Integrating Crisis Response Planning for Suicide Prevention into Trauma-Focused Treatments: A Military Case Example

Abstract

Objective:

Posttraumatic stress disorder (PTSD) and suicidal thoughts and behaviors are common in military members and veterans and produce anxiety for many clinicians. Although there are separate interventions for PTSD and elevated suicide risk, there is not much guidance on how to integrate these approaches. Crisis response planning (CRP) is an evidenced-based tool used to prevent suicide attempts that can easily be integrated into trauma-focused therapies for patients with PTSD.

Method:

Given the high frequency of suicidal thoughts among patients with PTSD, the current paper discusses how the CRP can be integrated into trauma-focused therapy. A clinical case example is provided to demonstrate how the CRP can be integrated into cognitive processing therapy for a suicidal veteran diagnosed with PTSD.

Results:

Using CRP within a CPT treatment program reduced both PTSD and suicidal ideation.

Conclusions:

Suicide specific treatments can be integrated effectively into trauma-focused treatments.

Introduction

Military personnel and veterans have high rates of posttraumatic stress disorder (PTSD) and suicidal thoughts and behaviors (Institute of Medicine, 2013, Tanielian & Jaycox, 2008). Among veterans, PTSD is one of the most frequently diagnosed mental health conditions. In addition, suicide rates in this population continue to rise, growing 20% faster than the U.S. general population (VA Suicide Prevention Program, 2016). Research has shown that PTSD and trauma exposure are risk factors for suicidal behaviors (May & Klonsky, 2016). Although there are high rates of PTSD and suicidal thoughts and behaviors in veterans, targeting both at the same time in treatment is not typically done.

Historically, treatment guidelines have recommended against the use of trauma-focused therapies with patients who are high-risk for suicide (e.g., Department of Veterans Affairs and Department of Defense, 2010; Forbes et al., 2008). The combination of suicidal thoughts and behavior with a diagnosis of PTSD is often a source of anxiety for clinicians, owing to limited resources outlining how to best treat these individuals. In fact, individuals at high-risk for suicidal behaviors are often referred to other treatments focused on depression to reduce the risk for suicidality. Although these treatments may provide some symptom relief, the additional course of therapy prior to starting trauma-specific treatments can double the patient’s length of treatment, increasing the likelihood of dropout. Newer thinking about the safety of trauma-focused therapies for suicidal patients has therefore emerged, particularly when empirically-supported treatments for PTSD and suicide have overlapping theoretical mechanisms (Bryan & Rozek, 2017).

Cognitive Processing Therapy (CPT)

Research has shown that cognitive processing therapy (CPT) for PTSD is efficacious in reducing PTSD related symptoms, has long lasting results of over five years, and has the largest effect size of any PTSD specific treatment (for review, see Resick, Monson, & Chard, 2017). Recent research examining CPT has shown a reduction in suicidal ideation as well as PTSD symptoms. Given these strengths, the VA/DOD as well as other institutions have recommended CPT as a first line-treatment for PTSD.

CPT is a 12-session manualized cognitive behavioral based treatment for PTSD. CPT, based on the social cognitive theory of PTSD, focuses on how thoughts, behaviors, feelings, and physiology are interconnected. Traumatic experiences disrupt and change preexisting beliefs and these new beliefs are often inaccurate, unrealistic, and linked to the patient’s negative emotions and symptoms. The therapist and patient work together to identify cognitive “stuck points” or negative distorted cognitions about the self, others, world, and future. After identifying stuck points, patients learn specific skills to challenge the negative thoughts in order to develop more accurate and realistic thoughts through cognitive restructuring.

The first component of CPT is psychoeducation about trauma, PTSD, and its associated symptoms (e.g., avoidance). During this early stage, the therapist and patient work together as a team to understand the individual’s PTSD presentation. Additionally, the therapist orients the patient to the background theory of CPT, the structure of CPT, and the goal of providing the patient with tools to use in the future. The second component of CPT is to provide a step-wise approach to learning how to reappraise the patient’s “stuck points.” In this stage, the therapist teaches the patient how to identify negative thoughts and how they are linked to emotions, then skills focused on how to challenge stuck points are introduced with an end goal of generating more balanced beliefs. In the last component of treatment, CPT focuses on stuck points related to five specific themes that are common among trauma survivors: safety, trust, power and control, esteem, and intimacy. Throughout treatment the patient gradually takes the lead with respect to skill use while the therapist acts as more of a consultant to help hone these skills. At the end of this process, patients have developed a skillset to challenge negative thoughts both about the trauma and other stressors that occur in everyday life.

Crisis Response Planning

The Crisis Response Plan (CRP), similar to a safety plan, was developed as a procedure to help suicidal patients manage acute suicidal crises (Bryan et al., 2017a; Rudd, Mandrusiak, & Joiner, 2006). The CRP, typically written on an index card, is a personalized problem-solving tool that serves as a plan to help an individual manage a crisis. The first component of the CRP is to engage the patient in a narrative assessment of his or her most recent suicidal crisis by inviting the patient to “tell the story” of the crisis. Through this process, the therapist and patient start to identify the patient’s warning signs and strengths. This narrative approach has been shown to help regulate the patient and provides the therapist with an understanding of the presentation style of an acute crisis for the patient (Bryan et al., 2018). Upon completing the assessment, the therapist and patient collaboratively develop the CRP. The CRP includes several categories (see Table 1), including identifying personal warning signs of an emerging crisis, self-management and coping skills that can be used across a variety of crises, reasons for living, social support and contact information, and professional services including how to contact healthcare providers and crisis services (e.g., 911, an emergency department).

Table 1:

Components of the Crisis Response Plan and their descriptions

Component	Description
Narrative assessment	Chronological “story” of the suicidal crisis. Assessing for warning signs (e.g., thoughts feelings, physiology, behaviors), coping strategies, social support, and lethality. Typically done for first, worst/most lethal, and last suicidal crisis.
Warning signs	Indicators that a crisis may be starting and that the plan should be used. Warning signs can be behaviors, thoughts, emotions, or physical sensations and should be specific to a potential crisis.
Self-management	Helpful strategies that can be used to reduce stress. Should vary and be useful across situations.
Reasons for living	Reason for living; sense of purpose in life.
Social support	Someone who can be contacted to help reduce stress. May be family member, friend, coworker. Do not have to disclose to this person about the crisis.
Healthcare professionals	Contact information for psychologist/therapists, other medical providers, and other professional sources of help.
Crisis services	Crisis hotlines, emergency response, and/or presenting to an emergency department.

Research has shown that the CRP, used as a one-time intervention, reduces suicidal behavior by 76%, reduces suicidal ideation, decreases the number of psychiatric inpatient days, and increases optimism as compared to treatment as usual (TAU; Bryan et al, 2017a, Bryan et al., 2017b, Rozek et al., 2018). Additionally, the CRP has been integrated into treatment protocols including brief cognitive behavioral therapy for suicide prevention (BCBT), which has been shown to reduce suicide attempts by 60% compared to TAU (Bryan & Rudd, 2018; Rudd et al., 2015). Integrating empirically-supported strategies specific for suicide risk within CPT enables the therapist to provide the best care for high-risk suicidal patients diagnosed with PTSD.

It is important to note that poorly constructed and used safety plans do not reduce suicidal behavior (Green, Kearns, Rosen, Keane, & Marx, 2017). Therefore, therapists seeking to integrate the CRP into their treatment plans should be mindful of fidelity. BCBT provides a framework for this integration. After creating the CRP during the first session of BCBT, the CRP is reviewed and discussed at the beginning of all subsequent sessions. During this review, the therapist checks in with the patient to determine if the CRP was used and, if so, how it worked. As the patient describes successes and learns new strategies to solve life problems, the therapist works with the patient to update and modify the plan, thereby increasing its effectiveness. If the patient did not use the plan, however, the therapist troubleshoots why the plan was not used and, if there were barriers to using it, helps the patient to modify the plan accordingly. The framework used in BCBT could be used in a similar fashion within trauma-focused therapies. In CPT, for example, therapists can reserve time at the beginning of each session during homework review to check-in on the patient’s use of the CRP and modify as needed.

The case example below will 1) illustrate how a CRP can be integrated into CPT; 2) demonstrate that the addition of a CRP does not reduce fidelity to the CPT protocol; and 3) provide practical guidance for clinicians who treat high-risk suicidal individuals with PTSD.

Case Illustration

Presenting Problem & Client Description

“Winston” is a single male Caucasian veteran of the US Army in in his forties who was referred for PTSD treatment. Winston had a history of combat trauma during several deployments to the Middle East. Prior to his combat trauma, he reported being a “happy normal guy.” At the start of treatment, he was not working and had no children. After retiring from the Army, he worked as an emergency medical technician, but due to anger outbursts with coworkers and his boss, he was no longer working. Winston met full criteria for PTSD based on the Clinician Administered PTSD Scale for DSM-5 (CAPS-5, Weathers et al., 2013). He had previously been in treatment for depression and elevated suicide risk. During the course of this treatment, his mental health provider noted he had ongoing suicidal ideation with a plan. Winston also reported a history of four previous suicide attempts with varying levels of lethality (i.e., overdosing on pills, suffocating himself, cutting, firearms). Winston’s presenting concerns were anger outbursts, suicidal thoughts, and hypervigilance. He felt his previous treatment was not helping as much as he had hoped and was worried that he would never have a “normal” life.

Winston had a supportive family including his parents and three brothers. He noted that although he had become distant from his family because he felt like a burden, they continued to be supportive. He had been married twice and was currently single. Winston described these relationships as unhealthy and blamed himself for the ending of both relationships due to being angry and withdrawing from his partners. Winston has one close friend and several friends he was close to in the past, but at the outset of treatment he had become isolated from most of his social network. His strengths included his religious beliefs, supportive family, and seeking treatment.

Case Formulation

This case was conceptualized from a cognitive and behavioral framework. Winston’s combat related trauma significantly changed his view of himself, the world, and the future. He noted several negative thoughts during his intake including “I’m a burden”, “I’m worthless”, and “I’m a failure”. These negative cognitions were related to his strong feelings of guilt, shame, and anger. His avoidance of family and friends was also related to these negative thoughts; the negative thoughts, in return, reinforced further avoidance. These negative cognitions spiraled around each other, such that Winston saw suicide as the only solution to ending these mutually reinforcing thoughts and emotions. These thoughts and beliefs were further reinforced by his suicide attempts; after each of his suicide attempts, Winston reported feeling guilty and perceived himself as “a coward” for attempting suicide.

As noted earlier, Winston’s prior treatment had not helped him as much as he had hoped, which reinforced his negative thoughts about himself. As a result, he felt “stuck.” Due to his lack of progress in depression-oriented therapy, his previous provider referred him to a specialty PTSD clinic for trauma-focused therapy. Winston was cognitively rigid upon entering treatment and was unable to identify alternative thoughts. He also had difficulties with regulating his emotions and would often have bursts of anger. He reported having “no skills” that would help him manage stressful situation, adding that all of his previous coping strategies were no longer effective. Because of this, in order to avoid anger outbursts, Winston further isolated himself. This only made things worse, and reinforced his negative self-perception. He reported that he felt at his lowest point in life and that his suicidal ideation was becoming more frequent and intense. He did not, however, want to die by suicide and was hopeful that he could get better. Given his diagnosis of PTSD and his readily available negative cognitions, Winston and his therapist chose CPT for his treatment. Due to his high-risk and history of suicidal behaviors, however, Winston and his therapist agreed to incorporate the CRP into the treatment and to directly challenge suicide related cognitions in addition to trauma-related stuck points during the course of CPT. The therapist conducting Winston’s intake therefore conducted a narrative assessment of Winston’s most recent suicide attempt, which had occurred approximately three months prior, and helped him to create a personalized CRP (for CRP from end of treatment see Figure 1).

Figure 1:

Winston’s end of treatment Crisis Response Plan

Course of Treatment

An outline of topics for each CPT session are summarized below with a description of how the CRP was integrated into treatment. Winston had already completed a CAPS-5 interview and the creation of a CRP. A review of the CRP is discussed in the first session of CPT. Throughout the course of treatment, symptom progress monitoring was used, a procedure with considerable empirical support (APA Presidential Task Force on Evidence-Based Practice, 2006; Lambert et al., 2003). Session by session PTSD symptoms were monitored and routinely discussed during treatment. Suicidal thoughts and behaviors were also assessed in session and more formally with a self-report measure, the Suicide Cognition Scale (SCS; Bryan et al., 2014), both pre- and post-treatment.

Session 1: CRP Review and Introduction to CPT

Following the intake, Winston attended his first session of CPT with an assigned therapist at the treatment center. At the beginning of the session, his CRP (Figure 1) was reviewed with the new therapist along with a review of his narrative assessment. Winston initially provided only barebones details about his suicide attempt: waking up, having a fight with his brother, feeling “overwhelmed,” and taking a handful of sleeping pills. The therapist encouraged Winston to provide more details, but he was reluctant to do so for fear of being hospitalized. The therapist engaged Winston in a discussion about when hospitalization would be warranted and provided psychoeducation on how they would collaboratively make decisions on when hospitalization would be indicated. This was done to help reduce the patient’s anxiety related to being hospitalized.

The therapist also provided the rationale for wanting more details about the suicide attempt: to better understand Winston’s experience and to better help him achieve his treatment goals. After this conversation, Winston discussed the circumstances leading up to his recent suicide attempt in more detail. Initially, the crisis seemed to Winston to come on fast. However, with the added detail, Winston revealed that over seven hours had passed between the fight with his brother and his suicide attempt. During these hours, Winston had tried several strategies to cope with the situation including watching TV, exercising, and calling his parents. He noted that these strategies helped to distract him. The therapist therefore asked if Winston thought that these self-management strategies should be added to the CRP; Winston agreed. He also agreed to using the CRP if a new crisis were to occur before the next session.

Following this initial review of the CRP, the first session of CPT was conducted as described in the CPT manual, which includes psychoeducation about PTSD symptoms, an explanation of the cognitive model related to the development and maintenance of PTSD, and the rationale for treatment. The therapist also described how CPT focuses on challenging negative beliefs or “stuck points” that maintain PTSD. Winston provided a brief description of his combat trauma and was assigned homework to write an impact statement focused on how his combat trauma had impacted his thoughts and beliefs. Additionally, he was instructed to use his CRP as needed.

Session 2: Meaning of the Event

At the beginning of this session, the therapist added a review of the CRP as the first task on the agenda, and then talked with Winston about how agenda-setting and CRP review would be a standard part of each session. When reviewing the CRP, the therapist asked if Winston had used the CRP and how it went, and explained that they would work together to revise and improve the CRP as treatment progressed to make it more personalized and effective. Winston reported that he had used the CRP when he became distressed writing the impact statement. He noticed only a few minor warning signs of negative thoughts (i.e., “I’m worthless”) and that he was able to use one of his coping strategies (i.e., taking a walk around the block with his dog) to reduce the intensity of his thoughts. He voiced surprise at how easy the index card was to use when he kept it with him.

After the CRP review, the therapist continued with the standard CPT session elements. Winston read his impact statement out loud and described how his thoughts and beliefs became more negative and skewed after his combat trauma. Specifically, he noted themes of burdensomeness, worthlessness, and being a “coward.” He also discussed themes of blame related to how he “should have done more” to save his fellow service members during an attack. Winston’s impact statement was full of negative cognitions that fueled the thought that he should not be alive and deserved to die. Although his impact statement focused on trauma, the exercise also revealed several examples of how avoidance, notably his tendency to isolate and his unemployment, served as strong evidence to him that his life was worthless and he was a burden to others. The relationships among these thoughts, feelings, and behaviors were reviewed, using Winston’s suicidal thoughts to illustrate the cognitive model and to demonstrate how the A-B-C worksheets could be used to understand these processes. Winston agreed to do these worksheets as homework for his next session. Two specific worksheets were assigned, one related to his trauma and one related to his suicidal thoughts.

Session 3: Identifying and Connecting Thoughts and Feelings

The third session started with a review of the CRP. Winston had not used his CRP since the prior session and noted that he did not always keep his plan with him. To troubleshoot this, he and the therapist discussed taking a photograph of the CRP on his phone so he would have a copy readily available at all times. Additionally, Winston noted it might be helpful to have a copy of the CRP in his office because he often retreated to this location when stressed. Following this discussion, Winston reviewed his A-B-C worksheets related to the trauma and his suicidal thoughts. The goal of this homework was to further highlight the connection among thoughts, feelings, behaviors, and physiological responses and to identify additional stuck points. Winston noted that the A-B-C worksheets were helpful in organizing stressful events and also helped him to identify his negative thoughts. Given the usefulness of the A-B-C worksheets, the therapist asked if the worksheet might be a useful coping strategy to add to the CRP; Winston agreed and added the strategy to his index card. The homework assignment for the next session was to continue doing A-B-C worksheets and to use the CRP as needed. Additionally, Winston agreed to make a handwritten copy of the CRP for his office.

Session 4: Identifying and Connecting Thoughts and Feelings Part 2

Winston came to the fourth session ready to review his CRP. He had copied the CRP onto another index card for his office and placed it in a visible spot. He also reported that he had identified a new self-management strategy during his homework. While working on an A-B-C worksheet he reported feeling a lot of anger so he tried doing yoga, an exercise he used to do frequently, but had not done in several years. He found that doing a yoga workout led to a significant decrease in anger. Because of its usefulness, he had already added this strategy to his CRP. The A-B-C worksheets were reviewed about the trauma and suicidal behavior, and Winston was able to make the connections between his thoughts and feelings. He also showed an initial ability to reappraise his negative thoughts, although he still believed they were true. To challenge these stuck points further, the therapist introduced the Challenging Questions Worksheet and the stuck point “I should have done more to save him” was used as an example. Winston found it difficult to answer the questions in a balanced manner; the therapist assured him that this was common when learning a new skill. In addition to a trauma-focused stuck point, the therapist and Winston agreed that he would complete a worksheet focused on the suicide-related stuck point, “I’m always hurting my family and would be better off dead,” and would review this stuck point during the next session as a part of homework review. Winston agreed to doing Challenging Questions Worksheets and continuing to use his CRP as homework.

Session 5: Challenging Questions for Stuck Points

Winston came to the fifth session more agitated than normal. He noted that he had been experiencing more intense thoughts of suicide and that he was finding the challenging questions difficult. He noted that his suicidal thoughts were not related to the homework, but rather were related to a verbal argument with his oldest brother that caused him to spiral down. The therapist and Winston therefore reviewed the CRP first. Winston reported that he used his self-management skills, one of which was to visit an online forum for military peer support. When he did this, however, he found himself becoming angrier because of the content of some of the posts. Winston and the therapist decided that this strategy might not be useful to have on his plan, as there were times that the forum served as a source of stress rather than support.

Winston next described using other self-management strategies, thinking about his reasons for living, and using the social support section of his CRP after leaving the forum. Winston’s oldest brother was on the CRP as a source of social support, but given their recent argument he had skipped this step. The therapist reinforced and supported Winston for his adaptability and ability to make this real-time modification to the CRP. Winston agreed to update his CRP in his office with these minor changes.

The Challenging Questions Worksheets were reviewed from homework, including one about the trauma and one related to suicidal thoughts. Winston had some difficulty with these worksheets so the therapist helped to clarify what the questions were about and to support the cognitive restructuring process. Winston found that the most difficult worksheets involved stuck points related to being a burden to other people. He was very rigid in this regard, and, even though he had identified evidence against this thought, he became noticeably withdrawn during the session. The therapist therefore directly addressed this issue. Winston was eventually able to counter his burden-related stuck point to be more balanced (“I’m not always a burden”), although he still noted that many times he believed this to be true. The therapist asked if sometimes feeling like a burden was different from always feeling like a burden; Winston agreed. In contrast to his difficulties with suicide-related cognitions, Winston was able to more easily challenge his self-blame stuck points related to his trauma. He noted the Challenging Questions were difficult, so he needed more practice. The session concluded with introducing the Patterns of Problematic Thinking worksheet. Examples from the session were used to demonstrate these patterns. This worksheet and CRP use was assigned as homework for the next session.

Session 6: Patterns of Problematic Thinking

At the start of the sixth session, Winston reviewed his CRP and noted that he replaced the A-B-C worksheet with the Challenging Questions Worksheet under his self-management strategies. He noted that the CRP was helpful when he had thoughts related to being a burden or ending his life, and reported that his suicidal thoughts were less intense than before. The Patterns of Problematic Thinking worksheets were next reviewed. Winston said he did not find this worksheet as helpful as the previous worksheets, but he would still try to use it to help him identify when his thinking was becoming progressively more negative, which could serve as a warning sign. He was able to identify which patterns of problematic thinking were most common for him—mind reading and jumping to conclusions—and decided to add these to his CRP under as warning signs. The Challenging Belief Worksheet (CBW) was then introduced and an example stuck point related to suicide (“I don’t deserve to live”) was introduced. Winston was able to successfully challenge and reframe this belief and expressed hope that he would be able to better do this in the moment with continued practice. CBWs were therefore assigned with one focused on self-blame related to the trauma and one related to suicidal thoughts.

Session 7: Challenging Beliefs and Introduction to Modules

Winston came to the seventh session highly distressed, explaining that he had another fight with his brother that ended in a physical altercation. He reported his CRP did not work and he felt out of control. When asked to talk more about how he used the CRP, Winston said the self-management strategies “didn’t work” so he ended up calling the crisis line. The therapist reinforced Winston’s use of the CRP and discussed how the CRP may not always eliminate all negative feelings and thoughts, while pointing out that calling the crisis line was included as one of the final steps of the CRP. Winston commented that he hadn’t considered this before, and agreed that having the crisis line on his CRP was a good step to have when other strategies were not enough to help him calm back down. Then, Winston and the therapist completed a CBW on “I’m out of control” using the crisis as the situation. Winston was able to reframe this and indicated that his use of the CRP was evidence against his stuck point. A second CBW example from his homework was reviewed and used to further hone his skills. Winston added CBWs to his CRP and said that he can use them when he is feeling overwhelmed by his negative thoughts and prevent them from spiraling down. The five modules—safety, trust, power and control, esteem, and intimacy—were reintroduced. The safety module was assigned as homework as well as continuing CBWs.

Session 8: Safety

Winston did not have any crises during the eighth week, and he continued to practice his self-management strategies. He added additional activities to his CRP, such as biking and running, because he had recently started these activities again and found them helpful. The CBW homework related to safety stuck points were reviewed. Winston’s safety stuck point was “The world is a dangerous place,” and was related to his combat trauma. After the worksheet, Winston reported believing there is danger in the world but that should not stop him from doing activities he enjoys. The trust module was assigned in addition to continuing the CBWs.

Session 9: Trust

The CRP was reviewed at the start of the ninth session and no changes were made during this session. Winston said he continued to practice his self-management strategies and reported a decrease in the frequency and intensity of his suicide related thoughts as result. In reviewing his assigned CBWs, one stuck point related to both his trauma and suicidal behaviors was identified: “Every decision I make is wrong.” This stuck point was related to his guilt from his combat trauma as well as related to his current self-perception. Winston explained that he was self-critical in decision making, especially when he thought his decision was not “perfect,” which would lead to rumination that eventually triggered suicidal ideation. Winston and his therapist agreed that this was a very important stuck point to reframe because it stemmed directly from the trauma and also served to drive his recent suicidal behavior. He was able to reframe this into “Although not every decision turns out the way I want it, it does not mean it was wrong. Sometimes things do not turn out the way I think they will.” The power and control module with CBWs were assigned for homework for the next session.

Session 10: Power and Control

During the tenth session, Winston said he had noticed a continued decrease in his suicidal ideation and a new-found ability to challenge or dismiss these thoughts when they occurred. The therapist and Winston discussed how keeping the CRP can still be useful and continue to be updated as new self-management strategies, social support, and/or reasons for living are identified. Winston reported that he had recently reconnected with some of his military friends and that he felt hopeful for the future. He was able to articulate that he was excited to build a new life for himself, and added this to his reasons for living. Due to the many edits made to his CRP up to this point, Winston decided to rewrite his CRP on a new index card.

CBWs related to power and control were reviewed next. Winston decided to focus on a trauma-focused worksheet and discussed how he could not have done more during his traumatic event because was not in control of the situation. He also noted that even if he could have done more, the outcomes might not have changed. He then reviewed a CBW focused on the suicide-related stuck point “If I lose control of my anger, I will end up killing myself.”. He was able to reframe this belief to “I can control my behaviors and I have plenty of reasons to live.” Winston expressed that continuing to do these worksheets made him worry and think less about suicide as an option. The esteem module and CBWs were assigned for homework.

Session 11: Esteem

During the review of the CRP at the start of the eleventh session, Winston decided to change some of his warning signs because they included stuck points that he no longer believed. He edited his warning signs to include other stuck points that he believed could recur during stressful situations. He reviewed CBWs related to esteem, including a stuck point about being worthless. He shared that he does not currently feel worthless but that this thought had been a common theme of his stuck points in the past. Winston was able to work through the worksheet with little input from the therapist and was by this point showing mastery of both the CPT worksheets and the CRP. His homework including the intimacy module and CBWs, as well as a second impact statement to write about his current thoughts and beliefs about himself, the world, and future related to his traumatic experience.

Session 12: Intimacy

In the final session of CPT, Winston reported that his CRP was a tool he intended to use for the rest of his life. He had made another update to the CRP by adding reminders of certain CBW worksheets that he could review if his thoughts of suicide returned. His final CBW focused on “I can’t handle my emotions,” which he was able to reframe to “I have the tools to manage my reactions to emotions; natural emotions will come and go.” Winston read his new impact statement and compared it to the old statement. He was able to recognize significant change in his thinking that was more realistic and balanced. His suicidal ideation had reduced and he said that he no longer saw suicide as the only option when he was overwhelmed. Termination of treatment was mutually agreed upon and a plan for when booster sessions would be needed was discussed. Winston agreed to continue practicing the CPT worksheets and using his CRP.

Outcome and Prognosis

Winston made significant progress in treatment with respect to two clinical outcomes: PTSD symptoms and suicidal ideation. His PTSD symptoms were measured at baseline and daily using the PTSD Symptom Checklist for DSM-5 (PCL-5; Blevins et al., 2015) and his suicidal ideation was captured pre- and post-treatment using the Suicide Cognition Scale (SCS; Bryan et al., 2014). These outcomes can be seen in Figure 2 and match the how Winston presented his symptoms in treatment. Over the course of treatment, Winston showed a 70% reduction in PTSD symptoms and 60% reduction in suicidal cognitions. His PTSD outcomes are what would be expected for a course of CPT. By targeting his suicidal ideation through integrating the CRP and addressing the suicide related stuck points, his prognosis regarding maintenance of these gains is good.

Figure 2:

Pre- to post-treatment scores on PTSD symptoms and suicide related cognitions.

PCL-5: Posttraumatic stress disorder symptom checklist for DSM-5; SCS: Suicide cognition scale.

Clinical Practices and Summary

Suicidal thoughts and behaviors are common in military members with PTSD and lengthening treatment to address suicide and PTSD separately may not be in the best interest of the patient. Instead, suicide specific interventions (i.e., CRP) that are complementary and do not interfere with the trauma focused therapy (i.e., CPT) may provide a treatment package that can address both issues during the course of treatment.

There are several aspects to highlight in the integration of CRP into CPT. In the case example, the patient came into the first session of CPT with a CRP already created during his intake. A CRP can be made during the first session of CPT or it could be made during an intake or separate session. It is possible that the patient may not disclose previous suicidal thoughts and behaviors prior to treatment for a variety of reasons (e.g., anxiety about provider response); in these cases, a CRP can be made during treatment without the need to terminate the trauma-focused treatment. Once the CRP is made, it can be integrated into treatment going forward. Providers are encouraged to have an open discussion about suicidal thoughts and behaviors to help destigmatize how the patient may feel. Discussing that disclosing suicidal thoughts and behaviors does not automatically result in hospitalization and sharing the decision-making process with the patient can help build rapport, especially related to the discussion of suicidal thoughts and behaviors.

The CRP check-in at the beginning of each session often took between 5-10 minutes, having very little impact on the pace of the session. The main purpose of the check-in is to troubleshoot the steps of the CRP and tweak components that either were ineffective or could be improved. When reviewing the CRP, the patient and therapist should work collaboratively to determine how much to modify. It may be as simple as crossing a strategy off or identifying barriers and how to overcome them. The therapist should use Socratic questioning and guided discovery throughout this process and refrain from instructing the patient what should and should not be on the plan, allowing the patient to maintain a sense of control and personalization of the CRP.

If the patient used the CRP, the actual crisis can be integrated into CPT through standard worksheets. Stuck points that occur from the crisis can be challenged and can create a transition from the CRP check-in to the normal CPT agenda. If no crises occur, it is still important to target the suicide related cognitions in CPT. As modeled in the example case, homework assignments often include one worksheet about the trauma, per the CPT protocol, and a second related to suicidal thoughts and behaviors. This strategy is based on the previous research showing that treatments that target suicide cognitions specifically reduce suicidal behaviors. Often there is overlap in these cognitions and making this connection can be helpful to the patient.

As noted in the case example, components of CPT can be added into the CRP. For example, once the patient has shown mastery on a worksheet and notices benefits from the worksheets, it becomes a self-management strategy. Patients may even have “review CPT workbook” on their completed worksheets from CPT upon completion of treatment. Therapists should also be aware when PTSD symptoms lessen, as the patient may engage in activities or other self-management strategies that can be added to the CRP. Ultimately, the CRP can be used as a relapse prevention tool and guide termination by summarizing treatment for both suicidal behaviors and PTSD.

Including CRP into trauma-focused treatments is not necessarily exclusive to CPT. The CRP is easily implemented into other evidenced-based trauma focused treatments such as Prolonged Exposure (PE) and CBT for PTSD. The integration may vary slightly, but the principles remain the same. The CRP is used as a tool to prevent suicide and help the individual complete the trauma focused therapy and in turn, reduce suicidal ideation. Clinicians can use brief check-in at the beginning of the session to focus on the suicidal ideation and behaviors and integrate other aspects of the treatment into the CRP.

It is important to note potential limitations of the case study and integrating CRP into CPT. First, CRP is not a “fix” or treatment for the underlying mechanisms of suicidal behavior. Often the cognitive mechanisms can be targeted using CPT and a second round of treatment specifically for suicidal thoughts and behaviors may not be necessary. However, if suicidal behavior and ideation continue following CPT or other trauma focused treatments, it is important to treat the suicidal behavior directly with a suicide specific treatment (e.g., BCBT).

Overall, the goal of this case example was to provide a practical framework for clinicians who work with high-risk suicidal individuals with PTSD. By integrating the CRP, a suicide specific prevention tool, into CPT, both the PTSD and suicidal behaviors can be targeted during the standard course of CPT treatment without reducing fidelity. Although these cases can provoke anxiety, with a plan on how to address suicide and PTSD within an evidenced-based treatment, providers can be more confident in providing treatment that maximizes the probability of successful outcomes.