It’s high time we had another post from Stephen O’Connor, a founding contributor of this site and a faculty member in the department of psychiatry and behavioral sciences at the University of Washington. The timing works well after last week’s post created interest in forming an online support group.

After discussing a couple of familiar therapies, this week’s post explores the subject of support groups for attempt survivors. “This is a sensitive topic,” Stephen writes. “I have noticed many of my colleagues recoiling at the idea of groups where the content focuses explicitly on suicidal ideation, out of fear that it may actually lead group members to feel more suicidal and reinforce self-harm behaviors.”

But be sure to read on.

One quick, unrelated note: The Talking About Suicide blog has posted its 50th interview with an “out” attempt survivor, a modest milestone, and will post a new one later today.

Now, here’s Stephen:

There is a rich history of research conducted with the intention of improving the understanding of, and quality of life for, suicide attempt survivors. At the same
time, our field is much less developed than others such as depression, anxiety
and schizophrenia research, where interventions and medications have been
studied extensively and are being disseminated on a national level.

There are multiple reasons for this, including a traditional focus on psychiatric
disorders when thinking about treating suicidal thoughts and behaviors (which
doesn’t have much evidence of being effective at reducing suicidal thoughts and
behaviors) and stigma associated with having made a suicide attempt that may
have dissuaded individuals from wanting to participate in a formal research study
in the past.

It wasn’t until the 1970s when researchers really began increasing efforts to empirically test interventions targeting suicide attempt survivors. There are numerous types of interventions that providers can choose from when providing clinical care. However, in order to establish a particular approach as effective, it is necessary to develop manuals and follow strict guidelines when delivering care. Otherwise, consumers wouldn’t know whether a treatment works because of its specific aspects or because of some other reason.

One of the most accessible approaches to standardize involves cognitive behavioral therapy (CBT), which consists of individuals learning new skills for solving problems and changing thought patterns to be more balanced when evaluating personal beliefs and expectations. CBT was initially shown to help reduce depression and anxiety, so it was naturally adapted to help suicide attempt survivors.

Over the past 40 years, CBT-based approaches have been tested in many studies (though still much less frequently than we would like) with suicide attempt survivors, and the results suggest this type of approach is most likely effective. Those CBT approaches that focused more heavily on improving problem-solving skills often showed greater reductions in suicide attempts than comparison treatments, which focused on a combination of medication management, supportive therapy and crisis intervention services. Most recently, a large study of individuals treated in an acute care medical setting after a suicide attempt found that those who received a robust CBT protocol focusing specifically on suicidal thoughts and behaviors were 50 percent less likely to make a suicide attempt than the comparison group.

Another type of therapy that has shown good evidence of reducing suicide attempts and self-injury is dialectical behavior therapy (DBT). This is an intensive treatment that includes weekly one-on-one therapy, weekly skills group training, 24/7 phone consultation and a consultation group for the therapists who provide DBT. The overarching focus of DBT is to help individuals build a life worth living so that suicide seems less appealing. Clients learn skills for managing intense emotions and crisis situations, as well as interpersonal skills so they can build and maintain meaningful relationships and feel good about themselves. Much of this is done through practicing skills, but it also involves improving awareness of
one’s thoughts, emotions and behaviors through mindfulness exercises.

Overall, it seems that CBT and DBT work well for helping suicide attempt survivors reduce subsequent suicide attempts and improve their overall quality of life, but the obvious problem is that there is more demand than supply when it comes to therapists who provide these treatments. If you think about this in terms of the overall population impact, fewer suicidal people can receive CBT and DBT, but those who receive it probably get much better. As a result, researchers are now testing innovative ways to engage suicide attempt survivors in efforts to reduce subsequent suicide attempts and help facilitate linkage to outpatient treatment, with less emphasis on treating longer-term issues that
may partially contribute to mental health concerns. This means less intensive
services that could keep someone from dying, but may not lead to as large of an
improvement in one’s life.

For example, a groundbreaking study focusing on impacting a larger population
of at-risk patients was conducted in the years 1969-1974, when Jerome Motto
and Alan Bostrom pioneered the use of “caring letters” sent to a sample of
individuals who had recently been treated in an inpatient psychiatric hospital
and were determined not to have engaged in their outpatient therapy plan
one month following discharge, which typically meant seeing a therapist in the
community. This group was split in half, and one group received supportive
follow-up letters at least four times per year for five years, and the other group
did not. The group who received the letters had significantly lower rates of
suicide across the first two years, with diminishing effects thereafter.

Although this study did not specifically recruit suicide attempt survivors, it has
inspired other studies that have recruited individuals treated after a suicide
attempt in emergency departments and inpatient psychiatric units. Although
not always found to be more effective than a comparison group, brief, low-cost interventions such as letters, postcards, and phone calls do seem to show
evidence of reducing suicide attempts for suicide attempt survivors. Of note,
none of these approaches have been compared to CBT or DBT, so it’s not clear
how they compare. But such a comparison would be inherently difficult, since the
smaller effects of brief intervention require larger samples, while the resources
needed to treat patients with a DBT limits how many people you could recruit.

What is less clear is why these contacts have such a positive impact. Motto used
his experience of having a wartime pen pal as inspiration for sending caring
letters, but researchers aren’t sure exactly what it is about the contacts that
people find useful. One hypothesis is that follow-up contacts help maintain a
connection with another human being for people who may be isolated or feel
that they are nothing but a burden to others. Or perhaps receiving follow-up
contacts may lead to a greater willingness to connect with outpatient treatment,
which may ultimately be responsible for better outcomes.

Several studies are currently under way replicating the Motto and Bostrom study with different forms of follow-up contacts with suicide attempt survivors and other at-risk individuals, including letters and text messages, which may provide
answers to why these contacts are effective.

One additional area that needs further exploration is the impact of support
groups and group therapies for suicide attempt survivors. This is a sensitive
topic. I have noticed many of my colleagues recoiling at the idea of groups
where the content focuses explicitly on suicidal ideation, out of fear that it
may actually lead group members to feel more suicidal and reinforce self-harm
behaviors. For instance, suicidal thoughts and behaviors are not discussed in
DBT groups, out of fear of contagion among members. Instead, suicidal thoughts
and behaviors are discussed in individual therapy sessions where they can be
understood in depth and targeted with proactive problem-solving strategies.

Our suicide prevention community tends to be a tight-knit group, and I don’t
think that researchers are trying to prevent forms of treatment that are preferred by suicide attempt survivors. Instead, I think that we are a data-driven contingent that wants to have evidence-based approaches to help ensure that suicide attempt survivors receive the most acceptable and effective interventions to help in attaining their personal goals.

Currently, I am collaborating on a study involving a group therapy originally
created for suicide attempt survivors receiving care in a Veterans Affairs
medical center. I admit that I was skeptical at first, but I was won over by the
thoughtfulness of the clinicians who created the group therapy and the
preliminary data demonstrating that many attempt survivors have transcended
beyond the identity of a full-time patient to that of an inspirational speaker
engaged in universal suicide prevention efforts at active-duty military bases.

Our study focus is on evaluating whether an additional collaborative suicide
risk assessment taken from the Collaborative Assessment and Management of
Suicidality (CAMS)* improves the overall impact of the group therapy. We opened
recruitment to all suicidal veterans discharged from an inpatient psychiatry unit,
many of whom report previous suicide attempts, and hope to recruit approximately
150 veterans to participate. We estimate the study will conclude in 2014 or 2015,
after which we will publish the results.

Finally, it is worth noting that we currently have no data on suicide attempt
survivor support groups, and this is needed badly. I would urge the suicide
attempt survivor community and my own colleagues to work together to study
the impact of attempt survivor support groups so that we have data to inform
future efforts and hopefully demonstrate that speaking about suicidal ideation
in a group setting can at times be healing and helpful, in certain contexts, if
conducted in a responsible and thoughtful manner.


* CAMS is a treatment framework that helps providers and clients focus on the specific factors underlying the suicidal wish, which involves collaborative assessments and treatment planning until the suicide crisis resolves.