Using Safety Plans in Cognitive Behavioral Therapy for Suicidal Patients

Jesse H. Wright, MD, PhD

The 2020 American Psychiatric Association (APA) Annual Meeting was cancelled this year, with plans made to convert the world-leading psychiatry conference into a two-part virtual session and educational platform for attendees.

In lieu of regular on-site coverage, HCPLive® will be running a series of interviews, insights, and reporting on topics that frequently headline the APA meeting—featuring familiar experts.

For many psychiatric patients, cognitive behavioral therapy (CBT) is seen as at least the equal of pharmacological treatments.

The therapy allows clinicians to outline triggers and behavioral problems and devise a method to address these factors and help the patient.

Part of that treatment is for both the doctor and the patient to collaborate on a “safety plan,” a comprehensive plan that includes information on people and organizations that may help the patient like the family members, friends, and the National Suicide Hotline.

The plan also includes potential triggers for the patient and whether or not they have access to harmful things like weapons.

In an interview with HCPLive, Jesse Wright, MD, Director of the University of Louisville Depression Center, explained how CBT and safety plans can help patients overcome some of the issues that has led to their psychiatric problems.

Wright was scheduled to present information on how CBT can be used to curb suicidal behaviors during the annual conference in Philadelphia, but the meeting was ultimately cancelled due to the coronavirus disease 2019 (COVID-19). He will, however, virtually present the session during the APA On-Demand platform, along with Judith Beck, PhD, Beck Institute for Cognitive Behavior and Donna Marie Sudak, MD, Drexel University College of Medicine.

HCPLive: How beneficial is cognitive behavioral therapy?

Wright: This has been studied in a number of trials and has shown to be quite beneficial.

For example, there was a large study at the University of Pennsylvania by Gregory Brown and coworkers published in the Journal of the American Medical Association several years back that found that if you did a cognitive behavioral intervention with patients that have had a suicide attempt and came to the emergency room the subsequent risk for suicide attempts fell about in half.

That was compared to treatment as usual, in which the patients were followed in an enhanced method to see how they did.

HCPLive: How do you plan to present this information during the virtual APA workshop?

Wright: In the workshop, Dr. Beck and Dr. Sudak and I will outline the basic strategies that one uses for cognitive behavioral therapy for suicide reduction. It includes several things that are important. One of them is to first assess the patient's risk for suicide and look at the cognitive behavioral contributions that one might be able to work with and treat the patient.

One of those is the degree of hopelessness. It's been shown in multiple studies that this sense that there's really nothing to look forward to, that your future is very bleak and there’s nothing much that you can do is going to make a difference is associated with elevated risks of suicide.

And this is a target for cognitive behavioral therapy because cognitive behavioral therapy's been shown to be something that can really help people cut through the negative depression and find ways to generate hope.

Some of the behaviors that are common with suicidal thinking are behaviors like social isolation, breaking important relationships that could sustain you, being reticent to reach out for help.

Having things around the house that are potentially lethal, like guns, the therapist will work with the patient on a plan to reduce the access to things like that.

Another thing that's a really important part of the intervention is asking questions that draws the person's reasons. One of the most important questions that’s asked is that we know that you are feeling really down and depressed and you told me about your hopelessness.

Take that and you can brush that out and add a lot of detail, that's a good sign that you're working together with the patient, that you're working toward a plan that it can reduce the risk of suicide.

On the other hand, if the patient is unresponsive and they would rather die, and they’ve made plans to actually do it then you might be more likely to recommend hospitalization for the patient or take more extreme measures other than working on an outpatient basis.

HCPLive: What are the best safety plans?

Wright: The heart of all this is the development of something called a safety plan, which has been studies in various research studied and has shown in itself to reduce the risk of suicide attempts by a great deal.

A safety plan is a written plan that is done collaboratively with the patient. It is not something you just do in 5 minutes at the end of the hospitalization. It is something you work on with the patient and draw up things that they want to put on it.

The safety plan would have all the triggers or return of suicidal thinking and things you need to be on the lookout for so if they start coming what should they do about it. The next thing would be to develop strategies, behavioral strategies and cognitive strategies the patient can use to reduce their level of despair or distress or hopelessness and break those specifically.

The next thing would be to develop a plan for your social network, people you can reach out to if you’re in trouble because you safe calling them and letting them know what’s going on. You actually put down the phone numbers for those people and if there is any barriers for you to reach them.

HCPLive: How much does the intricacies of the therapy differ based on the individual patient?

Wright: The basic structure of trying to develop a safety plan that would be done for every patient is always customized for that particular situation and their particular stresses they have or the resources they have, the strengths they have.

There are some things that are the same. You want to have in every plan a way to reduce access to dangerous things, I want to have phone numbers and details of where they can reach out.

HCPLive: What therapy options are available for patients where CBT is ineffective?

Wright: CBT is not a panacea It works with a lot of people; it’s generally considered to be about equal to the medication for depression as far as remission and response rates. It’s probably better for relapse prevention but there are lots of other treatments.

I typically use a combination of therapy and medication, but there are other psychotherapies that are effective. One size doesn’t fit all and if the person doesn’t have an affinity for CBT or it’s not working then you go on and think of something else that might be helpful.