Core principles of treating the suicidal adult: What we have learned from patients about restoring safety, emotion regulation, mentalizing, and epistemic trust.

Abstract

Treating the suicidal patient is a risky, often emotionally exhausting process that strains the best therapist's capacity to maintain the primary focus of psychotherapy. When fear, desperation, and urgency to resolve the suicidal state become overwhelming, therapists and patients can get lost in protracted power struggles and crisis management (Plakun, 2001). Starting from the proposition that suicidal states are primarily driven by overwhelming affective experiences (Maltsberger, 2004), the authors expand upon an earlier clinical article (Fowler, 2013) to include new facets of interventions accompanied by clinical vignettes. Targeted research findings supporting these core interventions follow each vignette. Therapists are encouraged to flexibly shift among clinical interventions while carefully monitoring the emotional state and responsivity of the patient: (a) creating a sense of interpersonal safety in the therapy dyad; (b) coregulation of emotion utilizing mentalization-based therapy interventions (Bateman & Fonagy, 2016) and elements of therapeutic presence (Geller & Porges, 2014); (c) enhancing mentalizing by modeling curiosity about suicidal states of mind (Allen, 2011; Bateman & Fonagy, 2016); (d) identifying meaning(s) and pattern(s) that precipitate suicidal states; and (e) aiding the patient in fostering an enduring sense of trust. While informed by attachment theory, mentalization-based therapy, and polyvagal theory, these interventions are best conceptualized as common factors and can be utilized in conjunction with third-wave cognitive behavioral therapy, interpersonal, and integrative approaches. (PsycInfo Database Record (c) 2025 APA, all rights reserved).