Novel Interventions for Suicide Risk

Abstract

Suicide is a leading cause of death worldwide. Assessment of individuals at risk for suicide is challenging and over the last 50 years the field has made minimal advancement in suicide prevention. Studies have shown that the ability for providers to predict who will die by suicide is no better than a coin flip. Improved interventions for those at elevated risk for suicide are needed. This chapter will explore well known and novel interventions for suicide prevention. Interventions discussed include safety planning, suicide consultation, the Collaborative Assessment and Management of Suicide (CAMS), Cognitive Processing Therapy (CPT), Cognitive Behavioral Therapy (CBT) and other promising interventions for the reduction of suicides. Also discussed is the need for suicide screening and populations outside of traditional mental health clinics.

1. Introduction

The interventions discussed in this chapter are for individuals who are at increased risk for suicidal behavior. They can be categorized as two types; 1) interventions that are for acute suicidal ideation or behaviors that indicate an immediate need for care, and 2) interventions for clients who experience chronic suicidal ideation and require a more extensive intervention over time. Some of the interventions can be used with clients as preventative measures while others may be used for clients that are actively suicidal. In addition, there are interventions that are designed to treat other conditions and have been shown to reduce suicidal ideation as well [1, 2]. Treatments reviewed consist of systematic, manualized treatments that are completed in multiple sessions over weeks [2]; as well as specific interventions completed in one meeting [3]. In those instances, follow up care would be based on the severity of suicidal thoughts and behaviors as well as other details specific to that client such as proximity to the clinic and availability of clinician for follow up care. Also discussed are the processes for transferring care successfully in cases where the client is seen in an emergency setting (i.e., warm handoff).

In addition to specific interventions, a review of available national and local resources is discussed that are often unknown to the general public. A public health approach to suicide would be helpful in getting the word out to the public to increase awareness of the multiple resources that are available. Examples include crisis and chat lines, support groups form clients and/or family members, mobile crisis, smartphone applications for safety planning and other online interventions, gatekeeper training, advocacy organizations such as National Alliance on Mental Illness (NAMI), and public health organizations such as the American Association for Suicidology (AAS).

2. Safety planning

The purpose of safety planning is to manage patients who are at increased risk of suicide. Elevated suicide risk is marked by frequent suicidal thoughts and/or behaviors indicating suicide risk. Safety planning is a collaborative intervention between a clinician and patient [3]. It can take place in a variety of settings, including over the phone, in the community with Social Workers, outpatient clinics, inpatient units, and emergency room settings. The primary objective of a safety plan is to devise a plan for the patient to implement on their own to manage and decrease psychological distress and ultimately reduce the likelihood of acting on urges to harm oneself.

To complete a safety plan, the patient and client meet and document five steps they will take if distress increases in the future outside of sessions with a clinician or therapist. The rationale is to increase the coping skills of the patient, thereby increasing the patient’s agency and not having to rush to the emergency room or make an emergency call to their therapist every time their distress increases. The safety plan emphasizes managing distress through coping skills and reaching out to professionals if the distress cannot be tolerated through other methods. The seven steps to safety planning include, 1) identify warning signs that the patient might be headed towards a crisis, 2) identify internal coping strategies to distract the patient from their problems, 3) identify people, places, and social settings that can distract from internal distress and possibly decrease distress, 4) identify people who you can ask for help (family, friends, co-workers), 5) identify professionals or agencies that can help when in distress, 6) making the environment safe by removing lethal means, and 7) Identifying reasons for living by naming things that are valuable to the patient and worth living for [3]. The idea behind being so deliberate with writing down the steps to the Safety Plan is that it can be called upon once a patient is starting to feel distress. Since the plan is written out, a person simply needs to pull it out and go through the predetermined plan. Given the unpredictability of the onset of a crisis, patients are encouraged to keep their Safety Plan with them either in a vehicle, bag or wallet, so they are always prepared. Phone applications have also been developed, which can be a useful way to keep a Safety Plan with you at all times.

3. Suicide consultation

Suicide consultation can be conducted in a variety of methods from less formal, impromptu one on one consultations with a colleague to formalized requests to a suicide consultation team. The purpose of consultation is dependent on the circumstances. When a clinician encounters a patient with an elevated suicide risk with a complex presentation, consultation with a colleague can be very useful. Clarifying questions and making sure the clinician gathers all the relevant history, treatment and current presentation is vital. Consultation with a colleague can help since they are not as “close” to the therapeutic relationship and may catch elements of the assessment that were missed or overlooked. Questions such as, “Have you gathered any collateral information to verify the patient’s reporting?”, are common follow up questions from a consultation. Informal consultations are indicated when the clinician needs to act in a timely manner, such as the day of appointment. Working with a suicide consultation team is a more deliberate process where the team will ask for a referral question and include an exhaustive chart review and patient interview and returning recommendations [4].

4. Collaborative assessment and management of suicide (CAMS)

The Collaborative Assessment and Management of Suicide (CAMS) is an intervention that focuses on the relationship between the clinician and the patient [5]. Through an interview process with the patient, a structured suicide risk assessment is performed by the clinician to understand the underlying mechanisms that drive the suicidal thoughts and behaviors. The client and clinician then develop a safety plan to address those factors. Examples of elements that can be involved in a safety plan are restricting access to means, recognizing specific thoughts that lead to action, creating a supportive network of family, friends, and providers, and improving coping skills. The development of the safety plan is ongoing across sessions with the clinician, and the hallmark of this treatment is the collaboration between clinician and client.

5. Cognitive processing therapy (CPT)

Cognitive Processing Therapy (CPT) is a manualized therapy designed for the treatment of Post Traumatic Stress Disorder (PTSD) [6]. CPT uses a cognitive based approach to treatment. The main goal is to identify exaggerated or imbalanced thinking (stuck points) that have emerged as a result of the impact of trauma. Often, people who have experienced trauma develop extreme beliefs about the dangerousness of the world and themselves-including whether they are at fault for the trauma having occurred. CPT works to identify stuck points and to investigate whether they are true. This intervention for PTSD has also been shown to have a beneficial in reducing suicide risk [7, 8]. Research with both inpatient residential and outpatient patients, measures of suicidal ideation decreased from pre to post treatment with CPT. Although not designed for treatment of suicidal ideation, CPT targets erroneous and exaggerated beliefs, which are common cognitions among people suffering from suicidal ideation.

6. Cognitive behavioral therapy (CBT)

CBT works to increase the awareness, frequency, and intensity of suicidal thoughts. This is completed through dialog between the client and therapist. CBT is a manualized treatment but can be tailored to target the intervention for clients at increased risk of suicide. A specific CBT intervention for patients at risk for suicide is cognitive behavioral therapy for suicide prevention (CBT-SP) [9]. The intervention is designed as a preventive and risk reduction approach. It uses principles from a number of theoretical frameworks, including dialectical behavioral therapy (DBT) and CBT. It uses chain analysis, safety planning family interventions, skills building and preventing relapse as aspects of the treatment [9]. There are worksheets that are assigned to be completed outside of sessions and reviewed in sessions. The idea behind the worksheets is to increase the autonomy and skills of the client thereby enabling them to have some control over managing future suicidal episodes outside of the therapist’s office. The intervention also provides a plan so that the client can have insight into when they are at increased risk by monitoring their thoughts and feelings and moving into active engagement through a detailed safety plan to avoid suicidal behavior.

7. Dialectical behavioral therapy (DBT)

Dialectical Behavioral Therapy (DBT) is an intervention [10] that mixes group support, individual therapy, and skills training. It was designed for certain populations, such as those experiencing chronic suicidal ideation as well as individuals diagnosed with Borderline Personality Disorder (BPD). The focus of the treatment is individual skill building. A hallmark symptom of clients who are indicated for DBT is a difficulty in emotional regulation. One of the skills that is focused on is improving the ability to regulate reactions to situations. For instance, if a client were to have a conversation with a friend and perceived that they were slighted or insulted, the focus would be on how to respond appropriately without further escalating the situation. In order to respond appropriately, clients are taught to learn to curb their immediate emotional reactions through exercises such as grounding techniques and breathing exercises. Once the client can adequately regulate their emotional reaction and improve distress tolerance to difficult situations that arise, they can then move to learning interpersonal effectiveness skills. These are taught in a group setting using interpersonal scenarios and asking group members to appropriate responses to challenging situations. An example would be boundary setting, for instance, where a client had previously had difficulty maintaining a boundary in a relationship. For a specific example, consider that a friend frequently asks to borrow your vehicle, and that in past experiences they return it hours or days late, and with an empty gas tank. The group leader would facilitate a discussion on this specific example and problem solve on ways to appropriately set a boundary around the use of the client’s vehicle. Interpersonal Effectiveness (IE) skills are very hands on and practical and can be very useful to clients who have difficulty with interpersonal boundaries. The logic of the inclusion of Interpersonal Effectiveness skills is that clients who suffer from BPD and experience chronic suicidal ideation conceptualize suicide as a solution to their problems. There is a tendency to avoid difficult interpersonal situations, which only increases distress when the client is not getting their needs met, and in turn the client turns to self-harm as a solution or “escape” from their problems. The inclusion of IE skills for these clients is a critical one beyond just regulating emotions because it addresses the etiology of the suicidal ideation – difficult and emotionally disturbing interpersonal interactions – and provides the client with a sense of control over difficult interactions instead of reverting to escapism and self-harm.

8. Collaborative care

Collaborative care refers to the interdisciplinary nature of healthcare that has emerged as a standard in healthcare. Often, clients or patients with chronic or acute suicidal ideation have an array of mental, physical, or environmental conditions that contribute to or exacerbate their increased suicide risk. Collaborative care could include providers such as a Primary Care physician, Psychiatrist, Social Worker, Psychologist, Nurse Practitioner, Registered Nurse, Dietician, Occupational Therapist, and Recreational Therapist. This list is not exhaustive, and the level of care is dependent on the acuity and pervasiveness of the problems that impact the patient or client. It is not uncommon in residential settings for a patient to have numerous psychosocial and medical problems that exacerbate suicidal ideation. Evidence from the literature suggests several correlates associated with suicidal thoughts and behaviors, including but in no particular order, psychosocial problems such as economic or financial difficulties, loss of employment, divorce, death of significant other or child, as well as medical problems, including, chronic, chronic or terminal disease, and substance abuse. Other concerns that are often overlooked or not necessarily the focus in a medical facility due to time constraints and prioritization but would be appropriate in a therapy setting are the loss of meaning or purpose, difficulty with transitions or transitional periods, and reintegration into a community in one’s life. A particular example of difficulty in transitions that has been shown to be highly prevalent is among military Veterans. Suicide rates among Veterans in the United States is approximately 17 per day [8]. The transition from active duty to civilian life is a common problem for military veterans due to the unclear path of transition. Skills that were gained and used daily in the military are not necessarily applicable in the civilian world. In addition, the hierarchical, chain of command, team environment of the military is somewhat antithetical to the autonomous and independent environment of modern civilian life. Disconnection and not belonging are also common correlates for increased suicide risk. Collaborative care is ideally suited to addressing the disparate needs of a client or patient with complex, chronic increased risk based on several factors. Providers specialize in different illnesses, chronic conditions and life problems. The use of collaborative care can provide holistic treatment for the patient. An important aspect of collaborative care is communication among providers. This can take many forms but ideally would go beyond simply adding the team to notes in the medical record. Regular weekly or monthly meetings to discuss each provider’s specific treatment plan can be useful to others to verify that the team is working in unison towards the same goals.

9. Mobile crisis

Mobile Crisis is an innovative approach to acute care for patients who are at imminent risk for suicide or homicide in the community. It is also indicated for patients that are mentally compromised due to impairment from their psychiatric illness. A typical Mobile Crisis team consists of two Social Workers or Nurses who are mobilized within a certain jurisdiction and visit clients in their homes or community. Licensure regulations vary by states and county, but Mobile Crisis workers often have the legal authority to write a 72-hour hold on a patient they deem to be imminently suicidal, homicidal, or unable to care from themselves due to deteriorating mental health symptoms. They are then transported to the local hospital through the emergency or psychiatric emergency room and further assessed for the level of care needed. Mobile Crisis workers in some communities’ work with local law enforcement, who are often the first responders to calls regarding psychiatric crisis. Mobile Crisis workers can be embedded within police district buildings and ride along with law enforcement when a call comes in for a mental health situation. Mobile crisis members are trained in de-escalation, which can help to avoid a mental health problem escalating into a crisis. Often the encounters consist of a conversation and do not escalate to the need for a 72-hour hold. Other outcomes include connecting community members with resources such as mental health appointments or case manager appointments. Mobile Crisis clinicians also complete Safety Plans to help patients at increased risk manage their suicidal thoughts. Safety Planning also provides a road map for decision making when suicidal thoughts and impulses escalate and what steps to take.

10. Restricting lethal means

Means safety counseling is an important aspect of any means restriction practices. Limiting access to medications, firearms and other objects that could be used for self-harm is a critical component of suicide prevention. Over half of all suicides in the United States occur from a firearm [11]. Restricting access to firearms alone could help prevent innumerable suicide deaths. The focus of many suicide prevention programs is means restriction, with the rationale being that it is the most practical way to prevent suicide. The premise of means restriction is that an individual’s state of mind who experiences chronic or periodic suicidal thoughts will vary over time. The baseline intensity of suicidal ideation may be quite low. When they experience periods of intense suicidal ideation, and you combine that with easy access to a firearm, you have a lethal situation. Removing access to a firearm may not change the intensity of suicidal thoughts, but it limits the ability to go through with suicide, at least in terms of firearm as a means. Other common types of means restriction includes access to medications, knives and other sharp objects, vehicles, and ropes. Means restriction is a practical and effective method of suicide prevention that should be incorporated into every clinician’s treatment plan when putting together a suicide prevention treatment plan.

11. Public health approaches

To increase awareness of the prevalence and impact of suicide, public health messages regarding the prevalence and rates of suicide in the overall population are advertised through various media outlets. Like many prevalent health problems, mental health and suicide prevention are highly stigmatized, which can be an enormous obstacle to seeking treatment. This has been particularly true among military and veteran populations. In order to combat the stigma associated with suicide, public health campaigns for the Department of Defense and the Department pf Veterans Affairs have been ongoing through efforts such as the Veterans Crisis Line that has talk, text and chat functions [12].

12. Screening beyond mental health clinics

Although mental health clinics and the patients they serve are often the focus suicide prevention efforts, suicide risk is present in a number of other populations, including primary care, chronic illness patients, the elderly, and lesbian, gay, bisexual, transgender, and queer (LQBTQ) communities to name a few. One method used to identify suicide risk among non-mental health populations is through screening instruments such as the Columbia- Suicide Severity Scale (C-SSRS), the Patient Health Questionnaire (PHQ-9), and the Brief Suicide Cognitions Scale (B-SCS) [13, 14, 15]. The purposes of these instruments are to provide a brief screening to identify patients at elevated suicide risk. A positive screen would then prompt a full assessment which in most cases would be in the form of a referral to a mental health professional. Screening instruments can be either self-report or administered by the health professional and can aid in the identification of risk in clinics that do not traditionally ask about risk for self-harm or suicide.

13. Conclusion

A number of interventions for suicide prevention are discussed in this chapter. Interventions include those for acute suicidal risk and more extensive systematic treatments over time. Interventions discussed include Safety Planning, CAMS, means restriction, CPT, CBT, DBT, suicide consultation, collaborative care, mobile crisis, and public health efforts in suicide prevention. Also discussed was the identification of populations at risk that are outside the traditional mental health populations, such as primary care, chronic illness, and LGBTQ populations. The use of screening tools aid in the identification of increased risk in an expedient manner. Future discussions could include the use of technology and artificial intelligence in interventions to assess and treat high risk individuals.

Conflict of interest

The author declares no conflict of interest.