The effect of online cognitive behavioral therapy program on suicidal thoughts, hopelessness, and cognitive flexibility in people with depression and a history of suicide attempt

INTERVENTION NAME: Online Individual Cognitive Behavioral Therapy (Online CBT) CONTENT AND PROCEDURES: Participants received a total of 20 individual online CBT sessions. Each session followed the standard CBT structure recommended by Beck: mood check, previous session feedback and homework review, agenda setting and addressing agenda items, assignment of new homework, session summary and feedback. SESSION CONTENT: Session 1: Introduction, CBT rationale, problem identification, therapy goal setting Sessions 2-3: Psychoeducation on cognitive model of depression and suicide, suicide action formulation, activity scheduling Sessions 4-7: Behavioral interventions including emotion-behavior-environment relationship, happiness/unhappiness cycles, increasing pleasurable activities, reducing avoidance behaviors, enhancing social support, addressing hopelessness, developing problem-solving skills, reducing impulsivity, creating coping cards Sessions 8-12: Cognitive interventions including identifying and modifying automatic thoughts, creating cognitive formulation schema, recognizing cognitive distortions, evidence examination, double standard technique, separating thoughts from facts Sessions 13-15: Working with intermediate beliefs including identifying and modifying intermediate beliefs, developing alternative thoughts, behavioral experiments Sessions 16-18: Working with core beliefs including identifying core beliefs, framing beliefs, cost-benefit analysis, core belief change interventions Session 19: Relapse prevention planning Session 20: Therapy process evaluation and termination SUICIDE RISK MANAGEMENT: Before therapy initiation, each participant underwent face-to-face assessment including evaluation of suicidal thoughts and attempts, identification of suicide risk and protective factors, and development of a personalized suicide safety plan. The safety plan included warning sign recognition, self-management coping strategies, list of family members and friends to contact, professional contacts and institutions with phone numbers, and means restriction. The plan was signed by both participant and researcher and updated throughout therapy. MATERIALS: Activity schedules, automatic thought records, homework assignments for each session, coping cards, cognitive formulation schemas INTERVENTION PROVIDER: Therapist Qualifications: Sessions were delivered by a doctoral researcher in psychiatric nursing with clinical experience. Clinical Experience: 6 years clinical experience in psychiatry clinics at Gaziantep Dr. Ersin Arslan Training and Research Hospital and Aydin State Hospital, with direct experience working with patients with suicide attempt history. CBT Training: Cognitive and Behavioral Therapy Theoretical Training 50 hours from Cognitive Behavioral Psychotherapy Association October 2019 to May 2020; CBT Skills Training 30 hours from Cognitive Behavioral Psychotherapy Association February to March 2021; Cognitive Behavioral Therapy Practitioner Certification from Izmir Psychology Institute February to March 2021. Academic Training: Completed Behavioral Therapies course during doctoral program. Supervision: Regular monthly supervision provided by Prof. Dr. Hulya Arslantas, thesis advisor, throughout therapy process. DELIVERY MODE: Individual, live synchronous video conference sessions via Aydin Adnan Menderes University Distance Education Center platform. Participants connected from their homes. All sessions were recorded with written and verbal consent obtained. DURATION AND FREQUENCY: 50-minute sessions, twice weekly, 10 weeks total with 20 sessions. Therapy days were scheduled individually for each participant on Monday-Thursday or Wednesday-Saturday. SCHEDULING AND REMINDERS: Appointments were scheduled every Sunday for the following week. Session time and connection link were sent via SMS at 08:00 on the session day. PERSONALIZATION: Therapy content was adapted to each participant's individual characteristics, suicide risk profile, and needs. Homework assignments were tailored to individual goals. ADHERENCE AND FIDELITY ASSESSMENT: All sessions were video recorded, homework was reviewed at each session, all 25 participants completed all 20 sessions with no attrition, and sessions adhered to Beck's standard CBT structure. IMPLEMENTATION DATES: First cohort of 13 participants from August 9 to October 16, 2021. Second cohort of 12 participants from December 6, 2021 to February 12, 2022.