In the past 30 years, a considerable body of research has been amassed regarding the use of psychotherapy to manage suicidal behavior. Much of this research included the premise that suicidal behavior must be dealt with as a problem separate from a primary diagnosis (eg, depression) and that techniques must be used to both manage the risk in the present and prevent recurrences in the future. Most clinicians are not aware that suicide risk should be addressed specifically and separately from the primary psychiatric diagnosis. Practical, evidence-based approaches have been developed that decrease the risk of present and future attempts. We aim to provide a brief synopsis of the research evidence, followed by several examples of strategies that such treatment employs.
Cognitive behavioral therapy for suicide
Several systematic reviews have analyzed existing data on the effect of therapeutic interventions to reduce suicide risk. In 2008, Tarrier et al1 examined 28 randomized controlled trials (RCTs) involving adults and adolescents. The researchers concluded that cognitive behavioral therapy (CBT)-based interventions demonstrated effectiveness in reducing suicidal behavior. A subsequent systematic review by Mewton and Andrews2 in 2016 limited its focus to RCTs examining the benefits of standard CBT in adults. Their conclusion agreed with the observation of Tarrier et al1: Treatment is more effective when directly targeting suicidal thoughts and behavior as opposed to when treatment is designed to address mental illness with the assumption that benefits will also impact suicidal behavior. Hence, the literature underscores the need for specific interventions targeting suicidal behavior.
The meta-analysis by Ougrin and colleagues3 in 2015 supported the effectiveness of therapeutic interventions including CBT, dialectical behavior therapy (DBT), and mentalization-based therapy in reducing self-harm in adolescents. The dearth of independently replicated studies impeded drawing firm conclusions on the comparative benefit of specific therapeutic strategies. Independent trials have looked at the effectiveness of DBT in adolescents who are at high risk for suicide. The RCT by Mehlum et al4 in 2014 and the recently published RCT by McCauley and colleagues5 suggest definite benefits of short-term DBT in adolescents with borderline personality traits who had engaged in prior self-harm and suicide attempts. The latter study also showed superiority of DBT with respect to treatment retention.
Engagement and retention of patients is a significant challenge in managing suicidal behavior. Often, such patients do not seek outpatient therapy and present for emergency care with suicidal crises. The emergency department (ED) must therefore be a key site for intervention. The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study by Miller and colleagues6 designed interventions for screening and provision of safety plans with follow-up phone calls to patients and significant others. Stanley et al7 discussed the benefits of such ED-based interventions in reducing suicidal risk. Their comparative cohort study showed that safety-planning interventions coupled with structured follow-up reduced the risk of suicidal behavior by 50% and achieved a twofold increase in the odds of treatment engagement over a 6-month period. The safety-planning intervention consisted of six specific strategies: identifying early warning signs, encouraging internal coping strategies, reaching out to family/friends, identifying other individuals who can provide support during suicidal crises, contacting mental health professionals, and lethal means planning. This large-scale study illustrates a feasible, pragmatic approach to suicidal behavior that does not demand extensive resources and can be easily delivered in an ED setting.
Cognitive behavioral therapy for suicide prevention is another short-term intervention designed to specifically address suicidal behavior that has significant effects in reducing future suicide attempts.8 It is composed of three phases: an initial phase promoting treatment engagement, an intermediate phase focused on cognitive and behavioral strategies targeting suicidal thoughts and mobilizing reasons to live, and a final phase that targets relapse prevention and consolidates the ability to effectively use strategies in the setting of future suicidal crises.
Each of the preceding studies have common psychotherapeutic strategies that may be employed by any clinician. All are rooted in the fundamental principle of the therapist as an empathic partner who forms a strong therapeutic alliance with patients and who acknowledges their suicidal thoughts and behaviors as a response to intolerable pain or acute subjective distress. The patient is enlisted as an active partner in the process of understanding personal risks for future suicide crises and developing remedies for such occurrences.
The following section describes four specific strategies common to these approaches, including lethal means reduction, safety planning, developing reasons for hope, and inspiring delay.
Dr Sudak is Professor and Vice Chair for Education, Drexel University, Philadelphia, PA, and Dr Rajalakshmi is a Resident, Department of Psychiatry, Drexel University, Philadelphia, PA.
The authors report no conflicts of interest concerning the subject matter of this article.
1. Tarrier N, Taylor K, Gooding P. Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. Behav Modif. 2008;32:77-108.
2. Mewton L, Andrews G. Cognitive behavioral therapy for suicidal behaviors: improving patient outcomes. Psychol Res Behav Manag. 2016;9:21-29.
3. Ougrin D, Tranah T, Stahl D, et al. Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2015;54:97-107.e2.
4. Mehlum L, Tørmoen AJ, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014;53:1082-1091.
5. McCauley E, Berk MS, Asarnow JR, et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial. JAMA Psychiatry. 2018;75:777-785.
6. Miller IW, Camargo CA Jr, Arias SA, et al; ED-SAFE Investigators. Suicide prevention in an emergency department population: the ED-SAFE study. JAMA Psychiatry. 2017;74:563-570.
7. Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry. 2018;75:894-900.
8. Wenzel A, Brown GK, Beck AT. Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications. Washington, DC: APA Books; 2009.