Letter to the Editor Received: March 11, 2014 Accepted after revision: July 15, 2014 Published online: October 16, 2014
Psychother Psychosom 2014;83:374–376 DOI: 10.1159/000365974
Acceptance and Commitment Therapy for Management of Suicidal Patients: A Pilot Study Déborah Ducassea, b, Eric Renéa, Séverine Béziata, Sébastien Guillaumea, b, Philippe Courteta, b, Emilie Oliéa, b a Department
of Psychiatric Emergency and Acute Crisis, Lapeyronie Hospital, CHU Montpellier, and b University of Montpellier UM1, Montpellier, France
With one million deaths every year, suicide is a major health problem worldwide. Recently, suicidal behaviour disorder (SBD) has been included in DSM-5 as an independent clinical entity [1]. It highlights the need to address the suicidal process as a primary target of concern and to identify corresponding transnosographic preventive strategies, including psychotherapy. Acceptance and Commitment Therapy (ACT), a ‘third-wave’ behavioural therapy, targets experiential avoidance (tendency to avoid unwanted thoughts or emotions) at the core of psychiatric disorders. Of note, suicidal subjects report intrusive mental images of suicide that they try to suppress, increasing in their intensity and frequency, independently from depressive symptoms [2]. Indeed, experiential avoidance would predict suicidal behaviours [3]. Moreover, two case reports have suggested the preventive role of ACT on suicidal reattempts at 1 year [4]. Thus, we aimed at examining the usefulness of an add-on ACT group programme to decrease suicidal ideation in high-risk patients. The study was conducted in the Department of Psychiatric Emergency and Acute Crisis, Academic Hospital of Montpellier, France. Thirty-five outpatients suffering from a current SBD according to DSM-5 [1] (history of suicidal attempt in the past year) were included in an ACT programme (table 1) [5–7]. Exclusion criteria were current mania or depressive episode with mixed features, and schizophrenia. Patients were assessed at inclusion (1 week before the programme, T0) and 1 week (T1) and 3 months (T2) after programme completion. Psychiatrists assessed: (1) suicidal ideation using the Columbia-Suicide Severity Rating Scale (C-SSRS) [8] (suicidal ideation subscore = severity and intensity items) and the Scale for Suicidal Ideation (SSI score) [9]; (2) psychiatric disorders using the French version of the Mini International Neuropsychiatric Interview; (3) borderline personality disorder using the Screening Interview for Axis II Disorder; (4) depressive symptomatology using the Inventory of Depressive Symptomatology (IDS-C30); (5) global functioning using the Functioning Assessment Short Test, and
© 2014 S. Karger AG, Basel 0033–3190/14/0836–0374$39.50/0 E-Mail [email protected] www.karger.com/pps
(6) pharmacological treatment and number of visits for psychiatric emergencies in the previous 3 months. Self-assessments included: (1) suicidal ideation on a visual analogue scale from 0 (none) to 10 (maximum), currently and during the last 15 days; (2) depressive intensity using Beck Depression Inventory-II (BDI); (3) psychological pain on a visual analogue scale from 0 (none) to 10 (maximum); (4) anxiety state using the State-Trait Anxiety Inventory (STAI); (5) hopelessness during the last month using the Beck Hopelessness Scale; (6) quality of life using the World Health Organization Quality of Life measure, and (7) acceptance using the Acceptance and Action Questionnaire (AAQ) [10]. Considering the small sample size and skewed distribution of most continuous variables, median (min–max) and non-parametric tests were used. Friedman’s tests for quantitative variables and Cochran’s Q test for categorical variables were used to globally compare the three time points. If the global p value was p < 0.05, two-by-two comparisons were run (signed rank, McNemar’s and kappa tests) and corrected for multiple comparisons (Bonferroni correction). Spearman’s rank order correlations were applied to measure associations between continuous variables. Statistical analyses were performed using SAS software, version 9.2 (SAS Institute, Cary, N.C., USA). Two patients did not start the programme; 78.8% attended all sessions. ACT was reported to be helpful by 96.9% patients. One patient (suffering from borderline personality disorder) committed suicide during the first month of the study, without any clear association with intervention. Sociodemographic characteristics were as follows: 57.1% males, median age 38.4 years (min–max: 18–60), 48.6% single, 60% fully employed. The majority of patients were currently depressed (94.3%), having attempted suicide the month preceding the inclusion (93.9%). Psychiatric disorders were unipolar (37.1%), bipolar (57.1%), anxiety (97.1%), addictive (28.6%), eating (17.1%), and/ or borderline personality (20%) disorders. All participants were on psychotropic medications. There were significant differences for all scores between the three visits (p < 0.001). Between inclusion and the 1-week followup, there was a significant reduction of the C-SSRS ‘suicidal ideation’ subscore [20 (0–30) vs. 0 (0–20), respectively; p < 0.001], SSI score [7 (0–22) vs. 0 (0–10); p < 0.001] as well as intensity of current and previous suicidal ideations during the last 15 days [1 (0–10) vs. 0 (0–3), 2 (0–9) vs. 0 (0–5), respectively; both p < 0.001]. Of note, reduction in the C-SSRS ‘suicidal ideation’ subscore was correlated to the AAQ score (p = 0.04, r = –0.37), but not to BDI and STAI scores. Between inclusion and 3-month follow-up, the reduction of all suicidal ideation scores remained significant. There were no suicide reattempts during the follow-up period.
Dr. Déborah Ducasse Department of Psychiatric Emergency and Acute Crisis Lapeyronie Hospital, CHU Montpellier FR–34295 Montpellier (France) E-Mail d-ducasse @ chu-montpellier.fr
Table 1. Psychotherapeutic protocol1
Session 1
Presentation of the trap of struggling using a ‘matrix’ (i.e. functional analysis adapted from Schoendorff [7]). The six core processes of ACT are briefly explained.
Session 2
Cognitive defusion Aim: to alter the undesirable functions of thoughts and other private events, rather than trying to alter their form, frequency or situational sensitivity. Defusion exercises: saying thoughts using the prefix ‘I have the thought that…’; naming the history our mind is rehashing to us: ‘hey, this is still the history of ...’; changing the shape of the thought as if it came from a computer screen; treating thoughts as passengers on a bus driven by the participant.
Session 3
Acceptance and self as context Acceptance aims at actively welcoming and making space for mental events, instead of struggling against them. Acceptance is the opposite of experiential avoidance (tendency to avoid unwanted thoughts or emotions). Exercises: naming the emotion, observing the emotion as a scientific curiosity or a physical object. Self as context aims at developing the participant’s sense of self as separate from their distressing thoughts and feelings. The participant observes their distressing psychological events while knowing that they are the container (context) for these events but not them. The ‘Chessboard Metaphor’: the participant is described as a chessboard and the pieces as psychological events. The ‘Sky and Weather Metaphor’: self as context is compared to the sky and psychological events to the weather.
Sessions 4 and 5 Values and valued actions Values are chosen qualities of purposive action, which are present at each moment. ‘Compass Metaphor’ and ‘model’ exercises are trained to define values. Sessions 6 and 7 Contact with the present moment It helps participants’ flexibility to attend to the world more directly, rather than to consider the world as constructed by the evaluative language processes. Experiential exercises: ‘Leaves on a Stream’ (mindfulness observation of the hands), training mindfulness skills in daily life. Two therapists (D.D. and E.R.) animated seven weekly sessions lasting 2 h. At the end of each session, a written summary was given to the participants in order to help them practice skills at home. 1Adapted from Hayes et al. [5], Harris et al. [6] and Schoendorff [7].
Between inclusion and the 1-week follow-up, there was a significant reduction of depression according to BDI [13 (2–28) vs. 4.5 (0–24); p < 0.001] and IDS-C30 scores [28 (12–61) vs. 8 (0–31); p < 0.001], anxiety state [53 (23–77) vs. 37 (20–58); p < 0.001], hopelessness [11 (2–20) vs. 4.5 (1–13); p < 0.001], and psychological pain [4 (0–10) vs. 1 (0–7); p < 0.001]. There was also a significant improvement in global functioning [37 (8–60) vs. 17 (0–47); p < 0.001] and quality of life [77 (43–107) vs. 93 (60–129); p < 0.001]. Between inclusion and the 3-month follow-up, the differences remained significant. During follow-up, dosages of benzodiazepines were reduced for 65% of the patients. Our study suggests that an adjunctive ACT group programme could be effective for suicidality, to decrease suicidal ideation in patients with current SBD. ACT may reduce the intensity and/or frequency of suicidal ideations through several factors: – increase in acceptance skills due to a change in the patient’s relationship to their internal experiences, and a clarification of what is really important in their life [2, 5]; – increase in the meaning of existence through personal engagement toward value-oriented actions [5]; – impact on modifiable suicidal risk factors (hopelessness, psychological pain, quality of life).
We conducted a naturalistic study (few exclusion criteria, medicated patients) aiming at reflecting ‘real life’ in order to increase external validity. ACT seems acceptable with low dropout and high satisfaction rates. Relative to Dialectical Behavioral Therapy, ACT is more easily feasible while sharing common skills. The strength of our study is the concordance between improvements of different suicidal ideation measures. Nevertheless, further studies should include a control group regarding the specific efficiency of ACT on suicidal ideations. Sample size and evaluation bias limit the generalizability of our results. The potential impact of ACT on suicidal ideations, clinical and functional measures associated with SBD as well as its good acceptability suggest that it is a promising adjunctive treatment for managing high suicidal risk patients.
Acceptance and Commitment Therapy for Suicidal Behaviour Disorder
Psychother Psychosom 2014;83:374–376 DOI: 10.1159/000365974
Acknowledgement The authors thank Valérie Macioce for her careful reading of the manuscript. Disclosure Statements All authors declare no conflicts of interest related to the manuscript.
375
References 1 American Psychiatric Association: The Diagnostic and Statistical Manual of Mental Disorders, DSM-5. Washington, American Psychiatric Association, 2013. 2 Pettit JW, Temple SR, Norton PJ, Yaroslavsky I, Grover KE, Morgan ST, Schatte DJ: Thought suppression and suicidal ideation: preliminary evidence in support of a robust association. Depress Anxiety 2009;26:758–763. 3 Chiles JA, Strosahl KD: Clinical Manual for Assessment and Treatment of Suicidal Patients. Washington, American Psychiatric Publishing, 2008. 4 Luoma JB, Villatte JL: Mindfulness in the treatment of suicidal individuals. Cogn Behav Pract 2012;19:265–276. 5 Hayes SC, Strosahl KD, Wilson KG: Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York, Guilford Press, 1999.
376
Psychother Psychosom 2014;83:374–376 DOI: 10.1159/000365974
6 Harris R, Penet C, Milleville L: Passez à l’ACT: pratique de la thérapie d’acceptation et d’engagement. Brussels, de boeck, 2012. 7 Schoendorff B: Faire face à la souffrance: choisir la vie plutôt que la lutte avec la thérapie d’acceptation et d’engagement. Paris, Retz, 2011. 8 Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin GA, Greenhill L, Shen S, Mann JJ: The ColumbiaSuicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 2011;168:1266–1277. 9 Beck AT, Kovacs M, Weissman A: Assessment of suicidal intention: the scale for suicide ideation. J Consult Clin Psychol 1979;47:343–352. 10 Stosahl K, Wilson KG, Bissett RT, Polusny MA, Dykstra TA, Batten SV, Bergan J, Stewart SH, Zvolesnsky MJ, Bond FW: Measuring experiential avoidance: a preliminary test of a working model. Psychol Rec 2004; 54: 553–578.
Ducasse/René/Béziat/Guillaume/Courtet/ Olié
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Psychother Psychosom 2014;83:374–376 DOI: 10.1159/000365974
Acceptance and Commitment Therapy for Management of Suicidal Patients: A Pilot Study Déborah Ducassea, b, Eric Renéa, Séverine Béziata, Sébastien Guillaumea, b, Philippe Courteta, b, Emilie Oliéa, b a Department
of Psychiatric Emergency and Acute Crisis, Lapeyronie Hospital, CHU Montpellier, and b University of Montpellier UM1, Montpellier, France
With one million deaths every year, suicide is a major health problem worldwide. Recently, suicidal behaviour disorder (SBD) has been included in DSM-5 as an independent clinical entity [1]. It highlights the need to address the suicidal process as a primary target of concern and to identify corresponding transnosographic preventive strategies, including psychotherapy. Acceptance and Commitment Therapy (ACT), a ‘third-wave’ behavioural therapy, targets experiential avoidance (tendency to avoid unwanted thoughts or emotions) at the core of psychiatric disorders. Of note, suicidal subjects report intrusive mental images of suicide that they try to suppress, increasing in their intensity and frequency, independently from depressive symptoms [2]. Indeed, experiential avoidance would predict suicidal behaviours [3]. Moreover, two case reports have suggested the preventive role of ACT on suicidal reattempts at 1 year [4]. Thus, we aimed at examining the usefulness of an add-on ACT group programme to decrease suicidal ideation in high-risk patients. The study was conducted in the Department of Psychiatric Emergency and Acute Crisis, Academic Hospital of Montpellier, France. Thirty-five outpatients suffering from a current SBD according to DSM-5 [1] (history of suicidal attempt in the past year) were included in an ACT programme (table 1) [5–7]. Exclusion criteria were current mania or depressive episode with mixed features, and schizophrenia. Patients were assessed at inclusion (1 week before the programme, T0) and 1 week (T1) and 3 months (T2) after programme completion. Psychiatrists assessed: (1) suicidal ideation using the Columbia-Suicide Severity Rating Scale (C-SSRS) [8] (suicidal ideation subscore = severity and intensity items) and the Scale for Suicidal Ideation (SSI score) [9]; (2) psychiatric disorders using the French version of the Mini International Neuropsychiatric Interview; (3) borderline personality disorder using the Screening Interview for Axis II Disorder; (4) depressive symptomatology using the Inventory of Depressive Symptomatology (IDS-C30); (5) global functioning using the Functioning Assessment Short Test, and
© 2014 S. Karger AG, Basel 0033–3190/14/0836–0374$39.50/0 E-Mail [email protected] www.karger.com/pps
(6) pharmacological treatment and number of visits for psychiatric emergencies in the previous 3 months. Self-assessments included: (1) suicidal ideation on a visual analogue scale from 0 (none) to 10 (maximum), currently and during the last 15 days; (2) depressive intensity using Beck Depression Inventory-II (BDI); (3) psychological pain on a visual analogue scale from 0 (none) to 10 (maximum); (4) anxiety state using the State-Trait Anxiety Inventory (STAI); (5) hopelessness during the last month using the Beck Hopelessness Scale; (6) quality of life using the World Health Organization Quality of Life measure, and (7) acceptance using the Acceptance and Action Questionnaire (AAQ) [10]. Considering the small sample size and skewed distribution of most continuous variables, median (min–max) and non-parametric tests were used. Friedman’s tests for quantitative variables and Cochran’s Q test for categorical variables were used to globally compare the three time points. If the global p value was p < 0.05, two-by-two comparisons were run (signed rank, McNemar’s and kappa tests) and corrected for multiple comparisons (Bonferroni correction). Spearman’s rank order correlations were applied to measure associations between continuous variables. Statistical analyses were performed using SAS software, version 9.2 (SAS Institute, Cary, N.C., USA). Two patients did not start the programme; 78.8% attended all sessions. ACT was reported to be helpful by 96.9% patients. One patient (suffering from borderline personality disorder) committed suicide during the first month of the study, without any clear association with intervention. Sociodemographic characteristics were as follows: 57.1% males, median age 38.4 years (min–max: 18–60), 48.6% single, 60% fully employed. The majority of patients were currently depressed (94.3%), having attempted suicide the month preceding the inclusion (93.9%). Psychiatric disorders were unipolar (37.1%), bipolar (57.1%), anxiety (97.1%), addictive (28.6%), eating (17.1%), and/ or borderline personality (20%) disorders. All participants were on psychotropic medications. There were significant differences for all scores between the three visits (p < 0.001). Between inclusion and the 1-week followup, there was a significant reduction of the C-SSRS ‘suicidal ideation’ subscore [20 (0–30) vs. 0 (0–20), respectively; p < 0.001], SSI score [7 (0–22) vs. 0 (0–10); p < 0.001] as well as intensity of current and previous suicidal ideations during the last 15 days [1 (0–10) vs. 0 (0–3), 2 (0–9) vs. 0 (0–5), respectively; both p < 0.001]. Of note, reduction in the C-SSRS ‘suicidal ideation’ subscore was correlated to the AAQ score (p = 0.04, r = –0.37), but not to BDI and STAI scores. Between inclusion and 3-month follow-up, the reduction of all suicidal ideation scores remained significant. There were no suicide reattempts during the follow-up period.
Dr. Déborah Ducasse Department of Psychiatric Emergency and Acute Crisis Lapeyronie Hospital, CHU Montpellier FR–34295 Montpellier (France) E-Mail d-ducasse @ chu-montpellier.fr
Table 1. Psychotherapeutic protocol1
Session 1
Presentation of the trap of struggling using a ‘matrix’ (i.e. functional analysis adapted from Schoendorff [7]). The six core processes of ACT are briefly explained.
Session 2
Cognitive defusion Aim: to alter the undesirable functions of thoughts and other private events, rather than trying to alter their form, frequency or situational sensitivity. Defusion exercises: saying thoughts using the prefix ‘I have the thought that…’; naming the history our mind is rehashing to us: ‘hey, this is still the history of ...’; changing the shape of the thought as if it came from a computer screen; treating thoughts as passengers on a bus driven by the participant.
Session 3
Acceptance and self as context Acceptance aims at actively welcoming and making space for mental events, instead of struggling against them. Acceptance is the opposite of experiential avoidance (tendency to avoid unwanted thoughts or emotions). Exercises: naming the emotion, observing the emotion as a scientific curiosity or a physical object. Self as context aims at developing the participant’s sense of self as separate from their distressing thoughts and feelings. The participant observes their distressing psychological events while knowing that they are the container (context) for these events but not them. The ‘Chessboard Metaphor’: the participant is described as a chessboard and the pieces as psychological events. The ‘Sky and Weather Metaphor’: self as context is compared to the sky and psychological events to the weather.
Sessions 4 and 5 Values and valued actions Values are chosen qualities of purposive action, which are present at each moment. ‘Compass Metaphor’ and ‘model’ exercises are trained to define values. Sessions 6 and 7 Contact with the present moment It helps participants’ flexibility to attend to the world more directly, rather than to consider the world as constructed by the evaluative language processes. Experiential exercises: ‘Leaves on a Stream’ (mindfulness observation of the hands), training mindfulness skills in daily life. Two therapists (D.D. and E.R.) animated seven weekly sessions lasting 2 h. At the end of each session, a written summary was given to the participants in order to help them practice skills at home. 1Adapted from Hayes et al. [5], Harris et al. [6] and Schoendorff [7].
Between inclusion and the 1-week follow-up, there was a significant reduction of depression according to BDI [13 (2–28) vs. 4.5 (0–24); p < 0.001] and IDS-C30 scores [28 (12–61) vs. 8 (0–31); p < 0.001], anxiety state [53 (23–77) vs. 37 (20–58); p < 0.001], hopelessness [11 (2–20) vs. 4.5 (1–13); p < 0.001], and psychological pain [4 (0–10) vs. 1 (0–7); p < 0.001]. There was also a significant improvement in global functioning [37 (8–60) vs. 17 (0–47); p < 0.001] and quality of life [77 (43–107) vs. 93 (60–129); p < 0.001]. Between inclusion and the 3-month follow-up, the differences remained significant. During follow-up, dosages of benzodiazepines were reduced for 65% of the patients. Our study suggests that an adjunctive ACT group programme could be effective for suicidality, to decrease suicidal ideation in patients with current SBD. ACT may reduce the intensity and/or frequency of suicidal ideations through several factors: – increase in acceptance skills due to a change in the patient’s relationship to their internal experiences, and a clarification of what is really important in their life [2, 5]; – increase in the meaning of existence through personal engagement toward value-oriented actions [5]; – impact on modifiable suicidal risk factors (hopelessness, psychological pain, quality of life).
We conducted a naturalistic study (few exclusion criteria, medicated patients) aiming at reflecting ‘real life’ in order to increase external validity. ACT seems acceptable with low dropout and high satisfaction rates. Relative to Dialectical Behavioral Therapy, ACT is more easily feasible while sharing common skills. The strength of our study is the concordance between improvements of different suicidal ideation measures. Nevertheless, further studies should include a control group regarding the specific efficiency of ACT on suicidal ideations. Sample size and evaluation bias limit the generalizability of our results. The potential impact of ACT on suicidal ideations, clinical and functional measures associated with SBD as well as its good acceptability suggest that it is a promising adjunctive treatment for managing high suicidal risk patients.
Acceptance and Commitment Therapy for Suicidal Behaviour Disorder
Psychother Psychosom 2014;83:374–376 DOI: 10.1159/000365974
Acknowledgement The authors thank Valérie Macioce for her careful reading of the manuscript. Disclosure Statements All authors declare no conflicts of interest related to the manuscript.
375
References 1 American Psychiatric Association: The Diagnostic and Statistical Manual of Mental Disorders, DSM-5. Washington, American Psychiatric Association, 2013. 2 Pettit JW, Temple SR, Norton PJ, Yaroslavsky I, Grover KE, Morgan ST, Schatte DJ: Thought suppression and suicidal ideation: preliminary evidence in support of a robust association. Depress Anxiety 2009;26:758–763. 3 Chiles JA, Strosahl KD: Clinical Manual for Assessment and Treatment of Suicidal Patients. Washington, American Psychiatric Publishing, 2008. 4 Luoma JB, Villatte JL: Mindfulness in the treatment of suicidal individuals. Cogn Behav Pract 2012;19:265–276. 5 Hayes SC, Strosahl KD, Wilson KG: Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York, Guilford Press, 1999.
376
Psychother Psychosom 2014;83:374–376 DOI: 10.1159/000365974
6 Harris R, Penet C, Milleville L: Passez à l’ACT: pratique de la thérapie d’acceptation et d’engagement. Brussels, de boeck, 2012. 7 Schoendorff B: Faire face à la souffrance: choisir la vie plutôt que la lutte avec la thérapie d’acceptation et d’engagement. Paris, Retz, 2011. 8 Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin GA, Greenhill L, Shen S, Mann JJ: The ColumbiaSuicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 2011;168:1266–1277. 9 Beck AT, Kovacs M, Weissman A: Assessment of suicidal intention: the scale for suicide ideation. J Consult Clin Psychol 1979;47:343–352. 10 Stosahl K, Wilson KG, Bissett RT, Polusny MA, Dykstra TA, Batten SV, Bergan J, Stewart SH, Zvolesnsky MJ, Bond FW: Measuring experiential avoidance: a preliminary test of a working model. Psychol Rec 2004; 54: 553–578.
Ducasse/René/Béziat/Guillaume/Courtet/ Olié
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
