1. New methods of thought-stopping in suicidal behaviour A. Schmidtke Paper presented at the Meeting on Suicide and Suicide Research On the occasion of the opening of the Beijing World Health Organization Coordination Centre 9th of March 2009 Unit for Clinical Psychology, Department of Psychiatry and Psychotherapy, University of Würzburg, Germany NASP Karolinska, Stockholm WHO/EURO Network on Suicide Research and Prevention WHO Research Group of Suicidal Behaviour Würzburg

2. Background Obsessional rumination (compulsive thoughts to kill themself) are often described in depressive and suicidal behaviour.

3. Example: Already in Ringel’s (1953) description of the “presuicidal syndrome” first intentional voluntarily thoughts to commit suicide then compulsive thoughts without intention, coming from the person himself, are described. These thoughts are similar to obsessional rumination. Voluntary thoughts Obsessional thoughts

4. Therefore, it seems plausible to use methods employed in behaviour oriented therapeutic strategies for obsessional rumination (compulsive thoughts) and depressive states. (Schmidtke & Schaller, 2006; 2008)

5. Classification: The methods can be differentiated in 1. Formal methods and 2. Content methods

6. 1.Formal methods One of the oldest formal method is the proposed “worrying time” by Beck. Method: A depressive patient should postpone the depressive thoughts to a later time (e. g. to a certain time in the evening).

7. 1.Formal methods Since this method seemed too difficult for suicidal patients, not able to postpone the thoughts the whole day, a method was developed to reduce the suicidal thoughts and to shape the time of obsessional rumination to a lesser extent and degree.

8. Scheme of a time reduction plan to reduce obsessional rumination Time of day Day k Day k+..... „Allowed time“ Time reserve

9. 2. Content methods Since the content of the classical thought-stopping itself (e. g. according to Rimm, 1973; Rimm & Masters, 1974; Rimm et al., 1975; Johnson et al., 1983) of overt and covert thoughts with a signal (e. g. word – firstly shouted - or a more or less painful stimulus for example a stimulus set by a rubber band) seemed to be too complex and predictable (expectancies influence the stopping; Morein-Zamir et al., 2007), a method of combination of somatic relaxation with imagination techniques (combined at the end with classical condition) was developed.

10. Thought-stopping Take breath and hold one‘s breath Abdominal muscles tense Fists clenching Physiological Relaxation Obsessional thoughts are put in a wool ball Wool ball put in a basket Basket put in a room Door closed Imagination technique Combination of „Lock away„ with physiological relaxation Classical Conditioning Pleasant thoughts: Sunset Relaxation ca 10 sec

11. Study: 3 Groups Classical MethodNew Method Control group (Waiting list) 11210421 8 Sessions 326 psychiatric inpatients 216 patients participated at least in 8 sessions

12. Study: Sample: Mean age: 39 years 44 % Males Diagnoses: Affective disorders50 % Neurotic disorders17 % Personality disorders15 % Schizoaffective disorders 11 %

13. Study: No differences with regard to sociodemographic variables Measurement about effectiveness directly after the group sessions Follow up measurement after 3 months 203 answers No differences with regard to patients answering the follow-up questionnaire or not

14. Study: Instruments: Worry Domains Questionnaire (WDQ, Tallis et al., 1992, Fehm, 1999) Penn State Worry Questionnaire (PSWQ, Meyer et al., 1990, Fehm, 1999) BDI STAI Questions about effectiveness of thought-stopping

15. Results: Thought-Stopping is effective: Participation in the thought-stopping groups reduced significantly the values in the Worry Domains Questionnaire (WDQ) and Penn State Worry Questionnaire (PSWQ) The effect sizes in total were significant The effect was specific: No reduction with regard to the number of psychic problems and anxiety

16. Comparison between thought-stopping and control group Effect size

17. Results: No main differences in the overall effectiveness of the 2 methods of thougth-stopping: The methods are at least equivalent However: More patients of the „new thought-stopping“ report that this method helps to relax more (83 % vs 65 %) The compliance may, therefore, increase.

18. WHO FORSCHUNGSGRUPPE WÜRZBURG Thank you for your attention WHO Research Group Dr. C. Löhr DP J. Volkert DP R. Sell DP I. Linkert