Good afternoon, and welcome to this webinar with Dr. Donna Sudak on Cognitive Behavioral Therapy for Suicidal Behavior. This webinar is sponsored by the Suicide Prevention Resource Center in collaboration with the American Psychiatric Association. Before Dr. Sudak begins the presentation, there are just a few housekeeping items to go over. SPRC at the University of Oklahoma is supported by a grant from the Substance Abuse and Mental Health Services Administration, or SAMHSA. The views, opinions, and content expressed in this product do not necessarily reflect those of SAMHSA or the Department of Health and Human Services. Next slide. SPRC is the only federally funded resource center devoted to advancing implementation of the National Strategy for Suicide Prevention. Supported by SAMHSA, SPRC builds capacity and infrastructure for effective suicide prevention by working with state, tribal, health, and community systems, as well as professionals, partnerships, and other stakeholders. Next slide. SPRC has the following land acknowledgment to honor and recognize the history of the indigenous people of the areas that now make up the United States of America. I'll pause here to give you a moment to read the acknowledgement. Next slide. We would like to make you aware that the webinar is accredited and implemented by APA, which has designated the activity for one PRA category one credit. Instructions for claiming credit will be provided at the end of the webinar. Next slide. Please note that the handout for the webinar can be downloaded from your screen. If you're using the desktop version of GoToWebinar, the file is located in the handouts area of the attendee control panel. If you have joined from the instant viewer instead, you'll click the page symbol to display the handout icon. Next slide. At the end of today's presentation, there will be a Q&A period where the audience may submit questions to the speaker. During that period, you can use the questions area of the control panel to ask questions by typing them into the display box on your screen. I'll read the question and Dr. Sudhak will then have a chance to respond. Next slide. Now it's my pleasure to introduce today's speaker. Dr. Donna Sudhak is Professor and Vice Chair for Education at the Department of Psychiatry at Drexel University and Director of Residency and Psychotherapy Training at Tower Health, Phoenixville Hospital. She is a clinician educator with a wealth of experience in teaching and patient care. She has made significant contributions to the literature and CBT education and has also played a major role in developing curricula and guidelines for supervision and resident competency in CBT. In addition to her teaching responsibilities at Drexel and Tower Health, Dr. Sudhak is an adjunct faculty member at the Beck Institute. She is also the past president of the Academy of Cognitive Therapy, the former editor of the PIPE examination, and she has served on the Board of Regents of the American College of Psychiatrists. She is a member of the Review Committee for Psychiatry at the ACGME and has held multiple leadership roles in the American Association of Directors of Psychiatry Residency Training, including as president. Dr. Sudhak, welcome and thank you for joining us. Thank you for that gracious introduction and for having me here today. These are my disclosures. I write books and I will not be referring to those in my presentation today. We have a lot of territory to cover today and here's what we're planning to accomplish. Some of this will be from a bird's eye view because obviously there's very little that you can sort of do in an hour, but I want to give you an overview of what CBT for suicidal behavior looks like. It's important that you know that originally we had designed this or thought about this in terms of looking at CBT for chronic suicidal behavior, but the research literature that disarticulates the effectiveness of this for more chronic individuals relative to individuals who have had a single instance of suicidal behavior just isn't there right now, with the exception of DBT, which is a special category that we'll get to later. But one of the things that's really important is to disarticulate this from CBT for depression or other kinds of illnesses. One thing that's very different in the way that we approach this now is deploying the therapy principles to target suicidal behavior specifically. It's no longer seen as sufficient to treat the underlying disorder, but we consider suicidal behavior as something that has to be separately tackled by the therapy in order to really inoculate the person with the resilience to be able to want to stay alive under stress and tools that will help them in the future. Now, Tim Beck was a giant in suicide research. One of the things that people often have said to me along the way is, you know, why is it that somebody interested in CBT would also be so interested in thinking about suicide? And it's really, it's been a cornerstone of some of the work that he did, particularly early on. Many of the questions that we ask or think about as we do risk assessments came about because he was so curious about how people think who have suicidal behavior. So he realized that intent, degree of intent, suicide attempts, perceived lethality, ideation were all separate risk factors. And very specifically, he identified that hopelessness was a key intervening variable. In fact, hopelessness by itself connotes a future risk for suicide even greater than having had depression. And the most important piece about today is that Tim and his collaborators at the University of Pennsylvania also were able to put together a protocol about CBT for suicide and investigate that, which is much of the work that we're going to talk about today. Now, one thing as we look at this evidence for the use of CBT in suicidal behavior is that it is far less robust, even though it's reasonably robust, it's far less robust than CBT for depression, which is one of the most well-researched things in all of medicine, frankly. And the reason for this is that for years, people with suicidal behavior were excluded from research studies. People, you know, we all thought maybe it wasn't so ethical that we should do this. Marsha Linehan has a quote that I'll, sort of a quote that I remember her saying was that this was one of the most discriminated against groups in all of medicine. And so it really hasn't been until the recent past that we've had evidence. However, there's a growing body of evidence indicating that CBT protocols protect patients in the most critical months after their initial treatment contact when they have had suicidal behavior. And one piece of that has to do with a part of the study that was done by Dr. Beck and his colleagues here in Philly called safety planning. And safety planning is now really seen a little as the state of the art in terms of what happens after someone is either admitted or seen in an emergency department with suicidal behavior. And it was actually an initial element of the CBT for suicidal behavior protocol. And patients really thought it was incredibly valuable. We're going to detail what this is all about in a few minutes, but we use this in lots of different settings as people are leaving the hospital, as they're seen in the emergency department and decided that the level of care does not reach the level of needing to be in the hospital. What we know is that many of those patients will still have a risk for suicidal behavior and also not always engage in follow-up. And safety planning has been shown to very robustly both decrease the risk of suicidal behavior, plus along with some caring contact phone calls, increase the odds of somebody getting into treatment. For those of you who want to know more about safety planning, if you go to this website, suicidesafetyplan.com, you can sign up and it is free. You can download a manual and some safety planning worksheets. It's incredibly helpful. Barbara Stanley and Greg Brown have put together a great website about this, and so I would encourage a visit if it's not something you normally are familiar with. There have been a number of meta-analytic studies that show that a variety of different CBT approaches are effective in decreasing suicidal behavior. The groups all differ. It can be behavior rating from people who just had ideation to making suicide attempts, and there are varying types of therapy that are used as well. These are in adults and also generally in individual therapy. But what is common to all of these approaches is an empathic assessment and a very careful chain analysis of the suicide attempt or suicidal behavior itself, a safety plan, understanding the behavior in detail, and we're going to go through how that looks in a few minutes, and then using very specific cognitive and behavioral interventions to target this in an individualized way so the person can practice doing other things when the stressors that invoke suicidal ideation and the desire to die come up. Now, this is a slide that details the results of the study of the Brown Back at Aust group in Philadelphia, and what this study was about was they took people who were seen here in downtown Philly. I'm going to be in downtown Philadelphia now, and they had been admitted to the hospital after a suicide attempt, and they were stratified into two groups. One group got treatment as usual. One group got standard treatment along with a 10-session CBT intervention, and that intervention really involved, again, that empathic assessment of the suicidal behavior, a safety plan, including tangible reminders for the person of reasons to stay alive, then targeting the suicidal behavior in detail, especially focusing on hopelessness, deficient problem-solving, decreasing impulsivity, and staying in treatment and interpersonal context, and then finally, to end treatment, they made people actually either in imagery or because of an example they've had in their life confront the same situations that were seen as provocative for the desire to die and be able on their own to come up with different skills to use during those episodes of distress, and what we can see is that in 18 months after those 10 sessions, the repeat attempts were almost halved in the group that got CBT, so it's a very, very profound amount of a decrease for 10 sessions. We know that dialectical behavior therapy is a highly potent intervention for suicidal behavior. I'm not going to speak about that today. It's mainly been studied in individuals with borderline personality disorder but clearly has a high degree of effectiveness in those individuals. Now, because I never know who's going to be out there in internet land, I don't know for sure how much you have knowledge of CBT, so I'm going to just do a quick review of some of the basic principles. CBT is a solution-focused, present-oriented form of treatment that's based on a collaborative therapeutic alliance and really guided by an understanding of the patient's problems via two lenses. One, the cognitive behavioral model, which I'll speak about in a moment, and learning theory, and it uses a variety of different techniques in a formulation-driven way. I think one of the important things is to know there's no cookbook involved here. We really look at the way the person learned to think about the world and the different things that reinforce and perpetuate the problems that they have and then deploy interventions to target those. One thing that's important is that we look at this particular model because this is the underlying model that we think through when we're looking at things through a cognitive behavioral lens. That is, that our response to situations is really greatly influenced by how we think about it. That's highly simplistic. We know that emotions and behavior also affect our appraisals of things, but we really think about how thinking can guide us, not only in terms of affecting our emotions and our behavior, but also can affect the information that we take in subsequent to having very strong perceptions of things. I often talk to my residents about the fact that CBT is really just learning to apply the scientific method to your thinking. We have double-blind studies because we know that our belief systems can affect the things we see. Now, our thinking, when we're really emotionally charged up, can be inaccurate or partly inaccurate, and we know that if we can correct that to help it reflect reality a little bit better, it can be helpful. We have, as I mentioned, really tried to truly individualize case formulation, and this is true in suicidal behavior as well. We're going to look to examine and explain the personal triggers for this person's behavior, their particular vulnerabilities, and that helps us to develop a treatment plan. In fact, we're actually looking to see how did this person learn to think about things. My conceptualization questions are generally what are the problems the person is having, and what solutions have they tried, and why haven't they tried some other alternative solutions on their own, or solutions that might work better. How do I understand that? That helps me to start to get a window into this. As I mentioned, we use a variety of different treatment modalities, and these are employed as the formulation dictates. It's not a cookbook, so in suicide, for example, if we had a person who had a lot of intolerance of emotion, we might increase their skills to tolerate distress. We might do things to teach them techniques to decrease emotional vulnerability, like engaging in more positive or social behaviors. We might examine cognitions that they had about emotions, like, I can't stand this pain. I won't get through it. Through all of those things, we might actually have them tolerate emotions to fortify them against certain emotions that were unpleasant to them that caused distress that might lead to the desire to die, like shame, for example. All of those things might be custom-tailored to help this individual, and we would do that in any CBT regimen for other disorders as well. Now, one thing that we are famous for in this form of treatment is a structured kind of treatment, and part of the reason for the structure, and I think most people don't understand this, is because we want people to learn what's happening. I see myself as having the job of making myself obsolete. I want patients to learn what it is that I know about their problem and what it is that I know that will help their problem that they could learn to do, and if we have a session that's relatively structured, it helps people learn better, and we think that in the average physician visit that 70% of the information is lost, and that's not even when somebody is anxious or depressed, so I want to think through with you the idea that helping people by writing things down, having lots of practice outside of session, being able to give them handouts or other things that can refer them back to what you did in the session can really jumpstart and accelerate things, because you're with that person one hour, and they have a lot of other hours in the week where they could interface with this material and help themselves to have different skills that might help their life to go better, and these are the elements of the structure of the session. They're really designed to help the person to build skills and knowledge, and one thing that this can do, particularly in suicidal behavior, is that it can really stimulate hope. If you are telling the patient, here's how we're going to spend our time together each time to maximize what we can do to make your life better, it really shows the patient that you have a plan and that you have a plan, and if somebody's highly hopeless, I would also recommend that you tell them you have a plan B in case this doesn't work, but it shows them that you've got a path to recovery that really can make sense. A key feature of CBT is that we are highly collaborative. We do not tell people what to think. In fact, one of the discoveries that Dr. Beck made early on in working with people that are depressed is that if you tell them, well, gosh, your life doesn't look so bad. You did this, you did that, you did this, they're not going to believe you, but people have to discover for themselves the evidence that you might help them to shine a light on and that they've been ignoring, and if they can discover that for themselves, it becomes much more believable. It also gives them the tool of learning how to shine the light on evidence in the future. We see ourselves as sort of, Jess writes a term for this which I love, friendly teachers, and this is very important in suicide, that being collaborative and being in the patient's corner is very, very key because the change that occurs is highly dependent on the quality of the therapeutic alliance. In fact, the most reinforcing thing for the person to do, for a therapist to do is to have a good alliance because that is actually going to facilitate change. Okay, so how do we think about suicidal behavior? What's our formulation? What we need is an in-depth understanding of a crisis. This is a recent article by John Mann and his colleagues. One thing that I think is really interesting is that he describes the suicide diathesis. If I were going to describe the way that we look at CBT for suicidal behavior, these are the things that we consider as fundamental to looking at the potential for the individual formulation. We're looking at emotional pain. We're looking at when the person thinks about things. They have beliefs and thoughts that make them more prone to look at things negatively and look at suicide as a desirable option. They have profound problem-solving deficits. We really have a sense that emotional pain and thinking habits are the things that we need to really target in therapy. In an individualized way, we try to characterize a person's suicide crisis based on this model. The more risk factors the person has, we think the more easily this model can be activated with stress so that people more rapidly get fixed on suicide as a solution. They have suicide-generating beliefs like, I can't stand this pain, their mood is unstable, and they don't have very good skills to cope, particularly problem-solving skills. They become more rigid, unable to reflect or see any other solution. These are the important features of how I think about the thinking of the person who has suicidal behavior. I look for each individual's particular combination of these and what activates them as a way to begin to think through what I'm going to need to implement in the treatment. One thing that's very important that we haven't spoken about is that people with suicidal behavior frequently have poor autobiographical memory. What that means is that they cannot see past successes, how they solved problems in the past, happy times in the past. When they're feeling desperate, they can't look back. If I had a bad time event, I could look back and say, well, Donnie, you got through this and that. The other thing, because my autobiographical memory, at least at this moment, is pretty good, but we have to remember as therapists that people don't have that. I have to look for ways to shine light on that. Maybe not directly telling the person, but by saying, I guess I'm wondering how you thought about yourself in college when things were happening then, so that we at least help them break through that tunnel vision of depression. One thing that's truly important is that when you are really struggling and you think, that's it, I'm going to die, I can't stand it anymore, frequently, this decreases negative affect. It makes people feel better. Of course, since we're primates, that means that it's going to happen more easily the next time. We need to have respect for the fact that decreasing negative affect initially will cause the person to almost be fundamentally preoccupied with suicide when troubles come up again. Over the long term in treatment, we know we need to help people with their problem-solving because problem-solving deficits are really significant in folks with suicidal behavior. They often engage in problem-solving that makes their lives worse. That needs to be something that gets tackled relatively quickly in helping the person to learn to do that differently. We would start with a risk assessment. That's going to give us a preliminary chain of events that help us to understand this particular person's brand of suicide crisis. Obviously, we're not going to go through those components here, but I'd like to focus your attention a little bit on things that you might not always ask about, the way the person thinks, perfectionism, for example, impulsivity, things that we know that cognitively could increase their risk, and that will help us. Particularly, if somebody has a history of suicide attempts, we know that this is a unique group that has a much higher risk for suicide, ultimately, and may have more severe difficulties along the way. What we want to do is to help the person take us through a very detailed picture, almost like I will say to people, I'd like to go back in a time machine with you to the last time or the worst time that this happened, and really just go through minute by minute, almost like we're watching a slow-motion movie. I'm going to ask questions as they tell me the story about what they were thinking at this point, what they were feeling, what their emotions were then, what did they think about doing or do at that point, what kind of feelings were they having in their body? I really want to get a chain of the antecedents and consequences every step of the way that really interact to initiate and maintain suicidal behavior. Particularly, if someone's made an attempt, the other things I want to know is what were their reactions to being alive and how much they thought that what they did was going to kill them because that indicates an increased lethality. One other area I think is important to remember is looking at does this person have reasons for living? Why would they stay alive? Marsha Linehan and Kirk Strussel and John Childs, very early on as Marsha was starting to develop her treatment for borderline personality disorder, started to look at individuals who were suicidal and individuals who never had suicidal preoccupations or ideas or attempts and came up with ideas that distinguish those two groups. If I'm interviewing someone and they say, yeah, I have a lot of problems, but I'll get through it. I'm a survivor. I would never die because I want to be responsible to my family. If I've got those ideas that the person is voicing, it's going to help me to feel like I've got other things to pin my hat on as I'm trying to make decisions about this person's level of care, as well as things that will help me carry the day in terms of strengths that they've got to help them to want to stay alive under stress. In addition to general hopelessness, we want to look for cognitions like I'm unlovable, my problems can't be solved, my pain is just unbearable, I'm a burden. And when people have this sort of behavior, they generally see things in very all or nothing terms. Perfectionism is generally another feature that really can set people up. And this is perfectionism where they're really punitive toward themselves when they don't measure up. They're angry at the world and other people when they don't measure up. They're worried about and preoccupied with other people judging them for not measuring up. And one curious thing is that we know that individuals who have bipolar diatheses also have a very high degree of perfectionism. And that intersection in that disorder may also increase their risk for suicide. Now, this is another way of looking at that conceptualization in a linear form. So I'm looking at the cues that might have set this all in motion. And what is the person thinking as they begin to have exposure to these cues? So maybe it's a setback at work and they start to think, this is terrible. I'm an awful failure. And they start to feel pain. And then they think, I can't stand this pain. And they become attentionally fixated and they have more and more negative thinking. They might feel a terrible feeling in the pit of their stomach and heat behind their eyes. And they start to think, I just can't get through life. I'm not, I don't deserve to live. And we can see potentially they go to the kitchen, look in the knife drawer, the behaviors get to be more geared toward dying. And so each of those would be the chain that I would put together. We would look for other vulnerabilities as well, such as over general memory, problem solving deficits, et cetera, to help us to put together our treatment plan. So again, it would be using this particular model. Knowing that once this begins to be activated, particular triggers may make it more easily activated each time. And that those triggers that activate despair and behavioral practice may make the person more at risk in the future. So why we do a conceptualization or formulation is because we want to plan treatment. And as I'm planning treatment with someone who's been acutely suicidal, I'm thinking, what are the problems, what are the skill deficits that are the most life-threatening or the most dangerous? And what are the interventions that are going to address that? Now, in a general sense, we have to change the mechanisms that lead to suicidal behavior and replace it with skills, right? We have to originally get an agreement that the goal of treatment is preventing death by suicide and ensure that the environment is safe. And in every single encounter, and I prepare people for this, I tell them that I'm going to assess their risk in an ongoing way. That's the very first thing I'm going to want them to do is to bring a diary card of the things that they've been thinking or doing in the realm of suicide in the course of the week. One thing that's important is that I retain a stance that's highly directed and active. I want to be calm and determined, empathic about the fact that this is painful and validating that, but also that I believe that things can be different, that I want the person to stay alive and that I believe that they can have a better life. In addition, this is not an area where I would want the person to not show up for their session and not do something about it. It's very important to me to take a case management approach to these patients. If someone hasn't made their appointment, actually, even if they're a little late for their appointment, maybe more than a little, I will call them and say, what's up? I want them to know that I'm invested in their coming and that it's important that they get there. One of the things we know is that people who have people reach out with caring contacts are less at risk, and I want to be one of those if I'm their treating psychiatrist. Another thing that's important is that I want to be able to talk about suicide when the patient brings it up. So I may go back to looking at the advantages and disadvantages of living versus dying and trying to come up with where the person is right now if their resolve begins to waver, and I need to have the ability to help the person cope ahead. I need to be proactive to look at what might be risk triggers in the future and help the person to be able to come up with plans for that so that if there's a trigger coming up, we've already taken a look at that and looked at what skills they can use. So the goal, really, is first, the person has to resolve to live even though they have stress and problems. I remember being a resident and being just overwhelmed, really, initially, when someone would come in and they'd have suicidal thinking and they'd also have a tremendous number of problems because I would be thinking to myself, like most residents, I would suppose, that I was going to need to solve all of these right now, and there were just too many of them. And I think that there's a difference in my mindset now because the approach I have with patients is to say, I believe that we can solve these problems, but we can't solve them all at once, and it's going to take some time, and we can't work on any of them until we help you to resolve that you're going to stay alive because, you know, if you're dead, we're not going to do very much problem solving. So we have to really work on this so that you and I can put this aside so we know you're safe, and then we can work on some of these problems. And the other thing that we need is a fire drill mentality, that the person has to practice the skills to stay safe enough so that they're going to be able to do that while we continue that work, and that's part of what we're doing when we're putting together a safety plan. One of the things that's a part of the safety plan is helping the person to begin to have reasons to live and reasons to be hopeful, and that leads us to safety planning, which I'm going to go over relatively quickly. So for those of you who don't know very much about this, you'll get a window, and I hope you'll do more reading about it and learn how to do this because it's really good risk management. It's systematically identifying a plan for the person to use both interpersonal and intrapersonal resources when they face a crisis and they have the risk of developing suicidal behavior, and this is designed to be a brief intervention, 30 to 40 minutes, that occurs with risk assessment, with the person who you feel is not someone who needs a level of care that requires immediate protection. And so the idea with this is that suicide urges tend to have an arc. Most people who have them know that they go up and go down and that they haven't, each time, haven't acted on them, but they know that they've gone away and that we know that a plan can manage these, can save the person's life. And so what we want to do is to get that chain of events and then write down a number of steps to follow, how the person will know they're in danger, what are the things that are red flags that they're in trouble and they may need to be putting this plan into action, thoughts that they might have or flashes of images that they have or things that they are thinking about doing. And then we want to come up with a number of coping strategies they can do on their own, people or places they can be with people that can distract them. My favorite is Trader Joe's. I walk through Trader Joe's. I can get very distracted, but you don't have to necessarily talk about your troubles, just some place where you're with other people that's distracting to you, and then people that can discuss the crisis with you. And then specific information about where you can contact professional help, hospitals, hotlines, therapists, psychiatrists, and in addition, agreeing to get rid of lethal means and coming up with reasons to stay alive. Those are all the steps that are involved in putting together a safety plan. And part of what's important is that you collaborate. You really need to overpractice this with the person, get them to really buy in, not give them places to go, but have them come up with their own solutions. Don't tell them what to do. And remind them that the goal with some of these things like going out to Starbucks is to not feel good. It's to just get through the crisis. They're not really there to feel better. It's to get through the crisis. And with each step you identify, you need to ask the person, what could get in the way? What could they do about it? Is it true that they're going to be able to do this? And give that time. So most of the time when I see people do safety plans that are less effective, they're just telling the person, here's the six things to do. Here's the piece of paper. Bye. And that's not really safety planning. Safety planning is very much using principles of getting the person to make commitments, of coming up with problems that could come up and having them think through the solutions and thinking about where the plan is going to be kept. Once you get that plan in place, the next thing you have to do is to get the person to agree to get rid of the thing they're thinking about using to die by suicide. And any guns in the house. Even if guns were not their mode of suicide. And so it's important sometimes to get other people to be a part of this. Who could you give these things to? The whole collaboration is about, this is an impulsive act. The longer it takes, the safer it is for you. And you have to really get granular with people about this. Because sometimes people want things around just to be ensured that if sometime in the future they would need this, they would have it. And so there are lots of things that you might do in terms of negotiation. Can I keep the medicines in my office until this crisis passes and we have the chance to work together and see if we can solve some of your problems? Can you give your weapons to your brother until we have some time to work together? Again, with the idea that we want the person to stay alive and stay safe. And that this could be a temporary hiatus in having these items. And lastly, we want to find reasons to live. Now, remember, we're using this safety plan on people that are going to be leaving the hospital or leaving our office, where we feel like they're fortified sufficiently to be able to have the wherewithal to stay safe. And so I'll say, well, you know, why is it that you think you're gonna be able to stay safe? What's the reason that you wanna stay alive? Now, if the person were to say to me, my husband and my daughter, I would say, well, could you tell me a little something about what you love about your husband? What do you like doing with him? What does he think is important about your relationship? I'm writing all of these things down, of course. And could you tell me what you would miss about your daughter's life if you were gonna die today? And what she would miss about having you in her life? And you really wanna get the person to paint an emotional picture to these reasons. I have had many people when I've taught this and they've started, I've asked them the questions I ask patients, they get tearful because when you start to amplify these reasons, it's quite touching sometimes. Now, there might be situations where the person can't really identify reasons and you might have to ask questions like, how would you have answered this before this setback, before you were depressed? What would your family say about this? And we wanna play for time. What about the future? If your life was better and you had the chance to change some of these things, what would you be missing in your life? And so we're really helping the person to get a little bit of a different perspective. We ask people to put together hope kits. Now we can do it virtually or we can do it in reality. What a hope kit is, is reminders of emotionally significant things that kindle an attachment to life. Patients like doing this. An assignment I give people is to keep adding to it. It's like my describing reasons to live and my seeing a picture of my husband and my kid. If I see a picture, I'm even gonna feel more attached to that. It could be things the person has, someone has said in an email or a letter, mementos of people that the person loved and you loved them well. And you can do this on your phone or in actuality. And again, having the person keep adding to it. This is a preliminary example of a list of reasons to live that someone made. And we ask people to keep adding to that over the course of the next week. Now, if you're having problems generating these, there are a number of different things to do. One is I mentioned the Socratic questions you can ask. You can also, if the person says, I don't know what I could do to make me feel less upset when I get so upset, you can be more directive. And if you don't know good skills to help people with distress tolerance, I highly recommend Marsha Linehan's work, her skills training work in specific distress tolerance is a fundamental skill that all humans need and not just people with suicidal behavior, but lots of people are deficient in it. And it's very helpful to think through or help people to know behavioral strategies that can help them. If folks are ambivalent about this, we need to go back to assessment and level of care. And that's beyond the scope of our discussion today. And I also mentioned coping ahead. So down the line, once we've got this plan in place, we wanna look in a systematic way as the drivers towards suicide. We wanna help people increase reasons to be hopeful, evaluate their negative automatic thoughts, help them to look at their lives with compassion and get them to be more problem solvers. And the hopelessness is something we really wanna tackle early. Now, one of the things that's a myth about CBT is that we put rose colored glasses on people and nothing could be further from the truth. What we wanna do is to create a reasonable doubt. It's highly unlikely that people would have 180 degree turnaround and many people have lives where there are lots of tragedies and painful things. However, we wanna help the person to shine the light on the best period of their life. Take a look at when they felt the best in their life, what they were doing then, and what they would like to have in their life that they don't have right now. I might help the person with hopelessness to look at how they think about therapy. Many people who have troubles with suicidal thinking have difficulties with feeling hopeless about therapy. And so I may actually explain, here's how I think we'll get better. Every week we're gonna figure out what problems we're gonna work on and the steps you can take to make things more meaningful or better for you. Let's see what got in the way and what could get in the way of those so that I can help with that. We wanna start to envision a life that the person wants and really work to increase their engagement with activity with other people. And we do mood checks along the week, but we'd also, how difficult things have been, but we also wanna check on what's gone well in the person's week. If there's something that they were able to do this week that they weren't able to do the week before, how did they face certain challenges? And then we might ask them, what would you say about a person who could do those things? We tend to look at behavioral things that will help the person early on. Sometimes if a person likes journaling, we will ask them to do that in specific, looking for positive things or meaningful things that happened during the course of the day, looking for things they're thankful for. They're busy, especially when people are in a lot of distress, collecting a lot of the other kind of information. So I actually generally help them to think about the fact that it gives them something to counter the way that they're generally looking at the world. We're gonna look at coping cards, which I'm gonna spend a minute on later, teach people how to do things that are soothing and caring for themselves. Often folks who have troubles with suicidal behavior think that other people don't need to do those things and that, you know, I'm just such a baby. They're really self denigrating about doing things that are nice for themselves. And so we'll have to counter those cognitions. Over a longer term, we wanna get a person to have a better repertoire of pleasurable and interpersonal activities to help them to really have a wider view of the things that they can do to help them feel good in their life. Now, acutely, we wanna play for time. We wanna not be afraid to help the person talk about the advantages and the disadvantages of living and dying for themselves, for today, for a year from now, for five years from now, for other people, for their family. We might make a timeline of if you die today, what would be all the things you could miss out on and what things could happen in the future that you would want that might be not available to you if you were gonna die? If somebody says to me, what's the use of staying alive? I'll say, great question. What is the use? Why have you agreed to this safety plan? Because that's actually using wonderful motivational interviewing techniques, getting the person to argue for the other side. And so that can be useful as well. Now, I mentioned coping cards. We used to do this with three by five cards. That's a long time ago. Now, people put them on their phone. We can do lots of different ways of doing this. But what these are is a way to jumpstart adaptive thinking. Most people have habits of thinking, just like they have other kinds of habits. And under certain stressors or with certain triggers, they will go to the habits that they've had before. And what we do in a session often is to disentangle those habits. We have the chance to come up with different ideas than the ideas that they might have automatically. But since it's a habit, we need to have something to help them to learn this new way of doing things. And so the coping card is there to do that. When I make an analogy for people, I often say that the way that they're thinking is kind of like knowing how to drive a car with an automatic transmission. And that what we're learning in CBT is a car with a standard shift. And it's gonna feel kind of clunky and you might need some reminders of how to do it until the new way of driving your car is second nature to you. So this is an example of a coping card. Now, the way we come up with the elements of a coping card is that we've worked through a problematic situation in a session. And we've come up with different ideas about this problematic situation. And we write down what those different ideas are, either in terms of what the person could think differently or what the person could do differently. So this happens to be a person who was particularly vulnerable to suicidal behavior when they felt shame or humiliation. And so the thought we worked with in the session was my boss humiliated me so I should kill myself. And we came up with a lot of different things to consider. One is that that idea was just an idea and it was a negative belief and that the person actually had a sense of emotion of being angry and also said that they felt hopeless. Actually, that's a thought, but we went through a whole list of things that the person could remember at that moment that would help detune that idea, give this person a different perspective, back up from it. And in addition, what the person could do after that idea was detuned. I should call a friend. If I don't feel better, I'll use my crisis card. So that's what a coping card would look like. And we would want the person to use this so that they would have different ways of thinking and behaving at times of past vulnerability. So I talked about as fast as I could probably. So I'm sorry if this was a very speedy way of going through this. I'm delighted to take questions for the next several minutes. I'm also delighted to have any of you email me with questions about CBT or about this way of using CBT in the future. My email is donna.sudak at towerhealth.org. I've been committed through my whole life in psychiatry to help people learn how to do this powerful form of treatment. And so I'd be glad to help you in the future with that as well. And I'll stop and I'll take a question or two. Thank you, Dr. Sudak. That was a fantastic presentation. A lot of insightful information and tips as well for people who are encountering suicidal patients in their practice. Again, as we move into the Q&A portion of the webinar, I'd just like to remind participants that they can use the questions area or the control panel to type in a question and I'll read them in the order that they come in. One question that has come up is, if you could talk more about some common problematic beliefs that people have about suicide and ways that you might address some of the more frequent beliefs that you encounter in practice. Sure. Well, one of the beliefs that I think is really problematic is that many, many people believe when you're dead, you're gonna feel better. And so, I kind of start with that. And because, who knows? So there's that part. A lot of people have beliefs about the intolerance of pain. I can't stand how I'm feeling, even though they've stood that over and over again. And this just sort of stirs things up. But there are other beliefs that can be problems. I deserve to die. And there are ways to encounter that. Sometimes it's because the person is feeling so guilty or upset about things that they've done. But one question I generally ask people is, if you were in court, would they be able to give you the death penalty for what you did? And most people have said no. And then in which case, well, then how is it that you can give yourself the death penalty for this? And what else can we do to help solve this problem? There have been occasions along the way, both in supervising people as well as in my own work, where the answer could be yes. In which case, I generally go to the, well, how does it make the world a better place if you're dead? Do you really wanna make up for this thing? Can we work together to do something that will help you to be able to make amends? There are other things that come up are things like, and this is often in adolescents or in people sometimes with personality issues. They'll be sorry when I'm dead. Or if I kill myself, I'll find out if this person really loves me. And so one of the problems is that the person has a romanticized view of being able to see everybody at the funeral or punishing people from the grave. And so sometimes it helps to point out all the things you would actually miss and the fact that you really don't know that you'd be able to come back. And the other thing I generally ask people is, can you find a way to get what you want that's less expensive? It's really expensive to die. So those are the kinds of things that I may work with besides hopelessness. Hopelessness is very high up there in terms of what happens in terms of particular beliefs. Great. A related question has come in related to what you were just saying. And it's about isolation as a factor in suicidal behavior. I can think about isolation, perhaps being related to hopelessness for some patients. And so for those patients who do not have any support and say that they don't have anybody to live for and might be unwilling to list people on the safety plan, initially, what would you say to those patients? I think that's a huge issue. And actually it was even more complicated during the pandemic, I've got to say. So first, if someone says, I don't have anybody, I'm generally thinking, okay, what are the lenses we're looking through? And I might say that sometimes when people feel as low as you do, they discount people who might be really important to them. Is there someone in the family that used to be in your corner that you can remember? Old friends, people you haven't been in contact, a neighbor, a pastor. And if the person says, absolutely not, I'll say, okay, the first thing we're gonna need to work on is to find you a group of people that can be in your life. And that this is a very important thing is to get you connected to people. And if the person says, well, you know, maybe that's a good idea, but I'm terrible with people. I'll never be able to have friends. I'm just not a person anybody ever wants to be friends with. I will often say, you know, I've had lots of patients along the way tell me that. And sometimes it was because they were feeling in such despair that it's been hard for them to look at relationships they've had that were successful. But if it's really true that you've had a really hard time with that, I'm a person who's a therapist. I can help you to get to be a person who's more likely to be able to have people in your life. There are things we can do together about that. And that might be the first place that I'd start. And I would start by helping the person to both assess their current social network, but also begin to develop other people within that network, whether that would be via volunteering, via support groups, in other places where the person can be closer to other people and a network. And I will often use the same analogy that I do with having people do pleasant activities, which is that this may not be something where we're gonna have you make the best friend you've ever had, but we're gonna gradually expose you to being with other people and have you potentially just notice the difference between being able to smile and say good morning to someone on the street and notice kind gestures that might happen with not having any contact with people at all. And we'd go from there. I think we have one slide I have to get to. Yes, before we finish. Yes, we are approaching time. And so before we conclude the webinar today, please take a moment to read the information on your screen for claiming credit for participation. If you would like to claim CME credit, and if you have any questions about the credit, please email learningcenteratpsych.org. Dr. Sudhak, I thank you again for your time and would just like you to scroll forward to the end of the presentation for your email address. A lot of questions came in. And so some people attending the webinar might want to follow up with you. And there it is. Oh, there's my Drexel email. So yes, you can use that one. It's a little easier to copy down. Thanks for reminding me that I did put it there. Yes, thank you. So we're so glad for this presentation. It's really filling a learning need in the field. And we also appreciate all of the participants who attended the webinar today. Just a final announcement. Please consider joining us at SPRC's next webinar, which is this Thursday at 3 p.m. Eastern for a discussion of the Zero Suicide Framework and Best Practices in Care Transitions from Inpatient to Outpatient Care. Thank you again for attending today's webinar. And this will conclude today's session. Thanks, everyone. Bye-bye.

Cognitive Behavioral Therapy

CBT

Suicidal Behavior

Empathetic Assessment

Safety Plan

Therapeutic Alliance

Problematic Beliefs

Reasons to Live

Coping Strategies

Hope Kits