Direct Care

Direct Care

Interventions and Treatments that Directly Address Suicidality

To treat suicidal thoughts and behaviors, systems can intervene through “interventions” and “treatments.” Interventions are typically briefer (e.g., one session encounter) and focus on acute crisis stabilization. Treatment modalities can vary from several sessions to several years. Please note that the supportive research for each intervention or treatment is not always included in this tab and within the Indirect Care tab. The research is constantly evolving and there are nuances within research studies that space precludes us from elaborating on the research for each intervention and treatment. Following is a list of interventions and treatments that directly treat suicidal thoughts and behaviors.

A word about the research

Below are listed multiple treatments and interventions. Some are considered evidence-based (multiple studies with high rigor) and other are considered empirically supported (fewer studies, potentially less rigor). Also, please note that the supportive research for each intervention or treatment is not always included. The research is constantly evolving and there are nuances within research studies that space precludes us from elaborating on the research for each intervention and treatment. Feel free to review the Evidence Base section of this website for overall research that supports suicide-specific treatment.

Interventions

Safety Planning

A safety plan is a prioritized written list of coping strategies and sources of support developed for individuals at risk of suicide in collaboration with a mental health provider.1, 2 In a meta-analysis, safety planning-type interventions were shown to prevent future suicide attempts compared to control.2 Safety planning is most effective in decreasing future suicidal behavior and inpatient hospitalizations when it is made collaboratively, is tailored to the unique experiences faced by the individual at risk of suicide,3 and when there is follow-up to update the plan and engage with future care.4, 5 Further, ensuring social contacts are listed in both the distraction and help contact sections has been shown to be crucial for decreasing odds of suicide attempts, emergency department visits, and inpatient hospitalizations in the year following the creation of the safety plan.6 Additional information about safety planning can be found in the Engage section of the Toolkit.

JASPR Health

Jaspr Health is a tablet-based app that provides access to four “evidence-based practices” for individuals who present to the emergency department for suicidal thoughts or behaviors. These individuals can engage with the app while waiting for emergency department psychiatric care. Jaspr Health includes the Collaborative Assessment and Management (CAMS)’s assessment guided by artificial intelligence-powered virtual chatbot that is summarized and provided to the care team, video messages of hope and insights by individuals with lived experience, video messages about navigating the emergency department by individuals with lived experience, and dialectical behavior therapy (DBT) skills. A pilot study found Jaspr Health to be feasible, acceptable, and clinically effective for individuals who are acutely suicidal and seeking emergency department psychiatric care.7, 8 

Teachable Moment Brief Intervention (TMBI)

TMBI was created for medically hospitalized individuals following a suicide attempt. This intervention has 9 components that are delivered in one 30-60-minute session. Developed based on core components from other suicide prevention interventions (i.e., CAMS, DBT, cognitive behavior therapy for suicide prevention), TMBI focuses on establishing rapport, then identifies drivers for the suicide attempt, engages the individual in a functional analysis of the suicide attempt, and identifies what the individual gained and lost from the attempt. Finally, a short-term crisis response plan and a longer-term treatment plan for recovery are created.

In a pilot randomized controlled trial, individuals at risk for suicide reported high satisfaction and those receiving TMBI were more likely to be motivated and engage in mental health services at 3 months.9, 10 

Direct Treatments

Evidence-Based Psychological Treatments
David Jobes
© 2018 EDC All Rights Reserved
The evidence-based treatments available for care.
Attempted Suicide Short Intervention Program (ASSIP)

ASSIP emphasizes the therapeutic alliance and is a brief, person-centered therapy for individuals who have attempted suicide. The protocol typically consists of 60-90-minute weekly sessions for 3-4 sessions as well as personalized letters sent for up to 2 years post therapy completion. ASSIP begins with a recorded narrative review of how the individual reached the point of attempting suicide. The therapist and individual at risk of suicide watch the review together and deconstruct the experience. The therapist provides psychoeducation on suicide, and they identify long-term goals, individual warning signs, and safety strategies.

In a randomized controlled trial, participants receiving ASSIP-based care had higher levels of satisfaction with the therapeutic relationship and the therapeutic outcome. That higher satisfaction with therapeutic outcome correlated significantly with lower suicidal ideation at follow-up; the control group showed no significant results.11 ASSIP has also been shown to be a cost-effective therapy.12

Dialectical Behavioral Therapy (DBT)

The term dialectical means a synthesis or integration of opposites, and in DBT, it refers to the seemingly opposite strategies of acceptance and change. DBT centers on four core skill areas: mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance.13 DBT has four components, although these may be adjusted in practice to suit specific circumstances:

  • A skills training group meeting once a week for 24 weeks
  • Individual treatment once a week, running concurrently with the skills group
  • Phone coaching, upon request by the individual in care
  • Consultation team meetings – a kind of “therapy for the therapists”14
Collaborative Assessment and Management of Suicidality (CAMS)

CAMS is an intensive suicide-focused treatment to help individuals develop means of coping and problem-solving to replace or eliminate thoughts of suicide as a coping strategy. CAMS focuses on treating suicide ‘drivers’ that make someone want to die and works to strengthen the therapeutic alliance and increase motivation. One of the core values of the CAMS model is that most individuals at risk of suicide can be treated effectively in outpatient settings. When receiving CAMS care, the individual fills out a “Suicide Status Form” (SSF) in collaboration with the clinician during every session to assess risk and document their treatment plan progress.

The “CAMS Stabilization Plan” is also used to reduce access to lethal means and increase coping strategies.15 Additional tools developed in research settings are described in the 3rd edition of the CAMS manual, including a Stabilization Support Plan to be completed with anyone supporting the care of their loved one who is in CAMS care (e.g., parents, spouse).16 CAMS effectiveness is supported by clinical research, multiple correlation studies, and six published randomized controlled trials.17, 18, 14, 19, 20, 21 

Brief Mindfulness-Based Intervention for Suicidal Ideation (MB-SI)

MB-SI is a brief, manualized intervention developed for Veterans who have been psychiatrically hospitalized. MB-SI includes four 45-minute individual sessions (one session per day, over a range of 12 subsequent days) and mindfulness homework is assigned at the end of each session. A handout reviewing the material covered in the session is also provided. Crisis Response Planning is also included in every session.

Cognitive Behavioral Therapy for Suicide (CBT-SP)

CBT-SP is theoretically grounded in principles of CBT, DBT, and specific therapies for suicidal individuals. It includes the concept of the “suicide mode,”22 and seeks to help individuals learn to recognize this mode, identify triggers, and learn coping skills. During treatment individuals work on:

  • Cognitive restructuring strategies, such as identifying and evaluating automatic thoughts from cognitive therapy.
  • Emotion regulation strategies, such as action urges and choices, emotions thermometer, index cue cards, mindfulness, opposite action, and distress tolerance skills from DBT.
  • Other CBT strategies, such as behavioral activation and problem-solving strategies.23

There are several iterations of CBT-SP including: Information processing biases, appraisals of defeat, entrapment, social isolation, emotional dysregulation, and interpersonal problem-solving suicide schema.

Post Admission Cognitive Therapy

Post Admission Cognitive Therapy (PACT) is an inpatient adaptation for CT-SP. PACT sessions typically include six 60-90 minute sessions of individual psychotherapy over the course of a 3-day hospital stay. The first 1-2 sessions focus on engagement, safety planning, and a cognitive behavioral conceptualization of the recent suicide attempt. The next 1-2 sessions focus on teaching and practicing cognitive behavioral skills. The last 1-2 sessions center on refining the safety plan and a series of relapse prevention exercises to prevent future suicide attempts.

Brief Cognitive Behavioral Therapy

Brief Cognitive Behavioral Therapy for suicide prevention (BCBT) is a shortened version of CT-SP and focuses on the development of a crisis response plan.24, 25 

Suicide Prevention Programme

This 8-session for 60-minutes-each, manualized group therapy includes three phases: cognitive reconstruction to overcome suicidal impulses and destructive feelings through, reinforcement of coping skills through behavioral training, and management of suicide risk factors through coping resources.

Survivors of Suicide Attempts (SOSA) Support Groups

SOSA is an 8-session, 60-minute, drop-in support group that included weekly closed groups where suicide attempt survivors discussed suicide triggers and safety plans, community resources, and hope.

 
Cognitive Behavioral Prevention for Suicide in Psychosis (CBSPp)

Cognitive Behavioral Prevention for Suicide in Psychosis (CBSPp) is a manualized 24-session individual therapy protocol with sessions occurring twice a week.26, 27 

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