Insights: A New Model Of Suicide With Professor Thomas Forkmann

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Psychologists have developed a new model of suicidality which uses a patient’s ambivalence as a therapeutic starting point

More than 720,000 people die by suicide every year. According to the World Health Organization, it is the leading cause of death among 15-29-year-olds. But researchers say that those who are suicidal usually have mixed feelings, reporting an internal struggle between wishing to die and wanting to live “before, during, and after suicidal behavior.”

Now the team from the University of Duisburg-Essen, Ruhr-University Bochum, and the University of Rochester have developed the ‘ambivalence model of suicidality’ (ABS), which they have introduced in a paper published in the journal Frontiers in Psychiatry. The new model aims to harness these individuals’ conflicted feelings to help them during crisis intervention and psychotherapy. It uses their ambivalence to motivate them to postpone a decision to die by suicide and to engage in treatment. We discussed this with Thomas Forkmann, a professor of clinical psychology and psychotherapy at the University of Duisburg-Essen in Germany, who was part of the team.

Why is the ABS model needed?

Common theoretical models of suicide (including the Interpersonal Theory of Suicidal Behaviour, the 3-steps theory, and the integrative motivational-volitional model of suicide behaviour) have significantly furthered knowledge of suicidal ideation and behaviour, but therapy-related elaborations of these models are still missing.

Forkmann observes that these models “focus on individual, very specific factors, that may not resonate with every suicidal person”, and are “primarily unidirectional, representing the factors that propel an individual towards suicidal behaviour, with minimal consideration of the countervailing factors that protect against it.

“We now know very well that suicidal ideation and behaviour, and the related warning signs, fluctuate greatly – sometimes within hours or days. Additionally, the individual constellation of factors relevant to a person’s suicide risk varies greatly from person to person. The ABS model aims to provide a framework for clinicians that helps them understand the individuality of their clients’ suicidal ideation and behaviour, and account for the highly volatile nature of suicidal ideation and behaviour.”

How does it work?

"The model does not necessarily suggest new treatment methods," says Professor Forkmann, "Rather, the model is intended to help place these methods in a meaningful context and explain them appropriately to patients. We also hope that the model can be a good explanatory framework for deriving individual therapeutic measures for clients and justifying them in a comprehensible way. The reasons for dying specify what further treatment must focus on.”

The flexibility of this approach is one of the major benefits of the ABS model. Suicidal ideation driven by a feeling of being a burden (for example) would need different treatment to someone with a sense of entrapment; trauma therapy, or support contacting specialised agencies (such as for debt), may also be required. The model can then help clients “establish what they need now to gain more security for themselves and allow the desire to end their life to recede somewhat into the background.”

The ABS model divides the suicidal process into the “uncertainty” phase, the “transition” phase, and the “action” phase. Not every person goes through the phases in the same way.

The uncertainty phase

This phase can last minutes, days, weeks, or even years. Individuals may not explicitly express ambivalence; it may be revealed by words such as “maybe”, “not now”, and “possibly” when talking about their suicidal intentions.

Clients are first invited to discuss their reasons for suicide. No weightings are to be given for different perceived reasons for suicide. This allows the person to share which factors they personally experience as particularly stressful or important – their own ‘suicide drivers’.

Using motivational interviewing techniques, therapists help the individual counter their reasons to die with reasons to live, with themes including family (“I don’t want my husband to think I didn’t love him”), enjoyable things (“I could never go swimming again if I were dead”), and self-image (“I want to be remembered as someone who kept going”). The aim is “to get the person into contact with their ambivalence, to empathically validate reasons for dying and to make reasons for living emotionally salient”.

Professor Forkmann warns that the experience of ambivalence can itself be a stressful state; persistent rumination can cause sleep problems or agitation that may in turn be associated with increased suicidal thoughts or behaviour. It is therefore important to support suicidal individuals in this phase to “step out of a constant engagement with suicidal ambivalence”. Motivational interviewing techniques may help reduce this rumination.

The transition phase

Next is the transition phase, when the person is in a state of imminent suicide risk. To enter this phase, it is not necessary for ambivalence to have been resolved – it just needs to be ‘pushed aside’. The researchers stress that the single most important factor at this point is whether the person has access to lethal means: “In the transition phase, there is a high risk that behavioural control over suicidal impulses will fail, a cognitive narrowing down to death and suicide will occur and a suicide attempt will be carried out if means are available (action phase).”

Additional factors that may determine whether a person enters the transition phase – or leaves it unscathed – are the availability of supporters, being able to remember reasons to live, and having skills in dealing with emotional turmoil. The team writes “suicidal individuals have to become prepared for dealing with strong suicidal impulses and urges: means restriction counselling [helping people reduce their access to methods they might use to end their life], safety planning, creating a hope box, [and] skills training are suitable interventions, in that they support suicidal individuals to establish behavioural control in dealing with suicidal impulses and might prevent them from entering the transition and action phases, and step back into the uncertainty phase.”

Studies suggest that after a suicide attempt is made, between 36% and 43% of those who try to take their lives feel ambivalent about having survived, while 35% feel glad, and 14-22% regret that they are still alive. Different approaches are needed depending on the person’s reaction to surviving: “an ambivalence-friendly approach that takes the experience of shame and stigma into account, psychoeducation and brief therapeutic interventions, appears to be suitable for this,” note the researchers. PTSD should also be considered, as not wanting treatment after a suicide attempt may be trauma-related avoidance behavior.

Key takeaways:

• A focus on the individual's mixed feelings about suicide can help to place treatment methods in a meaningful context for patients.

• Different treatments should be offered depending on which phase the client is currently in.

• Case conception and treatment planning should take into account that suicidal ideation, behavior, and the associated risk factors and warning signs are highly volatile. Changes from one phase to another – including an acute suicidal state – can happen quickly.