PPRNet Clinical summary: Core Principles of Treating the Suicidal Adult

There are few clinical situations that instill anxiety in clinicians like working with a suicidal patient. This work, for the clinician, is risky from an ethical-legal perspective and is emotionally exhausting. Often, therapists feel the urgency to resolve suicidal states in patients by prematurely putting into action crisis assessment and management plans that can lead to power struggles with patients rather than collaborative work. Under the sway of intense emotions, therapists can temporarily lose their emotional, relational, and cognitive attunement with the patient. In this review article of best practices for treating the suicidal adult from a mentalizing perspective, Fowler and colleagues argue that while there is often a focus on the patient’s physical safety, clinicians also must consider psychological safety, co-regulation of emotions, mentalizing, identifying meaning, and epistemic trust. Psychological safety refers to the interpersonal and emotional safety between a therapist and a patient. Therapists can engender safety in patients by using therapeutic presence (vocal tone, facial expression, body language) to convey acceptance and interest in the patient’s emotional life. To do this, a therapist must maintain their own emotional equilibrium and stay focused on the patient. Co-regulation of emotions refers to therapists communicating understanding and acceptance of the patient’s emotional experiences by empathic resonance. This includes validation of emotions while not escalating the suicidal crisis. Enhancing mentalizing is achieved by therapists modelling curiosity about the patient’s experiences, their life, and their suicidal ideation. This helps to restore the patient’s cognitive flexibility and the capacity to reflect on internal emotions, and requires the therapist to be empathically attuned and willing to hear about the patient’s wish to die. Identifying meaning is the process of therapists helping patients to understand the repetitive patterns that precipitate suicidal crises. This may help the patient gain a sense of mastery via insights and a greater capacity to regulate their emotions. Epistemic trust refers to the patient’s capacity to trust their own mind and discern trustworthiness in others. Suicidal patients often feel alienated and that others are not available to them or are self-absorbed. Therapists’ ability to communicate genuine understanding, acceptance, and empathy helps to disconfirm the expectations that others are only in it for themselves and affirms that what others have to offer can be meaningful and trustworthy.

Practice Implications 

Certainly, there are some situations in which patients remain at high risk despite best efforts, and in those cases, clinicians must contemplate unilateral management or even hospitalization. However, by being present, mentalizing, and empathic, therapists can be with the patient, easing their sense of isolation and alienation. This may help the patient to regulate their emotions, become curious about their inner life, trust that information coming from the therapist is in their best interest, and reflect on the triggers that drive their suicidal intentions.

 Fowler, J. C., Weir, S., & Orme, W. H. (2025). Core principles of treating the suicidal adult: What we have learned from patients about restoring safety, emotion regulation, mentalizing, and epistemic trust. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000601