Chapter 18:  Suicidality

            Nearly thirty thousand Americans take their own lives each year (Minino, Arias, Kochanek, Murphy, & Smith, 2002).  Suicidal behavior is one of the most commonly encountered emergencies among mental health professionals.  In fact, one in four psychologists and half of all psychiatrists will have a patient complete suicide during their careers (Kleespies, Deleppo, Gallagher, & Niles, 1999).  The informed assessment and intervention of suicidality is critical and complex for even the most seasoned clinician. This chapter offers an evidence-based approach for this patient population.  First, we define suicidality.  Second, we provide a list of key empirically- informed questions that should guide one’s assessment of suicidality.  Third, a brief review of the literature evaluating the efficacy of treatment strategies for suicidal patients is presented.  Lastly, we present our symptom-focused treatment strategies illustrated by a case example of an 18 year-old suicide attempter.



Suicide ideation, plan, and intent

            Our definition of suicidality includes three main factors: ideation, plan, and intent.  These factors are directly related to suicide risk and need to be assessed thoughtfully and responsibly.  Suicidality can range from suicidal ideation with no plan or intent to die to suicide attempts with intent to die.  Suicidal ideation, most generally, requires that the individual have current thoughts of death, of killing oneself, or of being killed.  Some patients may present with passive suicidal ideation (e.g., “I wish I were dead”) but report having no plan or intent to kill themselves.  For a subgroup of these patients, the idea of actively taking their own life is unfathomable.  In contrast, some patients report active suicidal ideation that is more alarming to the clinician (e.g., “I feel like killing myself”).  These patients, when asked, may report having a specific plan to kill themselves.  A suicidal plan involves identifying a specific method, and possibly a given timeframe, in which the individual plans to kill oneself.  The most common method of suicide, regardless of age, race, or gender, is firearms (Minino et al., 2002).  Other common methods used by men include jumping, hanging, and carbon monoxide poisoning.  For women, the next most frequent methods include overdosing on pills or ingesting solid and liquid poisons (AAS, 2002). 

Once a patient reports having a plan, the clinician must assess for suicidal intent.  Intent characterizes the individual’s level of commitment in carrying out the plan.  Interestingly, patients may report having a specific plan but have no intent to die (e.g., “I thought about jumping off a bridge but I would never do it”).  Others may describe their intent as ambivalent (e.g., “I am thinking about taking an overdose but I am not sure if I can go through with it”), while still others may have full intent to kill themselves (e.g., “I intend to shoot myself with my own gun this Sunday after my wife leaves town”). 



Suicide attempts

Clinicians may be faced with patients who have already attempted suicide (i.e., patients who have acted on their suicidal ideation and plan).  Roughly 750,000 Americans make suicide attempts each year that require medical attention (Minino, 2002).  As compared to patients who have only thought about suicide, this subgroup of attempters is in a higher risk category for future suicidal behavior.  In fact, 10% of all suicide attempters eventually die by suicide (Linehan, 1993a).  Having briefly reviewed information about suicide ideation, plan, intent, and suicide attempts, it is critical for the clinician to be prepared to assess the suicidal patient.  Below is an assessment guide comprised of empirically derived questions to aid the clinician.


Table 1: Assessment Guide[1]

1.     Given what you are saying about your current life circumstances, are you feeling hopeless or discouraged right now?

2.     Have you been feeling so unhappy lately that you are having thoughts about death or of killing yourself?

If Yes:

3.     Do you have a plan for how you would do this?  What is it and do you have the means to carry this out (i.e., accessibility of instrument)?

If Yes to Plan:

4.     How intent are you on carrying out this plan? What reasons do you have to live right now (i.e., assessing for intent and protective factors)?

5.     Have you ever attempted suicide before?



Brief Review of Empirical Support for Suicidality Treatment Strategies

The field of suicidology is lagging behind other areas of treatment research with respect to the number of randomized clinical trials and the clear definition of the primary outcome variable.  Regarding the latter, it has been challenging for suicidologists to come to a consensus on terminology used to differentiate self-injurious behavior with intent to die from non-suicidal self-injurious behaviors.  Hence, our subsequent review of the literature includes studies that reflect this definitional obfuscation.  

To date, there are four different psychosocial interventions and three psychopharmacological interventions that appear to reduce repeated deliberate self-harm and suicidal behavior.  A summary of these studies can be found in Table 2.


Insert Table 2 about here


Hawton and colleagues (1998) reviewed 20 randomized clinical trials of patients engaging in repeated self-harm.  Interventions used in these studies included problem-solving therapy, dialectical behavior therapy, inpatient hospitalization, the use of an emergency contact card in addition to standard therapy, and intensive outreach (e.g., home visits).   Based on this review, only one experimental intervention was better than a control condition in decreasing suicidal behaviors:  dialectical behavior therapy (DBT; Linehan et al., 1991). 

DBT is a principle based cognitive behavioral therapy that was originally developed by Linehan (1993a; 1993b) for the treatment of chronically parasuicidal adult outpatients diagnosed with borderline personality disorder (BPD).  DBT blends standard cognitive behavioral therapy with Eastern philosophy and meditation practices and it shares elements with psychodynamic, client-centered, gestalt, paradoxical and strategic approaches (Heard & Linehan, 1994).  Parasuicide, as defined by Linehan (1993), includes any acute, intentional, self-injurious behavior resulting in physical harm, with or without intent to die (i.e., suicide attempts and non-suicidal self-injurious behaviors).  In a controlled treatment trial, DBT significantly reduced suicide attempts and other parasuicidal acts (Linehan et al., 1991).  Results were generally maintained at 1-year follow-up (Linehan et al., 1993; Linehan, Tutek, Heard, & Armstrong, 1994).  More recently, two other randomized clinical trials using DBT with suicidal outpatients diagnosed with BPD have obtained promising results (Koons, Robins, Tweed, Lynch, Gonzalez, Morse, Butterfield, & Bastian, 2001; van den Bosch et al., 2002). 

            In addition to DBT, a psychodynamically-informed treatment approach was found to reduce suicidal behavior among adults diagnosed with borderline personality disorder (Bateman & Fonagy, 1999).  This was a randomized clinical trial conducted in a partial hospital program where subjects received the experimental treatment for 18 months. 

The third psychosocial intervention targeted repeated deliberate self-harm among outpatient adolescents (Wood, Trainor, Rotherwill, Moore & Harrington, 2001).  The adolescents in this study had to have engaged in at least two incidents of deliberate self-harm over the course of a year.  The study compared a group therapy containing elements of CBT and DBT coupled with care as usual to care as usual alone.  Results suggested that the experimental condition significantly reduced repeated, deliberate self-harm behaviors.  Because the investigators did not assess suicidal intent specifically, it is unclear whether any of these behaviors had suicidal intent. Noteworthy is that acutely suicidal adolescents were excluded from the study. 

The fourth intervention, a randomized controlled trial, investigated whether ongoing contact with a mental health professional would reduce suicide rates in persons at risk (Motto & Bostrom, 2001).  Patients hospitalized for depression or suicidality were contacted 30 days after discharge about follow-up treatment.  Those patients (N=843) who refused ongoing care were randomly divided into two groups.  The first group was contacted by letter at least four times a year for five years and the second group received no further contact.  Results found that patients in the contact group had a lower suicide rate in all five years of the study, with significantly lower rates in the first two years.  By year 14, no differences between groups were observed, suggesting a diminution of the frequency of contact and discontinuation of contact appear to reduce and eventually eliminate this preventive influence.

Regarding medication, Hawton and colleagues (1998) reviewed studies examining the effects of pharmacological interventions on suicidality in adults.  They found significant reductions in rates of suicidal behavior with trials of depot flupenthixol (a neuroleptic) as compared to placebo. Another recent review of the literature finds substantial evidence that long-term lithium treatment is correlated with reduced rates of suicide attempts and fatalities in patients diagnosed with bipolar disorder (Baldessarini & Jamison, 1999).  Others have reported Clozapine to be effective in reducing suicidal ideation/behavior among adult patients diagnosed with schizophrenia and schizoaffective disorder (Meltzer & Ghadeer, 1995).


Step-by-Step Protocols

            In an attempt to address the two most common presentations of a suicidal patient to a practitioner, we are first going to illustrate treatment strategies relevant for a patient recently discharged from an inpatient unit following a serious suicide attempt.  The second scenario entails the same patient becoming acutely suicidal during outpatient treatment.  The following is a case presentation that will be applied to both scenarios. 

            Bianca is an 18 year-old Hispanic female referred for outpatient treatment following a 2- week psychiatric hospitalization secondary to an overdose of 30 pills of her mother’s tricyclic antidepressants with intent to die.  During initial intake, Bianca revealed a long psychiatric history of depression, panic attacks, multiple suicide attempts, and non-suicidal self-injurious behaviors (e.g., self-cutting) since age 13.  Other areas of clinical concern include school truancy, significant relationship problems with family, peers and boyfriend, and a history of poor treatment compliance.  Her family psychiatric history was remarkable for depression and suicidal behavior by her mother, paternal grandmother, and older brother, as well as substance abuse and criminal activity by her older sister.  At the time of intake, Bianca denied experiencing suicidal ideation since discharge from the hospital.  The following is a protocol that includes specific treatment strategies targeting Bianca’s recent suicidality, briefly outlined in Figure 1.


Insert Figure 1 About Here


Scenario 1

Rapport Building, Confidentiality, and Psychoeducation

            As with all patients, the first step for the clinician is to build a therapeutic alliance with the suicidal patient.  Therapists working with suicidal patients have to consider several issues that are particular to this patient population.  First, they have to strike a balance between expressing concern while not being overly emotional or shocked by discussion of suicidal content.   Second, they need to exhibit confidence that they can truly help while at the same time not appearing wholly responsible or omnipotent.   Finally, therapists need to find within themselves a centeredness that allows them to listen and intervene without becoming overly distracted by their own anxiety about working with this challenging population.  

            During the first session with a suicidal patient, the therapist must alert the patient to issues of confidentiality about working with a suicidal patient.  The therapist explains that there may be occasions that the therapist is required to break confidentiality to ensure the patient’s safety or to keep the patient alive.  These occasions typically involve more than passive suicidal ideation; more likely, the patient will be expressing at least a suicidal plan.  Once a careful assessment has been conducted, rapport established, and confidentiality explained, the next major task for the therapist is to provide psychoeducation. 

            Psychoeducation of suicidal patients consists of three components.  The first is reframing suicidal behavior as a maladaptive attempt at problem-solving.  The goal here is not to overpathologize or judge the behavior as morally wrong, but rather to validate the patient’s attempt to ameliorate, albeit unskillfully, her seemingly overwhelming and insurmountable problems.  The second component of psychoeducation is to orient the patient to the treatment options available for suicidality including a variety of possible psychological and pharmacological interventions.  The final component of psychoeducation, if the suicidal patient opts to pursue outpatient treatment, is to reframe the treatment as a life enhancement program versus a suicide prevention program. 

            We go on to say, “there is no way that we can stop you from killing yourself if you are determined to do so; however, what we can help you with is to create a life that feels worth living and in so doing, reduce your wish to die.”  The rationale for this introduction is twofold.  First, we do not want to mislead the patient into believing that we have more power as clinicians than we in fact do.  There are no data, including from inpatient units that suggest we can prevent patients from committing suicide 100% of the time.  Second, framing the treatment as a life enhancement program begins to offer or highlight for the patient reasons for living instead of exclusively focusing on the problematic suicidal behavior.  This positive reframe may begin to chip away at the hopelessness often present in these patients.


Get Commitment

            At the end of the first session, we educate patients regarding their tasks and responsibilities to the treatment process.  First and foremost is obtaining the patient’s commitment to not engage in ANY suicidal or self-harm behaviors for the remainder of the treatment period.  Considerable evidence suggests that the commitment to behave in a particular way, especially when the commitment is made publicly instead of privately, is strongly related to future performance (Linehan, 1999).  When a patient does not readily agree to this condition (e.g., says, “I can’t commit to not hurting myself for 16 weeks), the therapist must apply specific commitment strategies to elicit some agreement to not self-harm even if it is pared down to only one week or even one day.  Dialectical behavior therapists use numerous commitment strategies such as “door-in-the-face” (ask for as much as possible at first with the expectation of taking less) to encourage patients to contract for safety (see Linehan, 1993a).  These same strategies are employed to obtain commitment to treatment, which is so important for engaging this difficult-to-treat, high drop-out patient population.  In this vein, the therapist should schedule four subsequent sessions at the time of the first visit.

            For the patient who expresses anxiety about maintaining her safety commitment, a common option is for the therapist to offer a replacement strategy for the suicidal behavior.  That is, the therapist instructs the patient to page him or her before she engages in self-harm behavior in order to receive coaching on the use of adaptive coping skills.  This also reassures the patient that she is not alone in coping with her suicidal feelings.

            Another task for which it is important to obtain commitment is maintaining a daily diary card.  The diary card prompts patients to self-monitor and records their suicidal thoughts and behaviors, their non-suicidal self-injurious thoughts and behaviors, a range of emotions and their use of new behavioral skills.  Patients are given four reasons why they should complete and return the diary card to each session.  “First, by self-monitoring your suicidal thoughts and behaviors, you are more likely to catch yourself in the process and thus reduce the likelihood of you carrying it out mindlessly.  Second, by completing the diary card each day, you will have much better recall as to what you were experiencing so that we can discuss it during our next session.  Third, this information is extremely important for us to have in order to set our session agenda each week.  Fourth, having the diary card helps me to see your week at a glance to have a global overview of how you’re doing.”  


Conduct a Behavioral Analysis of Suicidal Behaviors

            “Changing behavior requires, at a minimum, a good understanding of the behaviors in need of change” (Linehan, 1999, p. 159).  Following the initial evaluation, the clinician conducts a more thorough evaluation of prior suicidal behaviors in order to understand the function of those behaviors in the patient’s life.  When a patient has a long history, special attention is paid to the most recent and the most severe suicidal behaviors.  It is in this context that the therapist orients the patient to a primary method of assessment and treatment of suicidal behavior.  Behavioral analyses are employed in order to understand the function of previous and current suicidal behavior and reduce the likelihood of future suicidal behaviors.  Psychoeducation of a behavioral analysis with Bianca would sound like the following:


“Bianca, in order for us to better understand your suicidal behavior, we need to conduct a behavioral analysis. Now, what is a behavioral analysis (or as we say a “BA”)? A BA is a moment-to-moment analysis of your thoughts, feelings, and behaviors that led up to you attempting suicide.  We may identify some of these thoughts, feelings, and behaviors as key links in your chain.  We also want to understand if there were things that made you more vulnerable that day (e.g., sleep, eating, substance use, etc.), what the precipitating event may have been, and what the consequences of your actions were (both short-term and long-term).   Once we have determined the key links in the chain, we can develop alternative solutions in order to help you avoid engaging in the same life-threatening behaviors.”



            Once we orient Bianca to the function of a BA, the therapist initiates a BA on Bianca’s most recent suicidal behavior, which in this case was the overdose leading to her hospitalization. What follows is a snapshot introduction to a behavioral analysis. 

Therapist:  “So, Bianca, the problem behavior we are going to analyze is your overdose on your mother’s medication.  Can you remember what time of the day this was, who was home, and what was going on when you took this overdose?”  

Bianca:  “It was late afternoon, my parents were both home. I remember that because I got into a fight with my father.  I asked him to buy me a special pair of pants in Puerto Rico where he was going for a visit and he said he wouldn’t. 

Therapist:  “Why did he say no?”

Bianca: “He said because I didn’t deserve it.”

Therapist:  “What was your reaction?”

Bianca: “I felt hurt and angry!”

Therapist:  “I can see that your father really upset you when he said that.  What happened next?

Bianca:  “After my father said that, I tried to distract myself by washing clothes.  My mother walked in on me and said I was doing it wrong.”

Therapist:  “How did you experience that?”

Bianca:  “That was the straw that broke the camel’s back.  I thought that I could not do anything right and felt so alone that I ran into my mother’s bathroom and took all of her pills!”


            Through this abridged BA, the therapist has already begun to elicit enough detail to clarify the environmental events, emotional and cognitive responses, and overt actions that sequentially led up to the suicidal response.  Specifically, the therapist has identified Bianca’s reaction to her mother’s criticism as the precipitating event to her suicidal behavior.  As with all BAs, the therapist would continue this analysis by inquiring about the presence of specific vulnerability factors and consequences.  In Bianca’s case, she described having a conflict with her boyfriend two days earlier that resulted in her staying awake all night, both of which were identified as vulnerability factors.  At this point, she attempted to obtain support from her father that proved futile, as described above.  Regarding consequences, Bianca reported that after her suicide attempt, her boyfriend and family became loving, supportive, and nonjudgmental.  In fact, her father offered to buy her the special pants she requested.  After continued analysis, Bianca realized that her boyfriend and parents were inadvertently reinforcing her suicidal behavior.  This positive reinforcement was found to occur in prior instances of her suicidal behavior as well.


Conduct a Solution Analysis

            A comprehensive analysis requires the therapist to weave in solutions to the behavioral analysis described above.  The therapist and patient must ask: “What solutions other than suicidal behaviors could be applied to the problem at hand?”  More specifically, the therapist looks for different points in the chain to intervene.  For example, solutions need to be applied to target any potential vulnerability factors, the precipitating event, and key links such as specific cognitions, emotions, behaviors, and contingencies.

            Targeting Bianca’s vulnerability factors first, the assessment of the ongoing tension between her and her boyfriend revealed a communication skills deficit on Bianca’s part.  Therefore, the proposed solution was to enhance Bianca’s interpersonal effectiveness skills.  Bianca’s insomnia was targeted as her second vulnerability factor.  A review of sleep hygiene and relaxation techniques was offered.  Targeting the precipitating event (i.e., her reaction to her mother’s criticism), it was determined that when Bianca is in distress she had two options: 1) she could avoid her mother given her mother’s proclivity to invalidate her; or 2) she could directly express her feelings to her mother so that her mother knows that she is in distress.  The problem with the latter option was that Bianca was unaware of what she was feeling.  Thus, the recommended solution was for Bianca to practice identifying and labeling emotions when she was not in distress in order to prepare her for future scenarios in which she would inevitably become emotionally dysregulated.  “Bianca, before you can choose a coping strategy, you need to know what you are feeling.”

            Solutions are also applied to key links in the chain that contribute to suicidal behavior.  Two key links that were identified were her thought that she could not do anything right and her feeling that she was all alone.  The therapist employed cognitive restructuring techniques to target the cognitive distortion that she “cannot do anything right.”  It was explained to Bianca that if she could restructure her thoughts in the moment next time, she would be less likely to become suicidal.  A second point of intervention was Bianca’s experience of feeling “all alone.”  Upon further analysis, Bianca identified sadness as the primary emotion underlying the experience of ‘aloneness.’  The intervention was to conduct formal exposure exercises to her sadness.  “Bianca, it is important for you to be able to experience sadness as not dangerous and requiring escape.  The better able you are to sit with your sadness, the less likely you will turn to your maladaptive coping strategy of suicidal behavior.”

            The last component of the solution analysis is targeting the short-term and long-term consequences of the suicidal behavior.  As mentioned above, Bianca’s boyfriend and parents inadvertently reinforced her suicidal behavior by lavishing her with affection and offering her gifts (i.e., positive reinforcement) after the attempt rather than before.  The therapist role-played with Bianca to use her newly learned interpersonal effectiveness skills to explain to her boyfriend and parents that their actions are counter-therapeutic.  Bianca requested that they try to give her the affection, attention, and gifts when she is not suicidal and less of these positive things when she is.  She explained to them the principles of reinforcement and that she has learned (out of her awareness) that when she becomes suicidal, she gets what she wants from them. 

            Bianca acknowledged to them that her suicidal behavior also functioned as a method of escaping her emotional pain (i.e., negative reinforcement) and was effective to that end in the short-term.  However, she also admitted to feelings of shame that she had to resort to this extreme life-threatening behavior to achieve a sense of relief.  These feelings of shame outweighed the short-term benefit of escape that the suicidal behavior provided.  Bianca and the therapist identified adaptive skills that could be used to achieve a sense of relief such as distraction and self-soothing.  For example, Bianca agreed to watch her favorite comedic video or take a soothing bubble bath when feeling sad or thinking that she cannot do anything right. 

            A final intervention derived from the behavior analysis was the need for Bianca to practice paging the therapist during the following week when she was not in distress.  “Bianca, as you said, this was an impulsive act.  We need to help you slow down enough so that you can identify your distress, recognize your need for help, and generate alternative solutions.  If you have trouble doing that in the beginning, which you may, I want you to page me for coaching.  This way we can work together as a team.  Therefore, I want you to practice paging me on Tuesday night when you are not in crisis so that calling becomes more comfortable and automatic.” 


Tolerating Distress

Cognitive behavior therapists emphasize solving problems by changing one’s thoughts, behaviors, or one’s environment.  Cognitive behavior therapists working with suicidal patients need to suggest that one additional solution to their problems is to simply tolerate the painful consequences, including the negative affect, which the situation has generated.  At first blush, many suicidal patients have trouble grasping the value and function of this solution.  However, with practice, patients begin to recognize and appreciate the idea of tolerance as a solution.  For example, urge surfing (i.e., observing the urge to self-harm and riding it out like a wave without reacting to it) is a skill taught to suicidal patients.  Patients often believe they CAN NOT tolerate the painful affects and escape these affects by self-harming (negative reinforcement).  If patients can ride out the wave without bowing out by harming themselves as the urge rises, patients experience that they CAN tolerate and survive the urges and negative affects.


Troubleshooting/Relapse Prevention

            Despite the therapist’s best efforts to effectively deliver interventions and the patient’s apparent commitment to follow through, it is inevitable that obstacles will arise. Troubleshooting refers to anticipating these obstacles before they occur and proposing solutions for managing them.  When working with suicidal patients, it is even more imperative to troubleshoot the solutions, as it can be a matter of life and death.

            Typically, the first problem to troubleshoot is noncompliance related to the diary card.  The patient may forget to fill it out, fill it out but forget to bring it to the session, or refuse to do it altogether.  “Bianca, I am glad that you agreed to do the diary card every night.  My question is what might interfere with you not only completing it each night but also remembering to bring it in?”  In Bianca’s case, she mentioned that although she has her own room, she worried that her mother or sister would find her diary card and invade her privacy.  Once identifying this as an obstacle to her compliance, the therapist asked Bianca if she could generate a solution to this problem.  Bianca responded that she could keep the diary in a school notebook that she would store under her bed.  This particular notebook she used daily, which was another reminder for her to fill out the diary card.

            It is equally important to troubleshoot the solutions derived from the behavior analysis.  As mentioned above, while patients with their own best intentions in mind agree to solutions in the session, both as a consequence of time and unanticipated obstacles, their commitment and capacity may wane.  For example, in session, Bianca recognized the value of broaching the issue of her parents and boyfriend’s positive reinforcement of her suicidal behavior.  “Bianca, what do you think may interfere in your ability to actually say this to your family when you are not in session?”  Bianca identified a worry thought that could interfere—that is, “my parents will never do what I ask in terms of not reinforcing me when I become suicidal.”  Having identified this potential cognitive distortion, the therapist helps the patient challenge her automatic thought and has the patient agree to conduct a behavioral experiment to see if her hypothesis is in fact true.


Scenario 2: Management of Acute Suicidal Behavior in Session

            The second scenario involves Bianca becoming acutely suicidal during her outpatient treatment.  An active therapeutic response is needed when a patient communicates directly or indirectly an intent to commit suicide or engage in non-suicidal self-injurious behavior.  The therapeutic goal is to help the patient, whenever possible, learn how to effectively cope with her stressful life as it is and NOT to remove the patient from this environment (i.e., hospitalization) with several exceptions to be highlighted later.  The therapist conveys the philosophy that “now is the time to learn new behavior,” and thus, “we must strike while the iron is hot.” The following protocol addresses threats of imminent suicide during the course of an outpatient therapy session; a brief outline of this protocol can be found in Figure 2.


Insert Figure 2 About Here


Assess Risk of Immediate Suicide

Ask Questions Directly

            Sometimes a patient directly informs the therapist that she is feeling suicidal.  At other times, however, the patient may be thinking or even planning a suicide attempt without directly informing the therapist.  Should a therapist raise the question if the patient has not directly brought it up? The answer is a definitive YES.  The following are several occasions which Several events may prompt a therapist to ask whether the patient is having thoughts about suicide: 1) the occurrence of any event that was a precipitant to a prior suicide attempt or serious suicidal ideation (because prior behavior is the best predictor of future behavior in the same context); 2) worsening of psychiatric symptomatology, especially depressive symptoms, panic attacks, or psychotic symptoms; 3) increasing amounts of alcohol or drug use; and 4) statements made by the individual such as she wishes she were dead or she believes her family would be better off without her.


Conduct Thorough Assessment

            Once the therapist identifies that the patient is considering suicide, the therapist must conduct a more thorough assessment beginning with the Assessment Guide (Table 1) listed earlier in this chapter.  In Bianca’s case, she reported in her fourth individual therapy session that she was “feeling alone and unloved by her family.” The therapist realized that these reactions were similar to the ones Bianca experienced prior to her last suicide attempt.  Therefore, the therapist asked Bianca whether she was beginning to have any thoughts about death or suicide, to which Bianca answered in the affirmative.  The therapist inquired about how long she had been feeling this way and Bianca explained she had been having suicidal thoughts for the past three days. 

            The therapist pursued this assessment in greater depth, further questioning Bianca regarding the presence of a suicide plan, her intent, and accessibility to means.   Bianca reported that she was considering taking another overdose.  She denied having any intent to carry out her plan because she did not want to have to ingest charcoal again in the ER and require another psychiatric hospitalization.  Bianca noted that her mother kept her psychiatric medication secured since her last overdose. However, she mentioned that the house was loaded with Advil and Tylenol so that if she were intent on attempting suicide she would not have a problem carrying it out.  The therapist inquired about the presence of other prescription drugs that might be in the house.  It is important in the case of a proposed overdose to obtain the name of every drug, the number of pills remaining, and the dosage levels of the pills.


Educate Yourself about the Lethality of Specific Methods

            The therapist’s response to Bianca’s suicidal ideation and plan depends on the therapist’s estimate of the actual risk of death or degree of self-harm.  Thus, it is imperative that the therapist ascertain the lethality of the drugs the patient is considering ingesting.  In Bianca’s case, overdosing on a large number of Advil or Tylenol is potentially lethal.  Non-prescription and prescription medications can often be unfamiliar to the therapist. Thus, it is helpful to have information regarding the risk of overdose on specific pills by having a book (e.g., Physician’s Desk Reference) and/or by having access to a medical doctor who has a working knowledge of medications and overdose potential. 

            Certainly, common methods that range from most lethal to least lethal include: firearms, jumping, cutting or piercing vital organs, hanging, drowning (cannot swim), poisoning (solids and liquids), cutting and piercing nonvital organs, drowning (can swim), poisoning (gases), and ingestion of analgesic and soporific substances (Linehan, 1999).  Adolescents are often unfamiliar with the medical-biological consequences of their actions.  For example, some adolescents ingest 6 Tylenol with the expectation that they will die, while others ingest 50 extra-strength Tylenol with the intent of helping them sleep.  Hence, therapists must not infer intent from a patient’s anticipated act and associated lethality. 


Explore the Current Problem Using a Macro-Behavioral Analysis

            When patients are intensely emotionally dysregulated during the therapy session, which is common when they are experiencing suicidal ideation, they typically describe not only the precipitating event but also numerous other factors that are not necessarily related to the suicidal ideation.  Thus, it is imperative for the therapist to help the patient sort out the key events that set off the current emotional response and not become sidetracked by a variety of non-essential details that have occurred in the past week or two.  For example, after Bianca admitted to having had suicidal ideation during the past three days, she reported becoming intensely sad, angry, and ashamed as she described her parents’ criticisms of her.  She then highlighted how her parents treat her sister similarly and how her sister responds more adaptively to her parents in the face of being criticized.  The therapist recognized that Bianca was becoming even more dysregulated as she expounded on these family dynamics.  The immediate goal here was to refocus Bianca on the most relevant events that set off her suicidal ideation.  However, future educational and therapeutic efforts when Bianca is not acutely suicidal may be to analyze Bianca’s sister’s method of healthy coping and to focus on Bianca’s tendency to ruminate over unrelated negative situations when she is already distressed.


Identify Events That Have Precipitated Current Emotional Response

            As mentioned above, the therapist must listen and respond selectively to the material relevant to Bianca’s current emotional distress and ignore information that is irrelevant.  The therapist asked Bianca to be concrete and specific as she described what triggered her suicidal ideation this week.  We consider this a macro-level behavioral analysis in that the primary focus is on the precipitating event and any key links that precede the suicidal ideation or anticipated suicidal behavior.  Less attention is paid to the vulnerability factors.  Often, patients may ramble about a variety of topics. The therapist should listen for the patient’s report of negative affect, such as depressed, anxious, overwhelmed, angry, and ask the patient to pinpoint exactly when that emotion first began or when it increased.  The purpose is to help the patient link a specific crisis response to a specific event or series of events. For example, Bianca reported that when her parents began criticizing her about her poor school performance and her choice of “bad” friends, she became tearful and sad at first before experiencing anger and shame.  The macro-level behavioral analysis helped Bianca and her therapist recognize that it was her experiencing the emotion of shame that precipitated her suicidal ideation.


Summarize the Problem Situation

            Summarizing and formulating the problem situation is often necessary during a crisis session since the patient (not to mention the therapist) may become emotionally dysregulated and lose focus on the problem at hand. Thus, it is important for both patient and therapist to retain their focus on the problem situation that precipitated the suicidal crisis so that they do not start trying to solve “the problem” without properly defining it.  Due to anxiety, especially on the part of the therapist, the session may become overly focused on solving the problem of suicidal behavior (i.e., focus exclusively on safety planning) while often neglecting the actual problem(s) that precipitated the suicidal behavior.   The therapist needs to maintain a balance of targeting the key links that precipitated the suicidal behavior while also establishing solutions that target keeping the patient alive in the here and now.

            In Bianca’s case, she and the therapist identified that Bianca’s parents repeatedly criticized her for low grades despite the fact that she had recently worked hard to raise them from F’s to C’s.  This parental criticism and the subsequent sadness, anger and, in particular, shame, was what precipitated her suicidal ideation.  The therapist summarized for Bianca how this chain resembled prior chains that led to Bianca’s suicidal behaviors.  Interventions included targeting Bianca’s unjustified shame response with cognitive restructuring and exposure.  Bianca was oriented to the idea that if she could a) identify and restructure her automatic thoughts that induced shame and b) experience a non-reinforced exposure to shame in session, she would be less likely to experience suicidal ideation.

Second, the therapist acknowledged with Bianca the need to address high-risk environmental and behavioral factors associated with suicidal behavior.  These risk factors will be discussed below.


Target Environmental High-Risk Factors

            There are a number of environmental risk factors associated with suicidal behavior. Because a therapist will be much less clear about the risk factors and functions of suicidal behavior with a new patient, the treatment needs to be more conservative in the early stages of therapy.  The general rule regarding risk factors is that the higher the risk, the more active the therapist’s response should be. 

            Therapists working with suicidal patients must be familiar with these risk factors and be prepared to systematically address them in a crisis session.  They include but are not limited to: availability of means, lack of social supports, and negative life events (Linehan, 1993).  Social supports refer to marital status, interpersonal contacts, and employment.  Regarding marital status, marriage has been shown to be a protective factor.  Conversely, those who are divorced, widowed, or single (never married), respectively, are at greater risk for suicidal behaviors than those who are married.  Those who live alone or who have few or no confidants are also at higher risk for suicide.  Unemployed persons who do not have a method of earning a living or persons who have unsupportive colleagues in a workplace are also at higher risk for suicide (Hirschfeld & Davidson,1988).

            Negative life events refer to interpersonal losses such as a death or separation from loved ones, sexual abuse history, imprisonment, and suicidal behavior by a family member to name a few.  Persons with a family history of suicidal behavior are at higher risk for committing suicide themselves.

            One of the most common negative life events, especially for youth, is interpersonal conflict. For Bianca, interpersonal conflicts with her parents and her boyfriend were common negative life events precipitating her suicidal ideation and behavior.  Thus, in addition to targeting Bianca’s shame directly in session as mentioned earlier, the therapist urged Bianca to invite her parents to the next session in order to target the interpersonal conflicts that plagued her family, including the consistent criticism among them.  The goal of the family session was to help each family member, including Bianca, learn how to communicate his or her feelings (especially negative) more constructively.  While the therapist and Bianca recognized that this goal would not be accomplished in only one session, it was understood that this would be a first step.  In the next session, the therapist informed the family that the interpersonal conflicts this family had were more than your average family conflicts. It was communicated that these interactions, despite their best intentions, had the potential to trigger a suicidal crisis in their daughter.  Thus, it was imperative for each family member, including Bianca, to take a hard look at his or her communication style and figure out how to communicate in a more skillful and constructive manner. 

            The family was first asked to role-play in session and then practice at home, beginning each new communication with “I…” instead of “You…” Additionally, they were asked to describe their concerns without using judgmental language.  And, where possible, family members were instructed to validate each other’s experiences even when they had a different perspective on the issue.  Hence, instead of the parents saying, “You have the worst judgment when it comes to choosing friends and you are not permitted to see any of them ever again,” they were asked to reframe their statement.  With coaching, they explained, “I (we) recognize that you enjoy spending time with your friends.  However, I (we) feel concerned that your friends get into trouble at school and since you spend a lot of time with them, you are likely to get into trouble too.  I (we) want to figure out the best way for you to spend time with your friends and also not get yourself into trouble. I (we) am (are) open to suggestions.”  By the therapist validating the parents’ concerns about their daughter, the parents were able to be less critical and more validating of their daughter and her experience.  Bianca and her parents negotiated a compromise that entailed spending time with two of her closest friends during the weekend but not after school.  Bianca felt relieved and agreed to work out the plan with her friends that week.


Remove or Convince Patient and/or Family Members to Remove Lethal Means

            Regardless of whether the lethal means is a gun, a liquid poison, or pills of some sort, it is imperative that the therapist spends a portion of the crisis session ensuring that the removal of lethal means has occurred or will occur.  Depending on the acute nature of the crisis, the therapist may instruct the patient to bring the lethal items to the next session, or insist that the patient go home and bring in the items immediately.  In other cases, when the patient calls the therapist in a suicidal crisis, the therapist may instruct the patient to flush the pills down the toilet and wait on the phone while the patient complies.  Still in other cases, family members, significant others, or roommates, may be enlisted to facilitate the removal of lethal means from the patient’s home.  Having a firearm in the home increases the risk of suicide five-fold (Brent et al., 1991).   Locking up a firearm in the home or separating the ammunition from the gun is not sufficient.  The weapon needs to be secured outside of the home. 

            After Bianca disclosed having increased suicidal ideation with a plan to overdose, the therapist tried to convince Bianca to remove all lethal means of suicidal behavior.  Since Bianca denied having suicidal intent, she was reluctant to remove the Tylenol and Advil.  Bianca replied, “I can always go out and buy more if I want to.”  The therapist reminded Bianca that many suicide attempts, including the last one, are impulsive; hence, having less access to means may forestall suicidal behavior.   After Bianca refused to follow the therapist’s recommendations, the therapist told the patient that he had to contact the family in order to achieve this goal.  Hopefully the patient will consent in this case.  If the patient refuses to consent and is noncompliant with the therapist’s recommendations to remove lethal items herself, it is typically a bad prognosis regarding the patient’s willingness and capacity to maintain safety and thus may require (in addition to several other factors mentioned later) an inpatient admission.  Either way, because suicidal behavior is at issue, the therapist is justified in breaking confidentiality by calling a family member to remove the lethal means.        

Stay In Contact With Patient and Patient’s Network When Suicide Risk is High

            Interpersonal supports are a protective factor for the suicidal patient.  Thus, in addition to coaching the patient on enlisting her family members and friends for support whenever possible, the therapist must also make him or herself available during these crises.  The general rule is to stay in contact with the patient either in person or by phone until the therapist is convinced that the patient will be safe once the contact is broken off (Linehan, 1999).  At these times, therapy sessions or phone calls may need to be extended until a safety plan is established and the patient is committed to comply.  We suggest that therapists who carry pagers encourage their patients to make use of this method of contact. 

            Depending on the imminent nature of the crisis, the therapist may contact the patient’s significant others, family members, and certainly other treatment providers.  As mentioned previously, confidentiality may be breached in circumstances involving suicidal behavior, and the patient is informed of this during the first session.  The therapist should attempt to select the least intrusive intervention necessary (i.e., notify the fewest number of additional parties) to ensure the patient’s safety.  That is often a very challenging judgment call to make when the issue of suicidality arises.   Naturally, a non-medical therapist should always notify the patient’s prescribing doctor (if there is one) regarding the patient’s increased risk for overdose.  In addition, suicidal patients and their significant others (if appropriate) are always referred to their local psychiatric emergency room or to call 911 if the suicidal impulses escalate and they are unable or unwilling to contact their therapist. 


Give Crisis Card

            Every suicidal patient should receive a crisis card by the time they leave the session.  At a minimum, the crisis card contains important telephone and pager numbers for all designated people.  For example, in Bianca’s case, she was given a card that listed the therapist’s office and pager numbers, her aunt’s home and work telephone numbers, and her best friend’s cell phone number and pager number.  Although Bianca had all of these numbers listed elsewhere, she now had them all in one place and could work down the list until she made contact with one of her identified supports.  Her parents and boyfriend were not listed for two reasons: 1) they were typically the people involved in the interpersonal conflicts associated with her suicidality and 2) historically, they were prone to reinforce her suicidal behavior which was being addressed in treatment.  Thus, other non-reinforcing yet supportive people in Bianca’s life were identified to serve this function.  Additionally, some crisis cards contain a list of personalized coping skills.  Patients can refer to this list when they are in a crisis since it can be extremely difficult to recall specific skills during a suicidal crisis when one is emotionally dysregulated.  Bianca listed several DBT “crisis survival skills” (Linehan, 1993b) including distraction and self-soothing skills as well as pros/cons regarding her suicidal behavior.  Moreover, she chose to list several rational responses to her most common automatic thoughts that often precipitated her suicidal behavior.


Target Behavioral High-Risk Factors

            In addition to the environmental high-risk factors, there are several behavioral high-risk factors that should also be addressed during a crisis session.


Focus on Affect Rather Than Content

            When a patient is emotionally dysregulated, the therapist must help the patient identify her emotions, validate those emotions, and allow the patient to express them.  The patient often experiences some degree of relief from the emotional ventilation and the emotional processing of traumatic events associated with exposure-based treatment approaches.


Target Affect Tolerance

            Related to the issue of focusing on affect, the therapist wants to communicate to the patient that she CAN tolerate what is experienced as intolerable.  For example, Bianca expressed the feeling that she “couldn’t take feeling so sad and so ashamed….it’s too painful.”  The therapist told Bianca, “despite feelings to the contrary, you CAN tolerate it… in fact, you have tolerated these painful feelings before and survived them….painful emotions DO NOT last forever.  You have to fight the tendency to tell yourself that you CAN’T tolerate these feelings. I know it is painful but I am going to help you tolerate this pain! This is your number one job right now.”  Bianca did not fully appreciate these remarks in the early stage of treatment but the therapist still made the case for affect tolerance. 


Brief Somatic Interventions

            For many patients in crisis, there is often anxiety, physical discomfort, as well as disrupted sleep.  Bianca reported recent initial insomnia as well as symptoms associated with panic attacks (e.g., tachycardia, shortness of breath, lightheadedness, and feeling like she was going to lose control).  Sleeplessness alone can induce a crisis for some patients.  For some patients, teaching proper sleep hygiene and relaxation techniques (e.g., diaphragmatic breathing; progressive muscle relaxation) may be sufficient to address these aforementioned problems.  For other patients, a rapid pharmacological intervention to address the insomnia and anxiety may be indicated as well. 


Obtain Commitment to Discontinue Drug and Alcohol Use

            Some patients self-medicate with drugs or alcohol or may abuse or become dependent for other reasons.  Regardless, during a suicidal crisis, the patient needs to be instructed to discontinue any alcohol or drug use.  Because substance use is a known risk factor for suicide due to their disinhibiting properties, a commitment to discontinue use is required.  If the patient is unwilling to discontinue drug or alcohol use, the therapist must factor this high-risk behavior into the decision about psychiatric hospitalization.


Restore Hope and Identify Reasons for Living

            One of the greatest problems for a suicidal patient is that she cannot see a way out of the hell she is experiencing.  Many suicidal patients describe their experience as if there is a big mountain of accumulated problems in front of them that appears insurmountable.  Thus, the challenge for the therapist is to model how to break down this “mountain” into more manageable problems that can be solved.  Ideally, the therapist and patient will identify the problem(s) that are both most distressing and primed to be solved quickly.  In Bianca’s case, a brief family intervention targeting communication skills was initiated within several days to help reduce the interpersonal conflicts known to precipitate her emotional dysregulation that often lead to her suicidality.  In addition, the therapist immediately targeted Bianca’s own reactions to her parents’ criticism.  Employing cognitive restructuring and exposure-based procedures related to her sadness and shame also helped to reduce the intensity of her reactions that precipitated her suicidal ideation.  As the problems are systematically addressed, the patient’s sense of hope begins to be restored. 


“Bianca, we are going to help you deal with these problems one by one until they no longer feel so overwhelming and insurmountable.  Some of the solutions we employ will actually change the situations that upset you. I predict other solutions will require that you learn to radically accept certain situations in your life as they are.  I know this may sound incredibly difficult if not impossible.  Over time, you will find by truly radically accepting certain situations as they are, you will actually change the way in which you perceive and experience the problem.  This idea of acceptance takes more time than the problem solving ideas I mentioned.  So, let’s start today with the things we can change first.”


            By using “we” statements, the therapist communicates a strong commitment to do whatever is necessary to help the patient get through the present crisis.  Explicitly stated, “You are not alone. We are going to get you through this tough time!”    

            Another protective factor for suicide is when the patient can identify reasons for living.  The therapist should ask the suicidal patient, “Tell me, what reasons do you have for living right now?”  Hopefully the patient does not require significant prompting.  However, because suicidal patients are often in acute emotional distress, the therapist might prompt with statements such as, “What about your family? What about your friends? How would they feel if you killed yourself? What about your future? What do you want to accomplish in your life in the next 5 or 10 years? What about your religion?”  Without significant prompting, Bianca stated, “My mother would feel terribly guilty and that wouldn’t be so bad. But, my best friend would be so angry with me if I killed myself.  She told me that it would be selfish if I killed myself and left her to go on without me.  Also, I am Catholic and believe I would go to Hell.  And, I decided I wanted to get through college so I could become a counselor that helps teenagers get through this awful stage of life!”  These reasons for living were meaningful to the patient and demonstrated a significant protective factor against imminent suicidal behavior.  If the patient cannot identify any reasons for living and is unable to demonstrate any future time perspective in terms of goals, the therapist must recognize this as an absence of protective factors that needs to be factored into the decision about psychiatric hospitalization.

            It is important that the therapist provide a balanced perspective to the patient’s troubled life situation; hence, highlighting as many positive aspects of the patient’s current life circumstances (restoring hope) while also validating the intense pain and despair the patient is experiencing.


Focus on Problem Solving

            As mentioned throughout this crisis scenario, the therapist is continually trying to solve problems with the patient.  The challenge is to identify the more important problems to solve that will give some immediate relief to the patient which will hopefully restore hope and reduce her suicidal ideation.  Again, the key is for the therapist to help the patient identify the problem(s) that are both most distressing currently and primed to be solved quickly.  Thus, while having a history of sexual abuse 10 years ago is a risk factor for suicide, it is not a problem that can be solved quickly.  Thus, the therapist must reassure the patient that the treatment of her sexual abuse will be dealt with once her suicidality is addressed.  Hence, further assessment is required to identify other key links in the chain that precede her suicidal ideation that may be more easily addressed within the next several hours or days.  In addition to standard problem-solving strategies (Nezu, 1989), the following procedures should be followed with suicidal patients.


Emphatically Instruct Patient Not to Commit Suicide/Persist that a Better Solution Exists

            It is important for the therapist to emphatically tell the patient not to attempt suicide.  “Bianca, I do not want you to attempt suicide.  You made an agreement with me at our fist visit that you would not attempt suicide during our treatment together.  Let’s see if we can make a dent in some of these problems that I know feel overwhelming to you right now.  Remember, just because you do not attempt suicide right now doesn’t mean that you can’t do it some time in the future. Let’s give this therapy a chance to work.”  If the patient feels as though they have control and freedom to choose, they are more likely to comply.  It is equally important for the therapist to validate the patient’s pain while refusing to validate suicidal behavior as an appropriate solution (Linehan, 1999).  “I know this is a very difficult time for you right now; yet, I know if we work together we can generate some solutions that will get you out of this misery that don’t involve suicide!”


Focus on the Pros and Cons of Various Actions

            “Bianca, you need to remember that you have only one chance to live your life. In the short-term you say you will feel some sense of relief from the painful emotions you experience if you kill yourself. By the way, how do you know that? I don’t know of anyone who has data regarding that fact. Do you know anyone who says their problems go away when they die? Isn’t it possible that the pain and suffering may get worse? I don’t know…In any case, if your goal is to get along better with your family and boyfriend, as well as feel better about yourself, attempting suicide may not be the best solution.”  Frequently, the patient’s assumptions about the outcomes of her behavioral choices are unrealistic and need to be gently but directly confronted. 


Give Direct Suggestions

            Ideally, therapists help their patients generate their own solutions to their problems.  However, when in a crisis, there are times when the patient does not know what to do.  Under these circumstances it is advisable for the therapist to give direct, concrete suggestions about how to manage specific situations. Therapists should be careful not to assume that a patient who generates a solution also knows exactly how to carry it out.  Thus, attention should be paid to these details, and the therapist may generate solutions for the patient to try.  For example, “Bianca, I know you are having trouble thinking of ways to calm yourself down when you become anxious at home.  Thus, I want you to practice the breathing technique you learned before to help you relax.  Show me how you might do it.” 

            Throughout the session, the therapist wants to reinforce any and all adaptive responses on the part of the patient while identifying and correcting factors that may be interfering with productive plans of action.


Commit to a Plan of Action

            Once a sufficient number of solutions are generated, the therapist asks the patient to commit to a plan of action. 


“Bianca, let’s review.  Can you write down the things we discussed for you to follow up with before next session?  I know your mother has disposed of the Tylenol and Advil in the house since I called. I want you to honestly tell me that when you get home, you are going to request that your mother double check that all pills are out of the house or secured.  Also, you have your cognitive restructuring worksheet that lists your rational responses to your common cognitive distortions that lead to your feeling sad and ashamed. Will you keep that sheet handy and refer to it if your automatic thoughts return? Also, will you write down new automatic thoughts that relate to negative emotions you experience this week? You also have your crisis card that we developed. Will you commit to use that contact list if your suicidal ideation returns?  Finally, and very importantly--will you commit to attend your next session with your parents and will you commit to not hurt yourself before our next session?”

            Assuming Bianca agrees, the therapist shifts to troubleshooting mode.  That is, “OK, now what is going to interfere in your capacity to carry out each of these items on your action plan?”  It is important to carefully review each item with special attention to items that the patient expressed difficulty with earlier in the session.  For example, Bianca expressed disagreement with the removal of available means, which resulted in the therapist calling her family.  Hence, it is likely that she would have difficulty double-checking the house for additional pills. 


Reassess Suicidal Ideation and Anticipate and Plan for a Recurrence of the Crisis Response

            “Bianca, I am pleased that you are not presently feeling suicidal.  However, I am fairly certain given the stressors you are experiencing in your life and your recent emotional sensitivity to them, that you will likely experience suicidal ideation again.  So, tell me in your own words how you are going to handle that when it happens.”  Ideally, the patient will review the strategies discussed during the session and refer to the crisis card as a final safety check.


When Should Inpatient Psychiatric Hospitalization Be Recommended or Considered?

            There are no empirical data that support the notion that acute, inpatient hospitalization is effective in reducing the risk of suicide.  No studies find that hospitalization is the treatment of choice for the chronically suicidal patient (Linehan, 1999).  However, based on clinical experience, there are some situations in which the therapist should consider recommending brief, inpatient hospitalizations.  Below is a list of potential circumstances that may warrant this type of recommendation, the first five of which are adapted from Linehan, (1993a).

1)    The patient is psychotic and is threatening suicide and/or having command auditory hallucinations to kill himself or someone else.

2)    The patient is on psychotropic medications, the patient has a history of overdose on these medications, and is having problems that require close monitoring of medication or dose.

3)    The relationship between the therapist and patient is severely strained which is contributing to the suicidal crisis. The inpatient staff might be helpful in repairing the relationship by facilitating a meeting with both parties.

4)    The patient is not responding to outpatient therapy and there is severe depression or debilitating anxiety

5)    Operant suicide threats are escalating and the hospitalization is considered aversive by the patient.

6)    The patient is actively abusing alcohol or drugs and is refusing to reduce usage during the crisis.

7)    The patient refuses to remove lethal items from the home and/or refuses to use a crisis card and call the therapist or other identified support personnel if suicidal ideation returns.

8)    The patient is profoundly hopeless and unable to identify any reasons for living even with prompting.

9)    The patient cannot identify any social supports that she is willing to use for help during the crisis period.


This list is not meant to be exhaustive but merely represents several common situations that may individually, or in combination, warrant inpatient admission for the suicidal patient.  Of course, each of these aforementioned situations needs to be considered in a fuller clinical context.  The therapist must always take into account the patient’s prior history of suicidal behavior, current suicidal ideation, plan, and intent, as well as the myriad of environmental and behavioral high-risk factors.




Suicidal behavior is one of the most commonly encountered behavioral emergencies among mental health professionals.  The importance of an informed assessment and intervention of suicidality, therefore, cannot be overstated.  In this chapter, we described an evidence-based, symptom-focused approach for intervening with suicidal patients and illustrated this approach with a case example of an 18 year-old suicide attempter.  In an attempt to address the two most common presentations of a suicidal patient to a practitioner, we described treatment strategies relevant to a patient recently discharged from an inpatient unit following a serious suicide attempt as well as treatment strategies relevant to the management of an acutely suicidal patient in outpatient treatment.  In both scenarios, therapists must actively assess and intervene to reduce risk and increase the likelihood of a positive outcome.
Table 2. Controlled studies found to reduce deliberate self-harm and suicidal behavior


Authors                         Experimental Intervention             Target Behavior               Population/Setting


Linehan et al. 1991          DBT                                         Suicide attempts;                         Outpatient adults

parasuicidal behavior


Meltzer &                      Clozapine                                   SI/behavior                     Adults with Schizophrenia

Ghadeer 1995                                                                                                      and Schizoaffective D/O


Hawton et al. 1998          Depot flupenthixol                       SI/behavior                     Adults with psychotic D/O


Baldessarini &                Long-term Lithium                      Suicide attempts              Adults with Bipolar D/O

Jamison 1999                                                                                                    


Bateman &                     Psychodynamic therapy                Suicidal behavior             Partial hospital program

Fonagy 1999


Motto &                                    Ongoing follow-up                      Suicidal behavior/            Outpatients discharged

Bostrom 2001                                                                 depression                      from hospital


Wood et al. 2001             CBT & DBT with                       Deliberate self-harm         Outpatient adolescents

                                    Care as usual                 



DBT=Dialectical Behavioral Therapy; CBT=Cognitive Behavioral Therapy; SI=Suicidal Ideation



Figure 1.  Protocol for Persons with a Recent Suicide Attempt

Build Rapport


Discuss Confidentiality



Reframe Suicidal Behavior


Reframe Treatment as Life-Enhancing


Orient Patient to Treatment Options





Get Commitment


Conduct a Behavior Analysis of Suicidal Behavior

Behavioral analyses are employed in order to understand the function of previous suicidal behavior and reduce the likelihood of future suicidal behaviors. 






Weave in solutions to the behavior analysis, potentially targeting:

vulnerability factors, precipitating events, consequences, and key links

Key links include specific cognitions, emotions, behaviors, and contingencies

Conduct a Solution Analysis
Figure 2.  Protocol for Managing Acute Suicidal Behavior in Session

Oval: Ask direct questions…….Refer to Table 1
Educate yourself about lethality of 
specific methods
Assess Risk of Immediate Suicide




Explore and Summarize Current Problem


Target Environmental High-Risk Factors

Oval: Availability of Means Oval: Lack of social supports Oval: Negative Life Events


Remove lethal means and stay in contact with person



Target Behavioral High Risk Factors






Focus on Problem-Solving


Oval: Instruct patient not to commit suicide
Give Direct Suggestions
Commit to a plan of action
Reassess suicidal ideation and anticipate and plan for a recurrence of the crisis response
Consider psychiatric hospitalization as detailed in text









            Baldessarini, RJ, & Jamison, KR. (1999).  Effects of medical interventions on suicidal behavior.  Journal of Clinical Psychiatry, 60 (Suppl. 2), 117-122.

            Bateman, A, & Fonagy, P. (1999).  The effectiveness of partial hospitalization in the treatment of borderline personality disorder:  A randomized controlled trial.  American Journal of Psychiatry, 156, 1563-1569.

            Brent, DA, Perper, JA, Goldstein, CE, Kolko, DJ, Allan, MJ, Allman, CJ, & Zelenak, JP. (1991). The presence and accessibility of firearms in the homes of adolescent suicides.  Journal of the American Medical Association, 266, 2989-2995. 

            Hawton, K, Arensman, E, Townsend, E, Bremner, S, Feldman, E, Goldney, R, Gunnell, D, Hazell, P, van Heeringen, K, House, A, Owens, D, Safinofsky, I, & Traskman-Bendz, L. (1998).  Deliberate self harm:  Systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition.  British Medical Journal, 317, 441-447.

            Heard, H, & Linehan, MM (1994). Dialectical behavior therapy:  An integrative approach to the treatment of borderline personality disorder. Journal of Psychotherapy Integration, 4, 55-82.

            Hirschfeld,  RMA, Davidson, L. (1988). Risk factors for suicide. Review Psychiatry, 7, 307.

            Kleespies, PM, Deleppo, JD, Gallagher, PL, & Niles, BL. (1999).  Managing suicidal emergencies:  Recommendations for the practitioner.  Professional Psychology:  Research and Practice, 30, 454-463.      

            Koons, CR, Robins, CJ, Tweed, JL, Lynch, TR, Gonzalez, AM, Morse, JQ, Bishop, GK, Butterfield, MI & Bastian, LA. (2001).  Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder.  Behavior Therapy, 32, 371-390.

            Linehan, MM, Armstrong, HE, Suarez, A, Allmon, D, & Heard, HL. (1991).  Cognitive behavioral treatment of chronically parasuicidal borderline patients.  Archives of General Psychiatry, 48, 1060-1064.

            Linehan, MM. (1993a).  Cognitive behavioral therapy of borderline personality disorder.  New York: Guildford.

            Linehan, MM. (1993b). Skills training manual for treating borderline personality disorder.  New York:  Guilford.

Linehan, M.M., Tutek, D.A., Heard, H.L., & Armstrong, H.E. (1994).  Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients.  American Journal of Psychiatry, 151, 1771-1776.

            Linehan, M.M., (1999).  Standard protocols for assessing and treating suicidal behaviors for patients in treatment.  In DG Jacobs (Ed.) The Harvard Medical School Guide to Suicide Assessment and Intervention.  San Francisco:  Jossey-Bass Publishers, 146-187.

            Minino, AM, Arias, E, Kochanek, KD, Murphy, SL, & Smith, BL. (2002).  Deaths:  Final data for 2000.  National Vital Statistics Reports, 50 (15).  Hyattsville, MD:  National Center for Health Statistics.  DHHS Publication No. (2002-1120 (p. 99, Table 33).

            Meltzer, HY, & Ghadeer, O. (1995).  Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia:  Impact on risk-benefit assessment.  American Journal of Psychiatry, 152 (2), 183-190.

            Motto, JA, & Bolstrom, AG. (2001).  A randomized controlled trial of postcrisis suicide prevention.  Psychiatric Services, 52, 828-833.

            Nezu, A, Nezu, C, & Perri, M. (1989).  Problem-solving therapy for depression:  Theory, research and clinical guidelines.  New York:  Wiley.

            van den Bosch, L.M.C, Verheul, R, Schippers, GM, van den Brink, W. (2002). Dialectical behavior therapy for borderline patients with and without substance use problems:  Implementation and long-term effects.  Addictive Behaviors, 900, 1-13. 

            Wood, A, Trainor, G, Rothwell, J, Moore, A, & Harrington, R (2002). Randomized trial of group therapy for repeated deliberate self-harm in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1246-1253.














[1] All assessments of suicidality must include the presence or absence of psychiatric disorders including, but not limited to, affective disorders and substance-related disorders.