Client-reported impact of the Attempted Suicide Short Intervention Program

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Client-reported impact of the Attempted Suicide Short Intervention Program © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published version Gaily-Luoma, Selma; Valkonen, Jukka; Holma, Juha; Laitila, Aarno Gaily-Luoma, S., Valkonen, J., Holma, J., & Laitila, A. (2023). Client-reported impact of the Attempted Suicide Short Intervention Program. Psychotherapy Research, Early online. https://doi.org/10.1080/10503307.2023.2259070 2023 Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=tpsr20 Psychotherapy Research ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tpsr20 Client-reported impact of the Attempted Suicide Short Intervention Program Selma Gaily-Luoma, Jukka Valkonen, Juha Holma & Aarno Laitila To cite this article: Selma Gaily-Luoma, Jukka Valkonen, Juha Holma & Aarno Laitila (05 Oct 2023): Client-reported impact of the Attempted Suicide Short Intervention Program, Psychotherapy Research, DOI: 10.1080/10503307.2023.2259070 To link to this article: https://doi.org/10.1080/10503307.2023.2259070 © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group View supplementary material Published online: 05 Oct 2023. Submit your article to this journal View related articles View Crossmark data RESEARCH ARTICLE Client-reported impact of the Attempted Suicide Short Intervention Program SELMA GAILY-LUOMA 1 , JUKKA VALKONEN 2 , JUHA HOLMA 1 ,& AARNO LAITILA 1 1 Department of Psychology, University of Jyväskylä, Jyväskylä, Finland & 2 MIELI Mental Health Finland, Helsinki, Finland (Received 24 April 2023; revised 6 September 2023; accepted 7 September 2023) ABSTRACT Background A history of attempted suicide is the most significant predictor of suicidal death. Several brief interventions aimed at tertiary suicide prevention have been investigated in clinical trials. However, suicide attempt survivors’ experiences of such interventions have rarely been reported. Objective To explore how suicide attempt survivors perceive the impact of the Attempted Suicide Short Intervention Program (ASSIP). Method We interviewed 14 Finnish adults who had received ASSIP as an adjunct to treatment as usual. Semi-structured interviews took place 4–10 weeks after the last ASSIP session. A conventional content analysis of the interview data is presented. Results ThreecorecategoriesdepictingASSIP’s perceived impact were identified. The core category life-affirming change comprised subcategories of feeling better,thinking differently,acting differently,andhaving new resources. The core category collateral effects comprised difficult feelings and cognitive overload. The core category incompleteness of change comprised lack of desired change,gainsasincomplete,need for sustenance,andunrealized potential. Conclusion Clients perceived ASSIP as effectively facilitating life-affirming change but agreed that further support was necessary to retain and build on these gains. Identified needsfor improvement included more predictable post-ASSIP service paths and more support for involving affected loved ones. Keywords: suicide attempt; brief treatment; clients’perspective; qualitative; ASSIP Clinical or methodological significance of this article: Suicide attempt survivors are at high risk for further suicidal action and difficult to engage in services. Our findings indicate that the Attempted Suicide Short Intervention Program, a brief suicide-specific add-on intervention, has the potential to make an impact perceived by clients as deeply meaningful. Importantly, ASSIP seems to facilitate remoralization, the formation of credible safety strategies, and motivation to further engage in services and work on long-term recovery. However, our findings also call for closer attention to the accessibility of post-ASSIP support and opportunities for engaging affected loved ones after a suicide attempt. Introduction A history of attempted suicide presents a significant risk for eventual suicidal death (e.g., Bostwick et al., 2016). Suicide attempt survivors are not easily engaged in services, especially in the long-term, hence the need for interventions that are both readily available and brief (e.g., Lizardi & Stanley, 2010). Recent research has produced evidence supporting several brief or very brief interventions © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/ licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. Correspondence concerning this article should be addressed to Selma Gaily-Luoma, University of Jyväskylä, PO Box 35, University of Jyväskylä, Jyväskylä FI-40014, Finland. Email: [email protected] Psychotherapy Research, 2023 https://doi.org/10.1080/10503307.2023.2259070 (e.g., Brown et al., 2005; Gysin-Maillart et al., 2016; Jobes, 2012; Rudd et al., 2015; Stanley et al., 2018). Many of these share key components, including collaborative exploration of suicidality, planning for future crises, and “caring contact follow-up”(Jobes & Chalker, 2019). While the effectiveness of brief interventions in reducing repeated suicidal acts has been investigated (McCabe et al., 2018; Sobanski et al., 2021), suicide attempt survivors’evaluations of their impact have seldom been reported. The Attempted Suicide Short Intervention Program The Attempted Suicide Short Intervention Program (ASSIP) (Michel & Gysin-Maillart, 2015) is a brief, suicide-specific intervention designed as an adjunct to treatment as usual (TAU). ASSIP’s integrative approach was inspired by observations of the poor fit of the prevalent medical model to the needs of those who attempt suicide (Michel et al., 2002; Michel et al., 2017). In ASSIP, suicidal behaviour is primarily understood as goal-oriented action, i.e., a perceived solution to unbearable mental pain. ASSIP also draws on cognitive–behavioural theory, attachment theory, and narrative theory in its understanding of effective post-attempt intervention. ASSIP comprises 3–4 weekly sessions and follow-up letters over two years. Goals and tasks are manualized for each 60–90-minute session (see Table I). An early therapeutic alliance is facilitated by use of the narrative interviewing style and a non-judgmental, collaborative approach by the therapist. Video-playback of the suicidal narrative invites the patient to review the episode from a (co-)observer position within the safety of the therapeutic alliance. This allows for joint reflection and clarification of the chain of events leading to the suicide attempt, thereby fostering insight and the motivation to develop personal safety strategies. Sessions are highly collaborative and include psychoeducation, case conceptualization, the formulation of long-term goals, personal vulnerabilities, specific suicide triggers, personal warning signs, and safety strategies (Michel & Gysin-Maillart, 2015.). In Finland, ASSIP has been implemented by MIELI Mental Health Finland (MIELI), a national non-governmental organization (NGO). At MIELI Suicide Prevention Centers, it is provided by healthcare professionals but outside the healthcare system. While the ASSIP manual does not include the client’s natural network (e.g., family) in the intervention, clients in Finland are offered an opportunity to invite loved ones along in the fourth session. Previous Findings on the Outcomes of ASSIP To date, two randomized clinical trials of ASSIP have been published. Gysin-Maillart et al. (2016) originally compared ASSIP as an add-on to TAU to TAU alone. Respective re-attempt rates for groups receiving ASSIP + TAU and TAU alone were 8.3% and 26.7%. A mean hazard ratio of 0.17 for a suicide attempt in the ASSIP group indicated an 83% reduced risk of attempting suicide during two-year follow-up. In Finland, Arvilommi, Valkonen, Lindholm, Gaily-Luoma, Suominen, Ruishalme, et al. (2022) compared the rates of suicide attempts in groups receiving either ASSIP or crisis counselling as augments to TAU and found the difference in reattempt rates non-significant. In the United States, a modification of ASSIP delivered to suicide attempt survivors with substance abuse disorders during hospitalization was tested in a small pilot RCT (n= 34). This study reported high patient satisfaction but also relatively high reattempt rates (Conner et al., 2021). Secondary analyses of the RCT data from Gysin-Maillart et al. (2016) have explored, e.g., cost-effectiveness (Park Table I. Contents of the Attempted Suicide Short Intervention Program. Session 1 Clients are asked to narrate, in their own words, how it came about that they attempted suicide. This narrative interview is videotaped with the client’s consent. The first session ends with a collaborative suicide risk assessment using the Suicide Status Form (Jobes, 2006). Session 2 Client and therapist watch the videotaped narrative together, pausing to jointly reflect on important episodes. At the end of the second session, clients are given a psychoeducative handout (“Suicide Is Not a Rational Act”) and asked to return it with personal comments in the third session, after which the therapist prepares a draft summary of the client’s narrative for the case conceptualization. Session 3 The client’s comments on the psychoeducative handout are discussed. The case conceptualization is completed collaboratively. This includes reviewing and revising the summary of the client’s narrative; addressing key vulnerabilities and triggers associated with the suicidal episode; and identifying warning signs, safety strategies and long-term goals. These are documented in writing and given to the client. (Session 4) In the ASSIP manual, clients are offered an optional fourth session to complete tasks or practice safety measures. In our sample, clients were encouraged to invite their loved ones along for this fourth session. Continued contact After the sessions are completed, semi-standardized letters reminding the client of the work done and the possibility of contacting the therapist are sent for the next two years at 3, 6, 9, 12, 18 and 24 months after the last session. Clients are invited to reply to the letters with updates if they so wish. 2S. Gaily-Luoma et al. et al., 2018), the association between the therapeutic alliance and suicidal ideation during follow-up (Gysin-Maillart et al., 2017; Ring & Gysin-Maillart, 2019/2020), changes in coping (Gysin-Maillart et al., 2020), and changes in reasons for living and reasons for dying (Brüdern et al., 2018; Gysin-Maillart et al., 2022). Ongoing studies include a large ASSIP RCT in Sweden (National Library of Medicine, 2020). Quantitative research on ASSIP has accumulated, but qualitative reports of clients’experiences of the intervention remain scarce. This is typical in suicidology, as quantitative methods dominate the field and qualitative data –while often collected in some form during the developmental phases of novel interventions –remain unpublished. To date, the only empirical report from ASSIP clients’perspectives is from an unpublished mixed-methods effectiveness study conducted in Lithuania (Latakien˙ e et al., 2022). In this study, the five women and two men who received ASSIP as an add-on to TAU reported a positive perception of the respectful, collaborative nature of the therapeutic relationship and the focus on suicide-specific treatment tasks in ASSIP, while being rather critical of TAU. Aims of the Current Study We explored participants’reports of how their engagement in ASSIP had affected them in the short term. Our aim was to produce a data-driven interpretation of participants’experiences that can inform the further development and implementation of ASSIP. Method This study applied an exploratory qualitative design in a naturalistic setting. Participants had recently attempted suicide and subsequently received both healthcare services (TAU) and ASSIP. Here, we report our findings on participants’experiences of ASSIP. The present participants’experiences of TAU have been published elsewhere (Gaily-Luoma et al., 2022). Our primary data consist of in-depth participant interviews focusing on experiences of services received after the suicide attempt. We also had access to participants’ASSIP case conceptualizations. These were reviewed to enhance contextual understanding of the participants’ situation and routes to suicidal action. Study Recruitment Participants were recruited through the MIELI Mental Health Finland Suicide Prevention Center (MIELI) in Helsinki, Finland. Clients entering ASSIP, excluding those under age 18 and/or resident outside the Hospital District of Helsinki and Uusimaa, were invited to participate. In ASSIP, a suicide attempt is defined as a completed or interrupted action that, in the person’s own understanding, is aimed at taking their life. ASSIP is not recommended if (1) the suicide attempt occurred during a psychotic episode, (2) a current substance abuse disorder is serious enough to impede engagement, or (3) serious self-harm is habitual. These eligibility criteria were applied in this study. ASSIP was provided by four therapists, all of whom were trained healthcare professionals. The therapists were members of a team centred on the provision of ASSIP, with regular ASSIP-related team supervision. Three had completed their ASSIP training with the developers of ASSIP (Konrad Michel, MD and Anja Gysin-Maillart, PhD) some years prior to the study, and one completed training during the study. All eligible clients were informed about the study by their ASSIP therapist at the beginning of the first ASSIP session. Participants Of the 104 eligible clients informed about the study, 18 gave their initial consent and 14 participated in the research interview. The participants were diverse in both their demographics and history of suicidality. Seven (50%) were registered as female and seven as male. Five (36%) were aged 18–29 years, four (29%) 30–45 years, three (21%) 46–59 years and two (14%) were over age sixty. Ten (71%) participants were currently students or employed, two (14%) were unemployed and two (14%) were pensioners. Highest education ranged from a high school diploma to a graduate degree. Thirteen (93%) participants were white, and one was of mixed ethnicity. We use the term “index attempt”to refer to the suicide attempt that led the participants to engage in ASSIP. Eight (57%) participants reported a lifetime history of one or more suicide attempts before the index attempt. Methods planned or used in the index attempt included intoxication, self-cutting, leaping from a height, motor vehicle collision, and electrocution. Physical consequences ranged from need of emergency medical intervention to no physical injury. During the current episode, all participants had used emergency services, twelve (86%) were psychiatric outpatients, four (29%) had been inpatients, and two (14%) were receiving psychotherapy in addition to ASSIP. ASSIP is designed to target suicidal behaviour and is not focused on psychiatric diagnosis, and hence participants’diagnoses were not systematically Psychotherapy Research 3 documented. However, past and current diagnoses spontaneously reported by the participants included a range of mood disorders, anxiety disorders, trauma-related disorders, eating disorders, substance-abuse disorders and borderline personality disorder. Some participants reported a life-time history of delusions and/or hallucinations, but none during the current suicidal episode. Participants reported a variety of reasons for their suicide attempt in their ASSIP narrative. Most narrated relationship troubles as key triggers of their suicidal crisis, citing, e.g., a recent break-up, strained or abusive family relationships and/or loneliness as a major contributor to the attempt. Other prominent stressors included financial issues, work exhaustion, no fixed abode, and lack of work/meaningful pastimes. About half of the participants cited traumatic childhood experiences (e.g., loss of a parent, physical, sexual and/or emotional abuse in the family and/or in peer relationships) as contributing to their suicidality. Several reported having experienced the suicidal death of a close friend or family member. While in most narratives the suicidal process had begun in childhood or early adulthood, two participants reported having experienced psychological well-being into middle-age and linked their suicide attempt solely or primarily to a current stressor (e.g., unbearable physical pain due to a somatic illness). Study Interviews To allow participants some distance to review their experience of ASSIP, the study interviews were planned to take place 3–5 weeks after the last ASSIP session. Scheduling difficulties led to slightly longer delays (4–10 weeks). Differences between participants in their schedules for entering and/or completing ASSIP meant that time from the index attempt to interview ranged 3–6 months. The semistructured interviews were conducted by the first author, a psychologist experienced in the care of suicidal individuals, and took place at the MIELI Suicide Prevention Center. The interviews lasted 45–120 min and were video recorded. Experiences of ASSIP were investigated first, followed by exploration of any other services received by the participant. In addition to the participants’general experience of each service, the interview topic guide explored which aspects of services participants perceived as helpful, unhelpful, or even hurtful, surprising elements, suggestions for improvement, and participants’subjective assessment of whether each service received had been helpful to them. The interviewer had no part in the provision of ASSIP, and efforts were made to make participants feel comfortable in sharing both positive and negative experiences of ASSIP. Although all participants answered all the questions in the topic guide, the order of the topics varied, as the interviewer followed the participants’narrative lead. Initial impressions, insights, and questions elicited during each interview were documented in a reflective journal by the interviewer. Data Analysis To achieve a data-driven description and interpretation of participants’experiences of ASSIP’s impact, we used conventional content analysis (Hsieh & Shannon, 2005). The primary steps taken to ensure the quality and validity of the analysis included prolonged engagement, persistent observation, iteration, reflexivity, and a degree of investigator triangulation (e.g., Stiles, 2003). The analytical process was led by the first author and reviewed and refined jointly by all authors. First, the interviews were transcribed verbatim and read/listened to multiple times to enable immersion in the data. Next, data excerpts relevant to the research question were systematically identified in each participant’s transcript. These included all the meaning units in which the participant discussed being impacted in any way by their engagement in ASSIP. After identification, all meaning units were open coded. Open-coded units similar in content were then organized into clusters, creating emerging categories. This was followed by a cyclical process of (1) choosing a descriptive label for each tentative category, (2) checking for the fit of each piece of open-coded content under the chosen labels, and (3) either relabeling or re-organizing the data when the opencoded content and category labels showed poor fit. As the meaning units often contained multiple meanings, we allowed the same unit to be assigned under more than one category (e.g., when a positive change was also described as incomplete or accompanied by collateral anxiety). While clusters closely corresponding to the current core and subcategories emerged early in the analysis (e.g., as clusters of positive experiences; negative experiences; changes in ways of feeling and ways of thinking), the labels and hierarchical relation of the categories to each other were repeatedly refined throughout the writing process. In presenting the results, we report the number of participants informing each finding in general terms: 2–3participants = “a few”or “some”,4–6 =“several”,7–10=“many”and 11–13 = “most”of the total of 14 participants. Data quotes have been translated from the original Finnish and edited for readability, while preserving the original meaning as closely as possible. Brackets in quotes indicate where text has been altered or added for clarity and 4S. Gaily-Luoma et al. an ellipsis indicates where text has been removed to shorten a quote. Ethical Considerations Ethical considerations during the design and data collection of this study have been presented earlier (Gaily-Luoma et al., 2022). Here, we focus on the impact of researcher positioning on the validity of the current analysis. The study design was inspired by the first author’s wish to better understand the experiences of suicide attempt survivors, a population she was treating as a psychologist in healthcare services. ASSIP had been introduced in these services as an add-on opportunity for service users, inspiring this study design. The only member of the research group employed by the NGO providing ASSIP (JV) joined the research group after the basic study design had been agreed upon. No member of the research group has had any involvement in the development or provision of ASSIP and no vested interest in ASSIP has affected the study design or analysis. Results Participants’accountsofhowtheyhadbeenimpacted by ASSIP ranged from an appraisal that the intervention had provided some benefits but not made a significant difference to its being seen as a turning point providing crucial resources for a hopeful future. Many participants expressed surprise that such meaningful gains were achievable in such a brief time frame. The suicidespecific programme was perceived as allowing for the depth of the process, while also being adequately flexible or “personal”. While all participants agreed that ASSIP had provided at least some gains, they differed on the components they regarded as responsible for these gains. The therapeutic relationship was reported as a meaningful catalyst of change by all participants. A majority cited the safety planning and video playback assourcesofgains.Halfoftheparticipantscitedthenarrative interview and continued contact as personally important. Some described the case conceptualization, psychoeducative handout and/or collaborative suicide assessment as having a meaningful impact on them. Three core categories comprising ten subcategories were identified in the participants’accounts of the impact of ASSIP. The first core category described life-affirming change in four subcategories: feeling better,thinking differently,acting differently and having new resources. The second core category described the collateral effects in ASSIP in two subcategories: difficult feelings and cognitive overload. The third core category described incompleteness of Table II. Categories in participants’accounts of ASSIP’s subjective impact. Core Category Life-affirming change Collateral effects Incompleteness of change Subcategory Feeling better Thinking differently Acting differently Having new resources Difficult feelings Cognitive overload Lack of desired change Gains as incomplete Need for sustenance Unrealized potential Examples of open codings feeling relief; feeling valued; finding selfcompassion; finding hope realizing what happened to me; knowing what needs to change; gaining clarity functioning better; not bottling it all up anymore credible safety plan; having a safety net exhaustion; feeling anxious; worrying about my therapist dissociating due to stress; confusion; forgetfulness achieving no enlightenment; no change in the underlying desire to die need to verify insights; not all the way back to my normal functioning; need for further work gains vulnerable to set-backs; need for sustaining resources insufficient support for involving loved ones; hurried safety plan; no peer resources Psychotherapy Research 5 change in four subcategories: lack of desired change, gains as incomplete,need for sustenance and unrealized potential. The results are presented in Table II. Life-affirming Change All the participants reported that ASSIP facilitated some kind of life-affirming change. Change was described as new emotions, new cognitions, new behaviours, and new resources. Feeling better. Positive emotional experiences such as feeling “relieved”,“safe”or simply “better” were reported by most participants. Within the therapeutic relationship, participants’described feeling “valued”,“taken seriously”,“free to talk”,“free to set boundaries”,“not feeling judged or guilty”or “not feeling like such an alien”. Many described feeling that their ASSIP therapist was genuinely interested in them, cared, and wanted to help. This was often presented as a surprise (e.g., “Ievenwrotein my journal about it, that it felt like someone actually wants to talk to me and hear my thoughts!”) and/or as a contrast to other experiences of interactions with healthcare professionals. These positive experiences were reported as facilitated by organizational practices (e.g., “[the fact that] my therapist called to make the first appointment [instead of a clerical employee] made me feel welcome”;“there was no hurry”), the skill of the ASSIP therapist (e.g., “[they] really knew how to listen”) and the ASSIP programme (e.g., “it was crucial that I got to start by telling the story of my life”;“I got to really talk about my suicidality …the topic has been avoided in my other treatments”). Several participants reported feeling differently toward themselves as a result of ASSIP, typically describing more self-compassion and/or less guilt. This was attributed to the therapeutic relationship, video playback, and/or psychoeducation. One participant described the effect of the psychoeducation component: “It’s good to understand that it’sa dissociative state, an exceptional state …I was able to accept it so that I no longer blame myself for it … before I just wallowed in self-blame.” Many participants described feeling differently about the future. One participant expressed it thus: “Already in the first session I started feeling hopeful, I got so scared, thinking I’d never want to kill myself again.”Although only a few participants spoke explicitly of hope, most communicated a renewed motivation to see what the future would bring. No participant reported feeling actively suicidal at the time of the interview; instead, most spontaneously reported a determination to never attempt suicide again. Thinking differently. New insights were reported by most participants and typically concerned elucidation of the reasons behind the suicidal crisis and/or changes needed to prevent such crises recurring in the future. Some participants (particularly those reporting a proneness to dissociation) described as meaningful the realization that their suicide attempt was psychologically caused rather than a random occurrence: “Maybe I understood why I was there only when I started talking, and I realized that I’ve had quite a lot of stressors around me and it hasn’t happened in a vacuum that I suddenly feel really bad again”. Insights into the suicidal episode were attributed to the opportunity to discuss it thoroughly, something which many participants had found wholly lacking in their encounters with other healthcare professionals. Being able to narrate their suicidal episode, the use of video playback, and participating in safety planning and/or receiving psychoeducation were all cited as facilitators of these insights. Most participants reported personally meaningful insights into the specific dynamics fuelling their suicidal crisis. Such insights concerned a wide range of topics, including the effect of their upbringing (e.g., how difficult emotions were handled in their family of origin), significant life events (e.g., losses, significant relationships), interpretations of significant events (e.g., how a traumatic event had affected their self-image) and personal characteristics (e.g., a tendency to bottle up difficult feelings) on their suicide attempt. Insights into the suicidal process were often described as powerful, empowering and/or transformative, one participant stating, “I’ve been able to dig out of myself a perhaps significant insight …in the course of three short sessions I [realized] that I have no need for another suicide attempt, that’samazing.” This participant reported that insight into the causes of the suicide attempt also offered an alternative route out of suffering and thus resulted in no longer needing to die. Another participant described a meaningful insight concerning a behavioural pattern they experienced as frustratingly irrational: The problem was that when I get depressed, no one at work notices anything, but at home I’m absolutely devastated. In ASSIP I realized this pattern came from my childhood family …It felt important to find some reason for it, because I have wondered why I can’t act like others at work: that if I’m exhausted, I’d do [less]. Many participants described gaining a new perspective on themselves and/or their situation and commonly reported that this had also resulted in new thoughts and emotions. The therapists’questions, comments and/or active listening were often credited 6S. Gaily-Luoma et al. for facilitating such insights. One participant described the effect of hearing their expressions of suffering echoed by their ASSIP therapist: When you hear it from another person’s lips, even if it’s exactly the same thing [you’ve said], it brings a new perspective to it …it’s not so like selfish …and then you might experience a little feeling of sympathy …it doesn’t feel the same in your own head as when the other person says it, so it just opens your perspective a little more. New compassion for oneself and/or the alleviation of guilt were often reported as a result of new perspectives and insights. One participant also reported a new perspective offered by the ASSIP therapist as directly impacting their reasons for wanting to die: [The reason for my suicidal behavior was that] I wanted to cause as many problems as possible for the [institutions that had done wrong by me] …I wanted those people to feel bad …[my ASSIP therapist] found a counterbalance in saying that you won’t gain anything from it …that the only ones who will grieve are your family, and you don’t want to hurt your family like that, do you? That had a really important [influence]. Psychoeducation was reported by some participants as affecting their ability to understand what had happened, their emotional reaction to the situation and/ or their capability to resist the possible re-emergence of suicidal impulses in the future. A first-time user of mental health services described its effect: “[The psychoeducative hand-out was] useful in that everything kind of rang true …It [was] a bit of a wake-up call for me …I had never read or even thought about such things before.”Another participant with previous suicide attempts and ample experience of mental healthcare described a similarly meaningful impact: It helped me to understand what happened in me and that it is not such a rational act …to remember that [the attempt] leaves a memory mark so that you can understand that if you have the same kind of thoughts, you can know that it’s because of that …maybe it helps you so that you can maybe not go there or maybe you can resist those thoughts, when you can remind yourself [of the psychoeducative information]. Acting differently. A few participants reported the emergence of new observable behaviour as a result of ASSIP. For example, one participant’s insight that a family pattern had been fuelling their perfectionistic work performance had resulted in behaviour change: “At work, I find that maybe I no longer think I need to be an excellent employee, it’s enough that I’m good. …I do certain things well, but I don’t worry too much about the other stuff.” Some participants cited their silence around meaningful issues as a key contributor to their suicidal crisis: “Everything has always gone wrong because I haven’t talked, and I want to change that.”These participants described their engagement in ASSIP as breaking this behavioural pattern: For the first time we talked about things starting from my childhood. I had insights about why I am the way I am. These things had never been discussed or even asked about. My problem is that I don’t talk. It was important to be able to tell [my story]. While many participants described a marked positive change in their functioning in comparison to the period immediately following the suicide attempt, they typically made no explicit attribution of this change, or they attributed it to causes other than ASSIP. However, one participant reported that ASSIP had directly resulted in better day-to-day functioning: A month after [the attempt] it was really difficult to do the cleaning at home or get things done, everything felt like a burden, but then ASSIP made it easier to get back to my everyday life. When you could talk about things directly and not just have those thoughts stuck in your head, it was much easier to deal with them afterwards. Having new resources. Most participants reported gaining new, meaningful resources through ASSIP. Many participants emphasised the importance of a credible personal safety plan, as in the following example: We made me the safety plan, which seemed like a really good idea, because even though I’ve been in therapy for many years I’ve never actually had one …it was really concrete and specified how before I feel completely self-destructive, what precedes it, and I had to think about it and articulate it on paper and there were suggestions for interventions at different points, it wasn’t left so abstract …I like having very precise instructions so that if you’re feeling really confused, it’s easier to understand them. Several participants referred to a specific piece of advice that had made the safety plan feel usable. As one participant put it: At first I thought that the safety plan is no use in real life. The problem is, if I call emergency services when I’m standing there with the rope in my hand, what do I say? …But then [my ASSIP therapist] told me to Psychotherapy Research 7 Lizardi, D., & Stanley, B. (2010). Treatment engagement: A neglected aspect in the psychiatric care of suicidal patients. Psychiatric Services,61(12), 1183–1191. https://doi.org/10. 1176/ps.2010.61.12.1183 McCabe, R., Garside, R., Backhouse, A., & Xanthopoulou, P. (2018). Effectiveness of brief psychological interventions for suicidal presentations: A systematic review. BMC Psychiatry, 18(1), 120. https://doi.org/10.1186/s12888-018-1663-5 Michel, K., & Gysin-Maillart, A. (2015). ASSIP —attempted suicide short intervention program: A manual for clinicians. Hogrefe. https://doi.org/10.1027/00476-000. Michel, K., Maltsberger, J. T., Jobes, D. A., Leenaars, A. A., Orbach, I., Stadler, K., Dey, P., Young, R. A., & Valach, L. (2002). Discovering the truth in attempted suicide. American Journal of Psychotherapy,56(3), 424–437. https://doi.org/10. 1176/appi.psychotherapy.2002.56.3.424 Michel, K., Valach, L., & Gysin-Maillart, A. (2017). A novel therapy for people who attempt suicide and why we need new models of suicide. International Journal of Environmental Research and Public Health,14(3), 243. https://doi.org/10. 3390/ijerph14030243 National Library of Medicine (U.S.). (2020, October–). A randomized clinical study of “attempted suicide short intervention program”in Swedish Healthcare. Identifier NCT04746261. Retrieved April 24, 2023, from https://clinicaltrials.gov/ct2/ show/NCT04746261 Owens, C., Fox, F., Redwood, S., Davies, R., Foote, L., Salisbury, N., Williams, S., Biddle, L., & Thomas, K. (2020). Measuring outcomes in trials of interventions for people who self-harm: Qualitative study of service users’views. BJPsych Open,6(2), e22. https://doi.org/10.1192/bjo.2019.93 Park, A.-L., Gysin-Maillart, A., Müller, T. J., Exadaktylos, A., & Michel, K. (2018). Cost-effectiveness of a brief structured intervention program aimed at preventing repeat suicide attempts among those who previously attempted suicide: A secondary analysis of the ASSIP randomized clinical trial. JAMA Network Open,1(6), e183680. https://doi.org/10.1001/ jamanetworkopen.2018.3680 Qin, P., Stanley, B., Melle, I., & Mehlum, L. (2022). Association of psychiatric services referral and attendance following treatment for deliberate self-harm with prospective mortality in Norwegian patients. JAMA Psychiatry,79(7), 651. https:// doi.org/10.1001/jamapsychiatry.2022.1124 Ring, M., & Gysin-Maillart, A. (2020). Patients’satisfaction with the therapeutic relationship and therapeutic outcome is related to suicidal ideation in the attempted suicide short intervention program (ASSIP). Crisis,41(5), 337–343. https://doi.org/10. 1027/0227-5910/a000644 Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., Williams, S. R., Arne, K. A., Breitbach, J., Delano, K., Wilkinson, E., & Bruce, T. O. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry,172(5), 441–449. https://doi.org/10.1176/appi. ajp.2014.14070843 Schlichthorst, M., Ozols, I., Reifels, L., & Morgan, A. (2020). Lived experience peer support programs for suicide prevention: A systematic scoping review. International Journal of Mental Health Systems,14(1), 65. https://doi.org/10.1186/s13033020-00396-1 Sobanski, T., Josfeld, S., Peikert, G., & Wagner, G. (2021). Psychotherapeutic interventions for the prevention of suicide re-attempts: A systematic review. Psychological Medicine,51 (15), 2525–2540. https://doi.org/10.1017/S0033291721003081 Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry,75 (9), 894. https://doi.org/10.1001/jamapsychiatry.2018.1776 Stiles, W. B. (2003). Qualitative research: Evaluating the process and the product. In S. Llewelyn & P. Kennedy (Eds.), Handbook of clinical health psychology (pp. 477–499). Wiley. Valach, L., Michel, K., & Young, R. A. (2018). Self-reports of corrective experiences by suicide attempters in a video self-confrontation. Journal of Psychiatry Studies,1(1), 9. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). Routledge. 14 S. Gaily-Luoma et al.