Background
Methods
Design
Inclusion and exclusion criteria
Recruitment
Semi-structured interview
Analysis
Results
Participants
Ppt. | Reason for admission | Length of stay on ward in days | Admissions in last 12 months | Diagnosis | Previous psychological therapy |
---|---|---|---|---|---|
1. | Hearing voices | 21 | 1 | SCZ4 | No |
2. | Overdose | 21 | 1 | U | Yes |
3. | U | 112 | u | MDD2 | No |
4. | Sectioned | 336 | u | Alcoholism | No |
5. | Breakdown; overdose | 10 | 2 | U | Yes |
6. | Repeated overdoses | 49 | 1 | Emotionally unstable PD1 | No |
7. | Overdose (Sectioned) | u | u | Anxiety | Yes |
8. | U | u | u | U | No |
9. | Manic / high; overdose | 38 | u | Bipolar / PD1 | Yes |
10. | Hearing voices | 21 | 1 | Voices / SCZ4 | No |
11. | Suicidal | 17 | 1 | U | No |
12. | U | 14 | 1 | Bipolar / PD1 | No |
13. | U | 84 | 2 | SCZ4 | No |
14. | Suicidal | 21 | 0 | Depression | No |
15. | Stopped clozapine | 7 | 0 | SCZ4 | No |
16. | Suicidal | 10 | 0 | U | No |
17. | Self-harm | 672 | u | PTSD2 / Emotionally unstable PD1 | No |
18. | Feeling down | 2 | 0 | Depression | No |
19. | Mental breakdown | 7 | 0 | U | No |
20. | Hearing voices | 12 | 3 | U | No |
Overview of key findings
Theme 1: A Therapy that ‘works’ | Theme 2: Concerns about inpatient suicide -focused therapy |
---|---|
Past experiences shaped expectations | A secure therapeutic relationship |
Suicidality-specific goals | Potential for harm |
Mechanisms: how suicide-focussed therapy works | Ending therapy |
Stage of therapy | Client’s Need | Supporting data | Therapeutic approach |
---|---|---|---|
Immediate | Feel safe. Overcome fear of talking about suicide. |
“… it might make me more suicidal. Because the question is being asked all the time and even though I have tried to take my life numerous times …And if it’s prevalent, if it’s there and somebody’s reminding you of it, you’re more likely to do it” (P02)
| Explore potential barriers to therapy and if necessary defuse fears of talking about suicide. |
Development of strong therapeutic relationship. | “You can go and just relax and like express yourself with that person, with free of them judging you. ..” (P19) | Create a safe environment conducive to building secure, ‘containing’ therapeutic relationship. Promote trust by empathic validation of client’s distress and by allowing client to set the pace and depth of discussions. Demonstrate collaboration with client by negotiating acceptable levels of information sharing with ward staff. | |
Catharsis / Relief from distress. |
“Being able to talk about what you’ve done [suicidal behaviour] and someone to listen” (P06)
| Facilitate client to share experiences of suicidal ideation and behaviour by demonstrating non-judgement and empathy. Normalise client’s experiences to promote a sense of feeling understood. Self-soothing by relaxation/breathing practices. End of session grounding techniques during last 5–10 min. | |
Tolerating intense negative emotions / suicidal thoughts and prevention of suicidal behaviour. |
“I’d be worried what will happen once that barrier’s been broke down to tell you the truth. Because I don’t know whether I’d start crying or get angry.” (P14)
| Guide development and practice of distress tolerance skills / techniques to overcome emotional avoidance and emotional dysregulation. Develop attentional control, attentional broadening and switching techniques to reduce threat-based information processing biases. Promote clients’ sense of agency by assisting recall of experiences of overcoming suicidal states. | |
Intermediate | Make sense of suicidal thoughts and behaviour. |
“Trying to get rid of the suicidal thoughts, just talking about the suicidal thoughts… and why I’ve got them… talking about it would just help really ‘cos there’s no one to talk to about it, so it’d be best to just to have someone to talk to about the suicidal thoughts and what they’re about.” (P10)
| Collaborative development of individualised formulation. Foster therapist - client’s shared understanding of drivers and inhibitors of suicidality/suicidal behaviour. Identify therapeutic goals targeting suicide reduction. Reflect on experiences of helpful and unhelpful escapes from distress. |
Self-understanding and self-management of emotions and cognitions. |
“Help me to recognise when I’m going to be suicidal and perhaps be able to do something about it.” (P02)
| Provide exit points from suicidal thoughts and cognitions by: - Identifying and challenging negative self-appraisals. - Cultivating emotional regulation skills and positive affect / self-image techniques. - Generating problem-solving strategies to manage threats associated with suicidal cognitions. | |
Regain personal independence, and social confidence / functioning. |
“It’s more like building up my social skills a bit more and like talking to people in a group”. (P19)
| Behavioural activation and activity scheduling. Improve self-esteem / confidence building to develop stronger sense of personal agency. Promote positive beliefs about coping and resilience. | |
Longer term | Reclaim personhood and positive self-identity. |
“Getting me life back. Yeah and get back in work and get back to the person I used to be.”(P05).
| Develop stronger recognition of own values and hopes for the future. Re-establish connecting with previous achievements. |
Re-establishment / improvement of close relationships. Harnessing support and understanding of family. | “And it would help others come to terms with the illness as well, i.e. your mum or your dad or your brother or your sisters who you live with or your partner.” (P01) | Discuss possibility of information sharing with and/or involvement of family in therapy and longer-term suicide prevention plans. |
Theme 1: A therapy that ‘works’
One-fifth of participants reported they had previously received psychological therapy, although only one participant had received therapy in a psychiatric ward setting. Some participants were perplexed about the different terms used to depict psychological therapy: “I don’t know. What is psychological therapy? … I’ve done CBT?” (P09).
“I’ve had CBT, I’ve had lots and lots of therapies in [hospital]… when it comes to the severe depression, the suicidal feelings, the attempted suicides – they went away.” (P07)
“When I used to see the psychologist sometimes and started drinking heavier and heavier because I was having to talk a lot about me past and stuff… it was just all buried stuff.” (P02).
“I’m willing to give anything a go to stop me feeling like this.” (P11).
“probably any idea or whatever to try and stop self-harming or doing overdoses … I just hope it [therapy] would help and then I can get discharged.” (P06).
“Now, if you’re to sit me down and say, “Well, why do you want to take your life? What’s your thinking behind wanting to take your life? What’s causing you to think the way you do?” . . . looking at cognition, thinking styles, patterns, trying to challenge them.” (P07).
“help me to recognise when I’m going to be suicidal and perhaps be able to do something about it.” (P02).
“just talking about the suicidal thoughts… and why I’ve got them… talking about it would just help really ‘cos there’s no one to talk to about it, so it’d be best to just to have someone to talk to about the suicidal thoughts and what they’re about.” (P10).
“if I really wanted to kill myself I wouldn’t tell anybody I was going to do it I would go to a forest where no one would find me and hang myself from a tree… these people, who have had five failed suicide attempts, they are cries for help, they wanted to be found, because if you wanted to kill yourself, you’re not daft you know how to do it, wouldn’t you? It’s because they can’t get help, but now that your thing [suicide-focused therapy] will be implemented they won’t have to do that, think of all of the lives you’ll save.” (P12).
“in hospital they just ask you have you got them [suicidal thoughts] and if you have then they just try and give you some medication for it, they don’t talk about why you’ve got them…” (P10).
“Well, it’s to try to get you to open up isn’t it? ... And talk about things that are on your mind and your worries and all that. And I think the therapy part of it is to… help you to face your fears and your worries.” (P14).
“Getting me life back. Yeah and get back in work and get back to the person I used to be.”(P05).
“building up my social skills a bit more and like talking to people in a group.” (P19).
“coming to terms with your illness is one part. And it would help others come to terms with the illness as well, i.e., your mum or your dad or your brother or your sisters who you live with or your partner.” (P01).
“empathy, having the ability to climb into someone’s internal frame of reference. .. communicate on their wavelength. Being able to listen actively” (P07).
Theme 2: Concerns about inpatient suicide-focused therapy
“If I told you I’m going to hang myself tonight, you’d have to tell the nurses, wouldn’t you?” (P13).
“Well with me, it [sharing information] wouldn’t bother me. It just depends what they’re going to do with that information… How far is it allowed to go? ... In my case, there’d be one or two things where I wouldn’t be comfortable with staff knowing.” (P14).
“The family, I think, would, that’s on a need-to-know basis. You don’t want to upset family members for no reason.” (P11).
“No, I wouldn’t want it shared with family and friends ‘cause it’s supposed to be a private session.” (P10).
“If you give therapy and it’s not completed, they may have issues, very sensitive, emotionally driven issues, that have been touched upon, which made it worse and it’s not been treated effectively. You can end up being worse off. Whereas, to give them the continuous care therapy in the community, if they do get discharged… that would be a very good thing” (P07).
A therapy that ‘works’: User-informed conceptual model of in-patient suicide-focused psychological therapy
Discussion
Main findings
Incompatibility of service objectives and in-patient needs
Barriers to suicide-focussed therapy
Past negative experiences
Fears of increased suicidality
Strengths
Limitations
Recommendation for research and clinical practice
In-patients’ views | Implications for suicide-focused therapy | Recommendations for therapist |
---|---|---|
Past negative experiences of therapy | Unsatisfactory previous experience of therapy may prevent uptake of suicide-focused therapy. May lead to avoidable dissatisfaction and attrition if therapist not aware of clients’ expectations and preferences. | Enquire about and consider the impact of any past experiences of therapy. Provide clear information about the nature and demands of suicide-focused therapy and the potential for negative therapeutic reaction. |
Confusion / lack of understanding of aims and functions of psychological therapy | Potential for disappointment if client’s expectations of therapy cannot be met. Need to identify and manage realistic expectations. Need for active client engagement during and in-between sessions. | Discuss and mutually agree expectations including client’s expectations of own and therapist’s role, and therapist’s expectations of client’s role. |
Concerns about trust and confidentiality of information disclosed in therapy | Lack of trust and confidence in confidentiality may impact on continued uptake and engagement. Demonstration of openness and transparency by therapist explaining own responsibility for breaking confidentiality if concerned for client’s safety may serve to build trust. Therapist must inform ward team if actual or risk of harm to client or others disclosed in therapy. Need to clarify client’s wishes of who non-risk information may or may not be shared with. | Allow time for trust to develop recognising the particular challenges for inpatients who may be involuntarily detained. Demonstrate consistent reliable behaviour Discuss limits of confidentiality with client. Discuss when and how any disclosures of actual or risk of harm to self or others would be managed respecting clients’ preferences where possible. Agree what and with whom other information may be shared with (e.g., ward staff, family). |
Fear or unwillingness to talk about suicide | Willingness to discuss suicide is essential for suicide-focused therapy. Covert fears of potential for harm may impede engagement in therapy. | Important to give full information about the need to talk about suicide to enable informed consent. Proactive discussion to elicit any client fears about perceived dangers of talking about suicide. Provide reassurance that client will retain control of the depth and pace of therapy. |
Concerns about the ending of therapy | Anxiety about possibility of abrupt ending of sessions may affect ability to engage in therapy. | Involve client in discussions about preferences for ending of therapy. Offer ways of gradual spacing of session intervals, follow-up or booster sessions. |