1.1. Overview of cognitive behavioral therapy
Cognitive therapy is based on cognitive theory, which is an information processing model. Cognitive refers to how an individual interprets and assigns meaning to his or her experiences. We as humans are continually trying to make sense of our internal and external experiences for the purposes of survival and attachment. How we scan our environment and choose stimuli to attribute meanings is variable from person to person and based on past learning and beliefs. Over the course of our development, we acquire beliefs about ourselves, others, our environment, and our future. A.T. Beck et al. (1979) refers to these beliefs that have durability and rigidity over time as core beliefs . J.S. Beck (2005) categorizes core beliefs based on individuals sense of their lovability, worth, and control . These categories of core beliefs can be adaptive or maladaptive depending on our long-term experiences with significant people and situations. Thus, maladaptive core beliefs would be associated with beliefs of unlovability, worthlessness, and helplessness. New information is processed in the moment based on the balance between adaptive and maladaptive core beliefs among these three categories. Individuals who grow up in a mostly negative environment will likely develop more maladaptive than adaptive core beliefs. These core beliefs, when activated by associated events in the moment, influence objectivity and thus color how we interpret our experience in the present. Thus, the thoughts or interpretations in the present do not equal fact, but are subject to change with new information. When we are functioning well in the present moment, our adaptive core beliefs are prominent in conscious awareness and determine, in a positive manner, how we scan our environment and attribute meanings to new information. However, under stress, a crisis, or an acute onset or recurrence of a psychiatric disorder, our maladaptive core beliefs surface to conscious awareness and have a negative impact on how we scan our environment and process new information. When activated, maladaptive core beliefs mold new information to fit the current maladaptive core belief, thus making it stronger. Persistent maladaptive core beliefs are the basis, in part, of most psychopathology; however, CBT acknowledges the impact of biological and genetic factors, particularly in the case of major mental illnesses.
Cognitive theory teaches that our emotions, physiological responses, and behaviors are a product of our thinking in the present moment. The spontaneous, unpremeditated interpretations associated with specific events in the present are referred to as automatic thoughts . When the automatic thoughts are misinterpretations of current events, Beck refers to then as dysfunctional automatic thoughts . If in a given situation an individual has the dysfunctional automatic thought, “I’m a loser”, this interpretation is likely due to the activation of the maladaptive core belief “I’m incompetent”. The products of the dysfunctional automatic thought, “I’m a loser”, might include sadness, anxiety, increased autonomic system activity, and a desire to avoid people. Cognitive theory also teaches that our emotions, physiological responses, and behavior influence our thinking and beliefs as well. Studies have shown that people who are depressed have difficulty accessing positive memories of past experiences and past successes [3,4]. Because depressed patients tend to withdraw and isolate, they miss opportunities to obtain information that might provide a more balanced view of themselves. Thus, there are multiple interactions among thoughts, feelings, physiological reactions, and behaviors as shown in Figure 1.
The function of cognitive therapy is to reduce negative emotional reactions, distressing physiological responses, and self-defeating behaviors by modifying dysfunctional automatic thoughts, initially, followed by modifying maladaptive core beliefs. Dysfunctional automatic thoughts are challenged by having the patient look for evidence against the negative thoughts and/or by having the patient identify alternative explanations in a given situation. Maladaptive core beliefs are modified through a process called “belief work” , which will be reviewed later in the chapter. The underlying maladaptive core beliefs are revealed by observing patterns of dysfunctional automatic thoughts across multiple situations in the present. Although the primary focus of CBT is on targeting dysfunctional automatic thoughts and maladaptive core beliefs, negative emotions, distressing physiological responses, and self-defeating behaviors also become targets for treatment. In the case of a depressed patient, who was avoiding others out of fear of being criticized, behavioral activation strategies enabled him to discover that there were several supportive people available to him, which resulted in a marked decrease in his fear and anxiety. Thus, the behavioral intervention had a positive impact on both his negative thinking and negative emotions. According to A.T. Beck et al. (1979), in order to achieve lasting change of our emotional distress and self-defeating behaviors, cognitive and behavioral interventions are required to change the underlying maladaptive core beliefs .
In addition to dysfunctional automatic thoughts and maladaptive core beliefs, there are two other problematic aspects of cognition, maladaptive intermediate beliefs and errors in logic . In view of the fact that awareness of one’s maladaptive core beliefs creates emotional distress, the individual develops and implements cognitive compensatory strategies or maladaptive intermediate beliefs in order to prevent maladaptive core beliefs from being activated. Maladaptive intermediate beliefs consist of rules or assumptions that guide interactions with others and one’s environment. These rules or assumptions take on a form of “if…then…” statements that take on either a positive or negative valence. For example, a patient with a core belief, “I am incompetent” may develop a maladaptive intermediate belief, “If I avoid making mistakes, my weaknesses will not be seen by others” (positive form). Alternatively, “If I do not perform perfectly, I will fail” (negative form). In stressful situations, the negative forms are more prominent . From a treatment perspective, it is important to identify a patient’s maladaptive intermediate beliefs since they contribute to his or her self-defeating behaviors. Frequently, there are corresponding maladaptive behaviors associated with maladaptive intermediate beliefs. J.S. Beck (2011) refers to these behaviors as compensatory strategies . Like maladaptive intermediate beliefs, compensatory strategies serve the function of preventing maladaptive core beliefs from being activated. In the above example, “If I avoid making mistakes, my weaknesses will not be seen by others”, a typical behavioral compensatory strategy might be perfectionism. A patient would try to do his or her work perfectly in or to avoid the activation of his or her core belief “I’m incompetent”. Although performing perfectly has value in many situations, when perfectionism becomes a way of life, it can limit one’s experience and interfere with achieving value-based goals. Errors in logic are the final problematic aspects of cognition to be addressed. The most common errors in logic include: mind reading (assumption that others are reacting negatively without sufficient evidence); overgeneralization (specific events defines life in general); all-or-nothing thinking (events are seen in one of two mutually exclusive extreme categories); personalization (assuming responsibility for negative outcomes without considering other contributing factors); and catastrophic thinking (experiences or events are interpreted in terms of the worst possible outcomes). Errors in logic also contribute to faulty information processing and thus lead to misinterpretations of events and experiences in the present.
Figure 2 summarizes what has been reviewed thus far. Cognitive therapy begins by helping patients see the relationships among thoughts, feelings, physiological responses, and behaviors in a variety of situations in the present (illustrated in white). As patterns of interpretations emerge, the therapist and patient develop a case formulation with the goal of identifying core beliefs, intermediate beliefs, and compensatory strategies based on an analysis of the interpretations from multiple situations in present, and based on a review of probable contributing negative experiences from the past (illustrated in yellow). Once the individual’s core belief/s are identified, the focus of therapy is on modifying the underlying maladaptive core beliefs. J.S. Beck (2011) describes this process as “Belief Work” . In the case of a patient with a core belief, “I’m a failure”, the therapist would first have the patient reframe the maladaptive belief in less severe terms, “Having weaknesses does not mean I’m a total failure”. The therapist next has the patient identify evidence against the maladaptive or old belief and supports the new belief, “My evaluations at work are good, but not perfect”. Finally, the therapist has the patient identify evidence that supports the old belief, but with a reframe, “Although I have deficiencies, I am more than my weaknesses.” To further enhance perspective building with regards to maladaptive core beliefs, the therapist has the patient perform a historical review in order to identify important events in his or her life that might have contributed to the development of the maladaptive core belief. The therapist then has the patient focus on specific relevant events and generate alternative explanations by taking on an observer role using cognitive restructuring (identifying evidence for and against the belief); in addition, the therapist assists the patient in collateral data collection by designing behavioral experiments .
2. Cognitive factors for suicidal thinking and behaviors
There are a number of cognitive factors that contribute to suicidal thinking and behaviors. These factors can be categorized as cognitive content deficits and cognitive information processing deficits.
2.1. Cognitive content deficits
2.2. Cognitive information processing deficits
3. A CBT model of suicide
Figure 3 summarizes the research that has been presented in the previous paragraphs. This model emphasizes that an individual considers suicide if he or she sees no solutions to the problem that is creating pain that is perceived as intolerable, inescapable, and interminable. Thus, the focus of CBT in the depressed suicidal patient is to: identify the perceived unsolvable problem; reduce cognitive distortions and errors in logic with regards to his or her views of self, others, and future; improve problem solving skills; increase motivation to problem solve; reduce perceived emotional pain; and encourage acceptance of emotional pain as part of everyday life.
There are a number of predictors of suicidal thinking and behaviors that have been identified over the years including being elderly, male, divorced, widowed, separated, medically ill in the past 6 months, depressed, addicted to substances, and having made suicide attempts in the past to name a few . However, from a CBT perspective, it is not solely the situation that determines suicidal thinking and behaviors, but, the meaning that an individual attributes to his or her situation. This is not to say that the above predictors do not have some contribution to an individual’s decision to attempt suicide; rather, these predictors might indirectly contribute by increasing the individual’s vulnerability to choose suicide.
4.1. Rating scales
4.2. Motivation for suicide
Identifying the motive for suicide is crucial for determining the treatment approach. There are two primary motives for suicide, to escape from life with its pain or to produce some interpersonal change or change in their environment . In a study of 200 inpatients who had made a suicide attempt prior to admission, Kovacs, et al. (1975) found that 111 (56%) reported escape as their primary motive, whereas, 26 (13%) reported hope to effect a change in others or in their environment . The reminder reported motives that were a combination of the two. The motive to escape was associated with more serious suicide attempts. Escape from life with its pain may be based on reality (poverty, medical problems, social isolation, chronic illness); thus, the focus of treatment is on appropriate biopsychosocial interventions. However, the motivation to end one’s life may be based on distorted or pathological ways of viewing oneself, others, and the world, thus, the focus is directed on misperceptions and irrational belief systems. When the primary motivation is to create interpersonal or environmental change, the common reasons are for love and affection, revenge, or control. Under these circumstances, the focus of treatment is on improving social skills and learning more effective and adaptive ways of communicating.
4.3. Triggers for suicide
Rudd et al. (2001) stress the importance of identifying triggers of suicidal thinking and behaviors . Triggers can be categorized as being internal and external experiences or themes. Internal triggers include thoughts, images, feelings and physical sensations. External triggers include people, places, circumstances, and situations. Thematic triggers include activation of abandonment concerns or fears of rejection. Tools that can assist in identifying triggers include dysfunctional thought records and chain analyses. A dysfunctional thought record is divided into five columns including: situation, emotions, dysfunctional automatic thoughts, rational response, and re-rating the belief in the original dysfunctional automatic thoughts. The Dysfunctional Thought Record provides a strategy to not only identify the trigger for the decision to choose suicide, but it identifies the misinterpretations associated with the trigger as well. The sequential links in the Chain Analysis strategy include:
The goals of treatment for the depressed suicidal patient include: address specific cognitive biases and distortions; develop behavior skills (problem solving); acceptance and tolerance of emotional pain; improve communication skills (social skills, assertiveness training, conflict resolution skills); reduce environmental stress; and develop supports [13,27].
In order to engage a patient in the treatment of his or her suicidal thinking and behaviors, the clinician must convey an empathic approach. The patient enters therapy with concerns that he or she will be perceived as being irrational, trying to get attention, not being taken seriously, or potentially being punished. These are based on typical responses he or she has received from relatives and friends. It is important not to start psychotherapy by trying to talk him or her out of suicide. Such an approach convinces the patient that the therapist does not understand his or her situation and what he or she is experiencing. Rather, try to understand the patient’s logic for choosing suicide. Ask the question, “Help me understand what got you to the point that suicide seemed to be the only solution”. Through understanding his or her logic, the therapist may experience, to some degree, the patient’s despair. The therapist might also help normalize the patient’s decision by saying that “If I was in your situation, I might have also considered suicide”. However, it is important to offer hope by informing the patient that, by working together, solutions or partial solutions to his or her problem will emerge, thus, providing alternatives suicide. It is also important for the therapist to be aware of his or her beliefs about the patient, such as “He is untreatable” or “He is just being manipulative”. Awareness of these negative beliefs must be addressed by finding common ground from which to continue to work together.
5.1. Cognitive/behavioral targets for treatment
Problem solving: Schotte and Clum (1982)  were among the first to show that there is a significant relationship between poor problem solvers, who are experiencing high levels of stress, and the likelihood of developing suicidal thoughts. These researchers subsequently demonstrated that patients with suicidal ideations are less likely to come up with alternative solutions to their problems, they have little confidence in their problem solving ability, and they tend to focus on the potentially negative outcomes of their problem solving attempts. D’Zurilla et al. (2004)  conceptualize the problem solving deficits seen in suicidal patients into two categories, deficits in the skill of rational problem solving and deficits in motivation to engage in problem solving due to the lack of confidence and the tendency to expect negative outcomes. This distinction helps therapist to decide whether to focus treatment on building problem solving skills or working on the development of confidence while addressing unrealistic expectations or both. Reinecke et al. (2001)  demonstrated that the severity of depressed mood also interferes with problem solving by not only impacting motivation but by interfering with the encoding and retrieval of information. Studies by Teasdale and others have shown that the depressed state interferes with the acquisition of past positive experiences and successes [3,4].
Reinecke (2006) recommends the following approach to problem solving with the depressed suicidal patient . Treatment begins by helping the patient identify the problem that suicide would solve and to provide psychoeducation and understanding of potential contributing factors. From a CBT perspective, suicide is one solution to the problem that is creating emotional distress. The therapist next assesses the patient’s motivation and attitude about engaging in problem solving. According to Reinecke, ways to promote a more positive attitude about problem solving include helping the patient to accept that problems are a part of normal life, identifying possible contributing factors to his or her problem, identifying and correcting errors in logic (magnification, overgeneralization, personalization, etc.) that may interfere with problem solving, instilling a sense of self-efficacy and expectation that solutions will come, acknowledging that there may be only partial solutions, and that it might take time for the solutions to be realized . With improvement in motivation, the focus of therapy turns to improving rational problem solving skills. Once the problem is clearly identified, the patient is encouraged to articulate his or her related concerns and understanding of what maintains the problem. The patient is then encouraged to identify realistic goals regarding the problem and then start working on steps to solve the problem. Skills in generating alternative solutions, than suicide, become the next focus of attention. With each alternative solution, the patient carries out a pros and cons analysis, determines the short- and long-term consequences, selects what appears to be the most effective solution, implements a plan, and assesses the outcome. Reinecke utilizes psychoeducation, Socratic dialogue, role plays, and modeling to effect this approach.
Chiles and Strosahl (2005) identify two strategies, recontextualization and comprehensive distancing, to assist the patient in accepting painful thoughts and feelings . According to Chiles and Strosahl, “The objective of recontextualization is not to get rid of disturbing thoughts or feelings but to teach the patient to make room for them and do what needs to be done to get on with life. The objective is met when your patient learns that negative thoughts or feelings do not block adaptive behavior. The two can coexist”. With recontextualization, our thoughts and feelings do not define our experience, but are just there to be observed as an opportunity to learn in the process of problem solving. Comprehensive distancing refers to the willingness of the suicidal patient to detach from his or her suicidal thoughts and emotional distress. Chiles and Strosahl recommend the dual-thermometer exercise which is carried out by the patient daily. The patient will keep a daily diary and make daily ratings on two 1-10 thermometer scales with regards to two dimensions of experience, willingness and suffering. The ratings on the Willingness Thermometer, measure willingness of being present without judgment, being mildly interested, and being just an observant of what is. Alternatively, the Suffering Thermometer rates how much distress the patient feels with his or her daily experiences as a result of ruminating and worrying about his or her condition. The patient makes daily notes on factors that either increase or decrease ratings on the two measures. The ratings tend to be reciprocal of each other. The purpose of this exercise is to point out the uselessness of attaching to our negative thoughts and feelings. During the course of therapy, suicidal thoughts can be used as a measure of non-acceptance of negative emotions since the purpose of suicidal thinking is to avoid experiencing negative emotions.
6. Summary of a CBT approach to suicidal thinking and behavior in depression
In summary, I recommend the following approach to the acutely depressed patient with suicidal thoughts and behaviors. First, the therapist must determine what problem suicide would solve, followed by identifying the individual’s motive for suicide; is suicide desired to escape from pain or to make a change in his or her relationships or environment or a combination of both. In order to engage the patient and to develop trust, the therapist should inquire as to what got him or her to the point that suicide seemed to be the only solution; the therapists asks for understanding. Once the therapist believes he or she understands the patient’s logic, the therapist can acknowledge with the patient that he or she might have come to the same conclusion under similar circumstances; this response serves to help normalize the patient’s experience. However, the therapist next provides hope by stressing that there are solutions or partial solutions that the patient might have overlooked and that together alternatives to suicide will become apparent. If the patient believes that the therapist understands his or her perspective and rationale without judgment, the patient will more likely engage in treatment. Once engaged, the task is to understand the internal, external, and or thematic triggers for suicidal thinking and behaviors, as well as the factors that maintain the desire to suicide, using thoughts records and/or chain analyses. Next, the therapist assists the patient in challenging the distortions and misconceptions, including core beliefs, that interfered with his or her motivation to initiate the process of problem solving; this is followed by promoting the development of problem solving skills, if needed. In addition, the therapist addresses the patient’s view that he or she does not have the internal or external resources to solve his or her problem. An advantages and disadvantages analysis of suicide and not suicide should be performed early in the treatment in order to identify the positive and negative reinforcers for suicide. The negative reinforcers will help motivate the patient to think of reasons to live and not choose suicide; the positive reinforcers will be used to assist in identifying alternatives to suicide. Also, identifying alternatives to suicide helps to begin the task of problem solving. Once the alternatives have been identified, the patient continues with a pros and cons analysis for each alternative. The patient then develops an action plan once the best alternative is identified; this helps motivate the patient to implement the plan followed by an assessment of the outcome. Effective problem solving will be in the service of developing self-efficacy and to counter the patient’s sense of helplessness and worthlessness. Simultaneously with problem solving, the therapist helps the patient reduce his or her level of distress by working on acceptance of emotional and/or physical pain. The mindfulness strategy of learning the skill to broaden one’s awareness in the moment enables the patient to see that there is more to his or her reality than one’s pain. Learning to refocus attention on purpose without judgment, especially when the pain is intense, or observing the pain in order to determine what makes it worse or better are mindfulness skills that can be empowering. As with all CBT treatments, the final phase of treatment focuses on relapse prevention. The relapse prevention phase gives the patient an opportunity to demonstrate his or her ability to make use of the skills learned during the treatment and it gives the therapist an opportunity to assess whether the patient is appropriately applying his or her new skills, and thus ready for termination. Wenzel et al., (2009) caution about the risk of having an unprepared patient destabilize while re-examining the events that lead to the suicide attempt, especially through imagery . Careful collaboration with the patient about his or her readiness to review the suicide attempt in detail is essential along with close monitoring of his or her distress level in the review process. The patient may find it too overwhelming to use imagery, as if the events were occurring in the present. In this case, Wenzel et al. recommend using the past tense in summarizing the events and applying the newly learned techniques. I refer the reader to Wenzel et al. (2009) for the details regarding this exercise. Finally, relapse prevention focuses on having the patient imagine potential future suicide crises and review in detail how he or she would make use of cognitive and behavioral strategies to reduce the chance that he or she would engage in suicidal behaviors.
7. Evidence for CBT preventing suicide in depressed patients
There are very few randomized controlled trial (RCT) studies assessing the effectiveness of CBT in preventing suicide attempts in adult depressed patients. Earlier studies that focused on problem solving alone have failed to consistently demonstrate a reduction in future suicidal thinking and behaviors when compared to treatment as usual (TAU) . These findings argue for a more comprehensive CBT approach including not only problem solving, but cognitive restructuring, behavioral strategies, stress reduction and mindfulness, and interpersonal skills training. To date, there is only one adequately powered (RCT) study that included many of these treatment elements . Most other studies target changes in predictors of suicidal attempts rather than suicide attempts as the primary outcome measure. In the Brown et al., (2005) study, the researchers evaluated 350 adults and randomized 120 to 10 sessions of CBT or TAU, within 48 hours of admission to a university hospital emergency room after a suicide attempt . Seventy-seven per cent of the patients met DSM-IV criteria (SCID interview) for major depressive disorder and 68% had a substance use disorder; 85% had more than one psychiatric disorder. Sixty per cent were African American, 35% Caucasian, and 5% were Hispanic. The elements of the CBT treatment included; identification of proximal thoughts, images, and core beliefs to the suicide attempt; cognitive and behavioral strategies to address the identified proximal thoughts and beliefs prior to the suicide attempt; development of adaptive ways of coping with stress; targeting hopelessness, poor problem solving, impaired impulse control, non-adherence to treatment, social isolation; and relapse prevention. From baseline to reassessment at 18 months, 24% of the CBT group and 41.6% of TAU group made at least one suicide attempt (asymptotic z score, 1.97; P=.049). Survival analysis (Kaplan-Meier) at month-18 showed a reattempt-free probability of 0.76(95% confidence interval [Cl], 0.62-0.85) in the CBT group and 0.58(95% Cl, 0.44-0.70) in the TAU group. Patients in the CBT group had a significantly lower reattempt rate (Wald X2/1=3.9; P=.049) and were 50% less likely to reattempt suicide than the TAU group (hazard ratio, 0.51;95% Cl, 0.26-0.997). With regards to the secondary analyses, the CBT group scored significantly lower than the TAU group on Beck Depression Inventory at 6 months (P=.02), 12 months (P=.009), and 18 months (P=.046). The CBT group scored significantly lower on the Beck Hopelessness Scale than the TAU group at 6 months (P=.045). There were no differences between the two groups in the Scale for Suicide Ideation. It is important to point out that Brown et al. adequately powered their study; the sample size of 120 provided at least 80% power to detect a hazard ratio of 0.44 with regards to a subsequent suicide attempt between the two groups . Brown et al., point out that their results were consistent with an earlier small RCT study (n=20) by Salkovskis et al. (1990) . Salkovskis et al. demonstrated that patients randomized to a CBT problem solving therapy were significantly (p=0.049) less likely to repeat a suicide attempt compared with the TAU group at six months after the index suicide attempt. The mean time to the next suicide attempt was 9.3 months for the CBT group compared to 3 months in the TAU group. Raj et al., (2001)  examined the effectiveness of CBT (n=20) versus treatment as usual (n=20) in ages between 16 and 50 in reducing deliberate self-harm. Patients were included with anxiety, depression, or adjustment disorder; psychotic patients were excluded. The 10 session CBT therapy consisted of cognitive and behavioral strategies, problem-solving skills, and behavioral counseling to significant others. The CBT group, compared to TAU, showed significant decreases on the Scale for Suicidal Ideations, Beck Hopelessness Scale, Problem Solving Inventory, and on the Hospital Anxiety and Depression Scale.
Tarrier et al. (2008) performed a meta-analysis on 28 select studies (based on quality) to investigate whether CBT reduced future suicidal behavior . This is the first systematic review and meta-analysis of CBT and the prevention of suicidal behaviors. Suicidal behavior included completed suicides, suicide attempts, suicide intent or plans, and suicidal ideations. The diagnostic categories were broad across the 28 studies and not limited to depression. There were studies of patients with schizophrenia, first psychotic episodes, borderline personality, major depressive disorder, and personality disturbances. Thus their findings were not limited to a particular diagnostic disorder. Tarrier et al., concluded that CBT was highly effective in reducing suicidal behaviors within the 3 month period post treatment (combined Hedge’s g=-0.59, z=-5.26, p<.0001, 95% CI=-0.811 to -0.371). Subgroup analysis of CBT demonstrated significant results with: controls of minimal treatment, treatment as usual, or active psychological treatments; adults only; treatment directed towards reducing suicidal behavior rather than associated symptoms like depression; and reductions in hopelessness. Also, CBT studies using an individual approach were effective whereas group CBT was ineffective. The authors are cautious in their conclusions because of publication biases. Small studies with large effect sizes had a disproportionately large impact on the overall effect size.
A recent study by Stewart et al. (2009)  was among the first to compare CBT and SPST (Social Problem Solving Therapy) with each other and against TAU. However, rather than measuring suicide attempts as their primary outcome measure, their outcome measures focused on predictors of suicide attempts including hopelessness (Beck Hopelessness scale), poor problems solving (Social Problem Solving Therapy), suicidal ideation (Beck Scale for Suicidal Ideation), and treatment dissatisfaction (Client Satisfaction Questionnaire-8). Subjects completed 8.73 treatment sessions in the CBT group (SD=1.04, range from 7-10 sessions), 4.75 sessions in the SPST group (SD=1.42, range 3-7 sessions), and.67 in the TAU group (SD=2.0, range from 0-6 session). Eleven subjects completed the CBT therapy, compared to 12 subjects in the SPST therapy, and 9 in the TAU intervention (334.4%, 37.5%, and 26.1% respectively). Over the course of treatment, subjects receiving CBT showed significant improvement in hopelessness (Beck Hopelessness Scale) (z=-1.79, p<.05, r=.49), suicidal ideations (Beck Scale for Suicidal Ideations) (z=-2.32, p<.05, r=.49), and patient satisfaction (Client Satisfaction Questionnaire-8) (z=-2.81, p<, r=.60); however, the CBT group did not show improvement in problem solving (Social Problem Solving Therapy) (z=-1.02, ns, r=.21). The TAU group did not show significant improvement in any of the predictors of suicidal behaviors. The authors suggest that treatment with CBT reduced hopelessness and suicidal ideations while improving treatment satisfaction. All three measures would presumably reduce the risk for future suicidal attempts. Also, the authors conclude that by empowering individuals to solve their problems, it follows that there was a reduction in hopelessness and suicidal ideations and an increase in patient satisfaction, all of which should help reduce the risk for future suicide attempts.
These limited studies provide cautious optimism that CBT is effective in reducing suicide attempts. However, there continues to be a great need for more studies, that are adequately powered and that not only examine the effectiveness of CBT in reducing predictors of suicide (e.g. hopelessness; decreased problem solving) but also measure the rates of suicide attempts as the primary outcome measure. As noted above, the Brown et al. (2005) protocol included several treatment components including cognitive restructuring, problem solving, treatment adherence, and identification of social supports . It is unclear which elements are essential or most important for a positive outcome. Stress management and mindfulness training have not been consistently incorporated into CBT protocols for the suicidal patient; however, these elements should be considered for future studies. The duration, frequency, and intensity of CBT treatment for optimal outcomes is yet to be determined. Finally, future research needs to consider the value of CBT across clinical settings and various social economic groups.