generally completed
within six months. The acute phase of CBT-SP consists of approximately 12 to 16 weekly
sessions and is comprised of mostly individual sessions as well as up to 6 family sessions.
Family check-ins (515 minutes) may also be conducted on a weekly basis at the discretion
of the therapist, and were not considered to be family sessions. The acute phase of treatment
consists of an initial phase, a middle phase, and an end of acute treatment phase. This is followed
by a continuation phase of treatment.
Initial Phase of Acute Treatment
The intial phase of acute treatment occurs during the first three sessions and consist of five
main components: Chain Analysis, Safety Planning, Psychoeducation, Developing Reasons
for Living and Hope, Case Conceptualization. The Chain Analysis, Safety Planning, and
Psychoeducation components generally occur during the initial two sessions. Developing
Reasons for Living and Case Conceptualization generally occurs during the third session.
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Family members are involved in all of the initial sessions. Each of the components that occur
during the initial phase are discussed below.
Chain analysisThe basic strategy that sets the framework for the CBT-SP is a detailed
chain analysis of events associated with the index suicide attempt or suicidal crisis. The chain
analysis includes identification of vulnerability factors and activating events associated with
the crisis as well as the adolescents thoughts, feelings and behaviors in reaction to these events.
To conduct a chain analysis of a suicide attempt, the therapist asks the teen to describe the
events that led to and followed the suicide attempt as well as the details of the actual attempt.
A good metaphor for this process is to ask the teen to describe the frames in the film of the
suicide attempt.
32
The therapist can then guide the teen to freeze the frame at a specific point
in time so they can learn more details about thoughts, feelings and behaviors that were occurring
at that moment. Often, the chain analysis begins with a specific stressful life event that is
identified by the patient. However, the therapist may also begin the chain analysis by starting
at the time of the attempt and work backwards. Other recommended starting points for
describing the chain of events include when the patient woke up the morning of the attempt or
the evening prior to the attempt.
Conducting the chain analysis, by itself, is beneficial, not only because detailing the sequence
of events, thoughts and feelings from the adolescents perspective is crucial to selecting
intervention strategies, but also because it gives patients the opportunity to feel understood and
counteract a frequent feeling that the suicidal behavior just happened. Sharing of the details
of the suicide attempt or suicidal crisis (and circumstances surrounding it) facilitates rapport
building and helps patients engage in treatment. The intervention also facilitates the
development of a conceptualization of patients suicidality and assessment of future risk. Once
the chain was been fully described in written form, it can be revisited and revised during the
treatment.
Safety PlanningSafety planning is a technique to help patients remain safe and not to
engage in further suicidal behavior, at least until the next therapy session.
29,33
Safety planning,
as developed in CBT-SP, provides patients with a prioritized and specific set of coping
strategies and sources of support that can be used during a suicidal crisis. It also includes a
section on means restriction. The intent of safety planning is to help individuals lower their
imminent risk for suicidal behavior by consulting this pre-determined set of potential coping
strategies and list of individuals or agencies whom they may contact. Given that the highest
risk period for a re-attempt is shortly after the indexed attempt, as well as during during the
time immediately following dischange from inpatient treatment, it is essential to develop a
safety plan early in treatment for high suicide risk adolescents who are being treated as
outpatients. Its development conveys to the adolescent that the behavior is serious and worthy
of immediate attention, yet manageable.
The safety plan includes a stepwise increase in the level of intervention from internal (within-
self) strategies to external (outside-self) strategies. Internal strategies comprise a list of
activities that the patient could do to cope with suicidal urges without the assistance of other
people. These are usually behavioral activities that are done to distract the patient from thinking
about suicide. Patients are informed that when such internal strategies do not work, the patient
should then turn to external startegies. External startegies include a range of behaviors from
receiving help from friends or family members to emergency psychiatric evaluation and
possible hospitalization. The external strategies may start with people in the patients social
environment who can help distract them as well as adults whose help the patient can ask for.
The final external strategy includes a list of the emergency psychiatrc services available to the
teen.
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The therapist and patient should review each step of the plan and collaboratively problem-solve
any potential obstacles to implementation. The plan should also include a list of the patients
warning signs of a suicidal crisis (usually based on specific situations, emotional state and/or
cognitions) to indicate when the safety plan should be used. The safety plan is discussed and
revised in every CBT-SP session, especially after each time the safety plan is used. Usually
skills/strategies are added to the safety plan throughout treatment.
The safety plan is always written and kept where it can be retrieved during times of crises.
Family members, especially parents, may be involved in the safety planning. The therapist and
patient collaborate on how the family can be helpful in supporting the patient to use the safety
plan. It is important to discuss with the patient and parents the elimination of any potential
lethal means in the patients environment. Every effort must be made for a responsible adult
to remove firearms from the patients access.
For the initial session, there may not be sufficient time to develop a full elaboration of the
safety plan based on a chain analysis. However, it is essential to develop a rudimentary safety
plan and chain analysis, both of which are elaborated in later sessions. Thus, the first session
always includes a written safety plan and is further modified in subsequent sessions as more
information was gathered through a more detailed chain analysis.
PsychoeducationThe therapists role in CBT-SP includes educating the patient and
family in several areas during the initial phase of treatment. The therapists first task is to
explain to the patient and parents the nature of suicidal behavior, the role of depression and
the need for securing potential lethal means. The therapist also introduces the patient and family
to the basic principles and goals of CBT-SP. Parents may also help to further elaborate on the
chain analysis from their perspectiven and may contribute to development and implementation
of the safety plan. Although there is parental input to the chain analysis and safety plan, the
clinician works with the adolescent to determine which aspects of parental input are helpful in
advancing their understanding of the chain and enhancing safety. In other words, the
adolescents perceptions of the sequence of events is most crucial.
Addressing Reasons for Living and Building HopeGiven that hopelessness is often
associated with suicide risk, it is important to include treatment strategies that instill a sense
of hope. One strategy for increasing hopefulness early in treatment is to discuss the adolescents
personal reasons for living. Delineating reasons to live is an important activity because learning
to cope with suicidal urges is rather empty if there are no reasons to want to cope. The reasons
for staying alive may include the people who care about the patient; things the patient can look
forward to in the future; things the patient likes to do; and things that the patient cares about.
The therapist should explain how recalling reasons to stay alive may be impaired during a
crisis. The ability to recall reasons for living can be used as a specific coping strategy in
distressing times.
The adolescent is also encouraged to construct a Hope Kit, a concrete implementation of the
patients reasons to stay alive.34
35
The kit serves as a memory aid to be used in times of crisis,
can help to increase hopefulness about the future and provide reminders about patients sense
of purpose. Hope kits can contain pictures of loved ones, reminders of aspirations and places
that give them pleasure (e.g. seashells, picture of mountains).
Case ConceptualizationFollowing the first two sessions, the therapist develops a case
conceptualization based on the chain analysis. As mentioned earlier, the therapist identifies the
specific cognitive, behavioral, affective, and contextual problems that were identified during
the chain analysis and then selects corresponding strategies to address these problems. The
therapist and patient discuss the specific goals for reducing suicidal risk and then discuss the
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suggested approach in a collaborative manner. Adjustments to the treatment plan are made for
each patient. The prioritization of specific skills training should include those skills that are
most likely to prevent a subsequent suicide attempt and that build on the adolescents existing
strengths. Once the interventions are collaboratively selected by the therapist and patient, the
treatment plan is presented to the family for feedback.
Middle Phase of Acute Treatment
During the middle phase of acute treatment (approximately sessions 49), after the immediate
suicidal crisis has resolved, the primary area of intervention is behavioral and/or cognitive
skills training using individual or family sessions. Skills training is included as a series of
optional individual and family modules. These modules are presented below.
Individual Skill ModulesThe skill modules are drawn from empirically supported
cognitive behavioral treatments. Patients may receive some but not all of these modules. The
choice of modules is based on several factors: (1) Review of the chain analysis and subsequent
case conceptualization which identifies deficits and, therefore, skills that can be taught; (2)
Assessment of the patients strengths (e.g., if a patient is hopeless and has a cognitive approach
to problem solving, using cognitive restructuring may be most accessible to the teen and,
therefore, most helpful early on); and (3) Identification of skills that are most likely to yield
the quickest, most effective results. Choosing which skill module to implement is an extremely
important decision because of the time-limited nature of the treatment. Individual skill modules
include: (1) Behavioral activation and increasing pleasurable activities; (2) Mood monitoring,
(3) Emotion regulation and distress tolerance techniques; (4) Cognitive restructuring; (5)
Problem solving; (6) Goal setting; (7) Mobilizing social support; and (8) Assertiveness skills.
Family Skill ModulesThe goal of CBT-SPs family intervention is focused on reducing
suicide risk by encouraging family support; improving the familys problem solving skills; and
modifying the familys communication patterns. The family modules may be implemented as
part of or as adjunctive to the corresponding individual module, or they may be implemented
during a distinct, separate session. The family interventions include parents and the suicidal
adolescent, but do not normally include siblings.
During the family sessions, the therapist chooses which family skill modules to use and in what
order, based on the case conceptualization. The core family modules include: (1) Family
behavioral activation; (2) Family emotion regulation; (3) Family problem solving; (4) Family
communication; and (5) Family cognitive restructuring.
Session StructureThe general structure of the sessions is consistent throughout the
middle and ending phases of the acute treatment as well as during the continuation phase.
Sessions are typically one hour in duration, except for the first two sessions which are one and
a half hours because they include a family component. A typical CBT-SP session starts with
the patient and therapist collaboratively setting the agenda for the session. When setting the
agenda, priority should be given to those problems that are perceived to be the most life
threatening or dangerous by the patient and the therapist. In the beginning of each session, the
therapist reviews current mood symptoms and conducts an assessment of the patients ongoing
risk for suicide that includes the patients current suicide status. The therapist reviews with the
adolescent whether any elements of the safety plan have been used since the last session, and
whether changes in the plan are needed to improve it by making it more feasible, usable or
comprehensive. The adolescent and therapist then review the material covered in the prior
session and any homework given during the prior session. In every session the therapist and
adolescent conduct a review of progress that has been made in therapy and areas that still need
attention.
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The majority of CBT-SP sessions are devoted to introducing and teaching new skills and uses
multiple modalities to assist the teenager to learn the relevant skill. These include presenting
the rationale, explaining and teaching the skill, using role-play during the session to rehearse
the skill, reviewing the role-play to understand the adolescents (or parents) reaction, and
working collaboratively to develop a homework assignment so that the new skill can be used
in the patients life. Each session ends with a summary and a collaborative agreement about a
homework assignment. The therapist helps the teen to summarize the key points that have been
raised or the key elements of new learning that appear to be relevant to prevent recurrence of
suicidal behavior. In the first few sessions, the therapist may be very active in summarizing
the content of the session but it is important for the teen to do it by him- or herself as the therapy
proceeds. In addition, it is very important for the therapist to elicit feedback throughout the
session and at the end of the session. Feedback helps the therapist to understand those aspects
of the session that were perceived to be most helpful and to address any issues that may have
been upsetting for the patient.
End of Acute Treatment and Continuation Phase
The final component of the acute intervention phase includes a relapse prevention task. Once
patients have successfully completed the relapse prevention task, the continuation phase is
conducted.
Relapse Prevention TaskThis module, conducted at approximately sessions 10 to 12,
usually marks the end of the acute phase of treatment. The relapse prevention task is an in-
vivo guided-imagery technique to test the efficacy of the acquisition of skills and coping
capabilities in preventing suicidal behavior in the future.
3435
If the patient has difficulty
completing the relapse prevention task, the therapist and adolescent identify obstacles to its
completion and may review previously taught skills or add new skills.
The relapse prevention task includes five steps: (1) Preparation, (2) Review of the Indexed
Attempt or Suicidal Crisis, (3) Review of the Attempt or Suicidal Crisis using Skills, (4) Review
of a Future High Risk Scenario, and (5) Debriefing and Follow-up. During the preparation
phase, the therapist introduces the rationale for this task in an attempt to increase the patients
motivation, and obtains verbal consent. Patients are informed that they will be asked to recall
their recent suicide attempt or suicidal crisis, their thoughts, feelings and the reactions of people
and to try to imagine as much as possible that they are re-experiencing that time. They are told
that by imagining the suicide attempt and reliving the pain that was experienced, patients will
have the opportunity to assess whether the coping skills learned in therapy can be recalled.
During the review of the indexed attempt or suicidal crisis, the patient is asked to imagine the
sequence of events that led to the index suicide attempt and the associated thoughts and feeling
leading up to and following the suicide attempt. Next, the clinician again leads patients through
the same sequence of events, but this time the therapist encourages the patient to imagine using
the skills learned in therapy to cope with the events, feelings and thoughts. As they imagine
the chain, teens are asked to describe the sequence of events and coping skills out loud and
using the present tense. Teens are encouraged to rehearse applying the skills learned in therapy
to the situation described in the chain analysis to result in a better outcome. During the next
step, patients are encouraged to imagine, and describe in detail, a future scenario that could
lead to a suicidal crisis. A crucial part of the task is for patients to anticipate when and how
they can apply the skills learned in therapy in future situations. Finally, debriefing is conducted
after the relapse prevention task has been completed and follow-up plans are formulated.
Patients are provided with support and encouragement for conducting this task. In addition,
feedback should be obtained from patients. At the end of the intervention and in the following
sessions the therapist and patient review the changes the patient has made over the course of
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treatment and the skills he/she have learned. It is crucial that they also review the safety plan
before patients leave the relapse prevention session.
Continuation PhaseThe continuation phase is an additional 12 weeks and consists of up
to 6 sessions that are tapered in frequency. In addition, there may be up to three family sessions
during the continuation phase. During the continuation phase, the therapist may introduce new
skills or continue to help the patient or family to learn and implement the skills introduced in
the acute phase. The termination sessions include explicit discussion of reactions to the
conclusion of treatment, review of successful strategies that were learned in the therapy and
the goals that were accomplished as well as a discussion of whether treatment is needed for
other problems the adolescent may be experiencing, e.g. social anxiety, panic disorder, eating
disorder.
In this final phase, the therapist also encourages the adolescent to identify specific anticipated
difficult or stressful situations and review the use of the new skills as they would apply to these
future situations. It is important to prepare the patient for mood fluctuations and setbacks and
discuss specific signs of personal risk that have been identified through the chain analysis and
the course of treatment with the patient. The importance of continuation or maintenance
treatment for both partially and fully recovered teens should be emphasized. Issues surrounding
ending treatment also should be discussed with the family and include: (1) Review of warning
signs of depressive symptoms and suicidal crises, (2) Goals achieved in therapy, (3) Impact of
treatment on the rest of the family, (4) Strategies for handling possible future episodes, and (5)
The current need for further treatment.
Results
Treatment Retention, Acceptability and Adherence
Study Design and ParticipantsThe TASA study began as a randomized controlled
trial and due to feasibility issues, the methods were changed so that participants could decide
to be randomized or choose among 3 treatment conditions: (1) CBT-SP alone; (2) Medication
Management alone; or (3) Combination of CBT-SP and Medication Management (see Brent
et al., 2009 and Vitiello et al, 2009 for detailed description of the study design and group
comparisons). One hundred and ten adolescents, ages 13 to 19, received CBT-SP following
assent and permission of a parent or legal guardian. Inclusion criteria were a recent suicide
attempt (within the past 90 days) and clinically diagnosed depression (K-SADS PL) significant
enough to warrant treatment (CDRS Revised 36) at entry into the study. Table 1 presents the
characteristics of patients who received CBT-SP. Patients were predominantly female and
Caucasian with a mean age of 15.8 years. Most were high school students with a mean of 9.8
years of schooling. They came from fairly well-educated families with more than 75% of the
heads of household having at least some college education. The sample manifested significant
psychopathology having made an average of 2.3 suicide attempts, and relatively severe
depression at baseline as measured by both the Children Depression Rating Scale (CDRS) and
the Beck Depression Inventory (BDI-II).
Treatment RetentionThe majority of patients had a full course of the acute phase of
treatment with 72.4% of adolescents receiving 12 or more individual sessions (Table 2). Only
14.3% of the patients completed 5 sessions. There was a considerable number of drop outs
during the continuation phase with only 28.6% of patients receiving >16 sessions.
Treatment AcceptabilityA subset of patients (N=42) were questioned about their
knowledge of the treatment, the methodology and the acceptability of CBT-SP using an exit
interview designed by the investigators based on questionnaires used in their prior studies. The
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interview consisted of 20 open ended and closed (yes/no) questions asked by the local research
assistant or coordinator. A qualitative data coding guide was created by several investigators
by identifying major themes in the interviews and youth suicide research literature. All exit
interviews were then coded independently by four study staff. Consensus was reached by these
investigators in cases where less than 3 of the staff coded the item similarly. Therefore, these
results must be interpreted with caution due to the small, non-random sub-sample of particpants
who completed the exit interview. Within this subgroup, all patients (100%) reported feeling
that CBT-SP was helpful. When questioned about what they would change, 42% stated they
would not make any changes while 18% reported that they would change some aspect of the
therapy. The types of changes the youths suggested included specific aspects of the treatment
(e.g., use reward system to increase motivation), assessments (e.g., too lengthy), research
protocol (e.g., preferring not to be weighed or videotaped during sessions), developmental
appropriateness of the treatment (e.g., add interactive activities for younger adolescents), and
site specific variables (e.g., closer to home). Eighty-six percent reported that they would
recommend CBT-SP to a friend who was considering this treatment. Another 10% said that it
took a lot of time but was worth it. When asked whether the psychotherapy, medication or
the combination the two was most helpful, 44.7% cited the therapy, 27.6% reported that they
felt that the combination of therapy and medication was most helpful and only 6.4% reported
that they thought the medication was the most helpful component of their progress. Twenty-
one percent stated that there were other reasons that the treatment was helpful, with their
relationship with the therapist as the most important reason. Sixty nine percent reported that
they felt suicidal during the treatment. Because frequent direct assessment of suicidality is
intrinsic to the treatment approach, patients were asked about the impact of having their
suicidality assessed. Thirty percent of teens reported that it had no impact, 19% felt it had a
positive effect. However, 30.9% reported that it had a mildly negative result (common answers
included bored, repetitive, and annoying) and 11.9% stated that repeated assessment of
suicidality was very aversive (e.g., I didnt like it. and Uncomfortable.). But no patient
reported that it increased their suicide ideation.
AdherenceAdherence is defined here as the clinician-reported use of the mandatory
components of CBT-SP and teaching of appropriate skill modules. Therapist certification,
weekly multi-site calls with therapists and supervisors, and regular site supervision meetings
were used to enhance adherence. Assessing adherence through review of audiorecordings of
sessions is crucial. Those results will be reported in later manuscripts. However, at this phase,
it was important to first evaluate whether therapists and patients would perceive that they were
able to adhere to the demands of the treatment structure. After each session, therapists recorded
which modules or strategies that were used. Table 3 shows the number of patients and frequency
of use of the modules or strategies. As expected, almost all patients received the safety plan,
chain analysis and assessing/addressing suicidality and hopelessness modules. The safety plan
and assessing/addressing suicidality and hopelessness modules were the most frequently used
strategies and were addressed in an average of 8 sessions per patient. Relapse prevention, a
mandatory intervention conducted during the last sessions of the acute phase, was conducted
with 93.3% of the patients who received 12 or more sessions. A small number of patients
refused to perform this task. Of the optional modules, the most frequently used modules were
cognitive restructuring, mood monitoring. and emotional regulation. Modules addressing
social skills were least frequently used. Fewer than one third of the adolescents received these
modules. In contrast, family sessions (Table 4) were used most often to discuss the adolescents
safety plan, to address improving communication and to provide psychoeducation.
Discussion
CBT-SP is a cognitive behavioral therapy for suicidal depressed adolescents specifically aimed
at preventing reoccurrence of suicidal behavior and reducing associated risk factors. The
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treatment includes a 12-week acute phase and a continuation phase, over 6 months of contact.
CBT-SP is primarily individual therapy but also includes family interventions as needed to
reduce the adolescents suicide risk.
Results demonstrated that CBT-SP is a feasible treatment to deliver and is acceptable to
patients. Retention of patients, despite the difficult nature of the patient population, was
remarkably high. The majority of patients remained in therapy long enough to receive the
essential components. However, many patients terminated during the continuation phase. Our
high retention during the acute phase may be as a result of the focused nature of the treatment.
Several patients noted that they really appreciated the therapy because they were learning
specific skills as opposed to just talking about their problems. Also, the time limited nature
of this therapy, which was discussed at the outset with patients, may have increase retention
during the acute phase. Tapering treatment, as done in the continuation phase, seemed to
contribute to patients decision to leave treatment. In the future, treatments targeting this
population should perhaps include more frequent sessions at the beginning and limit the number
of sessions during the continuation phase or end the continuation phase earlier.
Based on therapist ratings, the essential modules of the treatment were delivered as prescribed
in the manual. Rating tape recordings of sessions to evaluate adherence to the model are
required to substantiate therapist reports and will be described in other reports. Although CBT-
SP is a manualized treatment, the content of the therapy sessions is flexible and is based on the
specific patients needs assessed in a formal case conceptualization. Variability in the
frequency of the modules that were used confirms that the treatment was provided in a flexible
manner.
This study has several limitations. Because this treatment was open and delivered in a non-
randomized manner, we cannot address questions of the efficacy of our intervention, or its
component parts. Furthermore, our findings are limited by the relatively small number of
participants and homogeneity in entry criteria. All adolescents met criteria for depression in
this protocol. A significant proportion of adolescent suicide attempts occur outside the context
of depression. Feasibility and acceptability of CBT-SP in the non-depressed adolescent suicide
attempter population is unknown. Furthermore, adolescents with psychotic symptoms or
requiring primary substance abuse treatment were excluded which limits the generalizability
of CBT-SP. Also, all adolescents had a recent suicide attempt in our study. Depressed
adolescents with significant suicide ideation are also at increased risk for suicidal behavior. It
is likely that CBT-SP can be adapted for this population but this study does not address this
population.
In conclusion, our results support the feasibility and acceptability of implementing this CBT-
SP treatment in the context of an open clinical trial of depressed, suicidal teens. CBT-SP
promises to be a flexible and appropriate treatment to prevent recurrence of suicidal behavior
in depressed adolescents. Testing its efficacy in an RCT is an important next step.
Acknowledgments
This study was funded by the National Institute of Mental Health through cooperative agreement grants MH66750
(Duke University Medical Center), MH66769 (J ohns Hopkins University), MH66762 (New York State Psychiatric
Institute), MH66775 (University of Pittsburgh), and MH66778 (University of Texas Southwestern Medical Center).
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Table 1
Cognitive Behavior Therapy for Sucide Prevention Patient Characteristics
Patient Characteristics N=110 Mean SD
Age 15.8 1.6
Female 84 75.5%
Race
Caucasian 72 66.0%
Black 17 15.6%
Hispanic 15 13.8%
Other 6 4.6%
Years in school (grade) 9.8 1.6
Head of Household Education Level
8th grade 3 1.9%
Some high school 4 2.9%
HS graduate 14 12.5%
Some college 30 27.9%
College graduate 32 29.8%
Advanced degree 27 25.0%
# of Suicide Attempts 2.3 2.3
Baseline Children Depression Rating Scale 51.2 12.5
Baseline Beck Depression Inventory 23.3 12.5
HS =high school
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Table 2
Number of Individual Cognitive Behavior Therapy for Suicide Prevention Sessions Completed*
# of Individual CBT-SP Sessions N %
5 15 14.3
611 14 13.3
1216 46 43.8
1720 25 23.8
>20 5 4.8
CBT-SP =Cognitive Behavior Therapy for Suicide Prevention
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Table 3
Cognitive Behavior Therapy for Suicide Prevention Individuals Modules: Frequency of Use and Percentage of
Patients Receiving the Module (Possible range =118)
CBT-SP Modules # of Sessions in which Module was used Mean + SD % of Patients Receiving Module
Safety Plan 8.7 4.8 98
Assess Suicide Risk and Hopelessness 8.6 5.1 95
Chain Analysis 2.2 1.6 97
Cognitive Restructuring 4.1 3.3 88
Mood Monitoring 3.4 3.9 71
Emotion Regulation 2.8 2.6 75
Problem Solving 2.2 2.3 68
Goal Setting 1.6 1.5 74
Behavioral Activation 1.2 1.5 57
Mobilizing Social Support 0.7 1.1 38
Social Skills 0.8 1.5 35
CBT-SP =Cognitive Behavior Therapy for Suicide Prevention
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Table 4
CBT-SP Family Modules: Frequency of Use and Percentage of Patients Receiving the Module
Module Frequency Mean + SD % of Patients Receiving Module
Safety Plan 2.2 +2.2 75
Communication skills 1.6 +1.6 70
Psychoeducation 1.5 +2.0 69
Goal Setting 0.9 +1.2 50
Family Problem Solving 1.0 +1.5 49
Contingency management 0.9 +1.8 34
Family pleasant activities 0.4 +0.7 30
Relapse Prevention 0.4 +0.8 29
Reducing negative emotions 0.4 +0.9 27
Mood Monitoring 0.4 +0.9 26
Increasing positive reinforcement 0.4 +0.9 26
Reducing high expectation 0.3 +0.8 23
Attachment and commitment 0.1 +0.4 10
CBT-SP =Cognitive Behavior Therapy for Suicide Prevention
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