Evidence for affective reorganization following two suicide-focused interventions delivered during massed cognitive processing therapy for PTSD.

BACKGROUND: Crisis response planning (CRP) reduces suicide attempts and suicidal ideation among high-risk patients, yet little is known about how it alters the processes through which suicidal ideation emerges and resolves. This study examined dynamic interactions among positive affect (PA), negative affect (NA), and suicidal ideation (SI) in treatment-seeking U.S. military personnel and veterans with posttraumatic stress disorder (PTSD) who received CRP or safety planning prior to PTSD treatment. METHODS: This secondary analysis used ecological momentary assessment (EMA) data from a randomized clinical trial comparing CRP and safety planning (SP) delivered alongside massed cognitive processing therapy for PTSD (N = 116). Participants completed four EMA surveys per day for 14 days assessing PA, NA, and SI. Differential equation modeling was used to estimate temporal stability and cross-variable coupling, followed by eigenvalue and eigenvector decomposition to characterize system organization and patterns of change. RESULTS: Across interventions, PA, NA, and SI exhibited negative autocorrelation effects indicating temporal stability; however, SI showed weak self-regulation, suggesting greater persistence once elevated. Coupling patterns differed by intervention. In SP, NA was directly coupled with SI, indicating distress readily translated into suicidal thinking. In contrast, CRP showed coupling between NA and PA rather than SI, suggesting distress was regulated before activating suicidal ideation. Follow-up analyses further indicated that CRP strengthened affective regulation and integrated SI with affective processes. CONCLUSIONS: Although both interventions produced stable cognitive-affective systems, CRP uniquely altered the relationships among affect and suicidal ideation, promoting regulatory feedback loops that may reduce vulnerability to acute suicidal risk.