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A safety plan is a critical evidence-based intervention that can reduce suicidal behavior, either as a standalone intervention or as part of a comprehensive treatment plan.

 The safety planning intervention described in this article was developed by Barbara Stanley, PhD, and Gregory K. Brown, PhD, and has been found to be effective at reducing suicidal behavior.

 Since its development, this critical evidence-based intervention has been embraced by clinicians around the world and extensively employed in a wide range of behavioral health settings. It is also commonly taught as part of suicide prevention curriculum.

The purpose of the safety plan is to provide patients who are at heightened risk for suicide with concrete, actionable coping strategies they can use during a suicidal crisis to decrease their risk of attempting suicide. In addition to its practical and intended use, a safety plan also conveys hope by demonstrating to an individual with suicidal ideation that there are more effective ways of managing their problems.

A safety plan is different from a no-suicide contract. Research has shown that no-suicide contracts are ineffective and can lead patients to withhold information about suicidal thoughts and behaviors from their providers.

At the beginning of treatment, or if a previously non-suicidal patient begins reporting suicidal risk factors, it is important to determine risk for suicide by conducting a comprehensive suicide risk assessment. This may include patients who have experienced previous episodes of suicidal ideation or behavior because, when the previous suicide risk is greater than the current risk, it is a better predictor of suicidal behavior.

 Safety planning should then be conducted immediately upon determining that a patient is at heightened risk for suicide.

As with all interventions, clinicians should provide patients with a rationale for safety planning. If possible, clinicians can emphasize the collaborative nature of the intervention by sitting next to the patient when completing the plan. Clinicians should start by eliciting warning signs that risk for suicide is increasing. This helps patients gain awareness of when they need to access and use their safety plan. It is typically easier for patients to implement safety plan coping strategies at the early stages of a suicidal crisis than it is after the episode escalates in intensity. Noticing warning signs can help patients begin using coping strategies so that a more severe crisis and related suicidal behavior are prevented.

Once the clinician and patient have a good understanding of the patient’s warning signs, the first section of the safety plan can be completed. Warning signs may include feelings of hopelessness or irritability; thoughts like, “I’ll always be alone”; behaviors like arguing with a parent; and/or physiological sensations such as intense pain from a chronic medical condition. They can also include events, such as the anniversary of the death of a loved one.

The next part of the safety plan involves identifying different categories of coping strategies patients will use once they have recognized that they are at heightened risk for suicide. The safety plan begins with internal coping strategies the patient can use without assistance from others and progresses through incrementally more intensive strategies the patient can use if the initial strategies are ineffective.

Internal coping strategies typically involve experiences that distract the patient from their suicidal thoughts, emotional distress, or urges by diverting their attention onto other activities, stimuli, or sensations. Clinicians can identify internal coping strategies by asking patients, “What have you done in the past that has been at least a little helpful when you have experienced any of these warning signs?” If the patient has trouble identifying coping strategies, you can make suggestions.

Some patients may benefit from focusing on sensory experiences like listening to music or taking a hot shower. Patients may also engage in a distracting activity, such as going for a walk, watching an entertaining TV show, or playing video games. When completing this section of the safety plan, clinicians should be as specific and detailed as possible. For example, if a patient identifies listening to music as a coping strategy, the clinician should find out exactly which songs or artists the patient finds helpful and how the patient will listen to them (eg, on their phone).

After completing each coping strategy section, clinicians elicit feedback from patients. Clinicians should assess how likely it is that the patient will use the strategies in a suicidal crisis and problem solve for any obstacles that may get in the way. A simple way to assess the utility of each part of the plan is to ask, “Thinking about how you feel when in a suicidal crisis, how likely are you to use these strategies on a scale of 0 to 100, where 0 indicates that you will definitely not use these strategies and 100 indicates that you have no doubt that you will use them?” If the patient provides a rating of less than 90, the clinician will need to do some additional work to assess practical problems or beliefs that may be interfering with the patient’s likelihood of using the strategies. This might involve eliminating some strategies and replacing them with other, more helpful ones.

For the next section of the safety plan, patients are asked to identify individuals and social settings that can serve as a distraction during a suicidal crisis. It should be emphasized that these are not individuals the patient is contacting to directly ask for help, but rather individuals who can provide social experiences that can divert the patient’s attention from suicidal thoughts or urges. The identified individuals should be known to be responsive and accessible, and the patient should be explicit about the medium for communication (ie, via phone, via text, or in person).

Patients may also wish to identify social locations they can visit, such as a local park, a coffee shop, or an AA meeting. Many patients find it helpful to be around other people during a suicidal crisis, even if the people are strangers. As with the section on internal coping strategies, clinicians should assess the likelihood that patients will use the strategies in this section before moving on.

Next, the patient will identify individuals that they can contact to directly ask for support. The identified individuals should have a history of being responsive or helpful when the patient has asked them for support in the past. The patient will need to determine whether they feel comfortable explicitly stating that they are having a suicidal crisis, or whether they would prefer to be vague (ie, telling the person they feel “down” or “anxious” instead). If the patient is not sure whether an identified person will be willing and able to help, they can have a conversation with the person in the coming week about their desire to reach out for support if needed. They may even tell the person what they would like them to do if they call on them for support. If the patient is not comfortable having this type of conversation, it may be helpful for the clinician to provide some brief coaching on communication skills and to offer to roleplay the conversation.

Once support people have been identified, clinicians should be explicit about the order in which the patient will contact them and the medium for contact. Finally, the names and phone numbers of the individuals should be added to the safety plan.

If the patient has moved through all the previous coping strategies and is still in suicidal crisis, the final strategy is to contact mental health providers or facilities that can intervene with professional help. Typically, the clinician’s name will be at the top of this section, followed by additional mental health clinicians and trusted medical professionals. Clinicians should be explicit with clients about how emergencies are handled both during and after business hours, whether they have an answering service, or if there is another provider in the practice who may be on call if the patient experiences a crisis after hours.

This section can also include hotline services, like the new mental health crisis number, 988, which is now available in the United States. Finally, patients should designate a local urgent care service or psychiatric emergency room if hospitalization is required. Patients should also determine how they will get to their designated facility (ie, will they call an ambulance or ask a friend or family member to drive them?).

The next step in safety planning is making the patient’s environment safer. Clinicians should focus on reducing the patient’s access to their identified means for suicide. It is important to restrict access to firearms, regardless of whether the patient expresses a desire to use a firearm for suicide. In the United States, approximately half of individuals who commit suicide do so using firearms.

 Having a firearm in the household is also associated with a 5-fold increase in death by suicide.

When asking the patient about their chosen means for suicide, collaboration is key. Often, patients view having access to a means for suicide as a coping strategy in and of itself. A patient may consider a stockpile of pills hidden in a drawer an “escape hatch” they can use if their problems become overwhelming. That patient may then have a negative reaction to the clinician’s suggestion that they turn their medication over to a friend for safekeeping.

Clinicians can be collaborative by asking patients for suggestions to make their environment safer before offering their own suggestions. For instance, a patient may prefer keeping a pill box with 1 week’s worth of medication while a family member has possession of the remaining bottle. A patient who is unwilling to give up their firearm may be willing to store it in a locked safe and give the key to a trusted friend. Clinicians can emphasize that the measures are temporary and will last only until the suicidal crisis is over.

The last component of the safety plan is identifying reasons for living. Clinicians should work with patients to identify at least 1 thing that makes the patient’s life worth living. The simplest way to help patients identify reasons for living is simply to ask, “What is 1 thing that is most important and worth living for?” If patients have difficulty identifying 1 reason for living, clinicians can prompt them by asking about different areas where individuals often find meaning, including relationships, important goals, or religion and spirituality. If the patient is still having trouble identifying a compelling reason for living, the clinician might suggest that even the potential of having a future reason for living, or the possibility that life might seem worthwhile, can also be reasons for living. For example, a young female patient of mine did not have children, but she identified wanting to be a mother sometime in the future as a potential reason for living.

Once the safety plan is complete, the clinician’s work is to increase the likelihood that the patient will actually use it in a suicidal crisis. The clinician will start by asking for general feedback about the safety planning process and whether the patient believes the plan will be helpful. The clinician will then try to uncover obstacles that might get in the way of the patient using the plan when needed.

Sometimes practical problems may get in the way. For example, the patient may not remember to use their plan, particularly when they are in the midst of a suicidal crisis. It is usually a good idea to ask patients to review their safety plan every day, regardless of whether they are feeling suicidal. Clinicians should be explicit with patients about when they will review their plan. Most patients can benefit from reviewing their plan each morning, as this helps keep the plan at the forefront of their minds throughout the remainder of the day. Another obstacle might be the accessibility of the plan. The clinician will want to be sure the patient has access to their plan wherever they are. Patients may wish to take a picture of it with their phone, or to make multiple copies and store them in different locations (ie, in their car, in their desk at work, on a nightstand).

Some patients may express doubt that the plan will be helpful. The clinician can communicate that the safety plan is not meant to solve all their problems—the safety plan is just meant to keep the patient alive so that they can continue to work on more longstanding problems in therapy. The clinician can also stress that the safety plan can evolve and change over time, as the patient determines that some of the strategies are not helpful and learns new strategies in therapy that may be more helpful. The patient just needs to agree to use the plan, regardless of whether they are confident it will be helpful.

Each subsequent session with the patient should begin with a review of the plan and a discussion of any strategies the patient has tried to determine their utility. If a patient outright refuses to use their safety plan, clinicians should consider whether the patient should be referred to a higher level of care.

is a licensed clinical psychologist at the 

Beck Institute for Cognitive Behavior Therapy

is the communications manager at the Beck Institute for Cognitive Behavior Therapy.

1. Nuij C, van Ballegooijen W, de Beurs D, et al. 

Safety planning-type interventions for suicide prevention: meta-analysis

Safety planning intervention: a brief intervention to mitigate suicide risk

3. Ferguson M, Rhodes K, Loughhead M, et al. 

The effectiveness of the safety planning intervention for adults experiencing suicide-related distress: a systematic review

The case against no-suicide contracts: the commitment to treatment statement as a practice alternative

Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients

Suicide case-fatality rates in the United States, 2007 to 2014: a nationwide population-based study

Gun safety management with patients at risk for suicide. 

What is a safety plan, and how can clinicians use it to help patients with suicidal behavior? 

Safety Planning: An Essential Feature of Cognitive Behavior Therapy for Suicide Prevention

 (CBT) has traditionally focused on alleviating symptoms of psychiatric disorders in addition to helping patients solve life problems. CBT practitioners illustrate this by monitoring therapeutic progress through symptom measures related to the psychiatric diagnosis (eg, Beck Anxiety Inventory, Beck Depression Inventory).

 Research on CBT outcomes generally use the same measures to determine treatment efficacy or effectiveness. CBT has gained a robust research literature demonstrating its ability to reduce symptoms of distress in multiple psychiatric disorders.

 Nevertheless, it has been argued that a greater focus is needed on enhancing overall 

This argument is not new, and many fields of psychology focus on overall well-being. The field of positive psychology was founded on the premise that it takes different types of interventions to enhance positive emotional states than to alleviate distress.

 For example, practitioners of positive psychology may help patients identify their signature strengths and find ways to use those strengths in daily life. Patients also can learn how to enhance positive emotional states by interventions aimed at increasing their sense of gratitude. Enhancing well-being also has been incorporated into “third wave” treatments such as acceptance and commitment therapy, which includes values as a central component of treatment.

 Patients learn how to identify their values and live according to their values as opposed to being guided primarily by their thoughts or emotions.

Recently, CBT has shifted to include a greater emphasis on enhancing well-being. One specific form of CBT, 

, helps patients with serious mental health conditions identify and live in accordance with their values and aspirations.

 These strategies also have been adapted into traditional CBT.

Cognitive Behavior Therapy: Basics and Beyond

, a text used by many training programs, includes an emphasis on values and aspirations, as well as a strengths-based method for CBT conceptualization. The following case example demonstrates how to incorporate strategies to enhance a patient’s well-being throughout a course of CBT.

“Henry” is a recently retired high school teacher who was referred to treatment by his primary care physician because of complaints about elevated anxiety and an overall depressed mood. He grew up in a household with a physician father who was dedicated to his job and rarely home as a result. Both parents stressed the importance of learning and hard work. For instance, as a child, Henry was not allowed to watch television programs, as it was considered “being lazy.” Henry’s parents also criticized him for not performing at the top of his class, a result of his undiagnosed attention-deficit/hyperactivity disorder. He tried to please his parents and avoid criticism by dedicating more time to schoolwork than his peers, which led him to neglect his social life.

Henry reported fairly consistent anxiety throughout his life, mainly related to his academic and later his work performance, as well as to how other people viewed him. He noted a prior untreated episode of depression, which occurred when he was graduating from college and was not accepted into any of the graduate school programs to which he applied. He originally planned on becoming a professor but decided on a career as a high school teacher, as he did not believe he would ever be able to get into an adequate graduate program. His second major depressive episode began about 3 months after he retired. Since becoming depressed, Henry became more withdrawn, and has spent most of his time on the couch watching news programs. The focus of his worry was whether he would be able to enjoy retirement and what the rest of his life would involve. Henry met diagnostic criteria for major depressive disorder and recurrent, moderate, and generalized anxiety disorder.

Goal setting is an important component in beginning CBT. Traditionally, treatment goals focus on resolving life problems as well as symptom reduction or management. When I asked Henry what he wanted to accomplish in therapy, Henry initially listed these goals: “Get out of this depression,” “stop worrying so much,” and “enjoy retirement.” Goal setting with clients should involve choosing specific goals that have measurable outcomes. Accordingly, I asked Henry what he would be doing differently—or how his life would be different—if he were not depressed, if he stopped worrying, and if he was enjoying retirement. Henry was able to come up with more specific behavioral goals: “Go on daily walks,” “read for fun,” and “complete more woodworking projects.”

Instead of stopping at standard CBT goals, I decided to determine whether we could set additional goals to enhance Henry’s overall sense of well-being. We accomplished this by first assessing his values. I read through different potential values and asked him to rate on a scale of 0 to 10 (0 = no value at all; 10 = the most something can be valued) how important each value was to him. The areas of value we covered were: work/career; learning; volunteering; intimacy; friendship; family; recreation; and health. I then asked Henry to look at his rated values and see if there was a discrepancy between what he valued and how he was living his life. We were then able to develop additional values-based treatment goals of: “developing and maintaining better friendships,” “developing joint interests/hobbies with my wife,” and “finding ways to contribute to society in retirement.”

Standard CBT treatment for a withdrawn, depressed patient begins with behavioral activation. Behavioral activation is aimed at helping depressed patients become more active and engaged in life by scheduling specific activities throughout the week. These activities allow the patient to have pleasurable experiences and to cut down on time spent ruminating. Traditionally, CBT practitioners help patients identify activities that give them either a sense of pleasure or a sense of accomplishment. For instance, watching a movie might be pleasurable, while exercising can lead to a sense of accomplishment.

To have a greater focus on enhancing well-being instead of solely alleviating depression, we used values-based activities for behavioral activation. Henry decided to schedule a daily walk with his wife, which was consistent with his values of connecting with his wife and helping her reach her health goals, as well as his own desire to live a healthier life. In line with his value of learning, he also signed up for a weekly woodworking class. Between classes, he decided to dedicate 2 days per week to using the skills he learned on his own woodworking projects, which was related to his work/career value of being productive. Lastly, Henry wanted to enhance the friendships he had neglected for most of his career due to his taking on an excess of work tasks. He was able to focus on his value of friendship by contacting a few existing friends; he set up a weekly lunch date with one and joined another friend’s cycling group.

After focusing on these activities for about 1 month, Henry’s major depressive episode resolved, but he still reported lacking an enhanced sense of well-being. We determined a few factors were getting in the way of his sense of well-being. The first was his deeply entrenched drive to be productive that he had learned from his parents. Initially, I used the standard CBT strategy of cognitive restructuring through Socratic questioning to try to help him determine that his current activities could be viewed as being productive. For instance, going on walks with his wife was productive for his own health and for enhancing his connection with his wife. Despite this, he still held on to the idea that productivity was work related and kept going back to the fact that his father had dedicated his life to his work and chosen not to retire. Instead of trying to help Henry change his view on work, I defined 

 as an important value of his. We then focused on how to include productivity in his life, and Henry came upon the solution of volunteering as a tutor 2 days per week. By volunteering, Henry was able to satisfy his treatment goal of finding ways to contribute to society in retirement.

The second factor interfering with Henry’s sense of well-being was worry. He reported that his current worries centered on how other people viewed him and whether he was enjoying retirement as much as he should. We started worry reduction of his social fears through the standard CBT strategies of Socratic questioning for cognitive restructuring of his worry thoughts and evaluating positive (worry is helpful) and negative (worry is uncontrollable and potentially harmful) beliefs about worry itself. In using cognitive restructuring for his social worries, Henry was able to realize that he likely did not give as negative of an impression as he imagined and that people tended to respond positively to him when he made an effort to converse. He also came to the conclusions that he cannot know for certain what other people think of him and he cannot control how others view him overall.

Given these conclusions, we then focused on what Henry was able to control (ie, his behavior). Attempting to enhance his sense of well-being, I asked Henry how he valued acting toward others. He determined that he valued being kind, supportive, a good listener, and more outgoing. We then concretely defined what this would look like in his weekly social interactions and role-played example social interactions during sessions. He was then able to act more in accordance with his social values.

The last component we focused on was Henry’s worry that he was not enjoying retirement as much as he should. Throughout his career, Henry had heard his fellow teachers discuss how amazing retirement was going to be and would hear from those who had retired how happy they were. As a result, Henry was constantly evaluating his emotional experience and thinking that he should be feeling happier in his day-to-day life. For instance, he would be completing a woodworking project, note he felt happiness at a 5/10 level, and believe he should be enjoying the project more, which would then cause his happiness to dip to a 2/10 level. Through these experiences, I helped him determine that both evaluating his sense of happiness and wanting to increase his experience of happiness tend to backfire and lead to less happiness. I also helped him come to the realization that he is not able to control his emotional state at will. I asked him to recount the last time he experienced at least a moderate amount of happiness, and whether he was focused on analyzing what was happening and how it was making him feel. He noted that he was not focused on analyzing his level of happiness at all; he was just fully engaged in the experience and even lost a sense of himself to a degree.

I guided Henry through a mindfulness exercise to strengthen his ability to notice his emotional state and related thoughts without getting caught up in them or trying to control them, while also becoming fully absorbed in the experiences around him. Henry then practiced taking this approach to his day-to-day valued experiences. He came up with the saying, “If I’m a 5 (happiness level), I can let myself be a 5.” Henry reported this intervention as being the most important in enhancing his sense of well-being, as he was able to “get out of [his] head” and experience life to the fullest.

CBT has traditionally focused on alleviating symptoms of psychiatric disorders and resolving problems, but it has recently included a greater focus on living a valued life and enhancing well-being. A CBT approach focused on enhancing well-being continues to include goal setting, problem solving, and standard CBT cognitive strategies such as cognitive restructuring and Socratic questioning, as well as behavioral strategies including behavioral activation and exposure exercises. Nonetheless, throughout the course of treatment, patients are encouraged to identify their values, live according to their values, and become fully engaged in valued experiences. Through a greater emphasis on valued experiences, well-being can be enhanced in addition to distress being alleviated.

is a licensed clinical psychologist at the 

Cognitive Behavior Therapy: Basics and Beyond. 3rd ed. 

2. Hofmann SG, Asnaani A, Vonk IJJ, et al. 

The efficacy of cognitive behavioral therapy: a review of meta-analyses

Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment

Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2nd ed.

Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions

"Accordingly, I asked Henry what he would be doing differently—or how his life would be different—if he were not depressed, if he stopped worrying, and if he was enjoying retirement."

Using Cognitive Behavioral Therapy to Enhance Well-Being

Is there a way to psychiatrically understand the 1/6 Congressional committee hearings?

Listening to some of the hearings about the unprecedented and dangerous storming of our Capitol for a coup reminds me some of the psychotherapy process with a patient suffering from posttraumatic stress disorder. As in such patients, finding the truth in the history and memories of trauma is a slow process. Sometimes values trump the truth. Ultimately, for recovery, some positive reframing, as occurs in cognitive-behavioral psychotherapy, is necessary to move forward successfully.

In a typical trauma psychotherapy process, there are risks, such as pushing the trauma into consciousness too quickly. The therapist can also make interpretations that the patient is not ready to access and accept. False memories can be implanted. Truth by itself may not be therapeutic.

The patient in the hearings may be our country itself. The committee may represent the therapist, the witnesses the avoided memories, and the perpetrators the psychological resistance.

It seems like some of the repressed trauma emerged on Tuesday, tearfully and therapeutically. There was Arizona Republican House Speaker “Rusty” Bowers, who had resisted the conspiracy accusations of voter fraud, and then testified that because of his faith in the US Constitution, that what he was asked to do was “foreign to my very being.” Then were 2 Georgia election workers, a mother and daughter, who testified that they lived in fear after being wrongly accused of voter fraud.

I am not at all sure if this is an appropriate or understandable parallel approach to analyze the hearings. Applying concepts that pertain to an individual may or may not fit the dynamics of groups but, then again, people are people and we share common human nature characteristics. Untreated major trauma in an individual, and perhaps in a country, can greatly impair functioning indefinitely. After yesterday, there will be a break in the hearings, allowing for time for us all to reflect on what it all means so far and how to further respond.

One thing I do know for sure is that our country needs the psychological healing of our increasing divisiveness and conflicts through the reduction or removal of this invasive trauma internally in our minds and externally in society.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

“Our country needs the psychological healing of our increasing divisiveness and conflicts…”

Trauma, Conspiracy, and Cognitive-Behavioral Therapy in the Congressional 1/6 Hearings

Traditionally, cognitive behavior therapy (CBT) has focused on alleviating symptoms of psychiatric disorders in addition to solving problems in patients’ lives. This is illustrated by CBT practitioners monitoring progress in therapy through symptom measures related to the psychiatric diagnosis (eg, Beck Depression Inventory, Beck Anxiety Inventory).

 Additionally, research studies on CBT outcomes typically use the same types of symptom measures to determine treatment effectiveness or efficacy. Since its inception, CBT has gathered a robust research literature demonstrating its ability to reduce symptoms of distress in a variety of psychiatric disorders.

 Nonetheless, it has been argued that although psychological treatments, such as CBT, have demonstrated the ability to alleviate distress, there needs to be a greater focus on enhancing overall well-being.

This argument is not new, and many fields of psychology do focus on overall well-being. The field of positive psychology was founded on the premise that it takes different types of interventions to enhance positive emotional states than to alleviate suffering.

 For example, practitioners of positive psychology may help patients identify their signature strengths and find ways to use those strengths in daily life. Patients can also learn how to enhance positive emotional states by interventions aimed at increasing their sense of gratitude. Enhancing well-being has also been incorporated into “third wave” treatments. Acceptance and commitment therapy includes values as a central component of treatment.

Recently, CBT has shifted to include a greater emphasis on enhancing well-being. One specific form of CBT, recovery-oriented cognitive therapy, helps clients with serious mental health conditions identify and live in accordance with their values and aspirations.

 These strategies have also been adapted into traditional CBT.

Cognitive Behavior Therapy: Basics and Beyond, 3rd Edition

, a CBT text used by many training programs, includes an emphasis on values and aspirations, as well as a strengths-based method for CBT conceptualization. The following case example demonstrates how I incorporated strategies to enhance well-being throughout a course of CBT.

“Henry” is a recently retired high school teacher who was referred to treatment by his primary care physician due to complaints about elevated anxiety and an overall depressed mood. Henry grew up in a household with a physician father who was dedicated to his job and rarely home as a result. Both of his parents stressed the importance of learning and hard work. For instance, as a child, Henry was not allowed to watch television, as this was considered “being lazy.” His parents also criticized him for not performing at the top of his class, a result of his undiagnosed attention-deficit/hyperactivity disorder (ADHD). Henry tried to please his parents and avoid criticism by dedicating more time to schoolwork than his peers, which also led him to neglect his social life.

Henry reported fairly consistent anxiety throughout his life, mainly related to his academic and then to his work performance, as well as to how other people view him. He noted 1 prior untreated episode of depression, which occurred when he was graduating from college and was not accepted into any of the graduate school programs to which he applied. He originally planned on becoming a professor but decided on a career as a high school teacher, as he did not believe he would ever be able to get into an adequate graduate program. His second major depressive episode began about 3 months after he retired. Since becoming depressed, Henry became more withdrawn, spending most of his time on the couch watching news programs. The focus of his worry was whether he would be able to enjoy retirement and what the rest of his life would involve. Henry met diagnostic criteria for major depressive disorder, recurrent, moderate, and generalized anxiety disorder.

An important component in beginning CBT is goal setting. Traditionally, treatment goals focus on resolving problems in life and symptom reduction or management. When I asked Henry what he wanted to accomplish in therapy, Henry initially listed his goals as being: “Get out of this depression,” “stop worrying so much,” and “enjoy retirement.” Goal setting with clients should involve choosing specific goals that have measurable outcomes. Accordingly, I asked Henry what he would be doing differently—or how his life would be different—if he were not depressed, if he stopped worrying, and if he was enjoying retirement. Henry was able to come up with the more specific behavioral goals of: “Go on daily walks,” “read for fun,” and “complete more woodworking projects.”

Instead of stopping at standard CBT goals, I decided to determine if we could set additional goals to enhance Henry’s overall sense of well-being. We accomplished this by first assessing his values. I read through different potential values and asked him to rate on a scale of 0 to 10 (0 = no value at all; 10 = the most something can be valued) how important each value was to him. The areas of value we covered were work/career; learning; volunteering; intimacy; friendship; family; recreation; and health. I then asked Henry to look at his rated values and see if there was any discrepancy between what he valued and how he was currently living his life. We were then able to develop additional values-based treatment goals of: “developing and maintaining better friendships,” “developing joint interests/hobbies with my wife,” and “finding ways to contribute to society in retirement.”

To have a greater focus on enhancing well-being instead of solely alleviating depression, we used values-based activities for behavioral activation. Henry decided to schedule a daily walk with his wife, which was consistent with his values of connecting with his wife and helping her reach her health goals, as well as his own desire to live a healthier life. In line with his value of learning, he also signed up for a weekly woodworking class. Between classes, he decided to dedicate 2 days per week to using the skills he learned on his own woodworking projects, which was related to his work/career value of being productive. Lastly, Henry wanted to enhance the friendships he had neglected for most of his career due to taking on an excess of work tasks. He was able to focus on his value of friendship by contacting a few existing friends; he set up a weekly lunch date with a friend and joined another friend’s cycling group. 

After focusing on these activities for about 1 month, Henry’s major depressive episode resolved, but he still reported lacking an enhanced sense of well-being. We determined a few factors were getting in the way of his sense of well-being. The first factor was his deeply entrenched drive to be productive that he learned from his parents. Initially, I used the standard CBT strategy of cognitive restructuring through Socratic questioning to try to help him determine that his current activities could be viewed as being productive. For instance, going on walks with his wife was productive for his own health and for enhancing his connection with his wife. Despite this, he still held onto the idea that productivity was work-related and kept going back to the fact that his father dedicated his life to his work and chose not to retire. Instead of trying to help Henry change his view on work, I defined 

 as an important value of his. We then problem-solved how to include productivity in his life, and Henry came to the solution of volunteering as a tutor 2 days per week. By volunteering, Henry was able to satisfy his treatment goal of finding ways to contribute to society in retirement.

The second factor interfering with Henry’s sense of well-being was worry. He reported that his current worries centered on how other people viewed him and whether he was enjoying retirement as much as he should. We started worry reduction of his social fears through the standard CBT strategies of Socratic questioning for cognitive restructuring of his worry thoughts and evaluating positive (that worry is helpful) and negative (that worry is uncontrollable and potentially harmful) beliefs about worry itself. In using cognitive restructuring for his social worries, Henry was able to realize that he likely did not give as negative of an impression as he imagined, and people tended to respond positively to him when he made an effort to converse. He also came to the conclusions that he cannot know for certain what other people think of him, and he cannot control how others view him overall.

Given these conclusions, we focused on what Henry was able to control (ie, his behavior). In attempting to enhance his sense of well-being, I asked Henry how he valued acting toward others. He determined that he valued being kind, supportive, a good listener, and more outgoing. We then concretely defined what this would look like in his weekly social interactions and role-played example social interactions during sessions. He was then able to act more in accordance with his social values.

The last component we focused on was Henry’s worry that he was not enjoying retirement as much as he should. Throughout his career, Henry heard his fellow teachers discuss how amazing retirement was going to be and would hear from those who had retired how happy they were in retirement. As a result, Henry was constantly evaluating his emotional experience and thinking that he should be feeling happier in his day-to-day life. For instance, he would be completing a woodworking project, note he felt happiness at a 5/10 level, and believe he should be enjoying the project more, which would then cause his happiness to dip to a 2/10 level. Through these experiences, I helped him determine that both evaluating his sense of happiness and wanting to increase his experience of happiness tend to backfire and lead to less happiness. I also helped him come to the realization that he is not able to control his emotional state at will. I asked him to recount the last time he experienced at least a moderate amount of happiness, and whether he was focused on analyzing what was happening and how it was making him feel. He noted that he was not focused on analyzing his level of happiness at all; he was just fully engaged in the experience and even lost a sense of himself to a degree.

I guided Henry through a mindfulness exercise to strengthen his ability to notice his emotional state and related thoughts without getting caught up in them or trying to control them, while also becoming fully absorbed in the experiences around him. Henry then practiced taking this approach to his day-to-day valued experiences. He came up with the saying, “if I’m a 5 (happiness level), I can let myself be a 5.” Henry reported this intervention as being the most important in enhancing his sense of well-being, as he was able to “get out of [his] head” and experience life to the fullest.

CBT has traditionally focused on alleviating symptoms of psychiatric disorders and resolving problems, but it has recently included a greater focus on living a valued life and enhancing well-being. A CBT approach focused on enhancing well-being continues to include goal setting, problem solving, and standard CBT cognitive strategies such as cognitive restructuring and Socratic questioning, as well as behavioral strategies including behavioral activation and exposure exercises. Nonetheless, throughout the course of treatment, patients are encouraged to identify their values, live according to their values, and become fully engaged in valued experiences. Through a greater emphasis on valued experiences, well-being can be enhanced in addition to distress being alleviated.   

 is a licensed clinical psychologist at the Beck Institute for Cognitive Behavior Therapy in Bala Cynwyd, Pennsylvania.

2. Hofmann SG, Asnaani A, Vonk IJ, et al. 

Acceptance and Commitment Therapy, Second Edition: The Process and Practice of Mindful Change

How can a greater emphasis on valued experiences both promote well-being and alleviate stress in patients?

Enhancing Well-Being with CBT

Individuals who receive a serious mental health condition diagnosis such as schizophrenia die on average nearly 3 decades earlier than members of the general population.

 This increased mortality results from medical illnesses (eg, heart disease, kidney disease),

 and the empirically supported psychiatric treatments for schizophrenia (eg, pharmacotherapy, psychosocial rehabilitation, cognitive therapy for psychosis) show little efficacy to reverse it.

 Two of the most prominent social determinants of health and wellness—connection and purpose

—are frequently missing in the lives of individuals who receive a schizophrenia diagnosis. Poor prognosis is also associated with treatment dropout or lack of engagement in treatment.

 or CT-R, is expressly formulated to meet the call for more personally relevant and appealing treatment approaches.

 By focusing on personalized connection, active purpose, and the pursuit of one’s desired life, along with empowerment relative to life’s stressors,

 CT-R aims to promote a high quality of life and transformative wellness.

The CT-R approach includes practical strategies and interventions that comprise recovery-oriented treatment, which has been the mandate for care in the United States since the publication of the President’s New Freedom Commission on Mental Health report.

 As an action-based, whole-person approach, CT-R is applicable across the human age range and fits flexibly into the scope of practice of health professionals and paraprofessionals working in a wide variety of care delivery settings. CT-R has been implemented as an individual and group intervention; it has been the basis of milieu-based programming; it has guided treatment efforts of community-based teams; it has galvanized peer specialist work; and it has produced recovery-oriented care while maintaining safety in forensic contexts.

We developed CT-R in partnership with Aaron Beck, MD. Three of Beck’s main contributions to medicine are hallmarks of the approach: the theory of modes,

 CT-R theory embeds the cognitive model within the theory of modes (

) to create a whole-person understanding of how each individual flourishes (the 

) and how they can get caught up in myriad challenges (the 

CT-R is based on the clinical observation that anyone can quickly change between positively oriented and negatively oriented modes of living.

Providers can locate the adaptive mode by asking what an individual is like 

: When is their affect brighter, their communication clearer, their energy enhanced? What are they doing in these times? Activating the adaptive mode makes positive beliefs—such as the ability to connect, contribute, and be valued—become more accessible, held with greater conviction, and prompt positive expectations for enjoyable, meaningful, or aspiration-driven action.

This positive cognitive triad (self, others, future) of the adaptive mode contrasts with the disconnected mode, which is dominated by greater activation of negative beliefs. In the disconnected mode, the individual may perceive themselves as incapable, disconnected, lacking purpose, or being broken. Consequently, they express negative expectations about the future (eg, “I won’t enjoy doing things” or “I can’t do anything”). They may respond to these beliefs with negative symptoms of withdrawal and isolation or with the reactive behavior of self-injury, aggression, or substance use. It is apparent when individuals are in the disconnected mode based on how they describe themselves, how they respond when presented with opportunities to engage in activities, or how dominant their psychiatric symptoms are, such as unduly attending to auditory hallucinations, expressing persecutory beliefs, or acting aggressively.

At the start of treatment, the disconnected mode is easily activated, and the individual spends a disproportionate amount of time in it. CT-R strategies and interventions aim to make the individual’s best self actively dominate their experience. Guided discovery questions (eg, “what does that say about you?”) turn this positive action into personal meanings that empower the individual to grow and sustain the life of their choosing.

The experiential process begins in finding activities to do together to 

 the adaptive mode. Making these activities occur more often and adding others 

it. Predictable shared activity makes CT-R appealing, enjoyable, and worth continuing. It also produces a meaningful connection and interpersonal trust—important wellness factors. Trust can be leveraged to 

 the adaptive mode, a process by which the individual shares and enriches cherished, long-term life targets. This process inspires hope—another key wellness factor—and leads to activity that 

 the meaning of the individual’s aspirations. In this way, the individual lives their values and experiences purpose every day—further accentuating wellness. Guided discovery can be employed at each of these steps—accessing, energizing, developing, and actualizing the adaptive mode—to help 

 the individual’s best self, cultivating resilience and empowerment to sustain their desired life (

“Gloria” stays in her apartment all day and believes that she is being monitored by her household appliances. Having cut off communication with her family and friends, she relies on a case management team to drop off food and other basic needs at the door. Gloria’s team is trained in CT-R, and they decide to use it to guide their work with her.

. The team begins by asking themselves, “Why might it be that she will not let them in the door?” Team members guess that Gloria believes she has no control over the monitoring, and that she is fearful much of the time. If they are going to connect successfully with her, they will need to give her control and help her feel safe. Because members of the team share culture with Gloria, they hit on the idea of asking her about specific recipes. Initially, a team member goes to her door and asks low-pressure, choice-based questions about which type of seasoning to use (“cumin or cayenne?”). At the next visit, the team member tells her how delicious the dish turned out and draws her attention to how helpful and capable she is, asking for another cooking tip before leaving (“tostones or potatoes?”). Soon team members visit and ask more open-ended questions to learn about new recipes (“Tell me a dish you love that I have to try making”).

Gloria comes to expect the brief and predictable visits, waiting by the door with her next meal recommendation. The visits grow longer and more animated; each time, the team member gives feedback of culinary success and guides her to see how helpful and valued she is. After a few of these conversations, Gloria invites the first team member into her apartment, excited to show them furniture and family pictures. This becomes the new routine for the team: Gloria greets team members warmly and takes them inside; they listen to music from the old country, talk about friends and family, and make a meaningful dish from their culture together.

Gloria’s trust of the team indicates the time might be right to ask about aspirations. “If you weren’t here with me now cooking on a Tuesday at 11 AM, what would you want to be doing?” Taking a moment, Gloria smiles and said she would be teaching her grandchildren about their family history and singing songs with them that her grandparents taught her. In later visits, Gloria expresses a desire to reconnect with old friends and to volunteer at her church. Sensing a pathway to motivation and possibly to Gloria leaving her apartment, a team member asks Gloria for more details: “It sounds like teaching your grandchildren and doing things with them is really important to you. What would the best day with them look like? Paint me a picture—I would love to envision this how you see it!” Gloria describes the songs they would sing and how they could draw out the family tree with lots of vibrant colors.

The team member then asks: “What do you think would be the 

about doing this with your grandchildren?” Gloria initially seems uncertain how to respond. She had not thought about this in a long time, having written it off as impossible. The team member sharpens the question: “I imagine for some people the best part would be feeling productive and active. For others it would be connecting. Or maybe it’s about a value of traditions. Are any of those it for you, or maybe it’s something else?” Gloria enthusiastically responds: “It’s about family. Family is the most important thing you can have! Family and being connected to your people—your history.” “Doing good for others” and “having a place where I belong” are the values that underly reconnecting with friends and volunteering at church.

The positive emotion Gloria expresses when talking about her aspirations and values leads the team to expect that Gloria will want to discuss taking steps to do those things for real. In the next visit to her apartment, one of the team members asks about her aspirations. He checks in to make sure he has it right (what she wants and why). A smile comes to her face; Gloria agrees it is still very important to her. “What are some things anyone would need to do to feel a part of their family? Would this be teaching or doing something related to your shared culture? What do you think that would look like for you?”

They sit together and write down all the possible steps. All along the way, the team member refers to key details of Gloria’s aspiration to maintain the energy and momentum. Together, they create a path that meets Gloria where she is: watching a church service online and possibly setting up a video chat with her children.

At every step along the way, the team helps Gloria notice key meanings in what she is doing. During the early contacts, the team focuses on expanding frequency of activity and number of connections (“I really am enjoying this; how about you? Should we do it again?" “Would you want to do this with other members of the team?”). Over time, the team directs the focus to the success Gloria is having with them (“Wow, you really taught me how to season the dish better than ever; what does that say about you?” “You have to be a pretty good and patient teacher to help me, huh?”) Later, the team homes in on the link between current actions and Gloria’s aspirations (“Every day we get up, log into church services, and make a meal together gets you closer to teaching your grandchildren, volunteering, and connecting with friends—what do you think?”).

An important part of strengthening the adaptive mode is resilience (“I know it was not always easy to feel safe and comfortable letting us come in, and here we are each week cooking more and getting better. I wonder if it’s sometimes worth taking a risk as things might go better than you first think they will?”). Throughout this process, Gloria sees herself as increasingly more capable, valuable, connected, and safe.

Like all empirically supported approaches, the evidence base for CT-R is emerging. Extensive, multimethod literature supports the conceptual model of the negative beliefs of thedisconnected mode for individuals who receive a diagnosis of schizophrenia.

 The positive beliefs of the adaptive mode are just beginning to find support in the literature.

 A randomized-controlled trial featuring blind raters supports the efficacy of CT-R over standard care in the community to improve functional outcomes, reduce avolition-apathy, and lower positive symptoms,

 and gains were maintained over a follow-up period where the therapy was withdrawn.

 In program evaluation studies, CT-R has been associated with reduction in the use of coercive control methods,

 an increase in number of days in the community, an increase in hope, and the achievement of at least 1 Substance Abuse and Mental Health Services Administration (SAMHSA) recovery dimension.

CT-R provides practical strategies and interventions to promote desired lives, reduce mortality, and enhance thriving in the face of life’s often very difficult challenges. It is readily learned and produces observable progress, as illustrated by Gloria’s course of treatment. Collaborative action produces a richer, desired life, empowered for vexing challenges. CT-R closes the distance between individuals who receive serious mental health diagnoses and everyone else.

is director of research, innovation, and practice at the Beck Institute Center for Recovery-Oriented Cognitive Therapy (CT-R). With Aaron T. Beck, MD, he originated CT-R and conducted foundational research to validate it. He is the co-author of 

Schizophrenia: Cognitive Theory, Research, and Therapy.

 is director of clinical training and implementation at Beck Institute Center for Recovery-Oriented Cognitive Therapy. A co-developer of CT-R, she has created transformative CT-R programming for psychiatric inpatient units, programmatic residences, schools, and community teams, with special focus on adolescents and young adults, individuals engaging in extreme forms of self-injury, individuals considering transitions into the community following extended periods of institutionalization, and families. Along with Aaron T. Beck, MD, and colleagues, she is co-author of 

Recovery-Oriented Cognitive Therapy for Serious Mental Health Conditions.

A widening longevity gap between people with schizophrenia and general population: A literature review and call for action

A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? 

American psychiatry in the new millennium: a critical appraisal

 [published online ahead of print, 2021 Jun 23]. 

The Rabbit Effect: Live Longer, Happier, and Healthier With Groundbreaking Science of Kindness

Together: The Healing Power of Human Connection in a Sometimes Lonely World

Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: a review of the literature

Treatment engagement of individuals experiencing mental illness: review and update

 [published correction appears in World Psychiatry. 2016 Jun;15(2):189]. 

9. Cohen AN, Hamilton AB, Saks ER, et al. 

How occupationally high-achieving individuals with a diagnosis of schizophrenia manage their symptoms

The President’s New Freedom Commission: recommendations to transform mental health care in America

The Roots of the Recovery Movement in Psychiatry: Lessons Learned

Recovery-oriented cognitive therapy: a theory-driven, evidence-based transformative practice to promote flourishing for individuals with serious mental health conditions that is applicable across mental health systems

. National Association of State Mental Health Program Directors; 2019.

Advances in cognitive theory and therapy: the generic cognitive model

The theory of modes: applications to schizophrenia and other psychological conditions

Thinking and depression. I. idiosyncratic content and cognitive distortions

In and out of schizophrenia: activation and deactivation of the negative and positive schemas

18. Grant PM, Perivoliotis D, Luther L, et al. 

Rapid improvement in beliefs, mood, and performance following an experimental success experience in an analogue test of recovery-oriented cognitive therapy

19. Grant PM, Best M. It is always sunny in Philadelphia: the adaptive mode and positive beliefs as a new paradigm for understanding recovery and empowerment for individuals with serious mental health challenges. Presented at the International CBT (Cognitive Behavioral Therapy) for Psychosis Annual Meeting; 2019.

20. Grant PM, Huh GA, Perivoliotis D, et al. 

Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia

Six-month follow-up of recovery-oriented cognitive therapy for low-functioning individuals with schizophrenia

22. Chang NA, Grant PM, Luther L, Beck AT. 

Effects of a recovery-oriented cognitive therapy training program on inpatient staff attitudes and incidents of seclusion and restraint

Recovery-oriented cognitive therapy: a promising whole-person approach to improve lives for individuals with serious mental health challenges.

Transformative Wellness

When English journalist and blogger Katie Mills asked me about gardening and its benefits for mental health, she reignited my interest in William Wordsworth. How fitting is that?

Wordsworth was an English-born poet, born in the countryside of Cockermouth. His mother died when he was almost 8 years old, and his father passed away 5 years later. After which, young William was sent to live with relatives.

 The year 2020 marked the 250th anniversary of Wordsworth’s birth. But as we reread his poems and rejoice in his ideas today, he is metaphorically reborn again and again. Some of those ideas are related to his recovery from depression, and other ideas can be considered deterrents of future depression.

Wordsworth’s impact extended far beyond the British Isles and well past the 19th century, for he birthed the romantic movement that spread across continents. He remains one of our most revered poets, with his 24-line “Daffodils” being the most-read poem in the English language.

 between Wordsworth’s poems, depression, and seasonal affective disorder and specifically about the beloved “

,” which opens with the words, “I wandered lonely as a cloud.”

 This implies that his seasonal affective disorder was dissipating—or possibly that a hypomanic state was developing—or that he simply exhibited spontaneous poetic impulses, which are sometimes called the “madness of the muses.”

Although seasonal affective disorder is not at the forefront of our thoughts, given that the darkest days of autumn are behind us, it is worth revisiting other ways that Wordsworth offset unwanted negative thoughts that pop up in almost all of us from time to time, and not only in autumn. Repeating Wordsworth’s words, which are excerpted from Mills’ blog

 and appear below (and on countless placards in Pinterest posts), may offer some solutions.

How have William Wordsworth's ideas about creative visualization influenced cognitive behavioral therapy in contemporary psychiatry?

Cognitive Behavioral Therapy

Safety Planning: An Essential Feature of Cognitive Behavior Therapy for Suicide Prevention

Using Cognitive Behavioral Therapy to Enhance Well-Being

Trauma, Conspiracy, and Cognitive-Behavioral Therapy in the Congressional 1/6 Hearings

Enhancing Well-Being with CBT

Transformative Wellness

Wordsworth, Wildflowers, and a Simple Prelude to Cognitive Behavioral Therapy

Cognitive Behavior Therapy and Medication-Assisted Treatment for Opioid Use Disorder

Cognitive Behavioral Therapy for a Challenging Patient

Weeds, Wildflowers, and Wordsworth

Treatment-Resistant OCD: Strategies and Novel Treatment Options