Zero Suicide

Interventions for Suicide Risk

Care for suicide risk should directly target and treat suicidal thoughts and behaviors and behavioral health disorders using effective, evidence-based treatments. 

Some interventions that might be more accurately designated as research-informed are also included in the standard of care for suicide prevention. Research-informed interventions are based on research and theory and perhaps even have components that are evidence-based, but they do not have a body of research showing effectiveness.

Evidence-Based Interventions

Evidence-based interventions include interventions and treatment that are designed to target suicide risk directly. These interventions have demonstrated effectiveness in reducing suicidal thoughts and behaviors. 

At this time, only a few interventions are supported by research. In the video to the right, David Jobes, PhD, a clinician-researcher at Catholic University of America, provides a quick overview of these interventions:

• Non-demand “caring contacts”
• Structured, problem-solving therapies
• Collaborative assessment and treatment planning1

Whichever specific model is used, interactions with patients should always be person-centered, collaborative, and careful to acknowledge the ambivalence that patients contemplating suicide risk often feel. Understanding that ambivalence—the desire to find a solution to the intense pain they feel versus the innate human desire to live—is essential for any clinician working with a patient at risk of suicide. 
 
The following sections provide more detail about the interventions Dr. Jobes describes. You’ll find links to resources about these interventions in the Readings and Tools section at the bottom of this page.

Non-Demand Caring Contacts 

A growing body of evidence suggests that post-discharge follow-up contacts with high-risk individuals may be an effective suicide prevention strategy. While non-demand, caring contacts are not treatment per se, they can be used as adjuncts to treatment to:

• Keep patients engaged
• Follow up with patients who are difficult to engage
• Extend the connection between provider and patient after treatment has ended 

Caring contact interventions include:

• Postcards and/or letters containing brief expressions of caring  
• Telephone follow-up contacts with patients after discharge 
• Telephone calls combined with in-person contact2

Organizations can use automated systems to send postcards, letters, e-mails, or text messages.3

Cognitive Behavioral Therapy for Suicide Prevention 

This intervention, known as CBT-SP, is theoretically grounded in principles of cognitive behavior therapy (CBT); dialectical behavioral therapy (DBT); and targeted therapies for suicidal, depressed adolescents and adults.

Two studies tested the efficacy of this intervention: one study with adults, which found reductions in attempts and symptoms, and a second study demonstrating the feasibility of using a similar intervention with adolescents.45 In Brown and colleagues' (2005) research with adults, a 10-session cognitive therapy intervention focused specifically on identifying proximal suicidal thoughts, images, and core beliefs activated before a suicide attempt. Subsequently, Stanley, Brown, and colleagues (2009) manualized a cognitive therapy intervention specifically for adolescent suicide attempters, called Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP).

CBT-SP can be used with adults and adolescents and includes:

• 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 strategies5

Because adolescents’ suicidal crises occur within an environment that may include problematic relationships, abuse, family dysfunction, or poor school performance, CBT-SP includes family interventions if needed. 

Dialectical Behavior 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 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 client
• Consultation team meetings—a kind of “therapy for the therapists”6

Numerous research studies, including several randomized control trials, have shown DBT to be effective in reducing suicidal behavior and other behavioral health issues. For example, Linehan et al. (2006) compared one year of DBT with women with borderline personality disorder and two or more suicide attempts and/or self-injuries in the past 5 years and at least one in the past 8 weeks to non-behavioral community treatment by experts. Those receiving DBT were significantly less likely to 

• Drop out of treatment
• Attempt suicide 
• Visit psychiatric emergency rooms
• Experience psychiatric hospitalization7

Collaborative Assessment and Management of Suicidality 

Outpatient care is the explicit goal of the Collaborative Assessment and Management of Suicidality (CAMS), which is designed to strengthen the therapeutic alliance and increase patient motivation. CAMS is best understood as a therapeutic framework that emphasizes a collaborative assessment and treatment planning process between the patient at risk of suicide and the clinician. 

CAMS is supported by six published correlational studies and one randomized feasibility study, described briefly as follows: 

• Two studies of suicidal college students in a college counseling center showed reductions in suicidal ideation.
• Two studies in outpatient settings in Denmark demonstrated the cross-cultural feasibility of CAMS.
• One study in an inpatient psychiatric setting showed reductions in suicidal ideation, depression, hopelessness, and suicidal cognitions.
• One study in U.S. Air Force outpatient clinics found suicidal ideation was reduced more quickly than in a control group. The intervention was also correlated with reductions in primary care appointments and emergency department visits.
• One study to test the feasibility of a randomized control trial, in an outpatient community mental health center, found reductions in suicidal ideation, overall symptom distress, and optimism/ hope, with the most robust effects occurring at the most distal assessment point—12 months after the start of treatment.8

Research-Informed Interventions 

The standard of care for patients with suicide risk includes some interventions that may be informed by research and clinical practice but do not have a body of research to support them. 

Safety planning and lethal means reduction are two such interventions. 

Safety Planning 

A safety plan is a prioritized written list of coping strategies and sources of support developed by a clinician in collaboration with patients who are at high risk for suicide.9

According to Dr. Stanley's webinar presentation to the right, safety planning incorporates elements of four evidence-based suicide risk reduction strategies: 

• Reducing access to lethal means 
• Teaching brief problem-solving and coping skills 
• Enhancing social support and identifying emergency contacts 
• Using motivational enhancement to increase likelihood of engagement in further treatment 

As Dr. Stanley emphasizes in the webinar, a safety plan is not a “no-suicide contract,” which is not recommended by experts in the field of suicide prevention. As they are generally used, no-suicide contracts ask patients to promise to stay alive without telling them how to stay alive. 

Additional information about safety planning, including a webinar and training module, can be found in the Engage section of the Toolkit. 

Reducing Access to Lethal Means 

Limiting access to medications and chemicals and removing or locking up firearms and other weapons are important actions to keep patients safe.10

Reducing access to lethal means is based on the following suppositions:

• Many suicide attempts occur with little planning during a short-term crisis 
• Intent isn’t all that determines whether an attempter lives or dies; means also matter 
• 90% of attempters who survive do NOT go on to die by suicide later 
• Access to firearms is a risk factor for suicide
• Firearms used in youth suicide usually belong to a parent
• Reducing access to lethal means saves lives11

Reducing access to possible methods of suicide may be one of the most challenging tasks a clinician faces with a patient. Organization policies should clearly state what clinicians should do regarding lethal means, including the protocol to follow in the event a patient brings a weapon or other lethal means to the clinical setting. More information about reducing access to lethal means, including a webinar and a link to an online training, can be found in the Engage section of the Toolkit.

• 1. Jobes, D. A. (2012), The collaborative assessment and management of suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42(6), 640–653. http://onlinelibrary.wiley.com/doi/10.1111/j.1943-278X.2012.00119.x/abst...
• 2. Luxton, D. D., June, J. D., & Comtois, K. A. (2013). Can postdischarge follow-up contacts prevent suicide and suicidal behavior? Crisis, 34(1), 32–41. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22846445
• 3. Berrouiguet, S., Gravey, M., Le Galudec, M., Alavi, Z., & Walter, M. (2014). Post-acute crisis text messaging outreach for suicide prevention: A pilot study. Psychiatry Research, 217(3), 154–157. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24736112
• 4. Brown, G. K., Ten Have, T., & Henriques, G. R. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA, 294(5), 563–570. Retrieved from http://jamanetwork.com/journals/jama/fullarticle/201330
• 5. a. b. Stanley B., Brown, G., Brent, D. A., Wells, K., Poling, K., Curry J., . . . Hughes, J. (2009). Cognitive behavioral therapy for suicide prevention (CBT-SP): Treatment model, feasibility and acceptability. Journal of the American Academy of Child & Adolescent Psychiatry, 48(10), 1005–1013.
• 6. Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York, NY: Guilford Press. Retrieved http://behavioraltech.org/resources/whatisDBT.cfm
• 7. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., . . . Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766. Retrieved from http://jamanetwork.com/journals/jamapsychiatry/fullarticle/209726
• 8. Comtois, K. A., Jobes, D. A., O’Connor, S. S., Atkins, D. C., Janis, K., Chessen, C. E., . . . Yuodelis-Flores, C. (2011). Collaborative assessment and management of suicidality (CAMS): Feasibility trial for next-day appointment services. Depression and Anxiety, 28(11), 963–972. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/da.20895/abstract?deniedAcces...
• 9. Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. Retrieved from http://www.suicidesafetyplan.com/uploads/Safety_Planning_-_Cog___Beh_Pra...
• 10. Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., ... & Mehlum, L. (2005). Suicide prevention strategies: A systematic review. Jama, 294(16), 2064–2074. Retrieved from http://www.daveneefoundation.org/wp-content/uploads/Suicide-Prevention-S...
• 11. Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M., ... & Purebl, G. (2016). Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry, 3(7), 646–659. Retrieved from http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30030-X/abstract