Attempted Suicide Short Intervention Program

1. Introduction

Version followed: Michel & Gysin-Maillart, ASSIP – Attempted Suicide Short Intervention Program: A Manual for Clinicians (Hogrefe, 2015; English adaptation of the 2013 German edition), as its procedures are described in the developers' RCT (Gysin-Maillart et al., 2016), Michel, Valach & Gysin-Maillart (2017) and the Bern training concept (UPD Bern). The manual's session chapter (ch. 3, pp. 33–74) is not drawn on; only its table of contents, preface and introduction are. Session-level detail therefore comes from the developers' published descriptions, and the manual's exact wording, handout text, forms and letter templates are not reproduced or reconstructed. Variants noted where relevant: the US Zero Suicide/New York delivery (Pisani et al., 2023), the Finnish MIELI delivery (Gaily-Luoma et al., 2023) and the Bern "ASSIP flex" format.

ASSIP is a brief, manualised, suicide-specific intervention for adults seen soon after a suicide attempt: three (optionally four) face-to-face sessions of 60–90 minutes, followed by semi-standardised letters for 24 months. It is explicitly an add-on to usual care, not a stand-alone treatment and not a substitute for longer-term therapy. [source: Gysin-Maillart et al. 2016; manual introduction; Focus 2022; Bern training concept]

Core idea of change: the developers treat suicide as a goal-directed action rather than a symptom of illness (manual preface: "Suicide and suicide attempts are not illnesses, but actions."). In an acute crisis, mental pain arising from threatened life goals and identity switches on a "suicidal mode", a cognitive-emotional-behavioural state with reduced reflective problem-solving and often dissociation, in which suicide appears to be the solution. Once experienced, this mode is held to be stored and easily reactivated. Change comes from (a) an early, strong therapeutic alliance that acts as a secure base; (b) the patient telling the story of the attempt and then watching it from an observer position on video, which reactivates the mode under safe conditions and lets patient and therapist jointly reconstruct how pain turned into action; (c) turning that shared understanding into a written formulation, personal warning signs and pre-planned safety strategies that are in place before the mode takes over again; and (d) maintaining the relationship over the long-term risk period by letters. [source: manual preface and introduction; Michel et al. 2017, sections 3, 7.1–7.8; Michel 2025]

2. Framework

ASSIP is a single short programme with a fixed sequence rather than a set of phases; the stages below follow the manual's chapter structure and the developers' descriptions. [source: manual table of contents; Gysin-Maillart et al. 2016; Michel et al. 2017]

Target group and timing

• Adults after a recent suicide attempt (self-inflicted, potentially injurious behaviour with non-fatal outcome and some intent to die). In the RCT, patients were referred from the emergency department; high-risk patients were seen once safe for escorted transport. The developers aim for the three sessions to take place ideally within about three weeks of the attempt; in the RCT intervals of up to three months were accepted. [source: Gysin-Maillart et al. 2016; Michel et al. 2017]
• Not used (RCT exclusions and Finnish guidance): habitual self-harm without suicidal intent, attempt during a psychotic episode or psychotic disorder, serious cognitive impairment, serious substance use disorder that prevents engagement. Developed and tested only in adults; untested in young people. [source: Gysin-Maillart et al. 2016; Gaily-Luoma et al. 2023; Focus 2022]
• Delivered by a trained ASSIP therapist who is not the patient's primary therapist, alongside the patient's usual inpatient or outpatient care. [source: Bern training concept]

Format

• Three sessions, usually weekly, 60–90 minutes each; a fourth session if considered necessary. All core sessions are video-recorded with written consent. Then six letters over 24 months. [source: Gysin-Maillart et al. 2016; Michel et al. 2017]
• Variants: in-person or telehealth via a secure video platform (US trial); clinic or home ("ASSIP flex", from inpatient care to home treatment); optional loved-ones session in Finland. [source: Pisani et al. 2023; Bern training concept; Gaily-Luoma et al. 2023]
• Room: a defined ASSIP room or mobile set-up with two fixed cameras for split-screen or one wide-angle camera; stored handouts, report templates and a letter-administration system. [source: Bern training concept]

Stages

[source: Gysin-Maillart et al. 2016; Michel et al. 2017; Gaily-Luoma et al. 2023; Bern training concept; Chun, Michel & Lee 2024]

Criteria for moving between sessions are not given as formal rules in any source; the "Move on when" column is a [synthesis] of the stated session goals. The content of the manual's sections 3.4–3.9 on each session is [uncertain].

3. Guiding principles

[source: manual preface and introduction; Michel et al. 2017; Gysin-Maillart et al. 2016; Bern training concept; Michel 2025]

• Suicide is an action, not an illness. Explore the attempt as a goal-directed act with a history and a purpose (ending unbearable pain), not only as a symptom of a disorder.
• Mental disorders are risk factors, not the cause. Treat depression and other conditions where present, but do not let a diagnosis replace understanding why this person, at this moment, acted. [source: Michel 2025]
• The patient is the expert on their own story. Take a "not knowing position": listen, follow the patient's account, avoid rash attributions; the therapist's expertise is in assessment and structure.
• Non-judgmental acceptance and empathic understanding. Convey that the attempt makes sense from the inside; do not argue, moralise or rush to reassurance.
• The alliance is the active ingredient and a secure base. Invest in the relationship from the first minutes; the early alliance predicted later reduction in suicidal ideation in the developers' data.
• Patient-centred, biographical understanding. Aim to understand vulnerabilities (life history) and triggers (recent events) as the patient sees them, then translate that into prevention.
• Threatened life goals and identity. Look for the long-term goals, projects and self-image that were threatened; the plan should reconnect the patient to long-term goals.
• The suicidal mode can return. Assume long-term vulnerability; strategies must be planned and written before the next crisis, because reflective thinking is reduced once the mode is active.
• Safe reactivation, then distance. Deliberately revisit the crisis (narrative, video) under controlled conditions, then step into the observer position to reflect.
• Collaboration and shared ownership. Everything written (formulation, warning signs, strategies) is drafted together or revised line by line until the patient owns it.
• Transparency and structure. State ASSIP's goals and structure at the outset; do not promise to "cure" suicidality.
• Concrete, written and portable. Give the patient their formulation and a credit-card-sized summary to carry at all times.
• Adjunct, not replacement. Coordinate with and inform usual care; send documents to involved professionals; ASSIP is no substitute for longer-term treatment.
• Early and routine. Offer ASSIP soon after the attempt and, per the Bern concept, routinely to everyone who has attempted suicide and is eligible.
• Continuity over time. The letters extend the relationship for two years; patients need not reply, but replies are welcomed and acknowledged.
• Separate role from the primary therapist. The ASSIP therapist is a dedicated person, not the patient's regular therapist. [source: Bern training concept]
• Fidelity through video supervision. Sessions are recorded partly so that adherence and competence can be reviewed in supervision. [source: Bern training concept; Pisani et al. 2023]

4. Intervention inventory

The developers' published descriptions name 16 components (4.1–4.16); 4.17 is a national variant. Steps are written in my own words from those descriptions; where a step fills a gap the sources leave, it is tagged [synthesis]. The manual's own step lists, handout, Suicide Status Form, case-conceptualization template, card and letter templates were not reproduced. [source for section: Gysin-Maillart et al. 2016; Michel et al. 2017; Focus 2022; Pisani et al. 2023; Gaily-Luoma et al. 2023; Chun, Michel & Lee 2024; Bern training concept]

4.1 Referral, engagement and orientation (start of session 1)

• Purpose / when: First contact after an attempt, usually on referral from the emergency department, inpatient ward or outpatient service; sets up the alliance and the structure. In the RCT the duty psychiatrist asked for consent to be contacted, and the first interview took place as soon as the patient was safe to attend. [source: Gysin-Maillart et al. 2016]
• Steps:
  1. Arrange the first session quickly (aim: the three sessions within about three weeks of the attempt). [source: Michel et al. 2017]
  2. Introduce yourself as the ASSIP therapist, separate from their regular clinician, and explain that ASSIP runs alongside their usual care. [source: Bern training concept; manual introduction]
  3. State the goals and structure openly: three (possibly four) sessions, what each is for, letters for two years; make clear it does not claim to cure suicidality. [source: Michel et al. 2017, 7.1–7.3]
  4. Explain why sessions are filmed, in plain words an overwhelmed person can follow, and obtain written consent (4.2). [source: Gaily-Luoma et al. 2023]
  5. Give appointment dates in writing. [synthesis, prompted by client reports of date confusion in Gaily-Luoma et al. 2023]
• Example language (illustrative): "I'd like to understand, from your point of view, what happened before you tried to end your life. We'll meet three times, perhaps four. Together we'll work out what led up to it and plan what you can do if a crisis like this starts again."
• Watch for: Shame, wariness, an expectation of being judged or hospitalised; whether the patient can take in information (offer it again in writing).

4.2 Video-recording set-up and consent

• Purpose / when: Before the narrative interview; the recording is needed for playback (4.5), reexposure (4.15) and supervision. All three core sessions are recorded. [source: Gysin-Maillart et al. 2016; Bern training concept]
• Steps:
  1. Prepare the room: two fixed cameras for split screen or one wide-angle camera, test before the patient arrives. [source: Bern training concept]
  2. Explain what is recorded, why (to watch parts together next time; for the therapist's supervision), who sees it and how it is stored and deleted. [synthesis on storage detail; local data rules apply]
  3. Obtain written consent; the manual includes a video consent form (not reproduced). [source: Dutch edition table of contents]
  4. Tell the patient they can pause the recording at any time. [synthesis]
• Example language (illustrative): "Next week we'll watch a few short parts of today's conversation together. Seeing yourself tell the story from the outside often helps people notice things they couldn't see in the moment."
• Watch for: Anxiety about the camera, which clients describe as a real barrier; it usually settles once the purpose is understood. [source: Gaily-Luoma et al. 2023]

4.3 Narrative interview (session 1)

• Purpose / when: Core of session 1. It activates the story of the suicidal crisis in a safe setting, builds the alliance, and gives a patient-centred, biographical picture of the mechanisms behind the pain and the act, including vulnerability factors and trigger events. [source: Gysin-Maillart et al. 2016; Michel et al. 2017]
• Steps:
  1. Open with a broad invitation for the patient to tell, in their own words, how they came to the point of wanting to die and how they went about it. An example opening from the developers' earlier narrative-interview research: "can you please tell me how you came to the point of harming yourself?" [source: quoted in Michel et al. 2017, section 3; it is not given there as an ASSIP script]
  2. Take the "not knowing position": let the patient lead, follow their sequence, use minimal prompts, avoid interpreting or diagnosing. [source: Michel et al. 2017]
  3. Follow the story through its stages: the background and mental pain; how suicide became an option; planning and choice of means; the act; what interrupted it and what happened afterwards. [source: Michel et al. 2017, 7.6 and 8.1 (stages: mental pain, action planning, action execution)]
  4. Listen for threatened long-term goals, relationships, identity and the moment the patient "wasn't themselves" (dissociation, acting "like a robot"). [source: Michel et al. 2017; Michel 2025]
  5. Where the account jumps, ask open questions to fill in thoughts, feelings, body sensations and actions at that point. [synthesis, consistent with the playback focus in Gysin-Maillart et al. 2016]
  6. Leave time at the end for the risk assessment (4.4) and to settle the patient.
• Example language (illustrative): "Take your time, start wherever it makes sense to you." / "What was going through your mind just then?" / "And then what happened?"
• Watch for: Over-structuring (turning it into a symptom checklist), premature reassurance, or the therapist steering away from the act itself. Signs it's working: a coherent, detailed account in the patient's own words, emotional engagement, and the patient's sense of being heard (alliance scores rose from session 1 to 3 in the RCT). [source: Michel et al. 2017, 7.3]
• Note: The manual's own guidance on conducting the interview (section 3.4) is not drawn on. [uncertain]

4.4 Collaborative risk assessment (end of session 1)

• Purpose / when: At the end of session 1 in the RCT and in Finland: a structured, collaborative assessment of current suicide risk using the Suicide Status Form (SSF-III, from Jobes' CAMS). [source: Gysin-Maillart et al. 2016; Gaily-Luoma et al. 2023]
• Steps:
  1. Complete the SSF with the patient (licensed instrument; items not reproduced here), sitting so that both can see the form. [source: Gaily-Luoma et al. 2023 describe it as collaborative; seating is synthesis]
  2. Assess current ideation, intent, access to means and protective factors as in usual practice; decide whether the patient is safe to leave. [synthesis, standard practice]
  3. If risk is high, follow the service's crisis protocol (urgent review, emergency department, admission if necessary). [source: Pisani et al. 2023; Chun, Michel & Lee 2024]
  4. Agree the interim plan until session 2, including who to call. [synthesis]
• Example language (illustrative): "Before we finish, I'd like us to look together at how you're doing right now, so we both know where things stand until next week."
• Watch for: Distress stirred up by the narrative; repeat the check at each later session for high-risk patients. [source: Chun, Michel & Lee 2024]

4.5 Video playback (session 2)

• Purpose / when: Session 2. Reactivates the patient's mental state during the crisis under safe conditions while giving them an observer's view, so that patient and therapist can jointly reconstruct how mental pain turned into suicidal action. [source: Gysin-Maillart et al. 2016; Michel et al. 2017]
• Steps:
  1. Before the session, review the recording and select sequences: the transition into the crisis, the point where suicide became the solution, the act, and moments where the patient's state changed. [source: "selected sequences", Gysin-Maillart et al. 2016; choice of sequences is synthesis, informed by Pisani et al. 2023 (focus on where the "suicidal mind" took over)]
  2. Sit side by side facing the screen, not face to face. [source: Gysin-Maillart et al. 2016]
  3. Play a sequence; pause from time to time and invite the patient to say what they notice now and what they were thinking, feeling and sensing in their body at that moment, and to add anything missing. [source: Michel et al. 2017, 5.2]
  4. Together, map the chain: automatic thoughts, emotions, physiological changes, behaviour. Name the moment the suicidal mode took over and the beliefs active then (for example about being a burden or of no value). [source: Gysin-Maillart et al. 2016; Pisani et al. 2023]
  5. Note vulnerabilities, triggers, critical points and possible alternatives that will feed the formulation and safety plan. [source: Michel et al. 2017]
  6. End by handing out the homework text (4.6) and settling the patient before they leave.
• Example language (illustrative): "Let's stop here. Watching yourself now, what do you notice?" / "At this moment in the video, what was happening in your body?" / "This looks like the point where the decision seemed to take over. Is that how you remember it?"
• Watch for: Strong emotion or dissociation on re-immersion (see section 5). Signs it's working: the patient can describe their own process from outside ("I can see I wasn't thinking straight there"), new details emerge, and patient and therapist arrive at a shared account.
• Note: The manual's rules on how often to pause and which questions to ask (section 3.5) are not drawn on. [uncertain]

4.6 Psychoeducational homework text (end of session 2)

• Purpose / when: Given at the end of session 2 as collaborative psychoeducation. A roughly four-page text titled "Suicide Is Not a Rational Act" covers mental pain, dissociation, the suicidal mode, risk factors and neurobiology. [source: Gysin-Maillart et al. 2016; Michel et al. 2017; Michel 2025]
• Steps:
  1. Give the text from the manual's appendix (not reproduced here). [source: Dutch edition table of contents]
  2. Ask the patient to read it at home and write personal comments, noting what fits or does not fit their own experience. [source: Gysin-Maillart et al. 2016]
  3. Ask them to bring it to session 3.
• Example language (illustrative): "This text explains what many people go through in a suicidal crisis. Please read it at home and write in the margins where it fits you, where it doesn't, and any questions."
• Watch for: Reading difficulties, concentration problems or overload after the session; offer to read key parts together if needed [synthesis]. In the US trial, homework review is a fidelity-rated component. [source: Pisani et al. 2023]

4.7 Drafting the case conceptualization (between sessions 2 and 3)

• Purpose / when: After session 2 the therapist writes a draft formulation based on the narrative and playback. [source: Gysin-Maillart et al. 2016]
• Steps: Draft a short written formulation covering, per the Bern training concept: (1) individual vulnerabilities; (2) threatened motives and life goals; (3) the suicidal process, including triggers; (4) long-term goals, warning signs and the crisis plan, with (4) left partly open to complete with the patient. The US version writes it as a first-person narrative. Use the patient's own words where possible. [source: Bern training concept; Pisani et al. 2023; use of patient's words is synthesis]
• Example language (illustrative, draft wording): "When I felt I had let my family down again, the pain became unbearable and I started to see ending my life as the only way out…"
• Watch for: Writing in clinical jargon or adding interpretations the patient did not offer; the draft is a proposal for revision, not a verdict. In training, the formulation is sent to the supervisor and revised. [source: Bern training concept]

4.8 Homework review (start of session 3)

• Purpose / when: Opens session 3: the patient's written comments on the handout are discussed, linking general knowledge to their own crisis. [source: Gysin-Maillart et al. 2016; Michel et al. 2017]
• Steps: Ask what the patient noticed; go through their comments; connect what fitted (for example the sense of being in a different state, dissociation) to what was seen in the video; note new material for the formulation. [steps: synthesis from source descriptions]
• Example language (illustrative): "Which parts of the text matched what you went through? Was anything quite different for you?"
• Watch for: Homework not done (see section 5); patients feeling relief that their experience is described as a recognisable state rather than a personal failing.

4.9 Collaborative revision of the case conceptualization (session 3)

• Purpose / when: Session 3, after the homework review. Turns the therapist's draft into a shared, patient-owned explanation of how the crisis developed, which justifies the warning signs and safety strategies that follow. [source: Michel et al. 2017, 5.3 and 7.7; Gysin-Maillart et al. 2016]
• Steps:
  1. Give the patient a copy and read the draft together. [synthesis on reading together]
  2. Go through it sentence by sentence; after each, ask whether it is accurate and in words they recognise; change it until they agree. [source: "sentence by sentence" revision, Michel et al. 2017]
  3. Check that the four parts are present: vulnerabilities, threatened goals and motives, the suicidal process with triggers, and (completed next) goals, warning signs and crisis plan. [source: Bern training concept]
  4. Print the final version for the patient. [source: Gysin-Maillart et al. 2016]
• Example language (illustrative): "This is my first attempt to put your story into words. You're the expert here, so please correct anything that isn't quite right."
• Watch for: Passive agreement (the patient nodding everything through); invite at least one change. Signs it's working: the patient edits wording, adds details and says it "makes sense" of what happened.

4.10 Long-term goals

• Purpose / when: Session 3. Reconnects the patient with the life goals and projects that were threatened, as a counterweight to the short-term goal of escaping pain. [source: Michel et al. 2017, 3 and 8.1; Gysin-Maillart et al. 2016]
• Steps: Ask what matters to the patient over the longer term (relationships, work, health, identity); write two or three concrete goals in their words; link each to what was threatened in the crisis. The case report's goals included reducing alcohol use, improving communication with a son and getting treatment for sleep. [source: Chun, Michel & Lee 2024; procedure wording is synthesis]
• Example language (illustrative): "When this crisis is behind you, what do you want your life to be about? What would you want to keep working on?"
• Watch for: Hopelessness making goals hard to name; start small and concrete. Goals go on the card (4.13).

4.11 Personal warning signs

• Purpose / when: Session 3. Identifies the individual early signals that a suicidal crisis is starting, drawn from the formulation and the video. [source: Gysin-Maillart et al. 2016; Michel et al. 2017]
• Steps:
  1. Go back to the chain reconstructed in playback (4.5); ask what came first: situations, thoughts, feelings, body signals, behaviour.
  2. Write specific, personal signs rather than generic ones (example from a published case: negative thinking patterns, family conflict, insomnia, alcohol use). [source: Chun, Michel & Lee 2024]
  3. Order them roughly from earliest to most acute. [synthesis, consistent with the staged model in Michel et al. 2017]
• Example language (illustrative): "Looking back at the video, what was the first sign that things were going downhill, before the thoughts of suicide came?"
• Watch for: Signs that only appear once the suicidal mode is already active are too late on their own; look for earlier ones too.

4.12 Safety strategies (two stages)

• Purpose / when: Session 3, tested in session 4. Pre-planned actions for when warning signs appear, written before the next crisis because reflective problem-solving drops once the suicidal mode is active. [source: Michel et al. 2017, 5.3, 7.5–7.6]
• Steps:
  1. First-stage strategies: what the patient can do on their own with their own resources (examples from a published case: watching videos, exercise, walking, mindfulness). [source: Michel et al. 2017; Chun, Michel & Lee 2024]
  2. Second-stage, acute strategies: contacting named personal helpers, then professionals and institutions (crisis service, emergency department). [source: Michel et al. 2017]
  3. Match strategies to stages of the crisis (mental pain, action planning, execution), so that there is something to do at each point. [source: Michel et al. 2017, 7.6, figure 1]
  4. Discuss reducing access to the means used or considered (safe storage, removal, involving a trusted person); lethal-means counselling is not mentioned in the ASSIP sources but is current standard practice after an attempt. [synthesis]
  5. Check each strategy is realistic: when, where, with whom; rehearse one aloud. [synthesis]
• Example language (illustrative): "If you notice you're not sleeping and the thoughts are getting louder, what's the first thing you could do on your own? And if that isn't enough, who would you call?"
• Watch for: Generic or wishful strategies; strategies that depend on people who are part of the trigger. One Finnish client felt producing alternatives was rushed; leave enough time or use session 4. [source: Gaily-Luoma et al. 2023]

4.13 Pocket card and crisis card

• Purpose / when: End of session 3. Makes the plan portable. [source: Gysin-Maillart et al. 2016; Michel et al. 2017]
• Steps:
  1. Copy the long-term goals, warning signs and safety strategies onto a credit-card-sized folded leaflet. [source: Gysin-Maillart et al. 2016]
  2. Give a separate crisis card with phone numbers of private and professional helpers. [source: Gysin-Maillart et al. 2016]
  3. Ask the patient to carry both at all times and use them in an emotional crisis; agree where they will keep them. [source: Gysin-Maillart et al. 2016; placement is synthesis]
• Example language (illustrative): "This card goes with you everywhere. In a crisis it's hard to think clearly, so this is your thinking done in advance."
• Watch for: Whether the patient can find and use the card; a Finnish client reported telling emergency services they were calling "because my safety plan says so". [source: Gaily-Luoma et al. 2023]

4.14 Sharing documents and handover to ongoing care

• Purpose / when: End of session 3 or 4. Keeps ASSIP connected to usual care. [source: Gysin-Maillart et al. 2016; Pisani et al. 2023]
• Steps: With the patient's agreement, send copies of the formulation and safety strategies to the involved professionals (GP, psychiatrist, therapist); confirm the patient is linked to their existing provider or referred to a new one. [source: Gysin-Maillart et al. 2016; Pisani et al. 2023]
• Example language (illustrative): "I'd like your psychiatrist to have a copy of what we've written, so everyone is working from the same understanding. Is that all right?"
• Watch for: Patients with no ongoing care: arrange a referral before ending. [synthesis]

4.15 Optional session 4: video-prompted reexposure

• Purpose / when: Added if considered necessary: to test and strengthen safety strategies by briefly re-entering the crisis via the video (described as a "mini-exposure" in the Bern training concept), or to complete unfinished tasks or practise safety measures. [source: manual introduction; Michel et al. 2017; Bern training concept; Gaily-Luoma et al. 2023]
• Steps:
  1. Explain the aim and get consent for re-watching a key sequence. [synthesis; consent step for exposure]
  2. Play a sequence from the crisis and let the patient re-enter the state in a controlled way. [source: Chun, Michel & Lee 2024]
  3. Pause and ask the patient to apply their card: which warning sign do they notice, which strategy would they use now. [synthesis consistent with "test and strengthen" in the manual introduction]
  4. Evaluate together whether the strategies would work and adjust them. [source: Chun, Michel & Lee 2024]
  5. Bring the patient back to the present before ending (grounding if needed) and reassess current risk. [source: Chun, Michel & Lee 2024]
• Contraindications and safety: Avoid or postpone when the patient is acutely suicidal, highly dissociative or unstable at the start of the session [synthesis]. Patients can become highly distressed; have a crisis plan for after the session. [source: Chun, Michel & Lee 2024]
• Example language (illustrative): "Let's watch that moment again. This time, stop me when you notice your first warning sign, and tell me what on your card you'd use."
• Watch for: The patient can name and imagine using a strategy at the right point; distress falls by the end. The manual's own procedure (section 3.7) is not drawn on. [uncertain]

4.16 Semi-standardised letters (24 months)

• Purpose / when: After the last session, for two years. Extends the therapeutic relationship as a secure base over the long-term risk period. [source: Gysin-Maillart et al. 2016; Michel et al. 2017, 5.4 and 7.8]
• Steps:
  1. Send six letters: every three months in year one, every six months in year two (3, 6, 9, 12, 18, 24 months after the last session). [source: Gysin-Maillart et al. 2016; Gaily-Luoma et al. 2023]
  2. Use the manual's semi-standardised template (not reproduced) reminding the patient of the long-term risk of future crises and the importance of their safety strategies. [source: Gysin-Maillart et al. 2016]
  3. Sign each one personally and add one or two personal sentences; invite feedback and mention that they can contact the therapist. [source: Gysin-Maillart et al. 2016; Gaily-Luoma et al. 2023]
  4. Replies are optional; acknowledge any reply in the next letter. [source: Michel et al. 2017]
  5. Keep a letter-administration system so none are missed. [source: Bern training concept]
• Example language (illustrative, personal lines): "I often think of our conversations and hope your plans for the garden are coming along. Your card is still there for difficult days."
• Watch for: A reply that suggests a current crisis needs a same-day response through clinical channels, not the next letter (see section 5). [synthesis]

4.17 Variant: inviting loved ones (Finnish delivery)

• Purpose / when: In the Finnish MIELI delivery, clients were encouraged to invite loved ones to the optional fourth session; this is not part of the original manual. No participant in the study took it up, and clients said the offer should be "pushed more". [source: Gaily-Luoma et al. 2023]
• Steps (if adapting): Offer the option early; prepare with the patient what will and won't be shared; use the session to explain warning signs and the role of the helper. [synthesis]
• Example language (illustrative): "Would it help if someone close to you knew your warning signs and what you'd like them to do?"
• Watch for: The loved one being part of the trigger; the patient feeling pressured.

5. Handling problems

The manual has a section on difficulties in practical use (3.9, p. 71) that is not drawn on [uncertain]. Guidance below is drawn from client reports, the case report and trial protocols where tagged; the rest is [synthesis].

• Reluctance to talk about the attempt or to start/continue. Discomfort with revisiting the attempt affects adherence. [source: Chun, Michel & Lee 2024] Response [synthesis]: explain the rationale (understanding the crisis is what makes the safety plan personal and effective); let the patient choose where to start; validate that it is hard; agree a signal for pausing.
• Anxiety about being filmed. Clients describe pre-session anxiety centred on the camera; one had not understood why they were filmed. [source: Gaily-Luoma et al. 2023] Response: explain purpose, viewers and storage simply, and again at the start of session 2 [source: Gaily-Luoma et al. 2023 stresses explanation]; offer to show the camera view; if the patient still refuses, do the narrative without video and use a written or verbal recap in session 2. Delivering ASSIP without video is a departure from the manual and its effect is unknown. [synthesis; uncertain]
• Overwhelming distress during the narrative, playback or reexposure. Some patients become highly distressed on re-exposure. In the case report the therapist encouraged full expression of emotion and used grounding, and advised going to the emergency department if suicidal thoughts persisted after the session. [source: Chun, Michel & Lee 2024] Response: pause the video; slow the pace; ground (orient to the room, breathing, feet on floor) [synthesis]; reassess risk before the patient leaves; arrange a check-in call. [synthesis]
• Dissociation, cognitive overload, partial amnesia. Clients reported dissociation, forgetting session content and confusing appointments with other services; written reminders helped. [source: Gaily-Luoma et al. 2023] Response: give appointment times, key points and the formulation in writing; summarise at the end of each session; keep playback sequences short. [synthesis]
• Exhaustion after sessions. Reported by clients. [source: Gaily-Luoma et al. 2023] Response: warn in advance; plan something calming afterwards; avoid scheduling before demanding commitments. [synthesis]
• Acute or rising suicide risk during the programme. Response: follow the clinic's crisis protocol (in person, phone or video); for high-risk patients reassess suicidal thoughts at every session and consider hospital admission if necessary. [source: Pisani et al. 2023; Chun, Michel & Lee 2024] Inform the primary clinician. [synthesis]
• Missed sessions / non-attendance. Not addressed in the sources. Response [synthesis]: contact the patient the same day by phone and in writing; treat non-attendance after an attempt as a possible risk signal and inform the treating clinician; offer flexible times, telehealth or a home visit (the Bern "ASSIP flex" and US telehealth delivery support this [source: Bern training concept; Pisani et al. 2023]).
• Homework not done. Response [synthesis]: read key sections together at the start of session 3 and ask for reactions; do not frame it as failure.
• Passive agreement with the formulation. Response [synthesis]: ask the patient to change at least one sentence; ask what is missing; check understanding by inviting them to explain the chain in their own words.
• Vague or unrealistic safety strategies, or a rushed plan. One client found generating alternatives rushed. [source: Gaily-Luoma et al. 2023] Response: use the optional fourth session to practise and refine [source: Gaily-Luoma et al. 2023 (manual's purpose for session 4)]; test each strategy against the video sequence. [synthesis]
• Worry about burdening the therapist; grief at ending. Both reported by clients. [source: Gaily-Luoma et al. 2023] Response [synthesis]: name the fixed, short structure from the start; say clearly that hearing the story is your role; prepare for ending in session 3, and point to the letters and the ongoing clinician as continuity.
• Ruptures (anger, feeling judged or misunderstood). Response [synthesis]: acknowledge the rupture directly; return to the not-knowing stance and the patient's expertise on their story; correct the formulation if it is where the misunderstanding lies. The developers found alliance quality linked to later outcome, so repairing it takes priority over finishing a task. [source: Michel et al. 2017, 7.3]
• Patient minimises the attempt ("it was a mistake", "it won't happen again"). Response [synthesis, consistent with the suicidal-mode model in Michel et al. 2017]: accept their current view while explaining that a suicidal state, once experienced, can be reactivated; frame the plan as insurance rather than an assumption of future risk.
• Reply to a letter signals a crisis, or letter returned/undeliverable. Response [synthesis]: respond the same day through clinical channels (phone, contact with the treating clinician), not in the next scheduled letter; for undeliverable letters check contact details with the referring service, within confidentiality rules.
• Re-attempt during follow-up. Response [synthesis]: continue letters unless the patient asks to stop; consider offering a further ASSIP-informed review of the new crisis with the video-based method, coordinated with the treating team. Whether the manual recommends repeating ASSIP is [uncertain].
• Substance use, psychosis, habitual self-harm. Excluded in the RCT; Finnish guidance advises against ASSIP when serious substance use impedes engagement or the attempt occurred during psychosis. [source: Gysin-Maillart et al. 2016; Gaily-Luoma et al. 2023] Response: refer for appropriate treatment and reconsider ASSIP when the patient can engage.
• Role confusion with the primary therapist. ASSIP should not be delivered by the patient's primary therapist. [source: Bern training concept] Response [synthesis]: agree roles with the treating clinician at referral; share documents (4.14).
• Adolescents. ASSIP was designed for and tested in adults only; using it with young people is untested. [source: Focus 2022]
• Therapist strain and drift. All core sessions are video-recorded and reviewed in supervision against adherence and competence criteria; certification requires at least five supervised cases over 6–12 months. [source: Bern training concept; Pisani et al. 2023] Response: keep using video supervision after certification, as the Bern concept recommends.

Sources

Sources:

• ASSIP – Attempted Suicide Short Intervention Program: A Manual for Clinicians, reading sample (front matter, preface, introduction, table of contents)
• ASSIP: Een programma van kortdurende interventies bij suïcidepogingen, Dutch edition sample (foreword, introduction, contents incl. appendices)
• ASSIP Therapist Manual, table of contents (Lehmanns)
• Gysin-Maillart A, Schwab S, Soravia L, Megert M, Michel K (2016). A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of ASSIP. PLoS Medicine
• Michel K, Valach L, Gysin-Maillart A (2017). A Novel Therapy for People Who Attempt Suicide and Why We Need New Models of Suicide. IJERPH 14(3):243
• Focus (2022). ASSIP article, Focus: The Journal of Lifelong Learning in Psychiatry
• Pisani A et al. (2023). Effectiveness of a targeted brief intervention for recent suicide attempt survivors: RCT protocol. BMJ Open 13:e070105
• Pisani et al. 2023, SUNY Research Connect record
• Gaily-Luoma S, Valkonen J, Holma J, Laitila A (2023). Client-reported impact of the Attempted Suicide Short Intervention Program. Psychotherapy Research
• Chun, Michel & Lee (2024). ASSIP case report. Psychiatry Investigation
• Ausbildungskonzept ASSIP (UPD Bern training concept)
• Michel K (2025). Suicidal thoughts and actions: We need a new model. Open Access Government

Books cited:

• Michel K, Gysin-Maillart A (2015). ASSIP – Attempted Suicide Short Intervention Program: A Manual for Clinicians. Hogrefe. (Only front matter and introduction are drawn on; chapter 3 is not.)
• Gysin-Maillart A, Michel K (2013). Kurztherapie nach Suizidversuch: ASSIP. Huber/Hogrefe (German original; not drawn on; title [uncertain]).
• Jobes DA (2006). Managing Suicidal Risk: A Collaborative Approach. Guilford (source of the SSF; cited via Gaily-Luoma et al. 2023; not drawn on).

Further reading (not drawn on): Arvilommi et al. (2022) ASSIP vs crisis counselling outcome-predictor analysis (listed key source; outcome-focused, not procedural).