Table 3 User-informed conceptual model of in-patient suicide-focused psychological therapy [52]

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.