Atlas›Domain II · Behavioural & cognitive›Guide 128
Guide II-128

Brief cognitive behavioural therapy for suicide prevention

Bryan, Rudd2015
A 22 · L 66 · M 1222 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the 12-session outpatient protocol in Bryan & Rudd (2018), Brief Cognitive-Behavioral Therapy for Suicide Prevention (Guilford, 1st ed.). I reconstructed its structure from the manual's published table of contents, the trial description in Rudd et al. (2015), Craig Bryan's own training slides (about 2020–2026) and Focus (2022). The manual's text is not drawn on. A second edition with a separate client workbook is announced for February 2027, and it is not drawn on. A 4-session inpatient adaptation (Tolin, Diefenbach and Rudd, NCT04168645) is noted where relevant. [source: Guilford 1st-ed. contents; Guilford 2nd-ed. page; Rudd et al. 2015; Bryan slides; Focus 2022]

Brief cognitive behavioural therapy for suicide prevention (BCBT) is a time-limited, skills-based individual psychotherapy. It treats suicidal behaviour as its own treatment target, separate from psychiatric diagnosis. It grew out of Beck's cognitive therapy, by way of Rudd's model of the suicidal mode. In that model, stable vulnerabilities interact with activating events (relationship problems, financial stress, loss, physical sensations, negative memories) to switch on a temporary state. That state links suicidal beliefs (hopelessness, feeling trapped, being a burden), emotions (depression, guilt, anger), physical states (agitation, insomnia, pain) and behaviours (substance use, withdrawal, preparation). [source: Bryan slides, Colorado and Oregon decks; Tolin protocol]

The theory of change is that suicide risk persists because of a core deficit in emotion regulation and cognitive flexibility. Treatment therefore does three things in turn:

  • It stabilises crises with a crisis response plan and means safety.
  • It builds emotion-regulation skills (Phase I).
  • It loosens the suicidal belief system (Phase II).

The patient then shows, in an imaginal relapse prevention task, that they can use the skills in a re-lived crisis (Phase III). Progress depends on demonstrated competence, not on the session count. [source: Rudd et al. 2015; Bryan slides; Focus 2022]

2. Framework

Format. BCBT is individual outpatient therapy, usually 12 sessions, weekly or every two weeks. In the 2015 trial, session 1 was 90 minutes and later sessions were 60 minutes, with BCBT added to usual care. The Brazilian trial protocol uses 12 weekly 60-minute sessions. Delivery has been tested in person, fully virtual (Baker et al. 2024, as listed in Bryan's slides) and mixed virtual and in person (the MSPIRE trial, Bryan et al. 2025, JAMA Psychiatry, which compared BCBT with present-centred therapy). Telehealth procedures are not described in the sources [uncertain]. [source: Rudd et al. 2015; NCT07574658 protocol; Bryan Oregon slides; MSPIRE abstract]

Standard session structure (every session after the first) [source: Bryan Colorado slides]:

  1. Review the crisis response plan and homework, and bridge from the last session.
  2. Introduce the new skill, describe it, and explicitly link it to the patient's suicidal mode.
  3. Demonstrate and practise the skill in session, discuss the patient's experience of it, plan practice and solve barriers.
  4. The patient writes the lesson learned in the treatment log.

The manual has a chapter on monitoring treatment progress. The measures it uses are [uncertain]. A practical default is to start each session with a brief check of suicidal ideation, any suicidal behaviour or preparation since the last session, and use of the crisis plan [synthesis].

Phases [source: Guilford contents; Focus 2022; Bryan slides; Rudd et al. 2015]

PhaseSessionsGoalContent
First session1Orient, assess and stabiliseDescribe BCBT structure; narrative assessment; treatment log and case conceptualisation (suicidal mode); crisis response plan; means safety counselling (Bryan slides place this in session 1)
Phase I: Emotion regulation and crisis management2–5Reduce acute risk; build emotion-regulation skillsTreatment plan and commitment to treatment statement; means safety and crisis support plan; sleep disturbance; relaxation and mindfulness; reasons for living list and survival kit. Bryan's 2026 slides also place activity planning and coping cards in this phase
Phase II: Cognitive flexibility (undermining the suicidal belief system)6–10Weaken suicidal beliefs: hopelessness, perceived burdensomeness, guilt and shameABC worksheets; challenging questions worksheets; patterns of problematic thinking worksheets; activity planning; coping cards
Phase III: Relapse prevention11–12+Show skill mastery in a simulated crisisRelapse prevention task (imaginal); review of the treatment log; ending treatment

Criteria for moving on and ending.

  • Progress is competency-based. Treatment ends when the patient has shown emotion-regulation and cognitive-flexibility skills, usually through using the crisis plan and other BCBT skills. [source: Rudd et al. 2015; Bryan Colorado slides]
  • The relapse prevention task is the final competency check. If the patient cannot complete it, sessions are added until they can. [source: Rudd et al. 2015; Bryan slides]
  • Explicit criteria for moving from Phase I to Phase II are not given in the sources [uncertain]. A reasonable working rule is to move on when the patient has a crisis plan they report using (or can say how they would use it), has practised at least one emotion-regulation skill between sessions, and has a reasons-for-living list or survival kit in place. Move on sooner if the session count requires it, and keep reviewing the crisis plan [synthesis].
  • The session ranges in the table are typical, not fixed. Skills can be reordered to fit the patient's suicidal mode. For example, sleep work comes first for a patient whose crises are driven by insomnia [synthesis; Bryan notes that early sleep improvement predicts later attempts, Oregon slides].

3. Guiding principles

The manual's chapter 3, "Core Principles of Treatment with Suicidal Patients", is not drawn on. These principles come from Rudd et al. (2015) and Bryan's slides, which cite Rudd et al. (2009) on the essential ingredients of effective treatments.

  • Suicide risk is a treatment target separate from diagnosis. Name suicidal behaviour as the problem being treated, rather than waiting for depression or PTSD to resolve. [source: Rudd et al. 2015]
  • Distinguish suicidal behaviour from suicidal thinking. The aim is to prevent attempts. Ideation may come and go while skills grow, so judge progress by behaviour and skill use. [source: Bryan Oregon slides]
  • Target mechanisms directly, with emotion regulation at the centre. Every skill is chosen and explained as a way to deactivate or interrupt the suicidal mode. [source: Bryan slides]
  • Use a simple model the patient can understand. Draw the patient's own suicidal mode, and refer back to it every session. [source: Rudd et al. 2009, cited in Bryan slides]
  • Hold high fidelity to the protocol. Follow the session structure and the fidelity checklists. Trial therapists were supervised against a fidelity checklist and reached over 90% fidelity. [source: Rudd et al. 2015; Guilford contents (B1 Fidelity Checklists)]
  • Prioritise patient adherence and skills training over insight. Practise skills in every session and assign them for practice between sessions. [source: Rudd et al. 2009, cited in Bryan slides]
  • Prioritise self-management. The patient, not the clinician, holds the plan and the skills. The crisis plan puts self-management strategies before calling others. [source: Bryan slides; Baker CRP slides]
  • Make crisis services easy to reach. Every crisis plan ends with professional and emergency contacts. [source: Rudd et al. 2009, cited in Bryan slides]
  • Collaborate. Build the crisis plan, the means plan and the treatment plan with the patient, using their own words and ideas. Ask what has worked before. [source: Rudd et al. 2015; Baker CRP slides]
  • No no-suicide contracts. The crisis response plan and the commitment to treatment statement replace no-harm or safety contracts. Never ask the patient to promise not to die. [source: Baker CRP slides; Guilford contents]
  • Risk is fluid. Baseline risk is fairly stable, but acute risk rises and falls with activating events (fluid vulnerability). Reassess every session and expect future spikes. [source: Bryan Oregon slides; Tolin protocol]
  • Understand the function of suicidal behaviour. Ask what the behaviour does for the patient. It may relieve or stop feelings (automatic), or communicate or escape demands (social). Then build skills that meet the same need. [source: Bryan Colorado and Oregon slides]
  • Competence, not attendance, decides when therapy ends. Do not end after 12 sessions if the patient cannot yet use the skills under emotional load. [source: Rudd et al. 2015]
  • Write it down and keep it portable. The treatment log, a handwritten crisis card, coping cards and the survival kit all serve as memory aids when the suicidal mode is active and thinking narrows. [source: Rudd et al. 2015; Baker CRP slides; Tolin protocol]
  • Document risk assessment and decisions. The manual includes a risk assessment documentation template, and the second edition adds a chapter on standard of care. [source: Guilford contents; Guilford 2nd-ed. page] Record risk formulation, the crisis plan and means steps at each contact [synthesis].

4. Intervention inventory

The inventory follows the manual's chapter order (Guilford contents). Each entry gives the procedure as far as the sources describe it. Steps marked [synthesis] are my own operational detail, added where the manual's text could not be checked. All example wording is illustrative unless it is quoted and cited.

4.1 Describing the structure of BCBT (informed consent and orientation), session 1

  • Purpose: Set expectations. Present BCBT as a skills-focused, time-limited, competency-based treatment that directly targets suicidal behaviour. Get informed consent, including the limits of confidentiality. [source: Guilford contents ch. 7, A2 patient information sheet; Tolin protocol (consent reconfirmed at the start)]
  • Steps:
    1. Explain the three phases and roughly 12 sessions. Say that therapy ends when the patient can show the skills, not at a set session number. [source: Rudd et al. 2015]
    2. Explain the session routine: review, new skill, practice, treatment log entry. [source: Bryan slides]
    3. Cover confidentiality limits and what happens if risk becomes imminent [synthesis].
    4. Give the patient written information. The manual's sheet is A2; do not reproduce it, write your own. Invite questions. [source: Guilford contents]
  • Example language (illustrative): "This treatment is about building specific skills so that the next time things get this bad, you have other ways through. We'll practise in every session. We finish when you can show yourself you can use them, not just when we hit a session number."
  • Watch for: Fear that disclosure means automatic hospitalisation. Be concrete about when you would act [synthesis]. Signs it's working: the patient can restate the structure and agrees to try it.

4.2 Narrative assessment, session 1

  • Purpose: Understand the index suicidal episode or attempt in detail, as a sequence of events, thoughts, emotions, physical sensations and behaviours. This builds the case conceptualisation and identifies warning signs for the crisis plan. It also serves as a risk assessment. [source: Bryan Colorado slides; Baker CRP slides; Rudd et al. 2015; Tolin protocol]
  • Steps:
    1. Ask the patient to tell the story of the most recent suicidal episode in chronological order, starting before the crisis began. [source: Bryan slides]
    2. Move through it step by step, asking what happened next. At each point, ask about events, thoughts (what they said to themselves), emotions, body sensations and actions. [source: Bryan slides; Baker slides]
    3. Keep the focus on the index episode. Gently steer back from tangents. [source: Baker slides]
    4. Note activating events, the first warning signs, any escalation, protective actions or interruptions, and what happened afterwards [synthesis].
    5. Use the narrative to complete a risk assessment and its documentation. The manual's template is B2. [source: Guilford contents]
  • Example language: Bryan's slides give the opening prompt "Can you tell me the story of what happened?" and the follow-up "What were you saying to yourself at that point?" [source: Bryan Colorado slides]. Illustrative continuation: "And what did you notice in your body then? … Then what happened?"
  • Watch for: Rising distress. Slow down and ground the patient, but keep going: the narrative is part of the treatment, not only an assessment [synthesis]. Also watch for shame-driven minimising. Signs it's working: the patient can see that the crisis unfolded in steps, with points where they could have intervened.

4.3 Suicidal mode psychoeducation and case conceptualisation

  • Purpose: Give the patient a simple, personal model of their suicidal crises to organise the rest of treatment. Every later skill is linked back to it. [source: Guilford contents ch. 2, ch. 9, A1; Bryan slides; Tolin protocol]
  • Steps:
    1. Explain that background vulnerabilities interact with activating events to switch on a temporary suicidal state. The state has four linked parts: thoughts, emotions, physical sensations and behaviours. [source: Bryan slides; Tolin protocol]
    2. Fill in the model with the patient's own material from the narrative. Their triggers go in the activating events box. Their exact suicidal beliefs (for example, being a burden or trapped) go in the cognitive box, alongside their emotions, physical states and behaviours. [source: Bryan slides]
    3. Point out that risk rises and falls over time, so the state will pass, and that each skill targets one link in the chain [source: Bryan Oregon slides (fluid vulnerability)].
    4. If useful, explore the function of past suicidal behaviour: relief from feelings, or communicating with or escaping from others [source: Bryan slides (functional model)].
    5. The patient copies the model into the treatment log. [source: Tolin protocol]
  • Example language (illustrative): "Let's map out what happened that night. The argument is the trigger. Then the thought 'they'd be better off without me', the feeling of shame, the restlessness, and pulling away from everyone. Each of these feeds the others. Our job is to learn how to break those links."
  • Watch for: A model that is too abstract. Use the patient's own words [synthesis]. Signs it's working: the patient uses the model on their own to describe a new episode.

4.4 Treatment log ("smart book")

  • Purpose: A portable record of the suicidal mode, the crisis plan and a lesson learned from every session. It aids memory during crises and becomes the relapse prevention manual at the end. [source: Rudd et al. 2015; Tolin protocol; Bryan slides]
  • Steps:
    1. In session 1, give the patient a pocket-sized notebook. [source: Rudd et al. 2015]
    2. At the end of each session, ask the patient to write one lesson learned in their own words. [source: Rudd et al. 2015; Bryan slides]
    3. Keep the suicidal mode diagram and crisis plan in it too. [source: Tolin protocol]
    4. Review it in Phase III and add the relapse prevention plan. [source: Rudd et al. 2015]
  • Example language (illustrative): "Before we finish, what's the one thing from today you'd want to remember if things got bad again? Write it in your own words."
  • Watch for: Generic entries such as "talk was good". Prompt for something specific the patient can act on [synthesis]. Signs it's working: the patient brings the log to sessions and refers to it on their own.

4.5 Crisis response plan (CRP), session 1, reviewed every session

  • Purpose: A short, handwritten, step-by-step plan for what to do when warning signs appear. It puts self-management first, then social support, then professional help. It replaces no-suicide contracts. [source: Bryan Colorado slides; Baker CRP slides; Rudd et al. 2015]
  • Steps (the eight steps Bryan and Baker present) [source: Bryan Colorado slides; Baker CRP slides]:
    1. Explain the rationale. Thinking narrows during a crisis, so decide in advance what to do.
    2. Give the patient an index card or business-size card. The patient handwrites the plan; do not use a pre-printed form.
    3. List personal warning signs, taken from the narrative assessment (thoughts, feelings, body signs, behaviours).
    4. List self-management strategies. Ask what has worked before.
    5. List reasons for living.
    6. List social supports: people to contact or be with.
    7. List crisis and emergency steps: professional contacts, a crisis line and emergency services.
    8. Review the plan out loud and ask the patient to rate how likely they are to use it. Problem-solve any low rating.
    • Suggest photographing the card and keeping it on the phone. [source: Baker slides]
    • At every later session, review the plan. Add newly learned skills and remove any the patient judged ineffective, impractical or too hard. [source: Rudd et al. 2015]
  • Example language: Illustrative: "When you start noticing those signs again, what could you do on your own first that has helped even a little?" "On a 0–10 scale, how likely are you to actually use this card next time?"
  • Watch for: Vague strategies such as "be positive". Make them concrete and doable at 2 a.m. [synthesis]. Watch for supports who are also triggers [synthesis]. Signs it's working: the patient reports using the card, or can describe when they would use it.

4.6 Means safety counselling (session 1 and early Phase I)

  • Purpose: Reduce access to lethal means during high-risk periods. A delay lets the crisis pass, and a less lethal method improves the chance of survival. [source: Tolin protocol; Bryan slides; Guilford contents ch. 12, A5 Means Safety Plan]
  • Steps (Britton, Bryan and Valenstein's four-phase motivational approach for firearms, from Bryan's slides):
    1. Engaging. Build collaboration. Ask matter-of-factly whether the patient owns or can get firearms, and what types.
    2. Focusing. Move towards safety, balancing direction and exploration. Ask about the safety practices they already follow.
    3. Evoking. Once the patient agrees to discuss it, ask for their own reasons to limit access and their views on secure storage. Asking about homes with children, or homes where someone is struggling, can open this up.
    4. Planning. Generate options, weigh their pros and cons, agree a plan and write it down.
    • Extend the same approach to medications and other means at hand. Options include having a family member lock up and dispense medications, and storing firearms outside the home. [source: Tolin protocol]
    • Share the plan with a support person if the patient agrees (in the inpatient adaptation, it was shared with the unit clinician). [source: Tolin protocol]
    • Follow up at the next session to check the plan was carried out. [synthesis]
  • Example language: Bryan's slides give "Where does this leave you?" for the shift into planning. Illustrative: "Many people decide to put some distance between themselves and a gun during a hard stretch, for example storing it with someone they trust. What would make sense for you?"
  • Watch for: Defensiveness, especially among firearm owners or military patients. Stay with their values (for example, responsible ownership) and avoid lecturing [synthesis]. Signs it's working: a specific action with a who, where and when, confirmed at follow-up.

4.7 Treatment planning

  • Purpose: Write a collaborative plan naming suicidal behaviour as the primary target, with measurable goals and the BCBT interventions. [source: Guilford contents ch. 11, A3]
  • Steps [synthesis]:
    1. Name the main problem: preventing suicidal behaviour.
    2. Add secondary targets from the suicidal mode, such as insomnia, hopelessness and anger.
    3. Set observable goals, such as no suicidal behaviour, using the crisis plan when warning signs appear, and less severe ideation.
    4. List the planned interventions by phase.
    5. Both of you sign or agree to it, and review it at the transition to Phase II and at the end.
  • Example language (illustrative): "The number one goal on this plan is that you don't make another attempt. Everything else we work on is there to serve that goal."
  • Watch for: Plans that target only diagnoses. Keep suicide as the explicit target [source: Rudd et al. 2015 principle].

4.8 Commitment to treatment statement

  • Purpose: A written agreement to engage in treatment. It covers taking part actively, talking openly about suicidal thoughts and using the crisis plan and emergency services. It replaces a no-suicide contract. [source: Guilford contents ch. 11, A4; Baker slides (CRP is not a contract)] The content is based on Rudd, Mandrusiak and Joiner (2006); That paper is not drawn on [uncertain].
  • Steps [synthesis]:
    1. Explain how this differs from a no-harm contract: it is about commitment to treatment, not a promise to stay alive.
    2. Agree the patient's commitments: attending, practising, honest disclosure and following the crisis plan. Also state the therapist's commitments.
    3. Write it in the patient's words, and both sign it.
    4. Revisit it if engagement drops.
  • Example language (illustrative): "I'm not asking you to promise you'll never feel suicidal. I'm asking whether you'll commit to this treatment for the next few months, including telling me when things get bad."
  • Watch for: The patient or clinician treating it as legal protection. It is a clinical tool [synthesis].

4.9 Crisis support plan

  • Purpose: A plan for a support person (family member, partner or friend). It covers how to recognise warning signs, how to respond helpfully and how to support means safety. [source: Guilford contents ch. 12, A6] The detailed content is [uncertain].
  • Steps [synthesis]:
    1. With consent, involve the support person, in session or by phone.
    2. Share the patient's warning signs and the crisis plan.
    3. Agree specific helpful actions, such as staying with the patient, prompting the card or calling the crisis line.
    4. Agree what to avoid, such as arguing about whether the patient "really" means it.
    5. Agree their part in means safety.
    6. Give them emergency contacts.
  • Example language (illustrative): "If you notice them going quiet and staying in their room, a good first step is to ask directly and remind them of their card."
  • Watch for: Conflict with the support person, or controlling behaviour from them. Choose supports with the patient [synthesis].

4.10 Targeting sleep disturbance

  • Purpose: Insomnia is a physical part of the suicidal mode and a risk factor. Improving sleep early lowers arousal. Bryan reports that early sleep improvement predicts later attempts. [source: Bryan Oregon slides; Guilford contents ch. 13, A7 'Improving Your Sleep' handout; NCT07574658 lists 'sleep stimulus control']
  • Steps (stimulus control plus sleep hygiene; the details are my rendering of standard CBT-I stimulus control [synthesis/uncertain whether identical to the manual]):
    1. Assess the pattern: bedtime, sleep onset, waking, naps, caffeine and alcohol, nightmares.
    2. Link it to the suicidal mode, for example rumination at night and exhaustion the next day.
    3. Teach stimulus control: use the bed only for sleep and sex; go to bed only when sleepy; if awake and not sleepy for what feels like a while, get up and do something calm elsewhere, then return; get up at the same time every day; avoid daytime naps.
    4. Add basic sleep hygiene points from your own handout.
    5. Set a one-week practice and review it with a sleep log.
  • Example language (illustrative): "Your bed has become a place where you lie awake with these thoughts. We want to retrain your brain so that bed means sleep."
  • Watch for: Getting out of bed at night in a high-risk home. Check that means safety covers night-time [synthesis]. Screen for sleep apnoea or nightmares that need specific treatment [synthesis]. Signs it's working: more regular rise times and less time awake in bed.

4.11 Relaxation skills training

  • Purpose: A body-based emotion-regulation skill to bring down physical arousal (agitation, tension) in the suicidal mode. It is added to the crisis plan. [source: Rudd et al. 2015; Guilford contents ch. 14, B6 Relaxation Script]
  • Steps (the manual script is not drawn on; the method below is a generic slow breathing and muscle relaxation procedure [uncertain/synthesis]):
    1. Give the rationale, linked to the patient's physical warning signs.
    2. Get a 0–10 distress or tension rating.
    3. Guide the patient through about 5–10 minutes of slow, paced breathing, with or without tensing and releasing muscle groups.
    4. Re-rate distress and discuss what the patient noticed.
    5. Assign daily practice, ideally with an audio recording.
    6. Add the skill to the crisis card.
  • Example language (illustrative): "Let's try this now and see what it does to that tension rating."
  • Watch for: Relaxation-induced anxiety, or trauma-related discomfort with closed eyes. Offer eyes open and a shorter practice [synthesis]. Signs it's working: a drop in the in-session rating and use between sessions.

4.12 Mindfulness skills training

  • Purpose: Practise noticing thoughts and feelings without acting on them or getting caught up in them. This weakens the link between suicidal thoughts and action. [source: Rudd et al. 2015; Guilford contents ch. 14, B7 Mindfulness Script; NCT07574658]
  • Steps (the manual script is not drawn on [uncertain/synthesis]):
    1. Give the rationale: thoughts are events that pass, not commands.
    2. Lead a short exercise attending to one focus, such as the breath, a sound or an object. When the mind wanders, the patient notes it and gently comes back.
    3. Debrief.
    4. Assign brief daily practice, and add the skill to the crisis card.
  • Example language (illustrative): "Notice the thought 'I can't take this' as a thought, just a passing event, and come back to the breath."
  • Watch for: Patients who get more absorbed in rumination. Use an external focus [synthesis].

4.13 Reasons for living list

  • Purpose: Make reasons to live (and reasons not to attempt again) vivid and easy to recall during crises. This counters hopelessness. [source: Guilford contents ch. 15; Tolin protocol; Bryan slides]
  • Steps:
    1. Ask the patient to list reasons for living and reasons that would stop another attempt, such as children, pets, things they enjoy and future events. [source: Tolin protocol]
    2. Lead a visualisation: the patient pictures each reason in sensory detail to make it vivid. [source: Tolin protocol]
    3. Write the list in the treatment log, and add the top reasons to the crisis card. [source: Bryan slides; synthesis]
    4. The Focus review says BCBT works with reasons for living and for dying. If you explore reasons for dying, do it openly, to understand what needs to change. [source: Focus 2022; procedural detail uncertain]
  • Example language (illustrative): "Close your eyes if that's comfortable and picture your daughter's face at her birthday. What do you see, what do you hear?"
  • Watch for: Reasons that also trigger guilt, such as "I'm a bad parent". Reframe them, or choose others [synthesis]. Signs it's working: the patient can recall the reasons quickly when upset.

4.14 Survival kit

  • Purpose: A physical container of reminders of reasons for living and positive experiences, to use during crises. CT-SP calls the equivalent a "hope box". [source: Focus 2022; Tolin protocol]
  • Steps:
    1. Explain the idea and agree a container (in the inpatient version, a cardboard box). [source: Tolin protocol]
    2. The patient collects items such as photos of loved ones, inspiring quotes, mementos, letters and things that soothe the senses. [source: Tolin protocol; the last two are synthesis]
    3. Review each item and its meaning in session, and screen out anything that could be harmful, such as items linked to grief, a lost relationship or means. [source: Tolin protocol]
    4. Agree where the kit is kept and when to use it, and add it to the crisis card. [synthesis]
    5. A digital version on the phone can supplement it [synthesis].
  • Example language (illustrative): "Bring in whatever reminds you, on your worst night, of why you're still here. We'll go through each item together."
  • Watch for: Ambivalent items. Signs it's working: the patient reports opening the kit during distress.

4.15 ABC worksheets (Phase II)

  • Purpose: Teach the patient to see how an activating event (A) leads to beliefs (B) and then to emotional and behavioural consequences (C). The aim is to show that suicidal feelings follow from interpretations, not from events alone. This is the first step in loosening the suicidal belief system. [source: Guilford contents ch. 16, A8; Focus 2022; Bryan slides]
  • Steps: The worksheet itself is not drawn on. These steps follow standard ABC procedure [synthesis].
    1. Explain the A-B-C sequence using a neutral example.
    2. Complete one worksheet in session, using a recent upsetting event linked to the suicidal mode.
    3. Separate thoughts from feelings, and rate how strong each feeling is.
    4. Ask whether the belief makes sense and what someone else might believe in the same situation.
    5. Assign one worksheet a day, or one for each upsetting event.
  • Example language (illustrative): "So the A was your sergeant criticising your report. The C was shame and wanting to disappear. What was the B, what did you tell yourself it meant?"
  • Watch for: Patients who list feelings as thoughts, or describe events in loaded terms. Signs it's working: the patient spots the B on their own.

4.16 Challenging Questions worksheets (Phase II)

  • Purpose: Test a single suicidal belief (hopelessness, burdensomeness, guilt or shame) against a set of questions. The goal is more flexible, balanced thinking. [source: Guilford contents ch. 17, A9; Rudd et al. 2015 (Phase II targets)]
  • Note: The worksheet names in Phase II (Challenging Questions, Patterns of Problematic Thinking, ABC) match those in Cognitive Processing Therapy (Resick et al.). Bryan has published combined CPT+CRP work. Whether the BCBT forms are identical to the CPT forms is [uncertain].
  • Steps [synthesis]:
    1. Choose one belief from the suicidal mode, for example "I'm a burden." Rate how strongly the patient believes it.
    2. Work through questions such as:
      • What is the evidence for and against it?
      • Is it a habit or a fact?
      • Is it all-or-nothing or extreme?
      • Does it leave out context?
      • Is the source reliable?
      • Is it based on feelings rather than facts?
    3. Write a more balanced statement and re-rate belief in the original.
    4. Assign the worksheet for practice between sessions.
  • Example language (illustrative): "Let's treat 'I'm a burden' as a hypothesis rather than a fact. What would you need to see to know whether it's 100% true?"
  • Watch for: Arguing or persuading. Use Socratic questions so the patient reaches the answer themselves [synthesis]. Signs it's working: lower belief ratings, and the patient can generate alternatives on their own.

4.17 Patterns of Problematic Thinking worksheets (Phase II)

  • Purpose: Help the patient spot recurring thinking styles that feed the suicidal mode, so they can catch them early. [source: Guilford contents ch. 18, A10; Focus 2022]
  • Steps [synthesis; the pattern list in the manual, uncertain]:
    1. Introduce common patterns, such as:
      • jumping to conclusions
      • exaggerating or minimising
      • ignoring important information
      • oversimplifying
      • overgeneralising
      • mind reading
      • emotional reasoning
    2. The patient finds personal examples of each, especially from suicidal episodes.
    3. Over the week, the patient logs which patterns appear and when.
    4. Review the log and link the patterns to the challenging questions.
  • Example language (illustrative): "Which of these shows up for you most when you start thinking about death?"
  • Watch for: Patients who use the labels to criticise themselves ("I always think wrong"). Keep it curious and non-judgemental [synthesis].

4.18 Activity planning

  • Purpose: Schedule activities that bring a sense of pleasure, mastery or meaning. This counters withdrawal and hopelessness in the behavioural part of the suicidal mode, and gives evidence against suicidal beliefs. [source: Guilford contents ch. 19; Focus 2022; Bryan slides (Phase I in the 2026 table, Phase II in earlier decks)]
  • Steps [synthesis]:
    1. Review the patient's current activity and mood.
    2. Agree a few specific, small activities linked to their values or reasons for living.
    3. Schedule each one with a day, time and place.
    4. Predict pleasure or mastery beforehand, then rate it afterwards.
    5. Review the results and use mismatches between prediction and outcome as evidence against hopeless beliefs.
  • Example language (illustrative): "You predicted the walk with your son would be a 2 out of 10, and it turned out to be a 6. What does that say about the thought 'nothing will ever feel good again'?"
  • Watch for: Plans that are too ambitious, or activities that involve alcohol or isolation [synthesis].

4.19 Coping cards

  • Purpose: Pocket cards that hold a skill or a balanced thought, so the patient can reach it while the suicidal mode is active and thinking is narrowed. [source: Guilford contents ch. 19; Tolin protocol; Bryan slides]
  • Steps:
    1. Write a suicidal-mode thought on one side of the card. On the other side, write an alternative response, which can be a balanced thought or a coping action. [source: Tolin protocol]
    2. Base the cards on completed challenging-questions work [synthesis].
    3. Practise reading them in session, and agree when the patient will read them, for example when a warning sign appears [synthesis].
    4. Keep the cards with the crisis card, or as phone photos [synthesis].
  • Example language (illustrative): "Front: 'They'd be better off without me.' Back: 'My kids told me they need me. Last time I felt this way it passed by morning. Call my sister.'"
  • Watch for: Cards written in the therapist's words. Have the patient phrase them [synthesis].

4.20 Relapse prevention task (Phase III)

  • Purpose: This is the final competency test. Under emotional activation, the patient shows they can use BCBT skills to resolve a re-lived past crisis and an imagined future one. It acts as imaginal rehearsal and exposure. [source: Rudd et al. 2015; Focus 2022; Bryan slides; Tolin protocol]
  • Consent and safety before starting [synthesis]:
    1. Explain the purpose and that it will be emotionally intense.
    2. Get explicit consent.
    3. Check current risk. Delay the task if risk is acute or the patient is intoxicated.
    4. Agree a stop signal.
    5. Make sure the crisis plan is current.
    6. Plan time to settle at the end of the session.
    • Use caution if the index episode involved trauma that might trigger dissociation. Consider grounding first or adjusting the pace.
  • Steps:
    1. The patient imagines the index suicidal episode in detail, including the events, thoughts, feelings and physical responses. [source: Rudd et al. 2015]
    2. The patient then imagines using one or more learned skills to resolve the crisis successfully. [source: Rudd et al. 2015]
    3. To increase emotional salience and intensity, the therapist may say aloud the patient's own suicidal thoughts and images from earlier sessions. [source: Rudd et al. 2015 (reported as "increase the emotional salience and intensity of this task")]
    4. Repeat this with the index episode until the patient can problem-solve effectively. [source: Focus 2022]
    5. Repeat the procedure with one or more hypothetical future crises that the patient anticipates. [source: Focus 2022; Tolin protocol]
    6. Update the crisis plan to cover the high-risk situations identified, and record the relapse prevention plan in the treatment log. [source: Rudd et al. 2015; Tolin protocol]
    7. If the patient cannot complete the task, add sessions until they can. [source: Rudd et al. 2015; Bryan slides]
  • Example language (illustrative): "You're back in the kitchen. The letter is on the table. You're thinking, 'There's no way out of this.' What do you notice now, and what do you do next?"
  • Watch for:
    • Distress that keeps climbing without any skill use. Pause, coach a skill, then resume [synthesis].
    • Overly easy "I'd just call someone" answers. Raise the intensity so the rehearsal is realistic [source: Rudd et al. 2015 rationale].
    • Signs it's working: the patient produces specific, sequenced skill use while emotionally activated, and falls back on the crisis plan without prompting.

4.21 Ending treatment

  • Purpose: End the course of BCBT once competence has been shown, and set up continuing care if it is needed. [source: Guilford contents ch. 20; Rudd et al. 2015 (patients could choose further care)]
  • Steps [synthesis]:
    1. Review the treatment log and the gains made.
    2. Update the crisis plan and means plan.
    3. Agree warning signs that would mean coming back.
    4. Arrange referral or a booster session if wanted.
    5. Document the final risk formulation.
  • Example language (illustrative): "Your log is now your manual. If you notice these early signs again, this is what you do first, and here's how to get back to us."
  • Watch for: Fear of ending in patients who are attached to the therapist. Discuss it openly.

4.22 Ongoing suicide risk assessment and progress monitoring (every session)

  • Purpose: Reassess risk across sessions as it fluctuates, track progress and document decisions. [source: Guilford contents ch. 4, ch. 5, B2; Bryan Oregon slides (0–10 risk tracking)]
  • Steps [synthesis; the manual's measures, uncertain]:
    1. At each session, ask about suicidal ideation since the last session, any suicidal behaviour, preparation or rehearsal, crisis plan use and means status.
    2. Use a brief standardised ideation measure and a 0–10 rating.
    3. Update the risk formulation, distinguishing baseline risk from acute risk.
    4. Document your clinical reasoning and the actions taken.
  • Example language (illustrative): "Since we last met, have you had thoughts of suicide? Did you do anything to prepare, or come close to acting?"
  • Watch for: A rise in acute risk. Revisit the crisis plan and means safety in that session, and increase the level of care if needed [synthesis].

5. Handling problems

The sources say little about problem handling beyond four points: extend treatment until the patient shows competence, prune crisis-plan strategies that don't work, use motivational means counselling, and avoid contracts. Everything else below is my own synthesis, built on BCBT's principles, and is marked [synthesis].

  • Acute risk escalates mid-treatment (new preparation, intent or a recent attempt):
    • Pause the planned skill. Repeat a brief narrative assessment of the new episode and update the crisis plan and means plan in that session.
    • Raise contact frequency or the level of care if risk is imminent.
    • Then go back into the protocol, using the new episode as the material to work on.
    • An attempt during treatment is not treatment failure. Treated groups still have attempts. [synthesis; trial context from Rudd et al. 2015 and the MSPIRE abstract]
  • Crisis plan not used:
    • Ask what got in the way: they forgot, the card was not with them, strategies were impractical, or they were in too much distress.
    • Remove strategies that didn't work, add easier ones, and re-rate how likely the patient is to use the plan. [source: Rudd et al. 2015 (pruning ineffective skills); Baker slides (likelihood rating)]
    • Rehearse using the card in session with a recent trigger. [synthesis]
  • Homework or practice non-adherence:
    • Link each assignment to the patient's own suicidal mode, and shrink it to something achievable.
    • Start it in session.
    • Use the treatment log as the minimum practice. [synthesis]
    • Remember that progress depends on competence, so missing practice delays the end of treatment. Say this plainly, without blame. [source: Rudd et al. 2015 principle]
  • Means safety refused:
    • Do not argue. Return to the patient's own values, offer graded options (for example, locking a gun versus storing it off site), and involve a trusted person if the patient agrees.
    • Document the discussion and revisit it at every session. [source: Bryan slides (four-phase motivational approach); the rest is synthesis]
  • Stuck in Phase II (beliefs won't shift):
    • Narrow to one core belief. Collect behavioural evidence through activity planning.
    • Move from "Is it true?" to "Is it helpful?", and use coping cards for the belief that remains.
    • Remember that the goal is flexibility, not getting rid of the belief. [synthesis]
  • Overwhelm or dissociation during the narrative or relapse prevention task:
    • Slow down and ground the patient with eyes open and present-moment cues. Use the relaxation or mindfulness skill.
    • Resume at lower intensity, and rebuild the intensity over later sessions.
    • End the session only once distress has come down and the crisis plan has been reviewed. [synthesis]
  • Relapse prevention task cannot be completed: Add sessions, review the skills involved and repeat the task. [source: Rudd et al. 2015; Bryan slides]
  • Ambivalence about living or about treatment:
    • Look at reasons for dying and for living openly, without judgement. [source: Focus 2022 (reasons for living and dying)]
    • Use the commitment to treatment statement as a check-in on the patient's commitment, not as leverage. [synthesis]
  • Rupture (anger at the clinician over risk actions or means questions, or feeling controlled):
    • Name it, invite the patient's view, and acknowledge your part in it.
    • Explain the reason for the safety steps and look for what you can agree on. [synthesis]
  • Over-reliance on the therapist (frequent calls instead of self-management):
    • Order the crisis plan so self-management comes first. [source: Bryan and Baker slides (self-management prioritised)]
    • Review how calls are being used, and reinforce the patient's own skill use. [synthesis]
  • Telehealth delivery:
    • At the start of each session, confirm the patient's location and an emergency contact.
    • Show the crisis card on camera, have the patient write it themselves, and send photos of worksheets securely.
    • For the relapse prevention task, make sure the patient is somewhere private and safe. [synthesis; virtual delivery is tested per Bryan Oregon slides, procedures not found, uncertain]
  • Substance use in the suicidal mode:
    • Add substance use to the warning signs and crisis plan, and target it as a behaviour in the mode. Note that intoxication rules out the relapse prevention task that day.
    • Refer for specialist care if needed. [synthesis]
  • Co-occurring PTSD or depression: Keep suicide as the primary target. Trauma-focused treatment can follow, or run alongside with coordination. Bryan has tested CPT combined with CRP. [source: Bryan Oregon slides; sequencing is synthesis]
  • Adolescents, inpatients and other settings:
    • The inpatient adaptation compresses BCBT into 4 sessions: narrative, crisis plan and log; reasons for living and survival kit; means safety and coping cards; then relapse prevention and discharge, with daily sessions and plans shared with the unit team. [source: Tolin protocol]
    • For youth, involve caregivers at an appropriate level and encourage the young person to own the plan. [source: Baker CRP slides]

Sources

Sources:

Further reading (not drawn on):

  • Bryan, C. J., & Rudd, M. D. (2018). Brief Cognitive-Behavioral Therapy for Suicide Prevention. Guilford. Only the table of contents is drawn on.
  • Bryan, C. J., & Rudd, M. D. (2027, forthcoming). Brief Cognitive-Behavioral Therapy for Suicide Prevention (2nd ed.) and the BCBT Workbook for Clients. Guilford.
  • Rudd, M. D., Mandrusiak, M., & Joiner, T. E. (2006). The case against no-suicide contracts: The commitment to treatment statement as a practice alternative. Journal of Clinical Psychology. [uncertain]
  • Rudd, M. D., et al. (2009). Essential ingredients of effective suicide treatments, as cited in Bryan's slides.
  • Britton, P. C., Bryan, C. J., & Valenstein, M. (2016). Motivational interviewing for means restriction counseling with patients at risk for suicide. Cognitive and Behavioral Practice, as cited (as 2015) in Bryan's slides.
  • Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive Therapy for Suicidal Patients. APA. The CT-SP foundation, as cited in Focus 2022.
  • Resick, P. A., Monson, C. M., & Chard, K. M. Cognitive Processing Therapy for PTSD (Guilford). The source of the similarly named worksheets; whether they correspond to the BCBT forms is [uncertain].

Not given in the primary text [uncertain]: the manual's own procedures for relaxation and mindfulness (scripts B6 and B7), sleep, the crisis support plan, commitment to treatment, the Challenging Questions and Patterns of Problematic Thinking lists, criteria for moving from Phase I to II, progress measures, and telehealth procedures.

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