ASSIP Treatment Protocol
ASSIP was administered in three 60- to 90-min sessions, usually on a weekly basis. A fourth session was added if necessary. These face-to-face therapy sessions were supplemented by regular, personalized letters to the participants for 24 months. The manual used throughout the study was first published in German [39] in May 2013; the translation in English [40] followed in June 2015. The manual is highly structured, and interventions for each session are described in detail.
First session.
A narrative interview [41] was conducted in which patients were asked to tell their personal stories about how they had reached the point of attempting suicide. The aim of the narrative interview is to reach—in a biographical context—a patient-centered understanding of the individual mechanisms leading to suicidal behavior and to elicit specific vulnerability factors and trigger events. All interviews were video-recorded, with the patients’ written consent. Suicide risk was assessed using the SSF-III [31].
Second session.
Patient and therapist, seated side-by-side, watched sequences of the video-recorded first session. The aim of the video playback [42] is to reactivate the patient’s mental state during the suicidal crisis, in a safe environment, and provide a detailed reconstruction of the transition from an experience of psychological pain and stress to the suicidal action. Automatic thoughts, emotions, physiological changes, and contingent behavior were identified. Patients received a psychoeducative handout (“Suicide Is Not a Rational Act”) as a homework task (S2 Text), to be returned with personal comments at the next session. Following the session, the therapist prepared a written draft of the case conceptualization.
Third session.
The patients’ comments to the handout were discussed. The case conceptualization was revised collaboratively. A list of long-term goals, individual warning signs, and safety strategies was developed in close cooperation with the patient. The written case conceptualization and the personal safety strategies were printed out and given to the patient, with additional copies for other health professionals involved in treatment. Long-term goals, warning signs, and safety strategies were copied to a credit-card-size folded leaflet and given to the patient. In addition, participants received a crisis card with a list of telephone numbers of private and professional helpers who could be contacted in case of a suicidal crisis. Patients were instructed to carry both with them at all times, and to use them in the event of a crisis.
Letters.
Participants were sent semi-standardized letters over a period of 24 months, every 3 months in the first year and every 6 months in the second year. The letters reminded participants of the long-term risk of future suicidal crises and the importance of the safety strategies. Letters were signed personally by the ASSIP therapist. Usually, one or two personal sentences were added, and participants were invited to give feedback about how things were going.