How Cognitive Behavior Therapy May Help Suicidal People

First, if CBT has worked for you, great. This is definitely one area where YMMV — your mileage may vary. But I do have a concern about this. I have depression — not to the degree of being suicidal — and every therapist I’ve been to has used CBT. Does the proficiency of the individual provider have any bearing on the success of the treatment? From my experience I’ve come to the conclusion that CBT is a complete and utter joke. From where I sit, I cringe to think that this is acceptable for those who are suicidal. Brief case in point: The latest advice I’ve been given in order to deal with some major life changes has been to join meet-ups, and to give my negative thoughts an “alter ego” — my therapist named mine “Minnie” — so I can tell these thoughts by name to go away: “That’s just Minnie talking again.” (I feel foolish even writing this.) Seriously? My other encounters with CBT have been just as inane, which makes me wonder if I’ve just had the bad luck to get incompetent providers. I laugh when I leave the office, but I can see a seriously suicidal person making the decision to follow through — just one more case of not being heard. Some people’s pain is deeper and cannot respond to band-aids like CBT. I’ve read that CBT is considered by some in the psychiatric community to be the “fast food” of treatment: Quickly and easily provided, but with little to no long-term value. And this is being advised for those who are suicidal? Really?

I see from a previous comment that Judith Beck is Aaron Beck’s daughter. This small but extremely relevant fact should have been explicitly disclosed in the article. To me, this is nothing more than a paid ad.

Studies show that no matter what form of psychotherapy actually only increases the effectiveness of anti-suicide/depression drugs by 20% (see 2015 article in the WP). The fact that we in the West haven't found a serious way to end depression and suicide yet might indicate that our very approach to "mental illness" is wrong. It might also explain why suicide among physicians is highest among ... psychiatrists. Fortunately, the West is now finally starting to look at other civilizations to deal with mood/existential problems, and Jon Kabat-Zinn at MIT for instance has developed a mindfulness based program (Mindfulness Based Stress Reduction) that then led Mark Williams at Oxford University to develop a MBCT (Mindfulness Based Cognitive Therapy) program which, when adapted to the specific situation of people suffering from depression, has already been scientifically proven to be AT LEAST as effective as antidepressants (without all the negative side effects, and with as positive side effect the fact that you're actually developing new brain circuits, which not only change the chemical balance in the brain but also install crucial self-care skills, including unconditional self-love - which by the way has been proven to be what determines the extent to which you're able to behave in a compassionate way towards others). Psychiatry isn't a science yet, and today science is proving that when it comes to "the art of living", the East, not the West, made the most progress.

By the way, shouldn't The Times have pointed out that Dr. Beck has a clear financial interest in publishing an article supporting the use of CBT. I'll bet if they published an article by a psychiatrist who had a financial interest in prescribing antidepressants supporting their use, it would have highlighted his or her possible conflict of interest. In fact, considering The Times firm antidepressant stance, I doubt it would even publish such an article.

I'm confused. The Times has repeatedly published articles saying antidepressants don't work even recently including such at statement in of its daily "facts." Yet there is far more evidence that they work than there is to support the use of CBT. Perhaps some editor at The Times might explain this apparent discrepancy on what evidence it requires to publish an article supporting anything. It seems that the paper's only requirement is that antidepressants, and, for that matter, all psychotropic medications are essentially worthless.

This is not enough.

CBT has been popular because it is an expression of the western fantasy that pesky emotions can be eliminated if you just change your outlook and get busy distracting yourself. Also, you can make a manual/cookbook of a CBT therapy, give it to people with limited training, and believe that you're providing mental health services. Research in the last 20 years supports a more complex psychophysiological and attachment-based theory of emotion, which CBT fails to acknowledge. Instead of acknowledging the contributions of other schools of therapy, they like to put old wine in new skins and claim it's a CBT invention (e.g., Acceptance and Commitment therapy, or ACT, which is what psychodynamic psychotherapists have been doing for over 100 years and call working with resistance). The psychotherapy outcome literature has looked in vain for a superior school of therapy - the results consistently show that type of therapy is not as important to outcomes as the therapeutic relationship.

I was a patient of Ira Herman, a cognitive therapist trained by Aaron Beck -- Judith Beck's father -- at Penn in the Spring of 1977. At our last session, after I had been calling suicide lines daily and crying in public restrooms for hours on end, Ira Herman told me he was going on vacation for a month and provided no follow up whatsoever. He never told me my diagnosis because "Labels don't matter". C.B.T. may be helpful for some people. It was not helpful for me. If my suicide attempt later that year had been successful then I would have been Ira Herman's "healthy learning experience". I was seeing Ira Herman weekly that Spring via Penn Student Health. He did not help me. He enabled my illness to get worse, but he did protect Penn Student Health. Had I committed suicide, and had my parents then sued Penn, they would have lost. Parents with depressed young adults away at school, keep in mind that the ranked priorities of any and all mental health providers assigned to help your child are: 1) protect the school, 2) protect themselves, 3) help your child.

I saw Ira Herman who was trained by Judith Beck's dad Aaron Beck when i was at Penn. I was calling suicide lines every day. At our last session, he told me he was going on vacation for a month and provided no back up or follow up for me at all. I was very nearly his "healthy learning experience". My experience with CBT was not helpful.

If I’d had to create a hope kit when I was suicidal, I would have had nothing to put in it. Complete loss of hope was where I was.

I think that for the most part suicidal thoughts arise from negative feelings and not the other way around. With that in mind it should be understood that the key is working with feelings not trying to change thoughts. Negative feelings not fully expressed from past events are a common cause of depression.

The premise of CBT is that changing one's thinking will change how one feels. It's your distorted thoughts that are causing your problems; learn how to identify and eliminate those distorted thoughts and you will no longer feel anxious or depressed. That works if your thinking is distorted. Often, in cases of anxiety and depression, it is. The situation isn't as horrible you as think, the worst case scenario likely won't happen, you won't always feel this bad so don't believe you will. But what about situations where the worst case scenario is the most likely outcome? What about situations where anxiety or depression is caused by what's really happening, by what the patient is really experiencing? In my case, CBT helped me reduce anxiety that was driven by irrational fears. But CBT hurt me in other situations where my concerns were legitimate and the situation was exactly as I saw it, yet I was told that if only my thinking weren't distorted, I wouldn't be feeling anxious. Sometimes, eliminating negative thinking and/or avoiding thinking about and preparing for a bad situation might be good advice, but sometimes it's terrible advice. Sometimes, heading into a difficult situation, you are better off if you know what's coming and have thought about how you will deal with it. Maybe it was my counselor or maybe it's the theory, but I found that every anxiety-inducing situation was treated the same; it was all caused by my distorted thinking. All my fault. That's depressing.

Marsha Lenihan created CBT in order to teach herself to stay alive and heal - the hospitalizations and therapy she experienced in her young life did not seem to help. It stands to reason that the method she devised best helped her. In her successful practice, I surmise she was able to help her clients by instructing, guiding and collaborating based on their own experiences. Given her own history, I doubt that she insisted on perfect compliance to the method she devised. How would one learn about their own cognitive patterns if clients need only comply with step-by-step instructions? I believe Dr. Beck’s descriptive article is intended for people eager to find ways to help loved ones struggling with suicidal thoughts. For the commenters who have pointed out that CBT has not worked for them, know that it took Marsha Lenihan quite a while to develop this process with lots of bad days interspersed with better ones. She began her journey to create CBT with a promise to herself: I will not commit suicide. Also for those commenters, do not give up. You are part of us - we need each other to walk together as we all face the reality of life. If you look around and see nothing but people who seem to be happier than you, look harder. They are hiding their doubt, despair, grief and disappointments well.

I've practiced CBT two times as an inpatient and continued with it as an outpatient for two-plus years and I'm still severely depressed. I also have a co-morbidity of ME/CFS -but that was consistently disregarded and was not incorporated into the therapy. The damaging part of all this was I was told by my Dr. that I just need to 'work it' better to see any progress even though I tried dearly to stick to CBT's teachings. Now I'm left with despair and guilt that I could not (or did not want to) help myself. Currently, I'm having trouble finding a therapist within a 35 mile radius that doesn't practice CBT because I'm looking for an alternative therapy to try. How I do wish there was more of an inclusive approach to managing mental health today.

CBT might be useful for minor anxiety occurrences. It will not stop or even mitigate major anxiety symptoms of breathlessness, crushing chest pain, crippling gut spasms, or the like. You cannot think or "breathe" your way out of autonomic responses, and do not let anyone guilt you into thinking that you can.

There was never anything wrong with my thinking when I was severely depressed. My problem was the disease of depression. (It took me over a decade to find medication that worked, but I did, and I’m no longer depressed.) I read about CBT years before it became popular and realized I could step outside my thinking and examine my assumptions. Useful on many occasions but not curative. Mental illness of all kinds has a genetic component. Up until recently no one talked about it, so there was no way to know that uncle’s vacation was actually a turn in the locked ward, or that granny talked to people who weren’t there.

Experienced psychotherapists, whatever their original "school" of practice, incorporate techniques and strategies from many schools. After 25 years of practice, I temper my psychodynamic approach with cognitive (CBT) interventions, existential and gestalt perspectives, etc. I also don't ignore real-life stress — or biology for that matter. Suicidal people can be helped by CBT; by expressing feelings in therapy instead of in impulsive acts; by being truly heard and cared about; by spiritual support; by making real-life changes in "hopeless" relationships or jobs; and many other ways, including medications sometimes. If you are feeling suicidal, seek what works for you. Keep seeking until you find it, as most suicide results from a kind of tunnel-vision. There are more options out there, and more hope, than you think.

It's great that CBT successfully helps people who benefit from that approach. I've been in various kinds of therapy for many years and have tried numerous types. Some helped me; others did not. I agree that different things work for different people. I've never tried CBT. A psychiatrist said I should do it in a hospital setting after having seen me once, and I was not suicidal or in crisis. He explained nothing about it but revealed a bias for CBT as a universal solution. It was enough for me to fire him. This article explains why none of my helpful providers ever mentioned CBT. I don't disbelieve the people who find their thinking is "disordered" and can use objective tools to sort it. In my therapy, a roughly equivalent suggestion felt simplistic and cruel. It caused my symptoms to plummet to the chasm I most fear. Unstructured, individualized empathy, acceptance, support, connection, understanding, loyalty, kindness, silence, space to be and know myself--those have helped me most and lifted me to where I can function and live. Those have felt most human. I do not judge CBT as one tool that may help some people. But for me I expect that CBT would cause me to feel judged and punished. I believe that other people like me would feel the same, and CBT should not initially be suggested as a prompt, convenient solution for eliminating symptoms of depression or anything else. I also have made lists and such, but it was only a fraction of a greatly different effort.

I've been anxious and depressed all my life, sometimes with suicidal thoughts. The approach described by Ms. Beck is the reason that CBT never worked for me. There is an underlying sense of utter hopelessness to this condition which is hard to grasp for anyone who has never been in this place. My only motivation for me to have participated in the actions she describes would have been to either please the therapist, or to conceal the real depths of my feelings of hopelessness. And maybe her approach works for some. But here's the challenge - there is no one answer to treatment. People are complicated and successful, skillful well-adapted people learn to conceal their true feelings from everyone, including their therapist. For me, what has changed my life is a low dosage of Prozac and 4 days a week Freudian analysis. My analyst doesn't give me advice. He listens to me. I have a close personal relationship with him that surprises even me. I don't hide anything from him, nothing is a secret. As a result, I've never felt happier or more secure in my life, ever. But how does someone like me find this kind of support? I'm not really sure how, or what accident of fate led me to this man's office. So, yes there is help. But this is a tough disease to treat, and there is still so much we don't know about it. But if the recent celebrity victims energize research or insight that saves one victim they may not have died in vain.

Suicide and other attempts to defeat one’s own life is a touchy-feely gray areas that I don’t think “ randomized “controlled Studies” could possibly get a feel on how to avoid these maladies

Contrary to popular belief (even among psychiatrists) if an anti depression medicine is going to help you, you are more likely than not to feel better the first week you take it. Large population studies demonstrate that suicide risk declines the day the prescription is filled. --practicing psychiatrist

You know what helps people feel better? Love..for self and others. Sometimes also a little Zoloft.

There's so much rancor in the comments here, you'd almost think this was a debate about abstinence-only versus medication-assisted substance abuse recovery. Perhaps someone should write a column about the tendency of experts in any field to read anything not directly in their line of work as a personal attack, and the pathological tendency to get hopelessly snippy and make over-general statements instead of submitting their own darned columns and essays for publication in order to expand the information available to the reading public. Anytime anyone gets absolute about there being only one way to treat something, skepticism is warranted. And I don't read this column as saying other things, like IPT, DBT, medication, and group therapy DON'T work or contribute to success. Rather, it's one practitioner's article on one set of tools that can help address a real problem. Also, to all the commenters who complain about CBT not addressing the social aspect-- well, duh. Any individual isn't going to magically overcome all of society. That's what your professional lobbying groups are for, not to mention your own columns regarding the macro contributors to poor mental health. Howsabout some education of the public, rather than internecine whinging in the comment sections?

Does it really make sense to have the daughter of the originator of CBT extolling its virtues? The "politics of therapy" is a very real thing and if one believes in the evidence-based trope in respect to therapeutic treatment then one also believes there is a view from nowhere in which human being can see themselves objectively. And I have a bridge to sell you. . .

Throughout this article suicidal tendency is attributed to their thoughts, their lack of “skills”, their impulsivity, their impaired judgement, and their distorted thinking. It’s the patients problem, not a societal one. Or is it a societal problem only because society generates the patient? Better to soothsay how bright the future could be, inner change is all that’s required. Never mind how the person feels toward the deceptive, corrosive, and regressive of current day realities. These problems are simply too complex for a therapist to fix so the proposed solution lies in restructuring the personality. Of course, in retort, it’s this type thinking that leads to “unhealthy” thoughts of suicide. Qualified with a lot of randomized controlled trials, and anecdotal successful outcomes it can legitimately be discussed as “your” and “their” problem while the “our” - the source, is ignored. I contend, suicide isn’t a contemptible solution, it should be lauded as an act of compassion. I recognize most, if not all here, will disagree with me but remember, your opinion about how someone else perceives the world and copes within extends to the point the solution doesn’t inconvenience you personally, beyond that they’re on their own. Unless, of course, they willingly accept the “right way” to think. The more rigid, unyielding and self serving society becomes the more it must recognize why similar traits are being acted upon by those comprising its population.

I'm a CBT therapist and supervise doctoral students learning it. I acknowledge there are a lot of other therapy approaches that can be a better fit for some clients, and of course there are limitations to CBT as well. I don't pretend that somehow we have figured out the secret to The Best Therapy Ever, and as a field we continue to refine our approaches. I just want to combat the widespread notion that CBT is supposed to just be a bag o'skills that one can simply learn from an app or a computer. Some people can learn to use CBT skills that way and that's great. Others need the connection, support and guidance of a skilled therapist to make changes and maintain them. I teach my students that the human connection is just as important as teaching our clients skills.

It probably helps those patients whose suicidal thoughts are brought on by depression or life situations. But it won’t help folks with chronic pain, often called “the suicide disease”. Painkillers are a true double edged sword. Helpful yes, but always demanding larger doses after tolerance is reached. So doctors are often loathe to prescribe the necessary doses (two words: Michael Jackson). Living with intense chronic pain quickly becomes unbearable. A throbbing pain that screams at you 24/7/365. The hallway of life narrows, darkens and suicide becomes the best option. It’s difficult to argue otherwise. I know because I watched my best friend try to live with it until one day he decided he couldn’t do it anymore. He wrote a note, swallowed all his pain pills and died. I can absolutely say a scrapbook would not have saved him.

I am a therapist who has also suffered through Major Depression with suicidal thoughts. CBT works well for some. In general, psychodynamic and/or interpersonal therapy itself involves challenging false assumptions while additionally exploring the root causes. I, for one, would never have gotten better through CBT alone. Some people are more introspective and unwilling to simply perform "homework" tasks or assignments which might be better used as an adjunct to insight-oriented treatment. You have to know your patient to best decide upon the best approach.

For the critics who say cbt is a one-size-fits-all approach, manualized and devoid of empathy or the concept of person-in-society, boo. In a therapeutic setting, with a trained cbt practitioner, you get all those things and more. Many many therapists say they ‘incorporate’ cbt into their practice. Also boo. Find yourself a licensed provider through the academy of cognitive therapy and start there. If it doesn’t help, absolutely try something else. Let’s do good work to alleviate suffering, not bash proven methods with inherent bias.

While CBT gets the majority of research grants, other psychotherapy methods have also proven useful. One is IPT, interpersonal psychotherapy. Unlike CBT which focuses on cognitive distortions, IPT acknowledges the actual sources of extreme unhappiness: bullying, death or loss of a loved one, unemployment and so on. The therapist addresses the feelings around these situations with empathy, letting the individual know that the sources of unhappiness can be understood and appreciated. Often, this empathic understanding establishes a connection between the therapist and individual and this, in turn, alleviates any suicidal thoughts. For the most part, when individuals are suicidal, they feel extremely isolated and the connection with a therapist or other concerned party is the first step towards feeling some hope again.

Some years ago I read an op ed in the Times about DBT - the writer had suffered from chronic suicidal thinking and this therapy worked very well for him. DBT is a form of CBT and in spite of years of therapy and medication, I have found it extremely helpful in managing chronic depression and suicidal thinking. I understand that some people dismiss it as simplistic but the evidence and research shows that it's effective. The biggest issue for many people is cost and access to treatment. I'm paying $700 a month for health insurance, and still have big deductibles and copays to make - it doesn't exactly make therapy accessible. Everybody's situation is different but quality of life is impacted for millions of people who suffer from mild to moderate depression and anxiety and if CBT teaches people how to be resilient and have some agency over their symptoms I wouldn't be so quick to dismiss it - or Judith Beck.

Judith Beck is an authority on only one thing, CBT, which is effective as a stop-gap measure but not in the long run. You don’t even need to see a therapist- do it on Google, do it in a workbook, very cost-effective. No need for human contact! Use an app, use a screen, stop your negative thoughts, and - if you don’t find this effective, you yourself must be defective. Enough to push someone to suicide, and terrible to take advantage of tragedy to promote a « method » that is infantilizing, oversimplistic, and proven to be less and less effective over the years it’s been in existence.

The number one problem is that CBT, like other treatments, is still totally focused on the individual. Depression is a social problem, with social solutions. We seem unable to approach it as such, so we are left to helping people do mental push-ups in an effort to become mentally fit, meanwhile not at all addressing the fact that they will just return to their isolated, individualistic, depressing lives when therapy ends.

I am a CASA. The youth I am a CASA for had several courses of Trauma Focused CBT, which helped slightly but still left her with serious depression and anxiety. What finally helped her? Neurofeedback. Many 'triggered 'emotional responses happen in the implicit/instinctive right brain, which is not the seat of cognition but of assumptions and emotion. As her brain got a sense of its own jumpiness, and began to modulate itself better, her anxiety and depression went down and he introspection and sense-making got better and better.

CBT works great for some. Drugs work for others. We need a lot more research on the unintended side effect (suicide) to a lot of prescription drugs. It is probably the unintended side effect of a lot of OTC drugs and food additives too. Just because a chemical, performs as advertised doesn’t mean that it has only one effect. We have the attitude, that which doesn’t kill us makes us stronger. An attitude based on what, exactly? It could be that which doesn’t kill us outright, depresses us and kills us slowly...

Ketamine. It works quickly and the best is, the person in trouble doesn't have to "work" at getting better. No intrusive hours of therapy and questions, no rumination about whether they are doing it correctly - the person in trouble can be left alone, be peaceful, doesn't have to believe in anything or do anything - just keep on breathing. I have not used it but I told someone to look into it. She found someone in her state and after 3 sessions noticed a difference. After 6 I could hear the strength in her voice. It was like talking to a different person. Here's from a YELP review for the ketamine MD's in Fremont and Palo Alto CA. (I don't know them nor do I know anyone who has seen them.) From their website: "Ketamine is unique in that it works very rapidly with some individuals seeing improvement in their symptoms within hours." Yelp review: "I went with a family member suffering from debilitating treatment-resistant depression. Ketamine was amazing. A decades-long depression lifted before my eyes. It took 5 treatments before it really turned a corner but we could tell a difference sooner than that." Some have struggled with depression and toxic meds for decades. Do we really want to make them wait any longer to listen to someone telling them to exercise, call a friend, call the hotline, blah, blah. It's enough to get you on the road to depression not off it. I celebrate all who have been helped but a few is not enough. Not with ketamine or microdosing available.

CBT is useful, and over $100 a session until I meet my deductible. It's cool. I'm sure there are some CBT apps that will carry me through until then. Hopefully the next article will be about those.

As someone who struggles with anxiety and depression, I really appreciated this article. I've benefited from CBT. I think it has worked for me because it put a flashlight on my very distorted thinking. I grew up in an environment that did not encourage expressing emotions. For me, this led to thinking that expressing any emotion that was not considered "good" was inappropriate. Instead of accepting the fact that sometimes we as human beings feel sad, angry, confused, etc., I would try to suppress those feelings and "make" myself feel happy. No wonder I started having panic attacks in my early 20s. When I decided to seek therapy, my therapist introduced CBT techniques very early on. I do recognize it may not work for everyone, but it provided me with a more objective framework to view my thought patterns. I've read others compare CBT to the socratic method. I think that's a fair comparison. When I have a thought, I now have the tools to question its validity. What evidence do I have to prove the thought I'm having is true? It's a very useful tool that I feel fortunate to have. On a final note, I think it's awful that (a) we live in a society where many still feel hesitant to seek help and (b) many CAN'T seek help due to lack of access. Everyone seeking treatment should have access to it. I don't like to think about where I would be if I would not have been able to get help when I first reached out for it. I am very fortunate. Not everyone is so lucky.

I've never been suicidal, but did go through a major depressive episode about three years ago. I was treated by a therapist who does CBT and was also prescribed antidepressants. The combination worked for me and I haven't had another depressive episode since. My therapist gave me homework (mostly involving keeping a daily log and doing some pleasurable activities). At the beginning, she told me that, if there was no improvement in eight weeks or so, we'd need to reevaluate. I was so worried that she would stop treating me if I didn't do my homework that I got out of bed and did the suggested activities, even when it felt awful. This was the beginning of my road to recovery.

CBT can be an effective therapy for those who have access to and/or can afford it. Not unlike so many other effective drugs and treatments not available to so many. Now that Dr. Beck (I assume a PhD) has extolled the virtues of CBT in treating what is a national epidemic of suicide, I am both curious and eager to learn of her proposed solutions to make this potentially life-saving treatment more readily and easily accessible to more citizens.

Oh God, not CBT. People are not one size fit all and there are many different reasons why people might feel suicidal. But generally speaking, people need connection. They need to feel that there is something beyond the darkness. They need to get out of their head, move around, do stuff. They don't need to be treated like a cog that needs re-education. More like a human being who's going through a hard time and is reacting to it in a certain way for complex reasons. If you want to suggest formal therapy, far better to suggest psychodynamic therapy (understanding what lies beneath) plus some form of meditative approach, Buddhist or other, plus a lot of plain old human support. Also, Medications are NOT very effective, antidepressants are as effective as placebo, no more, EXCEPT for very severe depression. Suicide does not necessarily occur in the context of very severe depression, so medications are not necessarily the solution to this problem. TLDR: we need less harping on about CBT, more real connection.

As someone who has been treated several times for major depression, and and has thought about suicide more times than I could count, thank you for this article. I was thinking only yesterday that the coping mechanisms I developed during a very violent childhood served me well as a child, but not as an adult. Being quiet and freezing up helped me to be out of sight and not 'provoke' my parents. Now as an adult many times I've found myself stuck or in a rut, and my emotional response is to feel trapped and retreat, and ponder what I thought was the only way out. Depression advances. I make a list of affairs to get in order. With the help of a therapist, I've been able to break down the issues and then solve even one small piece at a time--like getting rid of an aggressive and rude client that 'pushes my buttons', or making changes to my home and routines. Once a piece breaks free, I invariably realize I have been trapped by myself, and as I age, I am better equipped to recognize and deal with issues like this on my own or with professional support.