TABLE 1.

Cognitive Reappraisal Intervention for Suicide Prevention (CRISP): Main Stages and Techniques

Stage	Techniques
Identification of the “perfect storm”	Overview: After obtaining information from the patient, the therapist provides a realistic explanation of the path to suicidality (suicidal ideation or suicide attempt) that led to the current hospitalization. The goal is to help the patient understand the factors that may have contributed to increased suicidality (suicidal ideation or behavior). To understand the contributing factors, the CRISP therapist creates a path that describes the association of situations/triggers, emotions, and suicidal ideation or behavior. In addition, the therapist incorporates other risk and protective factors. The patient and the therapist work through each step of the path and identify areas and time points at which they could have intervened.
Identification of situations/triggers and negative emotions and thoughts	Overview: The therapist asks the patient to identify situations/triggers and negative emotions that preceded, are related or linked to recent and past incidents of suicidal ideation or suicide attempt. Triggers can be external or internal events, concerns, or problems. Even if the patient cannot identify a specific emotion, the therapist focuses on the emotional experience that is related to the trigger.
	Pertinent Questions and Suggestions When did you have suicidal thoughts or actions (e.g., wishes that you were dead or thoughts about hurting or killing yourself)? What was the situation/trigger that precipitated suicidal thoughts and actions? What were the emotions that were associated with this situation/trigger? Did you have any physical symptoms? Did you have these emotions and thoughts from the beginning of the day? Let’s walk through the last few days before your suicide attempt. This way we may better understand how situations, negative emotions and associated thoughts may have contributed to your suicide attempt.
Examination of the utility of negative emotions	Overview: The purpose of this stage is to understand the patient’s perspective on negative emotions and to explore the patient’s motivation to reduce these negative emotions. The examination starts by identifying the positive and negative aspects of these negative emotions.
	Pertinent Questions and Suggestions How much do negative emotions affect your everyday life? How much do they contribute to your thoughts of wishing you were dead or of harming or killing yourself? What do you gain or lose from having these feelings? How would it be helpful or not helpful if you reduce these negative emotions?
Reappraisal of an emotional trigger	Overview: The therapist systematically evaluates and helps the patient change perspective on the emotional trigger, for example, all aspects of the trigger, positive and negative perspectives of the trigger.
	Pertinent Questions and Suggestions What are all the aspects of the situation/problem/concern? What is a positive perspective of the situation/problem/concern? What is a negative perspective of the situation/problem/concern? Do you think that you perceive all aspects of the situation/problem/concern logically and accurately? Do the negative emotions make you see in a much more negative way? How? What is the worst part of the situation? What do you think can get better? What can’t get better?
Distancing (shifting away) from the emotional experience	Overview:“Distancing” is a cognitive reappraisal strategy which“involves changing one’s construal of an emotional event by increasing or decreasing one’s psychological distance from it”.30,39,42 To successfully apply this strategy, the therapist helps the patient perceive a situation or the emotional experience from an objective point of view.39,42
	Pertinent Questions and Suggestions Let’s see how other people close to you perceive this situation. Is there anyone’s perspective that you respect or even admire? What would that person think or say? How would he or she have perceived the situation? If your friend was facing similar situation, what would you say to him or her? Let’s describe the situation from an author’s perspective who is writing a book. Can you find a way to create distance from your emotions by shifting your attention away from the situation?
Reappraisal of the emotional response to the trigger	Overview: The therapist and the patient explore the patient’s emotional reaction to the situation. The therapist may identify ways to change the patient’s perspective to reduce the patient’s negative emotional response.
	Pertinent Questions and Suggestions Fully describe your negative emotions. How strong are the negative feelings? Is the intensity of the negative emotions high? How high on a scale of 1–10, 10 is the worse? Is the emotional response proportionate to the situation? ◦ If the intensity of your negative feelings is proportionate to the situation you are facing, what can you do to reduce your feelings and improve the situation? What could be alternative ways to react? ◦ If the intensity of your negative feelings is not proportionate to the situation, what can we say to reduce the intensity of these feelings? ◦ If your negative feelings are not proportionate to the situation, how much can you trust your feelings to guide you? How much do you believe that the feelings will lead you to the right decision or direction? What part of your emotional response may be stronger than expected by you or others? Are the negative emotions stronger than what the situation calls for? How might other people that you respect react to the situation? Let’s examine the emotional response from their point of view. What can we learn from this? How might these peoples’ reaction guide us to react to the situation? How have you tried to reduce your negative feelings? Which ways were successful? Which were unsuccessful?

Notes: The stages of treatment do not need to be followed sequentially, even though some of the stages appear to precipitate others. For example, it makes sense to evaluate the utility of negative emotions before you devise a plan with techniques to reduce them. Nevertheless, the therapist and the patient will work collaboratively to apply the stages necessary to reduce the negative emotions and their impact.