Running head: CBT TREATMENT WITH SUICIDAL ADOLESCENTS 1

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1 Running head: CBT TREATMENT WITH SUICIDAL ADOLESCENTS 1 Effective Theoretical Approaches Assessing Suicidal Adolescents Dana V. Comer North Carolina State University

2 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 2 Effective Theoretical Approaches Assessing Suicidal Adolescents Across all populations suicide is ranked as one of the top ten leading causes of death in the world (Alavi, Sharifi, Ghanizadeh, & Dehbozorgi, 2013). However, suicide tops out as the third most common cause of death among adolescents with a reported 9% of attempted suicide by adolescents within the past year (Bryant & Harder, 2008; Stanley, Brown, Brent, Wells, Poling, Curry, Kennard, Wagner, Cwik, Klomek, Goldstein, Vitiello, Branett, Daniel, & Hughes, 2009). As suicide has been and continues to be a major factor contributing to the deaths of adolescents, the concern is high for effective prevention, intervention, and postvention programs for adolescents. Through research, evidence shows that cognitive therapy (CT) and cognitivebehavioral therapy (CBT) have shown to be one of the most effective theoretical approaches in assessing individuals with suicidal thoughts, attempts, and ideation (Alavi et al., 2013; Bryant & Harder, 2008; Stanley et al., 2009). In addition to CBT, research is promising in the area of mindfulness-based cognitive therapy (MBCT) and the integration of Motivational Interviewing (MI) and Self-Determination Theory (SDT) with CBT (Williams, Duggan, Crane & Fennell, 2006; Britton, Heather, Wenzel, & Williams, 2011). The intention of many interventions of working with suicidal adolescents is to decrease the potential risk factors of suicide. These risk factors include: depression, hopelessness, aggressiveness, impulsivity, suicidal ideation, and previous suicide attempts (Alavi et al., 2013; Stanley et al., 2009). In addition to these most common factors are being diagnosed with a mental illness, the barriers to access mental health services, access to firearms, belief suicide can be appropriate, history of substance abuse, and family history of suicide (Bryant & Harder, 2008). Suicide is a topic with limited measurement because it is unclear when and if someone will ever attempt to commit suicide, but suicidal behavior, similar to major depression is

3 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 3 episodic, meaning that most of the goals of suicide occur in the context of a depressed mood (Williams et al., 2006). With the research to date, it is important to define and understand the theoretical approaches of CBT, CT, mindfulness, MI and SDT. Review of the Literature Cognitive behavioral therapy and cognitive therapy are both forms of psychotherapy with psychoeducational aspects that have proven to be real strengths of the therapies. As the name implies, CBT combines our cognitive processes with behavioral strategies. The therapy offers many useful intervention techniques that include problem-solving strategies, social skills training, self-monitoring, hypothesis testing, and time projection (Bryant & Harder, 2008). In a sense, this allows individuals to recognize how thoughts influence feelings and those feelings affect behaviors. In interventions using CBT for suicidal patients, the process is active and short-term. The intervention is divided up in to three phases: an early/initial phase, intermediate phase, and termination phase. In the early phase (session one through three) the focus is on treatment engagement consisting of five main components: chain analysis, safety planning, psychoeducation, developing reasons for living and hope, and case conceptualization. In the intermediate phase (session four through nine) clinicians help clients establish reasons for living with an emphasis on individual and family skills training. During the termination phase of therapy (session ten through twelve) focus is on suicidal relapse prevention and continuation of treatment (Alavi et al., 2013; Britton et al., 2011; Stanley et al., 2009). The treatment of using MBCT is an approach using cognitive therapy with mindfulness. The mindfulness aspect, much like meditation, originated from Buddhism tradition and is described as a particular way of paying attention: on purpose, moment-by-moment, and without judgment. In other words, mindfulness can be thought of as a way of being rather than a way of

4 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 4 doing, which allows participants to reflect on their routine behaviors and habitual thought patterns. Research using the combination of mindfulness and CT has shown potential usefulness in the prevention of recurrent suicidal ideation (Williams et al., 2006). MI is a client-centered, therapeutic approach that helps clients become motivated to change problematic behavior. The fundamental principles of MI are expressing empathy (clients experiences), rolling with resistance (rather than confronting and escalating conflict), developing discrepancy (between actual and desired behavior), and promoting self-efficacy (learning change is achievable). While it is easy to describe MI, SDT helps to show how its underlying principle is effective. SDT is a dialectical theory of human motivation that accounts for the direction and energization of behaviors. An assumption of SDT is clients are innately oriented toward growth and well-being, thus possess intrinsic energy to live (Britton et al., 2011). From these two forms of therapy, it is assumed that MI and SDT will be effective in the treatment of suicidal individuals due to an increased vitality that may manifest as a reduction in psychological suffering, therefore, increasing the motivation to live, and improve motivation for treatment (Britton et al., 2011). Cognitive Behavioral Therapy Research Evidence documenting the effectiveness of CBT is shown in Alavi et al. s (2013) study where decreasing suicidal ideation and hopelessness is shown among depressed 12 to 18 year old adolescents who had experienced a positive history of previous suicide attempts within the past three months. Using 30 adolescents, the participants were randomly assigned to an intervention or wait list control group. Before the intervention took place, all participants completed the Scale for Suicidal Ideation (SSI), Beck s Hopelesness Inventory (BHI), and Beck s Depression Inventory (BDI) for evaluation purposes (Alavi et al., 2013). While undergoing the intervention,

5 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 5 the intervention group received 12 sessions of CBT for suicidal ideation, while the control group was put on a wait list for the intervention. Both groups were evaluated after 90 days (three months) or completion of the intervention by completing the three inventories again (Alavi et al., 2013). Through statistical analysis using t-tests and chi-square tests, results portrayed that at the beginning of the study, there were no statistically significant differences between the inventory scores (SSI, BHI, and BDI) between the intervention and the control group. After the intervention, significant effects of decreased scores from the three inventories in those participants from the intervention group were apparent. However, inventory scores were unchanged for those who were in the wait list intervention control group (Alavi et al., 2013). Considering the findings from this study, CBT was effective in decreasing hopelessness and depression among suicidal ideation adolescents. Therefore, it can be concluded that CBT is an effective and acceptable treatment for adolescents who have had previous and recent suicide thoughts and attempts (Alavi et al., 2013). To further show how CBT is effective in treating adolescents with issues concerning suicide, Stanley et al. (2009) conducted a study using Cognitive Behavioral Therapy- Suicide Prevention (CBT-SP), a risk reduction and suicide prevention approach with intentions of reducing future suicidal behaviors in adolescents. CBT-SP is a treatment specifically designed for adolescents who have attempted suicide recently (<90 days) with the intervention goals being to reduce suicidal risk factors, enhance coping strategies, and prevent future suicidal behaviors. For the 110 adolescents in this study, treatment retention, acceptability, and adherence was assessed. Depression is a risk factor for suicide and therefore, adolescents who expressed symptoms of depression were also included in this study. Participants were given the option for

6 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 6 CBT-SP treatment alone, medication management (for depression) alone, or a combination of the two. For those seeking CBT-SP treatment, participants underwent the early/initial, intermediate, and termination phases (Stanley et al., 2009). Results from the study confirm that 72.4% of the participants completed the intervention treatment of 12 or more sessions, with a relatively lower percentage of individuals who completed less than half of the intervention. This shows that treatment retention CBT-SP for suicidal adolescents was effective. According to the treatment acceptability, individuals participated in a questionnaire regarding their thoughts of the CBT-SP treatment. All of the participants (100%) indicated feelings that the CBT-SP was helpful to their conditions of suicidal behavior, with 42% indicating that they wouldn t change a thing about the study and only 18% offering suggestions for future CBT-SP treatment such as offering rewards, decrease length of treatment, etc. (Stanley et al., 2009). Eighty-six percent of the treatment participants stated that they would recommend CBT-SP to a friend considering suicide treatment, and when prompted with whether CBT-SP alone, medication alone, or a combination of the two were most effective, 44.7% indicated CBT-SP alone. From these statistics, acceptability amongst the adolescents of CBT-SP is evident. Adherence of the clinician-reports, mandatory components of CBT-SP, a skills module of the treatment reported high as well. With this, the results demonstrated in Stanley et al. s (2009) study are clear that CBT-SP is a feasible and acceptable treatment for suicidal adolescents. Mindfulness Based Cognitive Therapy Many positive outcomes may be gained by individuals engaging in mindfulness activities as a means to reduce suicidal thoughts. Mindfulness works to reduce these thoughts in important ways (Luoma &Villatte, 2012). To start, mindfulness allows a person who is suicidal to

7 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 7 establish present-moment awareness in order to think of ongoing, nonjudgmental thoughts toward themselves when they feel the pain of today is inescapable and the only option they have is suicide. Secondly, mindfulness promotes psychological acceptance, embracing the psychological events of one s history and accepting them in order to move past terrible hardship, allowing freedom and flexibility to flood their lives to move toward a more meaningful life. Thirdly, individuals who are suicidal usually see themselves as damaged, broken, or hopeless. Using the mindfulness technique tends to generate a sense of self that is larger than their story or previous negative history. In turn, this allows the individual to open up to new avenues of living that differ from those of their past (Luoma & Villatte, 2012). Luoma and Villatte (2012) included a case study on Anne, a single white female with suicidal thoughts and behaviors in their research on mindfulness helping to mitigate suicidal behavior. The case study began with analysis of Anne s psychological distress, which indicated her own thoughts were harming her and her behavior. When other forms of therapy did not work for her, mindfulness was suggested in order to help her focus on changing, reducing, or eliminating unpleasant memories, sensations, and emotions in her life. Throughout the study Anne was able to transform her ways of thinking to looking at her thoughts instead of from them. After 18 sessions and biweekly sessions for 20 weeks, Anne was reevaluated for a one year follow-up that displayed high mindfulness scores and no longer expressing symptoms for any psychological disorders (Luoma & Villatte, 2012). Williams et al. (2006) also reported results from a case study in their research on MBCT. Before trying MBCT, Maria, was assessed after expressing low self-esteem, binge drinking, and increased frustration and hopelessness. To make the most out of Maria s therapy, attention was focused on the body scan practices of MBCT where paying attention to certain body parts was

8 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 8 enforced. At the eighth session of therapy Maria completed the Mindful Attention and Awareness Scale (MAAS) questionnaire that is designed to measure a person s level of mindfulness. From the beginning of the study when Maria initially took the assessment, until the eighth session when she completed it again, her mindfulness scores increased from 35 to 56. These findings suggest that although MBCT is viewed as an approach, the case study implies that MBCT is a useful treatment for those who have experienced suicidality in the past, and aiding them in finding ways to cope more skillfully in times of impending crisis (Williams et al., 2006). Motivational Interviewing and Self-Determination Theory MI is an underlying principle of SDT and when paired with CBT, there is an increase in treatment effectiveness. From a case study using the three phases of CBT and a pilot study using 28 participants incorporating MI and SDT, insight was gained on whether the treatment was beneficial for suicidal participants. A Client Satisfaction Questionnaire helped report positive information after the intervention. Clients from the study rated the intervention using MI and SDT along with CBT as very satisfied (Britton et al., 2011). Although MI is a brief intervention, treatment engagement increases as an outcome when paired with other treatments. SDT is a theoretical approach of human motivation that can explain how MI can be used to increase motivations for living and from that treatment becomes effective when combined with CBT (Britton et al., 2011). As with all current research that has been studied, future data is needed to be assessed. Besides the research conducted by Stanley et al., (2009) the sample sizes of the present research included comes from a relatively small pool of participants. It would be helpful to have larger sample sizes as well as research from a wider multicultural lens. For example, CBT research

9 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 9 with diverse populations is relatively scarce which makes this a contributing limitation of the research (Bryant & Harder, 2008). Another limitation and also a key problem to be mentioned is the lack of motivation for adolescent students to participate in a CBT treatment (Alavi et al., 2013). The overall task of engagement and keeping patients in treatment who are both adolescents and suicidal is daunting. Due to this fact, suicidal adolescents tend to often refuse or drop-out of treatment, especially the time-intensive treatment using CBT (Stanley et al., 2009). It was mentioned that the technique of using mindfulness has shown promise in the treatment of suicidal individuals, it is important to emphasize that, as a limitation, the utilization of mindfulness is not a stand-alone for intervention as little research has been done to back it up. However, when paired with other methods of interventions like MBCT it is effective (Luoma & Villatte, 2012). Furthermore, more research in this area would be beneficial. Lastly, a concern identified in Bryant and Harder s (2009) article was the potential for a therapist engaging in CBT with a suicidal client to become more satisfied with symptom relief from their clients instead of uncovering the underlying irrational beliefs that are at the origin of the symptom, suicide itself. This appears to be a major limitation. Although only mentioned from one source, further research should be conducted in this area. In conclusion, past and current research suggests that there are theoretical approaches and techniques that prove to be effective in the assessment of adolescents with a suicidal history, ideation, and previous attempts. CBT is among the best supported, highly researched and effective theoretical treatment and interventions for these individuals (Alavi et al., 2013; Stanley et al., 2009). The simplicity of CBT theory is easily understandable for adolescent clients, can help treat major depression that adds to suicidal thoughts, and can be used in family-based, group and individual sessions. CBT helps to teach adolescent clients to regulate their own thoughts and

10 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 10 feelings by the means of psychoeducation and by giving clients a voice to set treatment goals (Bryant & Harder, 2008). The integration of using CT, MBCT, MI, and SDT are other attractions that are promising in the research when combined with CBT (Williams et al., 2006; Britton et al., 2011). Suicidal adolescents are ambivalent about dying. They want to die, but also want to live with less pain (pain from whatever is causing their interest in suicide) (Britton et al., 2011). With that, increased knowledge about suicidal adolescents in the field of counseling is such an intriguing and important area of study due to the fact that suicide is the third leading cause of death among this age group. Ongoing research should be conducted to further prove the effectiveness of CBT as it has already displayed potential for lifelong impact and perhaps liberation in a wider sense (Bryant & Harder, 2008).

11 CBT TREATMENT WITH SUICIDAL ADOLESCENTS 11 References Alavi, A., Sharifi, B., Ghanizadeh, A., & Dehbozorgi, G. (2013). Effectiveness of cognitivebehavioral therapy in decreasing suicidal ideation and hopelessness of the adolescents with previous suicidal attempts. Iranian Journal of Pediatrics, 23(4), Britton, P.C., Patrick, H., Wenzel, A., & Williams, G.C. (2011). Integreating motivational interviewing and self-determination theory with cognitive behavioral therapy to prevent suicide. Cognitive and Behavioral Practice, 18(1), Bryant, C.E., & Harder, J. (2008). Treating suicidality in african american adolescents with cognitive-behavioral therapy. Child & Adolescent Social Work Journal, 25(1), 1-9. doi: /s Luoma, J.B., & Villatee, J.L. (2012). Mindfulness in the treatment of suicidal individuals. Cognitive and Behavioral Practice, 19(2), Stanley, B., Brown, G., Brent, D.A., Wells, K., Poling, K., Curry, J., Kennard, B.D., Wagner, A., Cwik, M.F., Klomek, A.B., Goldstein, T., Vitiello, B., Barnett, S., Daniel, S., & Hughes, J. (2009). Cognitive-behavioral therapy for suicide prevention (CBT-SP): Treatment model, feasibility, and acceptability. Journal of The American Academy of Child & Adolescent Psychiatry, 48(10), doi: /chi.0b013e3181b5dbfe Williams, J.G., Duggan, D.S., Crane, C., & Fannell, M.V. (2006). Mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. Journal of Clinical Psychology, 62(2),