Guest Perspective: Targeting suicide risk itself, not psychological disorders, reduces suicidal behavior
Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
By Craig J. Bryan, Psy.D., ABPP
Guest Columnist
This past year our research team published the results of a randomized clinical trial (RCT) testing brief Cognitive Behavioral Therapy (BCBT) as compared to treatment as usual (TAU) for the prevention of suicidal behavior among military personnel. BCBT is the first scientifically-supported intervention for preventing suicidal behavior in the military. Soldiers who received the 12-session BCBT were 60% less likely to make a suicide attempt during the 2-year follow-up as compared to Soldiers who received TAU. As the public’s awareness of BCBT grows, there has been considerable interest in understanding more about this treatment. Below I provide answers to some of the most common questions asked about BCBT.
BCBT performed better than treatment as usual. What is “treatment as usual”?
Treatment as usual (TAU), sometimes also referred to as “usual care,” is a common comparison condition in medical treatment. In essence, TAU entails the treatment package a typical person could reasonably expect to receive from a health care provider. For a mental health study such as this one, TAU could include a combination of individual psychotherapy, group therapy, medication, substance abuse treatment, marital therapy, case management, and more. TAU is often used as a comparison condition with suicidal patients because we are ethically required to provide treatment to suicidal individuals. When we say that BCBT has better outcomes than TAU, we are therefore saying that Soldiers are much less likely to attempt suicide during or after BCBT as compared to the typical treatment that is already available to them.
How do you know that BCBT is actually better than TAU?
In this study, we used simple randomization to determine which treatment a Soldier would use. This is similar to flipping a coin: we leave it up to chance. This is one of the best ways to reduce the biases we might have as researchers. Because we used this procedure, we were able to ensure that the Soldiers in each treatment did not differ from each other with respect to gender, age, clinical diagnosis, medication use, and other background issues. This increases our confidence in concluding that the differences in outcomes are due to the differences between the treatments. The final results of this study indicate that the 60% reduction in suicide attempts among Soldiers in BCBT is very unlikely to happen by chance alone; the probability of achieving an outcome this large (or larger) if BCBT really wasn’t superior to TAU is less than 2%.
Soldiers in BCBT attended more therapy sessions than Soldiers in TAU. Doesn’t that mean the benefits of BCBT are simply due to attending more therapy sessions?
We have considered this possibility and recently published the results of an analysis to answer this question. What we did was compare BCBT to TAU according to the total number of sessions attended by Soldiers. We found that BCBT continued to have better outcomes than TAU in both the short term and long term regardless of how many sessions Soldiers attended. In other words, Soldiers who received BCBT fared better than Soldiers who received TAU even if they attended a much smaller number of BCBT sessions.
Is BCBT less effective for Soldiers with certain diagnoses?
We have conducted additional analyses to see if BCBT is less effective among Soldiers diagnosed with substance use disorder, posttraumatic stress disorder, and borderline personality disorder. We did not have enough Soldiers enrolled in this study to definitively answer this question, but our preliminary analyses indicate that the effect of BCBT persists across all of these subgroups of Soldiers. We have found similar patterns for female Soldiers and Soldiers who have never attempted suicide. We plan to do more research to more definitively determine who benefits the most from BCBT and, conversely, who benefits less from BCBT. This supports the perspective that BCBT is a “transdiagnostic” therapy, which means it works across many different clinical problems, diagnoses, and patient populations.
Why does BCBT work better than existing mental health treatment?
We are currently trying to answer this question, and have a few promising possibilities. First, BCBT targets several core problems that contribute directly to increased suicide risk: tolerating uncomfortable emotions, problem solving, and evaluating ourselves and the world. By contrast, typical mental health treatment focuses on reducing symptoms like depression, anxiety, and suicidal thinking. Unfortunately, focusing on symptoms without also focusing on these three core areas doesn’t seem to be as helpful. We have recently completed additional analyses that suggest these three targets in BCBT may be reducing suicidal behavior through the following mechanisms:
- Soldiers in BCBT who do not attempt suicide have less desire for death, but have a stronger desire for life. In addition, the desire for life “pushes” or “resets” the Soldier’s desire for death in BCBT. This “resetting” process does not occur among Soldiers in TAU, and does not occur among Soldiers in BCBT who do attempt suicide. BCBT may therefore prevent suicidal behavior because it changes the relative balance between the desire to live and the desire to die. This probably occurs because BCBT includes several interventions and activities that focus on the Soldier’s reasons for living.
- Soldiers in BCBT tend to rate their clinicians as more empathic and collaborative at the end of treatment as compared to Soldiers in TAU. Soldiers in BCBT are therefore more likely to feel their clinicians are on the “same wavelength” as them across therapy. Agreement on the specific tasks and activities of therapy (e.g., skills training, assignments, conversation topics), in particular, is associated with reductions in suicide attempts during BCBT, which suggests that BCBT may facilitate agreement between Soldiers and clinicians about what’s important in treatment.
What’s the future of BCBT?
We will continue to work on understanding why and how BCBT works, and are already planning additional studies aimed at figuring out how to make BCBT work even better. This recently-completed study is therefore only the first step in developing new interventions for Soldiers in need.
How can I learn more about BCBT?
A description of BCBT and several adaptations of this treatment approach across a wide range of clinical settings and populations (e.g., inpatient psychiatric units, primary care clinics, emergency departments) can be found in my book entitled Cognitive Behavioral Therapy for Preventing Suicide Attempts: A Guide to Brief Treatments Across Clinical Settings.
Dr. Craig J. Bryan, PsyD, ABPP, is a board-certified clinical psychologist in cognitive behavioral psychology, and is currently the Executive Director of the National Center for Veterans Studies at The University of Utah. Dr. Bryan received his PsyD in clinical psychology in 2006 from Baylor University, and completed his clinical psychology residency at the Wilford Hall Medical Center, Lackland Air Force Base, TX. He has authored over 100 scientific publications and book chapters, including the books Brief Cognitive Behavioral Therapy for Preventing Suicide Attempts: A Guide to Brief Treatments Across Clinical Settings, and the forthcoming book, Handbook of Psychosocial Interventions for Veterans: A Guide for the Non-Military Mental Health Clinician. For his contributions to military suicide prevention, posttraumatic stress disorder, and traumatic brain injury, Dr. Bryan was recognized in 2009 by the Society for Military Psychology with the Arthur W. Melton Award for Early Career Achievement and in 2013 by Psychologists in Public Service with the Peter J.N. Linnerooth National Service Award. He can be contacted at ncvs@utah.edu
Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
By Craig J. Bryan, Psy.D., ABPP
Guest Columnist
This past year our research team published the results of a randomized clinical trial (RCT) testing brief Cognitive Behavioral Therapy (BCBT) as compared to treatment as usual (TAU) for the prevention of suicidal behavior among military personnel. BCBT is the first scientifically-supported intervention for preventing suicidal behavior in the military. Soldiers who received the 12-session BCBT were 60% less likely to make a suicide attempt during the 2-year follow-up as compared to Soldiers who received TAU. As the public’s awareness of BCBT grows, there has been considerable interest in understanding more about this treatment. Below I provide answers to some of the most common questions asked about BCBT.
BCBT performed better than treatment as usual. What is “treatment as usual”?
Treatment as usual (TAU), sometimes also referred to as “usual care,” is a common comparison condition in medical treatment. In essence, TAU entails the treatment package a typical person could reasonably expect to receive from a health care provider. For a mental health study such as this one, TAU could include a combination of individual psychotherapy, group therapy, medication, substance abuse treatment, marital therapy, case management, and more. TAU is often used as a comparison condition with suicidal patients because we are ethically required to provide treatment to suicidal individuals. When we say that BCBT has better outcomes than TAU, we are therefore saying that Soldiers are much less likely to attempt suicide during or after BCBT as compared to the typical treatment that is already available to them.
How do you know that BCBT is actually better than TAU?
In this study, we used simple randomization to determine which treatment a Soldier would use. This is similar to flipping a coin: we leave it up to chance. This is one of the best ways to reduce the biases we might have as researchers. Because we used this procedure, we were able to ensure that the Soldiers in each treatment did not differ from each other with respect to gender, age, clinical diagnosis, medication use, and other background issues. This increases our confidence in concluding that the differences in outcomes are due to the differences between the treatments. The final results of this study indicate that the 60% reduction in suicide attempts among Soldiers in BCBT is very unlikely to happen by chance alone; the probability of achieving an outcome this large (or larger) if BCBT really wasn’t superior to TAU is less than 2%.
Soldiers in BCBT attended more therapy sessions than Soldiers in TAU. Doesn’t that mean the benefits of BCBT are simply due to attending more therapy sessions?
We have considered this possibility and recently published the results of an analysis to answer this question. What we did was compare BCBT to TAU according to the total number of sessions attended by Soldiers. We found that BCBT continued to have better outcomes than TAU in both the short term and long term regardless of how many sessions Soldiers attended. In other words, Soldiers who received BCBT fared better than Soldiers who received TAU even if they attended a much smaller number of BCBT sessions.
Is BCBT less effective for Soldiers with certain diagnoses?
We have conducted additional analyses to see if BCBT is less effective among Soldiers diagnosed with substance use disorder, posttraumatic stress disorder, and borderline personality disorder. We did not have enough Soldiers enrolled in this study to definitively answer this question, but our preliminary analyses indicate that the effect of BCBT persists across all of these subgroups of Soldiers. We have found similar patterns for female Soldiers and Soldiers who have never attempted suicide. We plan to do more research to more definitively determine who benefits the most from BCBT and, conversely, who benefits less from BCBT. This supports the perspective that BCBT is a “transdiagnostic” therapy, which means it works across many different clinical problems, diagnoses, and patient populations.
Why does BCBT work better than existing mental health treatment?
We are currently trying to answer this question, and have a few promising possibilities. First, BCBT targets several core problems that contribute directly to increased suicide risk: tolerating uncomfortable emotions, problem solving, and evaluating ourselves and the world. By contrast, typical mental health treatment focuses on reducing symptoms like depression, anxiety, and suicidal thinking. Unfortunately, focusing on symptoms without also focusing on these three core areas doesn’t seem to be as helpful. We have recently completed additional analyses that suggest these three targets in BCBT may be reducing suicidal behavior through the following mechanisms:
- Soldiers in BCBT who do not attempt suicide have less desire for death, but have a stronger desire for life. In addition, the desire for life “pushes” or “resets” the Soldier’s desire for death in BCBT. This “resetting” process does not occur among Soldiers in TAU, and does not occur among Soldiers in BCBT who do attempt suicide. BCBT may therefore prevent suicidal behavior because it changes the relative balance between the desire to live and the desire to die. This probably occurs because BCBT includes several interventions and activities that focus on the Soldier’s reasons for living.
- Soldiers in BCBT tend to rate their clinicians as more empathic and collaborative at the end of treatment as compared to Soldiers in TAU. Soldiers in BCBT are therefore more likely to feel their clinicians are on the “same wavelength” as them across therapy. Agreement on the specific tasks and activities of therapy (e.g., skills training, assignments, conversation topics), in particular, is associated with reductions in suicide attempts during BCBT, which suggests that BCBT may facilitate agreement between Soldiers and clinicians about what’s important in treatment.
What’s the future of BCBT?
We will continue to work on understanding why and how BCBT works, and are already planning additional studies aimed at figuring out how to make BCBT work even better. This recently-completed study is therefore only the first step in developing new interventions for Soldiers in need.
How can I learn more about BCBT?
A description of BCBT and several adaptations of this treatment approach across a wide range of clinical settings and populations (e.g., inpatient psychiatric units, primary care clinics, emergency departments) can be found in my book entitled Cognitive Behavioral Therapy for Preventing Suicide Attempts: A Guide to Brief Treatments Across Clinical Settings.
Dr. Craig J. Bryan, PsyD, ABPP, is a board-certified clinical psychologist in cognitive behavioral psychology, and is currently the Executive Director of the National Center for Veterans Studies at The University of Utah. Dr. Bryan received his PsyD in clinical psychology in 2006 from Baylor University, and completed his clinical psychology residency at the Wilford Hall Medical Center, Lackland Air Force Base, TX. He has authored over 100 scientific publications and book chapters, including the books Brief Cognitive Behavioral Therapy for Preventing Suicide Attempts: A Guide to Brief Treatments Across Clinical Settings, and the forthcoming book, Handbook of Psychosocial Interventions for Veterans: A Guide for the Non-Military Mental Health Clinician. For his contributions to military suicide prevention, posttraumatic stress disorder, and traumatic brain injury, Dr. Bryan was recognized in 2009 by the Society for Military Psychology with the Arthur W. Melton Award for Early Career Achievement and in 2013 by Psychologists in Public Service with the Peter J.N. Linnerooth National Service Award. He can be contacted at ncvs@utah.edu