Cognitive therapy for suicide prevention

1. Introduction

Version followed: the outpatient adult protocol of Wenzel, Brown & Beck (2009), Cognitive Therapy for Suicidal Patients (APA), the Brown et al. (2005) trial version, as it is currently taught by the Penn Center for the Prevention of Suicide. Its three-phase structure comes from Penn, the Center for Deployment Psychology and Focus (2022). The Safety Planning step follows Stanley & Brown (2012). The 2009 book itself is not drawn on, so detail that comes only from the book is tagged [uncertain].

Cognitive Therapy for Suicide Prevention (CT-SP) is a structured, time-limited, individual outpatient cognitive therapy for adults who have recently attempted suicide or who have serious suicidal ideation. It treats suicidal thoughts and behaviour as the primary target in their own right, not as a symptom of depression or another disorder. The CDP calls it "transdiagnostic in nature", and it can be added to treatment the client is already receiving. [source: Penn CT-SP training page; CDP CT-SP page; Wenzel NJ-ACT workshop summary]

Core change idea: biopsychosocial vulnerabilities interact with suicidal thoughts and behaviours to produce a "suicide mode" [source: Focus 2022; CDP]. Therapy works in four ways:

It reconstructs the most recent suicidal crisis in detail, so that client and therapist can see the sequence of events, thoughts, feelings and behaviours that led into the suicide mode.
It puts crisis tools in place at once (the Safety Plan, means safety and the Hope Kit).
It teaches cognitive and behavioural skills aimed at the exact links in that sequence.
It checks, through a guided-imagery relapse prevention task, that the client can actually use those skills in a re-imagined past crisis and in a likely future one.

The Wenzel & Beck (2008) cognitive model adds trait vulnerabilities, state hopelessness and attentional fixation on suicide as the client's tolerance is exceeded. That paper is not drawn on [uncertain].

2. Framework

Format. Individual, outpatient, adults. About 10 weekly sessions of roughly 50 minutes [source: CDP; Penn; Wenzel NJ-ACT summary "10-session"]. Focus (2022) gives 10–12 weekly sessions for acute treatment, plus an optional continuation phase of up to 6 sessions over 12 weeks. Penn does not specify a session count. Penn offers training for adults only, because CT-SP has not been adapted and tested with youth [source: Penn].

Phase 1: Early phase (sessions 1 to about 3). Engagement, assessment and crisis management. [source: Focus 2022; CDP; Penn]

Goals: engage the client, complete a thorough suicide risk assessment and reduce immediate risk.
Contents:
- Collaborative Safety Plan and lethal means counselling.
- Narrative interview: a detailed timeline of the most recent suicidal crisis.
- Cognitive-behavioural case conceptualization.
- Treatment goals and an individualized treatment plan.
- Reasons for living and the Hope Kit.
Move on when (criteria [synthesis]; the sources give only the session range):
- a written Safety Plan exists and the client says they are likely to use it;
- means safety steps have been agreed;
- the crisis narrative has been mapped into a shared conceptualization;
- two or three concrete treatment goals are agreed.

Phase 2: Intermediate (middle) phase. Skill building targeted at the conceptualization. [source: Focus 2022; CDP; Penn]

Goals: build the specific skills that would have interrupted the sequence identified in the crisis narrative.
Contents. Interventions are selected according to the treatment goals, not delivered as a fixed sequence:
- Behavioural: relaxation, distraction, activity monitoring and behavioural activation, self-care, reducing emotional vulnerability, distress tolerance, problem solving, and increasing social resources.
- Cognitive: learning the cognitive model; identifying and evaluating the thoughts and beliefs that lead into the suicide mode; modifying core beliefs; working on reasons for living; coping cards.
Move to the later phase when (criteria [synthesis]):
- the client can describe and use the skills linked to each treatment goal;
- there have been no suicidal acts during the phase, or any new crisis has been mapped and addressed;
- Safety Plan use is being reviewed and updated.

Phase 3: Later phase. Consolidation and relapse prevention. [source: Focus 2022; CDP; Penn]

Goals: consolidate skills; complete the guided-imagery relapse prevention task, covering the past crisis and an imagined future crisis; plan further treatment.
Ending: the CDP describes the steps once the client has shown they can generalise skills in the task:
- debrief and summarise what was learned;
- complete a thorough risk assessment;
- offer further sessions or referrals as clinically indicated.
The book is widely described as not ending acute treatment until the task has been completed successfully. The CDP cites Bryan et al. (2012) on defining completion by competence. This rule could not be verified in the manual [uncertain].

Continuation phase. Up to 6 more sessions over 12 weeks, as needed [source: Focus 2022]. Use them to review and update the Safety Plan, apply skills to new stressors and repeat the relapse prevention task if risk recurs [synthesis].

Structure of every session [source: Focus 2022; CDP "general structure of a typical CBT session"]:

brief mood check and suicide risk check;
whether the Safety Plan was used since the last session, and how;
homework review;
a collaboratively set agenda, with suicidal ideation and any life-threatening problem placed first;
work on the agenda items: new cognitive restructuring or skills training;
new homework, a summary and client feedback.

The bridge from the previous session, the end summary and the feedback request are standard Beck CT elements; Focus does not name them for CT-SP [synthesis].

Training route [source: Penn]:

a 2.5-day experiential workshop (didactic teaching, demonstration role-plays, exercises across the three phases);
optional competency-based consultation: weekly 90-minute small-group calls for 6 months, using audio-recorded sessions with suicidal adult training cases, rated on the Cognitive Therapy Rating Scale.

3. Guiding principles

Suicidality is the primary target. Each session and goal is linked to reducing suicidal thoughts and acts, whatever the diagnoses [source: Penn; CDP; NJ-ACT].
Structured and time-limited. Plan around 10 sessions with a recognisable agenda, so the client knows what to expect and work does not drift [source: CDP; Focus].
Life-threatening issues come first. When setting the agenda, suicidal ideation or behaviour since the last session outranks everything; therapy-interfering behaviour comes next [source: Focus; Wenzel NJ-ACT summary, which compares this to DBT's hierarchy].
Assess risk every session. A mood and suicide-risk check and a Safety Plan check open every session, not just the first [source: Focus].
Collaboration. The agenda, Safety Plan, conceptualization and goals are built with the client, in the client's words; never hand over a generic plan [source: Focus; Stanley & Brown 2012].
Conceptualization drives choice. The timeline of the last crisis decides which skills you teach; skip modules that do not map onto the client's sequence [source: Focus; Penn; CDP].
The aim is to recognise and exit the suicide mode. Teach the client to notice the early signs that the mode is activating and what to do at each point [source: Focus].
Act on safety at once. Put the Safety Plan, means safety and Hope Kit in place in the first sessions, before longer-term skill work [source: Focus; CDP; Penn].
A Safety Plan is not a no-suicide contract. Never ask for a promise not to die; such contracts lack support and may hide true risk [source: Stanley & Brown 2012; NJ-ACT].
Build hope concretely. Reasons for living and a physical or digital Hope Kit give the client something to reach for when hopeless [source: Focus; Penn].
Skills must be shown to generalise, not assumed. The relapse prevention task tests whether the client can use skills while imagining a crisis [source: CDP; Focus].
Engage actively. Follow up missed sessions with a call, a phone session or an extra appointment; non-attendance is itself a risk signal [source: Wenzel NJ-ACT summary; the risk framing is synthesis].
Ask about the attempt as the client experienced it. Regret at having survived is a key risk marker and must be asked about directly [source: NJ-ACT summary; Ghahramanlou-Holloway et al. 2014].
Adjunctive and integrative. CT-SP can run alongside medication and other treatment; coordinate with other providers rather than replacing them [source: NJ-ACT; coordination is synthesis].

4. Intervention inventory

The primary-source descriptions used here (Penn, CDP, Focus, Stanley & Brown 2012, Wenzel's NJ-ACT workshop) name every component listed below. The step-by-step detail comes from Stanley & Brown (2012) for the Safety Plan, and from standard Beck cognitive therapy where CT-SP sources only name a technique; those parts are tagged [synthesis]. All example wording is illustrative, not manual text.

4.1 Structured session format

Purpose / when: Every session. Keeps risk visible, makes the hour efficient and models orderly problem solving [source: Focus 2022; CDP].
Steps:
1. Mood check, using a 0–10 rating or a brief self-report measure. Then a suicide check: any ideation, urges or actions since last session, and how strong at worst.
2. Safety Plan check: did a crisis occur, which steps were used, what helped, what got in the way? Update the plan if needed.
3. Brief bridge from the previous session [synthesis].
4. Set the agenda together. Any suicidal thinking or life-threatening issue goes first, then therapy-interfering issues, then skill work.
5. Review homework.
6. Work through the agenda items, each tied to a treatment goal.
7. Agree new homework. Summarise, then ask for feedback.
Example language (illustrative): "Before we set today's agenda, on a 0 to 10 scale, how strong were thoughts of suicide at their worst this week? Did you need your Safety Plan?"
Watch for: Agenda drift into general venting; skipped risk checks once the client looks better. Signs it is working: the client starts proposing agenda items and reports Safety Plan use without prompting [synthesis].

4.2 Suicide risk assessment (initial and ongoing)

Purpose / when: A thorough assessment in session 1; brief re-assessment every session; a full re-assessment before ending acute treatment [source: Focus; CDP].
Steps:
1. Current ideation: frequency, intensity, duration, intent, any plan, preparatory behaviour.
2. History: past attempts and interrupted or aborted attempts, especially the index attempt.
3. Reactions to surviving the most recent attempt. Regret at surviving signals the highest risk [source: NJ-ACT; Ghahramanlou-Holloway et al. 2014].
4. Risk factors: hopelessness, substance use, psychiatric symptoms, recent losses or stressors, access to lethal means. Protective factors: reasons for living, supports, engagement in treatment.
5. Integrate the findings into a risk formulation and a level of care decision. Document the reasoning [synthesis: standard practice].
Measures: The Penn group developed standardised measures that are commonly used in CT-SP research, such as the Scale for Suicide Ideation and the Beck Hopelessness Scale. These are licensed; administer them as published, and their items are not reproduced here. Whether the manual requires particular scales was not verified [uncertain].
Example language (illustrative): "When you woke up in the hospital, what went through your mind? Some people feel relieved, some feel disappointed, some both. What was it like for you?"
Watch for: Minimising in order to avoid hospitalisation. Discrepancy between what the client says and what they do. Sudden calm after a decision. If the client cannot stay safe even briefly, arrange emergency care immediately [source: Stanley & Brown 2012].

4.3 Safety Planning Intervention

Purpose / when: Session 1, or as early as possible. Gives a prioritised, written, personalised list of steps to use when warning signs appear. Review it every session and revise it as new skills, triggers or supports appear [source: Stanley & Brown 2012; Focus; Penn].
Steps [source: Stanley & Brown 2012]: 0. Use the client's account of the recent crisis to find what preceded it. Explain that suicidal crises rise and fall, so a plan for getting through the peak can help.
1. Warning signs. Specific situations, thoughts, images, moods or behaviours that come before a crisis, in the client's words. Specific signs work better than vague ones.
2. Internal coping strategies. Things the client can do alone to take their mind off things (e.g. walking, music, a hobby). Rank them by likely effectiveness. Ask how likely they are to use each one and problem-solve barriers. Replace any strategy the client does not believe in.
3. People and social settings for distraction. Places and people that offer contact and distraction without disclosing the crisis. Exclude settings with alcohol or drugs.
4. People to ask for help. People the client would tell about the crisis and ask for help, with phone numbers. Weigh the pros and cons of disclosure. A good distractor may not be a good helper.
5. Professionals and agencies. Therapist and clinic, after-hours contacts, local 24-hour emergency department, a national crisis line (in the US, 988). Include only contacts the client is willing to use. Talk through fears, such as fear of being hospitalised.
6. Making the environment safe. See 4.4.
- Afterwards: ask which parts seem most helpful and how likely the client is to use the plan. Problem-solve any ambivalence.
- If time allows, role-play: the client describes a crisis, finds the plan and walks through each step.
- The client keeps the original and the record keeps a copy. Suggest several copies or a phone version. With consent, give a copy to a support person.
Example language (illustrative): "Let's write down what you can do, step by step, if things start building toward a crisis. We'll use your words and only things you'd actually do. What's the very first sign, in your body or your thoughts, that things are heading that way?"
Watch for:
- A plan written by the clinician, not the client.
- Steps the client rates as unlikely to be used.
- Contacts who are themselves a source of conflict.
- Framing the plan as a promise or contract.
- Working well looks like this: the client reports using early steps and de-escalating before reaching step 5.

4.4 Lethal means counselling (means safety)

Purpose / when: The early phase, as the final Safety Plan step. Revisit whenever risk rises [source: Stanley & Brown 2012; Focus; CDP].
Steps [source: Stanley & Brown 2012]:
1. Ask which methods the client has considered. Always ask about access to firearms.
2. For firearms and other highly lethal means, arrange storage away from the home with a responsible third party, or locked storage with the key held by someone else. A high-risk client should not handle the firearm themselves to arrange this.
3. For lower-lethality means, the client may ask a trusted person to hold or secure them.
4. Write down the specific agreed action, who does it, and for how long (e.g. two weeks or a month).
5. Check at the next session that it happened.
6. Explain that restricting one method does not guarantee safety, so the other Safety Plan steps still matter.
Example language (illustrative): "Suicidal crises often pass, and putting time and distance between you and the means can get you through the worst of it. Who could hold on to that for a while?"
Watch for: Vague agreements with no named person; unverified follow-through; substitution of another method. Involve family with consent [synthesis].

4.5 Narrative interview of the recent suicidal crisis (timeline)

Purpose / when: Early phase, usually session 1 or 2. Builds a detailed account of the sequence of external events, thoughts and images, emotions and behaviours before, during and after the most recent crisis. It is the raw data for the conceptualization and Safety Plan, and it builds rapport [source: Focus; CDP; Penn; NJ-ACT; Stanley & Brown 2012].
Steps:
1. Explain the purpose: understanding exactly how this crisis built up will show where to step in next time.
2. Ask the client to tell the story in their own words, starting where they think it began, often hours or days before. Let them narrate before structuring.
3. Then walk it forward point by point. At each point: what happened, what went through your mind, any images, what you felt and how strongly, what you did next.
4. Mark the point where suicidal thinking became the focus and the point where the client acted.
5. Cover the aftermath: how the attempt ended, help-seeking, reactions to surviving (see 4.2).
6. Draw it as a timeline on paper with the client. Wenzel's workshop example runs from criticism to anger, an automatic thought, depression and then the attempt [source: NJ-ACT].
7. Close by naming two or three points where a different thought or action might have changed the outcome. These become treatment targets [source: NJ-ACT].
Example language (illustrative): "Can you take me back to the day this happened, maybe even the day before, and tell me what was going on? Then we'll slow it down and look at each moment."
Watch for: Rising distress during the retelling. Pace it, ground the client and close with the Safety Plan [synthesis]. Gaps due to intoxication or dissociation can be marked as unknown. Shame-driven omissions call for normalising, nonjudgmental curiosity.

4.6 Cognitive case conceptualization

Purpose / when: Early phase, after the narrative. A shared map linking vulnerabilities and early experiences to beliefs and to the crisis sequence. It guides which interventions follow [source: Focus; CDP; Penn; Ghahramanlou-Holloway et al. 2014].
Steps:
1. From history, identify background and dispositional vulnerabilities, e.g. early adversity, impulsivity, problem-solving deficits, substance use, psychiatric problems [source: Ghahramanlou-Holloway et al. 2014; the content of the vulnerability list is uncertain, from Wenzel & Beck 2008].
2. Identify core beliefs (e.g. worthless, unlovable, helpless, a burden) and conditional assumptions.
3. Lay the timeline from 4.5 beneath them, showing how triggers activated the beliefs, how automatic thoughts and hopelessness escalated, and where attention narrowed onto suicide.
4. Draw it as a diagram with the client. A Judith Beck-style conceptualization diagram is one option [source: Ghahramanlou-Holloway et al. 2014].
5. Check fit: does this make sense? What would you change?
Example language (illustrative): "So when your partner criticised you, the thought 'I always ruin everything' showed up, and that fits a bigger belief that you're a burden. Does that ring true?"
Watch for: A diagram imposed by the therapist. Revise it as new crises reveal new pathways.

4.7 Treatment goals and treatment plan

Purpose / when: End of the early phase [source: Penn; CDP; Focus].
Steps:
1. Convert each high-leverage point in the conceptualization into a goal, e.g. reduce hopelessness, improve problem solving with partner conflict, reduce drinking when distressed, increase contact with friends.
2. Keep the overarching goal explicit: preventing a suicidal act.
3. Match each goal to middle-phase interventions (4.10–4.20).
4. Agree on how progress will be noticed [synthesis].
Example language (illustrative): "If we look at your timeline, which two changes would have made the biggest difference that night?"
Watch for: Goals too broad ("be happy"). Goals unconnected to suicide risk.

4.8 Reasons for living (and reasons for dying)

Purpose / when: Early phase, alongside the Hope Kit, and repeated in the middle phase when hopelessness is high [source: Focus; CDP; NJ-ACT].
Steps:
1. Ask the client to list reasons for living. Prompt across domains: people, pets, faith, future goals, values, things still to experience.
2. Acknowledge the reasons for dying openly. The NJ-ACT summary describes discussing both; weigh them together without dismissing either.
3. List past accomplishments and times the client got through hard periods [source: NJ-ACT].
4. Write the reasons down. Add them to the Hope Kit or coping cards.
5. Re-rate how believable each reason feels when distressed, and strengthen weak ones with evidence [synthesis].
Example language (illustrative): "Part of you wanted to die that night, and part of you is here today. Can we hear from both parts?"
Watch for: Lists the client says they don't believe; reasons that depend on one fragile relationship.

4.9 Hope Kit (hope box, coping box)

Purpose / when: Early phase. A collection of tangible reminders of reasons for living, positive memories and hopes, for use when the suicide mode is active [source: Focus; Penn; NJ-ACT; Ghahramanlou-Holloway et al. 2014].
Steps:
1. Explain that hopelessness narrows memory and attention, so concrete reminders can help.
2. Brainstorm items, e.g. photos of loved ones, letters, a prayer card, a meaningful poem or song, souvenirs, coping cards [source: NJ-ACT; Ghahramanlou-Holloway et al. 2014].
3. Ideally assemble or plan it in session. Review every item for real helpfulness, and remove any that could trigger grief or guilt [source: Ghahramanlou-Holloway et al. 2014].
4. Agree where it is kept, and add it to the Safety Plan's internal coping step.
5. A digital version is an option: a phone folder or the Virtual Hope Box app [source: NJ-ACT; Ghahramanlou-Holloway et al. 2014].
6. Review it at the next session: what was added, and was it used?
Example language (illustrative): "If you opened this box on your worst night, what would you want to find in it?"
Watch for: Items that backfire (e.g. a photo of an estranged ex); a box that never gets built. Make it homework with a specific start.

4.10 Psychoeducation: the cognitive model and the suicide mode

Purpose / when: End of the early phase or start of the middle phase. Gives the client a framework for noticing when the suicide mode is activating and why skills help [source: Focus; CDP].
Steps:
1. Using the client's own timeline, show how situations trigger thoughts, how thoughts drive feelings and actions, and how feelings feed back into thoughts.
2. Introduce the idea of a suicide mode: a state in which attention narrows, hopelessness rises and suicide looks like the only option.
3. Identify the client's personal early signals of the mode. Link them to the Safety Plan's warning signs.
Example language (illustrative): "When you're in that mode, your mind tunnels in on one option. Our job is to help you spot the tunnel early and have ways out."
Watch for: Abstract teaching. Always use the client's own material.

4.11 Identifying and evaluating suicide-relevant automatic thoughts (cognitive restructuring)

Purpose / when: Middle phase, when the conceptualization shows hopeless, burdensome, unbearable or 'no way out' thoughts driving the sequence [source: Focus; CDP; Penn name the technique. The steps below are standard Beck CT, applied as synthesis].
Steps:
1. Pick a thought from the crisis timeline or from the past week, e.g. "Nothing will ever change".
2. Rate how strongly the client believes it (0–100%) and the emotion it produces.
3. Socratic questions: evidence for and against; other explanations; what the client would tell a friend; the worst, best and most realistic outcomes; what effect holding the thought has.
4. Build a balanced alternative thought together, then re-rate belief and emotion.
5. Practise between sessions with a thought record. Transfer the best alternative thoughts onto coping cards (4.12).
Example language (illustrative): "You wrote 'I'll always be alone.' What's happened in the last month that fits that, and what doesn't fit it?"
Watch for:
- The client agrees intellectually but feels no change. Use behavioural experiments or work on core beliefs.
- Challenging the thoughts too hard too early, so the client feels invalidated. Validate the pain first.
- Signs it is working: belief in hopeless thoughts drops and the client can generate alternatives unaided.

4.12 Coping cards

Purpose / when: Middle phase, and earlier if useful. These are portable prompts for crisis moments. One format puts an automatic suicidal thought on one side and an adaptive response on the other; other cards list reasons for living or coping steps [source: NJ-ACT; Ghahramanlou-Holloway et al. 2014; Focus names it only for BCBT; inclusion in CT-SP per NJ-ACT].
Steps:
1. Write the card together in session, in the client's words, wallet-sized or on the phone.
2. Side A: a typical suicide-mode thought. Side B: the alternative response from restructuring, plus one or two actions.
3. Rehearse reading and using it in session.
4. Homework: read it daily, including when not in crisis, so it is familiar when needed [source: Ghahramanlou-Holloway et al. 2014].
5. Add the card to the Hope Kit and refer to it in the Safety Plan.
Example language (illustrative): "Let's put the thought that shows up at 2 a.m. on the front, and on the back what you'd want your future self to read in that moment."
Watch for: Generic slogans the client doesn't believe; cards left in a drawer. Check use at every session.

4.13 Modifying core beliefs

Purpose / when: Middle phase, once thought-level work is under way, for enduring beliefs such as being worthless, unlovable, helpless or a burden that keep reactivating the suicide mode [source: Focus; CDP. Methods are standard Beck CT, synthesis].
Steps:
1. Name the belief from the conceptualization and rate how strongly it is held.
2. Draft a more adaptive belief.
3. Gather evidence over time for the new belief, e.g. a daily positive data log; reinterpret past evidence for the old one.
4. Use historical review and behavioural experiments.
5. Re-rate both beliefs periodically.
Example language (illustrative): "This week, could you note anything, however small, that doesn't fit 'I'm a burden'?"
Watch for: Spending scarce sessions here while acute skills are missing. In a 10-session protocol, prioritise crisis-relevant skills [synthesis].

4.14 Problem solving

Purpose / when: Middle phase, when the timeline shows that unsolved problems (relationship, financial, legal, housing) fed hopelessness, or that the client sees no solutions [source: Penn names it as a middle-phase intervention. Steps follow the standard problem-solving format, synthesis].
Steps:
1. Define one problem concretely.
2. Brainstorm options without judging them.
3. Weigh pros and cons.
4. Choose one option and break it into steps.
5. Anticipate obstacles.
6. Act on it as homework.
7. Review the outcome and adjust.
Example language (illustrative): "Suicide seemed like the only solution that night. Let's see how many other options we can list for this problem, even ones that seem unlikely."
Watch for: The therapist generating all the solutions; problems too big to tackle in one go. Break them down.

4.15 Behavioural activation and activity monitoring

Purpose / when: Middle phase, for withdrawal, inactivity, anhedonia or depression in the sequence [source: Focus; CDP (activity monitoring); Penn].
Steps:
1. Monitor activities hourly for a week, rating mastery and pleasure.
2. Review the record: which activities lift mood and which lower it.
3. Schedule a small number of valued, achievable activities.
4. Grade the tasks and plan for obstacles.
5. Review and expand [synthesis: standard BA steps].
Example language (illustrative): "Your log shows Sunday was the hardest day and the one with nothing planned. What's one thing we could put there?"
Watch for: All-or-nothing planning. Celebrate partial completion.

4.16 Relaxation training

Purpose / when: Middle phase, for high arousal, agitation or insomnia in the crisis sequence [source: Focus; CDP; NJ-ACT (muscle relaxation)].
Steps:
1. Teach one method in session, e.g. progressive muscle relaxation or paced breathing.
2. Practise it in session and rate tension before and after.
3. Assign daily practice when calm, so it is available in crisis.
4. Add it to the Safety Plan's internal coping step.
Example language (illustrative): "Let's practise this now so it's familiar before you need it."
Watch for: Relaxation-induced anxiety; use in place of other Safety Plan steps when risk is high.

4.17 Distraction and self-soothing

Purpose / when: Early and middle phases, to ride out acute peaks of suicidal urge [source: Focus; NJ-ACT; Stanley & Brown 2012].
Steps:
1. List absorbing activities and self-soothing activities (exercise, music, a shower, going to a public place).
2. Rank them by effectiveness and practise at low distress.
3. Add them to the Safety Plan.
Example language (illustrative): "What has taken your mind off things before, even for twenty minutes?"
Watch for: Distraction via alcohol or drugs; isolation masked as 'distraction'.

4.18 Reducing emotional vulnerability, self-care and distress tolerance

Purpose / when: Middle phase, when poor sleep, irregular eating, substance use, untreated illness or low distress tolerance lower the client's threshold for crisis [source: Focus ("reducing emotional vulnerability", "self-care"); Penn ("distress tolerance"); NJ-ACT ("mindfulness")]. CT-SP-specific procedures were not found [uncertain]. The steps below are synthesis.
Steps:
1. Review sleep, eating, exercise, substance use and medical care against the crisis timeline.
2. Choose one target and set a concrete behavioural goal.
3. Teach brief distress tolerance or mindfulness skills, e.g. grounding, or observing an urge without acting.
4. Practise them in session and track them as homework.
Example language (illustrative): "Both of your worst nights followed several nights with almost no sleep. Shall we make sleep one of our targets?"
Watch for: Overloading the client with lifestyle goals. Keep it to one or two.

4.19 Increasing social resources and support

Purpose / when: Middle phase, for isolation or conflictual relationships in the sequence [source: CDP ("increasing social resources")]. Steps are synthesis.
Steps:
1. Map current contacts, noting who helps and who harms.
2. Choose one connection to strengthen or reconnect with.
3. Rehearse the contact (role-play) and set it as homework.
4. With consent, consider a session with a support person to review the Safety Plan.
Example language (illustrative): "Who is one person you'd feel even slightly OK reaching out to this week?"
Watch for: Rejection experiences. Plan for how the client will cope if a contact does not respond.

4.20 Improving adherence to adjunctive care

Purpose / when: Throughout, when the client also needs psychiatric, substance-use, medical or social services [source: the NJ-ACT summary says CT-SP is added to other treatment. The book is reported to cover compliance with adjunctive services, but this was not verified [uncertain]].
Steps [synthesis]:
1. List the client's other providers and appointments.
2. Identify barriers (beliefs about medication, transport, cost, stigma).
3. Problem-solve the barriers and rehearse calls.
4. With consent, coordinate with prescribers and share the Safety Plan.
Watch for: Stopping medication suddenly; unshared risk information across providers.

4.21 Homework

Purpose / when: Every session [source: Focus (homework review is part of the structure)].
Steps:
1. Agree one or two small tasks linked to the session's work.
2. Rate how likely the client is to do them and problem-solve barriers.
3. Start the task in session if possible.
4. Always review it next session [synthesis: standard CT].
Example language (illustrative): "On a 0 to 100 scale, how likely are you to do this? What could get in the way?"
Watch for: Tasks the therapist chose alone; reviewing homework only when it was done.

4.22 Relapse prevention task (guided imagery)

Purpose / when: Later phase, once skills are consolidated. The client shows they can use the skills, cognitive restructuring and Safety Plan while imagining the past crisis and a plausible future one, instead of acting on suicidal thoughts [source: Focus; CDP; Penn; NJ-ACT]. Detailed protocol steps are from secondary descriptions; the book's exact procedure is [uncertain].
Steps:
1. Preparation. Explain the rationale and that the task may stir up strong feelings. Obtain consent. Agree a stop signal and make sure the Safety Plan is at hand. Do not start this in a session where the client arrives in acute crisis [synthesis].
2. Imagine the index crisis. With eyes closed if comfortable, the client imagines the events leading to the most recent crisis, moment by moment, as reconstructed in the narrative, describing thoughts, feelings and actions aloud.
3. Re-imagine the index crisis with skills. The client goes through the same sequence again, this time using the coping skills, alternative thoughts, Hope Kit and Safety Plan steps at the identified points [source: NJ-ACT; Focus].
4. Imagine a future crisis. Together, identify a realistic high-risk future situation, e.g. a relationship ending, an anniversary or a relapse to drinking. The client imagines it and walks through how they would cope [source: NJ-ACT; CDP].
5. Debrief. Discuss what was learned and what was hard. Summarise the skills used. Update the Safety Plan [source: CDP].
6. Re-assess risk [source: CDP].
7. Decide next steps. If the client generalised the skills well, move to ending or the continuation phase. If not, return to skill building for the gaps and repeat the task later [source: CDP "offers further sessions"; the repeat rule is uncertain, attributed to the book].
Example language (illustrative): "Close your eyes if that's comfortable and take me back to that afternoon. Where are you, and what's happening? ... Now let's run it again. This time, when that thought comes, what do you do?"
Watch for:
- Overwhelm: pause, ground the client, and resume or split the task over two sessions.
- Imagery that is too vague to test anything; the client skipping steps.
- Signs it is working: spontaneous, specific use of skills at each decision point, and the client's confidence rising.

4.23 Continuation and booster sessions

Purpose / when: After acute treatment, up to 6 sessions over 12 weeks, as needed [source: Focus].
Steps [synthesis]:
1. Space the sessions out.
2. Each session: risk check, Safety Plan review, application of skills to new stressors.
3. Repeat the relapse prevention task if a new crisis occurs.
4. Plan referrals and the handover to ongoing care.
Watch for: Abrupt ending in a high-risk period, e.g. near an anniversary or after a loss.

4.24 Active engagement and missed-session follow-up

Purpose / when: Throughout. Clients after an attempt often drop out of care [source: Stanley & Brown 2012 on poor follow-up; NJ-ACT].
Steps:
1. Agree in session 1 what you will do if the client misses a session.
2. If a session is missed, call the same day and offer a phone session or an extra appointment [source: NJ-ACT].
3. Assess what provoked the non-attendance and problem-solve it [source: NJ-ACT].
4. Check risk on the call.
Example language (illustrative): "I noticed you weren't able to make it today and wanted to check in. How are things, and how are the thoughts of suicide?"
Watch for: A missed session after a stressor; no reply to outreach. Follow the agreed plan and local policy for welfare checks [synthesis].

5. Handling problems

The sources give direct guidance only on missed sessions, ambivalence about the Safety Plan, reluctance to contact professionals, and the order of priorities. Everything else here is marked [synthesis].

Acute crisis or imminent risk in session.
- Set the agenda aside and work through the Safety Plan steps live.
- If the client cannot commit to staying safe even for a short time, arrange emergency evaluation or hospitalisation [source: Stanley & Brown 2012].
- Afterwards, map the episode as a new mini-timeline and fold it into the conceptualization [synthesis].
A new suicide attempt during treatment.
- Re-assess and decide the level of care.
- Conduct a fresh narrative interview of the new crisis.
- Revise the Safety Plan at the point where it failed.
- Extend the middle phase as needed; do not move to the relapse prevention task until the new pathway is addressed [synthesis].
Ambivalence about the Safety Plan, or low rated likelihood of use.
- Identify the specific obstacles and problem-solve them together.
- Remove steps the client won't use, rather than keeping a plan that looks complete [source: Stanley & Brown 2012].
Reluctance to call professionals or crisis lines, often fear of hospitalisation.
- Discuss the fear explicitly and correct misinformation about what happens on a call.
- List only contacts the client is willing to use [source: Stanley & Brown 2012].
Missed sessions and dropout.
- Follow up by phone, offer a phone session or an extra appointment, and analyse the reasons [source: NJ-ACT].
- Treat therapy-interfering behaviour as the second agenda priority after life-threatening behaviour [source: NJ-ACT].
Homework non-adherence.
- Shrink the task, start it in session, and ask about the meaning of not doing it, e.g. hopelessness ("what's the point") or perfectionism.
- Use that thought as a target for cognitive restructuring [synthesis].
Persistent hopelessness, or the client says nothing will help.
- Validate the pain. Use reasons-for-living work and the Hope Kit.
- Frame therapy as an experiment with a defined length, i.e. about 10 sessions.
- Look at evidence from past times the client felt this way and it changed [synthesis, consistent with Focus emphasis on hopelessness].
Overwhelm during the narrative interview or the relapse prevention task.
- Slow down, ground the client, and split the task across sessions.
- End with the Safety Plan and a check of current risk. Never end a session at peak distress [synthesis].
The client wants to talk only about the attempt's precipitants, e.g. a partner, not their own role.
- Validate the stressor.
- Then return to the client's own thoughts and choices at each point on the timeline, where they have leverage [synthesis].
Minimising or concealing ideation, e.g. to avoid hospitalisation or to please the therapist.
- Normalise disclosure and explain how information will be used.
- Never use a no-suicide contract, which encourages concealment [source: Stanley & Brown 2012].
- Use collateral information with consent [synthesis].
Substance use in the crisis chain.
- Map it on the timeline. Remove settings with substances from the Safety Plan [source: Stanley & Brown 2012].
- Treat substance use as a treatment goal, and coordinate or refer for substance-use treatment [synthesis].
Chronic ideation without recent attempts.
- CT-SP targets ideation as well as behaviour; the conceptualization can be built from the worst recent episode of ideation.
- Penn and Focus note ongoing work extending CT-SP to people with severe ideation without attempts [source: Penn; Focus]. Expect the time-limited goal to be reduced intensity and better coping, not zero ideation [synthesis].
Means-safety refusal, e.g. a client who won't give up firearms.
- Explore options with less loss, such as temporary off-site storage or locks with the key held by someone else, and time limits.
- Involve family with consent, document, and revisit each session [source: Stanley & Brown 2012 for options; the rest is synthesis].
Ruptures, e.g. anger at the therapist about involuntary care or a risk-driven decision.
- Name the rupture, invite the client's perspective, and acknowledge your part.
- Explain the safety reasoning transparently and return to shared goals.
- Use the CTRS-rated feedback request at the end of each session to catch early strains [synthesis].
Therapist anxiety, or over-focus on risk management at the expense of skill work.
- Use consultation (Penn's model includes weekly group consultation).
- Keep the risk check brief and structured, then protect time for skills [source: Penn for consultation; the rest is synthesis].
Ending while risk persists.
- Do not end acute treatment on the calendar alone. Use the relapse prevention task, a full risk assessment and the continuation phase or referral [source: CDP; Focus].
Adolescents.
- CT-SP has not been adapted or tested with youth, and Penn does not train for it [source: Penn].
- Use a youth-adapted protocol (e.g. CBT-SP for adolescents) rather than improvising [synthesis; that protocol is not detailed here].

Sources

Sources: