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Conclusion

It has long been acknowledged that there are cultural influences on the incidence of criminal behaviour. Certain values such as ‘toughness’ and ‘masculinity’ are reinforced by our society and may actually invite a higher percentage of crimes than in a society which does not prize these values (Toch 1969).

Within the individual such values have an influence on the formation of dysfunctional assumptions, which this chapter has shown can play a major part in negative automatic thinking and the committing of offences.

There are obvious implications for the assessment and treatment of offenders, and indeed for legislation. Cognitive therapy techniques can contribute greatly to the assessment and management of interaction with offenders. Cognitive theory can aid in the understanding and analysis of offence behaviour. Cognitive therapy would seem to be an approach to emotional and behavioural change, which adds fundamentally to the approaches available to date for the treatment of offenders with a general or a specific psychological problem.

The development of the approach with this group, along with controlled treatment trials, process studies, and single case reports, is awaited with interest.

References

Bancroft, J. (1979) ‘The nature of the patient therapist relationship: its relevance to behaviour modification for offenders’, British Journal of Criminology 19:416.

Bandura, A. (1971) Aggression: A Social Learning Analysis, New York: Prentice-Hall.

Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders, New York: International Universities Press.

Beck, A.T. and Emery, G. (1977) ‘Cognitive therapy of substance abuse’, unpublished manuscript, Philadelphia, PA: Center for Cognitive Therapy.

Beck, A.T., Emery, G. and Greenberg, R. (1985), Anxiety Disorders and Phobias: A Cognitive Perspective, New York: Basic.

Beck, A.T., Rush, A.J., Shaw, B.F., and Emery, G. (1979) Cognitive Therapy of Depression, A Treatment Manual, New York: Guilford Press.

Blackburn, I.M., Bishop, S., Glen, A.I.M., Whalley, L.J., and Christie, J.E. (1981) ‘The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination’, British Journal of Psychiatry 139:181–9.

Craft, A. and Craft, M. (1984a) ‘Treatment of sexual offenders’, in M.Craft and A.Craft (eds) Mentally Abnormal Offenders, London: Bailliere Tindall.

Craft, M. and Craft, A. (1984b) Mentally Abnormal Offenders, London: Bailliere Tindall.

Crawford, D.S. (1979) ‘Modification of deviant sexual behaviour: the need for a comprehensive approach’, British Journal of Medical Psychology 52:151.

Crawford, D. (1984) ‘Behaviour therapy’, in M.Craft and A.Craft (eds) Mentally Abnormal Offenders, London: Bailliere Tindall.

Ellis, A. (1979) ‘The sex offender’, in H.Toch (ed.) The Psychology of Crime and Criminal Justice, New York: Holt, Rinehart & Winston. Emery, G. (1980) ‘Self reliance training in depression’, in D.P.Rathjen and J.P. Foreyt (eds) Social Competence: Interventions for Children

and Adults, New York: Pergamon Press.

Feindler, E.L., Marriott, S.A., and Iwata, M. (1984) ‘Group anger control training for high school delinquents’, Cognitive Therapy and Research 8:299.

Gudjonsson, G. (1986) ‘Sexual variations: assessment and treatment in clinical practice’, Sexual and Marital Therapy 1:191.

Howells, K. (1982) ‘Aggression: clinical approaches to treatment’, in D.A.Black (ed.) Issues in Criminological and Legal Psychology, No. 2, Leicester: British Psychological Society.

Lopez, F.G. and Thurman, C.W. (1986) ‘A cognitive behavioural investigation of anger among college students’, Cognitive Therapy and Research 10:245.

Meichenbaum, D. (1975) ‘Self-instructional methods’, in F.Kanfer and A. Goldstein (eds) Helping People Change, New York: Pergamon Press.

Murphy, G.E., Simons, A., Wetzel, R.D., and Lustman, P.J. (1984) ‘Cognitive therapy and pharmacotherapy, singly and together in the treatment of depression’, Archives of General Psychiatry 41:33–41.

Nomellini, S. and Katz, R.C. (1983) ‘Effects of anger control training on abusive patients’, Cognitive Research and Therapy 7:57. Novaco, R. (1975) Anger Control: The Development and Evaluation of an Experimental Treatment, Lexington, MA: Heath.

Novaco, R. (1977) ‘Stress inoculation: a cognitive therapy for anger and its application to a case of depression’, Journal of Consulting and Clinical Psychology 45:600.

Novaco, R. (1978) ‘Anger and coping with stress: cognitive behavioural interventions’, in J.Foreyt and D.Rathjen (eds) Cognitive Behaviour Therapy: Research and Application, New York: Plenum.

Perkins, D. (1984) ‘Psychological treatment of offenders in prison and the community’, in T.A.Williams and J.Shapland (eds) Options for the Mentally Abnormal Offender: Issues in Criminological and Legal Psychology, No. 6, Leicester: British Psychological Society.

Perkins, D. (1986) ‘Sex offending: a psychological approach’, in C.Hollin and K. Howells (eds) Clinical Approaches to Criminal Behaviour: Issues in Criminological and Legal Psychology, No. 9, Leicester: British Psychological Society.

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Rush, A.J., Beck, A.T., Kovacs, M., and Hollon, S.D. (1977) ‘Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients’, Cognitive Therapy and Research 1:17–37.

Schlichter, K.J. and Horan, J.J. (1981) ‘Effects of stress inoculation on the anger and aggression management of institutionalized juvenile delinquents’, Cognitive Therapy and Research 5:359.

Segal, Z.V. and Marshall, W.L. (1986) ‘Discrepancies between self efficacy predictions and actual performance in a population of rapists and child molesters’, Cognitive Therapy and Research 10:363.

Toch, H. (1969) Violent Men, Harmondsworth: Penguin.

Chapter nine

Suicidal patients

J.Mark G.Williams and Jonathan Wells

Introduction

In this chapter, we will consider some of the skills required and issues raised in cognitive therapy with suicidal patients, both those under treatment for depression, and those referred following a suicide attempt. Case examples from our clinical practice will be used to illustrate approaches that we have found useful and some problems in applying them.

The degree to which they express suicidal thoughts needs to be routinely assessed when depressed patients start their treatment. However, there are two contexts in which a therapist will most commonly have to deal with the theme of suicide. First, when a patient expresses suicidal thoughts during the course of therapy, whether or not they have exhibited suicidal behaviour before, these thoughts must be taken seriously. One in ten depressed patients attempts suicide within a year of entering treatment (Paykel and Dienelt 1971). Second, cognitive therapy is increasingly being explored as a means of secondary prevention—the prevention of a new suicide attempt when the client has been referred immediately following an attempt. Such exploration seems timely since no psychological treatment has yet been found which affects the repetition of such behaviours (Hirsch et al. 1982; Williams 1985; Hawton and Catalan 1987). To date, no research trial has evaluated cognitivebehavioural therapy interventions with this population, though Fraser’s (1987) study of group cognitive therapy (which lasted eight sessions) has given encouraging results. Until more work is done, however, we need to rely on clinical judgement to decide which approaches are likely to prove most effective.

Suicidal thoughts during therapy for depression

Beck et al. (1979) emphasise the importance of assessing suicidal risk in depressed patients. If someone expresses suicidal ideas, it is important to determine what method is contemplated, how familiar the patient is with the lethality of medicines, and the availability of methods (e.g. firearms). Assessing the environmental resources for intervention will also be important (i.e. how likely is it that serious suicidal intent would be detected, how likely is it that intervention would be made in time, and how likely is it that adequate medical help could be secured). The therapist will need to be vigilant for verbal or mood cues which might indirectly signal suicidal intent. Verbal expressions of hopelessness provide the best clue. Not all depressed patients are hopeless, and there is an accumulating body of evidence to suggest that hopelessness is the factor which mediates between depression and suicidal intent (e.g. Dyer and Kreitman 1984). Sudden changes in affect in either direction may also signal impending suicidal behaviour.

An assumption of cognitive therapy with these patients is that suicidal intent is a continuum. There is a balance between the intention to live and the intention to die, and even relatively insignificant chance factors may tip the balance. Beck et al. (1979) also assume that there are two dimensions along which the motivation of the suicidal patient may vary: the desire for escape or surcease; and the desire to communicate. People vary in the extent to which either or both of these motivations are present, but the assumption is that the more hopeless patients are those for whom the desire for escape predominates.

Finally, Beck et al. (1979) describe in broad terms the stages in helping the suicidal patient: stepping into the patient’s world, viewing it through their lens, and attempting to tip the balance against suicide. If escape is the main motivation, then the therapist concentrates on the patient’s hopelessness and lack of positive expectation. (If hopelessness is due largely to real social problems, then social intervention may be necessary.) If communication is the main motivation, the therapist concentrates on determining what is being communicated to whom, and how it can be done more adaptively.

Tipping the balance against suicide also involves building a bridge to the next session, if possible, by getting the patient to see the next episode of suicidal feelings as an opportunity to note in detail how they feel, in order to bring the data to the next session. The therapist might encourage the patient to agree to make explicit what are the pros and cons of living and dying. Dealing with hopelessness will involve careful assessment of the contribution of the reality of the life situation of the patient and of the interpretative schemata which the patient uses to evaluate that life situation. For many there will have been real

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failures and/or real rejection experiences which must not be minimised by the therapist. But the patient’s depression may also have made them select the most catastrophic interpretation of these life situations and of their implication for the future. In this case the question is: what erroneous conclusions are blocking out hope? What alternative behaviours and choices are realistically available to the patient? Stress inoculation can be used, in which the patient uses their imagination of a crisis situation to generate within the session some of the same hopelessness and despair that is typically felt outside the therapy situation. Under these conditions, the patient attempts to generate some alternative coping responses.

Secondary prevention immediately following deliberate self-harm

One of the tasks for a therapist following an attempted suicide episode is to assess suicidal intent and the probability of repetition. Assessment of suicidal intent is best made on the basis of the circumstances surrounding the episode. As a crude guideline, the more the behaviour approximates to suicide, the greater the assumed intent. This has been spelt out in more detail by Beck et al. (1974). Critical issues to assess are:

1.How isolated was the person at the time?

2.Was it timed so that intervention was likely or unlikely?

3.Were there any precautions taken against discovery?

4.Did the patient do anything to gain help during or after the attempt?

5.Did the patient make any final acts anticipating they would die?

6.Did they write a suicide note?

The patient’s own self-report is also important to take into account:

1.Did they believe what they did would kill them?

2.Do they say they wanted to die?

3.How premeditated was the act? (Two-thirds of patients have not thought about it for more than an hour beforehand. The longer the idea of suicide had been in the mind the greater the suicidal intent.)

4.Is the patient glad or sorry that they have recovered?

Whether the actual medical risk should be taken into account remains a controversial issue. Over a large number of cases there is a significant correlation between actual lethality and suicidal intent (Power et al. 1985) but it may be difficult to infer intent from the medical lethality in an individual case. This is because some patients (especially those who are not used to taking pills) may believe that relatively few pills are lethal. In such cases actual physical risk would be no guide to what may in fact be a very serious suicidal attempt. Note, however, the obvious but often overlooked point that the correlation between actual physical lethality and intent is much stronger in cases where the patient is knowledgeable about the lethality of drugs available to them.

Repetition probabilities can be judged through assessment of hopelessness and of suicidal intent for the current episode, and through observing how many of Buglass and Horton’s (1974) six vulnerability factors a patient has:

1.Does the patient have problems in the use of alcohol?

2.Have they ever been diagnosed sociopathic or personality disordered?

3.Have they ever had in-patient psychiatric treatment?

4.Have they ever had out-patient psychiatric treatment?

5.Are they living with relatives? (If not, they are more vulnerable.)

6.Have they ever attempted suicide before?

(Buglass and Horton (1974) found that these six items predicted repetition of suicide attempt in an additive fashion. The more vulnerability characteristics, the greater the repetition probability. Even so, the predictive value is limited, for, of those with five or six of the characteristics, only 48 per cent repeated within 1 year.)

Outline for therapy

As noted above, although depression is often associated with suicidal thoughts, not all depressed people are suicidal: it is when depressed people also become hopeless that they are most likely to feel suicidal. Therefore a primary goal of cognitive therapy with suicidal patients, whether the aim is primary or secondary prevention, must be (1) accurate assessment of their state of hopelessness; (2) vigilance for further changes in level of hopelessness; (3) reduction of current state of hopelessness