Surviving Suicide: Interventions-- Animal Assisted & Cognitive Therapies

 

Abstract

Surviving a suicide attempt allows for an opportunity for recovery. In terms of prevention and intervention, research is relatively limited and does not always account for the influence of individual experience. To better understand the trends and discrepancies, it is important to consider typical interventions, such as cognitive therapy, and explore unfamiliar interventions, like animal-assisted activity. When looking for applicable or relevant interventions, it is beneficial to compare variables, methodology, as well as the overall effectiveness. The reason for this, as social workers, is to ensure the well-being of clients while continually expanding an adequate skillset (National Association of Social Workers, 2017).

Keywords: attempted suicide, suicide attempt, interventions, cognitive therapy, animal-assisted activity, NASW

 

Surviving a Suicide Attempt: Interventions

            The complexity of suicide intervention is due to the personal nature of the act; the experience for one is never the same for another. Surviving a suicide attempt is an opportunity to restructure circumstances. According to the National Institute of Mental Health (NIMH, 2018), a suicide attempt is “a non-fatal, self-directed, potentially injurious behavior with the intent to die as a result of the behavior.” Attempted suicides happen four times more frequently than completed suicides (NIMH, 2018). Since every attempt is unique, interventions are limited, thus challenging social workers. There is a need for suicide prevention training, involving better intervention application and risk assessment (Rothes, Henriques, Leal, & Lemos, 2013).

Interventions

Selection Process

            Interventions for survivors are ambiguous, causing the results to be inconsistent. Thus, finding interventions with substance is difficult. In an effort to explore the spectrum of intervention, cognitive therapy and animal-assisted activity are chosen for discussion.

Cognitive Therapy

            Cognitive therapy is often applied in practice. The foundation of this intervention accentuates a multidimensional approach which results in a more holistic recovery. Rudd, (2000), compiled several fundamental assumptions when applying suicidality to cognitive interventions: (1) cognition is at the core of suicidality, making it completely personal, (2) a multidimensional approach is integral because all systems (biological, psychological, social, belief) influence the other, (3) assessing the nature of suicidality also depends on “content and context of the various psychological systems,” (4) potential of suicidality is a indication of “cognitive vulnerabilities,” and (5) understanding the relevance at every level of consciousness (preconscious, conscious, and unconscious) which is improved through cognition (Rudd, 2000).

            Brown et al. (2005) conducted a randomized controlled trial to examine the effects of cognitive therapy on a group of adults who had recently attempted suicide. This intervention was selected to best evaluate suicidal behaviors to prevent repeat suicide attempts. The purpose of cognitive therapy is to uncover personal intentions prior to the attempt and utilize a psychosocial approach to improve problem-solving and coping strategies (Brown et al., 2005). The primary objective of this study was to determine which variable led to a reduction of future suicide attempts. A further measure was to observe the prevalence of suicidal ideation, hopelessness, and depression at monthly intervals throughout treatment (Brown et al., 2005).

            The trial studied 120 individuals who were: (1) evaluated within 48 hours of a suicide attempt, (2) aged 16 and older, (3) able to speak English, (4) able to complete a baseline assessment, (5) able to provide contact information, and (6) able to provide informed consent (Brown et al., 2005). Individuals were then randomly placed in a cognitive therapy group or a “treatment as usual” group. Regardless, both groups received treatment as usual, which consisted of clinician and case manager involvement, as well as available community resources (mental health, referrals, substance abuse, etc.). The cognitive therapy group received 10-sessions and met weekly, biweekly, or as needed over the period of 18 months (Brown et al., 2005). Collection of data occurred predominantly at monthly intervals (1, 3, 6, 12, and 18 months). A plethora of scales and tests—Hamilton Rating Scale for Depression, Beck Depression Inventory II, Beck Hopelessness Scale, Scale for Suicide Ideation, and Kaplan-Meier method, to name a few—were implemented to calculate the effectiveness of the treatments (Brown et al., 2005).

            While Brown et al. (2005) used a variety of testing, results of the study were thorough. At the conclusion of the trial, the treatment as usual group had 23 participants that re-attempted suicide, while the cognitive therapy group had 13 participants make another attempt (Brown et al., 2005). The cognitive therapy group also showed a greater reduction in depression and hopelessness than the treatment as usual group. The only measure that saw no significant change was the presence of suicidal ideation. Overall, Brown et al.’s (2005) randomized controlled trial supported their hypotheses that cognitive therapy would have a greater impact on individuals who recently attempted suicide, as well as improve depression and hopelessness.

Animal-Assisted Activity

            Animal-assisted activity is defined as “any use of trained animals for the therapeutic, motivational, or educational benefit of patients,” (Nepps, Stewart, & Bruckno, 2014). As explained further by Nepps et al. (2014), the term activity is used instead of therapy to better represent the vastness of integrating animals into treatment. Animal-assisted activity is practiced as a psychotherapy, but helping professionals are still not well exposed to the benefits and uses in treatment (Risley-Curtiss, Rogge, & Kawam, 2013). The University of California at Los Angeles (UCLA, n.d.) shared research-supported benefits of animal-assisted therapy including lowered anxiety, increased comfort, reduced feelings of loneliness, better mental function, which enhance the intervention process. UCLA also identifies physical benefits in relation to animal-assisted therapy like lowered blood pressure, improved heart rate, and decreased physical pain.

            Nepps et al. (2014) composed a study to determine the effects of animal-assisted activity on psychological (depression, anxiety, and pain) and physiological (blood pressure, heart rate, and cortisol) variables, in comparison to a stress management program. This institutes a focus on factors commonly seen in suicide attempters, supporting the notion of an underlying cause affecting the greater whole.

Participants were patients in a mental health unit of a community hospital with an existing animal-assisted program. Potential participants received a description of the study and granted informed consent. The study gathered 218 individuals to participate in group sessions of either animal-assisted activity or a stress management program. Animal of choice for the activity group was a registered therapy dog, a Border Collie named Jesse (Nepps et al., 2014). The research was conducted over a year, while the estimated length of stay for each patient was a week. Data was collected through a Likert-type questionnaire (The Burns Depression and Burns Anxiety Inventory scales), completed by each individual before and after every session, acquired information regarding depression, anxiety, and pain. Physiological assessments were gathered by trained staff, also, before and after each session (Nepps et al., 2014).

The baseline measurements (prior to either session) suggested no obvious differences between the animal-assisted activity group or the stress management group. Both groups showed improvements. Specifically, data supporting the animal-assisted activity indicated a reduction of depression, anxiety, and heart rate. Significant improvements in other physiological factors (blood pressure and cortisol) were not apparent. Nepps et al. (2014) concluded the results supported the hypothesis that animal-assisted activity improves factors related to mental health.

 

Discussion of Interventions

Comparisons

The interventions previously mentioned share some similar qualities, especially in methodology and achievement of outcomes. Both interventions approached the study by providing descriptions of the study, obtaining informed consent, and gathering baseline information for a similar duration (12 months to 18 months). Each recruited two differing groups to serve as a basis of comparison. The cognitive therapy intervention, provided by Brown et al. (2005), was paired with a group who received treatment as usual, while Nepps et al. (2014) chose a stress management program to compare animal-assisted activity. In terms of hypotheses and outcomes, there is a resemblance as well. Though the cognitive therapy intervention was specific to attempted suicides, it also measured for factors of vulnerability (suicidal ideation, depression, and hopelessness), much like the animal-assisted activity that hypothesized improvement in mental health. Both acknowledged the problem of mental health is expansive (Brown et al., 2005; Nepps et al., 2014). Lastly, the styling of these studies appears quantitative, focusing on statistics to support the hypothesis.

Contrasts

            The differences revolved around data collection. The cognitive therapy intervention evaluated measurements at monthly intervals through scales and tests, compared to the animal-assisted activity which assessed questionnaires completed by participants before and after each session. The cognitive therapy focused on following up to measure individual long-term progress. Alternatively, Nepps et al. (2014) focused on the immediate effects of the intervention and had less consistency of participants (average stay of patient was 7 days) and therefore lacked follow-up results. In other words, the cognitive therapy study conducted by Brown et al. (2005) focused on gathering comprehensive data, while the animal-assisted activity intervention analyzed immediate effects (Nepps et al., 2014).

Effectiveness

            Individually, each approach is effective depending on application. Based solely on the information shared by each intervention, the most feasible study with the greatest potential success is cognitive therapy. Though this approach was overwhelming with use of testing instruments, the outcomes were well supported—whereas the animal-assisted activity was concise, the data was deficient. The cognitive intervention demonstrated the value of collecting background and applying it to a more specific treatment, optimizing recovery for someone who has attempted suicide. Brown et al. (2005) leaves space for additional methods of treatment—for example, begin a client evaluation with cognitive therapy and then apply animal-assisted activity.

National Association of Social Worker’s Code of Ethics

Application of Ethics to Interventions

            The National Association of Social Worker’s (2017) outlines ethical principles and values—three of which were most apparent in aforementioned interventions: service, integrity, and competence. Efficiently conducting a research study fulfills the value of service, which encourages social workers to strive to improve clients’ well-being while furthering knowledge to confront social injustice. Research is the epitome of this, requiring a substantial commitment to uncover information toward solutions. Only in seeking research can we develop our competence and integrity, ultimately for the benefit of clients. Suicidality is a problem any social worker may encounter, we must always be prepared with applicable knowledge.

Application in Social Work Practice

Cognitive therapy is most easily applied in social work. There is extensive research and numerous approaches that make it appropriate to use in many situations. Risley-Curtiss et al. (2013) found that the lack of use of animal-assisted activity was largely due to professionals simply not being exposed to the research. Ultimately, successful treatment for an individual who has attempted suicide requires a thorough assessment and ability to select the most appropriate intervention; suicide is a very personal action and not one treatment is effective for all. As previously stated regarding the discussed interventions, try a multidimensional intervention—assess the client with cognitive therapy and then incorporate an animal-assisted approach. Beyond applying these interventions, Rothes et al. (2013) established the lack of training for suicide prevention in terms of intervention application and risk assessment, supporting the need for continual research to improve service and competency.

Conclusion

An individual seeking treatment after a suicide attempt should be able to rely on a social worker to provide proper intervention specific to personal experience. Social workers have a responsibility to address this problem with a sense of urgency, while effectively incorporating the ethical values of the National Association of Social Workers. It is necessary to explore all types of interventions, like cognitive therapy and animal-assisted activity, for the benefit of the client. We are change-agents, and this is a call to action.

References

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National Association of Social Workers. (2017).  Code of ethics of the National Association of

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https://www.nimh.nih.gov/health/statistics/suicide.shtml

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