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Reducing potential risk factors for suicide-related behavior with a group intervention for clients with recurrent suicide-related behavior

Yvonne Bergmans, MSW, RSW

Suicide intervention consultant, Suicide Studies Unit, Arthur Sommer Rotenberg Chair in Suicide Studies, St. Michael’s Hospital University of Toronto, Toronto, Ontario, Canada

Paul S. Links, MD, FRCP(C)

Chair, Arthur Sommer Rotenberg Chair in Suicide Studies, St. Michael’s Hospital University of Toronto, Toronto, Ontario, Canada

BACKGROUND: This paper reports the results of a pilot study of a 20-week outpatient Psychosocial/Psychoeducational Intervention for Persons with Recurrent Suicide Attempts (PISA) targeting potential risk factors and areas of deficit, including cognitive, affective, and impulsivity known to characterize persons with recurrent suicide-related behavior.

METHODS: One hundred sixty-three persons completed the 20-week intervention. Self-report questionnaires related to psychological deficits and risk factors associated with suicide-related behavior were given to participants before and after the intervention. Descriptive and paired t tests were performed using SPSS 15.

RESULTS: This pilot study demonstrated that a 20-week group intervention led to significant pregroup and postgroup reductions in the risk factors associated with suicide-related behavior. Risk factors included cognitive factors: Beck Hopelessness Scale (P=.006), Satisfaction With Life Scale (P=.001), Problem Solving Inventory (P=.008); affective factors: Beck Depression Inventory (P=.018), Toronto Alexithymia Scale (P=.001); and impulsivity factors: Barratt Impulsivity Scale (P=.034).

CONCLUSIONS: Findings in this pilot study suggest that participants in this short-term intervention report changes in identified risk factors and psychological deficits. These modest changes may be an important first step that facilitates persons at high-risk for suicide to access additional mental health services.

KEYWORDS: recurrent suicide-related behavior, intervention, deficits, risk factors



In the United Kingdom, persons who have a history of suicide attempts are approximately 66 times more likely to die by suicide than those without previous attempts.1 In the United States, the estimated ratio of suicide to attempted suicide is 1:8 to 1:25, with a higher ratio for women and youth.2 Based on the World Health Organization (WHO) statistics for 2000, if 815,000 persons died by suicide, this could potentially mean 6 million suicide attempts worldwide.3 In the United States, for every suicide there are an estimated 5 hospitalizations and 22 emergency department visits for suicide-related behaviors.4 This suggests a large financial burden on the health care system, alongside the financial and emotional ramifications to individuals, families, and friends.

Difficulties understanding individuals with recurrent suicide attempts arise from the varying research approaches used to study this population. Studies have varied in their inclusion of patients who are acutely suicidal or who have substance abuse and other comorbidities.5-7 Personality traits may or may not be investigated, and some studies will focus on particular diagnoses, whereas others will investigate symptoms, with little or no focus on diagnoses.8-13 Finally, the definition of repeat suicide attempts or attempts with intent to die vs self-injury without intent to die is not always delineated.6,8,14,15

To date, effective treatments shown to reduce rates of recurrent suicide-related behavior include problem-solving interventions, dialectical behavior therapy, cognitive behavior therapy, home visits to actively address issues of noncompliance, and maintaining nondemanding contact with high-risk individuals.5,6 Although evidence supports the efficaciousness of some interventions in preventing recurrent suicide-related behavior, there is a lack of evidence for the effectiveness of psychosocial interventions following suicide-related behavior to prevent actual suicides.5,16-19 A recent review indicated that evidence is “emerging,” based on a limited number of high-quality studies, that restricting access to means, maintaining ongoing contact with suicidal persons, and providing specialist services hold promise for reducing rates of death by suicide. Cognitive behavior therapy for persons with a history of suicidal behavior and dialectical behavior therapy with persons with borderline personality disorder (BPD) were identified as promising for reducing future suicide-related behavior.

For the past 10 years, there has been a call for practical but comprehensive interventions that would target persons with recurrent suicide-related behavior.20-24 However, as suicidal behavior and suicide are still rare clinical outcome events, even among persons with recurrent suicide-related behavior, establishing treatment efficacy is challenging. Pitman20 suggested that research utilizing outcome measures that go beyond the outcome of suicide or suicide-related behavior might have more utility. She recommended that intermediate measures that reduce potential risk factors for suicide-related behavior, such as depression and hopelessness, could be used as feasible yet important proxy outcome measures.

This article reports on the results of a 20-week out-patient intervention, the Psychosocial/Psychoeducational Intervention for Persons with Recurrent Suicide Attempts (PISA), on risk factors and areas of deficit known to characterize persons with recurrent suicide-related behavior.25 For the purposes of this article, the nomenclature of Silverman et al15 will be used, with particular focus on suicide-related behavior, defined as “a self-inflicted, potentially injurious behavior for which there is evidence (either explicit or implicit) either that (a) the person wished to use the appearance of intending to kill himself/herself in order to attain some other end; or (b) the person intended at some undetermined or some known degree to kill himself/herself. Suicide-related behaviors can result in no injuries, injuries or death.”15 They further explain that suicide attempts are defined as “self-inflicted, potentially injurious behavior with a nonfatal outcome for which there is evidence (either explicit or implicit) of intent to die. A suicide attempt may result in no injuries, injuries or death.”15

Recurrent suicide-related behavior

Various comorbidities, psychological deficits, and potential risk factors have been identified as characteristic of persons with recurrent suicide-related behavior. Diagnostically, persons with recurrent suicide-related behavior are reported as having a variety of comorbidities that include combinations of depressive illness, substance abuse, BPD, and/or bipolar disorder.26-28 Women with bulimia nervosa and recurrent suicide-related behavior, when compared with those without suicide-related behavior, had greater lifetime comorbidity, including anxiety disorders, depression, and higher rates of alcohol dependence.27 Rudd et al30 reported that a childhood history of anxiety disorder or major depressive disorder predisposed a person to both later multiple suicide attempts and personality psychopathology; further, they noted that for women, exhibiting recurrent suicide attempts was a function of having childhood anxiety disorders, not mood disorders. Forman et al31 found that multiple suicide attempters vs single attempters had more severe psychopathology, suicidality, and interpersonal difficulties when assessed following presentation to the emergency department after an attempt. Taken together, these findings indicate that persons with recurrent suicide-related behavior are not characterized by one diagnosis, but more so by the magnitude and breadth of their psychopathology.

Alongside a complex combination of comorbidities, a variety of psychological deficits and potential risk factors have been identified in persons with recurrent suicide attempts. These include problem-solving deficits, cognitive rigidity, hopelessness, alexithymia, negative self-evaluation, and negative affectivity.8,32,33 Evidence has indicated that those who experience recurrent suicide-related behaviors and BPD suffer with instability and/or the following: deficits in emotion regulation, decreased levels of emotional awareness, difficulty in problem solving, or difficulties in managing interpersonal relationships.20,34-37 Current research suggests that neurobiological factors may also contribute to some of the identified deficits and/or psychological factors.38-40 Given these factors, we specifically chose variables that reflect potential personal risk factors or psychological deficits associated with recurrent suicide-related behavior that purportedly could be changeable as targets for our PISA intervention. The potential risk factors chosen were: affective (alexithymia because of its relationship to emotional awareness, depression), cognitive (hopelessness, life satisfaction, problem solving), and impulsivity.

A psychosocial/psychoeducational intervention for persons with recurrent suicide attempts

PISA is a 20-week psychosocial/psycheducational group intervention program developed for clients with a history of recurrent suicide attempts.25 (This article provides an outline of the intervention; for a more in-depth discussion, the reader is invited to refer to “A Description of a Psychosocial/Psychoeducational Intervention for Persons with Recurrent Suicide Attempts.”25)

The group intervention targets skills or coping strategies to lessen the potential risk factors or psychological deficits associated with recurrent suicide-related behavior. Clients have a lifetime history of 2 or more suicide attempts and are self-referred or referred after a suicide crisis from a variety of in-hospital or community resources. Participation in the group is based on the presence of recurrent suicide attempts as identified by the client and is not based on the presence of a particular psychiatric diagnosis. Clients with active psychotic disorders or a recent history of interpersonal violence are excluded from the program. Clients are expected to have an individual therapist in the community while participating in the group. There are no restrictions regarding whether or not clients participate in other treatment; eg, entering specific programs for eating disorders or substance abuse.

Clients meet in small groups of 8 to 10 at the hospital, once a week for 1.5 hours for 20 weeks. After attending the 20-week program, clients are presented with a certificate of completion and are offered the option of returning for a second 20-week cycle to help cement their newly acquired skills. The program has been manualized to guide the work of the group facilitators.

The group is cofacilitated by an interprofessional team and undergraduate, graduate, and postgraduate students from a range of disciplines, including social work, nursing, psychology, and psychiatry. Training for therapists is in situ experiential, with weekly peer supervision of all facilitators by the originator of the intervention and a senior clinician to maintain adherence to the intervention protocol.

When possible, there is also a peer facilitator on the team. The peer facilitator is someone who has completed 2 cycles of the group, is a year away from their last participation, and continues to be in individual therapy. The person must express an interest in peer facilitation and/or facilitators must identify the individual as a potentially strong peer facilitator. Every effort is made to have at least 2 different professions represented on the facilitation team as a way of in situ modeling different approaches to a similar issue.

The intervention program consists of 4 modules of skill development in the areas of identified deficits: emotional literacy, problem solving, crisis management, and interpersonal relationships. Each of the modules contains a number of subskills. All modules are based on the belief that clients have the capacity to keep themselves safer when they have the understanding and skills to do so. The responsibility to keep themselves as safe as possible emerges from becoming aware of feelings, having a name for them, and having choices in means and methods to keep themselves safer. For example, the module on emotional literacy includes education regarding the role and function of emotion; developing a language for emotion that is not behavior based; recognizing physical, behavioral, and cognitive early warning signs; developing a scale of intensity; recognizing the “umbrella of anger”; unwritten rules; and negative self-talk. The skills and concepts emerged over time through literature review, facilitator observation, therapist and client feedback, and client contributions to content. Resources included the Internet, client contributions, popular media, concept or skill handouts developed within a group, and self-help references in related areas, including posttraumatic stress disorder, substance abuse, BPD, and depression. The topics are interchangeable, and the order is meant to vary so that facilitators can address clients’ current needs. Marziali et al41 found that for any intervention to be successful, therapists need to be flexible, creative, and skillful, as the content of intervention alone may not be sufficient to ensure the success of the treatment.

The PISA intervention embodies the following principles:

  1. keeping oneself as safe as possible

  2. developing a language to communicate distress in a nonbehavioral manner

  3. recognizing that every behavior is a choice and every choice has an effect

  4. learning that “a feeling is a feeling, it just is,” removing the judgments of good or bad, expanding one’s emotional vocabulary, and developing choices on how one experiences feelings in a safer manner.

This pilot study specifically addressed whether measures of the cognitive, affective, and impulsivity risk factors for suicide-related behavior were significantly reduced after the PISA intervention in clients with recurrent suicide-related behavior, regardless of diagnosis.



A total of 239 clients participated in the groups (64 men and 175 women). Clients were either self-referred or referred by health care or community caregivers. All participants were assessed by Y.B. prior to participation in the group. The assessment interview includes social, employment, and education history; family, social, and professional supports; child welfare, forensic, and substance use or treatment histories; suicide and self-injury histories, including the intent and meanings of each; reasons cited for living; previous hospitalizations; previous and current diagnoses; and the client’s goals for participation.

The mean age at study entry was 36.2 years (SD=10.83), with the average age between men and women (38.3 vs 35.3 years) being significantly different (F=4.91; P ≤ .028). The mean age of onset of suicide-related ideation for the total group was 15.8 years (SD=9.04; range, 2 to 50 years), and the mean age of first recalled suicide-related behavior was 20.35 years (SD=9.93; range, 4 to 52 years). Two hundred (83.7%) participants were single, and 52 (21.8%) were employed either full- or part-time. Seventy-nine participants (33%) had less than a high school education, and 74 (30.9%) had completed university. Ninety-eight (41.0%) lived on their own with no support, and 75 (31.3 %) reported living with family or friends. The others lived in shelters, boarding homes, the street, group homes, or supportive housing units.

Diagnoses were recorded solely based on the clients’ self-report at study entry. Clients most often reported multiple psychiatric diagnoses (see TABLE 1). Depression (66.5%) and BPD (50.6%) were the most frequently self-reported diagnoses.

The study received ethics approval from St. Michael’s Hospital Research Ethics Board, and all participants provided signed informed consent. Participants were not financially compensated for participation in the program.


Participants’ self-reported diagnoses at intake

  Participants (N=239)
AXIS I No. (%)*
Depression 159 (66.5)
Bipolar disorder 70 (29.3)
Anxiety/panic 62 (25.9)
Posttraumatic stress disorder 47 (19.6)
Eating disorder 33 (13.8)
Obsessive compulsive disorder 18 (7.5)
Alcohol and/or drug dependence and/or abuse 14 (5.8)
Schizophrenia and/or abuse 13 (5.4)
Borderline personality disorder and/or abuse 121 (50.6)
Antisocial personality disorder and/or abuse 4 (1.6)
PD-NOS/other PD and/or abuse 23 (10.1)
Other and/or abuse 96 (38.4)
PD-NOS: Personality Disorder Not Otherwise Specified.
*Numbers do not total 239 because of multiple responses.

Since PISA is an evolving pilot project, measures were introduced over a 3-year period, beginning in 2000. As such, the number of subjects differed for each measure. Analysis involved pretesting and posttesting in the areas identified as deficits or risk factors for clients with recurrent suicide-related behavior: cognition, affect, and impulsivity. Participants were given the pregroup measures at the first session, and postgroup measures were given at the second-to-last session. All measures were completed by participants at home and returned the following week. Within the affective, cognitive, and impulsivity domains, the following measures were given.

Affective. The 20-item Toronto Alexithymia Scale (TAS-20) is a self-report questionnaire containing items that are rated on a 5-point Likert-type rating scale from 1 (strongly disagree) to 5 (strongly agree). Total possible scores range from 20 to 100. Of a possible score of 100, a score ≤51 is considered nonalexithymic; a score of 52 to 60 is considered moderately alexithymic; and a score ≥61 is considered highly alexithymic. This scale was chosen because the 3 subscales captured concepts relevant to identified deficits in emotional awareness: (1) difficulties identifying feelings, (2) difficulties describing feelings, and (3) externalization of emotion. The TAS-20 has been used in a variety of populations, including psychiatric outpatients, and previous evidence supports the convergent, discriminant, and concurrent validity of the TAS-20.42,43

The Beck Depression Inventory (BDI) is a 21-item self-report questionnaire that assesses different aspects of depressive symptomatology.44 The BDI has demonstrated excellent psychometric characteristics, with a split-half reliability of 0.93, and excellent convergent and predictive validity, eg, significantly predicting suicide ideation and eventual suicide.44,45

Cognitive. The Beck Hopelessness Scale (BHS) is a 20-item scale measuring negative attitudes about the future. The scale has been shown to have high internal consistency (Kuder-Richardson-20 coefficient alpha=0.93) and a relatively high correlation with clinical ratings of hopelessness (r=0.74) in a population of 294 hospitalized patients with recent suicide attempts.46

The self-administered 5-item Satisfaction With Life Scale (SWLS) refers to the self-identified cognitive-judgmental aspects of general life satisfaction. The SWLS has demonstrated acceptable reliability, with high internal consistency, and test-retest reliability over periods of 2 months (r=0.82) and 4 years (r=0.54)40 respectively. The SWLS has demonstrated convergent and discriminant validity, relating positively with other measures of well-being, relating negatively with measures of distress, and yielding no significant relationship with emotional intensity.47

The Problem Solving Inventory (PSI) is a 32-item self-report scale that captures the person’s perception of his or her own problem-solving behaviors and attitudes.48 Joiner et al49,50 reported test-retest reliabilities from their previous research; coefficient alphas for the total scale were 0.93, and for 3 factor subscales they ranged from 0.76 to 0.87.

Impulsivity. The Barratt Impulsivity Scale (BIS) has been classically used in the investigation of impulsive behavior and, in its present format (BIS-11), consists of 30 items divided into 3 subscales. It is useful to identify impulsivity and evaluate the influence of this dimension on client performance without the influence of confounding factors such as anxiety traits.51


Data were analyzed using SPSS 15.0 for Windows. The data are presented using descriptive statistics and paired sample t tests. Response rates for completion of pregroup and postgroup measures were as follows: TAS-20, 68.3%; BDI, 62%; BHS, 66.24%; BIS-11, 59.7%; SWLS, 62.4%; and PSI, 73.6%. Missing data were accounted for through individual mean imputation if >10% of the values for a single respondent were missing.52

As noted, pregroup and postgroup measures were completed as a portion of the full sample as follows: TAS-20, 77 of 144 (53.4%); SWLS, 69 of 136 (50.7%); BIS, 55 of 110 (50.0%); BDI, 48 of 95 (50.5%); BHS, 55 of 95 (57.8%); and PSI, 42 of 81(51.8%).


Nearly two-thirds (163 [68.2%]) of the participants “graduated” from the 20-week group intervention. Those who graduated had a mean attendance of 76.3% of the scheduled sessions (median, 80; mode, 90; range, 20 to 100). Of those who were early terminators, ie, those who did not complete the group to graduate, 10 re-enrolled in another group and completed the intervention at a later date. As such, their data were incorporated into the present analysis of completers. Reasons for early termination included: potential problems with readiness for the group (22.8%), extraneous health, treatment, and life issues (53.9%); and no reason given or lost to follow-up (23.7%).

Pregroup and postgroup measures and paired t test scores are presented in TABLES 2 To 4.


Preintervention and postintervention scores on cognitive measures

Measure Preintervention Score (SD) Postintervention Score (SD) P value
Problem Solving Inventory (N=42)
  Global mean score
134.09 (24.71) 120.99 (27.48) .008
  Problem-Solving Confidence subscale 45.47(10.51) 39.45 (11.54) .001
  Approach-Avoidance subscale 64.54 (12.14) 58.72 (13.80) .023
  Personal Control subscale 25.88 (3.50) 22.45 (5.48) .006
Beck Hopelessness Scale (N=55) 14.58 (3.90) 12.55 (5.07) .006
Satisfaction With Life Scale (N=69) 10.02 (5.07) 12.30 (7.26) .001


Preintervention and postintervention scores on behavioral measures

Measure Preintervention Score (SD) Postintervention Score (SD) P value
Barratt Impulsivity Scale (N=58)
  Global mean score
77.60 (13.38) 75.03 (10.96) .034
  Nonplanning subscale 30.00 (5.85) 29.83 (4.29) .769
  Motor Impulsivity subscale 26.77 (5.75) 25.44 (4.87) .023
  Attentional Impulsivity subscale 17.57 (3.74) 16.6 (3.61) .017


Preintervention and postintervention scores on affective measures

Measure Preintervention Score (SD) Postintervention Score (SD) P value
Toronto Alexithymia Scale (N=48)
  Global mean score
63.84 (13.46) 58.38 (13.81) .001
  Difficulties Describing Feelings subscale 24.81 (6.51) 23.27 (6.9) .024
  Difficulties Identifying Feelings subscale 18.17 (4.67) 16.77 (5.03) .006
  Externally Oriented Thinking subscale 20.97 (5.45) 18.67 (4.97) .001
Beck Depression Inventory (N=48) 37.30 (10.96) 32.83 (15.17) .018

The overall total and all subscales of the PSI changed significantly from the beginning to the end of the group intervention. This indicates that after 20 weeks, participants subjectively reported that their ability to solve problems became better in terms of problem-solving confidence, approach avoidance, and personal control.

Results of the BHS indicated significant reductions in hopelessness from pregroup to postgroup; however, hopelessness scores remained moderate (range, 9 to 14) from pregroup (M=15; range, 4 to 19) to postgroup (M=12.6; range, 1 to 19) for the total group.

Mean scores on the SLS increased significantly, from pregroup (10.02; range, 5 to 26) to postgroup (12.3; range, 5 to 35).


A significant difference (P=.034) was found in the BIS mean score, which dropped from 77.6 pregroup to 75.0 postgroup (SD=9.01). All subscales in the BIS-11, except the nonplanning subscale, were significantly reduced by the intervention.


The total and all subscales on the TAS-20 showed significant changes by the end of the intervention. The means scores significantly decreased from the pregroup mean of 63.8 (range, 24 to 90) to the postgroup mean of 58.3 (range, 24 to 83). Overall, this indicated a shift from high alexithymia (>60) to moderate alexithymia (range, 52 to 60).

The change in BDI mean scores pregroup (37.3; range, 13 to 40) to postgroup (32.83; range, 1 to 56) indicates a significant reduction in self-reported depression; however, the overall depression scores remained severe (range, 30 to 63).


The results from this pilot study suggested that, overall, for those who completed the 20-week PISA intervention, significant changes in the potential risk factors or deficit areas characteristic of persons with recurrent suicide-related behavior were demonstrated. Specifically, from pregroup to postgroup, the participants had significantly less depression and hopelessness, reported more general life satisfaction, perceived themselves as better problem solvers, and scored themselves lower on alexithymia. Despite these significant changes, the overall BDI and BHS scores remained in the severe and moderate range, which likely reflected the magnitude of psychopathology that persons with recurrent suicide-related behavior are observed to manifest.53 Given that the changes were observed within a 20-week period, it is difficult to know if clients continued to make further gains in the longer term. Huband et al,54 working with individuals with personality disorders, suggested that perhaps it is unrealistic for a 20-week intervention to produce significant and enduring changes for persons with longstanding conditions such as personality disorders. Therefore, the modest changes found in this pilot study were to be anticipated. The PISA intervention might be one of several possible steps toward further reduced risk of suicide in persons with recurrent suicide-related behavior.

The results of this pilot study indicate that persons who participated in the PISA intervention were successful in reducing specific deficits associated with recurrent suicide-related behavior. An earlier qualitative study of men age 18 and older with substance abuse, a history of suicide-related behavior, and severe personality disorders provided some evidence to suggest that participating in the PISA intervention was helpful. These men reported difficulties in accessing mental health services, often reporting negative experiences with mental health providers that resulted in their avoiding health care settings until a crisis arose.55 They identified a cyclical pattern of fragmented pathways into care, utilizing emergency services for mental health care, and often accessing the service under strained and involuntary circumstances. They reported that positive interactions—many mentioning the PISA intervention—created a sense of hope for the future and engendered a greater openness to other formal mental health or addiction treatment.55 The modest effects of this study suggest that PISA might be a first step in engaging persons with recurrent suicide-related behavior to seek ongoing treatment, such as dialectical behavior therapy or rehabilitation for substance disorders.

Another new finding from this pilot study suggests that the TAS-20 is a useful measure of the difficulties with emotional processing that are characteristic of individuals with recurrent suicide-related behavior, and that this measure is able to capture change following a time-limited intervention. The PISA intervention targets emotion-processing difficulties and focuses on teaching emotional literacy, identifying and describing how one is feeling, and learning alternatives to suicide-related behavior in response to emotional distress. Alongside subjective reports that problem solving was better, group participants also changed significantly in terms of their alexithymia scores. Our results showed that with a focus on teaching the language of emotion, alexithymia scores changed significantly. Of the group participants who completed the pregroup and postgroup questionnaires (N=69), 42 (60.9%) scored in the highly alexithymic range, and 27 (39.1%) scored in the moderate or nonalexithymic range at the start of the intervention. Postgroup, 30 (43.5%) scored in the high range, and 39 (56.5%) scored in the moderate or nonalexithymic range (chi square=12.28; df=1; P=.0005). Alexithymia has been associated with several pathologies that are linked to suicidal behavior, eg, BPD, disordered eating, childhood sexual abuse, panic disorder, and depression.56-58 It could be suggested that a person who is neither able to identify or describe his or her emotions might be more prone to acting out distress. Without a language, feelings overwhelm or flood cognitive functions. Izard59 suggested that in times of emotional flooding, emotion will be the driver taking a “low road,” or noncognitive move to action—a process that occurs within milliseconds. These results suggest that the TAS-20 is a useful measure to capture the emotional-processing deficits found in persons with recurrent suicide-related behavior and, more importantly, the measure may be sensitive to change that results from psychosocial interventions.

As a pilot study, several important limitations of this work need to be acknowledged. First, given limited resources, we were not able to systematically diagnose group participants, and this will be necessary in future research. Second, the sample size is limited and varies from one measure to another. Sample loss was affected by noncompletion of both pregroup and postgroup measures and the staggered introduction of the questionnaires. Failure of participants to respond to items within the measures was also a challenge, consistent with the use of self-report scales.52 Resource limitations hindered our ability to aggressively pursue data collection of those who did not return measures at the last session of their group. A future controlled trial would assist in addressing the issues of missing data, limited measures, lack of a control group, and lack of outcome data on suicide-related behavior. Finally, if the PISA intervention is to go beyond demonstrating change in the potential risk factors for suicide-related behavior, further research will need to focus on demonstrating the efficacy of PISA in reducing the rate of future suicide-related behavior and indicating that PISA can enhance compliance with longer-term treatment.


This pilot study demonstrated that a 20-week group intervention led to significant reductions in the cognitive, affective, and impulsivity deficits and potential risk factors associated with suicide-related behavior. The findings suggest that this short-term intervention may be an important first step in engaging the client to seek longer-term help for problems associated with a high risk for suicide. From the current study, the TAS-20 appears to be a promising outcome measure of emotional-processing difficulties and is sensitive to change. Future research will include systematic evaluation of the intervention, including formal diagnostic evaluation, longer-term follow-up, and measuring suicide-related behavior as an outcome.

DISCLOSURES: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

ACKNOWLEDGEMENTS: The authors thank Dr. Anne Rhodes for her insightful comments in the preparation of this manuscript.


  1. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Brit J Psychiatry. 2003;182:537–542.
  2.  National Institute of Mental Health. HealthyPlace. Suicide facts. http://www.healthyplace.com/communities/depression/nimh/suicide_statistics.htm. Accessed November 8, 2008.
  3.  World Health Organization. Facts: self-directed violence. 2002. http://www.who.int/violence_injury_prevention/violence/world_report/factsheets/en/selfdirectedviolfacts.pdf.
  4.  Substance Abuse and Mental Health Services Administration. National Mental Health Information Center. National strategy for suicide prevention: Goals and objectives for action. http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3517/ch7.asp. Accessed November 8, 2008.
  5. Comtois KA. A review of interventions to reduce the prevalence of parasuicide. Psychiatr Serv. 2002;53:1138–1144.
  6. Leitner M, Barr W, Hobby L. Effectiveness of interventions to prevent suicide and suicidal behaviour: a systematic review. Health & Community Care Research Unit, Liverpool University. InfoTech UK Research. Scottish Government Social Research. January 11, 2008. http://www.scotland.gov.uk/Publications/2008/01/15102257/0. Accessed February 21, 2008.
  7. Brown GK, Have TT, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294:563–570.
  8. Marzuk PM, Hartwell N, Leon AC, et al. Executive functioning in depressed patients with suicidal ideation. Acta Psychiatr Scand. 2005;112:294–301.
  9. Links PS, Eynan R, Heisel MJ, et al. Affective instability and suicidal ideation and behavior in patients with borderline personality disorder. J Personal Disord. 2007;21:72–86.
  10. McMain S. Effectiveness of psychosocial treatments on suicidality in personality disorders. Can J Psychiatry. 2007;52(6 supp 1):103S–114S.
  11. Davidson K, Norrie J, Tyrer P, et al. The effectiveness of cognitive behavior therapy for borderline personality disorder: Results from the Borderline Personality Disorder Study of Cognitive Therapy (BOSCOT) Trial. J Personal Disord. 2006;20:450–465.
  12. Blum N, St John D, Pfohl B, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008;165:468–478.
  13. Warman DB, Forman EM, Henriques GR, et al. Suicidality and psychosis: Beyond depression and hopelessness. Suicide Life Threat Behav. 2004;34:77–86.
  14. Silverman MM, Berman AL, Sanddal ND, et al. Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part 1: Background, rationale, and methodology. Suicide Life Threat Behav. 2007;37:248–263.
  15. Silverman MM, Berman AL, Sanddal ND, et al. Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part 2: Suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav. 2007;37:264–277.
  16. Macgowan MJ. Psychosocial treatment of youth suicide: A systematic review of the research. Res Soc Work Pract. 2004;14:147–162.
  17. Crawford MJ, Thomas O, Khan N, et al. Psychosocial and pharmacological interventions following deliberate self harm: Systematic review of their efficacy in preventing subsequent suicide. Br J Psychiatry. 2007;190:11–17.
  18. Links PS, Bergmans Y, Cook M. Psychotherapeutic interventions to prevent repeated suicidal behavior. Brief Treat Crisis Interv. 2003;3:445–464.
  19. Linehan MM. Cognitive behavioral treatment of borderline personality disorder. New York, NY: Guilford Press; 1993.
  20. Pitman A. Policy on the prevention of suicidal behaviour; one treatment for all may be an unrealistic expectation. J R Soc Med. 2007;100:461–464.
  21. Leenaars AA. Psychotherapy with suicidal people: The commonalities. Arch Suicide Res. 2006;10:305–322.
  22. Livesley WJ. A practical approach to the treatment of patients with borderline personality disorder. Psychiatr Clin North Am. 2000;23:211–232.
  23. Links PS. Developing effective services for patients with personality disorders. Can J Psychiatry. 1998;43:251–259.
  24. Hawton K, Kirk J. Problem-solving. In: Hawton K, Salkovskis PM, Kirk J, et al, eds. Cognitive behaviour therapy for psychiatric problems: A practical guide. New York, NY: Oxford Medical Publications; 1998:406-426.
  25. Bergmans Y, Links PS. A description of a psychosocial/psychoeducational intervention for persons with recurrent suicide attempts. Crisis. 2002;23:156–160.
  26. Horesh N, Orbach I, Gothelf D, et al. A comparison of the suicidal behavior of adolescent inpatients with borderline personality disorder and major depression. J Nerv Ment Dis. 2003;191:582–588.
  27. Ystgaard M, Hestetun I, Loeb M, et al. Is there a specific relationship between childhood sexual and physical abuse and repeated suicidal behavior? Child Abuse Negl. 2004;28:863–875.
  28. Michaelis BH, Goldberg JF, Singer TM, et al. Characteristics of first suicide attempts in single versus multiple suicide attempters with bipolar disorder. Comp Psychiatry. 2003;44:15–20.
  29. Anderson C, Barter FA, McIntosh VV, et al. Self-harm and suicide attempts in individuals with bulimia nervosa. Eat Disord. 2002;10:227–243.
  30. Rudd MD, Joiner TE Jr, Rumzek H. Childhood diagnoses and later risk for multiple suicide attempts. Suicide Life Threat Behav. 2004;34:113–125.
  31. Forman EM, Berk MS, Henriques GR, et al. History of multiple suicide attempts as a behavioral marker of severe psychopathology. Am J Psychiatry. 2004;161:437–443.
  32. Pruessner JC, Baldwin MW, Dedovic K, et al. Self-esteem, locus of control, hippocampal volume, and cortisol regulation in young and old adulthood. Neuroimage. 2005;28:815–826.
  33. Williams JM, Barnhofer T, Crane C, et al. Problem solving deteriorates following mood challenge in formerly depressed patients with a history of suicidal ideation. J Abnorm Psychol. 2005;114:421–431.
  34. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48:1060–1064.
  35. Deiter PJ, Nicholls SS, Pearlman LA. Self-injury and self capacities: Assisting an individual in crisis. J Clin Psychol. 2000;56:1173–1191.
  36. Levine D, Marziali E, Hood J. Emotion processing in borderline personality disorders. J Nerv Ment Dis. 1997;185:240–246.
  37. Kern RS, Kuehnel TG, Teuber J, et al. Multimodal cognitive-behavior therapy for borderline personality disorder with self-injurious behavior. Psychiatr Serv. 1997;48:1131–1133.
  38. Bostwick JM. The stress axis gone awry: a possible neuroendocrine explanation for increased risk of completed suicide. Prim Psychiatry. 2005;12:49–52.
  39. van Heeringen K. The neurobiology of suicide and suicidality. Can J Psychiatry. 2003;48:292–300.
  40. LeGris J, van Reekum R. The neuropsychological correlates of borderline personality disorder and suicidal behaviour. Can J Psychiatry. 2006;51:131–142.
  41. Marziali E, Munroe-Blum H, McCleary L. The contribution of group cohesion and group alliance to the outcome of group psychotherapy. Int J Group Psychother. 1997;47:475–497.
  42. Taylor GJ, Bagby RM, Ryan DP, et al. Validation of the alexithymia construct: A measurement-based approach. Can J Psychiatry. 1990;35:260–267.
  43. Bagby RM, Parker JD, Taylor GJ. The Twenty-Item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. J Psychosom Res. 1994;38:23–32.
  44. Beck AT, Ward CH, Mendelsohn M, et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–571.
  45. Beck AT, Steer RA, Kovacs M, et al. Hopelessness and eventual suicide: A 10 year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry. 1985;142:559–563.
  46. Beck AT, Weissman A, Lester D, et al. The measurement of pessimism: The hopelessness scale. J Consult Clin Psychol. 1974;42:861–865.
  47. Pavot W, Diener E. Review of the Satisfaction with Life Scale. Psychol Assess. 1993;5:164–172.
  48. Heppner PP, Petersen CH. The development and implications of a personal problem solving inventory. J Couns Psychol. 1982;29:66–75.
  49. Joiner Jr, Pettit JW, Perez M, et al. Can positive emotion influence problem-solving attitudes among suicidal adults? Prof Psychol Res Pr. 2001;32:507–512.
  50. Rudd MD, Rajab MH, Orman DT, et al. Effectiveness of an outpatient intervention targeting suicidal young adults: preliminary results. J Consult Clin Psychol. 1996;64:179–190.
  51. Barratt ES, Stanford MS, Kent MA, et al. Neuropsychological and cognitive psychophysiological substrates of impulsive aggression. Biol Psychiatry. 1997;41:1045–1061.
  52. Shrive FM, Stuart H, Quan H, et al. Dealing with missing data in a multi-question depression scale: a comparison of imputation methods. BMC Med Res Methodol. 2006;6:57.
  53. Rudd MD, Joiner TE Jr, Rajab MH. Relationships among suicide ideators, attempters and multiple attempters in a young-adult sample. J Abnorm Psychol. 1996;105:541–550.
  54. Huband N, Mcmurran M, Evans C, et al. Social problem-solving plus psychoeducation for adults with personality disorder: Pragmatic randomised controlled trial. Br J Psychiatry. 2007;190:307–313.
  55. Strike C, Rhodes AE, Bergmans Y, et al. Fragmented pathways to care: The experiences of suicidal men. Crisis. 2006;27:31–38.
  56. Modestin J, Furrer R, Malti T. Different traumatic experiences are associated with different pathologies. Psychiatr Q. 2005;76:19–32.
  57. Hund AR, Espelage DL. Childhood sexual abuse, disordered eating, alexithymia, and general distress: a mediation model. J Couns Psychol. 2005;52:559–573.
  58. Iancu I, Dannon P, Poreh A, et al. Alexithymia and suicidality in panic disorder. Compr Psychiatry. 2001;42:466–481.
  59. Izard CE. Translating emotion theory and research into preventive interventions. Psychol Bull. 2002;128:796–824.

CORRESPONDENCE: Yvonne Bergmans, MSW, RSW, 30 Bond Street, 2 Shuter Wing 2-010C, Toronto, Ontario, Canada M5B 1W8. E-MAIL: BERGMANSY@smh.toronto.on.ca