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Key points
- People with lived experience of being suicidal can offer valuable perspectives on life.
- Safety planning for suicidal risk is better than coercive use of no-harm/no-suicide contracts.
- Research shows that safety planning type interventions are effective, but they can be misused.
- An emphasis on stabilization has promise and can become the foundation of a life worth living.
A few years ago, I participated in a unique venture bringing established suicide researchers together with people who had “lived experience” of being suicidal (i.e., people who have had suicidal thoughts and/or attempted suicide). The idea was to convene a series of meetings to find common ground about the role that people with lived experience (PLEs for short) can and should play within the field of suicidology.
As a person who may readily be perceived as a quintessential member of the field’s “old guard” across many years, I was initially a bit wary. My plan was to shut up, listen, and learn.
The ambitious effort turned out to be quite worthwhile and valuable in unexpected ways. I especially enjoyed our small group meetings as I grew to deeply appreciate the unique perspectives of the PLEs who were notably brave, touching, and remarkably wise. The experience ultimately inspired me to launch a new line of qualitative studies with PLEs. Two of my Ph.D. students shared my interest, so we launched two doctoral dissertation studies engaging—and compensating—PLEs for sharing their unique perspectives on suicide.
Mind you, I have studied suicide for several decades and I have clinically sat with countless patients over the years who were suicidal. I have also likely watched hundreds if not thousands of clinical trial videos for adherence and fidelity purposes across many clinical trials of the Collaborative Assessment and Management of Suicidality (CAMS, Jobes, 2023).
Still, I have neither harbored suicidal thoughts nor considered suicide. My clinical-researcher perspective has been my singular source of knowledge. However, the PLEs we engaged opened my eyes, and I learned just how much I did not know from this particularly unique view of the subject.
One of the dissertations centered on in-depth interviews with a small sample of twelve PLEs to discuss suicide, some of my pet ideas around a “post-suicidal life,” and related views on what makes life worth living. We carefully crafted a series of questions and went through an extensive informed consent and Institutional Review Board process at my University. With IRB approval in hand, we recruited PLEs (some from the aforementioned group exploration effort).
The twelve people we interviewed were remarkable—filled with valuable perspectives, strengths, and wisdom. While some had left suicide far behind, for others suicide was still close at hand as something they think about every day. Disappointingly, no one was particularly taken by some of my clever ideas (e.g., my notion of a “post-suicidal life”) but then the point of conducting any research is to actually learn new things!
An example of something new that we heard from a couple of people was a surprising wariness about “safety planning” which has become a mainstay innovation developed by the late (and great) Barbara Stanley and Greg Brown (Stanley & Brown, 2012). A valuable variation in the same vein is the “crisis response plan” developed by David Rudd and further studied by Craig Bryan (Bryan & Rudd, 2018).
Importantly, safety planning type interventions are effective and have become a valuable remedy for “no-harm” or “no-suicide” contracts (an intervention that never made sense to me). What's more, safety planning type interventions are superior and effective in comparison to coercive and invalidating no-harm contracts (refer to a superb meta-analysis by Nuij et al., 2021).
So given the evidence and the general embrace of safety planning, I was quite struck by one participant’s candid and critical commentary: “I got my first safety plan on an inpatient unit and I felt like the nurse was saying, we both know that you are a f**k-up, so I need for you to be safe for me and complete this plan so we can discharge you.”
Please know that this is exactly not how Stanley and Brown would ever want a safety plan to be done. But for this person, the experience left a mark and made a distinctly negative impression. When I asked her about stability, she reflected and said, “Would I like to be more stable? Yes, I personally aspire to being stable!”
The CAMS Stabilization Plan is a key focus within CAMS-guided clinical care (Tyndal, Zhang, & Jobes, 2022). Indeed, establishing and crafting a solid stabilization plan is foundational to the successful treatment of patient-articulated “drivers” of suicide (i.e., what problems and issues make them suicidal). Within CAMS, there is also a clinical assessment of a patient’s relative stability as an essential focus within the medical record progress note (Jobes, 2023).
As an aside, I would note that considering a patient’s relative stability helpfully side-steps a contentious topic these days about our inability to predict future suicidal behavior (a long-known reality that has somehow become a contemporary controversy in suicidology). But more to my central point, clinically establishing stability and directly treating what makes someone consider suicide can essentially set the stage for a patient who is suicidal to begin to entertain what could make life worth living.
Furthermore, the advent of the 988 Suicide and Crisis Lifeline in the U.S. has increasingly revealed the real needs of people who are in suicidal crises vs. the reality of what our existing healthcare system can actually do. Frankly, lengthy emergency department visits and/or very brief inpatient hospital admissions may not be helpful and can in fact make things worse for people who are suicidal. To this end, outpatient clinics like the one I'm affiliated with, called The Hope Institute, offer a compelling alternative; only CAMS and DBT are offered to patients and there is a singular clinical goal: stabilization.
Given all these considerations, there is promise in pursuing clinical care that unabashedly seeks to help people stabilize through their crises thereby opening the door for less tragic options such as suicide. I would thus argue that stabilization is a worthy treatment goal in and of itself. While it may not be a cure, it can nevertheless be a valuable diving board into the pool of life.
If you or someone you love is contemplating suicide, seek help immediately. For immediate help in the U.S., 24/7, Call 988 or go to 988lifeline.org. Outside of the U.S., visit the International Resources page for suicide hotlines in your country. To find a therapist near you, see the Psychology Today Therapy Directory.
References
Bryan, C. J., & Rudd, M. D. (2018). Brief Cognitive-Behavioral Therapy for Suicide Prevention. Guilford Press.
Jobes, D. A. (2023). Managing Suicidal Risk: A Collaborative Approach, 3rd edition. Guilford Press.
Nuij, C., van Ballegooijen, W., de Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., . . . Riper, H. (2021). Safety planning-type interventions for suicide prevention: Meta-analysis. British Journal of Psychiatry, 219(2), 419–426.
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264.
Tyndal, T., Zhang, I., & Jobes, D. A. (2022). The Collaborative Assessment and Management of Suicidality (CAMS) stabilization plan for working with patients with suicide risk. Psychotherapy, 59(2), 143–149.
