Treatment of suicidality: More thoughts on suicide in the military and an overview of treatment approaches

by Joye C. Anestis

We have written before about the serious need for appropriate mental health care for our country's soldiers, as they are returning from the Iraq and Afghanistan with increasing levels of psychopathology and devastating levels of suicidality.  The suicide rate in the U.S. military is quite alarming.  In fact, reports show that in January 2009 more soldiers died by suicide than by Al Qaeda.  The Army has announced that, in 2008, the suicide rate among U.S. soldiers rose to its highest level since 1980.  I came across this video on the Beck Institute's description of their new training initiative, Soldiers Suicide Prevention.  It tastefully describes one soldier's struggle.

Certainly, it is a national imperative to provide care for these men and women who are risking their lives for our safety, but what is the best approach to caring for our suicidal veterans?  There are a couple of schools of thought on how best to approach suicidal clients, but the most empirically-supported ones are cognitive behavioral in nature and/or incorporate aspects of Joiner's (2005) interpersonal-psychological theory of suicide.  Interestingly, suicide itself is not considered in lists of empirically-supported treatments, presumably because suicide alone is not a diagnosis.  Thus, I cannot state that the treatments and techniques described below are ESTs for suicide because no such distinction exists.  I can, however, state with full confidence that cognitive behavioral interventions for suicide and interventions incorporating Joiner's theory have been rigorously studied (e.g., Brown et al., 2005) and are based on the most prominent scientific theories of suicidality.

CBT for suicidality is not all that different from CBT for other mental illnesses, with a couple of important distinctions (mainly the types of distorted thoughts to focus on).  The treatment recommendations below are from 2 primary sources: Treating Suicidal Behavior: An Effective, Time-Limited Approach by Rudd, Joiner, & Rajab - an effective, empirically-based approach to treating suicidality - and The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Joiner, Van Orden, Witte, & Rudd.  Please see these manuals for more detailed descriptions of treatment recommendations.  I should also note that no psychotherapy for suicidality should be initiated without a thorough, empirically-supported assessment of an individual's suicide risk to determine if hospitalization is needed.  We will write about this in detail in a future post but see Joiner, Walker, Rudd, & Jobes (1999) for a detailed description on how to conduct such a risk assessment.

• In the very first session, Rudd et al. recommend having the client make a list of the various symptoms they are experiencing (e.g., feelings, thoughts, experiences) and then rating each of them on a scale from 1-10, with 10 being the most severe (similar to a fear hierarchy).  Then, the therapist should suggest simple and straightforward strategies to take the edge off the most problematic symptoms (e.g.,behavioral activation to increase pleasurable activities, sleep hygiene for insomnia, eliciting social support for feelings of isolation).  Providing treatment tasks right from the beginning is very helpful with such high-risk clients, many of whom feel incredibly hopeless about their prognosis.  Taking the edge off the most problematic symptoms right off the bat already begins to teach clients how malleable their symptoms truly can be. 
• Another primary treatment task in the Rudd et al. manual is the use of a Suicidal Thought Record.  Similar to a Dysfunctional Thought Record in CBT, the Suicidal Thought Record allows clients to learn about the interconnections between situations, their thoughts and feelings, and their suicidal behavior.  The material from this record lays the groundwork for future sessions in which the therapist teaches problem-solving, cognitive restructuring, and emotion regulation skills.  Within a Suicidal Thought Record, the client first identifies a problem, then the thoughts and/or feelings that accompanied that problem, and then the suicidal behavior which followed.  Cognitive restructuring, for example, can then be used to modify the thoughts which accompany such problematic situations.  Thought modification then changes the resulting behavior.
• Joiner's (2005) interpersonal-psychological theory of suicide argues that acquired capability for suicide and suicidal desire are the primary components of death by suicide.  Unfortunately, acquired capability for suicide is a static variable that cannot be altered by any form of current empirically supported psychotherapy; however, suicidal desire is highly malleable and very suitable for CBT techniques.  Suicidal desire, according to Joiner's theory, consists of thwarted belongingness, a distorted sense that no one truly cares or no one can truly relate, and perceived burdensomeness, a distorted sense that they are liabilities in the lives of others and that others would be better of without them.  These two variables should be the focus of cognitive restructuring and other behavioral techniques with suicidal clients.  For example, a client who thinks "My family would be better off without me around" can gather examine the evidence for that thought.

I started out this post by writing about the suicidal crisis facing the U.S.  military, but then zoomed out to talk about treatment of suicide in general.  I was inspired to write this article when I came across a posting on the Beck Institute Blog about their new training program for practitioners to gain facility in the treatment of suicidal behaviors/ideation in soldiers.  Called "Soldiers Suicide Prevention," this program offers scholarships for training in cognitive therapy/cognitive behavioral therapy for suicide in military populations and for mental illnesses that often lead to suicide in soldiers (e.g., PTSD).  The Beck Institute offers training programs around the world, and you can apply for a partial scholarships to help defray the cost.  Soldiers Suicide Prevention is an amazing opportunity to learn about an empirically-supported treatment for suicidality, and we at PBB are really impressed with this initiative. 

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.