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 evidence‐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 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 cognitive processing therapy treatment program reduced both PTSD and suicidal ideation. Conclusions Suicide specific treatments can be integrated effectively into trauma‐focused treatments.

Treating Veterans at Risk for Suicide: An Examination of the Safety, Tolerability, and Outcomes of Cognitive Processing Therapy

“…First and foremost, the present findings indicate that veterans with PTSD at an increased risk for suicide can safely tolerate and benefit from trauma‐focused therapy. Despite some recent support for the safety and tolerability of such interventions (e.g., Bryan et al., 2016; Rozek & Bryan, 2020), many clinicians and patients worry that individuals with suicidal ideation or a history of suicide attempts “cannot handle” trauma‐focused therapy or that it will “trigger a suicidal crisis.” Rather, we argue that withholding trauma‐focused therapy from individuals whose suffering is largely due to their PTSD symptoms is contraindicated and reinforces thoughts of hopelessness and poor self‐esteem that contribute to one's risk for death by suicide. For individuals who are deemed to be at an elevated risk of suicide, it is likely important to target negative cognitions related to suicidal ideation and/or behavior.…”

“…Another option is to integrate suicide‐specific interventions into CPT. Preliminary models show that integrating a suicide safety plan or crisis response plan into CPT can be effective while maintaining fidelity to both interventions (Rozek & Bryan, 2020). This integration prioritizes the discussion of suicide risk and coping strategies at each session.…”

“…Because trauma processing involves recalling distressing information, many providers may prefer to hold off on interventions that include this element when a patient is deemed to have elevated risk factors for suicide. However, there are models of incorporating suicide‐specific interventions into CPT to ensure that suicidality is a focus of treatment and thus being managed (e.g., Rozek & Bryan, 2020). Further, the current CPT manual (Resick, Monson, et al., 2017) lists several therapist “stuck points” involving patient readiness for treatment due to suicide risk despite the empirical evidence supporting the administration of CPT with ongoing suicidal ideation and/or behavior (e.g., Bryan et al., 2016; Rozek & Bryan, 2020).…”

“…However, there are models of incorporating suicide‐specific interventions into CPT to ensure that suicidality is a focus of treatment and thus being managed (e.g., Rozek & Bryan, 2020). Further, the current CPT manual (Resick, Monson, et al., 2017) lists several therapist “stuck points” involving patient readiness for treatment due to suicide risk despite the empirical evidence supporting the administration of CPT with ongoing suicidal ideation and/or behavior (e.g., Bryan et al., 2016; Rozek & Bryan, 2020). Although providers may desire to delay CPT administration to patients who are at risk of suicide, empirical evidence suggests that suicidal ideation reduces over the course of treatment with CPT (Bryan et al., 2016; Holliday et al., 2018; Stayton et al., 2019).…”

Introduction to the Special Issue on Posttraumatic Stress and Suicide

“…Nonetheless, suicide risk was not associated with client ratings of the tolerability of CPT nor were there differences in completion rates or the effectiveness of CPT for reducing PTSD symptoms across participants with and without suicide risk. This study highlights the high prevalence of suicidality among veterans seeking PTSD treatment, which suggests the value of training trauma therapists to integrate suicide‐specific interventions into evidence‐based treatments, such as the flexible incorporation of a safety plan into CPT, while maintaining fidelity to the overarching model (Rozek & Bryan, 2020). Importantly, these three papers are uniform in striking a hopeful note regarding the effectiveness of existing evidence‐based treatments for addressing co‐occurring PTSD and suicide.…”