Brief and Ultra-Brief Suicide-Specific Interventions

An innovative nonpsychotherapy approach, the TMBI, developed by Stephen O’Connor and colleagues (15), consists of nine components that take place during a one-time 30–60-minute interaction. This interaction takes place either on the medical-surgical unit or on a psychiatric inpatient unit within 2 days of a highly lethal suicide attempt. The idea is that engaging individuals while they are recovering from a medically lethal suicide attempt provides an opportunity to have them explore the motivations leading up to the attempt, as well as the aftereffects and consequences, and thereby identify proximal protective factors and increase motivation for future treatment toward suicide prevention.

Section 1 of TMBI begins as soon as the individual is medically stable (15). The clinician first approaches the individual on the medical-surgical unit and spends a few minutes building rapport and assessing the patient’s level of comfort in discussing the recent attempt. Second, the clinician makes a validating comment, such as how much pain the individual must have been in to try to take their own life. Third, the clinician explains that they would like to spend some time talking about the attempt, in order to understand the factors leading up to the attempt, to better clarify why it happened, and to inform steps for recovery.

In Section 2 of TMBI, the clinician expresses curiosity and encourages collaboration in trying to identify the drivers of the suicide attempt (15). This step leads to a discovery process as to how the client developed an orientation toward death. The clinician conducts a functional analysis to obtain as many details as possible regarding the function of the suicide attempt. The clinician then makes an inquiry into the individual’s perception of what was lost and what was gained by the attempt, nonjudgmentally raising the negative (i.e., medical and financial) consequences. The clinician also asks how the patient feels about having survived the attempt.

In Section 3 of TMBI, the clinician and patient collaborate on a short-term crisis response plan consisting of five coping strategies and provision of the crisis lifeline phone number (now 988 in the United States) (15). The next component consists of identifying major factors to be addressed in a suicide-specific treatment. The final component is to summarize what comes next in terms of treatment and in returning to life (work, family) outside the hospital.

A pilot randomized controlled trial (RCT) comparing 23 hospitalized individuals with a recent suicide attempt who received the TMBI versus 25 who received usual care (15) showed that, although the differences were not statistically significant, there was a trend toward increased treatment engagement among those receiving TMBI across a 12-month follow-up.

ASSIP is a brief, client-centered intervention designed to reduce suicide risk in 3–4 sessions, with the addition of contact letters sent across the next 2 years (17). As a brief intervention, ASSIP is not designed to be a stand-alone treatment, and the authors (21) noted that another long-term suicide-specific intervention should be used to supplement treatment. The therapeutic alliance, or collaborative relationship between the clinician and client, is a central component of ASSIP, and it is the foundation through which the clinician comes to understand the client’s suicidal experience and works with the client to reduce risk. ASSIP is based on action theory, narrative interviewing, cognitive-behavioral therapy (CBT), and attachment theory (21). Through this approach, clinicians view their clients as agents of goal-directed actions (e.g., suicide as a way to end their psychological pain) and use narrative interviewing to understand a recent suicidal crisis and to help strengthen the therapeutic relationship (21). These factors are thought to affect the client’s engagement in subsequent treatment sessions and the intervention’s utility.

Treatment begins by video recording clients telling their story of a recent suicidal crisis to describe “how they reached the point of wanting to kill themselves, and how they went about it” (17). In the next session, the clinician and client sit next to each other, as they watch the recording, to develop a deeper, shared understanding of the factors that led to the client’s suicide attempt. The clinician then provides the client with a psychoeducational handout on suicide. After the session is over, the clinician creates a draft case conceptualization. The third session consists of discussing the client’s feedback and questions on the psychoeducational handout, reviewing and revising the client’s case conceptualization, and writing down warning signs and safety strategies on a crisis card that is to be kept with the client at all times. During the next 2 years, semi-standardized letters, signed by the clinician, are sent to the client to reiterate the long-term risk of suicide and to remind the client about safety strategies. ASSIP was designed for adult populations, and to our knowledge, has not yet been adapted for or tested among youth populations.

Because ASSIP is a newer intervention, few trials have tested its efficacy. A 2016 RCT (22), conducted by the intervention’s developers, showed that participants treated with ASSIP had an 80% reduced risk of reattempting suicide and spent nearly 75% fewer days in the hospital across a 2-year follow-up, compared with those receiving treatment as usual. However, two later RCTs (23, 24) failed to replicate these results. Clients treated with ASSIP have tended to endorse higher ratings of the therapeutic alliance (22, 24, 25), treatment satisfaction (24), and satisfaction with therapeutic outcomes, which has been related to reduced suicidal ideation at 6-, 12-, and 24-months of follow-up (25). Secondary analysis of Gysin-Maillart et al.’s 2016 seminal work (22) has shown that ASSIP is more cost-effective than a single suicide risk assessment provided to control patients (26). Another examination of Gysin-Maillart et al.’s study showed that ASSIP was associated with more problem-focused coping, which has been inversely correlated with suicide ideation (27).

For many suicidal clients, an emergency or urgent care visit is the only occasion on which they receive services addressing their suicidal crisis and never receive follow-up care (28–30). This lack of care is alarming because risk remains high for some time after a suicide crisis or attempt (30). Providing clients with useful strategies during the emergency visit to prevent further suicidal behavior may prevent return emergency visits and further suicidal behavior (31). The SPI incorporates theoretical concepts from Cognitive Therapy for Suicide Prevention, dialectical behavior therapy (DBT), and behavioral rehearsal strategies (e.g., stop, drop, and roll). The approach emphasizes planning ahead for the next crisis while the individual is not currently in crisis, identifying individual warning signs and distress tolerance strategies, encouraging individuals to reach out, as well as enhancing independent coping, help-seeking behaviors, and treatment engagement. The SPI is typically developed with clients after a risk assessment that, in part, determines their suitability for the intervention. Suitability is based on the client being able to identify a discrete suicidal crisis. The basic steps of the safety plan include the following: warning signs indicating an impending suicidal crisis; internal coping strategies (typically solo distracting or engrossing activities) for use to avert a crisis from escalating; social support and social settings as a means of distraction from suicidal thoughts; family members or friends who can help resolve the crisis; mental health professionals or agency contacts, hospital where emergency care can be received, and crisis-line contact information; and identification and reduction of access to potential use of lethal means.

The first five components are used when suicidal thoughts and other warning signs emerge. Reducing access to means is discussed after the rest of the safety plan has been completed, often with the aid of a family member or friend, for an agreed upon period of time. Clients are advised to follow the steps in order, if possible.

SPI has demonstrated efficacy and effectiveness as a stand-alone intervention and as part of multicomponent suicide-specific treatments across various settings and populations. The SPI, along with structured follow-up and monitoring, was tested in a large-scale cohort study (32) of 1,680 veterans attending one of five Veterans Affairs (VA) Emergency Departments (ED) for suicide-related concerns. The number of individuals presenting to any of the five intervention VA EDs with suicidal behavior was 45% lower in the 6 months after ED discharge compared with those presenting to a control site during the same time period (31, 33). Furthermore, clients who had received SPI had more than double the odds of attending at least one mental health treatment appointment in the 6 months following ED discharge, compared with those who did not receive SPI (31, 32).

Moreover, those who received SPI were significantly more likely to attend an outpatient mental health or substance abuse treatment appointment in the 3 months postdischarge compared with those who had not received SPI (33). The effect of SPI on treatment attendance and engagement is of particular importance, given the heightened risk of suicide following ED discharge (30).

CRP is a brief intervention very similar to SPI, consisting of development of a crisis narrative and writing down on an index card, personalized warning signs, coping skills, social support contact information, and professional and crisis services (10). CRP has a growing body of research (34) supporting its effectiveness. An RCT (34) of 97 active-duty soldiers attending emergency behavioral health appointments showed that these soldiers were 76% less likely to attempt suicide during follow-up compared with those receiving treatment as usual.

Enhanced CRP (E-CRP) includes reasons for living and has been associated with a decreased likelihood of psychiatric hospitalization and greater increases in positive emotional states (calmness and hope) than standard CRP (S-CRP) (35). Furthermore, both E- and S-CRP have been associated with greater reductions in negative emotional states (depression, agitation or feeling on edge, urge to kill oneself, shame, and fatigue) than contracts for safety (35). Secondary analyses of clinical trial data (34) showed that more frequent use of E-CRP was associated with greater reduction in suicidal ideation and that this reduction was contingent on the participants’ ability to recall components of their CRP (20). CRP has also been incorporated into suicide-specific treatments, such as brief CBT for suicide prevention (36). An RCT (37) of active-duty soldiers at risk for suicide demonstrated that those who received brief CBT with CRP were 60% less likely to reattempt suicide during a 24-month follow-up than those who received treatment as usual.

CT-SP is a time-limited psychotherapy intervention that is based on Aaron Beck’s cognitive-behavioral model (38). According to this theory, an individual’s biopsychosocial vulnerabilities can interact with suicidal thoughts and behaviors to produce a “suicide mode” (38). CT-SP consists of an acute treatment phase consisting of approximately 10–12 structured weekly sessions, largely centered around the idea of applying CBT approaches to recognizing the suicide mode and knowing when one is in it and how to get out of it (39). This acute treatment includes an early phase of crisis management, an intermediate phase consisting largely of skills training, and a later phase that addresses relapse prevention (39). CT-SP also has a continuation phase, consisting of another six sessions provided across 12 weeks, as needed, after the acute treatment phase has been completed (39).

A typical CT-SP session is about 50 minutes long and is quite structured (38). The clinician and individual collaboratively set an agenda for the session, giving priority to suicidal ideation or to any life-threatening problems. The clinician conducts a mood and suicidal risk assessment, asks whether the safety plan has been used since the previous session, reviews homework, and focuses on new areas of cognitive restructuring and skills training.

During the first phase of the acute treatment protocol, which takes place across the first 2–3 sessions, the clinician conducts a thorough risk assessment and focuses on crisis management, which includes collaborative safety planning and means reduction counseling (40). The clinician obtains a detailed narrative timeline identifying the major situations, thoughts, and behaviors surrounding the most recent suicidal crisis, which is then used to generate a cognitive-behavioral case conceptualization to inform an individualized treatment plan. In addition, because hopelessness is often associated with increased suicidal risk, the first phase of CT-SP includes identifying reasons for living and developing hope kits that can remind individuals of their reasons for living, and the things they have hope for, when they are in a more suicidal mode of thinking.

In the intermediate phase, emphasis is placed on learning coping skills targeted to the particular risk factors, triggers, and cognitive-behavioral responses that were identified in the individual’s crisis narrative (41). These skills are based on evidence-based approaches, such as CBT and DBT, and include relaxation training, distraction, behavioral activation, self-care, and reduction of emotional vulnerability. Individuals are educated about the cognitive model and are taught how to restructure thoughts and beliefs that lead to the suicide mode and to modify dysfunctional core beliefs.

The later phase of CT-SP includes skills consolidation, relapse prevention, and treatment planning (42). The central relapse prevention exercise is a task in which the individual is guided to imagine how they might use the skills, cognitive restructuring, and safety planning learned in the earlier phases to prevent acting on suicidal thoughts (38). Once it is determined that the individual has consolidated the skills and can imagine using them and the safety plan, plans for further treatment, including a continuation phase of CT-SP, are considered.

In a well-powered RCT with an 18-month follow-up, Brown and colleagues (43) found that individuals in CT-SP treatment were 50% less likely to reattempt suicide compared with those in the usual care group. The researchers also found significant reductions in levels of depression and hopelessness in the CT-SP treatment group compared with the control group. Researchers of CT-SP are in the process of replicating these results in a community-based outpatient setting, with varied samples (including those with severe ideation but who have not attempted suicide) (44).

BCBT for Suicide Prevention, developed by Craig Bryan and M. David Rudd (36) as a next step in the development, refinement, and application of the cognitive-behavioral model to reduce suicidal behavior, is an adaptation of CT-SP. Similar to CT-SP, BCBT consists of three phases of treatment, spanning 12 sessions. Phase 1, session 1, of BCBT consists of orientation to the treatment, narrative risk assessment, and crisis management, including development of a crisis response plan and lethal means reduction counseling (36). Sessions 2–5 of phase 1 address treatment planning, skills for addressing sleep disturbance, mindfulness and relaxation, reasons for living and dying, and development of a survival kit. The primary tasks of phase 1 include describing the treatment, assessing the index suicidal episode, educating the client about the suicide mode, developing a crisis response plan, developing a treatment plan and obtaining the client’s commitment to the treatment, and providing training in emotion regulation skills.

Phase 2 (sessions 6–10) targets cognitive restructuring of suicidal belief systems, problem solving, and cultivation of cognitive flexibility (36). In this phase, the clinician teaches selected cognitive-behavioral skills by using ABC (antecedent, behavior, and consequence) worksheets, identifying patterns of problematic thinking, asking challenging questions, and teaching the use of coping cards and activity planning. The primary tasks of phase 2 are to review and rehearse emotion regulation strategies, in order to generalize use of these strategies across situations, and to target core beliefs and behaviors that contribute to the suicide mode. Phase 3 (sessions 11–12) is devoted to relapse prevention. The primary tasks of phase 3 are to conduct relapse prevention tasks repeatedly, to review the index suicidal episode several times until the individual demonstrates the ability to problem solve, and to develop hypothetical future crises and conduct imaginal exposure with the client imagining effective use of problem-solving skills. The treatment is more fully described in a book or treatment manual (36).

A number of studies have supported the effectiveness and efficacy of BCBT in reducing suicidal behavior. One RCT (37) found that, among active-duty U.S. Army soldiers who had either attempted suicide or experienced suicidal ideation with intent, those who were assigned to the BCBT condition were 60% less likely to attempt suicide in the 24 months between baseline and follow-up than those assigned to treatment as usual. In a secondary analysis of the same participant sample (6), three latent classes corresponding to low, moderate, and high suicide risk were identified, with classes significantly differing in terms of psychiatric symptom severity but not in demographic or historical variables. Rates of suicide attempts during the 2-year follow-up period significantly varied across these classes among those in the treatment-as-usual group, but did not vary across classes in the BCBT group, indicating that BCBT contributed to consistently low rates of suicidal behavior, despite psychiatric symptom severity (6).

CAMS (45, 46) is a therapeutic framework that guides clinicians in assessing, tracking, and treating clients’ suicidal risk and typically takes 6–8 sessions. A core feature of CAMS is the collaborative and transparent way in which clinicians work with clients to comprehensively assess and safely manage suicide risk (45). Assessment and management of risk are guided by Suicide Status Forms (SSFs), which are used to assess multiple dimensions of suicide risk, track risk fluctuations over time, assist with planning treatment to target “drivers” of risk, and evaluate treatment outcomes (47). The SSF and CAMS are based on Shneidman’s cubic model of suicide (48), which posits that suicidal behavior and death result from “psychache” (i.e., psychological pain), perturbation, and stress. Other conceptual influences on the CAMS framework include Beck’s theory of hopelessness (49) and Baumeister’s view of self-hate as a driving factor of suicide (50). Jobes proposes that these factors are critical to assess and target in treatment (45).

In the first part of the SSF, clients are asked to rate their current experience of six dimensions of suicide risk and then to rank them in order of importance: psychological pain, stress, agitation, hopelessness, self-hate, and overall suicide risk (overall suicide risk is not ranked) (51). Clients then rate the extent to which their suicidal thoughts are related to themselves versus others, list and rank their reasons for living and for dying, rate how much they want to live versus how much they want to die, and indicate the “one thing that would help me no longer feel suicidal” (46). Later portions of the SSF include a treatment plan that the clinician and client codevelop, traditional suicide risk assessment items for the clinician to complete (e.g., frequency and duration of ideation, history of suicidal behaviors), and a stabilization plan—which is similar to a safety plan (19) or crisis response plan (10).

The CAMS approach calls for the clinician to physically sit next to the client while the two together complete the SSF. By sitting next to the client, the clinician is demystifying therapy; the client can see what is on the SSF and what the clinician is writing. This gesture of sitting next to the client is used in part to convey the message that the two are on the same team, and that the client’s input in treatment is encouraged and expected (46). Jobes notes that this arrangement differs from the traditional medical model, which approaches treatment in a more directive way, where the clinician is deemed to be the expert in suicide who knows what is best for the suicidal client. In that scenario, the client is directed to follow the clinician’s suggestions without much input, if any. The CAMS approach, on the other hand, recognizes that clients are experts in their own experience of suicidal risk and that it is the clinician’s job to develop a shared understanding of this perspective and to work with clients to address the risk in a way that is acceptable to both parties. Because CAMS is a flexible framework, it can be used with a range of interventions from varying theoretical backgrounds (e.g., cognitive-behavioral, psychodynamic, humanistic).

A growing number of studies have tested the efficacy and effectiveness of CAMS compared with treatment as usual (52, 53). CAMS has largely been tested among civilian adults in outpatient settings, although a few studies have been conducted in inpatient units or EDs (54, 55) or with active-duty military personnel (56, 57).

In adult populations, CAMS has demonstrated effectiveness in reducing suicidal ideation and overall symptom distress, compared with treatment as usual (53), but not in reducing suicidal behavior (52). These gains have been sustained for 12 months after treatment was completed in some studies (58), although not every trial has found this same effect (59). Participants in CAMS trials have also exhibited improvements in suicide ideation and distress from pre- to posttreatment (60) and quicker reduction in suicide ideation (in ∼6–8 sessions), compared with treatment as usual (56, 61). In addition, participants who have received CAMS have reported significant increases in hope (58), greater decreases in hopelessness (59, 62), and lower rates of ED visits (56). Furthermore, CAMS treatment has been associated with greater client satisfaction (58, 59), treatment retention (58, 59), and treatment acceptability and feasibility (54, 63).

In a trial comparing CAMS to DBT, however, CAMS was not superior on any outcome variable (e.g., suicide ideation, suicide attempt, nonsuicidal self-injury, hopelessness) among clients with borderline personality disorder who had recently attempted suicide (62). Furthermore, to our knowledge, no published RCT to date has demonstrated a significant effect of CAMS in reducing suicide attempts or self-harm. More research is needed to better understand the effect of CAMS on suicide-related behaviors.

Ivan Miller and colleagues (64) have developed a brief suicide prevention intervention meant to reduce subsequent suicidal behavior during times of acute risk. The CLASP is an adjunctive intervention consisting of three individual in-person meetings, one meeting with the individual’s significant other or family, and 11 15–30-minute telephone contacts with the suicidal individual and his or her significant other or family member.

The CLASP intervention adapts strategies from Acceptance and Commitment Therapy (ACT) (65) and from Family Intervention-Telephone Tracking (FITT) (66) to reduce modifiable risk factors for suicide. Thus, the intervention aims to reduce hopelessness, bolster family and social support, teach problem-solving skills, and enhance treatment engagement. CLASP also focuses on identifying individual-specific risk factors.

During the initial meetings with the individual, a discussion informed by the ACT approach is begun to clarify the individual’s personal values toward facilitation of behavioral change (67). The focus on values leads to the setting of goals that are consistent with the individual’s beliefs. This approach is later extended to the meeting with the individual and their significant other or family member (SO) and results in an individualized life plan document that informs the telephone contacts.

Subsequent telephone contacts with the individual and their SO are modeled after the FITT intervention and are aimed at problem solving, including improvement of communication skills and monitoring of suicide risk (64). These telephone contacts also support problem-solving coping skills and enhanced treatment engagement by addressing any treatment barriers. The intervention is not considered to be psychotherapy—rather, the clinician is considered an advisor who takes a case-management type of approach.

In the first three sessions, the advisor meets with the individual, introduces the program, obtains a psychiatric history, evaluates current suicide risk status, develops or reviews a safety plan, begins a discussion of the individual’s values, and develops short-term treatment goals (64). This phase culminates in development of a life plan document that guides the telephone call component of the intervention. When the SO is included, in the fourth meeting, there is brief psychoeducation regarding suicide and suicide risk factors and a review of the life plan, which includes a safety plan.

Following these in-person meetings, the advisor conducts 11 15–30-minute telephone contacts with the suicidal individual and also with the SO separately (64). If no SO can be identified, the calls are conducted with the suicidal individual only. Frequency of these telephone contacts decreases across 6 months. The advisor monitors suicide risk, and when suicidality is present, the safety plan is reviewed. The advisor encourages problem solving and communication and discusses problems in terms of the identified values and the life plan document. Because CLASP is an adjunct treatment, when necessary, the advisor may contact the primary treatment provider.

In an initial open trial, CLASP was administered to 25 inpatients at risk for suicide (64). The in-person sessions were conducted on the unit, and the telephone calls were conducted during the 6 months postdischarge. CLASP was acceptable to about 75% of the clients, and most were able to identify a SO. Satisfaction with CLASP was high, and the 12% of clients who subsequently attempted suicide within the 6-month period represented a significantly lower number than previous subsequent suicide attempt rates among former inpatients. A pilot RCT (64) included an enhanced treatment-as-usual condition, called Safety Assessment and Follow-Up Evaluation (SAFE), which consisted of treatment as usual, plus enhanced monitoring of suicidal ideation and risk factors. Compared with control group participants, those receiving CLASP had lower rates of suicide attempts and hospitalizations during the 6-month follow-up. Thus, there is evidence for feasibility and acceptability of the CLASP intervention, as well as some promising pilot efficacy data.