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option would be to use ‘alternative therapy’ (Williams 1984:130) to examine a typical situation in which the patient feels despairing and hopeless. The patient would then generate alternative ways of coping, perhaps starting with the attempt to evaluate ‘nothing has changed’ by bringing to mind the things that have changed. It is likely that this procedure would reveal several obstacles to using such a strategy, which will need to be discussed. They could also become the focus of a homework assignment, the aim of which would be to discover if there are any further obstacles to such coping strategies that have not been anticipated. Note that, as with therapy for depressed patients, setting homework tasks which are aimed at discovering obstacles to be discussed later is more likely to motivate the patient to attempt the homework. The homework which is set with the implicit suggestion that it will make the patient feel better may be demotivating if it is not believable, or if the patient feels that the therapist is belittling their problem. Finally, note the hint towards the end of the transcript that it is her relationship with Keith that is the central concern. It is possible that the underlying belief is ‘unless things change in that relationship, then nothing has changed’. The therapist might work towards making this belief explicit, and helping the patient to build up or give adequate recognition to alternative sources of satisfaction.

Inability to imagine the future

We have observed that in both primary and secondary prevention the core techniques described in Beck et al. (1979) and Williams (1984) may be used. We have suggested that to these should be added a vigilance for expression of hopelessness and a willingness explicitly to discuss reasons for dying and reasons for living. One characteristic of the suicidal patient which often undermines such therapeutic attempts is their difficulty in imagining what the future would be like. Such a difficulty, and one possible technique for dealing with it (time projection), is illustrated in the following case.

Philip, a 40-year-old schoolteacher, was admitted to hospital after an overdose of fifty paracetamol, forty aspirin, and a bottle of whiskey. He had only been found several hours later, when his girlfriend called by chance at the house. He survived without sustaining liver damage, but his overdose clearly showed considerable suicidal intent. He spent several days in hospital, during which time he was assessed by a psychiatrist who did not find him to be suffering from any psychiatric illness.

It emerged that he had made this suicide attempt because of a marital situation that he found intolerable. He had been having an extra-marital affair for the past year, and several times his wife had persuaded him to give up this relationship, only for him to resume it. The day before the overdose his wife had left him, and he had felt that he had failed both his wife and his girlfriend by his indecisiveness.

After discharge from hospital, he stayed with friends ‘on neutral ground’, and came for weekly appointments with the therapist.

Philip admitted during these sessions that he still felt suicidal at times. For example, he described an incident when he had gone home to visit his wife and 9-year-old son, and had ended up begging her to give him tablets for him to take in overdose. After that evening, he had planned a suicide attempt and played himself melancholy classical music to maintain his depressed state. This mood was only broken when he had news from his girlfriend of a flat which they should be able to move into.

Over a number of sessions, various techniques were used to help Philip gain more control over his suicidal thoughts, which he described as at times suddenly engulfing him and carrying him along with frightening force. He was encouraged to record these thoughts, and the circumstances in which they occurred, in order to achieve more distance from them. As ammunition against these thoughts, he was encouraged to develop a list of ‘reasons for living’, and together with the therapist he visualised his son, for example, in the present and the future, and in as much detail as possible, so that a very vivid image of his son could then be available to him as a reason for living.

In a similar way, although Philip’s crisis was more to do with a perceived intolerable situation in the present than a hopeless future, he was unable to imagine various possible futures for himself that might again act as an argument against suicide. This difficulty in imagining the future became a target for therapy in the transcript which follows. The aim was for him to try and visualise his life as it might be in five hours, five days, five weeks, five months, and five years. It didn’t matter with whom he had decided to share his life. What was important was the sense this might give him of progression and continuity, at each stage enhanced by more pictures of his situation, with its possessions, people, activities, and feelings.

T:It seems as if what particularly frightens you is the way a suicidal feeling can sweep over you quite suddenly and almost carry you away.

P: Yes, that’s right.

T: We need to understand better, if we can, how this mood develops. Do you think much about the future? P: No, not really.

T: Can you imagine what life might be like in a year’s time?

P: No, it’s pretty blank. I don’t really know if I’ll be around then.

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P:For all I know I might be Head of Department by then! I think I’d enjoy that actually, and hopefully I’d still be at the same school. Alan would be 16, I suppose, but I like to think I’d have kept in regular contact with him, assuming, that is, that I don’t go back to Deirdre. I think we could be pretty good friends by then, Alan and I; with my job and everything, I don’t think I’m too bad with teenagers, and I’ll look forward to taking Alan out, perhaps fishing. I hope Karen and I will still be together; if we are, we will have come through a lot, and it will have made us very close.

T:OK, let’s leave it there. [Turn chairs back.] I know that felt artificial in a way, but that’s to be expected, because it was a particular exercise we were doing. But I think it showed that you could project yourself into the future, and by the end, you were coming up with quite a lot of things spontaneously, that seemed to hold your attention. Did you find it useful?

P:Well, I’m not sure how much impact all this would have when I was in one of my real ‘downers’. Is the idea that I should be able to call on some of these images to keep some of the blacker thoughts at bay?

T:Yes, I think you can look at it as a sort of distraction technique. It’s also a way of protecting yourself against the black thoughts of the present that you have when you’re depressed. The idea is that if you can be aware of detailed realistic images about the future, you are less likely to feel so hopeless in the present.

Note: (1) It is sometimes preferable to keep the time projection going longer, to try and capture the greater mood of optimism and perspective which the patient may have achieved. Some therapists would therefore instruct the patient to come slowly back in time to the present, while still relaxed, and perhaps to attempt to plan the next few days, before ending the time projection.

(2)The patient expresses some doubt about the ability to use the technique by himself. The therapist might instruct him to practise the technique by himself when he is not feeling so bad in order to become more proficient, and to increase its immunisation effect.

(3)The patient may have been presenting an overly optimistic view of the future. Time projection is likely to be of greater value if the patient is able to visualise some potential problems in detail, but also to imagine being able to cope with them.

Some common problems

Of all the questions that arise when doing cognitive behaviour therapy with suicidal patients, some of the more important may be considered here. First, do not many of these patients have severe real-life problems? Is not their hopelessness understandable? Second, might not consideration of reasons for dying precipitate a suicide attempt? Third, how do you know who will benefit from treatment? Which techniques are most appropriate for which patient?

Reality-based hopelessness is indeed often found. Many patients have some real problems that, as we observed, must not be minimised by the therapist. It is worth the therapist bearing in mind, though, that some people appear able to cope with apparently unbearable problems without becoming suicidal. Why? It is possibly because depressive hopelessness is not the same as normal sadness. Financial hardship and interpersonal chaos may reasonably cause a great deal of anger, frustration, and sadness. However, a person becomes depressed and suicidal when their reasonable sadness changes to a situation in which the person tells themselves ‘I’m to blame’, ‘I’ve never succeeded at anything in my life’, ‘There is no way things can improve’, ‘If my love leaves, I am nothing’, and so on. When people are under great stress—stress which has understandable consequences on their mood—they need all the coping resources they can muster. What they do not need is a constant stream of negative thoughts and images which convinces them that they are stupid, worthless, and good-for-nothing. Cognitive therapy can be conceived as enabling the person to discriminate between normal frustration and depressive hopelessness, so that the real problems can be faced realistically.

Second, might focusing on reasons for dying precipitate suicidal wishes? In fact, our experience shows that the act of making these factors explicit is more likely to be therapeutic. If the patient believes that there are over-whelming reasons for dying, proceeding with therapy as if these reasons did not exist is not beneficial. Making such reasons explicit encourages the patient to feel that their reasons are being taken seriously. Objective statement of the reasons is only the first step to evaluating the evidence for and against each one and discussing why some reasons are weighted in the patient’s mind more heavily than others. This procedure will include evaluating evidence for the reasons for living which may need strengthening. There is no evidence that explicit discussion of reasons for dying actually increases suicidal intent. Indeed, our clinical experience suggests the converse, that if therapists tend to concentrate only on the positive reasons for living their rapport with the patient may be lost and hopelessness increase.

We do not yet know who will benefit most from treatment, or which technique is most suitable for which patient. The evidence from Simons et al. (1984) and Fennell and Teasdale’s (1987) outcome trials of cognitive therapy with depressed patients suggests that the patients who naturally tend to adopt an active problem-solving coping style (which has been temporarily obscured by the current crisis) might be most suitable. In the case of depressed patients, this has been assessed using Rosenbaum’s self-control scale (Rosenbaum 1980) and by evaluating patients’ reactions to the Coping with Depression

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booklet which describes something of cognitive theory and therapy (Beck and Greenberg 1974). No such prospective study has yet been done with suicidal patients.

The question ‘Which technique?’ is most pressing for the management of post-attempt patients, since the large number of such patients may limit the amount of time available for each. Our clinical experience suggests that evaluating the balance between communication and escape motives is a useful first step, and may be followed by choosing the technique which is most likely to deal with the primary motivating factor. In either case, we suggest that cognitive rehearsal of particularly difficult situations similar to those which have precipitated crises in the past will be helpful (Williams 1984:127; Hawton and Catalan 1987). During cognitive rehearsal, any or all of the signs of hopelessness which we have illustrated in our transcripts may arise and will need to become the explicit focus of therapy.

Concluding remarks

Because work with suicidal patients uses the same techniques which have been described before in therapy for depressed patients, we have not attempted to illustrate them again in this chapter. Rather, we have focused on the management of suicidal tendencies within the framework which assumes a balance between reasons for living and reasons for dying. In making such a balance explicit, further expression of hopelessness may occur which needs to be dealt with rapidly. Further, it may become apparent that an important factor limiting progress in therapy is the inability to imagine a possible future. We wish to make no claim about which technique is most appropriate for which patient at which point in the development of the depression or suicidal feelings. The research has not yet been done to establish this. However, examination of how to deal in therapy with particular problems that arise in particular individuals, each showing different sorts of cognitive and behavioural difficulties, is an important first step in this endeavour.

Suicidal patients are a highly vulnerable group who naturally arouse considerable anxiety in clinicians. Amongst the range of interventions that may be used to treat this group—hospitalisation, physical treatments, environmental manipulation— cognitive therapy is beginning to show that it has a place. Through careful identification of the depressive thinking that may lead to hopelessness, and through the use of strategies to alter these habits of thinking, our impression is that significant progress can be made in helping such patients overcome their suicidal impulses.

References

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

Beck, A.T., Schuyler, D., and Herman, J. (1974) ‘Development of suicidal intent scales’, in A.T.Beck, H.L.P.Resnik and D.J.Lettieri (eds) The Prediction of Suicide, Bowie, Maryland: Charles Press.

Buglass, D. and Horton, J. (1974) ‘A scale for predicting subsequent suicidal behaviour’, British Journal of Psychiatry 124:573–8.

Dyer, J.A.T. and Kreitman, N. (1984) ‘Hopelessness, depression and suicidal intent in parasuicide’, British Journal of Psychiatry 144: 127–33.

Fennell, M.J.V. and Teasdale, J.D. (1987) ‘Cognitive therapy for depression: individual differences and the process of change’, Cognitive Therapy and Research 11:253–72.

Fraser, S. (1987) ‘Cognitive and behavioural strategies in the management of suicidal behaviour’, unpublished Ph.D. thesis, University of Leicester.

Hawton, K. and Catalan, J. (1987) Attempted Suicide: A Practical Guide to its Nature and Management, 2nd edn, Oxford: Oxford University Press.

Hirsch, F.R., Walsh, C, and Draper, R. (1982) ‘Parasuicide: a review of treatment interventions’, Journal of Affective Disorders 4:299–311. Paykel, E.S. and Dienelt, N.N. (1971) ‘Suicidal attempts following acute depression’, Journal of Nervous and Mental Disease 153:234–43. Pierce, D.W. (1981) ‘Predictive validation of a suicide intent scale’, British Journal of Psychiatry 139:391–6.

Power, K.G., Cooke, D.J., and Brooks, D.N. (1985) ‘Life stress medical lethality and suicidal intent’, British Journal of Psychiatry 147: 1655–9.

Rosenbaum, M. (1980) ‘A schedule for assessing self-control behaviours’, Behaviour Therapy 11:109–21.

Simons, A.D., Garfield, F.L., and Murphy, T.E. (1984) ‘The process of change in cognitive therapy and pharmacotherapy for depression’,

Archives of General Psychiatry 41:45–51.

Williams, J.M.G. (1984) The Psychological Treatment of Depression: A Guide to Theory and Practice of Cognitive Behaviour Therapy,

London: Croom Helm, and New York: Free Press.

Williams, J.M.G. (1985) ‘Attempted suicide’, in F.N.Watts (ed.) New Developments in Clinical Psychology, Leicester: British Psychological Society, and Chichester: John Wiley.