What Actually Works in Suicide Prevention

This is the third installment in a three-part series. Links to Parts I and II are available at the end of the story.

What works when it comes to suicide prevention? The short answer is we don’t necessarily need a new set of tools; we need to return to the oldest ones we have—relationships, presence, agency, and hope—organized today by a growing body of evidence that tells us exactly how to deploy them.

I find it helpful to think about suicide prevention along a continuum: upstream, midstream, and downstream. Upstream work bolsters protective factors and reduces risk before crisis takes hold. Midstream work meets emerging suicidal intensity and the relational ruptures that so often accompany it. Downstream work responds with skill, courage, and humanity when a person is standing at the edge.

Each level calls for a different kind of response, but all of them share a common foundation: the belief that people in suicidal pain are not problems to be managed, but human beings to be met.

Upstream: Fostering Belonging and Purpose

Thomas Joiner’s influential theory of suicide proposes that two of its most powerful drivers are thwarted belongingness—the feeling that one does not belong and is fundamentally alone—and perceived burdensomeness—the devastating belief that one’s death would be a relief to others.

If those are the wounds, then the upstream medicine is clear: connection, contribution, and meaning.

For youth, programs like Sources of Strength offer a powerful example of upstream suicide prevention: a peer-based model that builds help-seeking, belonging, coping, connection, and multiple sources of meaning before crisis takes hold. In a randomized controlled trial, Sources of Strength reduced new suicide attempts among high school students by 29 percent, even after accounting for student characteristics and recent sexual violence history. The finding is hopeful because it shows that suicide prevention can work at the level of culture, not only by identifying individual risk, but by strengthening the relational soil around young people. Rather than beginning with the question, “Who is most at risk?” Sources of Strength starts with a different one: “How do we build a community where young people are more connected, more resourced, and more likely to reach for help before despair hardens into crisis?”

My work with the construction industry has taught me this lesson repeatedly. In a field where suicide rates are heartbreakingly high, I’ve seen how belonging and contribution can become more than protective factors. They can become lifelines.

One union member I’ll call Mike was in his 40s when I met him. He was funny, sharp, fast-talking, and impossible not to like. He had the kind of energy that filled a room before he even sat down. But underneath that quick wit was a story no child should have to survive. He’d grown up with profound abuse and neglect, carried pain that no one had helped him name, and for a time, meth became the thing that helped him disappear from himself.

Eventually, he found his way into the trades, which gave him not only a paycheck, but structure, identity, skill, pride, and a crew. Work allowed him to build something solid while the rest of his life was still being repaired. Over time, Mike became not only a skilled tradesperson, but one of the strongest peer supporters I’ve ever known.

He could talk to people others couldn’t reach. He knew how to use humor without deflecting from pain. He knew when to swear, when to sit quietly, when to push, and when to simply say, “I’m not leaving.” Workers trusted him because he’d earned the right to speak from experience.

Then later, after a painful injury, Mike found himself in a dark place again. Injury in construction can threaten everything at once: livelihood, identity, belonging, masculinity, family stability, and the sense of being useful. For Mike, suicidal intensity returned.

What helped him hold on wasn’t a slogan, or a poster in a breakroom. It was the living reality of belonging and contribution. He thought about his family. He thought about the apprentices and journeymen who called him when they were in trouble. He thought about the men who might not be alive if he hadn’t picked up the phone. He thought about the peer team that had become part of his own recovery. He knew, in his bones, that he mattered to people—not in some abstract self-esteem-workbook way, but because they needed him and he needed them back. His mission helped tether him to life.

Belonging says, “You’re one of us.” Contribution says, “What you bring matters here.” Together, they answer two of suicide’s most devastating lies: I am alone and I am a burden.

Mike’s story reminds me that suicide prevention isn’t just what we do in the moment of crisis. It’s also what we build long before the crisis comes: communities where people are known, needed, missed, and given meaningful ways to care for one another.

Sometimes the thing that keeps a person alive isn’t being rescued by an expert, but realizing, in the darkest hour, “I still have people. I still have purpose. I still have work here to do.”

Midstream: Collaboration, Agency, and Empowerment

When someone is in suicidal pain, the most powerful thing we can often do is not take over. It’s to pull up a chair and work alongside them.

This is the animating spirit of CAMS—the Collaborative Assessment and Management of Suicidality—developed by David Jobes. In CAMS, the clinician literally moves their chair to sit beside the client as they work together on the same document. The message is radical in its simplicity: You are the expert on your own pain. Let’s figure this out together.

Several other evidence-informed therapies share the common gift of helping people build emotional and interpersonal regulation skills, not simply receive rescuing. Therapies such as Dialectical Behavior Therapy, Cognitive Behavioral Therapy for Suicide Prevention, Brief Cognitive Behavioral Therapy for Suicide Prevention, Collaborative Assessment and Management of Suicidality, Attempted Suicide Short Intervention Program, Mentalization-Based Therapy, and problem-solving approaches all, in different ways, help clients survive waves of unbearable emotion, navigate ruptures in relationships, interrupt impulsive action, and reach for connection before acting on suicidal urges.

A recent systematic review and meta-analysis found that suicide-focused interventions containing interpersonal effectiveness training were associated with a 53 percent lower relative risk of suicide attempts, and those containing emotion regulation training were associated with a 42 percent lower relative risk. These findings suggest that helping people regulate emotional storms and relational pain can reduce suicide attempts.

The THRIVE intervention (Toward Hope, Recovery, Interpersonal Connection, Values, and Engagement) builds on Joiner’s interpersonal theory by “flipping” suicide risk factors into recovery targets: belonging, contribution, hope, values, and meaningful engagement. THRIVE invites people to tell the story of their suicide crisis, place it within the larger arc of their life, and co-create a written Meaningful Living Plan. THRIVE’s promise is that it moves suicide care beyond “How do we keep you safe tonight?” and toward “What would help life become worth staying for?”

The field has made real progress. DBT works—for clinicians trained to deliver it, which most are not. CAMS works—in the settings and populations studied, which don’t yet represent the full range of people who show up in crisis. Safety planning works—when it’s done well, collaboratively, and followed up on, rather than scrawled on a form at the end of an overwhelmed session. None of these tools are magic, though, and all of them work best in the hands of a clinician who isn’t so frightened by liability that they’ve forgotten how to sit with another human being.

Downstream: Compassionate Crisis Response

Even in moments of acute crisis, the principles of connection and collaboration hold. Collaborative safety planning—done well—looks nothing like a no-suicide contract. It’s not a promise extracted from a person in pain. It’s a practical, personalized plan built with them, in their own language, for the moments when suicidal intensity returns.

The best versions are specific and portable: this person’s activating events, warning signs, coping strategies, reasons for living, people who help, professional supports, and steps for reducing access to lethal means.

Craig Bryan’s Crisis Response Planning model keeps this beautifully simple: the plan is typically handwritten by the client on an index card. That small act matters. When clients write the plan in their own words and their own handwriting, the message is: This belongs to me.

In a randomized clinical trial with suicidal U.S. Army soldiers, crisis response planning was more effective than contracts for safety, with suicide attempts reduced by 76 percent over six months compared to the contract-for-safety condition. The intervention also led to faster reductions in suicidal ideation and fewer inpatient hospitalization days.

So, when a client is awake at 2 a.m., they’re not looking at a document that says, “I promise not to kill myself.” They’re holding something they helped create: Here is what my crisis looks like. Here is what helps me ride it out. Here are the people I can reach. Here is what I have survived before. Here is what matters enough to keep me here.

Caring contacts are another deceptively simple practice: brief, warm, nondemanding messages sent between sessions, after discharge, or during high-risk transitions. They do not ask the person to call back, explain themselves, reassure the clinician, complete homework, or prove they are safe. They simply communicate care: I’m thinking of you. I’m glad you’re here. You matter to me. You don’t have to answer.

Therapists can send caring contacts, but so can friends, family members, peer supporters, faith leaders, and trusted coworkers. The power is simply in offering steady, low-pressure connection without making the person manage our anxiety. A systematic review and meta-analysis found that caring contacts were associated with reduced suicide attempts. Caring contacts don’t solve the crisis. They help interrupt one of suicide’s most dangerous lies: No one would notice if I were gone.

The practice of working with clients and their families to increase time and distance between a suicidal person and the most lethal methods is also one of the most practical suicide prevention interventions we have. Counseling on Access to Lethal Means (CALM), frames this work as collaborative, autonomy-preserving, and focused especially on firearms and dangerous medications during periods of elevated risk.

But how we facilitate these conversations matters enormously. The goal is not to shame, frighten, lecture, or grab control. It’s to say, with steadiness and respect: Because this part of you wants to die and another part of you is here talking with me, let’s make it harder for the suicidal part to act quickly while the part that wants to live gets more support.

Good lethal-means safety conversations are specific, temporary, and collaborative. We ask what lethal means are available, what the client is willing to change for now, who they trust enough to involve, and what option best preserves both safety and dignity. With medications, that may mean limiting quantities, locking them up, or asking someone else to hold them temporarily. With firearms, it may mean temporary out-of-home storage where legally permissible, using locks or safes, separating ammunition, or involving a trusted family member, peer, firearm retailer, range, or law enforcement partner who can help create distance during the crisis.

For many gun owners, firearms are tied to identity, safety, family tradition, work, sport, military service, or constitutional values. A clinician who approaches the conversation as if the firearm itself is the problem may lose the person before the safety planning begins. The messenger matters: gun owners, veterans, firearm instructors, retailers, peers, and culturally trusted clinicians often have credibility that an outside expert may not.

Firearm safety conversations land best when they emphasize respect, temporary voluntary action, and trusted relationships—not fear, judgment, or confiscation.

A Call to Courageous Connection

This work is hard. Genuinely, profoundly hard.

The fear clinicians feel when sitting with a suicidal client isn’t a failure of training, character, or compassion. It’s a human response to an unbearably high-stakes moment. But fear, left unexamined, can quietly take the wheel.

It can pull us toward control when the moment calls for connection. It can make us reach for the checklist when the client needs our curiosity. It can convince us that documentation is the intervention, that hospitalization is the plan, that a risk category is the answer, that getting through the session safely is the same as helping someone want to live.

We can do better, not by abandoning protocols, but by putting them back where they belong: in service of relationship. Risk formulation, safety planning, consultation, documentation, hospitalization, caring contacts, and lethal-means safety all have a place. But none of them can substitute for the deeper clinical task of meeting a suffering human being with steadiness, humility, and respect.

The skills that make us good therapists are also the skills that make us good suicide prevention clinicians: presence, curiosity, attunement, collaboration, honest conversation, and the willingness to sit in the dark with someone without rushing to turn them into a liability problem.

This doesn’t mean we carry the work alone. We need training that prepares us not only to understand suicide risk, but to stay relationally present inside suicidal intensity. We need supervision and consultation that help us think clearly without shaming us for being afraid. We need organizations that respond to client suicide with compassion and learning, not blame and professional isolation. We need a culture where clinicians can say, “This scared me,” “This loss changed me,” and “I need support,” without fearing that their honesty will be used against them.

Suicide care will never be easy. But it can be more honest. More relational. More humane. More worthy of the people who come to us in their most unbearable moments.

This is the work before us.

Read Part I of this series: Rethinking Suicide Prevention: Confronting an Unspoken Hazard of Our Work

Read Part II of this series: What Doesn’t Work in Suicide Prevention: Three Common Practices to Avoid