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Cognitive Behavioural Therapy Suicide Prevention (CBT-SP) imagery intervention: a case report

Published online by Cambridge University Press:  17 June 2019

Marie Carey  and
Catherine Wells
Marie Carey*
Affiliation:
Waterford Institute of Technology, Waterford, Ireland
Catherine Wells
Affiliation:
Waterford Institute of Technology, Waterford, Ireland
*
*Corresponding author. Email: mcarey@wit.ie
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Abstract

Very little clinical work or research to date has focused on the prioritization of suicidal imagery intervention in the stabilization of risk. Current Cognitive Behavioural Therapy Suicide Prevention (CBT-SP) does not specifically address suicidal imagery as a priority intervention. This paper prioritizes imagery modification as the central task of therapy with the suicidal client. This is a single subject case review describing specific imagery interventions used to destabilize the comforting component of suicidal images, de-glamourize the suicidal image as a problem-solving method and the reconstruction of new images to offset the emotional grasp of both ‘flash-forward’ violent suicidal images and suicidal ‘daydreaming’ rumination. It is hypothesized that when suicidal images become less emotionally charged, the desire to act upon suicide decreases. Focusing on imagery intervention as a priority aims to stabilize risk in a more clinically specific and targeted way. Rob is a 19-year-old depressed young man with chronic suicidal ideation/images with repeated suicide attempts. All GP referrals are of a crisis nature since the age of 16. He was referred to a CBT clinician with specific training and experience in CBT-SP who proposed the following brief imagery intervention. Socialization to treatment rationale was pivotal at the outset to help facilitate strong therapeutic alliance, ‘buy-in’ to the intended de-glamourization of suicide planning/daydreaming/rumination and the effects of intrusive ‘flash-forward’ images on emotional well-being. Therapy was facilitated weekly, supported by telephone contact, on an out-patient basis in the HSE (Health Service Executive) Irish Adult Mental Health service. The care plan and interventions were supported by access to the 24-hour acute Adult Mental Health services, as required. There was no requirement for direct client engagement with the acute services. Rob engaged with five treatments of CBT-SP imagery intervention and full stabilization of risk to self by suicide was achieved. At the time of writing, Rob is alive, has no engagement with the services and no further GP referral requests for intervention. Despite Rob leaving therapy before full completion, brief targeted suicidal imagery intervention was observed to stabilize the risk of suicidal behaviour. This young man has completed his schooling, engaged in ‘life’ planning rather than ‘death’ planning and has not required further intervention from this service. Further research is required to engage frontline clinicians on the merits of suicidal imagery assessment in routine clinical practice.

Key learning aims

  1. (1) To assess for imagery and violent day dreaming in suicidal patients.

  2. (2) Conceptualizing suicidal rumination and daydreaming as being a maladaptive problem-solving technique in overcoming psychological pain.

  3. (3) Use of suicide-specific assessment.

  4. (4) Ask about the presence of suicidal imagery as part of routine mental health assessment with the suicidal client.

Keywords

CBTcognitive behavioural interventiondepressionsuicide
Type
Case Study
Information
the Cognitive Behaviour Therapist , Volume 12 , 2019 , e31
Copyright
© British Association for Behavioural and Cognitive Psychotherapies 2019 

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References

Further reading

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Di Simplicio, M., McInerney, J. E., Goodwin, G. M., Attenburrow, M. J., & Holmes, E. A. (2012). Revealing the mind’s eye: bringing (mental) images into psychiatry. American Journal of Psychiatry, 169, 1245–1246. doi: 10.1176/appi.ajp.2012.12040499CrossRefGoogle ScholarPubMed
Holmes, E. A., Arntz, A., Smucker, M. R. (2007a). Imagery rescripting in cognitive behaviour therapy: images, treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry, 38, 297–305. doi: 10.1016/j.jbtep.2007.10.007CrossRefGoogle ScholarPubMed
Holmes, E. A., Crane, C., Fennell, M., Williams, M. (2007b). Imagery about suicide in depression – “Flash-forwards”? Journal of Behavior Therapy and Experimental Psychiatry, 38, 423–434. doi: 10.1016/j.jbtep.2007.10.004CrossRefGoogle ScholarPubMed
Ng, R. M. K., Di Simplicio, M., McManus, F., Kennerley, H., & Holmes, E. A. (2016). “Flash-forwards” and suicidal ideation: a prospective investigation of mental imagery, entrapment and defeat in a cohort from Hong Kong mental morbidity survey. Psychiatry Research, 246, 453–460. doi: 10.1016/j.psychres.2016.10.018CrossRefGoogle Scholar
Stanley, B., & Brown, G. K. (2012) Safety planning intervention: a brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19, 256–264. doi: 10.1016/j.cbpra.2011.01.001CrossRefGoogle Scholar

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