Evidence-Based Psychotherapies for

Suicide Prevention
Future Directions
Gregory K. Brown, PhD, Shari Jager-Hyman, PhD

Psychotherapeutic interventions targeting suicidal thoughts and behaviors are essential for reducing
suicide attempts and deaths by suicide. To determine whether specific psychotherapies are
efficacious in preventing suicide and suicide-related behaviors, it is necessary to rigorously evaluate
therapies using RCTs. To date, a number of RCTs have demonstrated efficacy for several
interventions focused on preventing suicide attempts and reducing suicidal ideation. Although
these studies have contributed greatly to the understanding of treatment for suicidal thoughts and
behaviors, the extant literature is hampered by a number of gaps and methodologic limitations.
Thus, further research employing increased methodologic rigor is needed to improve psychother-
apeutic suicide prevention efforts. The aims of this paper are to briefly review the state of the science
for psychotherapeutic interventions for suicide prevention, discuss gaps and methodologic
limitations of the extant literature, and suggest next steps for improving future studies.
(Am J Prev Med 2014;47(3S2):S186–S194) & 2014 American Journal of Preventive Medicine

Introduction State of the Science of Evidence-Based

T
he development and implementation of effective Treatments for Suicide Prevention
interventions are imperative for reducing rates of
Several RCTs2–5 have demonstrated promising results in
suicide and related behaviors. In response to the
reducing suicide attempts and self-directed violence. A
ongoing need for effective treatments aimed at prevent-
comprehensive review of the literature is beyond the
ing suicide and self-directed violence, the National
scope of this paper; however, reviews2–5 were used to
Action Alliance for Suicide Prevention’s (Action Alli-
identify studies to include in this brief review. A selection
ance) Research Prioritization Task Force (RPTF)1 has
of studies yielding positive effects will be highlighted and
proposed the following Aspirational Goal focused on
presented in Table 1. Briefly, cognitive therapy for suicide
psychotherapeutic interventions: “…develop widely
prevention (CT-SP)6; cognitive–behavioral therapy
available, more effective and efficient psychosocial inter-
(CBT)7; dialectical behavior therapy (DBT)8; problem-
ventions targeted at individuals, families, and community
solving therapy (PST)9; mentalization-based treatment
levels.”
(MBT)10; and psychodynamic interpersonal therapy
The current paper has three main aims in discussing
(PIT)11 have all evidenced positive effects for preventing
this Aspirational Goal. First, with a focus on RCTs, the
suicide attempts or self-directed violence in adults.
state of the science for evidence-based psychotherapy
More specifically, recent suicide attempters who
interventions for suicidal ideation and behavior is
received CT-SP were 50% less likely to reattempt than
reviewed. Second, limitations of the current research
participants who received enhanced usual care (EUC)
and suggestions for future research are discussed. Finally,
with tracking and referrals.6 CBT plus treatment as usual
a step-by-step pathway for evaluating psychotherapy
(TAU) also reduced self-harming behaviors relative to
interventions for suicide prevention is proposed.
TAU alone.7 For individuals with borderline personality
disorder (BPD), DBT demonstrated a greater reduction in
suicide attempts relative to community treatment by
experts.8 However, DBT was not statistically more effec-
From the Perelman School of Medicine of the University of Pennsylvania,
Philadelphia, Pennsylvania tive than a manualized general psychiatric management
Address correspondence to: Gregory K. Brown, PhD, Department of condition, consisting of case management, dynamically
Psychiatry, University of Pennsylvania, 3535 Market Street, Room 2032, informed psychotherapy, and medication management.12
Philadelphia PA 19104-3309. E-mail: gregbrow@mail.med.upenn.edu.
0749-3797/$36.00 Also focused on BPD, MBT, a psychoanalytically
http://dx.doi.org/10.1016/j.amepre.2014.06.008 oriented partial hospitalization program, was more

S186 Am J Prev Med 2014;47(3S2):S186–S194 & 2014 American Journal of Preventive Medicine
Published by Elsevier Inc.
76

Reducing the Risk of Suicide in Patients With Bipolar Disorder:

Interventions and Safeguards
Cory F. Newman, University of Pennsylvania

Bipolar disorder exacts a terrible toll on its sufferers owing to the repeated, severe disruptions in the patients’ lives, the discomfort and
uncertainties of being on rigorous, ongoing pharmacotherapy regimens, the emotional difficulties inherent in experiencing depression
and mania, and the fear of a deteriorating course. Patients with bipolar disorder can become quite hopeless about improving their lot,
a state of mind that is related to suicide risk. Indeed, the conservative lifetime suicide rate for bipolar sufferers is 15%, thus making
the risk of self-harm a typical part of the therapeutic agenda with this population. Therapists assess the patients’ risk for suicide via
structured interviews, self-report inventories, and an exploration of their “suicidogenic beliefs.” Treatment counteracts the potential
threat of suicide on a number of fronts, including: (a) establishing a collaborative, respectful therapeutic relationship in which the
therapist strives to understand the patient’s despair and provide accurate empathy; (b) devising antisuicide plans of action, including
contracts; (c) teaching a wide range of skills, including rational responding, problem solving, communication, moderating activities
to experience an optimal amount of mastery and pleasure, objectively assessing the pros and cons of living and dying, and others; (d)
maximizing the patient’s social support network, including improving family relationships, interacting more effectively with friends
and associates, and joining self-help, advocacy groups; and (e) fighting the stigma of bipolar disorder via the acceptance of limita-
tions, while still striving to live life to the fullest through treatment, an optimistic attitude, with long-range, meaningful goals.

T HERE ARE EASIER things in life than dealing with bi-

polar disorder. Persons with bipolar disorder face a
lifelong vulnerability to cyclical episodes of mood disor-
problems that bipolar patients incur (Bowden, 1999). Ad-
ditionally, Goodwin and Jamison (1990) reviewed 15 studies
and determined that the prevalence of suicide attempts
der, necessitating ongoing treatment and often involving in bipolar patients was as high as 50%, a figure that far
medications that can be difficult to tolerate. The symp- surpasses the rate for most other psychiatric populations
toms of bipolar disorder—from crushing depressions on (Lam, Jones, Hayward, & Bright, 1999). Thus, patients
one end of the spectrum to impulsive, reckless highs that with bipolar disorder comprise a population that is very
characterize the manic end of the spectrum—often wreak much at risk for suicide, requiring a high level of vigilance
havoc on people’s lives. Bipolar patients commonly have and competence in therapists who treat this disorder.
to reconstruct their lives after periods of depressive with- Therapists of bipolar patients will need to assess for
drawal or manic highs have led to their incurring major suicidality throughout treatment, and will need to be pre-
consequences, such as loss of academic and/or voca- pared to intervene promptly and effectively during sui-
tional standing, financial depletion, relationship rifts, and cidal crises. Therapists have to walk a fine line between
the like. When this scenario repeats itself again and validating the pain and suffering experienced by their
again, many bipolar sufferers begin to feel hopeless about patients and maintaining an unfailing determination to
their prospects for a meaningful life. Unfortunately, hope- help their patients overcome their difficulties to build a
lessness is a factor that is associated with heightened risk better, more stable, more fulfilling life. This is a dialectic
for suicide (Beck, Brown, Berchick, Stewart, & Steer, that is so commonly encountered in the treatment of
1990; Beck, Steer, Beck, & Newman, 1993; Young et al., high-risk populations (cf. Linehan, 1993). Inherent in
1996). Indeed, conservative estimates place the lifetime navigating this delicate balance is the necessity for thera-
risk of suicide for bipolar patients at 15%, a figure that pists to develop a case conceptualization for each patient
takes into account both those who receive treatment and that demonstrates an appreciation for the unique factors
those who do not (Simpson & Jamison, 1999). In fact, the of each person’s development, personal history, and cur-
impact of bipolar disorder on premature death may be rent life situation. This approach helps therapists and
even higher when one considers the increased number of patients alike to recognize patients’ harmful beliefs or
auto accidents and higher incidence of serious medical schemas (e.g., “I am incompetent in dealing with life’s
problems,” “I am unlovable,” etc.), as well as additional
vulnerability factors (e.g., a chaotic family life; the loss of
Cognitive and Behavioral Practice 12, 76–88, 2005
1077-7229/05/76–88$1.00/0 a relative through suicide; the loss of an academic degree
Copyright © 2005 by Association for Advancement of Behavior due to withdrawing from a program; etc.). Further, devel-
Therapy. All rights of reproduction in any form reserved. oping a case conceptualization shows respect for each
 Interventions for Suicidality 77

patient’s individuality, in that it works against the spuri- need to be modified. As long as the patient is alive, there
ous grouping of patients into a homogeneous mass simply is reason to believe that there is hope for an improved
by virtue of their sharing a similar psychiatric condition. quality of life (and a brighter future) through treatment.
Thus, it may be argued that case conceptualizations—
especially those that chronicle the patients’ personal
Assessing for Suicidal Risk
strengths—help fight the harmful specter of stigma.
The dialectic between empathic understanding and The alert clinician can assess a patient’s level of risk
striving for therapeutic change also requires that thera- for suicide at any time via convenient, straightforward
pists teach their bipolar patients a wide range of psycho- means. As will be described below, the therapist can ask
logical skills—such as learning more effective communi- patients directly about their thoughts about life and death.
cation skills, impulse control, self-instruction, problem This can be done in session (at intake, and perhaps rou-
solving, reflecting on (and moderating) their extreme tinely across sessions), as well as between sessions when
thoughts, negotiating proper interpersonal boundaries, patients telephone their therapist in crisis. Additionally,
and others—so patients can improve their self-efficacy, patients can be asked to complete self-report inventories
life situation, and sense of hope for the future. When pa- that tap into their moods in general, and their thoughts
tients learn skills to cope with their symptoms, to come to and intentions about suicide in particular. At the same
terms with painful past experiences, and to make posi- time, clinicians can gain extremely useful information
tive changes that improve their lot, the risk of suicide is by assessing patients’ maladaptive beliefs about suicide
decreased. and misconceptions about medications, which (if left un-
Nevertheless, therapists must always bear in mind that checked) can heighten hopelessness and concomitant
the subjective pain brought about by the affective symp- risk for self-harm.
toms of the disorder itself can be enough to make even a
socially skilled, academically and vocationally successful Interviewing and Self-Report
person who is loved by family and friends still want to die. It is appropriate to ask bipolar patients about their at-
In other words, even people who seem to “have it all” can titudes toward life and death on a regular basis. Thera-
and do kill themselves as a result of their struggle with bi- pists can prepare their patients to expect such question-
polar disorder. This is illustrated well by the works of ing as a part of good, clinical care in treating an illness as
Jamison (1993, 1995, 1999). In Touched with Fire: Manic- serious as bipolar disorder. Most fundamentally, thera-
Depressive Illness and the Artistic Temperament (1993), Jami- pists must not shy away from the topic of suicide out of
son describes the emotional problems endured by some exaggerated concern for alarming the patients. Instead,
of the most creative and accomplished persons in the therapists can realize that most patients will appreciate a
Western world in recent centuries. She hypothesizes that sensitive, empathic acknowledgment that they may be en-
many of these persons suffered from bipolar disorder, tertaining thoughts of suicide, at times more acutely than
and describes how the absence of viable treatments often others.
led to a deteriorating course that hindered and often Therapists who are familiar with the standard risk fac-
ended their lives. Jamison emphasizes how many of these tors for suicide can ask their patients a series of informal
talented persons were strong-willed, bold, and celebrated, questions. If a patient notes that he or she actually is con-
and yet still fell prey to the ravages of their bipolar illness. sidering a suicide attempt, perhaps the most basic ques-
Similarly, in Night Falls Fast: Understanding Suicide, Jami- tion to ask is “Why do you wish to end your life?” Al-
son tells the poignant story of an accomplished, young though this sounds quite fundamental, reports from
military cadet whose bipolar disorder ultimately led him some patients indicate that they have been hospitalized
to suicide. This man was admired and loved by many, but in the past without even being asked this simple question.
it was not enough to bolster his will to live at his time of As one patient put it, “Everybody was concerned about
greatest personal despair. how I was going to do it, and when I was going to do it,
The point of the above is not to imply that all is lost and where I was going to try it, and who they could con-
if someone develops the symptoms of bipolar disorder. tact; but nobody even asked me why I felt the way I did,
Rather, it is to remind us that persons with bipolar dis- and that’s what I really wanted to talk about.”
order go through repeated bouts of fearsome, painful ep- A more formalized approach involves using structured
isodes, the likes of which can make them believe that a liv- interviews such as the Beck Scale for Suicide Ideation
able life is no longer possible. Therefore, clinicians must (BSSI; Beck, Steer, & Ranieri, 1988).1 The BSSI covers
be ready to place the issue of suicide risk prominently on
the therapeutic agenda. By doing so, therapists can mon- 1 The BSSI and additional Beck inventories can be obtained from
itor the level of risk on a regular basis, and can be ever the Psychological Corporation, 555 Academic Court, San Antonio,
mindful to address the patients’ suicidogenic beliefs that TX, 78204-9990, USA; 1-800-872-1726; www.PsychCorp.com
78 Newman

the following such issues: a patient’s desire to live, desire Belief #5: “I’m so angry at everybody. I’ll just kill myself
to die, intentions to try suicide, frequency and duration because that’s the best way to teach them a lesson.”
of suicidal ideation, deterrents to suicide, subjective sense
Therapists who assess for these beliefs will be in an
of control over suicidal urges to act, specific plans, meth-
excellent position to provide interventions that address
ods available, final arrangements made, willingness to di-
these potentially harmful viewpoints. Later in the chapter,
vulge their feelings to others, and other important vari-
interventions to counteract these beliefs will be explored.
ables. Notably, the BSSI is administered so as to assess
patients’ levels of suicidality both in the present and at
Problematic Beliefs About Medication
their worst time in the past, including whether they have
It goes without saying that when bipolar patients take
tried suicide in the past. This historical information is ex-
their medications as prescribed they have a better chance
tremely important, as previous suicide attempts are indi-
of achieving therapeutic improvements than if they have
cators of present and future risk (Bongar, 1991).
difficulties in accepting the need for medication. By ex-
Self-report inventories are quite convenient and can
tension, the risk of suicide can be lessened if therapists
be filled out by patients at every session. Two useful exam-
can help their patients “make peace” with their medica-
ples of these are the Beck Depression Inventory (BDI),
tions (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai,
the newest version of which asks supplemental questions
2001). For example, a body of evidence suggests that
pertinent to mania (Beck, Steer, & Brown, 1996), and the
lithium—the medication which after decades of use is
Beck Hopelessness Scale (BHS; Beck, Weissman, Lester,
still at the vanguard of the pharmacotherapeutic stan-
& Trexler, 1974). The BDI broadly covers symptoms asso-
dard of care—has powerful protective value against the
ciated with depressive disorders and specifically has two
threat of suicide (Isometsä & Lonnqvist, 1998; Nilsson,
items (#2 and #9) that are relevant to suicidal risk. When
1999; Tondo, Jamison, & Baldessarini, 1997). Thus, a pa-
both of these latter items are strongly endorsed by pa-
tient’s decision about whether or not to take his or her
tients, the therapist should put the topic of suicidality
medication truly can become a matter of life and death.
front and center on the session agenda. The BHS, com-
It is not easy to take medications such as lithium, depa-
prised of 20 true-false questions about the patient’s view
kote, and others. Some patients have genuine difficulty
of his or her future, offers a more complete view of the
in tolerating such medications and/or may have medical
patient’s sense of hopelessness. Longitudinal studies on
contraindications to taking them. Such situations call for
large samples of patients have indicated that when pa-
active problem-solving between the patient, therapist,
tients endorse at least 9 hopeless responses on the BHS it
and pharmacotherapist (assuming the latter two are not
is an indicator of elevated suicide risk (Beck et al., 1993;
the same individual). However, there are times when the
Beck, Steer, Kovacs, & Garrison, 1985). While it is true
major problem in the patient’s decision not to take med-
that false positives are the norm, this is an acceptable sta-
ications as prescribed has to do with faulty beliefs about
tistical flaw when assessing a potentially life-or-death clin-
pharmacotherapy. Rather than simply exhorting bipolar
ical situation. Taken together, the BDI and BHS are
patients to take their medications, therapists can ask
quick, easy self-report inventories that patients can fill
them their reasons for eschewing pharmacotherapy. This
out conveniently at every session, thus giving the thera-
allows for a cognitive assessment of some of their poten-
pist an important spot-check on the patient’s current
tial misconceptions about medication.
views and intentions relevant to suicide.
For example, patients in a hypomanic or manic state
Suicidogenic Beliefs may be apt to maintain the following problematic beliefs
In addition to the empirical data implicating patients’ about medications and their prescribers:
hopeless views of their future in suicidality (both in terms Belief #1: “Medication is only for people who feel sick.
of baseline hopelessness and sensitivity to increases in I feel fine so there’s no reason for me to take the
hopelessness under duress; see Young et al., 1996), there medication.”
is anecdotal evidence that patients who feel suicidal Belief #2: “If I take the medication, I will lose my cre-
maintain at least one of five of the following maladaptive ativity and productivity.”
beliefs. Belief #3: “Medication will turn me into a dull, aver-
Belief #1: “My problems are too overwhelming. The age conformist.”
only way to solve all my problems is to kill myself.” Belief #4: “The therapist’s telling me to take my med-
Belief #2: “I am a burden to others, and they would be ication infringes on my freedom, and implies that I
better off if I killed myself.” am not competent to run my own life.”
Belief #3: “I hate myself, and I deserve to die.” Belief #5: “If I take my medications I will be personally
Belief #4: “I am in intractable pain, and only suicide and publicly admitting that something is seriously
can end it.” wrong with me, and I cannot bear to face this.”
 Interventions for Suicidality 79

Belief #6: “Taking medication puts me at undue risk cognitive case formulation helps therapists tailor-make
for loss of privacy and social stigma.” the following techniques to fit the specific needs of their
Belief #7: “If my therapist instructs me to take medica- individual patients with bipolar disorder.
tion, it means that he or she doesn’t trust me or
have faith in me the way I am.” Developing a Strong Therapeutic Alliance
In the same vein, persons going through a bipolar de- It is well-established that a healthy, solid therapeutic
pression may hold the following misconceptions about alliance facilitates treatment. This may be all the more
pharmacotherapy: important when the patients are thinking not only about
dropping out of treatment, but out of life altogether.
Belief #1: “I will become addicted to my medications.”
Therapy can be very difficult work, therefore patients
Belief #2: “If my therapist tells me to take medication,
benefit greatly from therapists whose caring demeanor
it means that psychotherapy cannot help me.”
and competent behavior can be sources of guidance, sup-
Belief #3: “If I take medications I will never be able to
port, and hope. Although it is sadly true that a strong
have children.”
therapeutic alliance does not guarantee that the patients
Belief #4: “If I take medications I am agreeing to be a
will refrain from acts of self-harm, it can make the differ-
guinea pig for all these doctors’ experiments.”
ence when patients are ambivalent about receiving ther-
Although a complete explication of the methods of apy, taking their medication, doing therapy homework,
rationally reevaluating all of these maladaptive beliefs and daring to hold out hope that their brave efforts will
about medications is beyond the scope of this paper (see improve their lives.
Newman et al., 2001, for a more thorough review), it will It is beyond the scope of this article to explicate fully
suffice to say that therapists cannot simply supply counter- the means and methods of negotiating a productive,
arguments against these beliefs. There must be a collabo- helpful therapeutic relationship (e.g., Safran & Muran,
rative approach, complete with a willingness to explore 2000). However, the following are some basic points that
the “kernel of truth” in some of these beliefs as part of the therapists can keep in mind when working with bipolar
process of modifying them to improve adherence. Fur- patients who may be suicidal:
ther, patients can be encouraged to read books that em-
pathically inform them about the necessity of taking med- • Be willing to talk about suicide in a forthright man-
ications, while validating some of their concerns (e.g., ner, demonstrating that the topic is of the highest
Jamison, 1995). In the end, our hope is that by reevaluat- clinical priority, and must not be avoided.
ing some of their problematic beliefs about medications, • Be a model for hopefulness and determination, show-
bipolar patients will accept that medications are a part of ing patients that while their feelings must be taken
their life, and by taking them as prescribed they will be seriously, their lives are too precious and important
less likely to commit suicide. to dismiss.
• Be collaborative, emphasizing that teamwork be-
tween therapist and patient is required to maximize
Interventions to Reduce Risk of Suicide success in therapy, and to ride out the times of crisis.
Therapists can intervene in a number of ways to weaken • Do not be too quick to suggest hospitalization unless
the bipolar patient’s suicidal feelings. For example, a strong all reasonable, outpatient safeguards have been con-
therapeutic relationship is a safeguarding factor (though sidered first. Respect the patients’ needs for privacy
perhaps not sufficiently so by itself). General techniques and autonomy as far as they can safely go.
such as the skillful crafting of an antisuicide contract can • Acknowledge the patients’ stated pain and suffering,
be useful as well, if composed in a collaborative spirit. while highlighting their strengths, including their
Specific cognitive therapy techniques—such as an evalu- diligent work in therapy, contributions to others,
ation of the pros and cons of living and dying, increasing skills and accomplishments, inherent worth as indi-
mastery and pleasure activities, improving interpersonal viduals, and the positive potential of their unknow-
communication and overall relating, learning the system- able future.
atic methods of problem solving, and utilizing a wide range
of cognitive enhancement techniques (e.g., rational re- Contracting for Safety
sponding, increasing cognitive flexibility, improving au- When patients express the desire or intention to act
tobiographical recall)—are particularly effective. Helping on their suicidal feelings, it is sometimes useful to try to
the patients to improve and broaden their social support negotiate an antisuicide “contract,” either verbally or in
resources is another vital area for intervention. writing (see Ellis & Newman, 1996). The good news is that
These interventions are spelled out below. Bear in mind, the formulation of such an agreement brings important
however, that “one size does not fit all.” A well-conceived, issues out into the open for frank discussion in session,
80 Newman

and can strengthen the therapeutic relationship (Stan- here to an antisuicide contract. Therapists must stay alert
ford, Goetz, & Bloom, 1994). The bad news is that an anti- to the potential for emergency situations, especially when
suicide contract in no way guarantees that patients will working with patients whose moods can fluctuate to
follow through and remain safe from self-harm (Kleepsies extremes.
& Dettmer, 2000; Silverman, Berman, Bongar, Litman, &
Maris, 1998). Such a contract is not a substitute for the Pros and Cons of Suicide
usual and customary methods for closely monitoring pa- A deceptively simple way to evaluate and potentially
tients’ levels of risk. Rather, it is simply a part of a com- modify a patient’s subjective reasons for wanting to die is
prehensive plan that allows therapists and their patients to examine the pros and cons of suicide, as well as the
to organize a response to a suicidal crisis situation. As pros and cons of choosing to live (Ellis & Newman,
such, an antisuicide agreement has a useful purpose 1996). Getting patients to articulate the “pros of suicide”
within the broader scope of treatment as a whole. is not as risky as it may sound. To the contrary, this
How can we maximize the benefits of an antisuicide method helps patients who have already drawn silent,
contract? Anecdotal evidence suggests that the following dangerous conclusions about wanting to commit suicide
are important characteristics and elements: to discuss their suicidal ideation out in the open with
their therapists. This enables the therapist to engage the
• The contract should make as many affirmative state-
patients in a dialogue about the merits and drawbacks of
ments as possible, rather than merely prohibitive
their potentially lethal thinking style. Furthermore, this
ones. For example, patients can agree to sign a state-
technique inherently demonstrates empathy in that the
ment that contains the line, “I recognize that my life
therapist is willing to evaluate the patients’ darkest thoughts,
is worth preserving, and therefore I will make a good
rather than avoid or reject them. In addition, this tech-
faith effort to cope with my pain through healthy
nique necessitates that patients look at the advantages
means.” This is preferable to a statement such as “I
of continuing to live, and the disadvantages of dying
agree not to hurt myself, and to refrain from idle
prematurely—areas of cognitive inquiry that the suicidal
threats as well.”
patient may have neglected.
• The contract should summarize the responsibilities
Bipolar patients sometimes contend that their illness
of both the patient and the therapist in an emer-
will necessarily take a deteriorating course, therefore sui-
gency situation. This approach emphasizes the need
cide would be a way to “cut their losses.” However, a full
for a collaborative response, and that the therapist
analysis of the advantages and disadvantages of continu-
and patient each have an important role.
ing to live versus committing suicide requires that this
• The contract can serve an educational purpose,
viewpoint be juxtaposed with more hopeful possibilities.
such as by reminding the patients of a variety of self-
The patients might be encouraged to imagine a future in
help skills they can utilize in order to help themselves
which their symptoms are better controlled, and there-
remain safe through a period of emotional distress.
fore they can involve themselves in activities and pursuits
• The contract can include a list of people whom the
that make life more enjoyable and meaningful. If this is
patient can choose to contact in order to obtain so-
true, they may have already been through the worst, and
cial support at critical times. Similarly, the contract
therefore committing suicide now would be an act of
can spell out emergency treatment options if the “cutting their future improvements.” From a different angle,
therapist or other support persons are unavailable this technique may point out to patients the harm that
in a crisis situation. their suicide would cause to important others in their
• The patient should feel empowered by the contract lives, and (conversely) the benefits that their commit-
as opposed to restricted. Toward this end, it is best if ment to treatment could give to their loved ones.
the therapist and patient create the contract collab- Sometimes a patient will state that this technique is
oratively. In addition, the contract should be re- simply conjecture, and therefore is moot. The therapist’s
viewed periodically and revised as deemed appropri- retort may be that this clinical method involves no more
ate by the therapist and patient as a team. conjecture than the patient is already engaging in to jus-
• It is best if the contract contains a provision that ac- tify suicide. Who is to say what the future will bring? Is the
knowledges that the parties should follow the life- patient really willing to forfeit his or her life on a guess
preserving spirit of the contract, even though loop- about how things will turn out? Is the patient willing to
holes may be found, and even when unforeseen cir- invest in the rigors of cognitive therapy and pharmaco-
cumstances make it difficult to follow the guidelines therapy and witness firsthand what the years to come will
word for word. be like? Perhaps the burdens of their bipolar illness will be
It is important to reiterate that therapists cannot relax lessened over time if they are willing to commit to their
their vigilance simply because a patient has agreed to ad- treatment, and to their well being in general, and if the
 Interventions for Suicidality 81

efficacy of treatment methods and medications continues commitment to take part in more activities may have sig-
to advance. nificant therapeutic effects. First, being more active
It must be acknowledged that many patients will find breaks the vicious cycle of helplessness, withdrawal, exac-
the above argument hard to buy, especially if they have erbated mood, and increased helplessness. Second, phys-
suffered many losses over the course of a chronic illness. ical activity has natural antidepressant effects (Tkachuk &
They may express the sentiment that they are afraid to Martin, 1999). Third, when patients engage in more ac-
raise their hopes for a better future, only to have these tivities, they increase their contact with other people.
hopes dashed once again. The empathic therapist can This can improve the quality of their lives, as well as serve
validate these feelings, while not necessarily validating as a safeguarding factor against impulsively acting on sui-
the logic behind them. For example, the therapist may cidal urges. Fourth, when patients do things that they
say the following: thought they couldn’t do (e.g., getting out of bed, taking
a shower, going for a walk, doing some writing at the li-
“I don’t blame you for being afraid to hope, but I’m
brary), it improves their sense of self-efficacy. Fifth, by
very concerned about what you will needlessly do to
doing more things for mastery and pleasure, patients in-
yourself if you avoid having hope. If you prevent
crease the probability that positive outcomes will occur as
yourself from imagining a better future and you
a result of their efforts. This creates the potential for a
resign yourself to a terrible fate, I am afraid that you
will create your own negative expectation, above positive feedback loop in which greater levels of activity
and beyond what the bipolar disorder is doing to lead to positive rewards, which encourage further activity.
you. By only seeing the pros of dying and the cons All of the above reasons have as a common goal the di-
of living, you may be setting yourself up for a self- minishing of the patients’ sense of helplessness and hope-
fulfilling prophecy. I am not asking you to have lessness, along with a concomitant reduction in the likeli-
blind optimism. I am inviting you to think about hood that they will consider suicide.
how your future could be better, and how living If patients insist that they are unable to become more
your life to its natural conclusion in the distant active, it is still useful for therapists to work with their pa-
future could present you with advantages you cur- tients to generate a list of tasks (preferably on paper) that
rently do not dare allow yourself to consider. Are they could do if their level of energy were to increase. In
you willing to work with me to explore this?” the meantime, the work of therapy can focus more on the
patients’ cognitive problems, including suicidogenic be-
Increasing Mastery and Pleasure liefs (see below).
There is more to life than simply focusing on the Impulse control. The fact that bipolar disorder involves
symptoms of an illness. Therapists can explain to their a war against extreme moods on two fronts poses signifi-
bipolar patients that their treatment—and their life in cant challenges for therapists and patients. There is al-
general — does not need to be merely about fighting ways the risk that as depressed bipolar patients strive to
bipolar disorder. Rather, life needs to be about connect- increase their activity levels, they may swing to the oppo-
ing with people, striving toward goals, learning new site end of the spectrum and behave in ways that induce
things, enjoying new experiences, gaining confidence, mania. Therefore, patients should be taught that “mas-
searching for meaning, and other life-affirming pro- tery” activities sometimes include the choice to refrain
cesses. This may seem to be quite a stretch for the se- from acting on impulse. For example, a patient may wish
verely depressed, hopeless, suicidal bipolar patient who to go on a shopping spree at the mall, but may stop him-
is quite disinclined to fill up his or her calendar with in- self after considering the risks. This is an example of the
teresting things to do. However, with caring, sensitive patient being the master of his impulses. Such restraint is to
guidance from the therapist, even anhedonic, inert, pes- be applauded. Thus, the “mastery” demonstrated by the
simistic patients can learn (by experience) an important patient in this example is his choice to do something less
principle—specifically, that it is beneficial to do the extreme instead.
things you would normally do if your mood was good, Moderating goal-directedness. Similarly, bipolar patients
even when you feel depressed. who significantly ramp up their goal-directed activities
The first step is to take stock of the kinds of interper- are at risk for cycling into mania ( Johnson, Sandrow, et
sonal activities and individual pursuits that the patients al., 1999). Thus, therapists need to help their bipolar pa-
have enjoyed in the past, and to plan to do some of these tients to do a moderate amount of such activities, and to
now, even if the patients believe it will not help. Thera- be able to distinguish between a therapeutic increase in
pists need to show compassion for patients who state that activities and mania-inducing levels of activity. Therapists
they are having great difficulty in overcoming their iner- and their bipolar patients continually try to find the
tia, lethargy, and anhedonia. Nevertheless, therapists can healthy middle ground between inactivity and hyperactiv-
provide the following five reasons for why making the ity. This “happy medium” is where hope lies, whereas the
82 Newman

extremes bring negative consequences, hopelessness, and so many other areas of functioning, the key is to find the
(at worst) the risk of a downward spiral toward a suicide golden mean, which involves talking with others about
attempt. appropriate topics, at reasonable hours of the day, with
Simple pleasures of life. Along the same lines as the above, reciprocal give and take in the exchange.
bipolar patients do not have the leeway to engage in all Therapists teach their patients to become better lis-
manner of pleasurable activities. Although the goal is to teners, as this is arguably the single most important com-
counteract depressive lethargy and hopelessness, we do munication skill. Periodic summaries of the contents of
not want bipolar patients to go to the opposite extreme the therapeutic dialogue over the course of the hour are
by pursuing markedly hedonistic activities. While it is un- part and parcel of a typical cognitive therapy session. Pa-
doubtedly pleasurable (in the immediacy of the moment) tients come to realize that they (and their therapists) will
to go on binges of drinking, spending, sex, and other ap- have to listen carefully if they are to give accurate summa-
petitive, consumptive activities, such behaviors invariably ries and thus demonstrate that they have been following
lead to negative consequences, shame, and a crash land- the thread of the discussion. They learn to reflect on
ing back into depression. Therefore, therapists encour- what they have heard and to show that they care about
age their bipolar patients to pursue the simple pleasures what is being discussed. This makes for better learning in
of life—those that create a sense of quiet satisfaction and the office and is good practice for conversations in every-
serenity, not necessarily wild excitement. The choice of day life.
activities is up to the individual patient and his or her When patients are depressed, anhedonic, lethargic,
therapist. However, typical examples include reading, withdrawn, and perhaps entertaining thoughts of suicide,
speaking with friends, watching a movie, playing music, they are not very likely to go out of their way to arrange
enjoying a well-cooked meal, writing, working on an un- interesting social events. However, it is not so rare for
complicated household project, exercising, doing a hobby, these individuals to receive social invitations, which they
and other activities that bring satisfaction, repose, and commonly ignore or turn down. In response to this un-
even serenity. fortunate state of affairs, therapists can give their patients
a friendly directive—namely, “Just say yes to social invita-
Improving Interpersonal Functioning tions.” In order to be satisfactorily effective in such social
A good social support system helps a bipolar patient’s situations, the patients need learn only two basic prin-
recovery and general well being ( Johnson, Winett, et al., ciples: (a) show interest in what other people are talking
1999). Conversely, social isolation is one of the risk fac- about, and (b) develop conversation topics that do not
tors for suicide ( Jamison, 1999; Trout, 1980). At intake, necessarily involve their disorder or their treatment. Al-
as part of a thorough psychosocial assessment, therapists though there is nothing wrong with being honest about
can take inventory of the quantity and quality of the pa- their status as bipolar patients, there is also nothing
tients’ familial and social relationships. When patients re- wrong with maintaining appropriate discretion and pri-
port that they feel lonely and/or isolated, it is especially vacy. Role-playing in session can be useful to help patients
important to help them establish and maintain healthy develop and practice a more effective repertoire.
connections to others in their lives. This may be particu- Familial interactions. Bipolar disorder adversely affects
larly difficult, especially if the patients have withdrawn both its sufferers and their families. The manner in which
from their family, friends, and associates, and/or if their patients and their families deal with each other in the
previous manic behaviors have alienated others. Never- midst of their difficulties is a potentially important factor
theless, if patients can make it a priority to improve their in predicting recovery, as well as the quality of life for all
interpersonal relationships, they will increase their chances parties concerned (see Miklowitz & Goldstein, 1997).
of making new connections with life itself, thus reducing One of the goals of treatment is to reduce the level of
the risk of suicide. negative, expressed emotion between bipolar patients and
Communication skills. One of the standard ways that their family members, especially those with whom they
therapists can help their patients bolster their interper- live (Miklowitz, Goldstein, Nuechterlein, Snyder, & Mintz,
sonal skills is by helping them modify their problematic 1988; Miklowitz, Simoneau, Sachs-Ericsson, Warner, &
styles of communication. For example, it is not uncom- Suddath, 1996; Miklowitz, Wendel, & Simoneau, 1998).
mon for bipolar patients to evidence maladaptive ex- Essentially, this means reducing the frequency, duration,
tremes in their dealings with others—either failing to be and intensity of hostile, verbal exchanges, modifying ma-
responsive (e.g., not returning the phone calls of well- levolent attributions made about each other’s behaviors
meaning friends who are calling to see how they are feel- and intentions, and increasing their skills for calm, col-
ing), or being domineering, irrepressible, and crossing laborative problem-solving.
boundaries (e.g., calling friends in the middle of the Some of the skills that bipolar patients can practice in
night to chat about some wonderful new ideas). As with order to improve the quality of their interactions (and
 Interventions for Suicidality 83

overall relationships) with family members include: (a) prove some of their cognitive skills that may be underde-
changing accusations into requests for change, (b) stay- veloped, underutilized, or otherwise hindered by the ef-
ing on one subject rather than counterattacking with un- fects of their bipolar disorder. Many of the techniques
related information, (c) using “I” and “we” statements below are applicable to a broad spectrum of clinical prob-
rather than “you” statements, (d) increasing expressions lems, though the emphasis here will be on their use with
of empathy and appreciation, (e) eliminating the use of depressed, suicidal bipolar patients.
profanity in the household, and (f) observing standard Modifying suicidogenic beliefs. As with any rational re-
etiquette, as if the family members were guests in the evaluation process, patients are more willing to reassess
house. These are rather lofty goals, sometimes inspiring their harmful beliefs if they sense that their therapists are
patients to laugh out loud (“You expect me to do what?”). willing to examine the bases for the problematic beliefs
Nonetheless, it is fitting and proper to set the bar high in in the first place. In other words, some measure of valida-
order to maximize positive expectations and the poten- tion is extremely important. Toward that end, the follow-
tial efficacy of therapy. ing summary touches upon both the reasons and the
It is extremely important for therapists to intervene counterarguments for the five “suicidogenic” beliefs
when family members believe that their bipolar relatives mentioned earlier.
are manipulating them with suicide threats, some of 1. “My problems are too overwhelming. The only way to solve
which they may believe are insincere. This is a dangerous my problems is to kill myself.” Bipolar disorder can wreak
situation in which nobody benefits. When this occurs, it havoc on people’s lives. Patients often have to face real-
usually means that effective communication and empa- life consequences for both their episodes of manic im-
thy have broken down in a dramatic way. The therapist’s pulsivity and depressive withdrawal, often resulting in a
task in this situation is to: (a) assess the actual risk for sui- sense of being overwhelmed by problems that cannot
cide, (b) take appropriate steps to safeguard the life of be solved. Further, the effects of the bipolar illness it-
the patient (e.g., hospitalization, if necessary), (c) teach self may make sufferers believe that they do not possess
the family how to avoid exacerbating the situation (e.g., the psychological wherewithal to cope, and to rebuild.
they should not say, “Go ahead and kill yourself already; They may believe that only through death can they es-
we’re sick of being held hostage by your threats!”), and cape from their problems. In fact, the degree of expect-
(d) teach the patients how to express their emotional ancy that suicide can solve one’s problems is predictive of
pain, shame, desperation, and anger without resorting to higher suicide intent (Linehan, Camper, Chiles, Strosahl,
extreme threats that only make family relationships worse, & Shearin, 1987).
and ruin the patient’s credibility in the process.2 Cognitive therapists have to demonstrate to patients
Support and advocacy groups. When friends are scarce, that suicide is not the “solution to end all problems,” but
and family members are depleted, it is particularly crucial rather “the problem to end all solutions” (Ellis & New-
to help bipolar patients find and take part in formal sup- man, 1996, p. 125). If the patient dies, the problems are
port groups for bipolar disorder, such as their local chap- simply inherited by others, compounded by the latter’s
ter of the National Depressive and Manic-Depressive grief, guilt, and other severe reactions. To live is to have a
Association (NDMDA), the National Alliance for the chance to make things better. Toward this goal, thera-
Mentally Ill (NAMI), and the Depression and Related pists entreat their patients to work on problem-solving
Affective Disorders Association (DRADA).3 When patients skills in session, and to apply them for homework. Ther-
reject this option outright, it is usually a signal that they apists give tremendous support and encouragement to
either believe that taking part in such groups is stigmatiz- patients for their involvement in this arduous but worth-
ing, or that it will be a waste of time. Both of these beliefs while process.
then must become targets for intervention, as any other 2. “I am a burden to others, and they would be better off if I
problematic belief system that increases the patients’ killed myself.” There is no dispute that bipolar disorder
sense of hopelessness and worthlessness. can be a burdensome illness. There is ample evidence
that the families of bipolar patients often have adverse re-
Improving Cognitive Functioning actions to the stresses and strains of having loved ones
In order to improve patients’ sense of self-efficacy, as with bipolar disorder (e.g., Brodie & Leff, 1971; Chakra-
well as facilitate hope, it is necessary to help them im- bati, Kulhara, & Verna, 1992; Coryell, Endicott, Andreasen,
& Keller, 1985; Miklowitz et al., 1998; Targum, Dibble,
Davenport, & Gershon, 1981). Therapists can acknowl-
2 In order to deal more effectively with their relative’s suicide
edge that the patients’ bipolar disorder places certain de-
threats, family members are referred to the Appendix of Ellis and
Newman (1996).
mands on their caregivers and support systems, but add
3 The websites for the NDMDA, NAMI, and DRADA respectively that suicide would be a far worse burden to impose on
are: www.ndmda.org, www.nami.org, www.med.jhu.edu/drada them—one that can never be “treated” or undone, and
84 Newman

perpetuates anger, helplessness, guilt, and grief in those day. More challenging but perhaps more meaningful are
left behind. the activities that represent having a “mission” in life,
Therapists can ask their patients, “Given the choice, such as turning one’s pain and suffering into the energy
would your [loved ones] prefer that you kill yourself, or to write a manual to help other patients, or to found a
that you invest yourself in your treatment to the fullest?” new, local chapter of a national self-help organization.
The purpose of this inquiry is to emphasize that if the Such behaviors give meaning to one’s plight, and provide
patients’ truly wish to alleviate the burden they are im- a purpose for moving forward (cf. Frankl, 1960). They
posing on their loved ones, their commitment to life, may also provide an oasis of comfort while the patients do
treatment, and a better future is a far more effecive the difficult work of therapy.
means to accomplish this goal. Patients sometimes re- 5. “I’m so angry at everybody. I’ll just kill myself because
spond that they have tried this more hopeful approach, that’s the best way to teach them a lesson.” When patients ex-
and it has failed. This is where therapists have to show press this viewpoint, it is advisable to engage them in a
some understanding, yet still engage the patients in an discussion about their anger. A discussion about anger is
exploration of the future, rather than have the patients far preferable to their acting out their anger. Additionally,
succumb to the worst kind of tragedy imaginable— that therapists learn more (and thus can validate and empa-
they may have died prematurely when it didn’t have to thize more) when they understand the underpinnings of
happen. the patient’s angst, rather than by having to respond to
3. “I hate myself, and I deserve to die.” This belief often re- the patient’s crisis situation.
flects the shame and regret that stem from past behaviors It is often the case that patients who think of suicide as
and incidents. The patients’ resultant self-loathing, aside a means of exacting revenge feel they have been mis-
from being depressongenic, also makes them prone to treated. Their threats of self-harm are a desperate effort
discount, minimize, or negate their therapeutic progress. to exert some measure of interpersonal control, and to
Helping self-hating persons to “reconcile with them- stage their protest so that others will stand up and take
selves” is a formidable task indeed. notice. Therapists can state outright that it would be use-
In order to assess and modify such a pernicious, viru- ful for the patients to be able to state their complaint in
lent belief, it is necessary to examine the patients’ stated an assertive way, and to have others listen. However, they
bases for this belief. Thus, a historical review of shameful can suggest that there may be better ways to do this than
events may be necessary, though this requires the utmost to threaten suicide.
delicacy and care. Therapists can also help their patients One way to illustrate this point is to ask the patients
to strive to “turn over a new leaf” or (if they are religious) what “lessons” their suicidal actions may actually teach
to make “penitence” or gain “absolution” through good others. The patients’ intention may be to show others
works in the future. For therapeutic shock value, thera- that they have hurt the patients in some way, but in fact
pists may ask the suicidal patients why they are willing to the result may be that others may simply learn that the
“execute the victim,” as they intend to do by leveling cap- patients are sick, fragile, unstable, difficult to deal with,
ital punishment on a person who has been stricken by an and gratuitously hostile and self-defeating. This is not the
illness. The purpose is to shed light on the cruelty of self- message patients wish to convey, yet it is what is often sur-
hatred and the benefits of self-improvement. mised, even by mental health professionals.
4. “I am in intractable pain, and only suicide can end it.” Therefore, therapists can help patients who maintain
One cannot blame someone for wanting a quick, perma- this problematic belief to spell out their grievances in a
nent anesthetic for severe, chronic pain. The problem constructive way, and to try to engage in interpersonal
is that suicide is not a local anesthetic — it eliminates problem-solving, rather than create a new problem by
everything, including one’s mind, one’s capacity to love, threatening and/or attempting suicide. Therapists get
one’s future, and every positive experience that could this process rolling by being intent listeners themselves,
still occur. Still, therapists can empathize with the pa- and by reinforcing the patients’ appropriate verbal
tients’ ongoing anguish, and their desire to be rid of summaries with sharply focused attention, accurate
these feelings. However, as long as they are striving for summaries, and an active desire to help them deal with
therapeutic improvement, suicide does not have to be their interpersonal problems most effectively, and least
the means by which to find a respite from their emo- violently.
tional pain. Improving problem-solving skills. All too frequently, bi-
It is advisable to collaborate with the patients to review polar patients underutilize problem-solving techniques.
all of their healthy, emotional palliatives, including newly This is apparent when patients in a manic state throw
brainstormed ones. The most practical ideas involve simple, caution to the wind, and when deeply depressed patients
self-soothing behaviors that can be implemented every feel overwhelmed and give up. Either way, the patients’
 Interventions for Suicidality 85

resultant life situation worsens. If they lack the formal perfectionism itself can be a risk factor for suicide (Blatt,
skills of problem solving, patients put themselves at rela- 1995; Ellis & Ratliff, 1986; Hewitt, Flett, & Weber, 1994).
tively greater risk of suicide than those patients who try to In fact, there is evidence that maladaptive perfectionism
make repairs (Schotte & Clum, 1987). in patients can even interfere with the development of an
Weishaar’s (1996) review of the cognitive risk factors optimal therapeutic relationship (Zuroff et al., 2000).
for suicide found that suicidal patients often perceive One of the positive lessons that therapists hope will be
more problems but generate fewer solutions than nonsui- communicated to their patients is that the therapeutic re-
cidal patients, and that this applies to both individual and lationship can be a model for how to overcome problems,
interpersonal problems. Further, suicidal individuals are misunderstandings, and the inevitable human flaws through
more likely to avoid actively dealing with their problems good will, mutual respect, and a sense of trust and collab-
than those who are nonsuicidal, perhaps as a result of oration against the odds. Unfortunately, perfectionistic
their sense of helplessness and hopelessness patients may not be so willing to accept these obstacles in
In response to this problem, therapists can entreat the process of forming and maintaining a positive thera-
their patients to learn and apply the skills of “damage peutic relationship.
control.” This involves understanding the basics of prob- Therapists have to find a way to encourage such pa-
lem solving (see Nezu, Nezu, & Perri, 1989), as well as tients to appreciate the drawbacks—indeed, the futility—
adopting a mindset that acknowledges the benefits of of trying for only the perfect solutions. Life inevitably in-
mending fences with others, correcting mistakes, and try- volves hurdles, setbacks, and other flaws, and much of a
ing to rebound after setbacks. It is useful to note the fol- person’s success may stem from his or her response to
lowing observation, that for every vicious cycle there is an trial-and-error learning. By contrast, maladaptive perfec-
equal and opposite positive feedback loop. One of the goals of tionism requires a never-ending struggle just to break
cognitive therapy is to find this positive counterpart to even. Patients who maintain this stance can never be
the patients’ more common downward spiral. pleasantly surprised, nor can they exceed their expecta-
Increasing cognitive flexibility . Along the same lines as tions. They cannot relax and enjoy their accomplish-
the above, suicidal persons have been found to demon- ments, neither can they reflect (for very long) on the
strate “cognitive rigidity,” a factor that certainly impedes things for which they are grateful. For bipolar patients,
problem solving. This problem typically is manifested by who encounter more than their share of obstacles in life,
the patient’s propensity for seeing things in black and it is that much more harmful to maintain an unshakably
white, all or none. This has been called dichotomous perfectionistic stance.
thinking or, more coincidentally, “bipolar” thinking (Beck, Utilizing specific autobiographical recall. Poor autobio-
Rush, Shaw, & Emery, 1979). Cognitive therapists respond graphical recall is a cognitive deficit that has been found
to this problem by helping patients learn to generate in unipolar depression (Evans, Williams, O’Loughlin, &
multiple ways to view their life circumstances, as well as Howells, 1992; Williams & Broadbent, 1986), as well as
specific dilemmas they face. By learning the skills of flex- bipolar depression (Scott, Stanton, Garland, & Ferrier,
ible, or divergent, thinking (often with the help of stan- 2000). When patients have difficulties in recalling, imag-
dard cognitive therapy techniques, such as the Daily ining, and describing specific, important events from the
Thought Record; see J. S. Beck, 1995), patients can find past, they tend to have a concomitant difficulty in culling
workable solutions to problems they previously thought useful lessons from these experiences. Thus, they may
were beyond repair. not be adept at learning from past mistakes, or incorpo-
A particular form of rigid thinking that needs thera- rating accomplishments in work and love into their self-
peutic attention is perfectionism. What characterizes mal- images and view of the future. Thus, the patients’ emo-
adaptive perfectionism is the patient’s demand that things tions tend to be driven more by their old, dysfunctional
work out “just so,” in combination with a belief that noth- beliefs, rather than useful, personal experiences.
ing else will be satisfactory, along with a rejecting, some- To deal with this cognitive problem, therapists teach
times punitive response to “second-best” solutions. For their patients to write about significant past experiences,
example, the bipolar patient whose illness has detracted perhaps facilitated by relaxation-induced imagery exer-
from his academic record may wish to kill himself rather cises. The goal is not to “recover lost memories,” but
than face a life in which he was unable to gain admission rather to train the patients to study their life experience,
to a top-tier medical school. He may reject viable options and to appreciate its richness and lessons. In order to fa-
(e.g., attending a more “modest” medical school) because cilitate the encoding of autobiographical memory from
he believes this represents failure and ultimate shame the present onward, patients are encouraged to keep
and misery. personal journals and to make and save audiotapes of
Indeed, there are data indicating that maladaptive their therapy sessions for future reference. Through these
86 Newman

seemingly simple methods, patients may become more cide prevention is often at the top of the therapeutic
adept at learning from previous mistakes, appreciating agenda during their course of cognitive therapy. In order
their successes, and gaining a fairer appraisal of the ratio to maximally safeguard the lives of bipolar patients in
between the two. treatment, therapists need to assess the risk factors quite
thoroughly, via such means as structured interviews at the
Overcoming Stigma While Accepting Limitations start of treatment, empathic inquiries on a frequent basis,
Therapists who treat suicidal patients who suffer from and regularly administered self-report measures that tap
bipolar disorder will need to address the difficult topics into depressive symptoms, hopelessness, and suicidality
of loss, grief, and stigma in order to provide accurate em- itself. Further, therapists should be aware of typical “sui-
pathy, and to help the patients find hope and meaning in cidogenic” beliefs harbored by many patients—beliefs
their lives. Bipolar patients face enormous difficulties, that require rigorous, rational reevaluation.
frequently including repeated interruptions and disrup- A problem as complicated and serious as suicidality
tions in their life pursuits, sometimes necessitating that requires interventions on multiple fronts. From a practi-
they “pick up the pieces” and start over again. The loss of cal standpoint, therapists help their patients devise and
relationships, academic opportunities, career tracks, fi- enact constructive plans of action in the event of a sui-
nancial stability, and confidence in their ability to run cidal crisis, sometimes in the form of a jointly authored
their lives can demoralize patients, making them wonder “antisuicide contract.” In terms of therapeutic skills,
why they should bother to go on living. patients must be taught to identify and modify their
Additionally, bipolar patients have to face the specter problematic beliefs that make them feel hopeless, help-
of stigma about their disorder, including societal miscon- less, ashamed, stigmatized, and averse to taking necessary
ceptions and prejudices, the fears of their own family and medications. It is also important to help them develop
friends, as well as their own shame, self-blame, and re- better cognitive skills overall, including greater cognitive
grets (Corrigan, 1998; Lundin, 1998). Although it would flexibility (e.g., reducing perfectionism and improving
be most desirable to change the stigmatic views about problem-solving), and an enhanced autobiographical re-
mental illness held by society at large, this goal is difficult call that can lead to more productive learning from past
to attain. However, it is possible to make inroads toward experiences.
overcoming the effects of stigma via addressing the pa- As bipolar disorder also is associated with interper-
tients’ own self-stigmatizing beliefs, such as when they sonal strife, patients fare better when their therapy in-
blame themselves for their bipolar disorder, call them- cludes communication skills training, modulation of so-
selves pejorative names (e.g., “hopeless nutcase,” “misfit”), cial behaviors, and the rational reevaluation of negative
and define themselves in terms of their illness, rather than interpretations of others’ behaviors. Improving the pa-
their multiple qualities as individuals. tients’ ability to build and maintain solid interpersonal
Fortunately, cognitive therapy itself presents a destig- relationships prevents social isolation—a risk factor for
matizing approach for patients in that it focuses on goals, suicide—helps them establish a support system beyond
tasks, hypotheses, and objective assessments, rather than therapy, and improves the overall quality of their lives. Ad-
labels, absolutes, and judgments (Holmes & River, 1998; ditionally, the patients’ involvement in support/advocacy
Lam et al., 1999). When patients learn the skills of ratio- groups can be an important part of the patients’ life-
nal responding, problem solving, and the like, they build enhancing connections with others.
self-efficacy as well as a better appreciation for their Finally, when bipolar patients go through cognitive
own efforts in facing a major illness. They are less likely therapy, they learn ways to empower themselves, and to
to engage in simplistic self-blame, or to evaluate them- behave in a manner that communicates self-respect to
selves in terms of a false success-failure dichotomy. In the world. This not only makes patients less likely to feel
short, cognitive therapy destigmatizes “from the inside suicidal, but also begins a process of educating society
out” (Newman et al., 2001), helping patients to accept that an illness such as bipolar disorder does not define
themselves, to present themselves to the public as having the individuals who have it.
self-respect, and thus becoming (by extension) more ef-
fective “ambassadors” for bipolar disorder to the larger
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The Guilford Press. ment of depression. Journal of Consulting and Clinical Psychology, 68,
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Young, M. A., Fogg, L. F., Scheftner, W., Fawcett, J., Akiskal, H., & Address correspondence to Cory F. Newman, Center for Cognitive
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Therapy, University of Pennsylvania, 3535 Market St., Philadelphia, PA
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19104; psydoc@mail.med.upenn.edu.
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Sanislow, C. A. III, & Simmens, S. (2000). Relation of therapeutic This article as accepted under the editorship of Anne Marie Albano.
Suicide and Life-Threatening Behavior 35(4) August 2005 413
 2005 The American Association of Suicidology

After the Attempt: Maintaining

the Therapeutic Alliance Following
a Patient’s Suicide Attempt
J. Russell Ramsay, PhD, and Cory F. Newman, PhD

The risk of a patient’s suicide is a prominent occupational hazard for psy-

chotherapists. The precise number of patients who attempt suicide while in treat-
ment and then resume therapy with the same therapist is not known, but this
situation is a relatively common occurrence in clinical practice. Such scenarios can
pose significant challenges to the reestablishment of therapeutic trust and a work-
able treatment alliance. The aim of this paper is to identify the challenges facing
a clinician treating a patient who resumes therapy following a serious suicide at-
tempt, and to offer guidelines for maintaining the viability of the therapeutic alli-
ance.

The suicide of a patient is a primary occupa- one in six or seven chance of experiencing a
tional hazard for psychotherapists. Among patient suicide (Brown, 1987; Kleespies,
individuals diagnosed with major psychiatric Smith, & Becker, 1990), with 40% of trainees
disorders, the estimated prevalence of death likely to encounter serious suicidal behavior
by suicide is about 10% to 15% (Brent, Kupfer, by a patient (Kleespies & Dettmer, 2000).
Bromet, & Dew, 1988, cited in Bongar, The intrusive stress levels reported by psy-
Maris, Berman, & Litman, 1998; see Bost- chologists who experience a patient suicide
wick & Pankratz, 2000, for a critical analysis are comparable to clinical levels of post-trau-
of these statistics). Studies indicate that there matic stress (Chemtob et al., 1988; Hendin,
is a 22% chance that a psychologist in clinical Lipschitz, Maltsberger, Haas, & Wynecoop,
practice will experience a patient suicide in 2000).
the course of a career; this chance is more Suicide attempts far outnumber com-
than 50% for psychiatrists (Chemtob, Bauer, pleted suicides. Although precise epidemio-
Hamada, Pelowski, & Muraoka, 1989; Chem- logical statistics on suicide attempts in the
tob, Hamada, Bauer, Torigoe, & Kinney, United States are not kept, it is estimated
1988). Even psychologists in training have a that there are from 765,000 to more than one
million suicide attempts annually (Crosby,
Cheltenham, & Sacks, 1999; Hoyert, Kocha-
J. Russell Ramsay and Cory F. Newman nek, & Murphy, 1999). There are about 10 to
are with the Center for Cognitive Therapy at the
25 attempts for each completed suicide with
University of Pennsylvania.
We wish to express our gratitude to Julie between 1% and 4% of adults and between
Jacobs, PhD, and to two anonymous peer review- 2% and 10% of adolescents having made at
ers for their helpful comments on an earlier draft least one suicide attempt ( Jamison, 1999;
of this article. Moscicki, 1999). For people aged 15 to 24, a
Address correspondence to J. Russell Ram-
100–200:1 ratio of suicide attempts to com-
say, PhD, Center for Cognitive Therapy, 3535
Market St., #2027, Philadelphia, PA 19104–3309; pletions is estimated. One out of every three
E-mail: ramsay@mail.med.upenn.edu attempts is serious enough to require medical
414 After the Attempt

attention ( Jamison, 1999). Furthermore, lon- have had an inadequate treatment response
gitudinal studies indicate that 10% to 15% of (Suominen, Isometsä, Henriksson, Ostamo,
those who attempt suicide will eventually kill & Lönnqvist, 1998).
themselves ( Jamison, 1999). These findings suggest that it is critical
Thus, the treatment of suicidal ide- for suicidal patients to get back into active
ation and behavior are standard features of treatment following a suicide attempt. They
clinical practice, though most mental health also raise an important clinical question:
clinicians receive little, if any, formalized How do the therapist and patient most pro-
training in treating suicidal patients (Bongar, ductively resume treatment and optimally re-
2002; Jobes & Maltsberger, 1995). This in store the therapeutic alliance? The wake of
spite of the fact that leading experts in suicid- the attempt finds the patient facing not only
ology have compiled treatment guidelines emotional distress and ambivalence about the
and standards of care tailored for inpatient “failed” attempt, but also further encroach-
treatment (Bongar, Maris, Berman, Litman, ment on his or her privacy, perhaps in the
& Silverman, 1993; Silverman, Berman, form of hospitalization and/or unwanted
Bongar, Litman, & Maris, 1994) and outpa- family involvement. The clinician is con-
tient treatment (Bongar, Maris, Berman, & fronted with treating a patient who perhaps
Litman, 1992), spanning different clinical remains at high and/or chronic risk for addi-
settings and patient populations (American tional attempts or completed suicide (Holley,
Psychiatric Association, 2003; Bongar, 1992, Fick, & Love, 1998; Isometsä & Lönnqvist,
2002; Chiles & Strosahl, 1995; Jacobs, 1999; 1999). The combination of a damaged sense
Maris, Berman, & Silverman, 2000). of controllability with a heightened aware-
Even with faithful adherence to the ness of professional accountability can be
aforementioned guidelines and competent daunting, making therapists shy away from
clinical practice, clinicians are at risk for en- taking such patients back into therapy. Those
countering patients’ suicidal behaviors in the therapists who resume treatment with these
course of their standard practice. As suicide patients may thereafter practice more defen-
attempts far outnumber completed suicides, sively and, in some cases, harbor strong am-
therapists who may never experience the bivalent or negative feelings about their pa-
trauma of having patients kill themselves are tients ( Jobes & Maltsberger, 1995; Maltsberger
nonetheless highly likely at some point to en- & Buie, 1974; Rudd & Joiner, 1997). In sum,
counter patients who attempt suicide during many issues arise in this context that could
the course of active treatment. Many of these conspire to disrupt treatment at a time when
patients will, after stabilization, plan to con- it is highly needed.
tinue in outpatient therapy with the same The primary objective of this paper is
therapist. Arguably, there may never be a to offer clinical guidance for therapists who
more critical time for the patient to be back find themselves faced with the stressful prop-
in treatment with the clinician who knows osition of resuming treatment with a patient
him or her best than following a suicide at- who has made a serious suicide attempt. To
tempt; yet, their working relationship may be accomplish this objective we will examine
significantly strained in the wake of the at- three steps in the process of reestablishing a
tempt. To our knowledge, there have been no therapeutic alliance with such a patient. The
studies of the prevalence of suicide attempt- first step involves the decision of whether or
ers under professional care who resume not, in fact, to agree to continue to treat the
treatment with the same clinicians after their patient and, if so, on what terms? Second, we
attempts. There are, however, data to suggest discuss the issue of addressing with the pa-
that patients who eventually commit suicide, tient the mutual rebuilding of trust and con-
when compared with matched controls, are fidence in the therapeutic relationship. The
more likely to have left therapy prematurely third step focuses on modifying the treat-
(Dahlsgaard, Beck, & Brown, 1998) or to ment plan and (perhaps) the composition of
Ramsay and Newman 415

the treatment team to provide the level of ratively developed, overarching crisis response
care and support commensurate with the pa- plan, run the risk of creating a false sense of
tient’s needs. security and could even trigger negative reac-
Our goal is to have these guidelines tions by patients (e.g., “If it only took a con-
help practicing psychotherapists regardless of tract to stop my suicidal thoughts, I would
their particular theoretical orientations. That not need therapy”) (Rudd et al., 2001). Fur-
said, our particular clinical approach to treat- ther, a mental health clinician claiming he or
ing suicidal behavior is grounded in the cog- she cannot treat suicidal behavior is, as one
nitive therapy model. Cognitive therapy (CT) author wrote, “akin to an internist offering
originally confronted suicide as part of the to perform routine physicals as long as the
treatment of depression (e.g., Beck, Rush, patient does not present with a life-threaten-
Shaw, & Emery, 1979) and it has continued ing illness” ( Jobes, 2000, p. 10). Still, there
to evolve as a useful and integrative treat- are times when a solid clinical rationale may
ment approach for suicidal behaviors (Ellis, dictate that the patient no longer should
1986; Ellis & Newman, 1996; Rudd, 2000; work with the same therapist, as described
Rudd, Joiner, & Rahab, 2001). While under- below.
standing suicidal behaviors (and other behav-
iors) via a bio-psycho-social model, cognitive Making an Appropriate Referral
therapists place a premium on understanding
each patient’s unique matrix of beliefs insofar There are times when therapists may
that they contribute to the maintenance of legitimately choose to discontinue their work
self-destructive impulses. with a given patient following his or her sui-
cide attempt. Based on the ethical principles
outlined by Thompson (1990), we suggest
MEETING EACH OTHER AGAIN the following examples.

Although the aim of this paper is to 1. A referral to a more experienced cli-

discuss guidelines for reestablishing the ther- nician or intensive treatment pro-
apeutic alliance following a patient’s suicide gram is ethically indicated when, for
attempt, many clinicians struggle with the example, the suicide attempt brings
question of whether to resume treatment with to light new clinical data that change
these patients at all. Some therapists refuse the diagnostic picture, such as an
to treat suicidal patients, claiming that the emergent manic or psychotic epi-
treatment of suicidality falls outside the sode, or ongoing substance abuse.
bounds of their professional competencies The patient’s level of functioning
( Jobes, 2000). Some clinicians consider high and risk for self-harm may have
lethality behaviors as violations of the thera- worsened, thus requiring more spe-
peutic contract in general, or an explicit anti- cialized or comprehensive clinical
suicide contract in particular, and may termi- attention than the current therapist’s
nate treatment outright with patients who practice environment can provide. If
engage in these activities. Generally speak- a prompt transfer to a more appro-
ing, a blanket policy of this sort is inadvis- priate treatment setting can be made,
able. It is our view that the therapist—with this may be advantageous for the pa-
few exceptions—should assume that she or tient.
he remains the outpatient therapist of record 2. A transfer to a new clinician is ap-
with all the attendant professional responsi- propriate when there is compelling
bilities, at least until the acute crisis has sub- evidence that the patient’s suicidal
sided and the patient’s condition has been behaviors represent repetitive at-
stabilized for a reasonable period of time. tempts to maintain an unhealthy de-
Suicide contracts, in the absence of a collabo- pendency on a given therapist, even
416 After the Attempt

when insufficient progress is being tient’s questions and concerns can be ad-
made and alternative treatments have dressed on the spot to minimize potential
been offered. In such cases, it may misinterpretations, including the patient’s
be argued that a continuing associa- view that he or she is being “dumped” or
tion between the patient and the otherwise punished. A final session allows the
therapist of record may in fact be therapist and patient the chance to finish on
iatrogenic, inasmuch as the auton- a positive note and, if appropriate, to arrange
omy of the patient is not being fos- for specific number of transitional sessions
tered, and risk remains high. until the patient gets started with a new clini-
3. Termination of treatment is permis- cian. Nevertheless, even if all of the above is
sible when the therapist has reason handled well, the patient may still feel aban-
to feel personally threatened by the doned, especially if this represents a lifelong
patient. Thankfully, such instances psychological issue.
are rare, but when therapists fear for
their safety, they are within their Updated Ground Rules
ethical purview to withdraw from for the Resumption of Treatment
further contact with the patient.
Still, it is helpful if they serve as The aforementioned stipulations for
consultants and facilitators in sug- referrals notwithstanding, the clinician who
gesting more intensive interventions is prepared to continue treatment with the
elsewhere. patient need not feel obliged to resume ther-
apy without renegotiating some minimal
Weighing the different variables af- conditions for doing so. This is an opportu-
fecting the decision of whether or not to con- nity to revise the ground rules for treatment
tinue treating a patient who has attempted in light of the emergency that took place.
suicide can be difficult. When the issue is not Presumably, the old ground rules were not
clear-cut, it is prudent to have a formal con- sufficient to prevent a near catastrophe, and
sultation with a professional colleague (which need to be updated.
is then recorded in the patient’s clinical For example, one of our patients re-
chart), who can provide an objective evalua- fused to talk about her experiences years ear-
tion of the situation. In addition to demon- lier as a sexually abused pre-adolescent, stat-
strating good professional practice, this sort ing dramatically that such a focus in therapy
of peer consultation provides the therapist would drive her to suicide. Based on this as-
with much-needed support and encourage- sertion, the therapist agreed to steer clear of
ment during a stressful time. this sensitive area, though he asked permis-
When it is determined that a referral sion to revisit the topic at a later date. The
to another therapist is clinically indicated and patient warned him that there would never
ethically appropriate, and the therapist does be a time when it would be safe to discuss the
not feel personally endangered by the pa- incest issue. Some months later, this patient
tient, it is preferable that the therapist and attempted suicide without apparent warning.
patient discuss the issues of termination and When she was released from the hospital to
referral face to face (perhaps in the presence the outpatient therapist’s care, the therapist
of the patient’s spouse, parent, or other im- used the observation that not talking about
portant person, with the patient’s permis- the abuse history had not had the intended
sion). This format allows the therapist to effect of reducing her suicide risk. Conse-
share with the patient his or her professional quently, he proposed that he and the patient
recommendations and rationale for referrals needed to unite forces and treat her suicidal-
to other treatment providers better suited to ity aggressively, including the need for all
the patient’s needs (e.g., “Dr. Smith special- topics to be fair game in therapy, including
izes in treating bipolar disorder”). The pa- her abuse history.
Ramsay and Newman 417

The reformulation of therapy ground TABLE 1

rules can be done in a constructive, positive Clinical Guidelines for Resuming Psychotherapy
manner, emphasizing the protective value for After a Patient’s Suicide Attempt
patients while also noting the patients’ active
responsibilities in collaborating with their • Confirm that the patient wishes to continue
therapy with the same therapist. With few ex-
professional and personal caregivers, as well
ceptions, be willing to resume treatment.
as taking care of themselves. At the same • Review any new clinical information arising
time, therapists may choose to set more strin- from the patients suicide attempt that might ne-
gent limits, explaining that certain patient be- cessitate a referral on ethical grounds. If in
haviors deemed to be counter-therapeutic doubt, consult with a professional peer.
will have predictable consequences. For ex- • If a transfer of care is ethically indicated, take
ample, in the first session following a pa- appropriate steps to facilitate the patient’s
tient’s alcohol-induced, impulsive suicide at- smooth transition to a new mental health profes-
tempt, the therapist may state that, “If you sional.
call me while inebriated and suicidal, I will • In light of the suicide attempt, clarify and/or
call the police first, and talk to you second.” modify the ground rules for continued therapy
with the patient.
When taking such a stance, it is advisable for
• Define the basic expectations for treatment ad-
the therapist to adopt a nonpunitive tone and herence and discuss the patient’s and therapist’s
to explain her or his therapeutic rationale mutual and distinct responsibilities in psycho-
with equanimity. therapy.
An overview of ground rules should • Communicate these guidelines in a positive, col-
also include a review of procedures for han- laborative manner.
dling cancellations, missed appointments,
and unanswered or unreturned phone calls
(e.g., in response to pre-arranged phone
check-ins as a means of risk management). cide attempt, the therapist might question
The therapist can articulate expectations for the patient’s ability or willingness to commit
regular attendance, including the minimum to treatment, and to abstain from active sui-
requirements for being considered “in treat- cidality. At the same time, the patient may
ment,” and a patient’s responsibilities for col- harbor doubts about whether the treatment
laboration with treatment recommendations. in general or the therapist in particular can
Clinicians also reaffirm their commitment to be effective. Further, the patient may not be-
the therapeutic process by highlighting (ver- lieve that the therapist truly wants to help
bally, and documenting in the chart) their (e.g., “You must hate me now”), and/or may
availability for sessions, appropriate proce- assume that the therapist will recommend
dures for between sessions and emergency hospitalization at the first hint of subsequent
contacts, and realistic expectations for the suicidality. These thoughts may greatly in-
length and outcome of therapy. (See Table 1 hibit the patient’s willingness to be forth-
for a summary of clinical guidelines for re- coming.
suming psychotherapy following a patient’s
suicide attempt.) Address the Issue of Therapeutic
Trust Directly

REBUILDING TRUST At the outset of the session in which

the therapist broaches the issue of reestab-
Of course, the agreement to resume lishing mutual trust following the patient’s
treatment, even under renegotiated terms, suicide attempt, it is helpful if they respect-
brings to the forefront the issue of trust be- fully address the following questions: Why
tween the patient and the therapist. Based on did the patient attempt suicide, and why did
the still fresh experience of the patient’s sui- she or he not take the agreed-upon precau-
418 After the Attempt

tionary steps, such as contacting the therapist “buttons” (e.g., schemas, see Young, 1999) in
beforehand? The therapist can lay the ground- order to avoid needlessly pressing them (and
work for the discussion by acknowledging the it allows the therapist to recognize his or her
sensitive nature of the topic, stating that it is own “buttons” related to suicide, e.g., Rudd
one to be dealt with in a collaborative spirit, & Joiner, 1997). A good case conceptualiza-
and expressing the hope that facing it will tion allows the therapist to hypothesize the
allow the patient’s treatment to resume in a reasons for a patient’s suicide attempt in a
positive way. Introducing the session agenda nonjudgmental, clinically astute manner.
in this manner implicitly demonstrates that Consequently, chances are improved that the
the therapist will neither deny nor shy away patient will feel understood, will not feel
from the topic of the patient’s suicide at- blamed or shamed, and will be willing to
tempt. level with the therapist about future suicidal
impulses before self-harming actions are taken.
Strive for a Better Understanding For example, Arnie had been appar-
of Each Other’s Actions ently doing well in therapy, when he unex-
pectedly tried to asphyxiate himself in his ga-
When the therapist is committed to rage. Later, the therapist tried to understand
the establishment and maintenance of a col- Arnie’s subjective experience leading up to
laborative therapeutic relationship, adverse the suicide attempt so as to conceptualize the
events in therapy do not necessarily have to behavior, rather than simply assuming that
damage or end a productive course of treat- Arnie had been blithely withholding infor-
ment. For example, circumstances involving mation about his level of risk. Arnie revealed
misinformation or resistance by the patient that his depression had been worsening
can be treated as a clinical matter and, when steadily over the past few weeks, but “nobody
handled sensitively and effectively, can bolster seemed to notice.” Indeed, a review of his re-
therapeutic trust and bring about positive cent Beck Depression Inventory scores (BDI;
change in the patient’s beliefs and behaviors Beck, Ward, Mendelson, Mock, & Erbaugh,
(Newman, 1994). Rather than rebuking the 1961) showed a steady worsening of symp-
patient for counter-therapeutic self-destruc- toms. Unfortunately, his presentation in ses-
tive behavior, therapists can try to put the pa- sion—and to the world at large—remained
tient’s suicidality into the context of a revised unchanged, and nobody noticed his decline.
case conceptualization and a better under- The therapist was able to posit that Arnie was
standing of the patient’s unique experience of still ashamed to admit his depressed feelings
and beliefs about suicide (e.g., Jobes, 2000; (something he had acknowledged earlier in
Rudd, 2000). treatment), but he hoped that others would
The case conceptualization is the inte- divine his condition unsolicited. When this
grated understanding of the patient’s present- did not happen, Arnie experienced the activa-
ing problems, the relevant developmental tion of his schemas of unlovability and aban-
history explaining the etiology of the clinical donment (cf. Young, 1999), and went to the
issues, and reasonable predictions of appro- extreme of attempting suicide to call atten-
priate interventions and future functioning tion to the personal misery that “nobody
(Beck, 1995; Persons, 1989). When facing cared to notice.” The therapist was also able
problematic points in therapy, the case con- to own up to the fact that he had not made
ceptualization is a useful tool for ferreting Arnie’s BDI scores a big issue in previous ses-
out the issues underlying resistance, misper- sions, and perhaps this was an error. This
ceptions, and strong negative affect the pa- conceptualization was instructive and non-
tient may have about therapy and the alli- stigmatic, allowing the patient and therapist
ance. It also allows the therapist to be aware to share responsibility for what had taken
of and sensitive to the patient’s emotional place, and leading to a new agreement—the
Ramsay and Newman 419

therapist would (from now on) always com- help suggestions won’t work for me because
ment on Arnie’s BDI scores, and Arnie would, I’m defective” or “I can’t handle things on
in turn, agree to reveal future suicidal ide- my own and only my therapist’s advice can
ation verbally and preemptively. help me”).
Similarly, the therapist can go to ex- For example, in the first session after
tended lengths to help his or her patients get being discharged from the hospital after
a better conceptualization of the therapist’s making an impulsive suicide attempt, one of
behavior, feelings, and thoughts pertinent to our patients said that the activating event for
the suicidal crisis. To this end, the therapist his attempt had been reading a flyer announ-
can use judicious self-disclosure pertinent to cing a luncheon held at the therapist’s clinic,
her or his clinical decision-making and emo- sponsored by a pharmaceutical company.
tional reaction to the suicide attempt. The The therapist gently and persistently in-
goals are to improve the patient’s under- quired about the meaning of the luncheon
standing of the therapist’s intentions, and for the patient. What slowly unfurled was a
perhaps to provide crucial feedback about the series of mistrustful interpretations and be-
effects of the patient’s suicidal behavior on liefs that culminated in the patient’s judg-
others. While doing so, the therapist can ment that, “My therapist is a puppet of the
maintain an empathic stance regarding the pharmaceutical industry who will eventually
patient’s thoughts and feelings, while still giv- refer me for medication management only.
ing frank, straightforward feedback. He does not care about me and he cannot be
For example, following Arnie’s return trusted.” The upshot of the session was that
to treatment, his therapist acknowledged that the patient had felt abandoned by previous
he was now more wary—perhaps even fright- helping professionals and felt particularly
ened—about the patient’s condition. He ex- vulnerable, even as he had been making
plained how unsettling it was not to be able progress in therapy and was developing trust
to fully trust Arnie’s condition at face value. in the therapist. The conceptualization of the
As the therapist noted, “I would much rather patient’s beliefs (i.e., schemas) about vulnera-
have a solid, unshakeable confidence in your bility, abandonment, and mistrust (and their
ongoing recovery from depression than cast relation to suicidal thoughts) set the stage for
a suspicious eye about how you’re really do- these themes to be the thrust of subsequent
ing at every appointment, but that may be sessions.
the safest way to proceed, at least until you In other cases, however, there may be
feel comfortable enough to wear your true stronger negative affect directed by the pa-
emotions and intentions on your sleeve.” tient toward the therapist (e.g., “You don’t
Some patients readily express their seem to have a clue as to how to help me”),
opinions about the treatment relationship, either explicitly or implicitly. The therapist
the therapy process, and factors contributing may have to draw on strong empathic listen-
to the recent suicide attempt. These factors ing and communication skills to handle criti-
can often be understood as mistrust of self- cal feedback or outright expressions of anger.
help techniques (e.g., “I just knew that calling In yet other cases, the therapist may have to
up a friend or writing out my thoughts would be sensitive to contradictions or nonverbal
not have made any difference”) or mistrust of communication that might suggest ambiva-
therapy support (e.g., “I did not page the on- lence or outright hostility toward the thera-
call therapist because I did not want to talk pist. Finally, the therapist would do well to
with someone who does not know me”). Re- bear in mind that patients may feel easily
inforcing the importance of making use of ashamed in such situations, thus, it is impor-
available therapeutic resources and exploring tant to communicate in a way that allows the
the source of mistrust might reveal deeper patient to “save face.” (See Table 2 for a sum-
beliefs that could affect therapy (e.g., “Self- mary of clinical guidelines for addressing the
420 After the Attempt

TABLE 2 coping skills. The revised case conceptualiza-

Clinical Guidelines for Addressing the Issue tion also can highlight the changes in the pa-
of Trust in Psychotherapy After a Patient’s tient’s belief system that need to be made in
Suicide Attempt order to reduce the risk for future suicide
(e.g., “Even if I cannot reach my therapist in
• Explicitly discuss the issue of trust in therapy a crisis, I have the skills to manage it, and
during a session following the patient’s suicide
to wait safely until tomorrow’s session”). The
attempt.
• Set the stage for discussing trust issues by ac-
therapist can encourage the patient to make
knowledging it may be a difficult topic to ex- a fresh start in therapy, utilizing past prob-
plore. lems in therapy as useful learning experi-
• Share and elicit feedback from the patient about ences, and the therapist and patient can move
his/her views of the therapeutic alliance. forward with renewed energy and hope.
• Maintain a nondefensive tone when dealing with
the patient’s expressions of mistrust and general Deconstructing the Suicide Attempt
negative feedback.
• To increase understanding, revise the case con- The recent suicide attempt offers an
ceptualization by incorporating clinical data aris- opportunity to explore the patient’s expecta-
ing from the most recent suicide attempt.
tions for what his or her completed suicide
• Explain the clinical rationale for the therapist’s
would have achieved. The patient’s responses
actions prior to, during, and after the patient’s
emergency. often are along the lines of “I wanted to es-
• Reframe patient’s mistrustful interpretations of cape my problems,” “I wanted people to see
the above. how sorry they would be when I was gone,”
• Regularly monitor the status of the therapeutic or “I wanted to make the pain stop.” The
alliance. therapist and patient can reframe the pa-
tient’s expectations into therapeutic goals
such as, “I want to solve some of my prob-
lems,” “I want to have better relationships
issue of trust in psychotherapy following a with others,” and “I want to feel better.” Al-
patient’s suicide attempt.) ternative strategies that do not require the
extreme behavior of suicide can be fashioned
for obtaining such ends. What’s more, the re-
REFORMULATING alization that the actual outcome of suicide
THE TREATMENT PLAN would not necessarily bring about the pa-
tient’s desired results creates cognitive disso-
Part of the process of resuming a pro- nance that might weaken a suicidal impulse
ductive course of therapy involves spelling (Ellis & Newman, 1996; Freeman & Rein-
out a revised treatment plan, updated in light ecke, 1993).
of the suicide attempt and its signal that Such explorations of the patient’s be-
something more and/or different is needed in liefs set the tone for subsequent clinical in-
therapy. The new treatment plan should terventions (e.g., Jobes, 2000; Rudd, 2000).
make overt use of the revised case conceptu- The stressful life circumstances the patient
alization, demonstrating how the suicide at- faces can be acknowledged, but the patient’s
tempt could be accounted for by the patient’s inference that “my problems are too over-
unique psychological vulnerabilities. Further, whelming for me to handle” can be gently
it can include interventions that will most questioned. Simply listing out the distinct
likely help the patient make the changes that problems the patient faces can help to decat-
are most needed, such as increasing self-effi- astrophize them, as each problem can be
cacy, hopefulness, trust in benevolent others, framed in specific behavioral terms (coupled
and a willingness to invest in the learning of with coping options) rather than as a general-
Ramsay and Newman 421

ization. For example, there is a palpable dif- invested in supporting the patient’s well-
ference between “I’m on the verge of losing being. It is clinically advantageous to elicit
my job and going broke” and “My boss their support, as they may be more likely to
seemed concerned about the amount of time be on the scene to help the patient during a
I took off from work (for my hospitalization) crisis. Therapists can encourage patients to
and I don’t know what to tell him because provide written consent to involve such per-
I’m afraid he’ll fire me.” sons in their treatment, with specific parame-
The patient’s reasons for dying are of- ters collaboratively negotiated in session.
ten cognitively well rehearsed. The interven- The participation of the patient’s significant
tion of formulating reasons for living may others provides another source of observa-
modify hopeless attitudes and be a protective tional data about the patient’s functioning
factor against further suicidal acts (Ellis & and follow-through on therapeutic recom-
Newman, 1996; Linehan, Goodstein, Niel- mendations. As we try to make clear to pa-
sen, & Chiles, 1983; Malone et al., 2000). In tients, identifying the need for and request-
addition to the assessment and therapeutic ing appropriate assistance are adaptive coping
benefits of compiling such a list (e.g., Jobes skills in line with the goals of therapy.
& Mann, 1999), patients should be encour- The inclusion of significant others in
aged to maintain a copy of it for reference the treatment team might be a suggestion
as a coping strategy when they encounter a welcomed by the patient; however, it is im-
recurrence of suicidal thoughts and hopeless- portant to be mindful of the patient’s rela-
ness about the future. tionship with her or his support system and
to determine whether the members’ partici-
Expanding the Treatment Team pation would indeed support the patient’s
well-being or would, instead, jeopardize it. In
The reworking of the treatment plan some cases, the patient’s experience of the
may well reveal that outpatient psychother- family involves memories of abuse or other
apy alone is insufficient to help the patient dysfunctional behaviors from which the pa-
achieve his or her treatment objectives; addi- tient is trying to gain distance. It is important
tional professional services may be needed. to thoroughly explore the pros and cons for
The treatment team approach is prudent including specific individuals in treatment
clinical practice when the patient has diverse and to proceed with this plan only with the
clinical needs, each requiring specialized at- patient’s explicit permission (short of an emer-
tention (Bongar, 2002). If the patient has not gency).
already been assessed for medications, a psy- The appropriate role of a willing sup-
chiatric referral may be indicated. There may port person needs to be clearly delineated. As
be other therapeutic services such as group the goal for treatment is to help the patient
therapy, day hospital programs, case manage- develop skills for handling his or her life and
ment, vocational rehabilitation, and 12-step emotions, it would be counter-therapeutic if
programs that help spread out the clinical re- the patient continues to expect that others
sponsibilities and provide appropriate com- will be responsible for his or her behavior.
prehensive care. Maintaining open lines of The scope of the support person’s involve-
communication among these professionals ment (e.g., frequency of sessions attended,
further promotes the sense of teamwork and duration of participation) can be negotiated
collaboration, and reflects good risk manage- with the help of the patient. In the absence
ment. of an acute crisis, patients determine how
Another potential source of aid comes much of their clinical information should be
from members of the patient’s personal sup- openly disclosed to the support persons, as
port system. These individuals may have fre- the latter do not have carte blanche access to
quent contact with the patient and may be confidential data without the patients’ explicit
422 After the Attempt

permission. At the same time, it may be em- guidelines for reformulating a treatment plan
phasized that it can be advantageous to treat- following a patient’s suicide attempt.)
ment if patients’ important others provide in-
formation pertinent to their care, such as the
patient’s level of functioning between ses- FUTURE DIRECTIONS
sions and medication compliance.
By including significant others into the Researching the role of the therapeutic
team, clinicians help to engender the good alliance after a patient’s attempt suffers all the
will sense that “we are all in this together.” challenges of suicidological research in gen-
The patient’s important others get the op- eral: suicidal behavior has a relatively low
portunity to see the therapist as a real person base rate, is difficult to predict and, conse-
who is acting professionally and who is sin- quently, much research is conducted only
cerely trying to help. Such a scenario is far after the attempted or completed suicide.
more favorable than when the patients’ fam- The first step in this area of research would
ily members view the therapist as an anony- be to collect data regarding the frequency
mous figure, knowledge of whom is gained with which suicide attempters resume ther-
only via the patient’s report (e.g., Bongar, apy with the same therapists. Surveys of prac-
2002). The notion of teamwork notwith- ticing clinicians and of suicide attempters
standing, it should be documented in the would yield more precise epidemiological
clinical record and made explicitly clear dur- data regarding the occurrence of suicide at-
ing a session and in the presence of other tempts in the course of active psychotherapy.
available treatment team members, particu- To gather data on the prophylactic ef-
larly support persons, that the patient is ulti- fects of the therapeutic alliance on suicidal
mately responsible for using the therapeutic behavior would require ongoing assessment
supports and following through on treatment of relationship factors and risk factors for sui-
recommendations (e.g., Ellis & Newman, cide throughout treatment, such as using
1996). (See Table 3 for a summary of clinical both patient and therapist assessments of the
alliance and their correlation with suicidal
symptoms. Even more useful would be to
have these sessions recorded (video and/or
TABLE 3 audio) to allow for the assessment (via coding
Clinical Guidelines for Reformulating a Treatment by raters) of crucial factors affecting the
Plan After a Patient’s Suicide Attempt treatment alliance. Clinical trials for de-
pressed and/or suicidal patients can readily
• Use the revised case conceptualization to update incorporate these measurements. Data of this
the treatment and safety plans. sort would allow researchers to (1) compare
• Review the events leading up to the suicide at- patients who attempt suicide during the
tempt for lessons to be learned that could in-
course of treatment with those patients who
form ongoing clinical safeguards and interven-
tions.
do not on measures of the treatment alliance;
• Review the effects of the suicide attempt on the and (2) determine relationship factors, if any,
patient’s subjective reasons for living and dying. that differentially predict a patient’s response
• Identify the residual problems the patient is fac- to the resumption of therapy with the same
ing after the suicide attempt and use a problem- therapist after an attempt.
solving approach to address them. The aim of this paper has been to pro-
• Consider the additional therapeutic and support vide clinically useful guidelines for resuming
services that might be required to promote the psychotherapy with a patient who has at-
patient’s safety and improved functioning. tempted suicide during the course of treat-
• Coordinate efforts with the other members of ment. Although this aspect of psychotherapy
the treatment team, ideally with the full partici-
has received little attention in the literature,
pation of the patient.
it is one that appears highly relevant for
Ramsay and Newman 423

many practicing clinicians. We have outlined tention to these matters will help clinicians
clinical strategies pertinent to resuming treat- effectively face the stressful proposition of
ment, reestablishing a sense of mutual trust resuming therapy with patients who have re-
in the therapeutic relationship, and reformu- cently made a serious suicide attempt, and to
lating the treatment plan. We hope that at- reduce the risks for both parties.

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Cognitive and Behavioral Practice 19 (2012) 256-264

www.elsevier.com/locate/cabp

Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk

Barbara Stanley, Columbia University College of Physicians & Surgeons
and New York State Psychiatric Institute
Gregory K. Brown, University of Pennsylvania School of Medicine

The usual care for suicidal patients who are seen in the emergency department (ED) and other emergency settings is to assess level of risk
and refer to the appropriate level of care. Brief psychosocial interventions such as those administered to promote lower alcohol intake or to
reduce domestic violence in the ED are not typically employed for suicidal individuals to reduce their risk. Given that suicidal patients
who are seen in the ED do not consistently follow up with recommended outpatient mental health treatment, brief ED interventions to
reduce suicide risk may be especially useful. We describe an innovative and brief intervention, the Safety Planning Intervention (SPI),
identified as a best practice by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention Best Practices
Registry for Suicide Prevention (www.sprc.org), which can be administered as a stand-alone intervention. The SPI consists of a written,
prioritized list of coping strategies and sources of support that patients can use to alleviate a suicidal crisis. The basic components of the
SPI include (a) recognizing warning signs of an impending suicidal crisis; (b) employing internal coping strategies; (c) utilizing social
contacts and social settings as a means of distraction from suicidal thoughts; (d) utilizing family members or friends to help resolve the
crisis; (e) contacting mental health professionals or agencies; and (f) restricting access to lethal means. A detailed description of SPI is
described and a case example is provided to illustrate how the SPI may be implemented.

A ssessing risk for suicide is a crucial component of

evaluations aimed at treatment disposition and
planning for individuals with psychological problems.
patients who are experiencing some measure of suicidal
feelings is the fact that many suicidal individuals do not
attend recommended outpatient treatment following the
Although clinical practice guidelines have been published ED visit (Craig et al., 1974; Krulee & Hales, 1988; Litt,
for conducting suicide risk assessments in emergency Cuskey, & Rudd, 1983; Rudd, 2006). Intervening in the
settings (American Psychiatric Association, 2003), current ED with suicidal individuals is important because between
standards of care do not include providing brief 11% and 50% of attempters refuse outpatient treatment
psychosocial interventions for suicidal patients in the or drop out of outpatient therapy very quickly (Kessler,
emergency department (ED) or other acute care settings Berglund, Borges, Nock, & Wang, 2005; Kurz & Moller,
(Allen, Forster, Zealberg, & Currier, 2002). Typically, 1984). Furthermore, up to 60% of suicide attempters
when suicidal patients are evaluated in the ED and attend only 1 week of treatment postdischarge from the
hospitalization is not clinically indicated, they are ED (Granboulan, Roudot-Thoraval, Lemerle, & Alvin,
provided with a referral for outpatient mental health 2001; Kurz & Moller, 1984; Litt et al., 1983; O'Brien,
treatment (Allen et al., 2002). Holton, Hurren, & Watt, 1987; Piacentini et al., 1995;
The “assess and refer” approach can be disconcerting Spirito, Stanton, Donaldson, & Boergers, 2002; Trautman,
to patients and their families as well as to clinicians Stewart, & Morishima, 1993). Of those suicide attempters
making disposition plans, and such concerns may be who attend treatment, 38% terminate within three
exacerbated by the potential for dire consequences months (Monti, Cedereke, & Ojehagen, 2003), a statistic
associated with not hospitalizing patients who may that is particularly troubling because the first three
actually need it. Adding to the anxiety of discharging months following a suicide attempt is when individuals
are at the highest risk of additional suicidal behavior
(Monti et al., 2003).
Thus, conducting a brief “treatment” when the suicidal
Keywords: suicide; suicide prevention; safety plan; safety plan patient is present in the ED may be valuable and is
intervention; suicide-related coping consistent with the way in which most medical conditions
1077-7229/11/256–264$1.00/0 are addressed in the ED. Treatment of acute medical
© 2011 Association for Behavioral and Cognitive Therapies. problems in the ED most often includes some form of
Published by Elsevier Ltd. All rights reserved. immediate intervention.
 Safety Planning to Mitigate Suicide Risk 257

Clinicians are beginning to recognize the ED setting as enable them to resist or decrease suicidal urges for brief
an opportunity to provide brief interventions for mental periods of time, then the risk for suicide is likely to decrease.
health problems (D'Onofrio, Pantalon, Degutis, Fiellin, & Similar approaches to addressing acute suicidal crises
O'Connor, 2005; Rotheram-Borus, Piacentini, Cantwell, have been developed by others, predominantly in the
Belin, & Song, 2000). For example, D'Onofrio and her context of ongoing outpatient or inpatient care, but not as
colleagues developed a 10- to 15-minute intervention stand-alone interventions. For example, Rudd and his
approach—Screening, Brief Intervention, and Referral to colleagues developed the crisis response plan that empha-
Treatment (SBIRT)—to counsel problem drinkers who sizes what patients will do during a suicidal crisis (Rudd,
visit the ED. The SBIRT intervention includes: (a) a Joiner, & Rajab, 2001). The crisis response plan is part of a
screening component to quickly assess the severity of cognitive behavioral therapy intervention that is aimed at
substance use and identify the appropriate level of reducing suicide risk. It involves helping patients to identify
treatment, (b) a brief intervention focused on increasing what triggers the crisis, use skills to tolerate distress or
insight and awareness regarding substance use and regulate emotions, and, should the crisis not resolve, access
motivation toward behavioral change, and (c) a referral emergency care. Specifically, the crisis response plan is a
for those identified as needing more extensive treatment. series of therapeutic interventions that ensures the safety of
We have developed a similar, innovative and brief the patient by removing access to lethal means; initiating
treatment, the Safety Planning Intervention (SPI), for self-monitoring of the suicidal thoughts, feelings, and
suicidal patients evaluated in the ED, trauma centers, crisis behaviors; targeting symptoms that are most likely to
hot lines, psychiatric inpatient units, and other acute care interrupt day-to-day functioning; targeting hopelessness
settings Stanley, B. & Brown, G. K. (with Karlin, B., Kemp, and sense of isolation, reinforcing the commitment to
J. E, VonBergen, H. A.) (2008). The SPI has its roots in CT treatment and solidifying the therapeutic relationship.
tested by Brown et al. (2005), further expanded by Stanley Similarly, David Jobes uses a safety plan approach in the
& Brown (2006) and then adapted for use by high suicide context of his approach, Collaborative Assessment and
risk Veterans (Stanley & Brown, 2008a) and depressed, Management of Suicidality (CAMS), a psychotherapeutic
suicidal adolescents in CBT for Suicide Prevention (CBT- approach for managing suicidal patients, in both outpatient
SP) (Stanley et al., 2009). SPI has been determined to be a and inpatient settings (Jobes, 2006). The CAMS safety plan
best practice by the Suicide Prevention Resource Center/ focuses on whom to call during a suicidal crisis and
American Foundation for Suicide Prevention Best Practices cleansing the environment of means to commit suicide.
Registry for Suicide Prevention (www.sprc.org). Further- Both safety plans and crisis response plans have been
more, this intervention can be used in the context of used as therapeutic strategies in the context of other short-
ongoing outpatient treatment or during inpatient care of term, empirically supported treatments that have been
suicidal patients. In this paper, the SPI is described in detail found to reduce suicide risk, such as cognitive therapy
and a case example is provided to illustrate how the safety (Brown et al., 2005; Wenzel, Brown, & Beck, 2009) or
plan may be implemented. cognitive behavior therapy for suicide prevention (CBT-SP;
Stanley et al., 2009). However, to our knowledge, the use of
Rationale for the Safety Planning Intervention (SPI) a safety planning intervention as a single-session, stand-
as a Clinical Intervention alone intervention for emergency care settings has not been
Recognizing that, despite best efforts, some patients will explicitly described. Yet other novel targeted interventions
not seek treatment following an emergency evaluation for a have been proposed. Rotheram-Borus et al. (2000) tested
suicidal crisis, and further recognizing that there is an an ED intervention for suicidal adolescents that involved
inevitable lag between an ED evaluation and outpatient psychoeducation about the importance of treatment in
mental health appointments, we suggest that the ED visit or suicidal teens for both the ED staff and the patients. Kruesi
other acute care setting may serve as a valuable opportunity et al. (1999) and McManus et al. (1997) developed
to conduct a brief intervention that may reduce further psychoeducation programs that stressed the need to restrict
suicidal behavior. Furthermore, given that suicidal crises may access to means when there was a suicidal adolescent in the
be relatively short-lived and have an ebb and flow pattern, an home. Sneed, Balestri, and Belfi (2003) adapted dialectical
intervention that assists patients in coping with such crises behavior therapy (DBT) skills in a single-session format for
may be particularly useful, even if the intervention is only the ED. Despite these proposed interventions, the standard
used for a brief period of time until the crisis diminishes. For of “assess and refer” approach to care remains.
example, the effectiveness of means restriction is largely While other efforts at safety planning have been
based on the fact that suicidal thoughts tend to subside over described in the literature, the SPI is unique in that it is a
time and that making it more difficult for patients to act on systematic and comprehensive approach to maintaining
these thoughts would be a helpful preventive measure safety in suicidal patients. Prior efforts have primarily focused
(Daigle, 2005). Similarly, if patients are given tools that on a single aspect of safety (e.g., means restriction or
258 Stanley & Brown

emergency contacts). Furthermore, the explicit focus on thoughts reemerge. The intent of the safety plan is to help
utilizing internal coping and distracting strategies as a step in individuals lower their imminent risk for suicidal behavior
an emergency plan to deal with suicidal urges is not typically by consulting a predetermined set of potential coping
an aspect of most safety plan efforts even though it is an strategies and a list of individuals or agencies they may
aspect of therapies targeting suicidal feelings (e.g., CT and contact; it is a therapeutic technique that provides
DBT). patients with more than just a referral at the completion
of the suicide risk assessment during an emergency
Safety Planning vs. No-Suicide Contract
evaluation. By following a predetermined set of internal
Another type of brief intervention that is provided for coping strategies, social support activities, and help-
suicidal patients is a “no-suicide contract.” This intervention seeking behaviors, patients have the opportunity to
is a written or verbal agreement between the clinician and evaluate those strategies that are most effective. While we
patient requesting that the patient refrain from engaging in recommend that the interventions be followed in a
suicide behavior. The SPI is quite different from a no-suicide stepwise manner, it is important to note that if a patient
contract intervention given that the no-suicide contract does feels at imminent risk and unable to stay safe even for a
not necessarily provide detailed information about how brief time, then the patient should immediately go to an
patients should respond if they become suicidal. emergency setting. Furthermore, some patients may feel
A no-suicide contract usually takes the form of asking that they cannot or do not wish to use one of the steps in
patients to promise not to kill themselves and to contact the safety plan. In this instance, they should not feel that
professionals during times of crisis (Stanford, Goetz, & they must do so as the intent of the safety plan is to be
Bloom, 1994). In contrast, the safety plan is not presented helpful and not a source of additional stress or burden.
to patients as a no-suicide contract. Despite the anecdotal The SPI is best developed with the patient following a
observation that no-suicide contracts may help to lower comprehensive suicide risk assessment (cf. American
clinician anxiety regarding potential suicide risk, there is no Psychiatric Association, 2003). During the risk assessment,
empirical evidence to support the effectiveness of no- the clinician should obtain an accurate account of the
suicide contracts for preventing suicidal behavior (Kelly & events that transpired before, during, and after the recent
Knudson, 2000; Reid, 1998; Shaffer & Pfeffer, 2001; suicidal crisis. Patients typically are asked to describe the
Stanford et al., 1994). To our knowledge, there are no suicidal crisis, including the precipitating events and their
randomized controlled trials (RCTs) that have examined reactions to these events. This review of the crisis
the efficacy of no-suicide contracts for preventing suicide or facilitates the identification of warning signs to be
suicide attempts. There have been a few studies that have included in the safety plan and helps to build rapport.
examined the clinical utility of no-suicide contracts, but Consistent with an approach described by Jobes (2006), a
findings have been inconsistent (Drew, 2001; Jones, collaborative stance is most effective for developing the
O'Brien, & McMahon, 1993; Kroll, 2000; Mishara & Daigle, safety plan. The basic components of the safety plan
1997). The methodological problems with these studies and include (a) recognizing warning signs of an impending
the lack of RCTs have led to the conclusion that there is no suicidal crisis; (b) employing internal coping strategies;
empirical support for the efficacy of this intervention. (see (c) utilizing social contacts as a means of distraction from
Rudd, Mandrusiak, & Joiner, 2006). Clinical guidelines also suicidal thoughts; (d) contacting family members or
caution against using no-suicide contracts as a way to coerce friends who may help to resolve the crisis; (e) contacting
patients not to kill themselves, as it may obscure the mental health professionals or agencies; and (f) reducing
determination of the patients’ actual suicidal risk (Rudd et the potential use of lethal means. The first five compo-
al., 2006; Shaffer & Pfeffer, 2001). For example, patients nents are employed when suicidal thoughts and other
may withhold information about their desire to kill warning signs emerge. Reducing access to means is
themselves for fear that they will disappoint their treating discussed after the rest of the safety plan has been
clinicians by violating the contract. Rather, the SPI is completed, often with the aid of a family member or
presented as a strategy to illustrate how to prevent a future friend, for an agreed upon period of time. Each of these
suicide attempt, and identifies coping and help-seeking steps is reviewed in greater detail below.
skills for use during times of crisis.
Methods Recognition of Warning Signs
The first step in developing the safety plan involves the
Intervention Description recognition of the signs that immediately precede a
The SPI, a very brief intervention that takes approxi- suicidal crisis. These warning signs include personal
mately 20 to 45 minutes to complete, provides patients situations, thoughts, images, thinking styles, moods, or
with a prioritized and specific set of coping strategies and behaviors. One of the most effective ways of averting a
sources of support that can be used should suicidal suicidal crisis is to address the problem before it fully
 Safety Planning to Mitigate Suicide Risk 259

emerges. Examples of warning signs include feeling their natural social environment who may help to distract
irritable, depressed, hopeless, or having thoughts such themselves from their suicidal thoughts and urges or
as, “I cannot take it anymore.” Similarly, patients can visiting healthy social settings. In this step, patients may
identify problematic behaviors that are typically associat- identify individuals, such as friends or family members, or
ed with suicidality, such as spending increased time alone, settings where socializing occurs naturally. Examples of the
avoiding interactions, or drinking more than usual. latter include coffee shops, places of worship, and
Generally, more specifically described warning signs will Alcoholics Anonymous (AA) meetings. These settings
cue the patient to use the safety plan, than warning signs depend, to a certain extent, on local customs, but patients
that are more vaguely described. should be encouraged to exclude environments in which
alcohol or other substances may be present. In this step,
Internal Coping Strategies
patients should be advised to identify social settings or
As a therapeutic strategy, it is useful to have patients
individuals who are good “distractors” from their own
attempt to cope on their own with their suicidal thoughts,
thoughts and worries. Socializing with friends or family
even if it is just for a brief time. In this step, patients are
members, without explicitly revealing their suicidal state,
asked to identify what they can do, without the assistance of
may assist in distracting patients from their problems and
another person, should they become suicidal again.
their suicidal thoughts; this strategy is not intended as a
Prioritizing internal strategies as a first-level technique is
means of seeking specific help with the suicidal crisis. A
important because internal strategies enhance patients’
suicidal crisis may also be alleviated if patients feel more
self-efficacy and can help to create a sense that suicidal
connected with other people or feel a sense of belonging-
urges can be mastered. This, in turn, may help them feel
ness.
less vulnerable and less at the mercy of their suicidal
thoughts. Such activities function as a way for patients to Social Contacts for Assistance in Resolving Suicidal Crises
distract themselves from the crisis and prevent suicide If the internal coping strategies or social contacts used
ideation from escalating. This technique is similar to those for purposes of distraction offer little benefit to alleviating
described in DBT (Linehan, 1993), a cognitive behavioral the crisis, patients may choose to inform family members
therapy for suicidal individuals with borderline personality or friends that they are experiencing a suicidal crisis. This
disorder that instructs patients to employ distraction step is distinguished from the previous one in that
techniques when they are experiencing intense urges to patients explicitly reveal to others that they are in crisis
make a suicide attempt. Examples of these coping strategies and need support and assistance in coping with the crisis.
include going for a walk, listening to inspirational music, Given the complexity of deciding if patients should or
going online, taking a shower, playing with a pet, exercising, should not disclose to others that they are thinking about
engaging in a hobby, reading, or doing chores. Activities suicide, the clinician and patient should work collabora-
that serve as “strong” distractions vary from person to tively to formulate an optimal plan. This may include
person and, therefore, the patient should be an active weighing the pros and cons of disclosing their suicidal
participant in identifying these activities. Engaging in such thoughts or behavior to a person who may offer support.
activities may also help patients experience some pleasure, Thus, for this step, someone who may help to distract
sense of mastery, or facilitate a sense of meaning in their patients from their suicidal urges may not be the best
lives. However, the primary aim of identifying and doing person for assisting patients with a suicidal crisis when
such activities is to serve as a distraction from the crisis. suicidal thoughts are disclosed. Patients should be asked
After the internal coping strategies have been gener- about the likelihood that they would contact these
ated, the clinician may use a collaborative, problem- individuals and whether these individuals would be
solving approach to ensure that potential roadblocks to helpful or could possibly exacerbate the crisis. If possible,
using these strategies are addressed and/or that alterna- someone close to the patient with whom the safety plan
tive coping strategies are identified. If patients still remain can be shared should be identified and should be named
unconvinced that they can apply the particular strategy on the plan. It should be noted that sometimes patients
during a crisis, other strategies should be developed. are unable to identify someone because they may not feel
Clinicians should help patients to identify a few of these comfortable sharing the plan with family or friends.
strategies that they would use in order of priority; the
Professional and Agency Contacts to Help Resolve Suicidal Crises
strategies that are easiest to do or most likely to be
This component of the plan consists of identifying and
effective may be listed at the top of the list.
seeking help from professionals or other clinicians who
Socialization Strategies for Distraction and Support could assist patients during a crisis. The clinicians’ names
If the internal coping strategies are ineffective and do and the corresponding telephone numbers and/or
not reduce suicidal ideation, patients can utilize socializa- locations are listed on the plan and may be prioritized.
tion strategies of two types: socializing with other people in Patients are instructed to contact a professional or agency
260 Stanley & Brown

if the previous strategies (i.e., coping strategies, contact- clinicians may ask patients to remove or restrict their
ing friends or family members) are not effective for access to these methods themselves when they are not
resolving the crisis. If patients are actively engaged in experiencing a crisis. For example, if patients are
mental health treatment, the safety plan may include considering overdosing, having them ask a trusted family
contact information for this provider. However, the safety member to store the medication in a secure place might
plan should also include other professionals who may be be a useful strategy.
reached, especially during nonbusiness hours. Addition- The urgency and importance of restricting access to a
ally, contact information for a local 24-hour emergency lethal method is more pronounced for highly lethal
treatment facility should be listed as well as other local or methods. For methods of high lethality, such as a firearm,
national support services that handle emergency calls, asking patients to temporarily limit their access to such
such as the national Suicide Prevention Lifeline: 800-273- means themselves by giving it to a family member or other
8255 (TALK). responsible person may be problematic, as patients’ risk
The safety plan emphasizes the accessibility of appro- for suicide may increase further as a result of direct
priate professional help during a crisis and, when contact with the highly lethal method. Instead, an optimal
necessary, indicates how these services may be obtained. plan would be to restrict patients’ access to a highly lethal
The clinician should discuss the patients’ expectations method by having it safely stored by a designated,
when they contact professionals and agencies for assis- responsible person—usually a family member or close
tance and discuss any roadblocks or challenges in doing friend, or even the police (Simon, 2007). Patients who are
so. Patients may be reluctant, at times, to contact unwilling to remove their access to a firearm may be
professionals and disclose their suicidality for fear of willing to limit their access to the firearm by having a
being hospitalized or being rescued using a method that is critical part of the firearm removed or by using a gunlock
not acceptable to them. As with the other components of and having the gunlock key removed. Clinicians should
the plan, the clinician should discuss any concerns or also be aware that restricting access to one lethal method
other obstacles that may hinder patients from contacting does not guarantee patients’ safety because they may
a professional or agency. Only those professionals whom decide to use another one. The specific behaviors
patients are willing to contact during a time of crisis necessary to make the patients’ environment safer should
should be included on the safety plan. be noted on the safety plan and the length of time (e.g.,
1 month, 2 weeks) that this restriction should be in place
Means Restriction can be noted.
The risk for suicide is amplified when patients report a
specific plan to kill themselves that involves a readily
available lethal method (Joiner et al., 2003). Even if no Implementation of the Safety Plan
specific plan is identified by patients, a key component of It is important to note that the SPI should be
the safety plan intervention involves eliminating or administered in a collaborative manner with patients.
limiting access to any potential lethal means in the The coping strategies, external supports and triggers to
environment. This may include safely storing and suicidal urges are generated together by the clinician and
dispensing of medication, implementing firearm safety patient and the patient's own words are used in the
procedures, or restricting access to knives or other lethal written document. The collaborative nature of this
means. In developing a safety plan, means restriction is intervention is essential to developing an effective safety
addressed after patients have identified ways of coping plan. A clinician-generated list of coping strategies is
with suicidal feelings because, if they see that there are unlikely to be helpful to a patient in the absence of
other options to acting on their suicidal urges than knowing what strategies are most compelling for the
committing suicide, they may be more likely to engage in individual. Similarly, “typical” triggers to suicidal feelings
a discussion about removing or restricting access to are not useful if they do not have personal relevance. On
means. Depending on the lethality of the method, the the other hand, the patient is not left alone to struggle
manner in which the method is removed or restricted will with identifying his or her triggers and best means for
vary. Generally, clinicians should ask patients which coping. Instead, clinicians can offer suggestions and
means they would consider using during a suicidal crisis inquire in a supportive manner to help the patient
and collaboratively identify ways to secure or limit access to these complete the intervention.
means. Clinicians should routinely ask whether patients After the SPI is complete, clinicians should assess the
have access to firearms, regardless of whether it is patient's reactions to it and the likelihood he or she will
considered a “method of choice,” and make arrange- use the safety plan. One strategy for increasing patient
ments for securing them. For methods with lower lethality motivation to use the safety plan during a crisis is to ask
(such as drugs or medication with a low level of toxicity), the patient to identify the most helpful aspects of the plan.
 Safety Planning to Mitigate Suicide Risk 261

If the patient reports or the clinician determines that encouraged or coached to follow their safety plan and
there is reluctance or ambivalence to use the plan, then when a higher level of observation or other external
the clinician should collaborate with the patient to identify precaution should be implemented.
and problem solve potential obstacles and difficulties to It is recognized that the application of the SPI will vary
using the safety plan. Role playing the use of the SPI may depending on the population as well. For example, when
be helpful if clinicians have sufficient time available and developing safety plans with adolescents, it may be
the patient is willing to engage in this exercise. Once a important to identify key adults who may become part
patient indicates his or her willingness to use the safety of the plan. Adolescents are able to aid in determining
plan during a crisis, then the original document is given to which family members or other responsible adults are
the patient to take with him or her and a copy is kept in more likely to have a calming and positive influence.
the medical record. The clinician also discusses where the Some family members, particularly those with whom the
patient will keep the safety plan and how it will be adolescents have frequent conflicts, may not be good
retrieved during a crisis. This may include making candidates to enlist as contacts on the safety plan. Family
multiple copies of the plan to keep in various locations members can also be coached to help the adolescent use
or changing the size or format of the plan so that it could the safety plan. In addition, special care must be taken
be stored in a wallet or electronic device that is easily when helping the adolescent identify individuals other
accessible. In order to increase the likelihood that the than family members who may offer support and
safety plan would be used, the clinician may consider distraction from the suicidal crisis.
conducting a role-play during which the patient would
describe a suicidal crisis and then would provide a
detailed description of locating the safety plan and Safety Plan Intervention: An Illustrative Case Example
following each of the steps listed on the it. A 28-year-old divorced male and father of two young
children presented at the local hospital ED following a
Training suicide attempt. The patient became depressed 2 months
ago after his paternal grandfather died from pancreatic
Clinicians with a wide range of backgrounds (e.g.,
cancer. The patient, who cared for his grandfather during
nurses, psychologists, primary care physicians, psychia-
his illness, was fired from his job due to excess absences.
trists, social workers) can be trained to implement the SPI.
In the past month, the patient began seeing a psychiatrist
The typical training includes: (a) reading the safety plan
at the local community mental health clinic for depres-
manual (Stanley & Brown, 2008a), reviewing the brief
sion.
instructions (Stanley & Brown, 2008b) and the safety
During ED evaluation with the psychiatry resident, the
planning form; (b) attending a training in which the
patient stated that he “felt down” and sometimes
intervention, its rationale and evidence base are de-
wondered whether “life was not worth living.” He
scribed; and (c) conducting role-plays to practice
described that the onset of his depression coincided
implementing the intervention.
with his grandfather's death and loss of his job. Most
recently, he stated that he had thoughts of killing himself
Adaptation for Special Settings and Special Populations following several intense arguments with his girlfriend
The SPI was developed to be used in settings where who was considering leaving him because he was out of
emergency services or acute care services are provided, work. After the most recent argument, the patient
such as EDs, trauma units, crisis hot lines, or medical impulsively ingested 4 to 6 (325 mg) tablets of acetamin-
emergency response units. In addition, the SPI may be ophen and six 12-ounce beers with the intention of dying.
used as a part of ongoing mental health treatment in However, immediately after he swallowed the pills, he
outpatient settings for individuals at risk for suicidal thought about his two young children, realized he did not
behavior. In this context, safety plans may be revised over want to die, and went to the ED. He had no prior suicide
time as new coping skills are learned, as new risk factors attempts and no psychiatric admissions. Upon clinical
and precipitants are identified or as the social network interview, the resident found the patient's mood to be
changes. We propose that the SPI may be useful in other depressed. The patient reported feeling hopeless, espe-
settings where psychiatric, medical, or psychosocial cially about resolving the conflict with his girlfriend and
services are provided, such as inpatient psychiatric finding a job, but denied any current thoughts of wanting
settings, military or correctional settings. For these to kill himself or plans to do so. He regretted that he had
settings, the SPI has to be adapted to acknowledge the made the attempt and stated that he realized he “could
limited availability of coping strategies and people who never do this to his children.” He denied hallucinations,
can be enlisted. Institutional staff may require specialized delusions, and homicidal ideation. His tentative diagnoses
training for determining when patients should be were major depressive disorder and possible alcohol
262 Stanley & Brown

abuse disorder. His blood alcohol level, 8-panel drug test, and scheduled for an appointment with his psychiatrist the
acetaminophen and liver function test results were within next day. The patient agreed to attend daily AA meetings
normal limits. The patient reported a history of “prob- and increase contact with his AA sponsor. The patient's
lems with drinking” in the past but, until the suicide motivation to continue psychiatric treatment was ambiva-
attempt, had been abstinent for the past year, having lent but he said he would attend the scheduled follow-up
found AA meetings to be very helpful. appointment. While it was determined that the patient
The resident consulted with the attending psychiatrist could be safely discharged from the ED, the resident
about whether the patient should be admitted for a remained uneasy about the disposition.
psychiatric hospitalization or discharged with a referral to This case illustrates a frequent clinical scenario in the
his local mental health clinic. The patient's risk for suicide ED. As is the case with most ED interviews with a suicidal
was determined to be moderately high but not at imminent patient, the interaction focuses on suicide risk assessment
risk. Based on the consultation, the patient was discharged and treatment disposition. We propose that the ED is

SAFETY PLAN

Step 1: Warning signs:

1. _Suicidal thoughts and feeling worthless and hopeless__________________
2. _Urges to drink_________________________________________________
3. _Intense arguing with girlfriend_____________________________________
Step 2: Internal coping strategies - Things I can do to distract myself without contacting anyone:
1. _Play the guitar_________________________________________________
2. _Watch sports on television________________________________________
3. _Work out______________________________________________________
Step 3: Social situations and people that can help to distract me:
1. _AA Meeting____________________________________________________
2. _Joe Smith (cousin)______________________________________________
3. _Local Coffee Shop_______________________________________________
Step 4: People who I can ask for help:
1. Name_Mother____________________________ Phone __333-8666_______
2. Name_AA Sponsor_(Frank)__________________Phone_ _333-7215_______
Step 5: Professionals or agencies I can contact during a crisis:
1. Clinician Name__Dr John Jones______________ Phone__333-7000_______
Clinician Pager or Emergency Contact #__555 822-9999_________________
2. Clinician Name_________________________ Phone____________________
Clinician Pager or Emergency Contact #_______________________________
3. Local Hospital ED __City Hospital Center______________________________
Local Hospital ED Address_222 Main St_______________________________
Local Hospital ED Phone ___333-9000________________________________
4. Suicide Prevention Lifeline Phone: 1-800-273-TALK______________________
Making the environment safe:
1. ____Keep only a small amount of pills in home___________________________
2. ____Don’t keep alcohol in home______________________________________
3. ________________________________________________________________

Figure 1. Safety Plan Example.

 Safety Planning to Mitigate Suicide Risk 263

ideally suited for implementation of a very brief psycho- This intervention has been used clinically by the
social intervention that may increase the safety of this authors (e.g., Stanley et al., 2009) and has been used as
patient and similar patients, particularly during the part of other evidence-based psychotherapy interventions
interval between ED visit and follow-up appointments. in clinical trial research. Its efficacy as a stand-alone
Figure 1 shows the safety plan that was developed for intervention is currently being evaluated by us in an urban
the patient. The patient explicitly identified suicide ED and nationally in a Department of Veteran Affairs
ideation, arguing with his girlfriend, urges to drink and clinical demonstration project. We describe only one
feelings of hopelessness and worthlessness as personal format or version of a safety plan and recognize that other
warning signs. His internal coping strategies included formats may be useful as well.
working out, playing the guitar, and watching sports on
television. Social distractors, where suicidal feelings are References
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Monti, K. M., Cedereke, M., & Ojehagen, A. (2003). Treatment (2008a). Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran
attendance and suicidal behavior 1 month and 3 months after a Version. Washington, D.C.: United States Department of Veterans
suicide attempt: A comparison between two samples. Archives of Affairs.
Suicide Research, 7, 167–174. Stanley, B., & Brown, G. K. (2008b). Safety planning intervention: Brief
O'Brien, G. A., Holton, A. R., Hurren, K., & Watt, L. (1987). Deliberate instructions. Washington, D.C.: United States Department of
self-harm and predictors of outpatient attendance. The British Veterans Affairs.
Journal of Psychiatry, 150, 246–247. Stanley, B., Brown, G. K., Brent, D., Wells, K., Poling, K., Curry, J.,
Piacentini, J. M., Rotheram-Borus, M. J., Gillis, J. R., Graae, F., et al. (2009). Cognitive Behavior Therapy for Suicide Prevention
Trautmant, P., Cantwell, C., et al. (1995). Demographic predictors (CBT-SP): Treatment model, feasibility and acceptability. Journal
of treatment attendance among adolescent suicide attempters. of the American Academy of Child and Adolescent Psychiatry, 48,
Journal of Consulting and Clinical Psychology, 63, 469–473. 1005–1013.
Reid, W. H. (1998). Promises, promises: Don't rely on patients' no- Trautman, P. N., Stewart, N., & Morishima, A. (1993). Are adolescent
suicide/no-violence ‘contracts’. Journal of Practice Psychiatry and suicide attempters noncompliant with outpatient care? Journal of
Behavioral Health, 4, 316–318. the American Academy of Child and Adolescent Psychiatry, 32, 89–94.
Rotheram-Borus, M. J., Piacentini, J., Cantwell, C., Belin, T. R., & Song, Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for
J. (2000). The 18-month impact of an emergency room suicidal patients: Scientific and clinical applications. Washington, DC:
intervention for adolescent female suicide attempters. Journal of APA Books.
Consulting and Clinical Psychology, 68, 1081–1093.
Rudd, M. D. (2006). The assessment and management of suicidality.
Sarasota, FL: Professional Resource Press.
Rudd, M. D., Joiner, T., & Rajab, M. H. (2001). Treating suicidal behavior:
The preparation of this manuscript was supported, in part, by grants
An effective, time-limited approach. New York: Guilford.
from NIAAA (P20 AA015630), NIMH (R01 MH06266 R02 MH061017
Rudd, M. D., Mandrusiak, M., & Joiner, T. E. (2006). The case against
no-suicide contracts: The commitment to treatment statement as and R01 MH60915, P20 MH71905) and the American Foundation for
a practice alternative. Journal of Clinical Psychology, 62, 243–251. Suicide Prevention.
Schulberg, H. C., Bruce, M. L., Lee, P. W., Williams, J. W., & Dietrich, A. J. Address correspondence to Gregory K. Brown, University of
(2004). Preventing suicide in primary care patients: The primary Pennsylvania, Department of Psychiatry, 3535 Market St., Room 2030,
care physician's role. General Hospital Psychiatry, 26, 337–345. Philadelphia, PA 19104; e-mail: gregbrow@mail.med.upenn.edu.
Shaffer, D., & Pfeffer, C. (2001). Practice parameter for the assessment and
treatment of children and adolescents with suicidal behavior. Journal of
the American Academy of Child and Adolescent Psychiatry, 40, 24S–51S. Received: February 24, 2010
Simon, R. I. (2007). Gun safety management with patients at risk for Accepted: January 9, 2011
suicide. Suicide & Life-Threatening Behavior, 37, 518–526. Available online 15 April 2011
September 2014

Table 1. Summary of select RCTs

Study Control Outcome Follow-up

Authors Sample intervention condition variables intervals Main findings

Bateman and Adults with BPD Partial Standard Suicide 3, 6, 9, 12, 15, Patients who received the study intervention
Fonagy referred to hospitalization psychiatric attempts 18 months experienced a significant reduction in attempts
(1999)10 psychiatric unit (n¼19) care (n¼19) from admission to 18 months (Kendall’s W¼0.59,
χ2(3)¼33.5, po0.001)
No differences in time to first suicide attempt

Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194

Blum et al. Adults with BPD STEPPS plus TAU (n¼59) Suicide 1, 3, 6, 9, 12
(2008)13 TAU (n¼65) attempts months between STEPPS þ TAU and TAU groups;
χ2(1)o0.1, p¼0.994
Brown et al. Adults recruited CT (n¼60) EUC (n¼60) Suicidal 1, 3, 6, 12, 18 At 6 months, using the Kaplan–Meier method,
(2005)6 from ED following ideation, months estimated reattempt-free probability: CT
a suicide attempt suicide group¼0.86 (95% CI¼074, 0.93); usual care
attempts ¼0.68 (95% CI¼0.54, 0.79)
At 18 months, estimated reattempt-free
probability: CT¼0.76 (95% CI¼0.62, 0.85); usual
care¼0.58 (95% CI¼0.44, 0.70)
Patients in the CT condition had a significantly
lower reattempt rate (Wald χ2¼3.9, p¼0.049) and
were 50% less likely to reattempt than the usual
care group (hazard ratio¼0.51, 95% CI¼0.26, 0.997)
There were no significant group differences in
suicidal ideation
Bruce et al. Depressed older Structured, TAU (n¼278) Suicidal 4, 8, 12 Rates of suicidal ideation declined faster for the
(2004)21 adults recruited team-based ideation months intervention group (12.9% decline from baseline)
from primary care intervention than the TAU group (3.0% decline from baseline;
including p¼0.01 for all depressed patients, p¼0.006 for
citalopram þ patients with MDD)
psychotherapy
(n¼320)
Comtois et al. Adults evaluated CAMS (n¼16) E-CAU (n¼16) Suicide 2, 4, 6, 12 Participants who received CAMS made fewer
(2011)17 for suicide attempts, months suicide attempts than those who received E-CAU
attempt or suicidal at 2-, 4-, and 6-month follow-upsa
imminent risk but ideation Suicidal ideation improved significantly for CAMS
judged safe for patients, reaching 89% reduction at 12 months,
discharge RR¼0.11, 95% CI¼0.04, 0.30; at 12 months,
E-CAU patients reported significantly worse
suicidal ideation than CAMS patients (RR¼4.81,
95% CI¼1.61, 14.33)

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S187
 S188
Table 1. Summary of select RCTs (continued)

Study Control Outcome Follow-up

Authors Sample intervention condition variables intervals Main findings

Davidson et al. Adults with BPD CBT þ TAU TAU (n¼49) Suicidal acts 6, 12, 18, 24 After 24 months, there was a greater reduction in
(2006)14 and an episode of (n¼53) months number of suicidal acts in the intervention group
DSH within the compared to the TAU group (mean difference¼
past 12 months –0.91, p¼0.020)
Diamond et al. Adolescents ABFT (n¼35) EUC (n¼31) Suicidal 6, 12, 24 At the 12-week assessment, patients receiving

Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194

(2010)19 identified as ideation weeks ABFT demonstrated a significantly greater rate of
suicidal by improvement in suicidal ideation than patients
screening during receiving EUC, F(1, 64)¼12.60, p¼0.001
primary care or ABFT had a significant effect on clinical recovery
ED visits (SIQ-JR r13) of suicidal ideation at all time points;
at 6 weeks, 69.7% of ABFT patients and 40.7% of
EUC patients reported suicidal ideation in the
normative range, OR¼3.35, 95% CI¼1.15, 9.73,
χ²(1)¼5.07, p¼0.02; at 12 weeks, 87.1% of ABFT
patients and 51.7% of EUC patients reported
ideation in the normative range, OR¼6.30, 95%
CI¼1.76, 22.61, χ²(1)¼8.93, p¼0.003; at 24
weeks, 70% of ABFT patients and 34.6% of EUC
patients reported ideation in the normative range,
OR¼4.41, 95% CI¼1.43, 13.56, χ²(1)¼7.01,
p¼0.008

Guthrie et al. Adults presenting Psychody- TAU (n¼61) Suicidal 1, 6 months At the 6-month follow-up assessment, patients
(2001)11 to ED after self- namic ideation receiving the study intervention reported lower
poisoning interpersonal levels of suicidal ideation compared to those
therapy receiving TAU (differences between means¼ –4.9,
delivered in 95% CI¼ –8.2, –1.6, p¼0.005)
home (n¼58)
Hatcher et al. Adults presenting PST (n¼522) Usual care Self-harm 3, 12 months Fewer patients receiving PST reported repeat
(2011)9 to a hospital after (n¼572) episodes of self-harm at the 12-month
self-harm assessment than those receiving usual care
(RR¼0.39, 95% CI¼0.07, 0.60, p¼0.03)
Huey et al. Youth following MSTb Standard Suicidal 4, 16 months MST was significantly more effective than
(2004)16 ED visit for suicide treatmentb ideation, standard treatment at reducing suicide attempts
attempt, ideation, suicide over 16 months, t(linear)¼2.61, po0.01, t
or planning attempts (quadratic)¼3.60, po0.001
www.ajpmonline.org

There were no significant group differences for

suicidal ideation

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September 2014

Table 1. Summary of select RCTs (continued)

Study Control Outcome Follow-up

Authors Sample intervention condition variables intervals Main findings

Linehan et al. Women with BPD DBT (n¼52) Community Suicidal 4, 8, 12, 16, Fewer patients receiving DBT had suicide attempts
(2006)8 with Z2 episodes treatment by ideation, 20, 24 months than those receiving treatment by experts (23.1%
of self-harm in the experts suicide vs 46%, hazard ratio¼2.66, p¼0.005, NNT¼4.24,
past 5 years, (n¼49) attempts 95% CI¼2.40, 18.07); the mean proportions of
including Z1 suicide attempters per treatment group per period

Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194

within the past 8 were 6.2% (95% CI¼3.1%, 11.7%) and 12.2%
weeks (95% CI¼7.1%, 20.3%) for the DBT and control
groups, respectively
Fewer patients receiving DBT than community
treatment by experts had non-ambivalent suicide
attempts (5.8% vs 13.3%, p¼0.18, Fisher’s exact
test and NNT¼13.3, 95% CI¼5.28, 25.41)
There were no significant group differences for
suicidal ideation
McMain et al. Adults with BPD DBT (n¼90) General Frequency and 4, 8, 12 There were no significant group differences for
(2009)12 with Z2 suicidal psychiatric severity of months suicidal episodes
or non-suicidal management suicidal
self-injurious (n¼90) episodes
episodes in the
past 5 years, Z1
episode in the
past 3 months
Slee et al. Adults who CBT þ TAU TAU (n¼42) Self-harm, 3, 6, 9 months At 9 months, patients who received CBT þ TAU
(2008)7 recently engaged (n¼40) suicidal had significantly greater reductions in self-harm
in deliberate self- cognition than those who received TAU alone (po0.05)
poisoning or self- CBT þTAU patients had significantly decreased
injury suicidal cognitions as compared to TAU patients at
the 3- (po0.05), 6- (po0.05), and 9-month
(po0.01) assessments
Stewart et al. Adults in CBT (n¼11), TAU (n¼9) Suicidal 4 weeks (PST), CBT was the most effective treatment for reducing
(2009)18 treatment PST (n¼12) ideation, 7 weeks (CBT), suicide attempts; patients receiving CBT made no
following a suicide suicide 2 months attempts during the study, whereas patients
attempt attempts (TAU) receiving PST and TAU made an average of 0.33
attempts and 0.22 attempts, respectively
Suicidal ideation decreased with both CBT (z¼
2.32, po0.05, r¼0.49) and PST (z¼2.39,
po0.05, r¼0.49); decreases in suicidal ideation
were greater for the PST than TAU group (U¼26.5,
pr0.05, r¼0.49)

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S190 Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194

DBT, dialectical behavior therapy; DSH, deliberate self-harm; E-CAU, enhanced care as usual; ED, emergency department; EUC, enhanced usual care; IMPACT, Improving Mood: Promoting Access to
ABFT, attachment-based family therapy; BPD, borderline personality disorder; CAMS, collaborative assessment and management of suicidality; CBT, cognitive–behavioral therapy; CT, cognitive therapy;
effective than general psychiatric services

24 (OR¼0.72, 95% CI¼0.57, 0.92, p¼0.01) months

24 (OR¼0.65, 95% CI¼0.46, 0.91, po0.01) months
than usual care reported thoughts of suicide at 6

Participants who received group therapy were less

likely to repeat self-harm than those who received
Fewer patients receiving the IMPACT intervention

Fewer patients receiving the IMPACT intervention

(OR¼0.52, 95% CI¼0.36, 0.75, po0.001), and

(OR¼0.62, 95% CI¼0.49, 0.79, po0.001), and

(OR¼0.44, 95% CI¼ 0.35, 0.56, po0.001), 18
in reducing suicidal and self-mutilatory

(OR¼0.54, 95% CI¼0.40, 0.73, po0.001), 18

(OR¼0.62, 95% CI¼0.49, 0.78, po0.001), 12

(OR¼0.54, 95% CI¼0.37, 0.78, p¼0.001), 12
acts.10 Similarly, relative to TAU alone,

There were no significant group differences

Collaborative Treatment; MDD, major depressive disorder; MST, multisystemic therapy; NNT, number needed to treat; PST, problem-solving therapy; RR, risk ratio; SIQ-JR, Suicide Ideation
routine care (OR¼6.3, 65% CI¼1.4, 28.7)
reported thoughts of death or dying at 6
PST plus usual care resulted in a decrease
in repeat hospitalizations for self-harm in
individuals with a history of previous self-
Main findings

harm.9 Finally, four home-based sessions

regarding suicidal thinking

of interpersonal therapy were more effec-
tive than TAU in reducing suicidal idea-
tion and repeated self-harm in individuals
who self-poisoned.11
Although a number of suicide-
prevention interventions have evidenced
efficacy, other interventions, including
systems training for emotional predict-
ability and problem solving13 and CBT for
Cluster B personality disorders,14 have
6, 12, 18, 24

6 weeks, 7

not been supported empirically. For a

Follow-up
intervals

months

months

comprehensive review of negative find-

ings, please see previous reviews.2–5
Fewer studies15,16 have demonstrated
Questionnaire–Junior; STEPPS, systems training for emotional predictability and problem solving; TAU, treatment as usual
efficacy for psychotherapy interventions
in reducing self-directed violence in ado-
lescents. Wood and colleagues15 found that
Repetition of
Outcome
variables

self-harm,

adolescents who received developmental

ideation

thinking
Suicidal

suicidal

group therapy (consisting of components

of CBT, DBT, and psychodynamic group
therapy) plus TAU were less likely to
engage in repeated deliberate self-harm
on two or more occasions than those
Routine care
condition
Control

Usual care

who received TAU alone. Finally, multi-

(n¼895)

(n¼31)

systemic therapy, an intensive family-

based treatment, reduced the frequency
Note: Only outcomes related to suicide ideation and attempts are reported.

of suicide attempts compared to treatment

received during inpatient hospitalization.16
Group therapy

In addition to psychosocial interven-

intervention

Study did not indicate the number of participants per condition.

intervention
Study

tions designed to prevent suicide

(n¼906)
IMPACT

(n¼32)

attempts, several psychotherapy treat-

No statistical analyses were performed for these results.

ments directly target suicidal ideation.

Table 1. Summary of select RCTs (continued)

Specifically, collaborative assessment and

management of suicidality (CAMS),17
CBT,18 PST,18 and PIT11 have resulted
referred to mental
MDD or dysthymia
Older adults with

after deliberate
health services

in the reduction of suicidal ideation in

Sample

Adolescents

adults. CAMS, a therapeutic framework

self-harm

focused on identifying causes of suicidal

ideation and treatment goals for reducing
suicidal ideation, was associated with
significantly greater and sustained reduc-
tion of suicidal ideation at 12 months
Unützer et al.

post-treatment compared to TAU.17 Sim-

Wood et al.
(2006)20

(2001)15
Authors

ilarly, both PST and CBT resulted

in greater reduction of suicidal ideation
than TAU.16 Attachment-based family
b
a

www.ajpmonline.org
 Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194 S191
therapy, which focuses on strengthening the parent– alarming given that the current standard of care is to admit
adolescent attachment bond, has also demonstrated high-risk patients to inpatient units. This suggests that
promise in reducing suicidal ideation in suicidal adoles- patients who are at high risk for suicide may not receive
cents relative to EUC.19 appropriate evidence-based treatments to prevent suicide.
Finally, to our knowledge, two studies have demon- A final gap in the extant research examining the
strated efficacy in reducing suicidal ideation in depressed efficacy of psychotherapy interventions for suicide pre-
older adults in primary care settings.20,21 The Improving vention is the failure to replicate studies in which
Mood: Promoting Access to Collaborative Treatment treatments have been found to be efficacious. It is
study determined that a collaborative, team-based especially critical that replication trials be conducted by
approach to treating depression resulted in a greater independent researchers, as in some cases replication
reduction of suicidal ideation than usual care. The studies conducted outside of the original research groups
Prevention of Suicide in Primary Care Elderly: Collabo- have failed to demonstrate the same beneficial effects.12
rative Trial intervention, consisting of a clinical algo- A variety of methodologic limitations of the existing
rithm for treating geriatric depression in primary care research hamper the ability to draw firm conclusions
settings and care management, was more effective in regarding the effectiveness and generalizability of various
reducing suicidal ideation than EUC. suicide prevention efforts (limitations have been pub-
lished elsewhere1–4). First, a lack of consensus regarding
Limitations of the Current State of the terms and operationalized definitions used to describe
suicide, attempts, ideation, and other related behaviors
Science limits the ability to generalize across studies and replicate
Although the aforementioned RCTs represent important findings. Researchers also often neglect to use reliable
first steps in gaining a deeper understanding of effective and validated measures of suicidal ideation and behav-
suicide prevention strategies, several gaps and methodo- iors, making it difficult to understand the specific
logic concerns limit conclusions that can be drawn from behaviors measured and targeted by the interventions
these studies. Several significant gaps in the literature in question.
should be noted. First, given the paucity of RCTs powered In addition, many previously published RCTs do not
to detect deaths by suicide, it is unknown whether death provide detailed psychotherapy manuals. The absence of
by suicide (rather than suicide attempts) can be prevented treatment manuals creates significant challenges for dis-
by psychotherapy. Moreover, it is unclear as to whether semination and implementation efforts in the community
the reduction of suicide attempts or ideation via psycho- and precludes appropriate replication studies. Furthermore,
therapy actually reduces deaths by suicide. researchers often neglect to include measures assessing the
Second, many studies focused on suicide prevention integrity of the study intervention. It is important to assess
exclude patients at imminent risk for suicide, making it the extent to which study therapists adhere to the theory
impossible to determine whether interventions that are and practice of the intervention of interest.
efficacious for lower-risk patients are also efficacious for An additional common methodologic problem is that
those at highest risk.22 Third, there are limited psycho- studies are underpowered to adequately detect treatment
therapy RCTs focused on preventing suicide attempts for effects, causing potentially efficacious treatments to yield
many at-risk populations, including older adults; Veterans negative results owing to lack of power rather than lack of
or military service members; lesbian, gay, bisexual, trans- efficacy. Moreover, very few studies include descriptions of
gender, queer, and two-spirit (LGBTQ2) populations; power analyses, making it difficult to determine the reasons
Native Americans and other minority groups; and survi- for failing to find positive effects. Other studies conduct
vors of suicide or suicide attempts. It is unclear whether the power analyses based on unlikely or biased estimates of
results of existing RCTs generalize to these populations. effects, leading to inadequate estimates of sample sizes.
Additionally, the majority of psychotherapy interven- Conservative estimates are necessary to ensure that sam-
tions for suicidal thoughts and behaviors have been ples are powered sufficiently to detect effects.
conducted in outpatient settings, and very few RCTs have Given that RCTs are generally longitudinal, attrition is
been conducted in acute care settings, such as emergency common and results in an additional methodologic issue
departments, inpatient units, and crisis hotlines. The of handling missing data. This is particularly problematic
development of interventions for these settings is partic- when dropout rates differ across treatment conditions,
ularly important given that many high-risk patients only which may result in biased results.7 As recommended in
present to acute care services and never receive additional the CONSORT guidelines for reporting RCT results,
psychosocial treatment. The dearth of knowledge about intention-to-treat analysis is a helpful statistical approach
effective treatments for inpatient settings is especially to handling missing data to minimize bias.23

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S192 Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194
Other methodologic limitations encountered in the An additional short-term goal is to develop interven-
extant literature include potential threats to external tions designed for high-risk populations, including older
validity by choosing highly selective samples11; failure adults, Veterans or military service members, LGBTQ2
to use blind investigators, assessors, or patients or specify individuals, minority groups, and survivors of suicide or
whether blinding was implemented; potential measure- suicide attempts as indicated by empirical research. There
ment bias (e.g., using differential measurement intervals is also a need for methods to screen and treat high-risk
and methods for assessing primary outcomes in inter- individuals in acute care settings, including emergency
vention and control groups10); failure to identify, meas- departments, crisis hotlines, and inpatient units.
ure, and control for potential non-study co-interventions As previously mentioned, many studies assessing the
(e.g., pharmacotherapy); and analyses capitalizing on efficacy of treatments for suicide prevention are under-
differences in baseline characteristics.16 powered. Although preliminary studies to determine
It is also advised that researchers focus on a priori acceptability and feasibility of specific interventions are
analyses and refrain from making firm conclusions on necessary, large-scale RCTs that are adequately powered
the basis of unplanned, underpowered subgroup analy- to detect treatment effects are also imperative. This is true
ses. Finally, stratified randomization is an important tool for studies assessing treatments focused on reducing
in preventing Type I errors and imbalance between suicidal thoughts, suicide attempts, and other self-
treatment groups, particularly for smaller trials in which directed violence, as well as those designed to evaluate
known factors influence treatment responsiveness. treatments for the prevention of deaths by suicide.
Because suicide is a low base rate behavior, very large
samples are required to conduct adequately powered
Next Steps and Breakthroughs Needed trials. Multi-site collaborations allow the collection of
Although the existing RCTs have created an important data from large samples while reducing financial and
jumping-off point for evaluating future psychotherapeutic organizational burden on any one site. In addition, the
interventions for suicide attempts and ideation, much use of standardized outcome measures and data sharing
work remains. The adoption of the following recommen- may facilitate meta-analytic approaches and circum-
dations may lead to increased methodologic rigor with vent problems associated with inadequately powered
which suicide research is conducted, and in turn, the studies.
development and dissemination of treatments that reduce Further development and dissemination of treatments
suicidal ideation, suicide attempts, and ultimately, suicide. specifically targeting suicidal ideation are also necessary,
Given that the current lack of consensus of terms and particularly for populations such as older men who have
definitions leads to difficulty in interpreting results and the highest rates of suicide of any age group.27 Despite
aggregating findings across studies, an important short- their increased rate of deaths by suicide, older adults are
term goal is to adopt an agreed-upon nomenclature for less likely to make suicide attempts than individuals in
all studies addressing suicide-relevant thoughts and any other age group.28 Suicidal ideation may thus serve as
behaviors, such as the self-directed violence nomencla- the only warning sign of future suicides in older adults,
ture proposed by the CDC’s National Center for Injury making it especially important to specifically target
Prevention and Control.24 It is then essential to employ suicidal ideation in this population. As frequent attempts
valid and reliable measures to assess these constructs. are less common in this population, treatments focused
The Columbia Suicide Severity Rating Scale (C-SSRS25) on preventing attempts may be less appropriate.
is one such measure endorsed by the U.S. Food and Drug Because suicidal ideation is a dimensional construct
Administration for use in pharmaceutical trials. It would that waxes and wanes over time, RCTs should include
also be beneficial to use an agreed-upon measure for appropriate measures for tracking fluctuations in suicidal
psychotherapy trials. Furthermore, to achieve continuity ideation. The use of ecological momentary assessment,
across studies, it would be helpful for all studies to use the for example, would provide much-needed insight into
same endpoints in reporting outcomes, thereby increasing the fluctuation of suicidal ideation and inform the
the ease with which results can be aggregated across development of timely interventions that specifically
studies via meta-analyses. target changes in suicidal ideation.
There is also a need for methods to address ambiguous Very little is known about whether positive effects of
suicide behavior that may not neatly fit into a specific psychotherapies for suicide prevention extend beyond
category of suicidal thoughts or behaviors. One potential laboratory settings. In addition to efficacy trials, effec-
solution to this problem is to form suicide adjudication tiveness trials are also needed to assess whether specific
boards to review ambiguous behaviors and reach a treatments work in real-world settings. Moreover, in
consensus regarding appropriate classification.26 order to increase external validity of psychotherapy trials,

www.ajpmonline.org
 Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194 S193
it is important that inclusion and exclusion criteria result development of more efficient, targeted treatments and
in samples that reflect patients as they present in the real may provide insight into which treatments work best
world (e.g., the exclusion of potential participants who do for whom.
not misuse substances may result in a biased sample of In addition to identifying treatments that are effective in
suicide attempters10). reducing suicide ideation and behaviors, it is also impor-
There is a need to better develop mechanisms to ensure tant to understand which treatments have not garnered
that the individuals at risk of suicide have access to support in psychotherapy trials. Systematic trial registra-
treatments that work. In designing interventions, tion is one method for reducing the “file-drawer effect” in
researchers should consider ways to increase the feasi- which negative findings are not presented to the public.
bility and ease with which treatments can be disseminated Given the gaps and methodologic flaws in the literature
and adapted to various settings. For example, future focused on psychotherapy interventions for suicide pre-
psychotherapies that can be implemented in rural settings vention, additional research is needed to determine the
using telehealth technologies are needed. efficacy of existing and future treatments. Thus, we propose
In addition, researchers are encouraged to clearly a general step-by-step research pathway for conducting
communicate the specific treatment components neces- future RCTs with high-risk patients for examining the
sary to successfully implement interventions in non- efficacy of new psychotherapy treatments (Figure 1).
laboratory settings. Another potential approach to The first step of this paradigm is to identify high-risk
increasing the availability of evidence-based treatments subjects by using agreed-upon nomenclature (e.g., CDC
is to develop innovative electronic health interven- nomenclature) as well as validated and reliable assess-
tions (e.g., smartphone applications, texting, web-based ment measures. These high-risk patients can be recruited
interventions, or chat rooms) as either widely available from a variety of settings including emergency depart-
stand-alone interventions or adjunctive treatments to ments, inpatient units, mental health outpatient clinics,
face-to-face interventions. Finally, further research is and primary care. Following recruitment and initial
needed to determine the cost-effectiveness and cost assessment to determine eligibility, it is recommended
utility of psychotherapy studies for suicide prevention. that patients be randomly assigned to either (1) the
As researchers continue to find support for treatments co-active intervention condition, which may include
that reduce suicidal thoughts and behaviors, it is necessary medication, treatment as usual, a comparative therapy,
to identify potential mechanisms of actions that account for or follow-up services, or (2) the same co-active interven-
therapeutic change. Thus, in addition to asking whether a tion plus a suicide-specific study intervention condition.
treatment works, it is essential to ask why a treatment Alternatively, depending on the question of interest, it
works. This can be achieved by including measures assess- may be more appropriate to omit the co-active inter-
ing constructs underlying treatment effects, such as vention for participants who are randomized to the
improvements in hopelessness or emotion regulation. suicide-specific study intervention condition. In order
Identifying mechanisms of action will allow for the to gain an understanding of the pathways by which

Figure 1. Proposed step-by-step research pathway for conducting RCTs

ED, emergency department; MH, mental health; PC, primary care; SDV, self-directed violence; Ss, subjects

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S194 Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194
treatment affects the outcome of interest (i.e., suicidal Arch Gen Psychiatry 2006;63(7):757–66.
ideation, suicide attempts, or suicides), it is imperative to 9. Hatcher S, Sharon C, Parag V, Collins N. Problem-solving therapy for
people who present to hospital with self-harm: Zelen randomised
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