What’s Unique About Therapy With Suicidal Patients?

There are two major problems in the treatment of people with a risk of suicide. First, far too many people who die by suicide do not seek professional help prior to ending their lives. Second, treatments offered are generally not very effective in reducing suicide risk. However, there is hope. Recent clinical studies give clear indications of how we can improve treatment outcomes.

We need new treatment paradigms for suicidality

For over half a century, suicide has been understood as a consequence of psychiatric illness. The logical treatment paradigm is that adequate treatment of psychiatric disorders reduces suicide risk. However, the illness-related model of suicide has not fulfilled its promises. There is no evidence that prescribing antidepressants is associated with declining suicide rates. Over the years, some national suicide rates have decreased, while others have been increasing.

Psychologist David A. Jobes[1] was one of the early advocates of a person-centered, collaborative treatment approach to the suicidal individual. In collaborative therapy, the therapist aims to understand the patient’s very personal inner experience, in contrast to the illness model, where the health professional is in the role of the expert who diagnoses and treats the assumed causes of suicide. This puts the patient in a passive role, while in collaborative therapy, the patient is an active participant in the assessment and understanding of the suicide risk, by collaborating with the therapist as a co-author to develop a specific treatment plan.

In Bern, Switzerland, we developed a novel patient-centered model of understanding suicide as an action. This treatment model was translated into a highly structured, manualized three-session therapy program (Attempted Suicide Short Intervention Program or ASSIP), aimed at optimizing collaboration and active patient engagement. The first session is fully dedicated to the patient’s narrative of the suicidal development and the related biographical background. This therapy model has proved to be very effective in reducing suicidal behavior. In a two-year follow-up, including 120 patients, ASSIP reduced the risk of suicide reattempts by 80%.

Clinical studies on treatment engagement and therapy outcomes

Early psychotherapy research has consistently found a relationship between therapeutic alliance and therapy outcome. Therapeutic alliance has been defined as the active and purposeful collaboration between patient and therapist [2]. Typical therapist characteristics related to therapeutic alliance are sensitivity, listening ability, and validation of the patient’s thoughts and feelings. Patients are considered the experts of their own history, their personal inner world, shaped by their individual biography.

Research on the therapeutic alliance with suicidal patients

In recent years, clinical studies have more and more focused on the specific aspects of therapy with suicidal patients and the effect on therapy outcomes. Therapy outcome is usually defined as the frequency of suicidal ideation and suicidal behavior during a follow-up period. The quality of the therapeutic alliance with suicidal clients has been the main focus of research. Gysin-Maillart et al. [3] and Bryan et al. [4] found an inverse relationship between alliance and suicidal ideation following brief therapies. Lohani et al. [5] in a study with 82 participants with a history of suicide ideation and/or attempts found that patient-clinician collaboration techniques, such as narrative assessment, effectively reduced suicidal thoughts. Systematic reviews of clinical studies came to the same conclusion [6, 7], the authors of the latter study characterizing the therapeutic alliance with suicidal clients as potentially lifesaving.

Therapeutic alliance is typically related to person-centered therapy models. Empathizing with a client’s suicidal ideation by sitting with their pain can be seen as an intervention itself, which facilitates a shared understanding of the suicidal client’s psychological and emotional pain. Rudd and colleagues[8] identified common elements of effective treatments. One such element is providing patients with simple and understandable models for suicidality. Cognitive Behavioral Therapy has introduced person-centered elements of suicidal behavior such as the concept of the suicidal mode and the Fluid Vulnerability Theory[9], a concept that assumes a long-term baseline risk that varies from individual to individual, and a short-term risk that is highly determined by aggravating factors active for limited periods of time (suicide triggers). The ASSIP therapy program uses concepts such as the suicidal person’s life goals, vulnerabilities and suicide triggers. A unique therapy process factor is the video playback session, where the therapist and patient collaboratively reflect on the patient’s suicidality. Therapeutic interventions that directly address suicidal thoughts and behavior have been reported to be particularly effective [10].

Conclusion

Every suicidal action has a very personal background and dynamic. The narrative interview is the golden path to collaborative therapy, in which the patient and clinician together explore the person’s suicidal development and develop adequate measures to keep the patient safe in the future. The ultimate goal is to empower suicidal patients to deal with future suicide risk. People must know that therapy cannot eliminate the risk of future suicidal crises. A realistic goal is to gain personal insight, and to know the personal warning signs and safety strategies.

A major problem is the dearth of health professionals trained in a truly patient-centered therapy approach. To meet the need of suicidal patients, training and supervision of therapists in acquiring the skills required for a collaborative therapy approach must clearly be scaled up.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.