New approach to recovery after attempted suicide

The researchers propose a conceptual model of personal recovery after attempted suicide that focuses on non-clinical factors such as helping people find meaning and purpose in their lives.

Developed by a group of mental health professionals and individuals who have attempted suicide, the COURAGE model has seven themes: choosing life, optimizing identity, understanding oneself, rediscovering meaning, acceptance, growing connection, and the empowerment.



Dr. Yosef Sokol

“Physicians can incorporate the COURAGE model into their practice by understanding the importance of each of the seven processes in the model and tailoring their interventions to meet their patients’ unique needs,” Yosef Sokol, PhD, with Touro University School of Health Sciences in New York, told Medscape Medical News.

“By recognizing the individual’s needs and experiences, professionals can prioritize addressing ‘life choice’ or ‘connection growth’ issues for a patient grappling with ongoing suicide or focus on “empowerment” for a patient who feels powerless in their recovery journey,” Socol said.

Sokol and colleagues describe their model in a paper in Opening of the British Journal of Psychiatry.

Unmet need

In 2020, an estimated 12.2 million adults in the United States seriously considered suicide, 3.2 million planned a suicide attempt, and 1.2 million attempted suicide, according to federal data.

Despite the significant need, there is currently no model for personal recovery after an acute suicidal episode that is empirically derived from the suicide literature, let alone one developed with input from individuals who have attempted suicide, say the investigators.

Individuals who attempt suicide often face existential challenges related to their life purpose and will benefit from a meaningful recovery framework that goes beyond the traditional model of safety planning and risk reduction.

The COURAGE model involves the following processes.

Choose life. The process of making a cognitive and emotional decision to live, allowing for an increase in interest in life and hope. This can aid the healing process by helping the patient regain the desire to live and start investing in life by planning for the future.

Optimize your identity. The process of developing a sense of self as a valuable individual with a consistent life history. This process may include the development of self-confidence, self-esteem, a clearer life role, and a “post-suicidal” identity in which the suicide episode itself is seen as a source of personal growth.

Understand yourself. The process of developing an understanding of oneself through reflection on one’s life history, emotional reactions, behaviours, strengths and weaknesses. This process often includes learning about one’s unique pattern of developing greater suicidality and moving toward personal recovery.

Rediscover the meaning.The process of discovering the purpose and meaning of life enhances future-oriented beliefs and builds psychological resilience. For many, engaging in religion and/or spirituality provides a sense of community and higher purpose.

Acceptance. The process of feeling accepted by others and accepting one’s internal contradictions, pain and misalignment with others. Feelings of acceptance often emerge in the context of a safe environment in which to safely discuss negative thoughts and experiences.

Cultivate connection. The process of developing quality relationships with family, friends, and community, which can decrease loneliness and increase a sense of belonging, feeling valued, gaining trust in humanity, and reintegrating into society. Support from others on a similar recovery journey will help generate a deeper sense of reintegration, belonging, and connection.

Strengthening. The dual process of developing internally focused skills (self-expression, self-compassion, and emotion regulation) and externally focused skills (empathy, hobbies, and career-oriented skills). This process often includes developing the knowledge and courage to seek and accept professional help.

“Taken broadly, these seven processes of COURAGE span the realm of human life — what it means to live, grow, and find meaning and purpose,” the investigators write.

They hope the COURAGE model will help colleagues and family, researchers and healthcare professionals reconceptualize the recovery of an individual who has experienced a suicidal episode.

Sokol said it’s important to realize that “personal recovery can look different for every individual and emphasize the importance of building on your patient’s strengths.”

The researchers note that the COURAGE model requires empirical testing using validated measures for consistency, reliability and validity.

They plan to test the model by developing and evaluating a treatment that incorporates each of the COURAGE processes. “This treatment will be compared to existing interventions to determine its effectiveness in promoting recovery after a suicidal episode,” Sokol said.

The research has not received specific grants from any funding agency, commercial or non-profit sector. The authors disclosed no relevant relationships.

BJPsych open. Published online November 17, 2022. Full text

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