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How old-fashioned, pen-to-paper letters could help pull people back from the brink of suicide


Anita Estrada first attempted to kill herself when she was 24 years old. She survived, and the doctors prescribed medication to manage her bipolar disorder. Three years later, Estrada ended up in intensive care from a second attempted suicide. Two years after that, she tried a third time and had to be placed on a ventilator. Immediately after she was released, she looked for ways to try to kill herself again.

Estrada’s multiple suicide attempts, recounted in the photojournalism project “Live Through This” in 2013, are not unusual. Repeated suicide attempts are a major problem in the United States and studies show that one in four people who attempt suicide will try it again within five years. Repeated suicide attempts is also one of the highest risk factors for successful suicide: About half of those who die from suicide have made at least one previous suicide attempt.

Hospitals have struggled for years to find effective strategies to help suicidal patients walking into their emergency rooms, but most of the established models involve personal, face-to-face visits and intensive therapy, which are too resource-intensive for many centers with large volumes to undertake.

A paper published in PLOS Medicine in March proposes a novel method of follow-up that they say appears to reduce suicide attempt reoccurrence by almost 80 percent. It involves having therapists hand-write letters to the patients over the course of 24 months. While the letters would be mostly scripted and focus on reminding people about the importance of safety strategies, they would also include one or two personal sentences and would be personally signed by the therapists.

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The method — known as the Attempted Suicide Short Intervention Program, or ASSIP — was tested on 120 patients who had been admitted to the Bern University General Hospital in Switzerland for recently attempted suicide. The patients were split into two groups: a control group that went through the standard treatment of therapy without the letter writing therapy, and a group that went through both standard therapy and letter writing therapy.

The group of patients that went through letter writing therapy also went through three sessions with therapists. In the first session, patients videotaped themselves telling their personal stories about the events leading up to the attempted suicide to a therapist. In the second session, the patient and therapist watched the video-recorded first session together. The patients were then asked to go home and reflect on their attempted suicide. In the third session, patients and therapists discussed ways to prevent future suicide attempts by talking about long-term goals, warning signs and safety strategies.

After the three sessions, these patients received a series of personalized letters from their therapists. The letters were sent every three months in the first year and every six months in the second year.

The difference between the outcomes for the letter group versus the standard therapy group were striking. In the two years of follow-up, each group had one death by suicide. But in the control group there were 41 repeat suicide attempts, while in the ASSIP group there were only five.

“We believe the caring letters gave patients a feeling that they were cared about and added a personal touch,” said Konrad Michel, one of the researchers involved in the study.

As one of the oldest and most intimate forms of communication, letters have started to gain traction in the therapeutic setting. Noted psychotherapist Albert Ellis was one of the first to try writing to his patients. In 1965, Ellis wrote in the book “The Use of Written Communications in Psychotherapy” that patients who received letters from him received “greater help from my letters than from their face to face therapeutic contacts.” Subsequent studies of Canadian nurses have shown that letters can double the effects of each clinical session. In 1990, Australian family therapist Michael White and New Zealand family therapist David Epston began formalizing therapeutic letters in a mode of therapy called “narrative therapy.” White and Epston believed that follow-up letters helped patients reflect over their therapy experience. They described letters and therapy sessions as “organically intertwined … like the drawing in and letting out of breath.”

“It’s a lovely sentiment that sends the message, ‘You’ve not been forgotten by us,’ ” said David A. Jobes, director of the Suicide Prevention Lab at Catholic University, who was not involved in the study. “This is important, especially for someone ... desperate enough to attempt suicide.”

The results from the letter-writing strategy have been so impressive that researchers in other parts of the world have begun to study whether it should be applied more broadly. The Finnish Association for Mental Health is launching a randomized clinical trial for ASSIP and the U.S. Veterans Administration Medical Center at Canandaigua, New York, is also investigating the possibility of integrating ASSIP into their suicide prevention program.

“The intervention itself is quite short as far as suicide prevention treatments go,” said Britton, a psychologist at the medical center’s Center of Excellence for Suicide Prevention. “That means you can administer them to larger group of people who are at risk. Brief interventions reduce burden on the patient, and they reduce economic burden on the system.”

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