Cognitive Therapy for Suicide Ideation and Assisted Dying Laws

Introduction: Clinical and Legal Context

The central issues examined in this paper concern suicide and a patient's request for assistance in dying in the state of Oregon. The patient is a Dutch national living alone and suffering from Parkinson's disease, a condition that will only further debilitate him in the coming years. He has no interest in enduring that suffering. Clinically, he appears to experience hopelessness, which research identifies as the primary predictor of suicide ideation (Beck, Kovacs, & Weissman, 1975, p. 1146). The discussion that follows addresses how cognitive therapy should be applied, what legal constraints govern the situation, and how the therapist's ethical obligations shape the course of treatment.

Cognitive Therapy for Suicide Ideation

Cognitive therapy (CT), also referred to as cognitive behavioral therapy (CBT), is well suited to addressing the patient's presenting issues of suicide because "a substantial body of research supports" its application as "effective in reducing symptoms and relapse rates" in cases of depression (Beck, 2005, p. 953). Because the patient's hopelessness is closely related to depression, CT represents a beneficial treatment modality. CT allows the patient to focus on aspects of his life that can be changed in order to produce a more positive outlook and reinforce a more stable disposition.

During cognitive therapy sessions, the therapist would draw upon congruent therapeutic traits to help the patient address his incongruence constructively (McNeil, 2013, p. 8). The process thereby helps a fractured and fragmented sense of self become more coherent. Beck's empirically validated treatments using cognitive therapy are particularly relevant here given the depressive hopelessness at the core of the patient's experience (Jones & Lyddon, 2000, p. 342). Additionally, Asamsama, Dickstein, and Chard (2015) demonstrate that cognitive therapy is an effective approach to serious depression and a beneficial treatment modality because of its emphasis on altering client behavioral patterns and its use of the Beck Depression Inventory-II.

The therapist would deal with this client by informing him that in Oregon it is illegal to assist in suicide except in strictly defined terminally ill cases — what is commonly known as a dying law. Because this patient's condition does not currently meet that threshold, even though it may in coming years, it is unlawful to assist him in the proposed suicide. What is required is cognitive therapy capable of reorienting the patient toward better ways of thinking about his situation and of overcoming the loneliness and isolation he feels. This CT approach would focus on "automatic thoughts and core beliefs" within the patient, identifying them and demonstrating why they need to be addressed more effectively (Berk, Henriques, Warman, Brown, & Beck, 2004, p. 265).

The therapist would also adhere to the Ethical Code of Conduct of the American Psychological Association, offering the client fidelity, responsibility, and integrity (APA, 2010). If, after a thorough discussion of the law's impact on the patient's situation, he still requested assistance with suicide, the therapist would alert the responsible authorities so that appropriate steps could be taken. As Sasso, Strunk, and Braun (2015) have shown, "therapist adherence is differentially related to outcome among depressed patients" (p. 976). The cognitive therapy approach is also directly helpful because it "lowers patients' risk for engaging in a future suicidal act by helping them to recognize the warning signs when they are in crisis and to use cognitive and behavioral coping strategies" to overcome suicidal ideation (Wenzel & Beck, 2008, p. 198).

Legal and Ethical Framework

The therapist would caution the patient that what he is proposing is unlawful under Oregon law. This would constitute the first phase of CT treatment. The second phase would focus on types of thinking that could be used to avert suicidal thoughts. This approach is also ethically grounded: the therapist is bound by the "moral principle of beneficence," which "compels psychologists to act to protect patients who threaten themselves" (Knapp & VandeCreek, 2006, p. 129).