When you have a child or teen who has suicidal thoughts, your instinct might be to get them treated for the depression, anorexia, or other mental health disorder that is linked to the suicidality. But while that care is important, research has found that treating the underlying mental health disorder often isn’t effective to prevent future suicide attempts — it’s essential to treat the suicidality itself. While there are several different treatment options, one of the most common and effective is cognitive behavioral therapy for suicide prevention (CBT-SP). CBT-SP helps children and teens recognize and change the thoughts that drive suicidal behavior and includes families to help prevent youth from acting on suicidal thoughts.
What is CBT-SP
Cognitive behavioral therapy (CBT) works with the idea that thoughts influence feelings, feelings influence behavior, and behavior influences thoughts. In CBT, kids and teens learn how to change their thoughts, which can then change how they feel and act.
“A child whose phone is taken away after returning home past curfew may think, ‘I hate my life,’” says Megan Ice, PhD, a clinical psychologist in the Mood Disorders Center at the Child Mind Institute. “So they lie in bed and don’t see friends, which makes them think, ‘No one wants to hang out with me,’ and they feel even sadder.” Then when they get to school and hear about activities their friends did without them, they may think, “I don’t want to be here anymore.”
In CBT-SP, the clinician works with the child to break that cycle, so when they think or feel something negative, it doesn’t lead to a downward spiral and suicidality.
How CBT-SP is different from cognitive behavioral therapy for depression
CBT-SP is different from cognitive behavioral therapy for depression or anxiety in that the treatment focuses specifically on the suicidal thoughts — the thought of “I want to die” — rather than negative beliefs. “What are the other things that would be helpful to think in that moment, and how can we help ourselves think those things?” explains Dr. Ice. “And that hopefully makes you feel less sad — or at least like it’s a tolerable sadness — so you can take the actions to get through that sadness safely. And when you are able to do the things that make you happier, you can have thoughts like, ‘I actually do have people who care about me.’”
Components of CBT-SP
The structure of CBT-SP involves weekly individual therapy sessions, as well as sessions that include family members, over the course of 3-6 months. The first few sessions are focused on figuring out the triggers for suicidal thoughts (something called “chain analysis”), teaching methods to counter the thoughts, and a safety plan so the child doesn’t act on those thoughts.
Chain analysis. When Dr. Ice initially meets with a child, she will ask them to tell their story about what led to the suicide attempt or suicidal ideation as well as what happened during and after. She will ask specific questions about how their body felt (for example, hot, hungry, or tired) and the environment they were in (what and who they had access to, or not).
“For some kids, if it’s the first time they’ve had a suicidal thought, it can be easy to pinpoint what led to it,” she says. “But for others it can be challenging to figure out the pattern of when and why it has occurred.” Exploring their expectations around what they thought would happen — as well as how they feel about what did happen — can help them find more effective ways to ask for the help they want.
Sometimes the thoughts can be chronic, and then something bad happens that might seem small to many people — not getting invited to a party, not being allowed to go to your boyfriend’s house, or your sibling getting something you didn’t — but it’s the proverbial straw that broke the camel’s back.
The goal is to figure out what makes the passive thoughts turn active — when the thought of “I don’t want to be here anymore” becomes “I’m going to do something to make myself not here anymore.”
The pattern of when passive thoughts turn active can be different for each individual, so the clinician works with them to piece together the puzzle. “A lot of times they can fall into a category — rejection or loss or criticism — and the thoughts are more persistent or distressing at night, when alone, or when bored,” Dr. Ice says. “We try to find the common threads to what leads to the suicidal thoughts and help the kid become aware of them.”
Education about suicidal behavior. Part of CBT-SP is helping the child and family understand the nature of suicidal behavior, how it relates to depression or other mental health disorders, and the goals of the treatment.
Once the pattern that leads to suicidal ideation or behavior is clearer, the clinician works with the child to challenge that pathway. Dr. Ice says she’ll ask, “What are some of the other solutions that would make things tolerable? If the problem is that your friends didn’t invite you to something, what if your friends did invite you to something — would that make life worth living? If you had different friends to hang out with when others don’t include you, would that make life worth living?” The idea is to help the child develop skills to cope with painful feelings, so when they experience them, they can think of other ways to react than turn to suicide.
Safety plan. If a child has had suicidal thoughts, those thoughts will often return — and they need to have a plan in place for when they do. The therapist will work with the child to develop a safety plan, which includes recognizing the warning signs that they might attempt suicide and the steps to take to mitigate that risk. For example, if the child is thinking about cutting their wrists, they need to tell a parent and make sure they don’t have access to knives. The family can have a lockbox ready to restrict access to pills that could be used for an overdose, or a way to lock windows or the door to the roof so the child can’t jump.
The aim of the safety plan is not to solve the child’s problems but to give them concrete steps to take so they can tell a parent or someone else about the urge to kill themselves and redirect their thinking to get past that urge when it strikes. It might include coping strategies that the child finds effective, like listening to music or doing deep breathing exercises.
“For many kids, communicating with others about their suicidal thoughts is hard, so it’s important to know how they will do it,” Dr. Ice says. She will ask them, “Are you going to have a code word? Are you going to have a sign on the door? Are you going to text your mom from the other room?” Whatever it is, they need to have a way to be able to tell other people that the thoughts are strong right now, and they’re not able to cope with them by themselves.
The safety plan also includes what to do when the strategies aren’t working. Where is the nearest emergency room that handles kids and teens? What transportation might they take to get there — walking, taking a cab, calling 911? Who would watch a younger sibling when you leave for the ER?
Building hope. When a child is suicidal, they often feel like killing themselves is their only option — they don’t see another way out of their pain. In CBT-SP, the therapist works with the child to figure what can make life worth living. It might be the idea that their family members would miss them, or that in a year they will switch schools and things can get better. The child can build a “hope kit” — a physical box or a virtual one with mementos and photos of people they care about and things they enjoy — with reminders of various reasons to keep living that they can turn to when they need it.
Cognitive behavioral therapy techniques. After the initial suicidal crisis has stabilized, the clinician works with both the child and the family on cognitive behavioral exercises, which vary depending on the individual child’s needs. A kid might work on how to tolerate distress and regulate emotions, for example. Or they can learn about behavioral activation — using activities they enjoy to improve their mood, which can inspire them to do more of those things. The family might work together on problem-solving skills or improving communication. In the later sessions of CBT-SP, the clinician also works with the child to prevent relapse.
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Parents are an essential partner in CBT-SP because they can monitor for warning signs of suicidality and reinforce coping skills. You need to know what the triggers are for the child, but “that doesn’t mean avoiding them,” Dr. Ice says. “It means knowing the child may need more support for those challenges.”
If you know a school break is coming or grades will be out soon, for example, you can plan for more one-on-one time with the child that day or put a fun activity on the calendar so that they have something to look forward to.
Parents are also helpful for making sure their kid has access to what they need to practice their coping skills. “Sometimes that means setting aside a room or a closet in the house with some of the kid’s favorite things, so when they need it, everything is right there,” Dr. Ice says.
If a child is struggling with suicidal thoughts, parents are there to remind kids about their safety plan and what they are going to do in those situations. Kids might not want to disclose that they are experiencing suicidal thoughts, so “you’ll will want to respond to them in a validating way — in other words, don’t freak out, don’t yell at them,” says Dr. Ice. “Be understanding, be confident, and know your safety plan so they feel like ‘This is something we can cope with.’”
Who CBT-SP is useful for
CBT-SP is intended to treat kids and teens who have recently attempted suicide (in the last three months) or have had strong episodes of suicidal ideation. It is not generally used with kids and teens who have had continuous, unrelenting suicidal thoughts or complex trauma. It is also not a good fit for kids who struggle with structure or goal-oriented therapy.
“The goal of CBT-SP is to make sure kids are safe enough to be out in the community,” Dr. Ice says. If you believe that your kid can be out and about and remain safe, they can engage in the activites that give their life meaning. And that gives them the confidence in their ability to cope with whatever might come their way.
If you or your child is in a mental health crisis, please do not wait for an appointment. Please call 911 or 988 (the Suicide and Crisis Lifeline), or visit 988lifeline.org.
How does cognitive behavioral therapy work to prevent suicide?
Cognitive behavioral therapy helps people develop skills to cope with painful feelings, so when they experience them, they can think of other ways to react than turn to suicide.
