Author Kevin Hines frequently speaks publicly about his suicide attempt at the Golden Gate Bridge in an effort to try and help others who are struggling with thoughts and feelings of suicide. One of the things he shares about that day is that he had decided in advance that if just one person asked him what he was doing, or cared enough to check in with him, he would stop and ask for help.
Sometimes, simply caring can save a life.
Undoubtedly, suicide is a complex behavior associated with unique combinations of many diverse risk factors. Even expert clinicians cannot predict suicide in an individual with any acceptable degree of accuracy. Because of this, patients who have multiple risk factors for suicide can create anxiety for providers who may feel unsure of what else they can do to help after having completed their usual suicide prevention strategies.
Caring Letters is a simple intervention that can be added to existing treatment plans and prevention strategies. It has been tested in multiple countries and involves providers, hospital staff or volunteers sending mailed letters, postcards, greeting cards, emails, and text messages to patients following treatment or hospital stays. The messages are often brief and simply let the person know that someone cares about them and wishes them well. An example of a caring letter from an early study of this intervention stated:
It has been some time since you were here at the hospital, and we hope things are going well for you. If you wish to drop us a note we would be glad to hear from you.”
(Motto & Bostrom, 2001, p.829).
Eight to 12 messages are typically sent to the patient over a period of about a year. Simple messages like the one above have been shown to reduce suicide and suicide-related behavior in several clinical trials. Dr. Kate Comtois, a psychologist and professor at the University of Washington, recently presented the results from a Caring Texts intervention for high-risk soldiers and Marines. After 11 Caring Texts were sent over a one-year period, preliminary analyses showed that service members who received the texts were less likely to experience suicidal ideation or make a suicide attempt during that year compared to service members who did not receive the texts. While beneficial results have not been reported in all clinical trials, the body of evidence for Caring Letters recently led the Joint Commission to promote the intervention.
How can such a simple intervention impact suicide behavior? This question is still being researched, but many service members feel the power of a “caring letter” during other situations, such as an overseas deployment. It is possible that repeated messages serve as a reminder that the individual is not alone in the world and that there is someone out there who cares. One of the leading theories of suicide, the Interpersonal Theory of Suicide, states that suicide risk decreases when individuals feel connected to others and cared for. It is also possible that Caring Letters remind individuals that help is available, thereby increasing treatment utilization. Caring Letters often include information about suicide prevention resources (e.g., a crisis line number). Investigators conducting Caring Letters research have noted that the intervention resulted in patients reaching out for help when messages were received during a time of crisis.
Caring Letters may be especially useful for service members during transitions from inpatient to outpatient care, from a crisis call to treatment, between scheduled treatment sessions, and during other transitions and gaps in care. They can also be helpful when a provider has done everything they can to address a service member’s needs, but there is a clinical sense that more is needed.
While Caring Letters cannot directly address underlying mental health disorders or solve major life problems, it is possible that the timing of receiving Caring Letters, or the additive effects of the letters over time, make a difference. Caring Letters can play an important role in a comprehensive suicide prevention plan by reminding patients that they are not alone and that help is available.
Reger is the chief of psychology at the VA Puget Sound Health Care System, and associate professor of psychiatry & behavioral sciences at the University of Washington School of Medicine. His research focuses on military and veteran suicide prevention.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.