Mental health care for Veterans with suicidal symptoms is of paramount import to the VA. Unfortunately, VA suicide reports show suicide rates increasing, suggesting a need for enhancing current VA suicide mental health care efforts. While several psychotherapeutic treatments exist for acute suicidality, there is a deficit in validated treatments designed to help Veterans following an acute suicidal episode (Post Acute Suicidal Episode; PASE) such as following a non-fatal suicide attempt after acute risk declines but when they still have ongoing mental health needs and, at times, chronic suicidal symptoms. Available suicide treatments are not designed to promote the recovery and rehabilitation of PASE Veterans. This is a significant gap in comprehensive suicide-focused mental health care. One avenue to close this gap lies through the development of a recovery-oriented psychotherapy for PASE Veterans. Developing recovery-oriented care, “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” is a VA priority; however, available treatments for suicidal Veterans have limited recovery-orientation. Decades of research into the development of suicide and processes of recovery highlight the importance of increasing Veterans hopefulness about the future, developing a positive self- identity, promoting Veterans’ sense of self-empowerment and improved relationships. Continuous Identity- Cognitive Therapy (CI-CT) is a promising new manualized suicide intervention focused on improving Veterans sense of their life story and personal future, with goals similar to recovery-oriented care. CI-CT was developed by the applicant and, as a group therapy, piloted for suicide reduction in Veterans with SMI and was found to have high levels of feasibility, acceptability and (in exploratory analyses) to lead to increased hopefulness about the future and decreased suicidal symptoms. However, CI-CT needs further adaptation for use with PASE Veterans and to enhance its alignment with the fundamentals of recovery-oriented care. The proposed study has three primary stages: First: develop an improved recovery-oriented version of the initial CI-CT Clinician Manual and Veteran workbook to further address components identified as critical for PASE recovery using, (1) an ongoing stakeholder study into the needs of PASE Veterans, (2) recovery literature, (3) scientific and Veteran consumer advisory boards and (4) iterative feedback from an online Veteran PASE sample (N=25) on each section of the workbook. This process will be guided by scientific and PASE Veteran Consumer advisory boards Second: use the materials developed in phase 1 to run 3 one-arm treatment development trials (each with an N of 4-6 PASE Veterans) to test and enhance the CI-CT treatment materials using Veteran feedback and acceptability and feasibility data. Then, with the guidance of our scientific and Veteran consumer advisory boards, use these results to update the treatment. Third: conduct a pilot RCT (N=30) comparing CI-CT for PASE Veterans to an AC (health education) to assess feasibility and acceptability of the treatment materials and research protocol including outcome measures selected and assessment strategy. We will assess rates of recruitment, intervention engagement, and session attendance (feasibility), Veteran satisfaction (acceptability), treatment adherence (fidelity) and preliminarily explore response to CI-CT. Findings will be used to make a final adaptation of the treatment materials and to develop a research protocol for a large scale RCT of CI-CT for PASE Veterans. This study will develop and pilot test a well-specified, group-based intervention tailored to the unique needs of PASE Veterans. The results of the proposed study will provide data to 1) identify adaptations needed to optimize CI-CT for PASE Veterans: 2) identify possible benefits of CI-CT; 3) inform development of a large scale RCT of CI-CT for PASE Veterans.

Suicide is a major problem in the Veteran population with 20 Veterans dying by suicide daily. While psychotherapeutic treatments are available for Veterans during the period of acute suicide risk, there are no treatments available specifically designed to promote the recovery of Veterans following a suicidal episode. This is a critical gap in Veteran mental health care and in comprehensive suicide treatment. This study aims to develop and pilot test a recovery oriented intervention for Veterans who have been acutely suicidal in the past year but are no longer at high risk. The treatment aim is to promote the Veteran’s development of a positive self-narrative extending into a vivid and desired future and is designed to closely map onto primary recovery processes such as increased life meaning, hopefulness, empowerment and improved personal identity. This project will result in Veteran specific treatment materials and information about the acceptability and feasibility of this intervention needed for a future large scale intervention trial.