Katherine Anne Comtois, PhD, MPH
Department of Psychiatry and Behavioral Sciences, University of Washington
Sara J. Landes, PhD
Department of Psychiatry, University of Arkansas for Medical Sciences, and Central Arkansas Veterans Healthcare System
When suicidality arises in therapy, there are two paths to follow: management of suicide risk and treatment of controlling variables to resolve the suicidality. Management includes the steps one takes to minimize the acute risk of suicide and self-harm, including the management of lethal means, development of a safety plan, and generation of hope. Though the management of risk is important, therapists often mistake it for suicide prevention treatment. Treatment is a collaborative and often reasonably long-term process between therapist and client to change the controlling variables for suicide, self-harm, and the factors that make life not worth living, such as pain, isolation, or lack of meaning.
This confusion between the management and treatment of suicidality often arises because therapists see suicide and self-harm only as symptoms of or tangents from the disorder or problem they are treating. They expect that suicidality will resolve as the disorder or problem resolves, and that it does not require treatment per se.
A more powerful alternative is to target suicidality directly with both management and treatment. This method may help resolve immediate symptoms/problems, and those that persist after suicidality has been resolved can be targeted without concern that the client might attempt or die by suicide before they are resolved.
The principles and guidelines in this chapter are based on principles and protocols of dialectical behavior therapy (DBT; Linehan, 1993, 2015a, 2015b) and the Linehan Risk Assessment and Management Protocol, or LRAMP, formerly the University of Washington Risk Assessment and Management Protocol, or UWRAMP (Linehan, Comtois, & Ward-Ciesielski, 2012; Linehan Institute, Behavioral Tech, n.d.; Linehan, 2014). This brief chapter is meant to provide general guidance for the behavioral management and treatment of suicidality, but additional formal training in DBT and LRAMP methods is recommended.
Managing suicide risk includes a number of tasks: suicide risk assessment, suicide risk decision making, safety or crisis response planning, and means safety. Each of these are described in detail below.
Suicide risk management starts with coming to a shared understanding with clients of what led to past suicidal behavior and current suicidal thinking. The target includes their behavior and that of others, as well as the emotions, cognitions, bodily sensations, and urges associated with suicidality. It can be useful to gather data using an assessment, such as the Scale for Suicidal Ideation (Beck, Brown, & Steer, 1997; Beck, Kovacs, & Weissman, 1979) in the interview or questionnaire form. This measure rates key areas, including desire for life and death, history of attempts, fear of death and other barriers to suicide, as well as efforts to prepare for suicide, and it has been shown to predict death by suicide among mental health outpatients (Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999). The assessment can be administered both for current suicidal ideation as well as for ideation at its worst point, the latter being a stronger predictor of subsequent suicide (Beck et al., 1999).
It is critical to gather a history of all suicide attempts and nonsuicidal self-injuries (NSSI). Two measures can be considered. The Suicide Attempt Self-Injury interview (SASII; Linehan, Comtois, Brown, Heard, & Wagner, 2006) is a structured interview that is essentially a functional analysis reformulated as a series of questions about the method, precipitants, consequences, and functions of self-injury. The Lifetime Suicide Attempt Self-Injury Count (L-SASI; Comtois & Linehan, 1999; Linehan & Comtois, 1996), a briefer version of the SASII, examines the range of suicidal behavior over a lifetime (or a recent time period) using the SASII rating scales. The L-SASI is an efficient initial assessment that can be completed in three to twenty minutes (depending on the number of suicidal behaviors). It begins with a few questions about the first, most recent, and most severe self-injuries and then efficiently gathers a total count of suicide attempts and NSSI by method, lethality, and medical treatment. A combination of the L-SASI with a full SASII on the most recent and worst suicide attempts provides a comprehensive history of behavior on which to base management decisions.
In addition to gathering history, it is important to observe any patterns of which the client may be unaware. The client’s environment may operantly reinforce suicidality, NSSI, or suicide communications. For instance, parents may have a large reaction and/or provide needed help when their adolescent harms herself, but when the adolescent is not self-harming the parents may orient their attention elsewhere. They may overlook or even punish attempts to ask for help and fail to attend to their adolescent until suicidal communications or actions occur. Thus, there is limited reinforcement for adaptive behavior, punishment for normative expressions of pain and requests for help, and reinforcement of suicidal behaviors. Another example is a client who functions at a high level until he feels overwhelmed and then attempts suicide. The spouse was likely unaware of the ways in which her husband felt himself a burden or needed assistance (as is often the case in situations like this) until after the suicidal behavior occurred. Attempts to then provide support or to remove overwhelming tasks are inadvertently timed with suicidal behavior, so they reinforce it in the future. These patterns generally develop without the conscious intent of the client or others—a fact that needs to be clear to the client and others. However, to prevent suicide it is equally critical that these contingencies are not ignored or missed, but rather that they are understood and changed.
Once the risk and protective factors are known, the next step is to determine the level of risk and the immediate treatment response. Clear empirical support suggests that outpatient psychosocial treatments are the most efficacious at reducing suicide ideation, attempts, and deaths (Brown & Green, 2014; Comtois & Linehan, 2006; Hawton et al., 2000). Rigorous studies have not been conducted comparing inpatient with outpatient mental health treatment. Only a single randomized controlled study of inpatient hospitalization has been conducted (Waterhouse & Platt, 1990), and it did not find a difference in subsequent suicide attempts. However, the study was flawed in that only those at low risk of suicide were included and the inpatient intervention was minimal. Thus, there is little empirical evidence on which to base clinical decision making regarding hospitalization. Predicting individual risk is essentially impossible given the low base rate of suicide attempts and suicide.
Evidence-based treatments for suicidality recommend basing clinical decision making regarding suicide risk on not only epidemiological risk and protective factors but also the controlling variables for the individual’s suicide risk and his or her commitment to an outpatient treatment plan. Those at high and imminent risk of suicide who are willing and able to take action to reduce their immediate risk in the short term may be managed in an outpatient setting, whereas individuals at lower risk but who are uninterested in or unable to engage in outpatient treatment may require referral to emergency or inpatient services. Knowledge of the controlling variables for suicidal behavior is therefore key to decision making. For each controlling variable, it is critical to evaluate the individual’s capacity and motivation for change. If individuals are capable of changing the controlling variable themselves or with the help of family, other support, or social services, then outpatient treatment is more feasible. This ability to change controlling variables is why the teaching of skills and coping strategies is central to behavioral psychotherapies that work with suicidal individuals. However, capability without the motivation to change is of limited value. Based on the assessment of an individual’s capability and commitment to change and sense of what constitutes a life worth living, the clinician and client can determine what the initial treatment response should be.
There is no formula that can tell a clinician whether a particular client will make a suicide attempt if treated in an outpatient setting. This is a matter of clinical judgment that is based on the best-quality assessment possible. Therapists benefit most from making these decisions in consultation with a clinical team or, at a minimum, a colleague familiar with the client. What clinicians, family, and friends need most when a client commits suicide is the conviction that the clinicians working with the client did all they could (for management guidance for this situation, see Sung, 2016). The clinician best achieves this conviction by consulting with others when making decisions, laying out the controlling variables and assessment of the client’s ability and commitment to change so others can offer their perspective, asking further assessment questions, and concuring with or helping edit the treatment plan. This thinking is then documented in the medical record. The risk of negligence (i.e., the basis of legal action against the therapist) is reduced when the decision-making process is clear and multiple clinicians concur on the plan, both of which increase the confidence of all concerned and buffer the self-doubt and/or blame that can follow a suicide.
It may seem that going through the effort to have a plan thoroughly evaluated will prevent its development, but the opposite is the case. Behavioral principles apply to the clinician as much as the client, and the future review of the clinical record, let alone suicide attempt or death by suicide, is too rare of an event to function directly as a consequence. A sense of relief or reassurance can be a powerful reinforcer, but a plan will function as a reinforcer only if it has been thoroughly evaluated and confirmed by those who might review it—such as the malpractice insurer, attorney, risk management office of a particular agency, organizational leadership, suicide prevention expert, and so forth—in the case of a negative outcome. Taking the time to develop the plan and paperwork and have them reviewed and endorsed by the relevant players can go a long way toward offering the clinician reassurance and relief, which increases the likelihood that this consultation and paperwork will be done for all subsequent clients. If the plan survives a negative outcome, and the result is what the plan is designed for and is not traumatizing for the clinician, the relief the clinician will feel for having followed the plan also increases.
Simultaneously, the aversiveness of completing extra paperwork must be addressed. If guidelines or a plan are put in place that are burdensome, especially for a rare outcome like suicidal behavior, the clinician will inevitably be reinforced for avoiding or minimizing it. Developing templates—either paper forms or those maintained in electronic health records—is a strategy that can improve the quality of documentation and the likelihood that a clinician will complete it correctly. Examples include the Suicide Status Form (Jobes, 2006; Jobes, Kahn-Greene, Greene, & Goeke-Morey, 2009), the Linehan Suicide Safety Net (Linehan et al., 2012; Linehan Institute, Behavioral Tech, n.d.), therapeutic risk management (Homaifar, Matarazzo, & Wortzel, 2013; Wortzel, Matarazzo, & Homaifar, 2013), and the Department of Veterans Affairs’ electronic health record templates for suicide risk assessment and safety plans. Templates have a number of advantages. For example, they contain prompts for all key content areas (e.g., suicide risk or protective factors), so the clinician does not need to be concerned about missing important components. Furthermore, many items involved in suicide decision making are fairly standard and lend themselves to templates, allowing clinicians to select from prepared text options (e.g., “Conducted assessment of risk and protective factors,” “Completed safety plan with client,” etc.) or combinations of prepared text and fields for open text (e.g., “Considered both hospitalization and continuing the outpatient treatment plan and decided not to hospitalize because…” or “Risk and protective factors remain the same as at the last assessment except…”). These options spare clinicians from substantial typing while also conveying a lot of information.
Making a public commitment to life can be therapeutic (Rudd, Mandrusiak, & Joiner Jr., 2006), and clients can do this without having to make a contractual promise not to harm themselves. A safety or crisis response plan is a more effective and useful method. These plans include two components: what the individuals can do themselves and how to effectively reach out for help. For example, in the safety plan developed by Greg Brown, Barbara Stanley, and colleagues (Kayman, Goldstein, Dixon, & Goodman, 2015; B. Stanley et al., 2015), the clinician and client identify (a) warning signs that suicidality may reappear so action can be taken at the earliest point, (b) coping strategies the individual can use, and (c) people and places the client can utilize for distraction until the suicidal moment passes. These strategies are designed to promote action on the part of clients and teach them how to self-manage their suicidality. The safety plan also includes social support the client can call on for help, including professional help.
For several reasons clinicians should strongly consider having suicidal individuals use crisis lines instead of the emergency room (ER). First, unless the ER has a psychiatric emergency service or mental health expert on call, its medical/surgical staff has less suicide prevention expertise than mental health clinicians and may have little to offer beyond temporarily securing the patient. A combination of volunteers and supervisors staff crisis lines, and assessing and responding to suicidal risk is their area of expertise. Crisis lines affiliated with the National Suicide Prevention Lifeline, funded by the Substance Abuse and Mental Health Services Administration, have specific standards and regular evaluations to ensure they use evidence-based suicide care (e.g., Gould et al., 2016; Gould, Munfakh, Kleinman, & Lake, 2012; Joiner et al., 2007). Second, a visit to the ER is both time consuming and expensive for the client and often involves coercive means, such as physical or chemical restraint, that may be distressing or traumatic. A crisis line is free and results in immediate help without coercive means. The crisis line has relationships with police and emergency services, so if its risk assessment indicates an immediate rescue is needed—voluntary or involuntary—it can ensure this is done swiftly and efficiently. Third, referring clients to the ER can have iatrogenic consequences. For example, the client may think the referral means the therapist is unable to help her, or the client may even view it as abandonment. Unless the therapist is indeed unable to help, referral to the ER should be avoided.
Crisis lines can also provide ongoing support to clients that supplements the therapist’s availability. This support reduces the amount of time the therapist must spend working with an acutely suicidal client, as well as the emotional demands, freeing up time and emotional energy for psychotherapy sessions and for out-of-session contact the therapist provides within his or her personal and professional limits. This, in turn, helps the therapist stay with a client who becomes suicidal until the suicidality can be treated and resolved. Thus, an intervention such as a crisis line that provides additional support to suicidal individuals and allows them to remain with their therapist is ideal.
A safety plan also includes a strategy for means safety, formerly termed means restriction, which has been abandoned due to its negative, counterproductive connotation (Anglemyer, Horvath, & Rutherford, 2014; I. H. Stanley, Hom, Rogers, Anestis, & Joiner, 2016; Yip et al., 2012). In outpatient psychosocial treatment, it is critically important for clients to make their environment free of the means for them to impulsively take their life. There are several guidelines for means safety that clinicians can consult to facilitate this discussion with clients (Harvard T. H. Chan School of Public Health, n.d.; Suicide Prevention Resource Center, n.d.). Removing access to lethal means is the ideal scenario. However, when the client is unwilling or reluctant to do so, the clinician faces the dilemma of whether to move assertively to reduce the client’s access to means and risk losing access to the client (e.g., the client leaves treatment or lies to the clinician).
As with suicide decision making in general, there is no rule to follow when making decisions about means safety. Again, the most effective strategy is to find consensus with other clinicians, who consider alternatives and agree that the therapist’s strategy is the most effective given the limitations of the situation. The clinician should collaborate with the client in session to make an initial decision. Except in rare cases of imminent risk, there is ample opportunity in the hours and days following the session to consult with other clinicians and, if it’s recommended, change the plan either by calling the client or as part of a subsequent session. Whatever decisions are made, the decision making and who is consulted should be clear in the medical record. In the case of a tragic outcome, the ability to review documentation that shows the thinking and information available at the time is critical, both for the therapist—in order to feel reassured about his work with the client—and others reviewing the records.
There are two primary behavioral interventions for suicidal behavior with replicated randomized trials: DBT (Linehan, 1993; Linehan, Comtois, Murray et al., 2006; Stoffers et al., 2012) and cognitive behavioral therapy (CBT) for suicide prevention (Brown et al., 2005; Rudd et al., 2015; Wenzel, Brown, & Beck, 2009). Both interventions have several common areas that clinicians can bring to their work: a focus on suicide rather than diagnosis; a focus on active engagement and retention in treatment; a functional assessment of the precipitants and controlling variables of suicidal behavior; problem solving; an active and directive stance toward helping clients develop alternative ways of thinking and behaving during periods of acute emotional distress instead of engaging in suicidal behavior; and generating hope for the future.
The first commonality is a focus on suicide as the primary target of treatment. This means that while depression, substance use, or other diagnoses are addressed in treatment, suicidality is not considered a symptom or a complication of the diagnosis that will necessarily be resolved as the diagnostic condition improves. Instead, it is considered not only an independent issue but a primary issue of treatment that remains the focus until it resolves.
Making treatment about preventing suicide and resolving a client’s desire to die requires the client to be engaged and committed to this target as well. Engaging the client is therefore also a focus. Both DBT and CBT have explicit strategies for engaging the client in treatment, preventing dropout, and troubleshooting and overcoming barriers to care. The DBT framework prioritizes clients taking action for themselves, whereas CBT includes an active case-management arm; however, both anticipate clients having problems attending treatment and view the responsibility to remain in treatment as shared between therapist and client. DBT also includes well-defined, active commitment strategies for linking treatment to the client’s goals as well as to preventing suicide. CBT enhances commitment by providing clients the opportunity to share their suicide narrative, with active validation from the therapist, as well as through psychoeducation.
A core element of behavioral interventions for suicide prevention is a functional assessment of suicidal thinking and behavior to determine the controlling variables, as discussed in detail above. The goal is to have an idiographic understanding that will lead to idiographic solutions. Once problems are identified, problem solving is a prominent therapy strategy to resolve controlling variables that are solvable. Simultaneously, the therapist teaches strategies for tolerating what cannot be solved or for coping until problems are solved. The goal is to collaborate with clients to find the most effective solutions for the problems that drive suicidal thinking and to get them to practice those solutions—even when emotions are high and perspective is limited, as is the case in moments of suicide risk.
Finally, a critical aspect of therapy for suicide prevention is creating a vision of and hope for the future. This will guide the person toward a life worth living instead of suicide and will obviate the need for suicidal coping. A central tenet of DBT treatment is to achieve a life worth living and of sufficient quality so that suicide is no longer an issue. In this way, DBT is a longer treatment. Suicidal coping is generally replaced by skillful coping in the first one to four months of DBT, which is typical of CBT and other behavioral interventions. The rest of therapy (six months, one year, or longer) focuses on resolving quality of life–interfering behaviors that prevent the client from achieving a life worth living. Therapy-interfering behavior—which is addressed early on and throughout treatment to increase a client’s skillful engagement in therapy and prevent dropout—falls between the primary target of suicidal and crisis behavior and the target of quality of life.
By contrast, CBT approaches to suicidality are much briefer—sixteen sessions or fewer—with a focus on resolving the suicidal coping and preventing relapse. Clients can pursue further therapy elsewhere for general quality of life. Thus, in these shorter therapies, the focus is on hope rather than achieving a life worth living. A key strategy in CBT is the “hope kit,” a box or other container that holds items and mementos, such as photographs and letters, that serve as reminders of reasons to live. The hope kit serves as a powerful and personal reminder of a client’s connection to life that can be used when suicidal feelings arise. Clients often find the process of constructing a hope kit very rewarding, as it leads them to discover or rediscover reasons to live.
Anglemyer, A., Horvath, T., & Rutherford, G. (2014). The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine, 160(2), 101–110.
Beck, A. T., Brown, G. K., & Steer, R. A. (1997). Psychometric characteristics of the Scale for Suicide Ideation with psychiatric outpatients. Behaviour Research and Therapy, 35(11), 1039–1046.
Beck, A. T., Brown, G. K., Steer, R. A., Dahlsgaard, K. K., & Grisham, J. R. (1999). Suicide ideation at its worst point: A predictor of eventual suicide in psychiatric outpatients. Suicide and Life-Threatening Behavior, 29(1), 1–9.
Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The Scale for Suicide Ideation. Journal of Consulting and Clinical Psychology, 47(2), 343–352.
Brown, G. K., & Green, K. L. (2014). A review of evidence-based follow-up care for suicide prevention: Where do we go from here? American Journal of Preventive Medicine, 47(3, Supplement 2), S209–S215.
Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA, 294(5), 563–570.
Comtois, K. A., & Linehan, M. M. (1999). Lifetime parasuicide count: Description and psychometrics. Paper presented at the 9th Annual Conference of the American Association of Suicidology, Houston, TX.
Comtois, K. A., & Linehan, M. M. (2006). Psychosocial treatments of suicidal behaviors: A practice-friendly review. Journal of Clinical Psychology, 62(2), 161–170.
Gould, M. S., Lake, A. M., Munfakh, J. L., Galfalvy, H., Kleinman, M., Williams, C., et al. (2016). Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: Evaluation of caller risk profiles and interventions implemented. Suicide and Life-Threatening Behavior, 46(2), 172–190.
Gould, M. S., Munfakh, J. L. H., Kleinman, M., & Lake, A. M. (2012). National Suicide Prevention Lifeline: Enhancing mental health care for suicidal individuals and other people in crisis. Suicide and Life-Threatening Behavior, 42(1), 22–35.
Harvard T. H. Chan School of Public Health. (n.d.). Lethal means counseling. https://www.hsph.harvard.edu/means-matter/lethal-means-counseling/.
Hawton, K., Townsend, E., Arensman, E., Gunnell, D., Hazell, P., House, A., et al. (2000). Psychosocial versus pharmacological treatments for deliberate self harm. Cochrane Database of Systematic Reviews, 2(CD001764).
Homaifar, B., Matarazzo, B., & Wortzel, H. S. (2013). Therapeutic risk management of the suicidal patient: Augmenting clinical suicide risk assessment with structured instruments. Journal of Psychiatric Practice, 19(5), 406–409.
Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York: Guilford Press.
Jobes, D. A., Kahn-Greene, E., Greene, J. A., & Goeke-Morey, M. (2009). Clinical improvements of suicidal outpatients: Examining Suicide Status Form responses as predictors and moderators. Archives of Suicide Research, 13(2), 147–159.
Joiner, T., Kalafat, J., Draper, J., Stokes, H., Knudson, M., Berman, A. L., et al. (2007). Establishing standards for the assessment of suicide risk among callers to the National Suicide Prevention Lifeline. Suicide and Life-Threatening Behavior, 37(3), 353–365.
Kayman, D. J., Goldstein, M. F., Dixon, L., & Goodman, M. (2015). Perspectives of suicidal veterans on safety planning: Findings from a pilot study. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 36(5), 371–383.
Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.
Linehan, M. M. (2014). Linehan Risk Assessment and Management Protocol (LRAMP). Seattle: Behavioral Research and Therapy Clinics. Retrieved from http://blogs.uw.edu/brtc/files/2014/01/SSN-LRAMP-updated-9–19_2013.pdf.
Linehan, M. M. (2015a). DBT skills training handouts and worksheets (2nd ed.). New York: Guilford Press.
Linehan, M. M. (2015b). DBT skills training manual (2nd ed.). New York: Guilford Press.
Linehan, M. M., & Comtois, K. A. (1996). Lifetime Suicide Attempt and Self-Injury Count (L-SASI). (Formerly Lifetime Parasuicide History, SASI-Count). Seattle: University of Washington. Retrieved from http://depts.washington.edu/uwbrtc/resources/assessment-instruments/.
Linehan, M. M., Comtois, K. A., Brown, M. Z., Heard, H. L., & Wagner, A. (2006). Suicide Attempt Self-Injury Interview (SASII): Development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury. Psychological Assessment, 18(3), 303–312.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766.
Linehan, M. M., Comtois, K. A., & Ward-Ciesielski, E. F. (2012). Assessing and managing risk with suicidal individuals. Cognitive and Behavioral Practice, 19(2), 218–232.
Linehan Institute, Behavioral Tech (n.d.). Linehan Suicide Safety Net. Retrieved from http://behavioraltech.org/products/lssn.cfm.
Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., et al. (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.
Rudd, M. D., Mandrusiak, M., & Joiner Jr., T. E. (2006). The case against no-suicide contracts: The commitment to treatment statement as a practice alternative. Journal of Clinical Psychology, 62(2), 243–251.
Stanley, B., Brown, G. K., Currier, G. W., Lyons, C., Chesin, M., & Knox, K. L. (2015). Brief intervention and follow-up for suicidal patients with repeat emergency department visits enhances treatment engagement. American Journal of Public Health, 105(8), 1570–1572.
Stanley, I. H., Hom, M. A., Rogers, M. L., Anestis, M. D., & Joiner, T. E. (2016). Discussing firearm ownership and access as part of suicide risk assessment and prevention: “Means safety” versus “means restriction.” Archives of Suicide Research, 13, 1–17.
Stoffers, J. M., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 8(CD005652).
Suicide Prevention Resource Center. (n.d.). CALM: Counseling on Access to Lethal Means. http://www.sprc.org/resources-programs/calm-counseling-access-lethal-means.
Sung, J. C. (2016). Sample individual practitioner practices for responding to client suicide. March 21. http://www.intheforefront.org/sites/default/files/Sample%20Individual%20Practices%20-%20SPRC%20BPR%20-%20March%202016.pdf.
Waterhouse, J., & Platt, S. (1990). General hospital admission in the management of parasuicide: A randomised controlled trial. British Journal of Psychiatry, 156(2), 236–242.
Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients: Scientific and clinical applications. Washington, DC: American Psychological Association.
Wortzel, H. S., Matarazzo, B., & Homaifar, B. (2013). A model for therapeutic risk management of the suicidal patient. Journal of Psychiatric Practice, 19(4), 323–326.
Yip, P. S., Caine, E., Yousuf, S., Chang, S.-S., Wu, K. C.-C., & Chen, Y.-Y. (2012). Means restriction for suicide prevention. Lancet, 379(9834), 2393–2399.