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Book Review-Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications

As effective treatments go, cognitive behavioral therapy (CBT) is the big hitter.  Several people have applied it to suicide prevention; Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications discusses the opportunities for its application to suicide prevention directly.

Lies, Damn Lies, and Statistics

There is a seemingly endless supply of things that have been correlated to suicide.  Some of them are clearly not changeable, such as age.  Ethnicity is similarly unchangeable but correlated in various positive and negative ways with suicide.  Previous attempts are a persistent favorite predictor of suicide.  These are powerful predictors but also unchangeable.

More concerning are the statistical relationships that people don’t process correctly.  There’s a positive, non-trivial, correlation between suicide and depression.  Similarly, there’s one for alcohol consumption and any kind of substance use disorder.  (See Recovery to better understand substance use disorder.)  While you can predict that someone is at higher risk, it’s not possible to say that someone will die by suicide because of these factors.  (See Rethinking Suicide for more on application of statistics to individual cases.)  Just because someone drinks – or is even an alcoholic – doesn’t mean they’ll die by suicide.  The actual incidence rate is low.  Not everyone who dies has depression – or a diagnosable mental illness.  Some do, but some do not.

It’s important as we work with others to recognize that we need to be appropriately cognizant of risk factors and their potential to impact someone while at the same time recognizing that a statistical correlation – particularly at the low levels we’re talking about – aren’t predictive of an outcome for an individual.

Equally important is to remember that correlation is not causation.  The work to identify causation is substantially harder and rarely done.  We first identify there is a relationship and later we need to do the hard work of understanding that relationship.  (For more on correlation vs. causation, see Redirect.)

Put Out the Fire


A strange predictor of suicide – that we’ve got everyday evidence to support – is perfectionism.  The Paradox of Choice might call it maximization.  In other words, everything must be the best – including people themselves.  Anders Ericsson and Robert Pool in Peak talk about people who are at the pinnacle of their chosen profession, top performers and athletes, and how they do purposeful practice to get better.  However, for the most part, none of them believe they’re perfect.  Josh Waitzken in The Art of Learning shares times when his performance in chess was negatively impacted by his emotions and need for perfection.

The tragedy we all know too well involves the artists, performers, CEOs, and leaders who die by suicide – despite having what others would describe as idyllic lives.  The same thing that drives them forward and allows them to reach the top – or near top – of their worlds is the thing that robs them of the joy of achieving it.  They can’t be happy with their lives, because they’re always striving for more – and in the meantime judging themselves as unworthy.

Suicide occurs at the bottom of the socioeconomic status (SES) and at the top.  It’s just like Adam Grant explains in Give and Take: givers are both at the bottom and the top, and takers are in the middle.  We’ve got to be just as cautious about people who seem to have it all as those who seem to have nothing.

Is Suicide Preplanned?

One of the challenges in the suicide space is the ongoing discussion about the degree to which suicide is preplanned.  This has implications for whether we can predict a suicidal attempt or, said differently, detect that someone is at eminent risk for a suicide attempt.  If suicides are planned, then it’s possible.  If they’re unplanned, it’s likely we can’t detect them.

In Myths About Suicide, Thomas Joiner explains it’s a myth that we can tell if someone is suicidal based on their appearance.  Many studies seem to indicate that suicide attempt survivors didn’t seriously consider or plan for their suicide more than a few hours before the event – all the way down to 10 minutes before the event.  Some suicidologists divided suicidal patients into those who have pervasive hopelessness and an intent to die – and a separate grouping including people who have difficulties regulating their affect (feelings) and impulsively attempt suicide.

The deeper we go into the rabbit hole, the more confusing things get.  Some studies show no correlation between impulsivity and suicide, while others – particularly those in adolescents – find that there is a significant correlation.

It’s my own perspective that impulsivity in the research is often treated inconsistently between researchers and, more importantly, is treated as a constant across areas of one’s life.  However, we know that behavior isn’t consistent within different areas of our life or in different circumstances.  Kurt Lewin defined behavior as an opaque function of person and environment – thereby indicating that there is no way to fully disambiguate causes by either.  (See A Dynamic Theory of Personality for more.)  We can be entirely impulsive in the way we operate with our hobbies and be quite reserved about the way that we work with our investments.

Thomas Joiner’s Interpersonal Theory of Suicide (ITS) and most other models make it clear that it’s not one factor.  (See Why People Die By Suicide for more on ITS.)  It is equally likely that there’s an activation component that triggers impulsive people to act.  The fluid vulnerability theory of suicide separates baseline conditions from acute conditions.  Perhaps it’s an acute trigger that is needed to activate impulsive suicidal behaviors that are sufficiently rare that they’re not observed in every study.  (See Brief Cognitive-Behavioral Therapy for Suicide Prevention for more.)

When I discuss this with others, I use Phillip Tetlock’s 50/50 chance of planning to mean that I don’t know.  (See Superforecasting for more.)  It’s relatively clear to me that not all suicides are planned – and that some are.  Getting to a societally accurate percentage of which is which doesn’t seem to help us prevent suicides.

Hopelessness Time

One of the key challenges that we face with suicide prevention is the feeling of hopelessness.  That is, we believe things are never going to get better – they may stay the same or they may be getting worse.  Phillip Zimbardo in The Time Paradox explains that people view time differently.  They can view the past positively or negatively, they may focus on a hedonistic today, or a fatalistic point of view about their present circumstances – that they can’t do anything about it, it’s been preordained.  Finally, there are future-focused folks who are willing to accept short-term sacrifice for a better future.  These future-focused people could be considered the opposite of impulsive.

Combatting hopelessness requires two components.  The first is that change is possible – if not probable or certain.  Generally, combatting this is relatively easy, as we’ve all seen things change in our lifetime that we never expected to see change.  The second component is more challenging – that is that things are going to get better.

In some cases, people literally can’t imagine a happy thought.  They can’t imagine a positive future.  The starting point there is for them to remember a positive time in the past – and then project similar situations into the future.  Our ability to project ourselves mentally into the future and to imagine is one of our superpowers as humans.

The problem comes when someone remembers the positive event and decides that that positive event can never happen in the future – and they can’t identify other past positive events that they could project into the future.  Suddenly, they believe that things will change – for the worse.

The Psychology of Hope

In The Psychology of Hope, Rick Snyder explains that hope isn’t an emotion, it’s a cognitive process consisting of willpower and waypower.  Waypower is an understanding of how it will get better – either through steps we’ll take or external intervention.  Willpower, as Roy Baumeister explains in the book with the same name, is an exhaustible resource.  We often think of willpower as our agency (ability to get things done) or grit.  (For more on grit, see Grit.)

If we want to create hope, we should consider both the source of agency (internal or external) and how positive changes will come to be.  When someone goes to college at night, they’re creating hope in a better future through their willpower and the knowledge (waypower) that learning improves long-term success metrics.

Problem Solving

Problem solving deficits are strongly correlated to hopelessness.  Given Snyder’s explanation, it’s easy to see how an inability to solve problems results in a failure to identify the path forward (waypower).  One of the things that CBT does is to help make people aware that there are solutions to the challenges they face, whether they’re anxiety, depression, or suicidal ideation.

The problem with problem solving is multifaceted.  We know that many people facing suicide experience cognitive constriction.  They literally don’t see other options.  This isn’t surprising given the research reported in Drive, where, when stressed, people performed more poorly on simple tasks.  What Drive doesn’t say directly is that the degree of stress applied to make performance lower was almost trivial – we can expect that the greater the stress, the less likely it is that we’ll consider other options – thus cognitive constriction.  In Creative Confidence, Tom and David Kelley explain that we all have the capacity to be creative and to come up with creative options when we’re children.  But for some, our lives make us hesitant to use these “wild” options.  In training for problem solving, the first step may be to restore the missing confidence and sense of self-efficacy that those who have suicidal ideation may have lost.

There are options for rational decision making, like those shared in the book, Decision Making.  However, we know that humans don’t make rational decisions.  We make emotional decisions that we rationalize.  So, teaching direct problem-solving techniques hasn’t shown great promise in reducing suicide.  Instead, the awareness of Gary Klein’s recognition-primed decisions (RPD) as shared in Sources of Power leads us toward creating experiences that allow learning.  RPD is where solutions seem to emerge from nowhere, because the decision makers have internalized their experiences to develop a rough model of how things work, and they use that model to simulate possible solutions.

Dave Snowden’s work on Cynefin challenges the idea that all problems have clean, consistent, and repeatable solutions in the same way that Horst Rittel described wicked problems.  Some of the life challenges that people need to address are chaotic.  As a result, while we can acknowledge that there are problem-solving deficits, it may not be as simple as teaching a few simple skills.

Stigma and Mystique

The problem may lie deeper in the idea that there’s a stigma (stereotype) against mental health care.  While we don’t blame the patient if they develop cancer, we will tell someone in depression that it’s their fault.  We’ve failed to appreciate that people aren’t bad, broken, or wrong if they’re struggling with their mental health.  They’re in need of help and support.

There’s also a certain mystique associated with mental health.  The lack of the key indicators that we have for many health conditions today has led us to be skeptical about whether someone is really in need of help or if they’re faking.  We still hear sometimes that suicide attempts are really cries for help, and they won’t really kill themselves.  We know this is wrong.  However, it doesn’t stop it from being the perspective of many.

We need to continue to push back on the stigma and demystify mental health issues.  One way of doing this is for everyone to have a mental health safety plan that identifies warning signs for when they’re transitioning to struggles.  It should contain the coping skills that the person has for returning to health.  It should also contain the relational resources, whether friend or family, they can tap when they’re struggling.  It should contain the reminder of the reasons for living – what brings them joy – and how to get professional help should that be necessary.


We’re trying to give people the capacity to escape the spirals that sometimes consume them.  In Capture, we learned how people can become excessively focused on something to the point that it’s consuming and can be difficult to see other options or things – that cognitive constriction that we discussed earlier.  The difficult bit is creating skills that make it easier – or possible – to escape these loops before it’s too late.  Some of those are the early warning signs that we discussed in the idea of the safety plan.

The greater degree that we’re clear about the signs we should be looking for, the greater likelihood it is that we’ll be able to recognize we’re in a downward spiral and break free of it.  Something as simple as helping people recognize warning signs may be enough to help them break free.

Immunity to Change

As explained in Immunity to Change, sometimes people’s espoused beliefs (what they say they want) are different from their beliefs in action (what they’re really doing).  When working to shift people’s way of processing their world to allow them to see the world they live in differently, we find that there is a hidden resistance that we can’t explain.

To break through these barriers, we need to explore what it is about the current systems of behaviors that are supporting, nourishing, or reassuring in ways that require trust to step away from.  How do we help people see that they can create a different world successfully?

The Worst, Best, and Realistic Case Scenario Game

Most of us have played the worst case scenario game at some point.  Few of us have played the best case scenario game, the realistic case scenario game, and the worst case scenario game at the same time.  We’ll go down the negative rabbit hole and enter a spiral instead of trying to evaluate worst, best, and most realistic cases side-by-side.  This approach allows us to calibrate our probabilities between the multiple cases and limits our drift towards the negative.

We can, through shifting our thinking about the world, realize that it’s not so bad, so permanent, and hopeless.  We can begin to see that suicide isn’t the option, maybe through Cognitive Therapy for Suicidal Patients.

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