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In this article, we discuss developments over the past two decades in the study of cogni-
tion and suicide. We review (a) research identifying cognitive characteristics and vulnera-
bilities of suicidal individuals, (b) recently developed mediational and multivariate
models, (c) recent theoretical advances, and (d) outcome research on therapeutic inter-
ventions derived from this body of work. We conclude that significant progress has been
made in terms of understanding the interplay of such cognitive processes as hopelessness,
problem–solving, and autobiographical memory, and in the development of the-
ory–driven and empirically supported interventions that specifically target suicidal think-
ing and behavior. We conclude with a discussion of challenging issues in this arena and
possible directions for further investigation.
Losing a psychotherapy patient to suicide looms as perhaps the most dreaded possible
outcome among psychotherapists (Pope & Tabachnick, 1993). This concern is under-
standable, given that psychotherapy patients are at significantly elevated risk relative to
the general population (Tanney, 2000). Beyond clinical concern and personal tragedy,
suicide is also a major public health problem, accounting for nearly one million deaths
per year worldwide. Indeed, suicide accounts for fully half of violent deaths worldwide,
outpacing homicide and war combined as causes of death (World Health Organization,
cited in Colt, 2006). Ironically, clinical studies showing that therapeutic interventions
actually reduce suicide risk are few and far between (Comtois & Linehan, 2006).
It has now been just over 20 years since the first author summarized research on
cognitive characteristics of suicidal individuals and recommended concerted efforts to
develop strategies specifically designed to reduce cognitive vulnerability to suicidal
ideation and behavior (Ellis, 1986). In the wake of Beck’s recent 40–year retrospective
on cognitive therapy for psychological disorders (Beck, 2005), it seems fitting to sum-
marize developments over the past two decades in cognitive approaches specific to
understanding and treating suicidal individuals.
We will begin with an update on research on cognitive features that characterize
suicidal individuals and are associated with increased vulnerability to suicidal ideation
Thomas E. Ellis, Psy.D., ABPP, is Professor of Psychology and Billy Rutherford, M.A., is a doctoral student at
Marshall University, Huntington, West Virginia.
Send all correspondence to Thomas E. Ellis, Department of Psychology, Marshall University, Huntington,
WV 25755. Email: ellist@marshall.edu
47
48 ELLIS AND RUTHERFORD
In a recent historical overview of cognition and suicide, Ellis (2006) identified Kelly’s
(1961) personal construct model as “the first explicitly cognitive conceptualization of
suicide" (p. 14). However, it was at roughly the same time that Neuringer was begin-
ning his work on a series of seminal studies testing Edwin Shneidman’s characterization
of suicidal cognition as rigid, illogical, and dichotomous (e.g., Neuringer, 1961, 1964).
In the first published review of cognition and suicide, Levensen (1974) announced “a
new means of assessment [which] emanates from the cognitive approach to suicide . . .
[wherein] the suicidal person is seen as possessing some unique thinking style or certain
cognitive characteristics which diminish his ability to find viable solutions to life’s prob-
lems and to diminish his capacity to cope with the stresses of life" (p. 150). Prominent in
his review was the work of Neuringer, who published his own review soon thereafter
(Neuringer, 1976). Neuringer concluded that “progress has been made in the study of
suicidal thinking" (p. 235), noting in particular work on structures of suicidal thinking,
rigidity and constriction, and time perception.
Later, Patsiokas, Clum, and Luscomb (1979) reported that suicide attempters ex-
hibited greater cognitive rigidity and field dependence, though not greater cognitive
impulsivity, compared to nonsuicidal psychiatric control subjects. They proposed a
“cognitive predisposition to attempting suicide,” which later evolved into a
diathesis–stress–hopelessness model of suicidal behavior that included deficient prob-
lem–solving skills and depressive attributional style as cognitive diatheses (Schotte &
Clum, 1987). This model later showed predictive utility for depression and suicidal
ideation in college students (Priester & Clum, 1993).
Arffa (1983) presented a critical review of the nascent field of cognition and sui-
cide, commenting that, although methodological problems remained, “consistent dif-
ferences in the cognition of suicidal and nonsuicidal groups have been demonstrated"
(p. 117). While noting that some findings (e.g., field dependence) were inconsistent,
she observed that “cognitive–rigidity (whether it is termed dogmatism, dichotomizing,
hopelessness, or whatever) is patently implicated in suicide" (p. 118). She suggested
that cognitive rigidity might function as a common denominator of other observed cog-
nitive characteristics. Ellis (1986) echoed Arffa’s conclusions with respect to cognitive
rigidity and ineffective problem–solving and extended the discussion to dysfunctional
attitudes and beliefs and cognitive distortions. In discussing possible clinical directions,
he suggested that the time had arrived to begin tailoring cognitive–behavioral therapy
in the direction of specific cognitive vulnerabilities identified in the research literature.
What can be said about progress in the field since publication of these reviews? The
following discussion will provide an update on research on topics covered in earlier re-
views, as well as describing new ground that has been broken.
COGNITION AND SUICIDE 49
COGNITIVE CHARACTERISTICS
Executive Functioning:
Cognitive Rigidity, Dichotomous Thinking,
and Deficient Problem–Solving
Among the earliest clinical observations of cognition in suicidal individuals were cogni-
tive rigidity, dichotomous thinking, and deficient problem–solving. As early as the
1960s, suicidal patients were noted to view life in black–and–white terms and to be
“locked–in” to their current perceptions, unable to imagine alternatives or consider new
courses of action to solve their problems. Studied separately, cognitive rigidity, dichoto-
mous thinking, and problem–solving have shown consistent, strong associations with
suicidal thinking and behavior (e.g., Neuringer, 1961, 1964), but are increasingly being
approached together as closely related processes.
Cognitive rigidity has intuitive appeal to clinicians who have encountered the sui-
cidal patient’s difficulty imagining alternatives to his or her current state of suffering.
Research findings have consistently shown greater cognitive rigidity among suicidal in-
dividuals, even as a variety of instruments were used to measure the construct, from the
Alternate Uses Test to sophisticated neuropsychological test batteries (e.g., Keilp et al.,
2001). Marzuk, Hartwell, Leon, and Portera (2005) conceptualize cognitive rigidity as
a characteristic underlying dichotomous thinking and problem–solving deficits. Sui-
cidal individuals tend to rigidly see people as either good or bad or themselves as having
only misery or death from which to choose, while finding it difficult or impossible to
think flexibly enough to generate solutions to current problems. A similar view is taken
by Keilp at al. (2001), who view cognitive flexibility as a key aspect of overall executive
functioning and as a distinguishing feature of high– versus low–lethality suicide at-
tempters. An ongoing issue in this context (shared by various other cognitive constructs
as well) is the extent to which this characteristic represents a transient aspect of the sui-
cidal state or a more trait–like risk factor. Some evidence suggests that cognitive rigidity
distinguishes suicidal individuals only in the midst of a suicidal episode (e.g., Perrah &
Wichman, 1987), although firm conclusions await longitudinal studies.
Dichotomous thinking is widely accepted as a feature of suicidal cognition, al-
though relatively few studies have been conducted since the seminal work of Neuringer
(1961). Recent clinical studies are consistent with earlier findings of dichotomous
thinking in suicidal patients (e.g., Litinsky & Haslam, 1998; Wedding, 2000), al-
though it is unclear to what extent this may be related to the prevalence of borderline
personality disorder in this population (e.g., Veen & Arntz, 2000).
The closely related construct of problem–solving is perhaps the most thoroughly
researched cognitive process related to suicidality. Predictions that cognitive rigidity
and dichotomous thinking would be associated with impaired problem–solving be-
cause of difficulty generating alternate solutions have been supported in several studies,
both in terms of impersonal problem–solving (e.g., Levenson & Neuringer, 1971;
Patsiokas et al., 1979) and interpersonal problem–solving (e.g., Schotte & Clum, 1987;
Priester & Clum, 1993). However, interpretation of these results is made difficult by
variations among researchers in definitions of problem–solving, use of a variety of in-
struments for measuring the construct, and differences in comparison groups used (sui-
cide attempters, suicide ideators, psychiatric and nonpsychiatric control groups, etc.).
50 ELLIS AND RUTHERFORD
Questions also remain regarding state versus trait issues, which aspect of prob-
lem–solving is studied (skills vs. appraisal vs. orientation), and the extent to which varia-
tions in problem–solving impairment may be affected by depression, hopelessness, or
other variables. Regarding the latter, in a short–term, longitudinal study of hospital-
ized, suicidal patients, Schotte, Cools, and Payvar (1990) concluded that “interpersonal
problem–solving deficits may be a concomitant, rather than a cause, of depression,
hopelessness, and suicide intent" (p. 562). On the other hand, Williams, Barnhofer,
Crane, and Beck (2005) conducted a mood induction study with formerly depressed
patients, some with and others without a history of suicidality. Only the formerly de-
pressed individuals with a history of suicidality showed mood–related deterioration in
problem–solving performance, suggesting the possibility that problem–solving pro-
cesses may have both state– and traitlike characteristics in suicide–prone individuals. In-
terestingly, this vulnerability was moderated by lack of specificity in autobiographical
memory (discussed below).
In their systematic review, Pollack and Williams (1998) describe problem–solving
as a “promising” area for study and intervention with suicidal individuals, though not
without significant methodological challenges, including definitions, measurement,
and state–trait issues. More recently, Speckens and Hawton (2005) reviewed the child
and adolescent literature on problem-solving and suicidality and cautiously concluded
that “there is some evidence for an association between suicidal behavior and prob-
lem–solving deficits in adolescents" (p. 383), but no evidence for such a relationship in
younger children. They noted that causal relationships among problem–solving, de-
pression, and suicidality are not well understood at this time. Promising early results of
studies of problem–solving interventions (discussed below) suggest that research on
these issues is warranted.
The causes of problem–solving deficits in suicidal individuals are not well under-
stood currently, although progress is apparent on at least two fronts. The work of Wil-
liams and associates provides evidence that, aside from the impact of depression per se,
problem–solving deficits are associated with overgeneral autobiographical memory
(e.g., Pollock & Williams, 1998; Pollock & Williams, 2001; Williams, Barnhofer,
Crane, & Duggan, 2005), the significance being that specific recall of similar past prob-
lem situations is essential to effective problem–solving in the present. In addition,
neuropsychological studies of executive functioning have shed light on possible
brain–based sources of problem–solving deficits. Keilp et al. (2001) showed that pa-
tients with a history of suicide attempts manifested greater neuropsychological dysfunc-
tion than comparison groups, that the deficits were greater among high lethality
attempters, and that the differences remained after controlling for depression severity.
This rigorously designed study included a drug washout period, and the investigators
found no indication that the brain dysfunction was due to the effects of the suicide at-
tempts themselves. Tasks requiring organization and focused effort were notably in-
volved. The authors interpreted the results as evidence of cortical dysfunction in the
prefrontal lobes. Marzuk et al. (2005) reached similar conclusions, with differences
between suicidal and nonsuicidal individuals remaining after controlling for age, IQ,
depression severity, and prior suicide attempts.
In summary, a large research literature has consistently demonstrated significant
relationships among various aspects of executive functioning (particularly prob-
lem–solving) and stressful life events, depression, hopelessness, and suicidality. Implica-
COGNITION AND SUICIDE 51
tions for treatment are considerable (see below). For a more thorough review of the
problem–solving and suicide literature, the reader is referred to Reinecke (2006).
Hopelessness
Hopelessness, conceptualized as the expectation that undesirable events will occur and
that one will continually fail to attain one’s goals, has received consistent support
through the years as a key aspect of suicidal thinking and behavior. More than three de-
cades ago, Minkoff, Bergman, and Beck (1973) found that hopelessness mediated the
relationship between depression and suicidality; similar findings were reported by Ellis
and Ratliff (1986). Hopelessness has been shown to correlate with suicidal behavior in-
dependent of depression (Steer, Kumar, & Beck, 1993). It has also been shown to pre-
dict as many as 90% of suicides prospectively (Beck, Brown, & Steer, 1989), although
not without a substantial rate of false positives (Niméus, Träskman–Bendz, & Alsén,
1997). In addition, multiple studies have shown that hopelessness mediates the rela-
tionship between stressful life events and suicidal ideation and behavior (e.g.,
Abramson et al., 1989; Patsiokas & Clum, 1985; Schotte & Clum, 1982). It is not well
understood why some individuals are more prone to develop hopelessness than others,
although Clum and associates have conducted an important series of studies showing
that hopelessness is predicted by stressful life events and self–appraised poor
problem–solving skills (Yang & Clum, 1994).
In a recent review, Pettit and Joiner (2006) observed, “A plethora of empirical re-
search has supported a relation between hopelessness and suicide" (p. 128). Indeed,
hopelessness serves as a central construct in a variety of clinical interventions developed
for suicidal individuals (see below). Weishaar (1996) cautions that hopelessness does
not independently predict suicide among alcoholics (Beck, Steer, & Trexler, 1989).
Moreover, a recent study suggests that the relationship between hopelessness and sui-
cidal ideation is weaker among individuals with optimistic explanatory style (Hirsch &
Conner, 2006). On the other hand, Weishaar’s concern about inconsistent findings
among suicidal adolescents has been addressed somewhat by subsequent multivariate
research, some cross–cultural, that continues to suggest a robust relationship between
hopelessness and suicidal ideation and behavior (e.g., Stewart et al., 2005; Thompson,
Mazza, Herting, Randell, & Eggert, 2005).
Few constructs are more relevant to cognitive therapy with suicidal individuals than rea-
sons for living (RFL). Developed by Linehan and colleagues (Linehan, Goodstein, &
Nielsen, 1983), RFL has been shown to discriminate between suicidal and nonsuicidal
individuals and to be associated with a variety of outcomes (e.g., Bonner & Rich, 1987;
Cole, 1989; Connell & Meyer, 1991; Strosahl, Chiles, & Linehan, 1992), including sui-
cidal intent and behaviors in age groups from adolescents to elderly, and in clinical as
well as nonclinical populations (e.g., Galfalvy, Oquendo, & Carballo, 2006; Osman,
Kopper, & Linehan, 1999; Rietdijk, van den Bosch, & Verheul, 2001). In the same
vein, Brown, Steer, Henriques, and Beck (2005) developed an index of difference be-
tween wish to live and wish to die. In a 10–year longitudinal study, they found that the
52 ELLIS AND RUTHERFORD
hazard ratio for death by suicide among patients whose score indicated maximal
orientation toward death (2 on a scale from –2 to +2) was 6.51.
Perfectionism
Perfectionism, holding or perceiving impossibly high expectations for oneself, has long
been viewed as an important vulnerability factor for suicide (see Hewitt, Flett, Sherry,
& Caelian, 2006, for a thorough review). Researchers have divided the construct of per-
fectionism into three types: self–oriented (setting and holding unrealistic standards for
oneself), other–oriented (demanding perfection from others), and socially prescribed
(believing that others expect one to be perfect; Hewitt, Flett, & Turnbull–Donovan,
1992). Of these, socially prescribed and self–oriented perfectionism are more strongly
associated with suicidality (Flamenbaum & Holden, 2007; Hewitt et al., 1992).
In a recent review, Hewitt et al. (2006) observed that socially prescribed perfec-
tionism has shown a consistently strong association with suicidal ideation and attempts
in both adult and adolescent samples, independent of other factors such as level of de-
pression and hopelessness. Passive forms of perfectionism, such as procrastinating to
avoid making mistakes, are associated with suicidality among college students, whereas
active forms of perfectionism, such as striving for achievement, are not (Kittler–Adkins
& Parker, 1996.)
Correlations between perfectionism and suicidality are both direct and indirect.
Flamenbaum and Holden (2007) found that “psychache” (intolerable psychological
pain, as described by Shneidman, 1993) mediates the relationship between socially pre-
scribed perfectionism and suicidality in a sample of college students. The relationship
between socially prescribed perfectionism and suicidality disappeared when the effects
of psychache and unfulfilled psychological needs were statistically controlled. On the
other hand, Beevers and Miller (2004) found that perfectionism directly predicted sui-
cidal ideation at 6 months, without mediation by hopelessness, level of depression, or
severity of suicidal ideation (see discussion of multivariate models below).
Although the specific mechanisms by which perfectionism is related to suicidality
are not well understood, it is clear that perfectionism (socially prescribed perfectionism
in particular) is an important cognitive aspect of suicidal ideation and behavior. The
clinical implication of this finding is significant: “Just as both depression symptoms and
hopelessness are assessed and used as factors in evaluating suicide risk, perhaps
perfectionistic behavior should be strongly considered" (Hewitt et al., 2006, pp.
230–231).
Self-Concept
A negative view of the self occupies a place with negative views of the world and the fu-
ture in the “negative cognitive triad” proposed by Beck in his early formulation of de-
pression (Beck, Rush, Shaw, & Emery, 1979). Research has since shown that negative
self–concept may be a particular risk factor for suicidality, independent of other cogni-
tive characteristics such as hopelessness (Weishaar, 1996). A specific aspect of self–con-
cept, body image, has been shown to be an especially robust predictor of suicidality
(Orbach, 2006).
COGNITION AND SUICIDE 53
Because depression is one of the most robust predictors of suicide (Tanney, 2000), it is
reasonable to explore cognitive risk factors for depression for clues about suicidality.
Ruminative response style (chronically focusing on depressive symptoms and on the
causes, meanings, and consequences of depressive symptoms) predicts depression lon-
gitudinally and is associated with longer and more severe episodes of depression (Alloy,
Abramson, Safford, & Gibb, 2006; Nolen–Hoeksema, 2000). Specific to suicidality,
Eshun (2000) showed that rumination explained significant gender and cultural vari-
ance in suicidal ideation. Furthermore, Smith, Alloy, and Abramson (2006) showed
prospectively that ruminative style predicted hopelessness and suicidal ideation in ini-
tially nondepressed college students over a period of 2½ years. Another line of research
has shown that rumination may be characterized by, and perhaps prolonged by,
cognitive rigidity (Davis & Nolen–Hoeksema, 2000).
Autobiographical Memory
A clear trend in recent years has been movement away from studies of isolated cognitive
characteristics and toward examination of how multiple variables, psychological and sit-
uational, interact to produce suicidal ideation and behavior. Such designs allow re-
searchers to study relationships among variables, as well as to determine whether those
54 ELLIS AND RUTHERFORD
Finally, a recent study has attempted to bring together three cognitive variables
that have been individually shown to be associated with suicidality: negative cognitive
style, rumination, and hopelessness (Smith et al., 2006). This model is set in the context
of the Attention Mediated Hopelessness Theory of depression, a revised version of the
hopelessness theory of depression (Abramson, Metalsky, & Alloy, 1989). University
students were monitored for depression and suicidality over a period of 2½ years. Cog-
nitive style was defined as a composite of attributional style (measured with the Cogni-
tive Style Questionnaire; Alloy, Abramson, & Hogan, 2000) and depressogenic
attitudes (measured with the Dysfunctional Attitude Scale, Weissman, 1979). Smith et
al. found that negative cognitive style predicted rumination, which in turn predicted
hopelessness and suicidal ideation. Duration of suicidal ideation was predicted by rumi-
nation, fully mediated by hopelessness. Thus, cognitive style was only distally associated
with later suicidal ideation, via rumination and hopelessness, and the development of
hopelessness appears to be significantly influenced by rumination.
THEORETICAL CONTRIBUTIONS
In addition to the substantial empirical work summarized above, recent years also have
seen significant theoretical advances in cognitive–behavioral models of suicidal behav-
ior. Much credit for fueling interest in cognitive aspects of suicidality belongs to Edwin
Shneidman, whose early contributions highlighted the key roles of such factors as cog-
nitive constriction and various types of illogical thinking (e.g., Shneidman & Farberow,
1957). As previously noted, Neuringer’s seminal research on cognition and suicide was
largely stimulated by Shneidman’s theoretical work.
More recently, Baumeister (1990) proposed a comprehensive motivational/cogni-
tive model that revolves around the effort to escape from aversive emotion and
self–awareness. The model utilizes a six–step process, in which discrepancies between
desires and reality are blamed on the self, leading to severe emotional distress. A promi-
nent aspect of the model is the resulting “cognitive deconstruction,” a state that attenu-
ates the pain but is ultimately ineffective as a coping response. Suicide is made possible
by the combination of unremitting emotional distress and the appeal that death holds
when one is in the (irrational) deconstructed state. Baumeister’s model awaits thor-
ough, hypothesis–driven research. Pettit and Joiner (2006) observe that “little empirical
support exists for the role of escape–oriented cognitions in suicidality" (p. 145),
although empirical testing certainly seems warranted.
Recent developments in cognitive–behavioral therapy (CBT) have given rise to an
assortment of theoretical perspectives on cognition and suicide. Prominent among
these is the work of Rudd, Joiner, and colleagues (e.g., Rudd, Joiner, & Rajab, 2001).
This comprehensive approach conceptualizes suicidality as consisting of three domains
to be addressed in treatment: symptoms (depression, anxiety, etc.), skill deficits (prob-
lem–solving, emotion regulation, etc.), and maladaptive personality traits (self–image
and interpersonal relations). Following Beck’s lead, the therapy model revolves around
the cognitive case conceptualization, which includes components such as conditional as-
sumptions and core beliefs and behavioral aspects such as compensatory strategies (J.S.
Beck, 1995). Specific to suicidal individuals are the Suicidal Belief System (SBC) and
the suicidal mode. Consistent with Beck’s theorizing, the SBC revolves around the con-
56 ELLIS AND RUTHERFORD
INTERVENTION RESEARCH
What does outcome research tell us about the viability of treatment models based on
cognitive–behavioral models of suicidality?
Problem-Solving
The earliest CBT programs designed specifically for suicidal individuals focused on
problem–solving skills as a key vulnerability. In one of the first–ever randomized studies
of treatment of suicidal patients, regardless of therapeutic orientation, Salkovskis, Atha,
and Storer (1990) found that brief problem–solving therapy produced superior out-
comes to treatment as usual in a group of 20 patients with a recent suicide attempt. Pa-
tients in the problem–solving treatment showed significantly greater drops in
depression and hopelessness at posttherapy and 1–year follow–up, and a lower rate of
repeat attempts at 6 months. In the same year, Lerner and Clum (1990) published their
study comparing problem–solving therapy with supportive therapy in a group of 18- to
24-year-olds. They found problem–solving therapy to be superior for reducing depres-
sion and improving problem–solving self–efficacy at post–treatment. Problem–solving
therapy appeared slightly more effective for reducing suicidal ideation, but this result
did not reach statistical significance.
Rudd and colleagues (Rudd, Rajab et al., 1996) operationalized several aspects of a
cognitive–behavioral model in a randomized clinical trial with suicidal young adults.
The experimental condition included problem–solving as a prominent feature, as well as
social competence and adaptive coping. It was delivered in an outpatient (day hospital)
setting over a period of 3 weeks, primarily in group and classroom modalities. The com-
parison condition was treatment as usual, consisting of a combination of inpatient and
outpatient care, with varying duration of care and therapeutic orientations. Results
were somewhat mixed, in that statistically significant differences on depression, prob-
COGNITION AND SUICIDE 59
lem–solving, and other measures were not found at posttreatment or follow–up. How-
ever, the CBT condition was found to be effective in producing significantly reduced
symptoms in almost two thirds of patients at 12–month follow–up and was superior to
treatment–as–usual in retaining high–risk patients in treatment.
Brent and colleagues (1997) at the University of Pittsburgh compared CBT with
systematic behavioral family therapy and individual nondirective supportive treatment
in the randomized treatment of 107 adolescents with major depression. Although they
found that CBT was superior to the other two treatments regarding clinical recovery,
rate of improvement, and parent–rated treatment credibility, no differences were found
specifically with respect to suicidality or on functional status.
In one of the largest controlled trials of CBT with suicidal patients to date, Tyrer et
al. (2003) randomized 480 patients with a history of recurrent deliberate self–harm to
either treatment–as–usual or Manual–Assisted Cognitive Therapy (MACT). The
MACT intervention, modeled after DBT, consisted of up to five sessions, plus two re-
fresher sessions. Patients also were given a 70–page workbook for self–help activities.
Outcomes at 6 and 12 months showed no differences between treatment conditions on
any outcome measure, including suicide or deliberate self–harm. The authors acknowl-
edged that the lack of advantage to the cognitive condition might have been due to the
brevity of the intervention. Indeed, this, combined with the observed 40% dropout
rate, raises questions as to whether the trial constituted an adequate exposure to the in-
tervention. A later artice reported that the therapy did result in a 50% lower frequency
of self–harm behavior in the CBT group, but that it was generally ineffective for
individuals with borderline personality disorder (Tyrer et al., 2004).
Finally, Winter and colleagues (2007) recently reported results from a randomized clin-
ical trial of an intervention based on personal construct theory (see Neimeyer & Winter,
2006, for a description). They found that, compared with a treatment as usual condi-
tion, patients with recent deliberate self–harm episodes who received the experimental
therapy had significantly greater reductions in suicidal ideation, hopelessness, and de-
COGNITION AND SUICIDE 61
pression and a trend toward fewer subsequent self–harm episodes. The apparent prom-
ise of this new approach awaits further verification.
DISCUSSION
Research over the past two decades on cognitive aspects of suicidality and its treatment
has added substantially to the foundation of prior work in the area. Further evidence has
been provided for cognitive characteristics that had emerged earlier (particularly various
aspects of executive functioning, such as cognitive rigidity and problem–solving), plus
evidence in previously unexplored areas, such as autobiographical memory, perfection-
ism, and ruminative response style. The last two decades also have seen significant theo-
retical advances bringing coherence to the research, from Aaron Beck, Mark Williams,
and others. These theories, although not without their differences, are by no means mu-
tually incompatible. Perhaps most notably, recent years have produced empirical tests of
therapeutic interventions that incorporate what is known about cognition and suicide,
with outcomes that are strongly supportive of this approach. Cognitively oriented ther-
apies have outperformed conventional approaches on an assortment of outcomes, and
they have produced reductions in suicidal behaviors by as much as half.
The significance of these developments is great when one considers that current
conventional treatments fall somewhere between CBT’s diagnosis–driven model and a
“common factors” model in which the same “active ingredients” are considered benefi-
cial across diagnoses. Until recently, the typical article or chapter on interventions with
suicidal patients shied away from the term “treatment” in favor of “management.”
Stemming from roots in the crisis intervention literature, such guidelines focused on
such issues as increasing therapist availability between sessions and knowing when to
hospitalize. The operating assumption, generally speaking, was that “when the person is
no longer highly suicidal–then the usual methods of psychotherapy . . . can be usefully
employed” (Shneidman, 1981, p. 345).
The findings reviewed in this article suggest an alternate model in which identified
cognitive vulnerabilities that predispose patients to suicidal behavior are specifically tar-
geted in order to reduce risk for future suicidal episodes. This shift carries with it signifi-
cant implications for treatment, research, and training. Addressing these vulnerabilities
post crisis appears to be especially important. For example, mindfulness–based cognitive
therapy is specifically designed for people in recovery, to teach skills for observing and
disengaging from distressing thoughts, skills to be utilized during future periods of
stress that might otherwise trigger suicidal episodes (Williams, Duggan et al., 2006).
Beck’s approach includes a “relapse prevention task,” a guided imagery task involving
past and potential stressful scenarios that might trigger suicidal ideation. Successful ac-
complishment of this task determines whether termination is appropriate or whether
further therapy is needed.
Recent years also have seen a clear shift toward multivariate models of suicidality
that include psychological and situational influences and corresponding development of
multicomponent therapies that take these factors into account. This is in contrast to
early studies and therapies that focused on single cognitive characteristics such as cogni-
tive rigidity or deficient problem–solving. Current therapies tend toward multifaceted
approaches that are expressly designed to reduce suicidal thinking and behavior, in con-
62 ELLIS AND RUTHERFORD
ally decrease deaths by suicide) is not well understood at this time. By the same token, it
is important to better understand the significance of observed differences between
single and multiple attempters (e.g., Rudd, Joiner, & Rajab, 1996) for cognitive case
formulation and design of treatment programs.
This issue of generalizability versus population specificity arises in other contexts as
well. For example, whereas hopelessness was once considered a cornerstone of
suicidality, it now appears that it may function differently in substance abuser popula-
tions, and perhaps in adolescents as well. Another example is a study by Wingate, Van
Orden, Joiner, Williams, and Rudd (2005), who reported different treatment out-
comes for suicidal patients receiving problem–solving therapy, depending upon how
they self–appraised their problem–solving skills. A final example is a report by Tyrer et
al. (2004) that their brief CBT program (described above) was effective in reducing fu-
ture episodes of deliberate self–harm only in patients without a diagnosis of borderline
personality disorder. It is also not known whether diagnosis is an appropriate means of
studying differences or whether some other—perhaps cognitive—means of assessment
is preferable for understanding which therapies will be most beneficial for which
patients.
In any event, it is clear that the promise that was perceived in the 1970s and 1980s
regarding cognitive interventions with suicidal individuals has begun to be realized.
Plentiful evidence has accumulated that suicidal patients see and process experience dif-
ferently from nonsuicidal people and that, when these differences are targeted in treat-
ment, risk of future suicidal behavior can be expected to decrease, perhaps appreciably.
Moreover, a quick glance at publication dates of articles covered in this review suggests
that activity in the area is not only growing but also accelerating (more than half were
published in 2000 or later). Continued work in this exciting area can be expected to pay
further dividends for therapists and patients alike.
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