Cognitive behavioral treatment for suicidal substance users
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Cognitive Behavioral Treatment for Suicidal Substance Users . Mark Ilgen, Ph.D. VA Serious Mental Illness Treatment Research and Evaluation Center Assistant Professor of Psychiatry, University of Michigan. Acknowledgements.

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Cognitive Behavioral Treatment for Suicidal Substance Users

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Cognitive Behavioral Treatment for Suicidal Substance Users

Mark Ilgen, Ph.D.

VA Serious Mental Illness Treatment Research and Evaluation Center

Assistant Professor of Psychiatry, University of Michigan


  • This work was supported by the National Institute on Drug Abuse (R21DA026925).

  • Thanks to patients and treatment providers at Community Programs Incorporated.

  • I have no conflicts of interest to declare.


  • Describe the process of modifying CBT for suicidal substance users.

  • Discuss content of the intervention.

Interventions to Address Patients at High risk for Suicide

  • Intervention research on suicide is difficult

  • Most well-controlled experimental trials focus on suicidal thoughts or non-fatal attempts as the outcome

  • Linehan et al. (2006) - women randomized to DBT had lower rates of suicide attempt over a 2-year follow-up than those randomized to community therapists (N = 101)

  • Brown et al. (2005) – individuals randomized to CBT had significantly fewer attempts from baseline to 18-months than those randomized to usual care (N = 120)

  • Both Linehan and Brown have versions of their treatment for individuals with substance use disorders – mostly developed on patients in methadone maintenance treatment

  • Existing treatments tend to be relatively long term; could be difficult to implement in standard addictions treatment settings

Addressing Suicide Risk During Addictions Treatment.

  • Advantages of working in a residential treatment setting:

    • Period of sobriety and relative safety

    • Logistics of delivery treatment are easier

    • Patients may be motivated to re-evaluate their situation when in treatment

Study Design

  • First phase of study was to modify intervention.

  • Pilot RCT of men and women recruited from a large residential addictions treatment program in Waterford, MI

  • To be eligible, participants must report:

    • At least one prior suicide attempt

    • Current suicidal ideation (BSS > 5 during the past week)

  • 50 Participants randomly assigned to 8 sessions of:

    • CBT

    • Educational supportive therapy

Community Programs Incorporated

Case Example Background

  • 35 year old Caucasian man

  • Treatment in lieu of jail time for cocaine possession

  • Substances of misuse (since age 13):

    • Cocaine, Alcohol, Marijuana

  • Divorced; unemployed

  • Ex-girlfriend died by suicide

  • One prior suicide attempt; overdose found by mother

Overall of CBT for Suicidal Substance Users

  • Similar structure to CBT for depression and CBT for substance use.

  • Primary difference, most of the content focuses on avoiding/managing a suicidal crisis.

  • Based on:

    • Wenzel, A., Brown, G., and Beck, A. Cognitive Therapy for Suicidal Patients: Scientific and Clinical Approaches. American Psychological Association, 2008.

Structure of Sessions

  • Mood/check

  • Tie to previous session

  • Set agenda

  • Review homework

  • Cover primary session topics

  • Discuss homework assignment

  • Summary and feedback

Session Content

Case Example Response to treatment

  • Described prior attempt as a “huge mistake” that won’t happen again; however, during treatment reported that he often thought about how to “get it right” the next time

  • Appreciated chance to talk about suicidal thoughts and guilt over ex-girlfriend’s death

  • Hope kit – challenge to find things that did not glorify drug use

  • Benefitted from the imaginal exposure

Update on Study

  • Recruited 25 participants

  • All have been accepting of our risk management protocol

  • Most participants reported that they had never discussed prior attempts previously in treatment

  • Most participants express some embarrassment about prior attempt and state that it “won’t happen again”

  • Homework compliance has been excellent

  • Sessions sometimes feel rushed

  • Participants are generally positive about session content (including coping cards and hope kits)

Changes in post-session mood ratings in CBT condition


  • CBT techniques can be applied to treating suicidal substance users

  • Many patients are reluctant to discuss prior suicidal episodes but, over time, appear to appreciate this opportunity

  • This topic seems to receive little attention during “standard” addictions treatment

  • Although faced with challenging circumstances, all participants expressed hope about the future and investment in staying safe following treatment

Thank You!

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