Many types of psychosocial interventions are beneficial for individuals who are experiencing suicidal ideation or behaviors. Psychotherapy is one type of psychosocial intervention that has been shown to reduce suicide risk. It can help people learn new ways of dealing with stressful experiences, recognize patterns of thinking, and identify alternative actions when thoughts of suicide arise.
Psychotherapy usually takes place in a one-on-one or group format and can vary in duration from several weeks to ongoing therapy, as needed. Treatment that employs collaborative and integrated care can engage and motivate patients, increasing retention in therapy and decreasing suicide risk (Stone et al., 2017). Other psychosocial interventions are described in the following case.
The Importance of Therapy: Terry
On the morning of December 25, 2000, Terry Wise tried to kill herself by taking an overdose of Tylenol. She awoke two days later in the intensive care unit.
Assessment in the ICU
In the ICU, Terry received an evaluation from a social worker. Terry reported that the death of her husband from Lou Gehrig’s disease was a trigger for her suicide attempt. She said she felt lost, didn’t know what to do, and found no joy in living.
During this initial assessment, Terry admitted that her attempt was the culmination of years of depression and other problems that started in her childhood. She said she was overwhelmed by an intense emotional pain that had been building for years, and when her husband died the pain became unbearable.
Certain groups have higher suicide attempt or completion rates than the general population. Terry has likely been living with clinical depression most of her adult life. Along with this suicide attempt, the death of her husband and her stated history of depression, Terry was at increased risk for self-harm.
What Actions Should You Take?
A previous suicide attempt is known to be a strong predictor of future attempts and deaths by suicide.
Correct answer: d
Mental Health Services
Terry agreed to start therapy, and ultimately it changed her life. By working with a counselor, Terry realized that the trauma she experienced when she was younger still affected her emotions as an adult. Her counselor helped her find ways to cope with her feelings.
Therapy also allowed her to see how others would have reacted to her death by suicide. Most important, Terry’s therapist trusted and respected her, and for Terry, her therapist’s compassion made a huge difference.
It is important that Terry’s intervention and treatment be direct and specific to address potential risk factors. Effective management of mental health conditions (particularly major depression) can reduce the risk of suicide and may decrease suicide rates.
Terry’s recovery was a process. It took time and hard work. She recalls: “And that is really the first step, to go from feeling that life is an endurance test to being able to tolerate being alive. And then you hope that the unendurable becomes bearable. Then you hope the bearable becomes manageable. Then you hope the manageable becomes pleasurable. And so, it’s a process. It evolved over time.”
Source: Adapted from the National Suicide Prevention Lifeline
Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP)
Cognitive Behavior Therapy for Suicide Prevention (CBT-SP) is aimed at preventing suicide re-attempts. It uses a “risk-reduction, relapse prevention” approach, which includes an analysis of risk factors and stressors leading up to and following the suicide attempt. This approach also includes development of a safety plan, skill building, and education. CBT-SP supports families, focusing on communication patterns as well as on improving the family’s problem-solving skills (Stone et al., 2017).
The early phase of treatment focuses on treatment engagement, risk assessment, and crisis management. During the intermediate phase, behavioral strategies are implemented to help the patient develop cognitive, behavioral, and affective copings skills. This can include relaxation training, activity monitoring, and increasing social resources. Cognitive strategies modify unhelpful beliefs associated with the risk of triggering a suicidal crisis (USU, Nd).
The final phase includes relapse prevention exercises that consolidate skills learned during therapy. These exercises use guided imagery, in which the patient is directed to implement skills learned during therapy. Once the patient is able to generalize these skills, a debriefing and summary is completed. At this time, the provider conducts a risk assessment and offers additional treatment session or referrals as indicated (USU, Nd).
Dialectical Behavioral Therapy (DBT)
Dialectical Behavioral Therapy (DBT) is for individuals at high risk for suicide and who may struggle with impulsivity and emotional regulation issues. DBT includes individual therapy, group skills training, between-session telephone coaching, and a therapist consultation team (Stone et al., 2017).
DBT has also been shown to reduce the rate of suicide among people with borderline personality disorder, a mental illness characterized by unstable moods, relationships, self-image, and behavior. A therapist trained in DBT can help a person recognize when his or her feelings or actions are disruptive or unhealthy, and teach the skills needed to deal better with upsetting situations.
Improving Mood—Promoting Access to Collaborative Treatment (IMPACT)
The Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) program aims to prevent suicide among older primary care patients by reducing suicide ideation and depression. IMPACT facilitates the development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, as well as proactive followup (biweekly during an acute phase and monthly during continuation phase) by a depression care manager. The program has been shown to significantly improve quality of life, and to reduce functional impairment, depression, and suicidal ideation over 24 months of followup relative to patients who received care as usual (Stone et al., 2017).
Collaborative Assessment and Management of Suicidality (CAMS)
Collaborative Assessment and Management of Suicidality (CAMS) is a flexible therapeutic approach for suicide-specific assessment and treatment. The program involves the clinician and patient working together to develop a patient-specific treatment plan. Sessions involve constant patient input about what is (and is not) working with the goal of enhancing the therapeutic alliance and increasing treatment motivation (Stone et al., 2017).
CAMS has been tested and supported in six correlational studies, in a variety of inpatient and outpatient settings. A feasibility trial with a community-based sample of suicidal outpatients randomly assigned to CAMS or enhanced care as usual (intake with a psychiatrist or psychiatric nurse practitioner followed by 1 to 11 visits with a case manager and medication as needed) found better treatment retention among the CAMS group and significant improvements in suicidal ideation, overall symptom distress, and feelings of hopelessness at the 12-month followup (Stone et al., 2017).
Attachment-Based Family Therapy (ABFT)
Attachment-Based Family Therapy (ABFT) is a program for adolescents aged 12 to 18 designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce anxiety. In one study, suicidal adolescents receiving ABFT experienced significantly greater improvement in suicidal ideation over 24 weeks of followup than did adolescents assigned to enhanced usual care. Additionally, a significantly higher percentage of ABFT participants reported no suicidal ideation in the week prior to assessment at 12 weeks and again at 24 weeks than did adolescents receiving enhanced usual care (Stone et al., 2017).
Gatekeeper training—also called “recognition and referral training”—helps people without formal psychosocial training play a critical role in suicide prevention. It teaches educators, coaches, clergy, emergency responders, primary and urgent care providers, and others in the community to identify people who may be at risk of suicide (WSDOH, 2016).
Gatekeeper training provides information on how to respond, including encouraging the at-risk person to seek treatment and support services. Research shows that many at-risk people turn to family or friends for help. They often show warning signs that family and friends may notice first. An at-risk person benefits from an informed support network ready to connect them to the right help (WSDOH, 2016).
A Note on Language
Training on recognizing a person at risk and connecting them to an appropriate resource is often called gatekeeper training. In some communities, the word gatekeeper is a reminder of people and systems that create barriers to getting help. Instead, the Washington State Department of Health recommends the term Recognition and Referral (R&R) training.
Source: WSDOH, 2016.
The Applied Suicide Intervention Skills Training (ASIST) program helps hotline counselors, emergency workers, and other gatekeepers identify and connect with suicidal individuals and direct them to available resources. Researchers have found that callers who spoke with ASIST-trained counselors were significantly more likely to feel less depressed, less suicidal, less overwhelmed, and more hopeful by the end of their call, compared to callers who spoke to non-ASIST trained counselors. Counselors trained in ASIST were also more skilled at keeping callers on the phone longer and establishing a connection with them (Stone et al., 2017).
Gatekeeper training has been a primary component of the Garret Lee Smith (GLS) Suicide Prevention Program, which has been implemented in 50 states and 50 tribes. A multi-site evaluation assessed the impact of community gatekeeper training on suicide attempts and deaths by comparing the change in suicide rates and nonfatal suicidal behavior among young people aged 10 to 24 in counties implementing GLS trainings. This was compared to similar counties that did not implement these trainings (Stone et al., 2017).
Counties that implemented GLS trainings had significantly lower youth suicide rates one year following the training implementation. Counties implementing GLS program activities also had significantly lower suicide attempt rates among youth ages 16 to 23 in the year following implementation of the GLS program than did similar counties that did not implement GLS activities. More than 79,000 suicide attempts may have been prevented during the period examined (Stone et al., 2017).
988 Crisis Line
Crisis intervention programs provide support and referral services, typically by directing a person in crisis (or a friend or family member of someone at risk) to trained volunteers or professional staff via telephone hotline, online chat, text messaging, or in person. The National Suicide Prevention Lifeline (now known as the 988 Suicide & Crisis Lifeline) and is now active across the United States.
The 988 Suicide & Crisis Lifeline is made up of an expansive network of over 200 local and state funded crisis centers located across the United States. The counselors at these local crisis centers answer calls and chats from people in distress every day. The Lifeline’s crisis centers provide the specialized care of a local community with the support of a national network.
Source: SAMHSA, 2022.
In an evaluation of the effectiveness of the National Suicide Prevention Lifeline to prevent suicide, more than 1,000 suicidal individuals who called the hotline completed a standard risk assessment for suicide. Researchers found that over half of the initial sample had a plan for their suicide when they called (Stone et al., 2017).
Among 380 followup participants, there was a significant decrease in psychological pain, hopelessness, and intent to die between initiation of the call (time 1) to followup (time 3). Between time 2 (end of the call) to time 3, the effect remained for psychological pain and hopelessness, but was not significant for intent to die, suggesting that greater effort at outreach during and following the call is needed for callers with high levels of suicide intent (Stone et al., 2017).