Validation of Cognitive-based Mindfulness Program to Reduce Suicidal Ideation in Individuals with Depression

Suicide is a global epidemic phenomenon that is the third most common cause of death in the world. However, not many studies have focused on developing an intervention that specifically targets symptoms of suicidal ideation. Suicidal ideation is seen as part of a depressed condition. The purpose of this study was to validate a cognitive-based mindfulness program to reduce suicidal ideation in people with depression. The study was conducted through internal validity tests using expert judgment and external validity tests using the small-n AB design method, which involved three participants (n = 3). The visual inspection analysis was performed on the mean, trend, and level. Analysis of repeated measurements showed a decrease in suicidal ideation in all participants. This program has the potential to be developed as a companion to conventional interventions and can be an alternate activity to fill the waiting time for individuals to get the main intervention.

coping strategies (Alavi et al., 2013); dialectical behavior therapy (DBT), which provides psychoeducation and develop social skills involving family (Mehlum et al., 2014). There is an attention-based family therapy, which is an intervention that focuses on strengthening the relationship between a child and parents when suicidal ideation occurs (Diamond et al., 2010). Lastly, there is also mindfulness-based stress reduction (MBSR) which trains an individual to lead a mindful life by focusing on the now and accepting thoughts without judgment (Serpa et al. 2014).
The forms of interventions that involve other people like family members are great because they consider social support. However, in certain situations, the presence of others is not easily obtained. It is true, particularly among people who live far from their family or have limited social circles. Thus, the approach that suits such conditions is the combination of the cognitive approach and mindfulness. The cognitive approach is useful to develop an understanding of thought mechanisms. Meanwhile, mindfulness is utilized to provide individual training so that the person can live mindfully and experience thoughts non- judgmentally.
An intervention that combines a cognitive approach and mindfulness is mindfulnessbased cognitive therapy (MBCT). MBCT is shortly a combination of cognitive elements and mindfulness meditation exercises. Kabat-Zinn (1994) described mindfulness as a set of steps to centralize attention on each moment without judgment. The cognitive element of MBCT consists of education about the symptoms, the role of negative thoughts, and strategies to overcome maladaptive thoughts.
The aim of this study was to validate a cognitive-based mindfulness program to reduce suicidal ideation in individuals with depression. The program was expected to be able to reduce suicidal ideation through a cognitive approach and meditation exercises. The program's validity needs to undergo a series of internal and external validity tests (Azwar, 2018). Internal validity is done to see the program's suitability with the objective of the intervention. Meanwhile, external validity is necessary to see the change in an individual before and after given the intervention (Azwar, 2018). The hypothesis proposed in this study was that a cognitive-based mindfulness program can reduce suicidal ideation in individuals with depression.

Procedure
The study underwent two main procedures, namely internal validity and external validity.
Internal validity was done through expert judgment by 7 experts with psychology backgrounds (licensed psychologists and lecturers). The experts were asked to give scores ranging from 1 to 5 for the following aspects: a) the activity design for each session, b) the compatibility between activities and intervention's objective, c) the allocated time, d) the tasks given to participants, e) suitability to ethical code and f) the module's presentation.
The scoring results from experts were then analyzed using Aiken's V method.
The external validity of the study was done using a single-case, small-n experiment model with AB design. Participants in this study were three people. The participants went through three phases: a) baseline phase (A), b) intervention phase, and c) follow-up phase.
In each phase, the participants were observed and measured repeatedly. A single case design puts more focus onto each individual, thus from the detailed observation, the outcome will be more specific. The distinctive features of single-case design make it very usable in studies within clinical settings and it plays an important role in the history of psychotherapy development (Kazdin, 1982).
The program was developed according to the principles of experiential learning. Kolb and Kolb (2005) explained that experiential learning involves using direct experience in the learning process and feedback mechanism given to participants after practicing the materials. The principles were applied by having sharing and feedback session after every mindfulness meditation training session. Additionally, the experiential learning principle implemented is that learning is a holistic adaptation process in which elements cannot be separated. Thus, it is not only a result of the cognitive process, but also the integration of all individual functions namely cognition, behavior, and emotion. The principle is applied by developing a program that incorporates cognitive function through psychoeducation, behavioral function through exercise activities, and emotional function through sharing feelings. The program's components were derived from Mindfulness-based Cognitive Therapy (Teasdale et al., 2014) as shown in Table 1. Table 1. Providing understanding about automatic pilot mode that can cause thoughts to not be evaluated well The components of MBCT by Teasdale et al. (2014) were compiled for people with depression. Therefore, to develop an intervention program that specifically targets the reduction of suicidal ideation, some components should be modified. Rudd (2012) described that several effective therapies to reduce suicidal ideation share common characteristics: a) focusing specifically on suicidal ideation and not only the effect of the symptom, b) using a clear theoretical framework, 3) focusing on teaching skills, d) providing access to information during a critical period, e) emphasizing on individual's responsibility, and 6) participant's adherence towards the process of therapy.

Components of MBCT Program
Based on that finding, the researchers arranged a cognitive-based mindfulness program by adding the components of cognitive therapy for suicidal patients (Wenzel et al., 2009). Table 2 describes the components of the therapy. Making Hope Kit Activities for relapse prevention by compiling valuable items and summary of therapy process.
Those components were then combined into a program according to the module development principle by Russell and Johanningsmeier (1981). The program starts with an initial assessment to see the participants' characteristics, the instruction is designed according to the principle of concrete instruction to the more abstract one, then the design of partial activities towards integrated activities.

Study design
External validation implemented in the present study used a single-case, small-N experiment model with AB design which involved three participants. The participants underwent three phases: a) baseline phase (three days before the intervention), b) intervention phase (for four days), and follow up (seven days after intervention). For each phase, the participants were observed and measured repeatedly. The analysis was done using visual inspection. The components examined by visual inspection are the change in the mean score, level, and trend (Lobo et al., 2017;Sunanto et al., 2005). The change of components was observed in each phase done by participants then compared with their own data (Lobo et al., 2017).

Internal validity
Based on an assessment by seven experts, the lowest Aiken's V coefficient obtained was 0.71 and the highest was 1.00. The average Aiken's V score for activities in the module was 0.84, the average score for module's tasks was 0.83, and the overall score for the module was 0.80.
The detailed Aiken's V scores can be seen in table 3 to table 5. The text is neat and easy to read 0.82

Suicidal ideation
According to the SIDAS assessment conducted in the baseline phase, MR showed a score stability rate between 80% and 90% from the data (Sunanto et al., 2005),   During the intervention phase, it can be seen that the trend line (the intermittent line) comes down. It shows that suicidal ideation was reduced during the intervention phase. In addition to a change of trend, there were also changes of level and mean score in MR.
During the baseline phase, MR showed an increase of SIDAS score up to 3 points, while during the intervention there was a reduction of 22 points. The change of SIDAS mean score also happened in measurements conducted between baseline and intervention phases. In the baseline phase, the SIDAS mean score was 39.66 and after entering the intervention phase the mean score changed to 34. After that, during the follow-up phase for seven days, the mean score was down to 25.571.

Emotion monitoring
Emotion monitoring was performed to provide additional data. The monitoring was conducted on the intensity of disappointment, feeling of failure, hopelessness, loneliness, and sadness. Monitoring as an additional data collection method was only done during the intervention and follow-up phases. When the intervention was given, there were reductions of all emotional aspects. Meanwhile, during the follow-up phase, the emotional aspects saw an increase. It implies that negative emotions only arose during the first four days of intervention, while after it ended, the trend of emotional change tended to go up ( Figure 2).

Manipulation check
Based on the score comparison of manipulation checks using KIMS prior and after the intervention, MR experienced a 3-point reduction in KIMS score, from 28 to 25. According to inter-rater observation with three observers, MR showed an average score of 3.5 out of 4. It means that MR had participated in the mindfulness training well, namely: following the facilitator's instructions, doing proper meditation postures, and showing a relaxed body.

Suicidal ideation
During the baseline phase, MT showed 66% score stability with a range of scores between   1-25 = -24 (Improved) In the visual inspection, changes in level and mean scores were also visible. During the baseline phase, MT showed an increase in SIDAS score up to 8 points. Meanwhile, during the intervention, there was a 16-point decrease in the score. The shift of mean score also occurred during measurements performed between baseline and intervention phases.
During the baseline, the SIDAS mean score was 30.66 but when entering the intervention phase the score became 14.5. Monitoring during the follow-up phase showed a depleting trend line and the mean score change became 2.42. It implies that the effect of intervention could last for seven days after the intervention.

Emotion monitoring
Monitoring was performed on the intensity of disappointment, feeling of failure,  and showed a relaxed body. In addition, during the intervention phase, MT could participate in the discussion well. She was able to tell her experiences and write tasks given by the facilitator.

Suicidal ideation
In the baseline phase, KJ showed a score stability, with the stability criterion between 80% and 90% of the data. It means that all scores were within the range of 19.494-23.826. Visual inspection on the trend lines showed decreases in the intervention and follow-up phases.
This indicates that there was a decrease in suicidal ideation in KJ during the two phases.
Further information can be seen figure 5 and table 8.

Emotion monitoring
Researchers conducted monitoring on the intensity of disappointment, feeling of failure, hopelessness, loneliness, and sadness during the intervention and follow-up phases. In the intervention phase, there was a trend of decrease in all aspects of emotion. The result can beseen in figure 6. could discuss the session's materials, tell their story, and finish tasks.

Discussion
The study aimed to validate a cognitive-based mindfulness program in its effort to reduce suicidal ideation. Based on internal validity in the form of assessment by seven experts, Aiken's V scores which ranged from 0.71 to 1.00 were obtained. Thus, the program is concluded to have adequately validated activity components. The program components were arranged accordingly; starting from concrete activities like education about thought mechanisms to more abstract activities such as practicing mindfulness. The principle of module development starting from concrete concept to abstract concept makes it easier for someone to learn the materials and increase competence (Russell & Johanningsmeier, 1981).
Based on the repeated measures using SIDAS, it was found that the decrease of suicidal ideation happened after the second meeting. The decrease happened in the three participants and could be seen in the mean score, level, and trend line. Evaluations from the participants revealed that they were capable not to get caught up in the arising thoughts.
Participants could develop the here-and-now ability to anchor them from getting swept up by negative thoughts that led to suicide intention. The decrease in suicidal ideation lasted for seven days after the intervention. The finding is aligned with a study conducted by Barnhofer et al. (2015) which found an individual who received mindfulness intervention can see reduced suicidal ideation compared to individuals who receive a conventional intervention. Someone with suicidal ideation has re-occurring thoughts and mindfulness skills could equip the person with an ability to see thoughts without judgment (decentering) and here-and-now.
At the beginning of the intervention, there was a sharing session in a group setting so participants could share their backgrounds and problems. The sharing session, which facilitated participants to do self-disclosure at the beginning after baseline, did not immediately reduce the severity of suicidal ideation. It was evident in the SIDAS score that started to decrease in the second session. This occurred because, during the sharing session, participants started to validate their problems and become more open to the repressed issues. An individual with suicidal ideation tends to have a low self-disclosure tendency about the ideation (Horesh & Apter, 2006). The person chooses to remain silent to avoid stigma, protect privacy, maintain well-being, and avoid intervention from other people who they cannot trust yet (Hom et al., 2017). However, by avoiding the self-disclosure process, they might feel even lonelier.
The mindfulness skills taught in this program were strengthened by psychoeducation about the mechanism of thought processing, thus participants could have a more rational understanding that thought is not a fact or truth. An individual with suicidal ideation tends to have a dichotomic and rigid mindset as well as negative self-evaluation (Luoma & Villate, 2012). The person will develop suicidal ideation through the mediating process of entrapment when faced with life problems (Li et al., 2018;O'Connor & Kirtley, 2018;Shelef et al., 2016). The sense of being entrapped arises when the person does not have alternative ways to get out. Mindfulness skills provide alternative methods to deal with life problems, such as observing the occurring thought, so that an individual can distinguish between helpful and disturbing thoughts.
The novelty of the present study is the development of an intervention program that focuses on suicidal ideation, thus not only viewing suicidal ideation as a part of depression.
Different from previous studies, the present study modified the MBCT program by adding a cognitive approach that focuses on suicidal ideation. Therefore, participants received specifically tailored methods to deal with the ideation, such as hope kit and safety planning.
The strength of the present study is repeated measures in each participant, thus providing more data on the dynamic of suicidal ideation and participants' emotional condition every single day. In addition, the study performed data triangulation by interrater observers to provide more objective data. This study was conducted for four days without break, thus minimizing the threat of confounding variables between interventions.
The study has several limitations. First, the single-case research model cannot immediately be generalized therefore there is a series of steps to replicate the study. The brief duration of the intervention phase did not only benefit the study but also became its limitation as participants might not have enough time to process the information given. It could also potentially incite fatigue in participants.

Conclusion
The finding showed that the cognitive-based mindfulness program was proven to reduce suicidal ideation in an individual with depression. It is visible from the changes in level, trend, and mean score between the baseline and intervention phases. In addition, the decrease in suicidal ideation could last for seven days after the intervention. Thus, a cognitive-based mindfulness program was substantially and empirically valid in reducing suicidal ideation individually.

Suggestion
The program has the potential to be developed as an accompaniment to conventional intervention and can be an alternative activity to fill the time while a client is waiting for the main intervention.