Suicide Ideation Is Related to Therapeutic Alliance in a Brief Therapy for Attempted Suicide

Client-reported impact of the Attempted Suicide Short Intervention Program

BACKGROUND

A history of attempted suicide is the most significant predictor of suicidal death. Several brief interventions aimed at tertiary suicide prevention have been investigated in clinical trials. However, suicide attempt survivors' experiences of such interventions have rarely been reported.

OBJECTIVE

To explore how suicide attempt survivors perceive the impact of the Attempted Suicide Short Intervention Program (ASSIP).

METHOD

We interviewed 14 Finnish adults who had received ASSIP as an adjunct to treatment as usual. Semi-structured interviews took place 4-10 weeks after the last ASSIP session. A conventional content analysis of the interview data is presented.

RESULTS

Three core categories depicting ASSIP's perceived impact were identified. The core category life-affirming change comprised subcategories of feeling better, thinking differently, acting differently, and having new resources. The core category collateral effects comprised difficult feelings and cognitive overload. The core category incompleteness of change comprised lack of desired change, gains as incomplete, need for sustenance, and unrealized potential.

CONCLUSION

Clients perceived ASSIP as effectively facilitating life-affirming change but agreed that further support was necessary to retain and build on these gains. Identified needs for improvement included more predictable post-ASSIP service paths and more support for involving affected loved ones.

Re-imagining crisis care: experiences of delivering and receiving the Assured brief psychological intervention for people presenting to Emergency Departments with self-harm

Background

Risk of suicide is increased immediately following emergency department (ED) attendance for self-harm. Evidence suggests that brief psychological interventions delivered in EDs are effective for self-harm. The Assured intervention comprises an enhanced biopsychosocial assessment in the ED, collaborative safety planning and three rapid solution focused follow-up sessions.

Aim

We addressed the following research questions: What were ED mental health liaison practitioners' and patients' experiences of the Assured intervention? What were the barriers and facilitators? What might the mechanisms be for improving experiences and outcomes?

Methods

We conducted a feasibility study of the Assured intervention in four EDs in Southeast England. Semi-structured interviews were conducted with 13 practitioners and 27 patients. Interviews were transcribed, coded line-by-line in Nvivo and thematically analysed using an inductive approach. Inter-rater reliability was calculated with a kappa coefficient of 0.744.

The Influence of Treatment Latency on Suicide-Specific Treatment Outcomes

INTRODUCTION

The Attempted Suicude Short Intervention Program (ASSIP) provides an effective and cost-effective treatment option for people who have attempted suicide. Studies suggest that longer treatment latency is associated with poorer response to therapy, more severe symptomatology, and more suicide attempts This study examined the influence of treatment latency (time between suicide attempt and initiation of therapy) on the number of suicide attempts over the long-term course of ASSIP and the influence of treatment relationship on the extent of suicidal ideation.

METHOD

Survival and regression analyses were performed on 60 participants who had recently attempted suicide and received ASSIP at an outpatient psychiatric clinic. 60% were women and 40% were men.

RESULTS

The results found no significant association between treatment outcome in ASSIP and treatment latency (HR = 1.06; 95% CI: 0.92- 1.21, p = .44). Treatment relationship significantly influenced suicidal ideation at time t4 (B = - .35, t(55) = -3.21, p = .002), but treatment latency was not significantly associated with suicidal ideation (B = .02, t(55) = 0.87, p = .39).

CONCLUSION

No relationship between treatment latency and treatment outcome could be found, suggesting that ASSIP can be implemented at any time after the last suicide attempt. In contrast, the treatment relationship plays a central role in ASSIP.

The Moderating Role of Working Alliance in the Association Between Depression and Suicide Ideation in Messaging Therapy

Introduction: Suicide is one of the leading causes of death worldwide, and it can be prevented by psychotherapy. The objective of this study was to examine the risk factors predicting suicide ideation during messaging psychotherapy, and the moderating role of working alliance (WA) in the association between baseline depression and later suicide ideation. Materials and Methods: A large outpatient sample (n = 4,388) engaged in daily messaging with licensed clinicians from a telemedicine provider. Using a longitudinal design, depression and anxiety symptoms were assessed at baseline, using the Patient Health Questionnaire (PHQ-8) for depression and the Generalized Anxiety Disorder (GAD-7) for anxiety. The WA was measured with the short version of the Working Alliance Inventory after 3 weeks of therapy, and suicide ideation was assessed at baseline and after 6 weeks of therapy, by item 9 of the Patient Health Questionnaire (PHQ-9). Demographic measures were also assessed. Results: Results indicate that depression (β = 0.09, p < 0.001), baseline suicide ideation (β = 0.50, p < 0.001), and WA (β = -0.08, p < 0.001), especially the task subscale (β = -0.14, p < 0.001), significantly predicted suicide ideation after 6 weeks. WA (β = -0.07, p < 0.001), especially the task (β = -0.14, p < 0.001) and bond subscales (β = 0.06, p = 0.002), moderated the association between depression at baseline and suicide ideation after 6 weeks, so that experiencing higher quality of WA decreased the association between depression and suicide ideation. Discussion and Conclusions: Suicide ideation may be reduced by experiencing the therapeutic relationship as beneficial, even among at-risk populations, which suffer from depressive symptoms. It is the first study to show this moderation effect in any platform of therapy.

The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review

It is well established that there is a fundamental need to develop a robust therapeutic alliance to achieve positive outcomes in psychotherapy. However, little is known as to how this applies to psychotherapies which reduce suicidal experiences. The current narrative review summarizes the literature which investigates the relationship between the therapeutic alliance in psychotherapy and a range of suicidal experiences prior to, during and following psychotherapy. Systematic searches of MEDLINE, PsycINFO, Web of Science, EMBASE and British Nursing Index were conducted. The search returned 6472 studies, of which 19 studies were eligible for the present review. Findings failed to demonstrate a clear link between suicidal experiences prior to or during psychotherapy and the subsequent development and maintenance of the therapeutic alliance during psychotherapy. However, a robust therapeutic alliance reported early on in psychotherapy was related to a subsequent reduction in suicidal ideation and attempts. Study heterogeneity, varied sample sizes and inconsistent reporting may limit the generalizability of review findings. Several recommendations are made for future psychotherapy research studies. Training and supervision of therapists should not only highlight the importance of developing and maintaining the therapeutic alliance in psychotherapy when working with people with suicidal experiences but also attune to client perceptions of relationships and concerns about discussing suicidal experiences during therapy.

Longitudinal Development of Reasons for Living and Dying With Suicide Attempters: A 2-Year Follow-Up Study

BACKGROUND

Clinical interventions for patients after a suicide attempt might include a focus on Reasons for Living (RFL) and/or Reasons for Dying (RFD). The present study examined the longitudinal development of RFL and RFD in patients with and without a suicide-specific intervention - the Attempted Suicide Short Intervention Program (ASSIP).

METHODS

In this secondary analysis of a 2-year follow-up randomized controlled study, participants completed the Suicide Status Form II to assess RFL and RFD, at baseline, as well as at 6-, 12-, 18-, and 24-months follow-up. Growth models and latent class analysis were used to investigate longitudinal developments in RFL and RFD. Regression models were used to test the association between RFL, RFD and suicidal reattempts and ideation.

RESULTS

Cross-sectionally and longitudinally, RFD, but not RFL, were associated with suicide reattempts and suicidal ideation. The number of RFD decreased significantly across the 24 month period (from 1.90 at t1 to 1.04 at t5 in the control group and from 2.32 at t1 to 0.51 at t5 in the intervention group), and this decrease was stronger (b = -0.02; p = 0.004) in the ASSIP group than in the control group. There was no overall change in RFL. Three latent trajectories of RFD were identified: a decreasing (n = 77), a steady high (n = 17) and a trajectory with first increasing and then decreasing RFD (n = 26). The proportion of patients in the ASSIP intervention was highest in the decreasing trajectory and lowest in the steady high trajectory. Patients in the steady high trajectory were characterized by worse mental health and fewer social obligations (partner, children) at baseline.

CONCLUSION

The results confirm the importance of RFD within the suicidal process and show that the number of RFD can be further reduced over the period of 24 months with short interventions such as ASSIP. The relevance of number of RFL in the suicidal process, as protective factor, was not confirmed. In the subgroup of patients whose RFD did not decrease over a long period of time, there is a particularly high risk of suicidal ideation/behavior. Clinical interventions should focus more closely on RFD, their etiology and maintenance.

A lived experience co-designed study protocol for a randomised control trial: the Attempted Suicide Short Intervention Program (ASSIP) or Brief Cognitive Behavioural Therapy as additional interventions after a suicide attempt compared to a standard Suicide Prevention Pathway (SPP)

Background

Despite being preventable, suicide is a leading cause of death and a major global public health problem. For every death by suicide, many more suicide attempts are undertaken, and this presents as a critical risk factor for suicide. Currently, there are limited treatment options with limited underpinning research for those who present to emergency departments with suicidal behaviour. The aim of this study is to assess if adding one of two structured suicide-specific psychological interventions (Attempted Suicide Short Intervention Program [ASSIP] or Brief Cognitive Behavioural Therapy [CBT] for Suicide Prevention) to a standardised clinical care approach (Suicide Prevention Pathway [SPP]) improves the outcomes for consumers presenting to a Mental Health Service with a suicide attempt.

Methods

This is a randomised controlled trial with blinding of those assessing the outcomes. People who attempt suicide or experience suicidality after a suicide attempt, present to the Gold Coast Mental Health and Specialist Services, are placed on the Suicide Prevention Pathway (SPP), and meet the eligibility criteria, are offered the opportunity to participate. A total of 411 participants will be recruited for the study, with 137 allocated to each cohort (participants are randomised to SPP, ASSIP + SPP, or CBT + SPP). The primary outcomes of this study are re-presentation to hospitals with suicide attempts. Presentations with suicidal ideation will also be examined (in a descriptive analysis) to ascertain whether a rise in suicidal ideation is commensurate with a fall in suicide attempts (which might indicate an increase in help-seeking behaviours). Death by suicide rates will also be examined to ensure that representations with a suicide attempt are not due to participants dying, but due to a potential improvement in mental health. For participants without a subsequent suicide attempt, the total number of days from enrolment to the last assessment (24 months) will be calculated. Self-reported levels of suicidality, depression, anxiety, stress, resilience, problem-solving skills, and self- and therapist-reported level of therapeutic engagement are also being examined. Psychometric data are collected at baseline, end of interventions, and 6,12, and 24 months.

Discussion

This project will move both ASSIP and Brief CBT from efficacy to effectiveness research, with clear aims of assessing the addition of two structured psychological interventions to treatment as usual, providing a cost-benefit analysis of the interventions, thus delivering outcomes providing a clear pathway for rapid translation of successful interventions.

Trials registration

ClinicalTrials.govNCT04072666. Registered on 28 August 2019

The Relationship between the Therapeutic Alliance and Suicidal Experiences in People with Psychosis Receiving Therapy

Few studies have examined the relationship between the therapeutic alliance in therapy and suicidal experiences. No studies have examined this relationship with people with non-affective psychosis. The present study sought to redress this gap in the literature. Sixty-four participants with non-affective psychosis and suicidal experiences who were receiving a suicide-focused cognitive therapy were recruited. Self-reported suicidal ideation, suicide plans, suicide attempts, depression, and hopelessness were collected from participants prior to starting therapy. Suicidal experience measures were collected again post-therapy at 6 months. Therapeutic alliance ratings were completed by clients and therapists at session 4 of therapy. Dose of therapy was documented in number of minutes of therapy. Data were analyzed using correlation coefficients, independent samples t-tests, a multiple hierarchical regression, and a moderated linear regression. There was no significant relationship found between suicidal ideation prior to therapy and the therapeutic alliance at session 4, rated by both client and therapist. However, there was a significant negative relationship between the client-rated therapeutic alliance at session 4 and suicidal ideation at 6 months, after controlling for pre-therapy suicidal ideation, depression, and hopelessness. Furthermore, the negative relationship between the client-rated alliance and suicidal ideation was the strongest when number of minutes of therapy was 15 h or below. A stronger therapeutic alliance developed in the first few sessions of therapy is important in ameliorating suicidal thoughts in people with psychosis. Nevertheless, it is not necessarily the case that more hours in therapy equates to a cumulative decrease in suicidal ideation of which therapists could be mindful. A limitation of the current study was that the alliance was analyzed only at session 4 of therapy, which future studies could seek to redress.

Experiences of care for self-harm in the emergency department: comparison of the perspectives of patients, carers and practitioners

Background

Each year, 220 000 episodes of self-harm are managed by emergency departments in England, providing support to people at risk of suicide.

Aims

To explore treatment of self-harm in emergency departments, comparing perspectives of patients, carers and practitioners.

Method

Focus groups and semi-structured interviews with 79 people explored experiences of receiving/delivering care. Participants were patients (7 young people, 12 adults), 8 carers, 15 generalist emergency department practitioners and 37 liaison psychiatry practitioners. Data were analysed using framework analysis.

Results

We identified four themes. One was common across stakeholder groups: (a) the wider system is failing people who self-harm: they often only access crisis support as they are frequently excluded from services, leading to unhelpful cycles of attending the emergency department. Carers felt over-relied upon and ill-equipped to keep the person safe. Three themes reflected different perspectives across stakeholders: (b) practitioners feel powerless and become hardened towards patients, with patients feeling judged for seeking help which exacerbates their distress; (c) patients need a human connection to offer hope when life feels hopeless, yet practitioners underestimate the therapeutic potential of interactions; and (d) practitioners are fearful of blame if someone takes their life: formulaic question-and-answer risk assessments help make staff feel safer but patients feel this is not a valid way of assessing risk or addressing their needs.

Conclusions

Emergency department practitioners should seek to build a human connection and validate patients’ distress, which offers hope when life feels hopeless. Patients consider this a therapeutic intervention in its own right. Investment in self-harm treatment is indicated.

[Collaborative Assessment and Management of Suicidality: An Effective Brief Intervention for the Treatment of Suicidal Patients]

Das "Collaborative Assessment and Management of Suicidality" (CAMS) ist einer von mehreren Interventionsansätzen zur Behandlung von suizidalen Patienten und Patientinnen und wurde weltweit seit 3 Jahrzehnten untersucht und weiterentwickelt. Das CAMS ist auf die Etablierung einer tragenden therapeutischen Beziehung auf Augenhöhe zu einer suizidalen Person ausgerichtet. Der Patient wird aktiv an der Einschätzung seines Suizidrisikos beteiligt und zum "Mitverfasser" seines eigenen suizidspezifischen Behandlungsplans. Das konkrete therapeutische Vorgehen wird durch ein vielseitig anwendbares Instrument, die sogenannte Suizidstatusform (SSF), strukturiert und geleitet. Das CAMS kann von verschiedenen therapeutischen Berufsgruppen sowie bei Patienten und Patientinnen mit unterschiedlichen Diagnosen angewandt werden. Die Wirksamkeit im Hinblick auf eine Verringerung von Suizidgedanken, der allgemeinen psychischen Belastung und Depressivität sowie auf eine Zunahme von Hoffnung und Zuversicht ist mittlerweile empirisch gut belegt.The "Collaborative Assessment and Management of Suicidality" (CAMS) is an intervention approach for the treatment of suicidal patients that has been studied and developed for three decades around the world. CAMS is focused on establishing a continuing therapeutic relationship at eye level with a suicidal person. The patient is actively involved in assessing his or her suicide risk and becomes the "co-author" of his or her own suicide-specific treatment plan. The specific therapeutic procedure is structured and guided by a versatile instrument called the Suicide Status Form (SSF). CAMS can be applied by different therapeutic professional groups to patients with different diagnoses. Its effectiveness in reducing suicidal ideation, general psychological distress and depressiveness, and increasing hope and confidence is now empirically well established.

Suicide Models and Treatment Models Are Separate Entities. What Does It Mean for Clinical Suicide Prevention?

Theoretical models of suicide are based on risk factors associated with suicide, such as psychiatric pathology, genetics, epigenetics, functional brain disorders, and impaired decision making. In current clinical practice, the predominant risk model is the medical model, which posits that treating suicide risk is primarily a matter of treating psychiatric disorders. However, even comprehensive risk factor models cannot overcome the basic problem that, by their nature, they cannot accommodate the suicidal person's psychological experience of suicidality. Risk factor models do not translate into effective treatment models. Suicide risk is highly personal and fluid, and is related to individual vulnerabilities and to person-specific events triggering suicidal thoughts and actions. Clinicians need treatment models that are meaningful to suicidal patients. Understanding the single person's suicidality requires a patient-centered approach. Therapeutic interventions that effectively reduce the risk of suicidal behavior have been developed from general principles of psychotherapy. Therapy process factors associated with effective therapies are working alliance, validation of the individual patient's thoughts and feelings, active treatment engagement. Psychological therapies need patients who are active participants in a collaborative working relationship between therapist and patient. The goal must be to jointly develop a meaningful understanding of the suicidal crisis. In view of the limited personal resources in health care systems it is important that effective therapies are brief and effective. Future research must aim to improve our understanding of the factors involved in effective therapies in order to optimize treatments for individuals at risk. This may also include the integration of biological risk factors in psychological treatment models.

Positive Association Between Therapeutic Alliance and Quality of Life in Psychodynamic Psychotherapy, Cognitive Behavior Therapy, and Interpersonal Therapy: The Patient's Perspective

BACKGROUND

The therapeutic alliance (TA) is considered a common psychotherapeutic factor associated with positive results in psychotherapies. There are no studies relating the TA with quality of life (Qol).

OBJECTIVES

Our objective was to evaluate whether there is an association between the TA and Qol across three different psychotherapies.

METHODS

A cross-sectional study, which included outpatients undergoing individual psychotherapeutic treatment was conducted. When analyzing the total sample, the correlation of the TA with Qol domains did not present statistical significance. When considering only the sample of patients who were undergoing treatment in psychodynamic psychotherapy (PP), there was a statistically significant association between the TA and the psychological domain of Qol (p < 0.05). When using a regression model for adjusting for confounding factors, the association between psychological domain with the TA on the PP patients sample lost significance (p = 0.221).

DISCUSSION

These findings suggest that the TA seems to be more strongly related to better QoL in PP.

Patients' Satisfaction With the Therapeutic Relationship and Therapeutic Outcome Is Related to Suicidal Ideation in the Attempted Suicide Short Intervention Program (ASSIP)

Abstract. Background: The therapeutic alliance may be a moderating factor of outcome in the Attempted Suicide Short Intervention Program (ASSIP). Aims: This study investigates the two components of the therapeutic alliance, patients' satisfaction with the therapeutic relationship and therapeutic outcome and their associations with suicidal ideation over time. Method: A total of 120 patients (55% female; mean age = 36 years) with a history of attempted suicide were randomly allocated to either the intervention group ( N = 60) or the control group ( N = 60). Patients' satisfaction with the therapeutic relationship and outcome were measured with the two subscales of the Helping Alliance Questionnaire. The Beck Scale of Suicide Ideation was used to measure suicidal ideation in this 24-month follow-up study. Results: The ASSIP group showed that patients' satisfaction with therapeutic relationship and outcome increased significantly from the first to the third session. Higher satisfaction with therapeutic outcome correlated significantly with lower suicidal ideation at follow-up. Conversely, the control group showed no significant results. Limitations: The collaborative approach adopted in the initial clinical interview of the control group could possibly have influenced the results of both scales. Conclusion: In particular, the component satisfaction with therapeutic outcome seems crucial to the subjectively perceived satisfaction of treatment and is associated with lower suicidal ideation over time. Thus, an enhanced understanding of components of the therapeutic alliance plays an important role in the development of interventions for suicidal patients.

The working alliance with people experiencing suicidal ideation: A qualitative study of nurses' perspectives

AIMS

This study aimed to enhance the conceptual understanding of the working alliance in the context of nursing care for people experiencing suicidal ideation.

DESIGN

A qualitative study based on grounded theory was conducted.

METHODS

Two authors conducted individual semi-structured interviews from September 2017-January 2019. Twenty-eight nurses in 13 wards of four psychiatric hospitals participated. The Qualitative Analysis Guide of Leuven was used to support constant data comparisons and the cyclic processes of data collection and data analysis.

FINDINGS

The nurses' perspectives revealed that the working alliance can be understood as an interpersonal and collaborative relational process. This relational process highlighted the core variable 'seeking connectedness and attunement with the person at risk of suicide'. The core variable underpinned three clusters: investing in the foundations of the working alliance, nourishing the clinical dimension of the working alliance and realizing an impact with the working alliance.

CONCLUSION

This study highlights the importance for nurses to assess, evaluate and respond to persons' suicidal ideation in harmony with a commitment to connect with them and attune to their perspective.

IMPACT

The relational process uncovered through this study offers valuable insights to support advanced nursing practice, where nurses meaningfully integrate relational elements of care with their contributions to suicide prevention and treatment.

Trajectories of Well-Being Among Latina Adolescents Who Attempt Suicide: A Longitudinal Qualitative Analysis

Significant research questions persist regarding the short- and long-term outcomes of Latina adolescents who attempt suicide. To address these limitations, we utilize an ecodevelopmental framework to identify potential factors that shape differential outcomes following a suicide attempt. Through an exploratory, longitudinal, qualitative research design, we investigate two research questions: How do trajectories of well-being vary among Latina teens after a suicide attempt? What risk and protective factors might contribute to different trajectories? We conducted qualitative interviews with 17 Latina participants living in predominantly low-income households in New York City. Interviews took place within the 6 months following their suicide attempts, and again, 12 months later. Analysis revealed three distinct trajectories after a suicide attempt: resilience, tenuous growth, and chronic stress. Our findings elucidate potential factors that contribute to resilience following a suicide attempt and underscore the importance of prevention and intervention programs that foster adolescents' connectivity across ecodevelopmental contexts.

Effects of prolonged exposure and virtual reality exposure on suicidal ideation in active duty soldiers: An examination of potential mechanisms

OBJECTIVE

The current study sought to investigate the effects of exposure therapy on suicidal ideation (SI), as well as potential mechanistic pathways of SI reduction among active duty military personnel.

METHODS

Active duty army soldiers (N = 162) were recruited from a military base in the U.S. and were enrolled in a randomized clinical trial comparing Prolonged Exposure (PE), Virtual Reality Exposure (VRE), and a wait-list control for the treatment of posttraumatic stress disorder (PTSD) stemming from deployments to Iraq or Afghanistan. PTSD diagnosis followed DSM-IV-TR criteria. Outcome measures were assessed via self-report and clinician interview. PTSD symptoms, depressive symptoms, and SI were included in an autoregressive cross-lagged panel model to examine mechanistic pathways.

RESULTS

Analyses revealed that PE/VRE had a lower probability of post-treatment suicidal ideation (OR = 0.23, 95% CI [0.06, 0.86]) compared to the waitlist control. Mediation analyses revealed a significant indirect effect from treatment condition to post-treatment PTSD symptoms through mid-treatment SI (Estimate = -1.420, 95% CI -3.559, -0.223]). Baseline suicidal ideation did not interact with treatment condition to predict PTSD symptom change at mid-treatment (p = .231) or post-treatment (p = .672).

CONCLUSION

PE/VRE successfully reduced SI, and the presence of SI at baseline did not affect PTSD symptom reduction, promoting the utility of using PE/VRE to address suicidality among individuals with PTSD. Mediation analyses suggest that reductions in SI were achieved early in treatment.

Effectiveness of brief psychological interventions for suicidal presentations: a systematic review

BACKGROUND

Every year, more than 800,000 people worldwide die by suicide. The aim of this study was to conduct a systematic review of the effectiveness of brief psychological interventions in addressing suicidal thoughts and behaviour in healthcare settings.

METHODS

Following PRISMA guidelines, systematic searches were conducted in MEDLINE, CINAHL, EMBASE, the Cochrane Central Register of Controlled Trials and PsycINFO databases. A predefined search strategy was used. Two independent reviewers screened titles and abstracts followed by full texts against predefined inclusion criteria. Backward and forward citation tracking of included papers was conducted. Quality appraisal was conducted using the Cochrane Risk of Bias Tool for Randomized Controlled Trials and the CASP tool for randomised controlled trials. The small number and heterogeneity of studies did not allow for meta-analysis to be conducted. A narrative synthesis was conducted.

RESULTS

Four controlled studies of brief psychological interventions were included, conducted in Switzerland, the U.S. and across low and middle-income countries. Three studies were conducted with adults and one with adolescents. All studies were judged to be at low risk of bias. All of the interventions were implemented with patients after attending emergency departments and involved 3412 participants. The main outcomes were suicide, suicide attempts, suicidal ideation, depression and hospitalization. The components of the interventions were early therapeutic engagement, information provision, safety planning and follow-up contact for at least 12 months. The interventions drew to, different degrees, on psychological theory and techniques. Two trials that measured suicidal ideation found no impact. Two studies showed fewer suicide attempts, one showed fewer suicides and one found an effect on depression.

CONCLUSIONS

Although the evidence base is small, brief psychological interventions appear to be effective in reducing suicide and suicide attempts. All studies to date have been conducted with people who had attended the ED but the interventions could potentially be adopted for inpatient and other outpatient settings. Early engagement and therapeutic intervention based on psychological theories of suicidal behaviour, sustained in follow-up contacts, may be particularly beneficial.

TRIAL REGISTRATION

Systematic review registration: PROSPERO CRD42015025867.

A Novel Therapy for People Who Attempt Suicide and Why We Need New Models of Suicide

This paper presents a model of suicidal behaviour based on suicide as a goal-directed action, and its implications. An action theoretical model has guided the authors in the development of a brief therapy for individuals who attempt suicide (ASSIP—Attempted Suicide Short Intervention Program). Key elements are an early therapeutic alliance, narrative interviewing, psychoeducation, a joint case conceptualization, safety planning, and regular letters over 24 months. In a randomized controlled trial, ASSIP was highly effective in reducing the risk of suicide reattempts. The therapeutic elements in this treatment are described and possible implications for future directions in clinical suicide prevention discussed.

Psychiatrists' experiences of suicide assessment

BACKGROUND

Clinical guidelines for suicide prevention often stress the identification of risk and protective factors as well as the evaluation of suicidal intent. However, we know very little about what psychiatrists actually do when they make these assessments. The aim was to investigate psychiatrists' own accounts of suicide assessment consultations, with a focus on their behaviors, attitudes and emotions.

METHOD

Semi-structured in depth interviews were carried out with a purposive selection of 15 psychiatrists.

RESULTS

Thematic analysis revealed three main themes: understanding the patient in a precarious situation, understanding one's own reactions, and understanding how the doctor-patient relationship impacted on risk assessment and management decisions. Emotional contact and credibility issues were common subthemes that arose when the respondents talked about trying to understand the patient. The psychiatrists stressed the semi-intuitive nature of their assessments. Problems related to the use of risk factor assessments and rating scales were apparent. Assessment consultations could evoke physical and emotional symptoms of anxiety, and concerns about responsibility could lead to repressive management decisions. In situations of mutual trust, however, the assessment consultation could kick-start a therapeutic process.

CONCLUSION

This study highlights psychiatrists' experiences in clinical suicide assessment situations. Findings have implications for professional development as well as for service delivery.