Working with Suicidality Within Bipolar Disorder

The long-term risk of completed suicide in persons with bipolar disorder is considerable, with lifetime estimates in the range of 15–19%. Thus, appropriate treatment requires regular attention to the matter of patients’ thoughts and intentions regarding suicide. The ever-broadening field of cognitive-behavioral therapies (CBT) has developed efficacious interventions to address the clinical challenges faced by patients across the bipolar spectrum (as described in this volume), but it is equally noteworthy that evidence-based interventions have also been used to target the symptoms of suicidality in their own right. These methods include a collaboratively designed, individualized Safety Plan, cognitive techniques to assess and modify hopeless, self-devaluing beliefs, behavioral methods to promote moderate activity and healthy connectedness, and the building and application of self-care habits to dampen severe emotional distress. In light of the fact that symptoms of bipolar disorder can persist for the long term, even at times when the patient does not officially meet diagnostic criteria for being in an active symptom episode, patients are at risk for feeling demoralized and trapped by their illness. Thus, CBT must not only provide patients with methods for reducing their risk of suicide in crisis situations, it must offer a pathway to improve their quality of life for the long run, including improved self-concept and self-efficacy. A case illustration (that includes accompanying videos of two role-played sessions) highlights CBT as applied to a severe bipolar depressive state with suicidal ideation. The therapist pays close attention to the therapeutic relationship as he tries to collaborate with the patient on a Safety Plan, as well as applying interventions to re-build her self-confidence and her career, while maximizing her attention to (and appreciation of) her personal strengths and interpersonal resources.