Playing the coping card
The protection and treatment of warfighters is a primary focus of the 2012 Military Health System Research Symposium being held in Fort Lauderdale, Fla., and this concern for the men and women in uniform extends far beyond their time on the battlefield. The prevention of suicide among military personnel both during active duty and upon return is of paramount importance for the researchers and attendees of this year's conference.
In a breakout session dealing with advances in military suicide and psychological health research Aug. 15, Dr. Laura Neeley of the Uniformed Services University of the Health Sciences in Bethesda, Md., offered insight regarding her study of Post Admission Cognitive Therapy, or PACT, for the prevention of suicide in military personnel with histories of trauma.
Working with Dr. Marjan Holloway, Neeley's research shows that there is strong empirical support for the relationship between psychological trauma and suicide-related behaviors. However, she states that no evidence-based interventions exist for suicidal individuals with psychological trauma, as suicidal participants are often excluded from psychological research.
This is where PACT may help patients to cope effectively with suicidal thoughts and actions.
"The goal of our research," said Neeley, "is to develop and empirically evaluate a brief inpatient cognitive behavioral treatment for individuals with psychological trauma who have attempted suicide."
Presenting statistics from the current Department of Defense Suicide Event Report, Neeley said that of service members that had attempted suicide, 21.8% had prior psychiatric hospitalizations, and among those service members that died by suicide, at least 10% (and up to nearly 17%) had received inpatient psychiatric care.
"Out of all the various anxiety disorders," said Neeley, "PTSD [post-traumatic stress disorder] has the strongest association with attempting suicide. And combined with alcohol-related problems, it increases the risk of suicide by six-fold."
Considering this, Neeley's research may be quite important, as PTSD is a very active topic currently throughout the military population.
Neeley's PACT program has three phases, with two distinct therapy sessions in each phase. Phase I begins with an analysis of the patient's current suicide attempt, and this leads into a cognitive conceptualization of the events leading up to the attempted suicide. This involves retracing the thoughts of the individual to determine a mood set and behavior. Phase II moves into "cognitive restructuring," to review the negative automatic thoughts of the individual while looking for ways to modify these negative thoughts.
Neeley said that when someone is in a highly emotional state, sometimes it is difficult to generate alternative ways of thinking, so she suggests the use of "coping cards." These cards contain positive statements that provide support to the person who may be in jeopardy of self-destruction.
"Patients can carry these cards in their pocket," said Neeley, "and every time that they have an [event] that leads to an emotional reaction, they can take this out and read it to themselves, to start working on changing their thinking patterns, and working on emotional regulation."
This second phase also includes the implementation of a "Hope Kit," in which patients keep positive reminders inside of a box that they can pull out to remind themselves of the good things in life -- things worth living for. These items can include photos, coping cards, journals, gifts, or other things associated with good memories for the patient.
Finally, the sessions in Phase III are focused on relapse prevention and safety planning.
"In the final stage, we go through the suicide story again, but this time we rewrite it so the patient can incorporate her newly learned skills," said Neeley.
In this stage, the patient must look for ways to challenge thoughts of negativity and suicide, and in doing so, should realize their own self-worth as well as the worthiness of people and things around them.
"We also have them create a 'safety plan' for when they're discharged," Neeley said, "so that they know exactly what to do when they're in crisis."
Created by the patient, this safety plan not only contains certain scenarios of negative actions that the patient should watch for, but more importantly, it contains a list of positive reactions to use in order to squelch negative thoughts, as well as a list of contact persons who may help to calm down and reassure the patient.
Of course, despite Neeley's therapeutic approach to helping change the suicidal thoughts and actions of her patients, the patient's own readiness to change may often provide a roadblock which is difficult to overcome.
In the case of her clinical study patient, Neeley said, "We focused on changing her negative automatic thoughts, which related to a sense of poor self-efficacy, coping with trauma, and other life domains."
Neeley believes the results of this study clearly support the need for evidence-based psychotherapy research for traumatized suicidal individuals. Currently, her group is working on a manualized session-by-session inpatient cognitive behavioral treatment protocol for the treatment of trauma and suicide behavior.
When asked of the patients' response to this PACT treatment program, Neeley said that the reaction to this program has been very positive.
"I've had patients at the end of therapy say that this really helped them, and that the individual attention was very important," said Neeley. "Having this very intensive treatment is very helpful to them, and having it completely tailored to their individual experiences is highly effective."