# David Tolin - Brief CBT for Suicide Prevention

## Метаданные

- **Канал:** PsychiatryLectures
- **YouTube:** https://www.youtube.com/watch?v=5gi_5osYXE0
- **Источник:** https://ekstraktznaniy.ru/video/42659

## Транскрипт

### Segment 1 (00:00 - 05:00) []

Christian what time uh we will start in 1 minute okay e okay welcome everyone to today's kinska suicide seminar my name is chrisan Rick I'm a professor of Psychiatry here at kin institut at in Stockholm Sweden and this is a lecture in our kolinska suicide seminar series and very welcome all of you who listen H this uh lecture will be recorded uh you as participants will not be seen or heard and you can write your questions in the uh Q&A uh function U at the bottom of the zoom window uh today we are very honored to have um Dr David tolin here with us David Tolen is the founder and director of the anxiety disorder centers at The Institute of living and an Adjunct professor at of P at Yale University School of Medicine he's the author of over 250 scientific articles and several books he is also the past president of the abct Association for Behavior and cognitive therapists uh and the past president of the Clinical Psychology division of the American Psychological Association and recently Dr Tolen and others published a very interesting article that called many's attention I think here about brief cognitive behavior therapy for suicidal inpatients and um I think I speak for many of us here when I say that this is something that is very dearly needed as we know that the risk for suicide is extremely high after discharge from hospital and it seems to make sense then that we do something before discharge and not wait with treatment until after discharge uh so I'm very much looking forward to hear your talk David um please fire away thank you very much Christian and hello everybody it's nice to be with you today um so we're gonna be and as Christian mentioned we uh recently completed a study of inpatient Suicide Prevention and that's going to be the bulk of what I talk about today um let's see there we go I do want to thank a couple of uh really important key collaborators David Rudd who was a very important consultant on our research and Gretchen debach who was my project manager uh on the impatient suicide trial um really is respon and was the lead author on the jamama Psychiatry paper and in fact um drafted most of the slides that you're going to see today this is the uh a book that I highly recommend which doesn't talk about inpatient treatment we're working on that but does kind of give an overview of the kind of work that we're going to be talking about today uh so David Rudd has done a lot of work in the area of uh Suicide Prevention and one of the things that he has identified in a systematic review is that if you look at all of the things that have ever been proven effective for reducing suicide risk it really boils down to a small number of essential ingredients those treatments that are effective appear to be based on a simple empirically supported model with high treatment Fidelity by the clinician significant adherence to the treatment protocol by the patient with an emphasis on skills training self-management and access to crisis services and so we wanted to make sure that all of these were part of the treatment that we uh put together our treatment is based in part on the fluid vulnerability theory of

### Segment 2 (05:00 - 10:00) [5:00]

suicide and the basic idea behind fluid vulnerability theory is that suicide risk is comprised of both stable and dynamic properties and so there are some things that elevate a risk over time but the suicidal episodes themselves tend to be Tim limited and the Baseline risk varies based on vulnerabilities and determines the threshold for activation and then the acute risk uh occurs when a certain combination of vulnerabilities and stressor exposures occur so the idea here is that individuals with high Baseline risk experience suicide episode suicidal episodes more often and for longer periods of time whereas individuals with low Baseline risk experience suicidal episodes less often and for shorter periods of time when we see people with multiple suicide attempts and lots of non-suicidal self-injury those are the clearest markers of an elevated Baseline risk the acute suicide risk has a tendency to resolve when the factors that maintain the suicidal mode are deactivated or reduced I'm going to come back to that discussion of suicidal mode in a moment and after the resolution of an acute suicidal episode the individual returns to his or her Baseline risk level this is an example of what I'm talking about these are two hypo itical patients measured over time and with regard to the degree of suicide risk rated from 0 to 10 and what you can see is that the patient in red has a relatively low Baseline risk and then there's an acute suicidal crisis that occurs somewhere in the middle here by comparison the patient in blue has a much higher Baseline suicide risk and so when they go into an acute suicidal episode you'll notice that it's higher and it's a little bit more prolonged this is the suicide mode that I was speaking of this is essentially a schema it's a case conceptualization which suggests that there is an interaction of emotions thoughts behaviors and psychophysiological signs that are malleable and that guide our implementation of treatment this is an example of a sample diagram of a suicide mode and what we can see is down at the bottom of the screen there are these Baseline predisposition that could be cognitive they could be emotional they could be behavioral they could be physical and when those predispositions moving up in the graph here when those predispositions are met with external triggers like interpersonal conflict being criticized financial troubles and so on we go into the suicide mode in which these cognitive behavioral emotional and physical signs become activated this lead us to brief cognitive behavioral therapy or bcbt now I'm going to show you here the outpatient version so this is David Rudd's treatment manual uh in which it takes place over 12 sessions and what you can see is that there's a lot of stuff packed into each of these sessions that the first phase is emotion regulation and that's the first five sessions that include things like a risk assessment crisis response plan mean safety C counseling working on a treatment plan sleep disturbance relaxation reasons for living a survival kit where they then move on to a second phase which is cognitive flexibility which is much more of a cognitive strategy a cognitive therapy strategy and finally moving on to phase three which is relapse prevention and that's done over two sessions now I'll just talk about that briefly here David rud showed notice this that when you do outpatient bcbt It's associated with a 60% reduction in suicide attempts for individuals who have attempted suicide what we needed to do was adapt this bcbt for an inpatient setting now there's a couple of reasons that we need to do this one is that there is very little research on inpatient suicide prevention treatment which is surprising since inpatient treatment is probably the number one thing we use to prevent suicide and we know almost nothing about its efficacy what we do know as Christian alluded to at the beginning is that there's a very high suicide risk post discharge in fact in the immediate aftermath of a psychiatric hospitalization the risk of suicide is a hundred times greater than the population average it's a common reason

### Segment 3 (10:00 - 15:00) [10:00]

for admission and we know that specific suicide interventions tend to be more effective and so what we're going to do is leverage the inpatient environment which includes the access to Providers the availability of treatment and the Readiness of the patient for therapy what we created was a four session protocol trying to distill David Rudd's 12 session protocol down to its very ESS Essential Elements and I'll talk about each of these as we go but briefly session one is a narrative review and case conceptualization and a crisis response plan session two involves reasons for living and what we sometimes call a survival kit or a hope box session three we develop coping cards and we do means restriction counseling and then finally in session four we do a review of all skills and some relapse prevention so I see that's a total of 4 and a half hours of therapy in our randomized control design uh we randomly assigned patients to either treatment as usual which is treatment as usual here in the hospital or treatment as usual plus what we're going to call now b cbti or brief CBT for inpatients we then assessed everybody and we followed everybody monthly after discharge for 6 months and the reason that we picked 6 months is that is the period of highest suicide risk uh essentially we had uh 200 people in the uh trial all of whom had a prior suicide attempt and were in the hospital um and I'll let you look at the rest of the demographics here but I want to just point out it was a fairly representative sample oh the one thing I will mention down at the very bottom here and because I'm going to come back to it is that 60% of our sample was diagnosed with a co-occurring substance use disorder and I'm going to talk about the importance of the substance use disorder as we go the outcomes were suicide attempts that was the primary outcome using the Columbia suicide severity rating scale as well as a med review of medical records we also looked at suicidal ideation on the adult suicidal ideation questionnaire as well as the presence and number of psychiatric readmissions so let's look at the results here in terms of suicide attempts uh statistically there was no main effect of time and no interaction with substance use disorder there was a main effect of treatment condition in so far as the odds of a suicide attempt in the BCB group were 60% lower than in treatment is usual exactly the same efficacy that David Rudd got in his outpatient trial we did get a main effect of substance use disorder such that the odds of suicide attempt overall were more than double when a patient had a co-occurring sub substance use disorder when we look at suicidal ideation it's not nearly as impressive a picture there was a main effect of time um in and in so far as everything got sort of better but there was no significant condition by time interaction and post talk analyses showed only at the one and two month in follow-ups were was C BCB Superior to treatment as usual what that means then if you take these last two uh slides together is that this treatment is quite effective at reducing suicidal Behavior it doesn't see seem to do much for suicidal ideation so we think of this as a very behavioral treatment we also saw an effect on psychiatric readmissions um here we did get an effect of treatment condition and substance use disorder so when the patient didn't have a substance use disorder their readmission rate over these next 6 months was 71% lower than in treatment is usual on the other hand when the patient did have a substance use disorder there was no difference in the readmission rate so there's something there about substance use disorders that is making patients not necessarily suicidal because the suicide rate was still down but they are still being hospitalized at an elevated rate so let's talk about these sessions bcti in all of them we set an agenda and we do a mood check scale of 0 to 10 how's your mood today we do a review of the lessons learned

### Segment 4 (15:00 - 20:00) [15:00]

and the patients crisis response plan and we talk about Skills Practice since the previous session then we introduce a new skill and practice it in the session we then assign skill practice and we ask the patients to rate the likelihood that they're going to actually try these things that they're actually going to use these strategies that we are teaching them and we ask them for a new lesson learned the lesson learned is essentially asking the patient to synthesize what they have learned from session so when we set an agenda we usually do this on a whiteboard in the room and the uh clinician is drawing things out and providing structure and getting agreement from the patient so an example might be the therapist says first we'll do our mood check next we're going to review Lessons Learned and review your crisis response plan and make some revisions because like I said it's a working document we'll review the practice which was to read the reasons for living list every 2 hours we're going to talk about means restriction counseling we're going to create some coping cards after that and then we'll figure out how you're going to practice and then we'll talk about the Lessons Learned for today okay this is the mood check in which we are measuring not only mood but we're also measuring the degree of wish to live and wish to die and I don't have a slide for this but very recently we did some analyses suggesting that the ratio of wish to live and wish to die is a very powerful predictor of subsequent suicide attempts uh in fact it performed better than all of the psychometrics uh that we had so in sessions 2 through 4 we talk about the lesson learned from the previous session and then we do the crisis response plan and the idea behind is we want to increase accessibility to things that will help so we ask the patient to talk through each step of their crisis response plan and we ask them to keep doing it even though it's repetitive then we do a lot of between session practice where we're praising the patients efforts problem solving is needed and incorporating any new insights that the patient brings in into their treatment as we introduce a new skill we provide a rationale for that skill and we fit it into the individualized case conceptualization we then practice that new skill reinforce the efforts and reinforce any changes in mood that are noted during the session when we assign between session Skills Practice homework we provide a rationale and we encourage the patient to practice these things even when they're not in crisis um now we tend to not use the term homework because at least in our population the term homework has a very academic connotation that puts off a lot of patients so we just call it skill practice um so an example might be so for practice I want you to make two more coping cards and let's make a schedule for you to look through uh look through your coping cards how about at every meal do you want to say before the meal or after the meal patient says I'm going to do it after the meal okay so after every meal I want you to review these coping cards look at them as though they're flashcards read the front and in the back and we'll talk more about the coping cards as we go today and as I mentioned we're asking patients for each skill that we introduce to rate the likelihood that they will use it so How likely between 0 and 10 are you to use your coping cards and the patient may say probably like a six I'm more likely to use the survival kit and then the therapist is going to ask what makes you less likely to use this and the patient says because it's so many cards okay so we can think of a solution to that a little problem solving what if we took a rubber band put all the cards together and then you put them in that same place that we would keep the survival kit maybe that would make it more likely for you to use it and the patient says yeah it's just so many cards I'm just worried I'm going to lose them maybe if we stapled them or used a binder clip therapist says that sounds possible would that change the number patient says yeah then it's more like an eight and then we end each session with the Lessons Learned what in the patients perspective are the key take-home points of the sessions um we identify these collaboratively we ask the patient and then if the patient's having difficulty we prompt them and we try to deepen the lesson learned to enhance the therapeutic value and we ask the patient to write that lesson down in their treatment log in their own words session one is involves a narrative assessment a conceptualization of the suicide mode

### Segment 5 (20:00 - 25:00) [20:00]

and a crisis response plan the narrative assessment is inviting the patient to tell the story of the suicidal episode usually that brought them into the hospital and we might use some guiding questions so we might ask the patient to describe the sequence of events like what happened then what happened at what point did you decide to make a suicide attempt and we identify the modes of the suicide or the components of the suicide mode for example what specifically was going through your mind at that moment what was the emotion you felt at that moment where did you feel that sensation in your body we formulate the model as we go and provide emotional validation I thank you for being willing to share your story with me I know it's not always easy to remember the details let alone share the details I'm going to show you a video here a brief one that just shows a little bit about of uh asking the patient for a narrative assessment so the next thing that I want to talk about is what brought you in here I know you had an attempt and that's the thing that I'd like to discuss I'm hoping you can share with me your story of what happened yeah so the thing is that this actually wasn't my first attempt okay I've had a couple of others okay and I'm noticing this pattern where every time an attempt happens it's after I've been in a unhealthy relationship or a friendship that goes badly and then I just really immerse myself in work and become this workaholic and start putting so much pressure on myself it's good that you're noticing a pattern there because that pattern is going to help us fit all this into a model that we can use during our treatment okay so this time um I was friends with this guy and he was really interested in being in a relationship and I like wasn't that interested but we stay friends and he kept promising me all this stuff like he kept saying he'd helped me pay for my car that didn't happen and then he said he'd helped me pay my rent and that didn't happen and so I kept getting into this hole that I had to dig myself out of and I started looking bad because of other people's failures and I started worrying that I would be a failure looking bad and being a failure yeah what was the concern there then my value would go down oh see so it gives you value when you don't have to rely on somebody else for those kinds of things yeah I take a lot of pride in working and doing well and being in school and that makes me feel good and without those things my value goes down okay so what happened next in this relationship so then he started calling me and he was like my brother saying all this bad stuff about you and he just kept calling me um and saying he's slandering you and then he would I would get aend he would be like oh but I'm not listening to my brother and I was like then why are you telling me all this stuff that he's saying about me I see so kind of tainting your image exactly is that related to the value yeah definitely it ruins my image it makes me look words okay he you've been working on overcoming some other personal problems in the past is that right yeah I know you know it's been really hard for me to battle these demons over the past couple coup of years and I was in a domestic violence relationship and then um I became an alcoholic and made some really bad decisions when did that period end about two years ago okay were there other stressors too recently yeah um so I went to my friend's bridal shower M and there was this other guy there who was interested in me and he asked for my phone number M and my best friend gave it to him but then I was talking to him and I said that I'm not interested in him and my friend kind of gave me a heads up that he's not po her material and so then he told her that and now she's upset at me too she's upset at you so there's anger at you yeah okay just sort of an upset feeling toward you upset feeling bad energy yeah she just okay now I seem to recall there was also something going on with your mom too right and yeah so my mom said I so I just called her and I said I think I'm going to rent on a partner and she was like oh you know right now I think that you should look at getting a house and I don't think she even meant anything by it but she was like at your age I had a house and so then I just got upset about that almost like you're being accused of not working hard enough not having enough that sort of thing exactly by all these different people not being a good enough friend not being the person that I want to be how did that feel emotion wise like can you give

### Segment 6 (25:00 - 30:00) [25:00]

me a couple like feeling words HS painful okay meaning what period of time did this all take place in the slandering from um that guy's brother was like took place in about a week but everything else seems to happen in like a day okay that's a lot in one day yeah all in the same day yeah so what happened next so then I went to my friend's house and we were just going to hang out and she went to the bathroom and I just got really upset and I got up and I was going to go take a drive um and she came out and she was like where are you going you tell me everything and I just said I just want to go for a drive in my car okay and so I went and I started playing this song um naked by L uhhuh and I don't know what's it about it's about this um woman that she just wants people to appreciate her for her and not for all these materialistic things and you feel this way about yourself yeah okay um and so I just really felt that way as I was playing song over and over again and driving around and I just wanted to be appreciated for me and I just started crying and I pulled over in the park um and I I'm on anti-depressants and so I just started taking them because I didn't want to feel this way did you take the anti-depressants with the intent to block your emotions or were you trying to kill yourself both and I started taking I had some medicine for headaches and I started taking that too I just wanted to feel better and then I started crying harder and panicking and got really overwhelmed what happened next I remembered that I was told that when the clinic is closed I should call 211 if I ever feel that way is that what you did okay anything else after that I remember police um coming in an ambulance okay wow it sounds like you were in a really tough place and I appreciate you sharing this with me this helps me a little bit to understand what was going on with you and will help me to put some things together for our treatment but I know that's not easy to talk about so it's a very Frank discussion of exactly what led up to the suicidal incident and what the suicidal incident was comprised of we then introduce the concept of the suicide mode which is a simple model that helps us understand both the Baseline and acute suicide risk um it is a validating experience for most patients to diagram their suicide mode because for them the suicidal crisis is really confusing and we're bringing some clarity to it the key points that we want to emphasize as we're introducing the suicidal mode to the is that your vulnerabilities are just that they are vulnerabilities they are not destiny that the suicidal crises tend to be Tim limited so the idea is that what we are trying to get the patient to do is just buy time when you're in a suicidal crisis can we just pass the time in a safe way the suicide mode components are each addressed with skills that they're going to learn in bcbt TI and that the last piece is that the patient's choices all the way through the process either lead them closer to a suicide attempt or lead them farther away from a suicide attempt and we're just going to encourage them to keep making choices that lead them farther and farther away from a suicide attempt so we develop this model collaboratively we do it on the Whiteboard um and it's a very directive process uh with lots of input from the patient where we're really trying to Hash this out and get agreement we assess this for patterns with past attempts you know many patients have multiple suicide attempts as did the young lady you just saw in the video and so we might use this to talk about past attempts as well we try not to get too bogged down about the exact correct placement I don't know is this an emotion or is it a physiology it doesn't matter right what we're really trying to do is help provide some clarity and give the patient a conceptual model that they can use we then have the patient write that down in their treatment log as you see here and we ask them to take a picture of it on their phone so they've got it always these are some common predispositions this is the vulnerabilities right cognitively it may involve a patient's self-regard and the degree of cognitive flexibility and problem solving capacity emotionally the presence of a psychiatric disorder or emotional libility or activation of the HPA axis

### Segment 7 (30:00 - 35:00) [30:00]

physically one's genetics one's medical conditions one's demographics all play a role and behaviorally prior attempts are a vulnerability Factor so is your capacity for emotion regulations so are your interpersonal skills Etc we then having talked about the vulnerabilities talk about the trigger so what actually brought those underlying vulnerabilities into an acute suicidal crisis and the clinician might say here the next part of the suicidal mode is what we'll call triggers are stressful situations or problems that you experience in life that activate a suicidal crisis triggers can usually be categorized into one of two groups external and internal external triggers are stressful situations that happen in your life such as a relationship problem financial hardship legal or disciplinary problems internal triggers by contrast are mental or physical experiences that occur inside of you like depression or worrying about a problem in Life or thinking about bad things that might happen to you in many cases suicidal crises are triggered by life events but other times they're triggered by some sort of feeling or experience inside of you that's not necessarily tied to any life event based on the story you just told me it sounds like your triggers included x y and z and then we move up to the suicide mode this is the point where the the schema has essentially become activated and we talk about the cognitive emotional physical and behavioral components of uh of the suicide mode including behaviorally the preparations that the patient made for the suicide attempt the next piece is to develop a crisis resp response plan and the rationale here is that we give to the patient is that when you're in the suicide mode your problem solving capacity has become impaired so what you really need is a very accessible concrete plan so we help the patient to identify what their warning signs are that is how do you know the suicide mode is becoming activated what are some self-management strategies that the patient can do who are some supportive other people like friends or family that they can contact and then finally as a last resort who are the Professional Resources that you can contact can we contact your providers or can we get you to Emergency Services as we introduce the crisis response plan we ENT I think I pretty much said this but we use an index card to write down the cons the crisis response plan and we ask the individuals to handw write it uh to make it a little bit more personalized so as we talk about the warning signs we might ask the patient what are some of the things you notice inside of yourself during these situations or what are some of your indicators that things aren't going so well and are getting out of control or if we wanted to prevent this from happening in the future how might we know when you're heading down this road we want to make sure that we're ensuring that the warning signs occur far enough in advance to be helpful that is I'm swallowing pills is not a very good warning sign right we need to think about what's coming before it in time and if the patient has difficulty we provide them with a list so it's very again a very directive kind therapy so these are some examples of common warning signs they may be uh certain thoughts they may be mental images they may be certain emotions or feelings behaviors or actions or they may be physical Sensations and we'll often suggest these to the patient was this part of what's Happening did you notice this we then give some ideas about self-management when you're feeling upset or stressed what are some things that help you to calm down or feel less stressed and even if the patient says nothing we might ask them what are some things you used to find helpful when stressed even if you don't do them anymore so we ask about things that have worked in the past now sometimes what you find is the patient strategy is very limited and it only would work in one setting so we prompt them and we push a little bit to ask about other strategies that might work in other settings and again if the patient has difficulty we provide a list that looks kind of like this what are some things that people sometimes do when they're in crisis can you could you maybe incorporate one or more of these into

### Segment 8 (35:00 - 40:00) [35:00]

your repertoire we pay attention to social support when you're feeling stressed or upset who helps you to take your mind off of things or cheer you up or who do you know who provides you with support during tough times people often have a family member or a friend or a co-worker who supports them in their times of need who would that person be in your life now if the patient can't ident ify any social supports we provide some general some suggestions and if they still can't we just move on that is some patients are truly socially isolated and we don't want to Bel labor that fact we also point out that reaching out to somebody in crisis doesn't necessarily mean that you have to talk about the crisis if you want to call your friend or your coworker when you're in crisis you don't have to tell them that you're feeling suicidal we could talk about other ways that you could structure that conversation and then finally there's the emergency Support Services which in my country is 988 or 911 or going to the hospital and we ask the patient would you go to the emergency service and if the patient's reluctant we ask them for their reasons why and we ask would you include Emergency Services on your list even if you don't right now feel very motivated to use them so I'll show you another video here of working out a crisis response plan with a patient well the reason that it's so important for us to have an understanding of this model is that because the behavioral responses that you're currently using aren't working right so we want to provide you with skills that you can use when you start to get into the situation so that you won't go to the point of a suicide attack right that's what leads us to a crisis response plan have you ever made a plan for something yeah I'm like obsessive about planning okay what about like a crisis plan like there's a big storm out something coming yeah I have a storm kit and flashlights and everything's colorcoded perfect so this is similar this is a plan that we create for an emotional storm right which would be a crisis so the first step when would you say is an appropriate time to use this plan what are some signals and I feel a lot of criticism around me a lot so let's write that down definitely criticism conflict yeah right okay that sounds like a big one so criticism interpersonal conflict with friends let's put depression and anger on the list because that's an internal experience that you had during that time maybe depression slash anger not feeling valued yeah okay the Second Step once you recognize that you're in that state how do we thwart that so the Second Step would be to think of things that you could do for half an hour that would bring you from like a 10 to a seven right so what would you say are some things that you could do because the behaviors that you're currently doing are not working as we mentioned right they made you feel worse so what are some behaviors that would make you feel better um I used to dance a lot when I was a kid so in a crisis sit situation right where you'd be going for a drive or listening to sad music repeatedly do you think dancing for a half hour would help maybe yeah do you want to put that down would that be something you think you'd actually do yeah I think I would do it um my best friend likes the play music in our kitchen sometimes and we like to dance and be kind of silly okay and what if you were alone maybe all right so that's amazing it depends on where you're at but that's one thing that you could potentially do what could be something you could do anywhere workout ah exercise let's put that down in the past I've done yoga journaling has helped me before you know that can be tricky because you know it depends on we were talking about how sometimes you can be in a negative place you know and then you're journaling negative thoughts yeah right and that perpetuates more negative thoughts exactly you got it so we want to make sure that we're choosing things that are really going to lead you in positive direction right so let's think of one more I don't know it has to be something physical because that always makes me feel better okay what about uh eating something really Youngy like cooking yeah you like cooking I do okay so what about cooking if cooking helps you feel better I'd say that's a great one to put on the list um me do you do self harm behaviors like cutting yourself no I did when I was 16 between the ages of 16 and 18 but not since okay I just want to be cognizant of what choosing is listenting no I haven't done that since I we're looking

### Segment 9 (40:00 - 45:00) [40:00]

for things that will calm you right so you mentioned exercise you mentioned yoga you mentioned cooking for a half hour you mentioned dancing fabulous so that all sounds really good so step number three would be if those don't work it's reaching out for support of somebody that you're close to and it sounds like during the last time that was a behavior that you struggled with so who could you think of who would be a good support for you to reach out to if you were to find yourself in a crisis situation I could reach out to my boyfriend because he also struggles with so your boyfriend is your current boyfriend who's that um Terrence okay and I've been friends with him since I was 12 years old I see you're romantically involved now okay is there somebody else who might be we also know that in a personal relationships and intimate relationships can at times be a trigger for you so is there somebody else long standing who you've known for a really long time like a friend or something like that no a lot of my friends don't really speak to me anymore family member I'm not really close to family H is there a teacher or somebody outside of friends or family no I don't really let people in like that because last time whenever I used to it would blow up so Terrence really seems to be the one who close to you at this point yeah and um my female best friend Monica okay that's good so you have the people to reach out to now you don't necessarily have to tell them that you're having a crisis you can just have a pleasant conversation that's an alternative activity you know you can open up to them if you'd like but you don't have to okay so then the last step is let's say that doesn't work or they're not available the last step is to contact professionals yeah I have a therapist and a psychiatrist ah so you can reach out to both of them so let's write their names down there and we'll get their numbers and we'll write them on the plan as well and obviously 911 if you can't reach those people so let's put that down too there's also a National Suicide Hotline it's 1 1800 273 talk so let's get that down too 1800 273 talk or you can go to the emergency room right and it sounds like you did that you called 211 yeah that was my first time doing that okay so how like on our scale from 0 to 10 with zero being not at all and 10 being definitely are you to use this crisis response plan probably like a seven okay it's a seven if there are some things that you can think of that will help bring that seven up to an eight nine 10 let's think about those and talk about it tomorrow okay the really tricky thing and I don't know if you saw me doing it here is making sure that the crisis response plan doesn't incl include iatrogenic uh things I mean so when she said I wanted to cook the first thing that came through my mind is she going to cut herself with a knife so I had to inquire about that and when we she said I want to include my boyfriend on the list I had to ask you know is that really going to be a source of support or is that going to stress you out even further so the highquality response plan crisis response plan is agreeable to the patient it's feasible it's flexible it's accessible on a note card or on the patient's phone it does not include any additional triggers it's personalized and it's detailed enough to be actionable these are some examples of writing down uh on a card what the crisis response plan is and we might have the patient then take a picture of this and put it on their phone we also do some introduction of deep breathing as a sort of generic self-management skill the rationale here is that it slows down the simple sympathetic nervous system it's easy to do most people say they've tried it most people say I sure I've tried breathing and we ask about you know what was it like how did it work now sometimes they say ah it doesn't work for me and I'll ask them show me what you did because often what we find is that what the patient's really doing is sort of hyperventilating and chest breathing and we're going to encourage diaphragmatic breathing you know putting a hand on the stomach and letting it go and being very slow uh you know very even sometimes counting the breaths as they go in through the nose and out through the mouth Etc the safety plan here it has overlapping concept con content with the crisis response plan but we fill this out with the session and we um in our inpatient trial shared that with the unit clinician so you see here what we're asking the patient to do is write down what their warning signs are

### Segment 10 (45:00 - 50:00) [45:00]

what their internal coping strategies are who the people are that can help and the social settings that can help the people that they could ask for help and the professionals that they can come through that they can go to as well as making the environment safe which we're going to talk a little bit about means restriction Counseling in a second session two is the reasons for living list as well as the Hope box or survival kit the rationale is cognitive bias that when the suicide mode is activated the person becomes very focused on reasons for dying and they fail to remember their reasons for living so we want to help share that concept of cognitive bias with the patient and then you use that to launch a discussion about what are the reasons for living and we increase the emotional salience of those reasons for living by asking questions like tell me more about that or why is that person so important to you we might do a visualization exercise in which they imagine some of their reasons for living and then practice always keep a written list of your reasons for living we put it in the treatment log put a picture on your phone and review that list routinely and again not just in times of Crisis we want them doing it as a regular activity so we ask the patient what are your reasons for living what gives you a sense of purpose and meaning in your life what stands in the way of you killing yourself now if the patient says there are no reasons for living we might just ask again you know what gets in the way of suicide and we don't necessarily quibble over the terminology we can also use information from the narrative assessment to help identify at least some reasons for living so these are some examples Faith kids dogs want to make my mother proud make music even things like I love waking up in the morning and seeing snow in the mountains or patient said as dumb as it may seem there's a book I want to read that comes out in January okay whatever it is let's put it on the list we do the visualization exercise in which we Savor a positive memory connected to one of the reasons for living letting the patient tell their story using Socratic questioning integrating all five senses if we can and what we're really trying to do is increase the accessibility of these positive memories and as we do it we bring the patients attention to changes in their mood it could be mood ratings or it could be a behavioral observation like you smiled just then as you were thinking about that I'm going to skip the video here uh in the interest of time um but then we create a survival kit or sometimes called a hope box it is literally a white box we bought a whole bunch of plain white boxes and we put the patient's name on it and we give them the opportunity to decorate it however they like with stickers or glitter or paint or markers or things like that and we put things in the box that symbolize reasons for living now we review each item and say tell me more about this or why did you include to decide to include this item when you think of this item what happens to your emot emotions we identify a location for keeping this survival kit and we always want to make sure there's at least one thing in the box now it could just be a reasons for living list or whatever we often will print items out because in the hospital we don't have access to all the these items but we may print them out from the Internet or things that we've typed out and bring them to the next session so some common things are pictures from places that patient wants to go or pictures of family special events pets Etc quotes that they find inspirational doesn't really matter except we want to be very careful to vet these items to make sure that there is nothing iatrogenic in them so for example methods used to commit suicide uh to to die Su by Suicide would not be appropriate uh things that are triggering a picture for example of that boyfriend in a highly conflicted relationship might not be a good thing to put into the box in session three we do means restriction counseling and coping cards means restriction the rationale is that the transition from ideation to action can be very rapid indeed in fact 36% of people found that they went from thinking about suicide to acting on it in less than 5 minutes meaning we have to buy time and make sure that you don't have easy

### Segment 11 (50:00 - 55:00) [50:00]

access to lethal means during those 5 minutes or however long it is so we assess the patients access to lethal means and then collaboratively develop a plan to reduce their access sometimes that means discarding it or removing it from the home sometimes that means creating barriers sometimes it means um you know creating the crisis response plan or other cues that are located with means uh so we engage we raise the issue of suicide means ask them to share their thoughts we focus on it by introducing the topic of safety we evoke we ask open-ended questions to encourage further discussion about the patient's commitment to safety and then we plan we assist the patient in developing a concrete plan of action for temporarily limiting access to lethal means now Firearms a big deal in I think both of our countries mine especially you have to ask at least here every patient about their access to Firearms now in the case of veterans we find that often they will not agree to remove firearms from the home but consider alternatives we dismantle the firearm and give a give the firing pin for example to somebody else or store it in a tamperproof safe that is secured by somebody else store it unloaded and get the ammunition somewhere else use a cable lock just completely get the ammunition out of the house whatever it is so we might ask the patient what are your thoughts about firearm safety or maybe more to the point what do you think about somebody having access to Firearms when they're really upset and suicidal what might be some benefits of temporarily limiting your access to firearms and if we can't completely remove the firearm what are some other options the myths here myth number one is that it won't make a difference right obviously it it does I'm talking about this does in fact influence behavior myth number two this conversation is going to lead to a political argument um we're not here to debate somebody's politics and their gun rights so we consistently bring it back and frame this as a health issue that right now you're going through something that is impacting your judgement we need to help keep you safe myth number three which is my favorite is if somebody really wants to kill themselves they'll just find another way to do it the data actually say this isn't so um the Israeli Army did an interesting experiment in which uh they were noticing a high suicide rate among uh soldiers so they created a program in which soldiers had to check their weapons in over the weekend and the suicide rate plummeted when they had to do that it's not like they all went out and found some other means of killing themselves if you interrupt one means it can interrupt the entire thing we also identify other means are there other things that you've considered or used to kill yourself have you thought and I keep asking it have you thought about any other methods and you keep doing that until they say no so if the patient has medications in the home we figure out a plan for how we're going to either discard them or put them in a lock box or something like that if it's things like knives and rope well when possible we get rid of them but we sometimes you just have to get rid of their favorite knife or sometimes you just create barriers can you put them away somewhere where they're a little farther from you or could we place your reasons for living right next to it if it's the car like if the patient's going to drive off a bridge let's talk about your route to work how do you drive and why could we find another way that doesn't involve going over that bridge it is important to note that we don't insist on 100% restriction uh that's just a losing battle we want to preserve the patients's autonomy so you don't always for example want to have a family member in charge of the medication sometimes that's just humiliating and triggering we avoid getting into Power struggles over this we come back and emphasize our shared goals and if the patient's going nowhere on one of the arst discussions we say well why don't we come up with something different we also recognize that this effort is largely symbolic that is a patient could kill themselves if they were determined to but what we're trying to get them to do is demonstrate their commitment to living we're looking to get them to slow down the behavioral sequence at least long enough for them to start to become ambivalent about dying and we want to give them enough time to access alternative coping and

### Segment 12 (55:00 - 60:00) [55:00]

hope uh I'll skip that one and then we also create these coping cards and the coping cards is that we want to use a memory aid a concrete cue to use your skills so we go back to the suicide mode and the idea is you get these index cards and you write down the element of the suicide mode on one side and then you flip it over and you write a coping response and we have the patient rehearse this regularly so we have two different kinds of Co coping cards one is a cognitively oriented coping card in which side one is the suicidal or maladaptive belief and side two is an alternative perspective we prioritize this because if you if you're keeping track you may notice we have not done anything cognitive yet in the treatment this is the really the one place that we specifically address thoughts we also have behaviorally oriented coping cards in which there's a specific event or situation on one side and a list of concrete steps that the patient can take on the other side these are some examples you can see a couple of cognitive coping cards on the left and a couple of behavioral coping cards on the right we then do talk a little bit about system the suicidal belief system suggests that suicidal uh desire to die is driven essentially by three components of the Su of the of three components of pervasive hopelessness they are unlovability unsolvability and unbearability and these are the themes that we're looking for in those cognitive coping cards these are some examples unlovability thoughts are I'm a failure I'm damaged I'm weak I'm lost Etc unsolvability is I can't change it I'm helpless there's no future unbearability is I can't stand it I can't get through it and as we start to develop Alternatives we use common but very light uh cognitive therapy strategies like well let's talk about the evidence or what would you tell a friend who shared these thoughts or even simply what's another way to think about that maybe a more helpful way so what is something that you could tell yourself instead of people would be better off without me what evidence do you have against that thought and then finally our last session of the brief CBT is a review of all skills and the relapse prevention task and in we do an imaginal rehearsal of using skills twice once when thinking about the previous attempt so we're almost giving them a mental doover and second we anticipate a future suicidal crisis so the clinician script is uh for the review of all skills is I'd like to spend time today coming up with a plan for how these skills can help you to manage distress without hurting yourself after you leave the hospital first let's review then we write them on the white board we ask the patient to describe that skill and reflect on their experiences including things like the suicide mode the crisis response plan the reasons for living The Hope kit means restriction and coping cards and for each of those skills we develop a plan for how the patient is going to continue using those skills after discharge and we assess the patient's likelihood after discharge from 0 to 10 how like are you to keep using that skill the relapse prevention task is essentially based on the principle of covert rehearsal so we imagine ourselves compete coping with a suicidal crisis we do it twice one previous qu crisis and one that hasn't happened yet we encourage vivid imagery incorporating our senses although I will say it took a while maybe because we're fundamentally an anxiety and OCD program it took a while for our Ians to realize this is not imaginal exposure we're not seeking habituation or disconfirmatory uh experiences we're simply trying to use to get the patient to imagine rehe to imagely rehearse using these skills so we identify where to start be directively Orient the patient to the day of the attempt before beginning the task and identify what skill is going to be practiced we go back to the treatment log for that we talk about where to insert that skill again we don't want to do brinksmanship

### Segment 13 (60:00 - 65:00) [1:00:00]

we're not trying to get right up to the point of suicide and then start using skills early in the process we practice flexibility so we have the patient imagine it several times and imagine the seam guide them through the procedure with prompts to get a vivid picture in their mind so some sample prompts might be what is happening around you what does that sound like describe what it looks like where in your body do you feel that sensation Etc you know and those of us who are used to imaginal exposure are probably used to these kinds of questions but again this is not an exposure task it's a rehearsal task and then after we've done the imaginal rehearsal we consolidate by processing The Experience how was that what did you notice what was easy and difficult why did you choose to use the specific skill that you did what are some other ways you might have solved that problem and always highlight changes or shifts in the patient's emotions thoughts or behaviors as a result of implementing those skills in a minute I'm G to skip there so let me summarize and then I want to open it up for some questions and discussion brief cognitive behavior therapy is efficacious in reducing further suicide attempts among people who have attempted suicide and that's true at the outpatient level which is 12 sessions and it's true at the inpatient level which is only four sessions 4 and A2 hours of therapy to get a 60% reduction in suicide attempts it is based according you know based going back to David rud's essential components it's based on a simple empirically supported model and the major interventions that we use in BCB are the narrative review and case conceptualization the crisis response plan the reasons for living the survival kit or hope box coping cards means restriction counseling and then finally relapse prevention and with that I want to say thank you very much for inviting me and thank you for your time and I'm happy to have your discussion thank you so much David and very interesting presentation and also I think very helpful and instructive to see your videos how you actually do things here uh so we have a couple of questions I'm going to read them out loud from the Q&A and for those who are still on please uh feel free to write more questions so first uh first question is uh thank you for this Insight insightful webinar are there any data on psychiatric readmission rates in patients with comorbid borderline personality disorder or PTSD within the context of BC BT and its impact on suicidal behavior these are great questions um let me answer it a couple of ways not because I'm trying to be dodgy the first is um that we didn't have big enough numbers to do a full mediational analysis the way that we did with substance use disorders so anything that I say is going to be a little bit um tentative what I can say however is that we did not see much of an association between scores on measures of borderline symptoms or the PTSD diagnosis that is that we didn't see any real indication that made much of a difference in terms of the efficacy of well interaction of time by treatment so obviously people with PTSD people with borderline symptoms are always going to be at elevated risk but we saw no reason to believe that meant made them less receptive to the treatment that we had offer if that makes sense yeah makes sense so um one related question about the group that you have treated comes from Lisa Gan and she writes thank you for the great presentation and she wants to ask about an exclusion criteria since you mentioned that this was a representative sample but then one exclusion CR was lifetime schizophrenia or schizoaffective disorder and since the these are disorders with a high risk of suicide could you explain the rationale behind selecting this in exclusion criteria please absolutely yeah thank you for that question um we went around and around about this for a long time because we really did want to make this sample as representative as possible but ultimately we were forced to exclude some patients that were thought to have impaired capacity to provide informed consent so for example we also couldn't

### Segment 14 (65:00 - 70:00) [1:05:00]

include acutely manic we had patients with bipolar disorder but we could not bring in a patient who was acutely manic specifically because um they couldn't we were concerned that they wouldn't be able to provide informed consent so I think that still does remain an area uh to be explored is how does it work among those patients okay thank you but everything else you know substance use and even Psych by the way was allowed I mean we had lots of patients with psychotic symptoms you know major depression with psychotic features we had a few patients with delusional disorder it was really just the schizophrenia and schizoaffective disorder that we had to exclude and the accum so one question that I had reading uh about the um your study uh was the rate of um reattempt suicide re attempts uh I if I remember correctly you had 65% reattempts in six months or something like that does that sound familiar or that sounds Vaguely Familiar yeah I should have studied so and I in some other studies the the studied group had has a much lower reattempt rate so does that re reflect something about the group that you have in your hospital are there many people who are like you know continuously self Haring or something like that it made very well I mean I'll tell you about the Institute of living it is an urban hospital um in a relatively poor area of the city and that's largely the population that we serve we also had a number of patients who were uh unhoused we had a number so they were eligible for the treatment as well we also noticed that we had a lot a relatively High number of patients who were sexual and gender minority and they did seem to be at elevated risk of suicide as well um so again it didn't seem to matter um uh affect the degree to which the treatment was helpful for them but we do note that there were lots of red flags for elevated suicide risk across the population okay so questions are pouring in here Jennifer Stanley asks what are your thoughts on using this approach with children well I would love to see it studied um I mean I think we just don't know intuitively it's a relatively I I think that the treatment could be simplified enough that it could be applied to Children um but I think we just don't we simply don't know um whether it's going to be effective uh for children or not I will say we did a little bit of pilot testing of an app-based version of this treatment in on the Adolescent inpatient unit and it was more of a feasibility trial than an efficacy trial but certainly it seemed feasible among the children that we stud another question here is from feda she is interested about the ratio between wish to live and wish to die and if that's a predictor for suicide is that more long term or short-term risk what's an acceptable ratio I don't think we know that's a great question what the cut scores are just yet but we will be working on them we are going to be coming out with an article uh fairly soon that talks about the predictive validity of the ratio of wish to live wish to die um but in terms of the long-term versus short-term risk we just measured over six months so that's as much a time as we can speak to thank you and Johanna Moran asks H as did this treatment requires that you're hospitalized for at least four business days the question is um sometimes one find that it's better for the patient to be discharged as soon as possible to avoid instit sorry I can't pronounce the word but I think you know what word I'm after I think I get it yeah uh what do you think about this we have the same issue some patients are discharged in two days or three days what we would do is give them more than one session per day if we had to and in fact that happened a lot of the time so it wasn't one session per day okay yeah that that's good to know that it can be flexible um you have to be on an impatient unit because it's just it things move so fast uh Oscar fle got writes you briefly mentioned that the question about wish to live and wish to die were associated with risk of future suicide attempts well maybe this is let's see if this is

### Segment 15 (70:00 - 75:00) [1:10:00]

maybe overlaps with the last question could you elaborate on this and maybe speculate on why this is the cause well the why is always the toughest part um I think that what we're you're looking at is biased cognition right I mean when the suicide so I think when you look at wishes to live and wishes to die in part I think what that is it's a reflection of the degree to which the suicide MO mode is activated because the suicide mode like all schemas um biases information processing and it focuses the person on their reasons to die and it gets them to ignore or forget about their reasons to live um so what we found in short is that when there are a lot more reasons to live than there are to Die the person probably doesn't attempt suicide but on the other hand when the balance is tipped to the other side the risk is greatly elev ated over a six-month period and I think probably because their cognition is biased they you have a biased cognitive process so I think the this wish to live and we wish to die has raised a lot of interest here here's another question about it about is it really in the same Dimension or is there any advantage or disadvantage of having two scales it is two scales because we don't re we don't necessarily think that they are different po on one construct okay you could in fact have a high rate of you could have a high wish to live and a die or you could be low on both so it you really have to look at them as two separate constructs okay thank you so Frei yansan has read your paper very uh deeply here I can see from the question he asked your table too that treatment as usual included a lot of Psychosocial intervention for instance 6 % had CBT is that typical for inpatient settings in the US well I don't know if I could speak to what's typical for inpatient settings in the US but yes I think it's it's reasonable that most patients are receiving at least groups that involve some degree of therapeutic activity obviously most of them are receiving medication stabilization um and so on oh actually that reminds me I want to go back to the exclusion criteria as well because there was another really important exclusion Criterion that I wish we didn't have to have but we did which was that if the patient was going to receive trans uh ECT electric convulsive therapy we could not include them in the trial because there would be no retention of the material that we were using so we probably lost out on a certain percent of the sample by exclusive going to receive so there are some questions on what the treatment as usual was and what it did include did it also include crisis planning for instance it did yeah although we've just done some analysis showing that independent Raiders rated our crisis response plans as being better and more thorough than the crisis response plans that were used on the unit so yeah there is some of that I mean so it you know it's a standard Hospital and we didn't tamper with their interventions at all uh but we did try to improve on them uh yes he asks here interesting study in Sweden psychologists are rarely involved in patient care where the biological medical model predominantly prevails uh do these findings suggest that this might be problematic very that's a wonderful It's a Wonderful question I think very much I mean I think this suggests to us that adding a little psychology really helps um and I think most of us are aware that it's very hard to medicate away suicide uh that it's just not very responsive to medication including anti-depressant medication I mean you can medicate the person's depression and they still uh engage in suicidal behaviors so I don't think you can simply treat this as something to be medicated they do in fact need some therapy thank you so a couple of questions here about the followup after these BCB sessions the four sessions how were the follow-up sessions structured and what did they include the follow-up sessions over the six months were solely assessment so they were telephone and it was to redo the Su the Columbia suicide severity scale okay good so uh well if I may um ask the question myself here so I think one in your study you had very

### Segment 16 (75:00 - 80:00) [1:15:00]

strong effects I think it's fair to say right I you were probably a bit surprised yourself or I don't know wasn't surprised yeah so I think in in the literature uh it has been hard to find such strong effects and for instance for AIP which is tried at some Swedish clinics the Swiss uh protocol which has probably similar size in terms of therapeutic effort it has failed to replicate in the only replication study in Finland for instance so do you think that how do you see this very strong effect have you really struck gold here or what is the explanation well in some ways I think that our study was a replication I mean it was an extension at least of David Rudd's outpatient study essentially what we found is that when you bring it to an inpatient unit and distill it down to its core elements you get the exact same results but obviously we need a lot more replication and I'd love to see it tried in different hospitals and in different countries as well okay thank you car linsa if you'd like to do this please let me know yes uh let's see um so uh good psychiatric management GPM has become uh quite popular over here in Sweden at least in just in the recent years H and Anette antoanet lundal here writes that it reminds her of that probably the Simplicity of it is reminding her I'm guessing now H are there any studies comparing G GMP or sorry GPM and bcbt not that I'm aware of but I think that's an excellent idea I think we need to look at multiple comparison conditions and we need some horse races to determine what's the very best thing to do so hwan KMS uh asks did the patient with substant abuse in general have higher RIS reasons not to live than the patients with no substance abuse that's a good question you know what I don't know the answer to that I don't know if we looked at substance use as a moderator of uh wish to live wish to die that's now I want to go back and look at that but I'm not sure but remember the discrepant results with the suicidal uh with the substance using patients were not on suicidal behaviors that is when a suici when a substance using patient received BCB TI their suicide rate went down at the exact same rate that it went down for patients without a substance use disorder it's just that there was this main effect such that they were higher um so that everything was worse you know pre and post treatment uh in substance using patients so I don't know if that's because of which to live but you know what we saw is the discrepant result was in hospitalization rates which tells me I think if I if I'm thinking about this correctly that patients with substance use disorders are still being hospitalized at a high rate but not necessarily for suicide so we managed to get the suicidal Behavior out but we didn't affect the overall hospitalization rate so given how obvious to be honest it seems to do something like this I mean the we know that the rates of discharge are super high H and I mean the patients are already in the hospital so you don't have this problem that you lose people and that are hard to contact Etc why do you think there is uh I mean what do you see as the obstacles for any such me methods to be more W widely implemented I'll tell you a story um and I won't name the hospital but gret and debach and I gave I a daylong workshop to a a hospital here in the United States and the reaction that we got bordered on Revolt wow they were not by everybody I think most people were very appreciative but there were definitely a sizable minority in this audience who were angry that we were suggesting that they do anything different and they kept coming up with all kinds of reasons why this can't

### Segment 17 (80:00 - 82:00) [1:20:00]

possibly be done and we don't have a psychologist on the unit and we can't afford to give individual therapy sessions to these patients and so on so I think at least in my country there is a big resistance to change and I think there's allocating resources on the impatient unit even though I think the resource utilization is quite modest here four and a half hours of therapy um you know on an impatient unit that they treated that as if it was we were asking for the moon so I don't know I think that there's there's going to be some cultural and by cultural I don't mean like American culture I mean Hospital culture I think there are going to be some cultural issues that we have to address hospital by hospital to get wide uptake okay however that is sort of the next direction we want to go is dissemination and implementation you want to sort of see how well can we train people to use this protocol and and if we do train people in a different hospital system to use this protocol does it aieve the same effects well I hope um you you will U well achieve this goal it seems very important to me uh and I think that that was a good way of ending this uh seminar as well um so uh this is not and thank you very much for taking the time um uh this has been recorded So if someone wants to look at this later or recommend it to someone it's possible to do that the video will be up within a week I hope and this will not be our last kinska suicide seminar if you are on this call then you will automatically get an email about the next one so thank you everyone for attending and thank you very much Dr tolin for a wonderful presentation thank you very much for inviting me and thanks everybody for your great thank you