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Cognition and Suicide: Two Decades of


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Article in International Journal of Cognitive Therapy · February 2008


DOI: 10.1521/ijct.2008.1.1.47

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International Journal of Cognitive Therapy, 1(1), 47–68, 2008
© 2008 International Association for Cognitive Psychotherapy
COGNITION
ELLIS AND SUICIDE
AND RUTHERFORD

Cognition and Suicide:


Two Decades of Progress
Thomas E. Ellis and Billy Rutherford
Marshall University

In this article, we discuss developments over the past two decades in the study of cogni-
tion and suicide. We review (a) research identifying cognitive characteristics and vulnera-
bilities of suicidal individuals, (b) recently developed mediational and multivariate
models, (c) recent theoretical advances, and (d) outcome research on therapeutic inter-
ventions derived from this body of work. We conclude that significant progress has been
made in terms of understanding the interplay of such cognitive processes as hopelessness,
problem–solving, and autobiographical memory, and in the development of the-
ory–driven and empirically supported interventions that specifically target suicidal think-
ing and behavior. We conclude with a discussion of challenging issues in this arena and
possible directions for further investigation.

Losing a psychotherapy patient to suicide looms as perhaps the most dreaded possible
outcome among psychotherapists (Pope & Tabachnick, 1993). This concern is under-
standable, given that psychotherapy patients are at significantly elevated risk relative to
the general population (Tanney, 2000). Beyond clinical concern and personal tragedy,
suicide is also a major public health problem, accounting for nearly one million deaths
per year worldwide. Indeed, suicide accounts for fully half of violent deaths worldwide,
outpacing homicide and war combined as causes of death (World Health Organization,
cited in Colt, 2006). Ironically, clinical studies showing that therapeutic interventions
actually reduce suicide risk are few and far between (Comtois & Linehan, 2006).
It has now been just over 20 years since the first author summarized research on
cognitive characteristics of suicidal individuals and recommended concerted efforts to
develop strategies specifically designed to reduce cognitive vulnerability to suicidal
ideation and behavior (Ellis, 1986). In the wake of Beck’s recent 40–year retrospective
on cognitive therapy for psychological disorders (Beck, 2005), it seems fitting to sum-
marize developments over the past two decades in cognitive approaches specific to
understanding and treating suicidal individuals.
We will begin with an update on research on cognitive features that characterize
suicidal individuals and are associated with increased vulnerability to suicidal ideation

Thomas E. Ellis, Psy.D., ABPP, is Professor of Psychology and Billy Rutherford, M.A., is a doctoral student at
Marshall University, Huntington, West Virginia.
Send all correspondence to Thomas E. Ellis, Department of Psychology, Marshall University, Huntington,
WV 25755. Email: ellist@marshall.edu

47
48 ELLIS AND RUTHERFORD

and behavior, including contemporary multivariate and mediational models. We will


then present an overview of recent theoretical models proposed to contribute to the un-
derstanding and treatment of suicidal individuals. We will then summarize outcome re-
search on cognitive–behavioral interventions that have been introduced to address these
vulnerabilities and thereby reduce suicide risk, and conclude with a discussion of
possible routes to further advancing knowledge and practice.

EARLY COGNITIVE INSIGHTS

In a recent historical overview of cognition and suicide, Ellis (2006) identified Kelly’s
(1961) personal construct model as “the first explicitly cognitive conceptualization of
suicide" (p. 14). However, it was at roughly the same time that Neuringer was begin-
ning his work on a series of seminal studies testing Edwin Shneidman’s characterization
of suicidal cognition as rigid, illogical, and dichotomous (e.g., Neuringer, 1961, 1964).
In the first published review of cognition and suicide, Levensen (1974) announced “a
new means of assessment [which] emanates from the cognitive approach to suicide . . .
[wherein] the suicidal person is seen as possessing some unique thinking style or certain
cognitive characteristics which diminish his ability to find viable solutions to life’s prob-
lems and to diminish his capacity to cope with the stresses of life" (p. 150). Prominent in
his review was the work of Neuringer, who published his own review soon thereafter
(Neuringer, 1976). Neuringer concluded that “progress has been made in the study of
suicidal thinking" (p. 235), noting in particular work on structures of suicidal thinking,
rigidity and constriction, and time perception.
Later, Patsiokas, Clum, and Luscomb (1979) reported that suicide attempters ex-
hibited greater cognitive rigidity and field dependence, though not greater cognitive
impulsivity, compared to nonsuicidal psychiatric control subjects. They proposed a
“cognitive predisposition to attempting suicide,” which later evolved into a
diathesis–stress–hopelessness model of suicidal behavior that included deficient prob-
lem–solving skills and depressive attributional style as cognitive diatheses (Schotte &
Clum, 1987). This model later showed predictive utility for depression and suicidal
ideation in college students (Priester & Clum, 1993).
Arffa (1983) presented a critical review of the nascent field of cognition and sui-
cide, commenting that, although methodological problems remained, “consistent dif-
ferences in the cognition of suicidal and nonsuicidal groups have been demonstrated"
(p. 117). While noting that some findings (e.g., field dependence) were inconsistent,
she observed that “cognitive–rigidity (whether it is termed dogmatism, dichotomizing,
hopelessness, or whatever) is patently implicated in suicide" (p. 118). She suggested
that cognitive rigidity might function as a common denominator of other observed cog-
nitive characteristics. Ellis (1986) echoed Arffa’s conclusions with respect to cognitive
rigidity and ineffective problem–solving and extended the discussion to dysfunctional
attitudes and beliefs and cognitive distortions. In discussing possible clinical directions,
he suggested that the time had arrived to begin tailoring cognitive–behavioral therapy
in the direction of specific cognitive vulnerabilities identified in the research literature.
What can be said about progress in the field since publication of these reviews? The
following discussion will provide an update on research on topics covered in earlier re-
views, as well as describing new ground that has been broken.
COGNITION AND SUICIDE 49

COGNITIVE CHARACTERISTICS
Executive Functioning:
Cognitive Rigidity, Dichotomous Thinking,
and Deficient Problem–Solving

Among the earliest clinical observations of cognition in suicidal individuals were cogni-
tive rigidity, dichotomous thinking, and deficient problem–solving. As early as the
1960s, suicidal patients were noted to view life in black–and–white terms and to be
“locked–in” to their current perceptions, unable to imagine alternatives or consider new
courses of action to solve their problems. Studied separately, cognitive rigidity, dichoto-
mous thinking, and problem–solving have shown consistent, strong associations with
suicidal thinking and behavior (e.g., Neuringer, 1961, 1964), but are increasingly being
approached together as closely related processes.
Cognitive rigidity has intuitive appeal to clinicians who have encountered the sui-
cidal patient’s difficulty imagining alternatives to his or her current state of suffering.
Research findings have consistently shown greater cognitive rigidity among suicidal in-
dividuals, even as a variety of instruments were used to measure the construct, from the
Alternate Uses Test to sophisticated neuropsychological test batteries (e.g., Keilp et al.,
2001). Marzuk, Hartwell, Leon, and Portera (2005) conceptualize cognitive rigidity as
a characteristic underlying dichotomous thinking and problem–solving deficits. Sui-
cidal individuals tend to rigidly see people as either good or bad or themselves as having
only misery or death from which to choose, while finding it difficult or impossible to
think flexibly enough to generate solutions to current problems. A similar view is taken
by Keilp at al. (2001), who view cognitive flexibility as a key aspect of overall executive
functioning and as a distinguishing feature of high– versus low–lethality suicide at-
tempters. An ongoing issue in this context (shared by various other cognitive constructs
as well) is the extent to which this characteristic represents a transient aspect of the sui-
cidal state or a more trait–like risk factor. Some evidence suggests that cognitive rigidity
distinguishes suicidal individuals only in the midst of a suicidal episode (e.g., Perrah &
Wichman, 1987), although firm conclusions await longitudinal studies.
Dichotomous thinking is widely accepted as a feature of suicidal cognition, al-
though relatively few studies have been conducted since the seminal work of Neuringer
(1961). Recent clinical studies are consistent with earlier findings of dichotomous
thinking in suicidal patients (e.g., Litinsky & Haslam, 1998; Wedding, 2000), al-
though it is unclear to what extent this may be related to the prevalence of borderline
personality disorder in this population (e.g., Veen & Arntz, 2000).
The closely related construct of problem–solving is perhaps the most thoroughly
researched cognitive process related to suicidality. Predictions that cognitive rigidity
and dichotomous thinking would be associated with impaired problem–solving be-
cause of difficulty generating alternate solutions have been supported in several studies,
both in terms of impersonal problem–solving (e.g., Levenson & Neuringer, 1971;
Patsiokas et al., 1979) and interpersonal problem–solving (e.g., Schotte & Clum, 1987;
Priester & Clum, 1993). However, interpretation of these results is made difficult by
variations among researchers in definitions of problem–solving, use of a variety of in-
struments for measuring the construct, and differences in comparison groups used (sui-
cide attempters, suicide ideators, psychiatric and nonpsychiatric control groups, etc.).
50 ELLIS AND RUTHERFORD

Questions also remain regarding state versus trait issues, which aspect of prob-
lem–solving is studied (skills vs. appraisal vs. orientation), and the extent to which varia-
tions in problem–solving impairment may be affected by depression, hopelessness, or
other variables. Regarding the latter, in a short–term, longitudinal study of hospital-
ized, suicidal patients, Schotte, Cools, and Payvar (1990) concluded that “interpersonal
problem–solving deficits may be a concomitant, rather than a cause, of depression,
hopelessness, and suicide intent" (p. 562). On the other hand, Williams, Barnhofer,
Crane, and Beck (2005) conducted a mood induction study with formerly depressed
patients, some with and others without a history of suicidality. Only the formerly de-
pressed individuals with a history of suicidality showed mood–related deterioration in
problem–solving performance, suggesting the possibility that problem–solving pro-
cesses may have both state– and traitlike characteristics in suicide–prone individuals. In-
terestingly, this vulnerability was moderated by lack of specificity in autobiographical
memory (discussed below).
In their systematic review, Pollack and Williams (1998) describe problem–solving
as a “promising” area for study and intervention with suicidal individuals, though not
without significant methodological challenges, including definitions, measurement,
and state–trait issues. More recently, Speckens and Hawton (2005) reviewed the child
and adolescent literature on problem-solving and suicidality and cautiously concluded
that “there is some evidence for an association between suicidal behavior and prob-
lem–solving deficits in adolescents" (p. 383), but no evidence for such a relationship in
younger children. They noted that causal relationships among problem–solving, de-
pression, and suicidality are not well understood at this time. Promising early results of
studies of problem–solving interventions (discussed below) suggest that research on
these issues is warranted.
The causes of problem–solving deficits in suicidal individuals are not well under-
stood currently, although progress is apparent on at least two fronts. The work of Wil-
liams and associates provides evidence that, aside from the impact of depression per se,
problem–solving deficits are associated with overgeneral autobiographical memory
(e.g., Pollock & Williams, 1998; Pollock & Williams, 2001; Williams, Barnhofer,
Crane, & Duggan, 2005), the significance being that specific recall of similar past prob-
lem situations is essential to effective problem–solving in the present. In addition,
neuropsychological studies of executive functioning have shed light on possible
brain–based sources of problem–solving deficits. Keilp et al. (2001) showed that pa-
tients with a history of suicide attempts manifested greater neuropsychological dysfunc-
tion than comparison groups, that the deficits were greater among high lethality
attempters, and that the differences remained after controlling for depression severity.
This rigorously designed study included a drug washout period, and the investigators
found no indication that the brain dysfunction was due to the effects of the suicide at-
tempts themselves. Tasks requiring organization and focused effort were notably in-
volved. The authors interpreted the results as evidence of cortical dysfunction in the
prefrontal lobes. Marzuk et al. (2005) reached similar conclusions, with differences
between suicidal and nonsuicidal individuals remaining after controlling for age, IQ,
depression severity, and prior suicide attempts.
In summary, a large research literature has consistently demonstrated significant
relationships among various aspects of executive functioning (particularly prob-
lem–solving) and stressful life events, depression, hopelessness, and suicidality. Implica-
COGNITION AND SUICIDE 51

tions for treatment are considerable (see below). For a more thorough review of the
problem–solving and suicide literature, the reader is referred to Reinecke (2006).

Hopelessness

Hopelessness, conceptualized as the expectation that undesirable events will occur and
that one will continually fail to attain one’s goals, has received consistent support
through the years as a key aspect of suicidal thinking and behavior. More than three de-
cades ago, Minkoff, Bergman, and Beck (1973) found that hopelessness mediated the
relationship between depression and suicidality; similar findings were reported by Ellis
and Ratliff (1986). Hopelessness has been shown to correlate with suicidal behavior in-
dependent of depression (Steer, Kumar, & Beck, 1993). It has also been shown to pre-
dict as many as 90% of suicides prospectively (Beck, Brown, & Steer, 1989), although
not without a substantial rate of false positives (Niméus, Träskman–Bendz, & Alsén,
1997). In addition, multiple studies have shown that hopelessness mediates the rela-
tionship between stressful life events and suicidal ideation and behavior (e.g.,
Abramson et al., 1989; Patsiokas & Clum, 1985; Schotte & Clum, 1982). It is not well
understood why some individuals are more prone to develop hopelessness than others,
although Clum and associates have conducted an important series of studies showing
that hopelessness is predicted by stressful life events and self–appraised poor
problem–solving skills (Yang & Clum, 1994).
In a recent review, Pettit and Joiner (2006) observed, “A plethora of empirical re-
search has supported a relation between hopelessness and suicide" (p. 128). Indeed,
hopelessness serves as a central construct in a variety of clinical interventions developed
for suicidal individuals (see below). Weishaar (1996) cautions that hopelessness does
not independently predict suicide among alcoholics (Beck, Steer, & Trexler, 1989).
Moreover, a recent study suggests that the relationship between hopelessness and sui-
cidal ideation is weaker among individuals with optimistic explanatory style (Hirsch &
Conner, 2006). On the other hand, Weishaar’s concern about inconsistent findings
among suicidal adolescents has been addressed somewhat by subsequent multivariate
research, some cross–cultural, that continues to suggest a robust relationship between
hopelessness and suicidal ideation and behavior (e.g., Stewart et al., 2005; Thompson,
Mazza, Herting, Randell, & Eggert, 2005).

Reasons for Living

Few constructs are more relevant to cognitive therapy with suicidal individuals than rea-
sons for living (RFL). Developed by Linehan and colleagues (Linehan, Goodstein, &
Nielsen, 1983), RFL has been shown to discriminate between suicidal and nonsuicidal
individuals and to be associated with a variety of outcomes (e.g., Bonner & Rich, 1987;
Cole, 1989; Connell & Meyer, 1991; Strosahl, Chiles, & Linehan, 1992), including sui-
cidal intent and behaviors in age groups from adolescents to elderly, and in clinical as
well as nonclinical populations (e.g., Galfalvy, Oquendo, & Carballo, 2006; Osman,
Kopper, & Linehan, 1999; Rietdijk, van den Bosch, & Verheul, 2001). In the same
vein, Brown, Steer, Henriques, and Beck (2005) developed an index of difference be-
tween wish to live and wish to die. In a 10–year longitudinal study, they found that the
52 ELLIS AND RUTHERFORD

hazard ratio for death by suicide among patients whose score indicated maximal
orientation toward death (2 on a scale from –2 to +2) was 6.51.

Perfectionism

Perfectionism, holding or perceiving impossibly high expectations for oneself, has long
been viewed as an important vulnerability factor for suicide (see Hewitt, Flett, Sherry,
& Caelian, 2006, for a thorough review). Researchers have divided the construct of per-
fectionism into three types: self–oriented (setting and holding unrealistic standards for
oneself), other–oriented (demanding perfection from others), and socially prescribed
(believing that others expect one to be perfect; Hewitt, Flett, & Turnbull–Donovan,
1992). Of these, socially prescribed and self–oriented perfectionism are more strongly
associated with suicidality (Flamenbaum & Holden, 2007; Hewitt et al., 1992).
In a recent review, Hewitt et al. (2006) observed that socially prescribed perfec-
tionism has shown a consistently strong association with suicidal ideation and attempts
in both adult and adolescent samples, independent of other factors such as level of de-
pression and hopelessness. Passive forms of perfectionism, such as procrastinating to
avoid making mistakes, are associated with suicidality among college students, whereas
active forms of perfectionism, such as striving for achievement, are not (Kittler–Adkins
& Parker, 1996.)
Correlations between perfectionism and suicidality are both direct and indirect.
Flamenbaum and Holden (2007) found that “psychache” (intolerable psychological
pain, as described by Shneidman, 1993) mediates the relationship between socially pre-
scribed perfectionism and suicidality in a sample of college students. The relationship
between socially prescribed perfectionism and suicidality disappeared when the effects
of psychache and unfulfilled psychological needs were statistically controlled. On the
other hand, Beevers and Miller (2004) found that perfectionism directly predicted sui-
cidal ideation at 6 months, without mediation by hopelessness, level of depression, or
severity of suicidal ideation (see discussion of multivariate models below).
Although the specific mechanisms by which perfectionism is related to suicidality
are not well understood, it is clear that perfectionism (socially prescribed perfectionism
in particular) is an important cognitive aspect of suicidal ideation and behavior. The
clinical implication of this finding is significant: “Just as both depression symptoms and
hopelessness are assessed and used as factors in evaluating suicide risk, perhaps
perfectionistic behavior should be strongly considered" (Hewitt et al., 2006, pp.
230–231).

Self-Concept

A negative view of the self occupies a place with negative views of the world and the fu-
ture in the “negative cognitive triad” proposed by Beck in his early formulation of de-
pression (Beck, Rush, Shaw, & Emery, 1979). Research has since shown that negative
self–concept may be a particular risk factor for suicidality, independent of other cogni-
tive characteristics such as hopelessness (Weishaar, 1996). A specific aspect of self–con-
cept, body image, has been shown to be an especially robust predictor of suicidality
(Orbach, 2006).
COGNITION AND SUICIDE 53

Ruminative Response Style

Because depression is one of the most robust predictors of suicide (Tanney, 2000), it is
reasonable to explore cognitive risk factors for depression for clues about suicidality.
Ruminative response style (chronically focusing on depressive symptoms and on the
causes, meanings, and consequences of depressive symptoms) predicts depression lon-
gitudinally and is associated with longer and more severe episodes of depression (Alloy,
Abramson, Safford, & Gibb, 2006; Nolen–Hoeksema, 2000). Specific to suicidality,
Eshun (2000) showed that rumination explained significant gender and cultural vari-
ance in suicidal ideation. Furthermore, Smith, Alloy, and Abramson (2006) showed
prospectively that ruminative style predicted hopelessness and suicidal ideation in ini-
tially nondepressed college students over a period of 2½ years. Another line of research
has shown that rumination may be characterized by, and perhaps prolonged by,
cognitive rigidity (Davis & Nolen–Hoeksema, 2000).

Autobiographical Memory

Overgeneral autobiographical memory was first implicated in suicidal behavior in the


1980s (Williams & Broadbent, 1986; Williams & Dritschel, 1988). This refers to the
type of episodic memory of one’s unique life history; it has been associated with depres-
sion and posttraumatic stress disorder as well as suicidality (Williams, Teasdale, Segal,
& Soulsby, 2000). Suicide attempters have been shown to display greater difficulty at
autobiographical memory recall tasks and to produce autobiographical memories of
events that are vague and general (Williams & Broadbent, 1986). Williams, Barnhofer,
Crane, and Duggan (2006) hypothesized that although nonspecific autobiographical
memory may have a short–term protective effect against negative experiences, the
long-term effects of a memory system that does not go beyond general categories are re-
lated to suicide in three important ways: (a) Overgeneral autobiographical memory
causes episodes of emotional disturbance to be more persistent, (b) it impairs interper-
sonal problem–solving because past experiences cannot be used as references for effec-
tive coping strategies in the present, and (c) it impairs a person’s ability to imagine the
future in a specific way. Any of these factors could increase an individual’s level of
hopelessness and thereby contribute to suicidality.
These findings and others on the role of overgeneral autobiographical memory
suggest that treatments that specifically target overgeneral memory may improve out-
comes with suicidal patients. One promising example is the finding that mindful-
ness–based cognitive therapy reduces overgeneral autobiographical memory in
formerly depressed patients (Williams et al., 2000).

MULTIVARIATE AND MEDIATIONAL MODELS

A clear trend in recent years has been movement away from studies of isolated cognitive
characteristics and toward examination of how multiple variables, psychological and sit-
uational, interact to produce suicidal ideation and behavior. Such designs allow re-
searchers to study relationships among variables, as well as to determine whether those
54 ELLIS AND RUTHERFORD

variables contribute uniquely to suicidality or perhaps overlap with or are mediated by


other variables.
Among the first such models was the cognitive diathesis–stress model of Schotte
and Clum (1987), which showed that deficient problem–solving mediated the relation-
ship between stress and suicidality. This was followed by Yang and Clum’s (1994)
multivariate model showing relationships among stress, problem–solving, hopeless-
ness, social support, depression, and suicidality, with problem–solving and hopeless-
ness playing prominent roles. Yang and Clum (1996, 2000) have since added
developmental influences to their model, showing that early negative life events have an
impact on suicidal behavior by negatively affecting cognitive functioning; this, in turn,
produces risk for suicidality through interactions with current stress and social support.
A somewhat similar model was tested by Lewinsohn, Rohde, and Seeley (1996),
who showed in a longitudinal study of adolescents that cognition fully mediated the re-
lationship among interpersonal problems and suicidality and partially mediated the rela-
tionships between psychopathology, physical illness, negative events, and suicidality. In
this study, the cognition variable was a composite of depressogenic cognitions,
attributional style, self–esteem, and coping skills. This study introduced the Life Atti-
tudes Survey (LAS), which measures thoughts, feelings, and actions regarding
self–care, ranging from diet and exercise to substance abuse and self–harm behaviors.
The LAS has been shown in several studies to be a robust predictor of both health–re-
lated behaviors and suicidality (e.g., Ellis & Trumpower, in press; Rohde, Seeley,
Langhinrichsen–Rohling, & Rohling, 2003).
Proceeding from Beck’s cognitive theory of depression (Beck et al., 1979), Beevers
and Miller (2004) examined the roles of perfectionism, cognitive bias (negative infor-
mation processing), and hopelessness in predicting suicidality. In a 6–month prospec-
tive study of patients hospitalized for depression, they found that perfectionism at study
outset predicted greater suicidal ideation at follow–up, while cognitive bias was associ-
ated with future hopelessness, which in turn predicted suicidality. Importantly, the rela-
tionship between perfectionism and suicidality was not found to be mediated by
hopelessness. In contrast to the predictive utility of the cognitive variables, severity of
depression and suicidal ideation did not uniquely predict future suicidality (Beevers &
Miller, 2004).
Williams and associates (Williams, Crane, Barnhofer, & Duggan, 2005) recently
reviewed their own and related research and proposed a comprehensive cognitive model
of suicide, which they have named the entrapment model (also referred to as the “cry of
pain” model). The model consists of three components: (a) sensitivity to environmental
cues that signal defeat or humiliation, resulting in urgent feelings of needing to escape,
(b) a sense of being unable to escape, and (c) the perception that the situation will con-
tinue indefinitely. The model draws on their research on overgeneral autobiographical
memory (see above). They cite related research showing that social support serves an
important buffering function, moderating the impact of perceived defeating events
(O’Connor, 2003). An important aspect of the model is the theory of “differential acti-
vation,” which is proposed to explain how associations among various aspects of depres-
sion and suicidality (such as hopelessness, anhedonia, and suicidal thoughts) become
associated with one another and set the stage for suicidal crises (see discussions of
“suicidal mode” and the trait–state issue below).
COGNITION AND SUICIDE 55

Finally, a recent study has attempted to bring together three cognitive variables
that have been individually shown to be associated with suicidality: negative cognitive
style, rumination, and hopelessness (Smith et al., 2006). This model is set in the context
of the Attention Mediated Hopelessness Theory of depression, a revised version of the
hopelessness theory of depression (Abramson, Metalsky, & Alloy, 1989). University
students were monitored for depression and suicidality over a period of 2½ years. Cog-
nitive style was defined as a composite of attributional style (measured with the Cogni-
tive Style Questionnaire; Alloy, Abramson, & Hogan, 2000) and depressogenic
attitudes (measured with the Dysfunctional Attitude Scale, Weissman, 1979). Smith et
al. found that negative cognitive style predicted rumination, which in turn predicted
hopelessness and suicidal ideation. Duration of suicidal ideation was predicted by rumi-
nation, fully mediated by hopelessness. Thus, cognitive style was only distally associated
with later suicidal ideation, via rumination and hopelessness, and the development of
hopelessness appears to be significantly influenced by rumination.

THEORETICAL CONTRIBUTIONS

In addition to the substantial empirical work summarized above, recent years also have
seen significant theoretical advances in cognitive–behavioral models of suicidal behav-
ior. Much credit for fueling interest in cognitive aspects of suicidality belongs to Edwin
Shneidman, whose early contributions highlighted the key roles of such factors as cog-
nitive constriction and various types of illogical thinking (e.g., Shneidman & Farberow,
1957). As previously noted, Neuringer’s seminal research on cognition and suicide was
largely stimulated by Shneidman’s theoretical work.
More recently, Baumeister (1990) proposed a comprehensive motivational/cogni-
tive model that revolves around the effort to escape from aversive emotion and
self–awareness. The model utilizes a six–step process, in which discrepancies between
desires and reality are blamed on the self, leading to severe emotional distress. A promi-
nent aspect of the model is the resulting “cognitive deconstruction,” a state that attenu-
ates the pain but is ultimately ineffective as a coping response. Suicide is made possible
by the combination of unremitting emotional distress and the appeal that death holds
when one is in the (irrational) deconstructed state. Baumeister’s model awaits thor-
ough, hypothesis–driven research. Pettit and Joiner (2006) observe that “little empirical
support exists for the role of escape–oriented cognitions in suicidality" (p. 145),
although empirical testing certainly seems warranted.
Recent developments in cognitive–behavioral therapy (CBT) have given rise to an
assortment of theoretical perspectives on cognition and suicide. Prominent among
these is the work of Rudd, Joiner, and colleagues (e.g., Rudd, Joiner, & Rajab, 2001).
This comprehensive approach conceptualizes suicidality as consisting of three domains
to be addressed in treatment: symptoms (depression, anxiety, etc.), skill deficits (prob-
lem–solving, emotion regulation, etc.), and maladaptive personality traits (self–image
and interpersonal relations). Following Beck’s lead, the therapy model revolves around
the cognitive case conceptualization, which includes components such as conditional as-
sumptions and core beliefs and behavioral aspects such as compensatory strategies (J.S.
Beck, 1995). Specific to suicidal individuals are the Suicidal Belief System (SBC) and
the suicidal mode. Consistent with Beck’s theorizing, the SBC revolves around the con-
56 ELLIS AND RUTHERFORD

struct of pervasive hopelessness and is characterized by four primary themes: helpless-


ness, unlovability, distress intolerance, and perceived burdensomeness. The suicidal
mode is described as an integrated, organismic response with synchronized activity in
cognitive, affective, behavioral, and physiological systems (Rudd, 2004). It is proposed
as a means of understanding the waxing and waning of suicidal urges over time and of
reconciling conflicting observations regarding both traitlike and statelike features of
hopelessness (Rudd, 2006).
Joiner (2005) has recently proposed a compatible though distinct model that pro-
poses three necessary components in completed suicide. For suicide to occur, two cog-
nitive components (perceived burdensomeness and thwarted belongingness) must be
accompanied by an acquired capability to self–harm. This capability is thought to de-
velop through a gradual desensitization process, such as through prior suicide attempts
or episodes of self–harm. Joiner (2005) presents direct and indirect evidence in support
of this framework, although confirmation awaits further investigation.
As summarized above, Beck’s work has firmly established hopelessness as a compo-
nent of suicide risk. Indeed, Abramson, Alloy, and colleagues have integrated hopeless-
ness with their work on negative cognitive style and depression to develop their
Hopelessness Theory of Suicidality (Abramson et al., 2000). Through a systematic pro-
gram of research, they have provided substantial evidence for negative attributional
style as a cognitive diathesis for a specific subtype of depression, called hopelessness de-
pression (Abramson et al., 1989). Citing “a vast number of studies [showing] a power-
ful link between hopelessness and suicidality" (p. 23), they have extended their model to
propose that suicidality may be a core symptom of hopelessness depression, emerging at
higher severity levels of depression (Abramson et al., 2000). The researchers have tested
their model prospectively in their longitudinal study, the Temple–Wisconsin Cognitive
Vulnerability to Depression Project. This study recruited individuals not currently ex-
hibiting symptoms of psychological dysfunction and followed them for more than two
years. They found that negative cognitive style, measured at the study’s outset, predicted
later depression and suicidal ideation. Importantly, this relationship held even when
prior history of suicidality was controlled. Later work has shown that rumination may
set the stage for hopelessness, as well as predicting suicidality directly (Smith et al.,
2006). Although it is still early, the Hopelessness Theory of Suicidality appears to hold
promise, and merits further study.
It is important to note in this context that depression and hopelessness are not the
only affective states implicated in the suicidal process. Indeed, it is rare to find a de-
pressed individual who is not also experiencing significant anxiety. Anxiety has been
found to increase suicide risk among depressed individuals (e.g., Fawcett, Schefter,
Clark & Hedeker, 1987). “Looming vulnerability,” the experience of negative occur-
rences as rapidly escalating, is one of the best–demonstrated cognitive vulnerabilities for
anxiety disorders and one of the few that does not overlap with predictors of depression
(Riskind & Williams, 2006). Riskind and associates have recently proposed looming
vulnerability as a key component of a model that includes depression, hopelessness, anx-
iety, and suicidality, a model that helps to account for the sense of urgency or despera-
tion that drives a suicidal individual to drastic actions to terminate emotional distress
(Riskind, Long, Williams, & White, 2000).
COGNITION AND SUICIDE 57

“Third Wave” Models

Recent years have seen the development of an assortment of therapeutic approaches


sometimes referred to as “third wave” therapies (Hayes, 2004); these include Dialectical
Behavior Therapy (DBT; Linehan, 1993) and Acceptance and Commitment Therapy
(ACT; Hayes, 2004). These therapies, which emphasize greater usage of acceptance
strategies, attention to second–order processes such as metacognition, and mindfulness
meditation training, show considerable promise in conceptualizing and effectively in-
tervening with suicidal behavior. Indeed, DBT initially was developed for use with bor-
derline personality disorder, with a prominent focus of decreasing self–harm behavior
(Linehan, 1993). The DBT model views suicidal behavior less as a symptom than as a
coping response to emotional distress. Therefore, treatment of emotional dysregulation
is viewed as a crucial aspect of treatment. Importantly, such treatment is not immedi-
ately assumed to entail reduction or elimination of negative thoughts or emotions;
rather, because it is assumed that “invalidation” of emotion has contributed to the indi-
vidual’s failure to develop adequate coping and problem–solving skills, the intervention
begins by teaching acceptance of thoughts and feelings as they are. Cultivation of aware-
ness and acceptance is pursued via meditation and other mindfulness activities. DBT is
also fundamentally behavioristic in its attention to stimulus triggers and reinforcing or
punishing consequences of behaviors (Brown, 2006). Considerable research evidence
has accumulated on the DBT approach to suicidal behaviors (see below).
Following Linehan’s lead in using mindfulness meditation as a means of cultivating
awareness and acceptance, Mark Williams and colleagues developed Mindful-
ness–Based Cognitive Therapy (MBCT). They have shown it to be an effective relapse
prevention strategy in recurrent major depression (Teasdale, Segal, & Williams, 2000)
and have recently extended the model to suicidal individuals as well (Williams, Duggan,
Crane, & Fennell, 2006). Rather than emphasizing modification of suicidal cognitions,
MBCT teaches “metacognitive awareness,” i.e., seeing thoughts as only thoughts,
rather than as reflections of reality. Patients also are taught to pay attention
nonjudgmentally to negative thoughts and emotions, rather than to ruminate about or
attempt to suppress them. Studies are currently under way to determine whether in-
creases in mindful awareness and acceptance are associated with changes in suicidal
ideation and behavior (Williams, Duggan, Crane, & Fennell, 2006).
Acceptance and Commitment Therapy (ACT) is a rapidly emerging therapeutic
approach that has roots in both behavioral and cognitive traditions, but that de–empha-
sizes cognitive restructuring and symptom reduction in favor of altering an individual’s
“stance” toward thoughts and emotions through acceptance and “defusion” strategies
(Hayes, 2004). ACT targets “experiential avoidance” (covert and overt behaviors that
serve to shield the individual from unwanted thoughts and feelings, but that often make
problems worse in the long run), with suicide viewed as its ultimate expression. The sui-
cidal person views emotional pain as (a) intolerable, (b) inescapable, and (c) intermina-
ble (Strosahl, 2004), with self–harm behaviors serving to interrupt or terminate the
pain. Reinforcement (e.g., temporary emotional relief, or caring reactions from signifi-
cant others) takes a prominent place in the model in terms of maintaining the suicidal
mindset and associated behaviors. Any relief derived from suicidal ideation and behav-
ior, however, comes with a cost because “this behavior pattern has an extremely short
58 ELLIS AND RUTHERFORD

half–life. It must be engaged in repeatedly to maintain its effectiveness" (Strosahl, 2004,


p. 223).
This theoretical model carries important implications in terms of intervention
strategies, which differ (markedly at times) from conventional approaches. For exam-
ple, elimination of suicidal ideation and behavior is generally not a focus of discussion in
therapy; rather, suicidality is grouped together with other escape behaviors (such as
drug abuse or purging) that are not only ineffective in achieving desired relief but also
problematic in and of themselves. The focus shifts instead to the patient’s values and
goals, with the patient being urged to cultivate “willingness” to experience discomfort
in service of pursuing value–derived goals that will bring greater fulfillment in life.
Relatedly, the ACT therapist maintains a focus on “workability,” that, whether (in this
case) suicidal thinking and behavior are effective in “building the patient as a human be-
ing and promoting a sense of vitality, meaning, and purpose" (Strosahl, 2004, p. 226).
Here, therapists are urged to shift focus away from their usual agenda of eliminating sui-
cidal ideation and behavior: “In order to use the workability strategy, you have to be re-
lentlessly pragmatic and nonjudgmental, and to truly mean it. This is not a verbal game,
a trick or a form of therapeutic manipulation" (Strosahl, 2004, p. 226).

INTERVENTION RESEARCH
What does outcome research tell us about the viability of treatment models based on
cognitive–behavioral models of suicidality?

Problem-Solving

The earliest CBT programs designed specifically for suicidal individuals focused on
problem–solving skills as a key vulnerability. In one of the first–ever randomized studies
of treatment of suicidal patients, regardless of therapeutic orientation, Salkovskis, Atha,
and Storer (1990) found that brief problem–solving therapy produced superior out-
comes to treatment as usual in a group of 20 patients with a recent suicide attempt. Pa-
tients in the problem–solving treatment showed significantly greater drops in
depression and hopelessness at posttherapy and 1–year follow–up, and a lower rate of
repeat attempts at 6 months. In the same year, Lerner and Clum (1990) published their
study comparing problem–solving therapy with supportive therapy in a group of 18- to
24-year-olds. They found problem–solving therapy to be superior for reducing depres-
sion and improving problem–solving self–efficacy at post–treatment. Problem–solving
therapy appeared slightly more effective for reducing suicidal ideation, but this result
did not reach statistical significance.
Rudd and colleagues (Rudd, Rajab et al., 1996) operationalized several aspects of a
cognitive–behavioral model in a randomized clinical trial with suicidal young adults.
The experimental condition included problem–solving as a prominent feature, as well as
social competence and adaptive coping. It was delivered in an outpatient (day hospital)
setting over a period of 3 weeks, primarily in group and classroom modalities. The com-
parison condition was treatment as usual, consisting of a combination of inpatient and
outpatient care, with varying duration of care and therapeutic orientations. Results
were somewhat mixed, in that statistically significant differences on depression, prob-
COGNITION AND SUICIDE 59

lem–solving, and other measures were not found at posttreatment or follow–up. How-
ever, the CBT condition was found to be effective in producing significantly reduced
symptoms in almost two thirds of patients at 12–month follow–up and was superior to
treatment–as–usual in retaining high–risk patients in treatment.
Brent and colleagues (1997) at the University of Pittsburgh compared CBT with
systematic behavioral family therapy and individual nondirective supportive treatment
in the randomized treatment of 107 adolescents with major depression. Although they
found that CBT was superior to the other two treatments regarding clinical recovery,
rate of improvement, and parent–rated treatment credibility, no differences were found
specifically with respect to suicidality or on functional status.
In one of the largest controlled trials of CBT with suicidal patients to date, Tyrer et
al. (2003) randomized 480 patients with a history of recurrent deliberate self–harm to
either treatment–as–usual or Manual–Assisted Cognitive Therapy (MACT). The
MACT intervention, modeled after DBT, consisted of up to five sessions, plus two re-
fresher sessions. Patients also were given a 70–page workbook for self–help activities.
Outcomes at 6 and 12 months showed no differences between treatment conditions on
any outcome measure, including suicide or deliberate self–harm. The authors acknowl-
edged that the lack of advantage to the cognitive condition might have been due to the
brevity of the intervention. Indeed, this, combined with the observed 40% dropout
rate, raises questions as to whether the trial constituted an adequate exposure to the in-
tervention. A later artice reported that the therapy did result in a 50% lower frequency
of self–harm behavior in the CBT group, but that it was generally ineffective for
individuals with borderline personality disorder (Tyrer et al., 2004).

Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) is a year–long, cognitive behavioral treatment pro-


gram originally developed for suicidal clients with borderline personality disorder
(Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). Among the main goals of
DBT are reducing suicidal behaviors, managing treatment–interfering behaviors, and
reducing other dangerous or risky behaviors. DBT has been shown to be superior to
treatment as usual for reducing medical risk of parasuicidal behavior, improving therapy
retention, and decreasing the number of days required for inpatient psychiatric hospital-
izations in a one–year, controlled, randomized trial as well as a one–year naturalistic fol-
low–up of that study (Linehan et al., 1991; Linehan, Heard, & Armsrong, 1993).
Recently, Verheul et al. (2003) conducted a 12–month, randomized clinical trial of
DBT versus community treatment as usual for a sample of 58 women with borderline
personality disorder. Results again showed that DBT was superior at retaining patients
in therapy during the 12–month period, and it was also associated with a greater
reduction in self–harm behaviors and impulsive acts of self–harm compared to
treatment as usual.
Another recent study compared DBT and community treatment by experts
(CTBE) for suicidal behaviors in a population of individuals with borderline personality
disorder (Linehan et al., 2006). A group of 101 women who met criteria for borderline
personality disorder were randomly assigned to either the DBT or CTBE conditions.
The study was designed to investigate whether the effectiveness of DBT in treating sui-
60 ELLIS AND RUTHERFORD

cidal behaviors is attributable to common factors of receiving therapy by experts in gen-


eral or to specific ingredients of the DBT approach. Controlled variables included
availability of treatment, assistance finding and getting to the first appointment with a
therapist, hours of individual therapy offered, therapist variables (sex, training, clinical
experience, and expertise), and allegiance to treatment approach, among others. After a
two–year, randomized, controlled trial and follow–up, DBT outperformed non–behav-
ioral CBTE in reduction of suicide attempts. The authors concluded, based on the haz-
ard ratio for suicidal behaviors, that “suicide attempts can be reduced by half with DBT
compared to non–behavioral therapy by experts” (Linehan et al., 2006, p. 763).
Over the past several years, researchers at the University of Pennsylvania have pub-
lished a series of articles describing and testing a brief (around 10 sessions) outpatient
cognitive–behavioral therapy program based on Beck’s theory of suicide (e.g., Berk,
Henriques, Warman, Brown, & Beck, 2004). This program is specifically focused on
identifying and modifying beliefs, images, and other cognitive processes that become
activated prior to suicidal acts. Vulnerability factors such as poor problem–solving and
impulsivity are addressed, and patients are coached in effective coping behaviors, such as
seeking social support. An important and innovative aspect of the program is tracking
and referral services, which occurred throughout the 18–month follow–up period. Dur-
ing treatment, case managers remind patients of appointments; after treatment is con-
cluded, they contact study participants regularly by phone or mail, and they secure
permission to contact specific significant others if they are unable to reach patients. Suc-
cessful completion of the program is assessed by means of a relapse prevention task, in
which thoughts, images, and feelings associated with the index suicide attempt are
deliberately primed to determine whether patients are able to respond in an adaptive
way (Brown et al., 2005).
In a recent clinical trial, 120 individuals with a recent, serious suicide attempt were
randomized to this therapy program or treatment as usual (Brown et al., 2005). The
participant mix was diverse: Racial proportions were 60% black and 35% white; major
depression was diagnosed in 77% of the participants, 68% of the patients had a sub-
stance use disorder, and 85% of the participants had more than one diagnosis. Results
showed that patients in the CBT condition had a trend toward a lower dropout rate
(25% vs. 34%) and that fewer patients in the CBT condition made another suicide at-
tempt during the 18–month follow–up period (24% vs. 42%). The calculated hazard
ratio was 0.51, suggesting that patients in the CBT group were less likely by half than
comparison group patients to attempt suicide during the study period. The CBT group
also showed significantly greater reductions in depression and hopelessness; both
groups showed reductions in suicidal ideation over the study period, with no significant
difference between treatment conditions.

Personal Construct Theory

Finally, Winter and colleagues (2007) recently reported results from a randomized clin-
ical trial of an intervention based on personal construct theory (see Neimeyer & Winter,
2006, for a description). They found that, compared with a treatment as usual condi-
tion, patients with recent deliberate self–harm episodes who received the experimental
therapy had significantly greater reductions in suicidal ideation, hopelessness, and de-
COGNITION AND SUICIDE 61

pression and a trend toward fewer subsequent self–harm episodes. The apparent prom-
ise of this new approach awaits further verification.

DISCUSSION

Research over the past two decades on cognitive aspects of suicidality and its treatment
has added substantially to the foundation of prior work in the area. Further evidence has
been provided for cognitive characteristics that had emerged earlier (particularly various
aspects of executive functioning, such as cognitive rigidity and problem–solving), plus
evidence in previously unexplored areas, such as autobiographical memory, perfection-
ism, and ruminative response style. The last two decades also have seen significant theo-
retical advances bringing coherence to the research, from Aaron Beck, Mark Williams,
and others. These theories, although not without their differences, are by no means mu-
tually incompatible. Perhaps most notably, recent years have produced empirical tests of
therapeutic interventions that incorporate what is known about cognition and suicide,
with outcomes that are strongly supportive of this approach. Cognitively oriented ther-
apies have outperformed conventional approaches on an assortment of outcomes, and
they have produced reductions in suicidal behaviors by as much as half.
The significance of these developments is great when one considers that current
conventional treatments fall somewhere between CBT’s diagnosis–driven model and a
“common factors” model in which the same “active ingredients” are considered benefi-
cial across diagnoses. Until recently, the typical article or chapter on interventions with
suicidal patients shied away from the term “treatment” in favor of “management.”
Stemming from roots in the crisis intervention literature, such guidelines focused on
such issues as increasing therapist availability between sessions and knowing when to
hospitalize. The operating assumption, generally speaking, was that “when the person is
no longer highly suicidal–then the usual methods of psychotherapy . . . can be usefully
employed” (Shneidman, 1981, p. 345).
The findings reviewed in this article suggest an alternate model in which identified
cognitive vulnerabilities that predispose patients to suicidal behavior are specifically tar-
geted in order to reduce risk for future suicidal episodes. This shift carries with it signifi-
cant implications for treatment, research, and training. Addressing these vulnerabilities
post crisis appears to be especially important. For example, mindfulness–based cognitive
therapy is specifically designed for people in recovery, to teach skills for observing and
disengaging from distressing thoughts, skills to be utilized during future periods of
stress that might otherwise trigger suicidal episodes (Williams, Duggan et al., 2006).
Beck’s approach includes a “relapse prevention task,” a guided imagery task involving
past and potential stressful scenarios that might trigger suicidal ideation. Successful ac-
complishment of this task determines whether termination is appropriate or whether
further therapy is needed.
Recent years also have seen a clear shift toward multivariate models of suicidality
that include psychological and situational influences and corresponding development of
multicomponent therapies that take these factors into account. This is in contrast to
early studies and therapies that focused on single cognitive characteristics such as cogni-
tive rigidity or deficient problem–solving. Current therapies tend toward multifaceted
approaches that are expressly designed to reduce suicidal thinking and behavior, in con-
62 ELLIS AND RUTHERFORD

trast to conventional approaches that view suicidality as a symptom that is expected to


remit when the underlying disorder is treated.
The recent work of Beck and associates (Brown et al., 2005) is especially notewor-
thy, not only because of its encouraging outcome (50% reduction in risk for future sui-
cide attempts following a 10–session intervention), but also because of the “risky test”
nature of the study. Inclusion criteria for participants were quite broad (85% had
comorbid conditions, including 68% with substance abuse), the study sample was eco-
nomically and racially diverse, and the CBT condition was compared to a group that re-
ceived an enhanced form of treatment–as–usual. The study also addressed important
realities of the populations of suicidal patients (a trail blazed previously by Linehan,
1993) by building in aggressive case management strategies, such as contacting partici-
pants throughout the follow–up period on a weekly to monthly basis by mail and
telephone.
Significant challenges in the area of cognition and suicide remain, however, in both
research and clinical arenas. Although we now have some important leads in determin-
ing what distinguishes the thinking of suicidal people from that of nonsuicidal people,
the significance of these differences is only beginning to be understood. Specifically, the
question of causality looms large. Studies of cognition and suicide have been largely
correlational in nature, leaving open the question of whether cognitive impairment
might be a result (or concomitant) rather than a cause of the suicidal state (the reader is
referred to Williams, Crane et al., 2005, for a useful discussion of the state vs. trait issue).
Longitudinal studies such as the Wisconsin study (Alloy et al., 2006) are essential to
establishing to what extent cognition functions as a causal factor.
A further empirical issue has to do with how various cognitive variables relate to
one another: Do the cognitive vulnerabilities identified thus far operate independently,
or can one or a few “common denominators” be identified? Overgeneral autobiographi-
cal memory, for example, has now been shown to be (a) state dependent to a significant
degree (Au Yeung, Dalgleish, Golden, & Schartau, 2006) and (b) not unique to suicidal
individuals (Williams et al., 2007). Further study has shown central executive control to
be largely responsible for the relationship between depressed mood and overgeneral au-
tobiographical memory (Dalgleish et al., 2007). Problem–solving deficits, hopeless-
ness, and other aspects of suicidal depression may be related as well. Sorting through
associations such as these will be critical to a fuller understanding of suicidal thinking
and development of more precise, targeted treatment strategies.
More specific to clinical practice, we still know relatively little about how research
findings translate into working with specific individuals. Lack of clarity in the field re-
garding classification and nomenclature (Ellis, 1988; Silverman, 2006) contributes to
inconsistency from study to study in definitions of suicidality, population characteris-
tics, outcome indices, and so on. We do not know, for example, the extent to which
Linehan’s findings with borderline personality disorder might apply to individuals with
other diagnoses. In a similar vein, we know that major differences exist between groups
of individuals who die by suicide and those who engage in nonfatal self–harm behavior
(the latter are more predominantly female, younger, use less lethal means, etc.). A large
portion of research on cognition and suicide has focused on people with suicidal
ideation or a history of deliberate self–harm, sometimes with minimal lethality. The ex-
tent to which these individuals are representative of people who die by suicide (and the
related question of whether the treatments under development can be expected to actu-
COGNITION AND SUICIDE 63

ally decrease deaths by suicide) is not well understood at this time. By the same token, it
is important to better understand the significance of observed differences between
single and multiple attempters (e.g., Rudd, Joiner, & Rajab, 1996) for cognitive case
formulation and design of treatment programs.
This issue of generalizability versus population specificity arises in other contexts as
well. For example, whereas hopelessness was once considered a cornerstone of
suicidality, it now appears that it may function differently in substance abuser popula-
tions, and perhaps in adolescents as well. Another example is a study by Wingate, Van
Orden, Joiner, Williams, and Rudd (2005), who reported different treatment out-
comes for suicidal patients receiving problem–solving therapy, depending upon how
they self–appraised their problem–solving skills. A final example is a report by Tyrer et
al. (2004) that their brief CBT program (described above) was effective in reducing fu-
ture episodes of deliberate self–harm only in patients without a diagnosis of borderline
personality disorder. It is also not known whether diagnosis is an appropriate means of
studying differences or whether some other—perhaps cognitive—means of assessment
is preferable for understanding which therapies will be most beneficial for which
patients.
In any event, it is clear that the promise that was perceived in the 1970s and 1980s
regarding cognitive interventions with suicidal individuals has begun to be realized.
Plentiful evidence has accumulated that suicidal patients see and process experience dif-
ferently from nonsuicidal people and that, when these differences are targeted in treat-
ment, risk of future suicidal behavior can be expected to decrease, perhaps appreciably.
Moreover, a quick glance at publication dates of articles covered in this review suggests
that activity in the area is not only growing but also accelerating (more than half were
published in 2000 or later). Continued work in this exciting area can be expected to pay
further dividends for therapists and patients alike.

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