Written by Orla Gleeson whilst working as a Research Assistant for the CARMS project but has now left to start a Trainee Clinical Psychologist role at Teeside University


Suicide is a global problem and arguably preventable. In England 13 people kill themselves every day, one person every 90 minutes in the UK [1]. Suicidal behaviour is common on acute psychiatric wards [2, 3] and 92 inpatient suicides were recorded in the UK in 2017 [4]. Some might find this odd since being an inpatient you are surrounded by staff 24 hours a day. However, the current measures in place to target suicidal experiences do not offer the space and time necessary to discuss these thoughts and feelings.


Being on an inpatient ward can seem scary and challenging. People often do not want to be there for many reasons, some may believe they don’t deserve help or that they are not ‘unwell’ enough. Often people are placed on one to one observation for suicidal thoughts and behaviours, which means someone is watching you all of the time, which can be embarrassing and degrading. This situation feels necessary for staff to keep inpatients safe. However, this can also lead to shutting down relationships and trust with the patient, leaving the suicidal thoughts and feelings unexplored.


From my experience working in an acute inpatient environment I am aware people can find it really difficult to open up to staff about their suicidal thoughts and feelings for many reasons. Sometimes when attempts are made by inpatients to explore these thoughts and feelings they can be met with offers of medication from staff, as an attempt to alleviate distress. This can lead to emotional avoidance and potential for the person’s suicidality to increase. Some may feel that if they open up about suicidal thoughts and behaviours that this information will be “used against them” [5] e.g. their observation level being increased or their personal belongings being removed. Often this leads to inpatients feeling they cannot talk to staff, either there is no space to do so or there are unwanted consequences, so they attempt to hide suicidal thoughts and behaviours. When people are discharged from hospital and they don’t feel any differently about their suicidal thoughts and feelings, this can be a very difficult and lonely time for them. There is evidence to suggest that 43% of suicides happen in the first month after discharge from an inpatient unit [6]. Not working through suicidal experiences could also contribute to multiple re-admissions for people.


Psychotherapy for people with suicidal experiences on a mental health inpatient ward

People being admitted onto inpatient wards presents a critical opportunity to engage them in effective treatment to reduce and help people cope with suicidal experiences, which essentially would preserve life.


Delivering therapy to inpatients could have some hurdles, for example, being admitted to hospital can be a time of high risk [7] and people could feel that talking about suicide may make them ‘more suicidal’ [8]. However, people’s experience of participating in suicide-related research has shown the opposite; researchers found that participants had positive experiences, including increased altruism and self-understanding. For some participants, these benefits remained in the month’s post-participation [9].

Furthermore, people may feel uncomfortable talking about suicide due to the stigma attached to these conversations – something we’ve talked about previously in our blog about ending stigma surrounding suicide. People may also have concerns about confidentiality between therapist and the staff members [5]. However, information only needs to be shared if there is imminent risk. One potential way of addressing these issues, is to be clear about limits to confidentiality. A second approach could be to reassure people that they will be talking through suicidal thoughts and feelings in a place where support is available 24/7. There is evidence to suggest talking about and finding ways to cope with suicidal experiences, could lead to fewer suicidal thoughts and feelings in the future, instead of trying to push them away [5].


In order for CARMS to introduce this Cognitive Behavioural Suicide Prevention (CBSP) therapy onto the wards, these issues were explored qualitatively in a pilot trial, INSITE. Before piloting the therapy, the study team asked inpatients what they thought about a suicide-focussed therapy for inpatients [5]. The participants stated they felt the suicide-focussed therapy could be a therapy that ‘would work’ for psychiatric in-patients and that it was needed, one person stated, “I’m willing to give anything a go to stop me feeling like this” [5]. Other priorities included being discharged and suicide-focussed therapy was viewed as a way to help people work towards discharge. People felt it could offer a route to understanding their suicidal thoughts and behaviours which can lead to developing strategies to avoid future suicidal behaviours, “help me to recognise when I’m going to be suicidal and perhaps be able to do something about it”. This is really important as the main reason for prolonged admissions to hospital is suicidal behaviour [5].


The INSITE study found that a suicide-focussed psychotherapy was feasible and acceptable for people who were acutely suicidal whilst on an inpatient unit and also following discharge [10]. Therefore, delivering a suicide prevention therapy to people on inpatient wards could help to create a safe environment which facilitates clients to share and explore suicidal experiences. Delivering CBSP therapy to people on inpatient units could help to provide a route to understanding their suicidal crisis and learn self-management strategies on the road to discharge. This may help them to recognise their suicidal feelings as they come up and be able to do something about it whilst in the community, leading to less suicidal thoughts and behaviours.


Research on delivering CBSP on mental health inpatient wards

Since the INSITE trial proved that it was feasible and acceptable to recruit and deliver CBSP on the inpatient wards, the CARMS (Cognitive AppRoaches to coMbatting Suicidality) project [11] amended their inclusion criteria just over 1 year ago to include people with psychosis and suicidal experiences on mental health inpatient wards. Just in case you’re new to our blog, you can find out more about the CARMS project on the main part of our website here. The new suicide-focussed therapy has been in development over the last decade by a team interested in suicide prevention at the University of Manchester. CARMS focusses on tailoring CBSP to people experiencing psychosis.

In terms of CBSP therapy delivered as part of CARMS on the inpatient wards, an assertive and flexible approach is used to make it easier for people to be seen whilst on an inpatient ward. Therapy can start in the place where people most need it, offering a space to talk through suicidal thoughts and feelings, which can then be carried on into the community.  Often, psychotherapies are paused when people are admitted onto a ward or they receive some psychotherapy whilst on the ward and then therapy does not continue when they are discharged, leaving issues ‘unfinished’, which can be harmful. When people leave from an inpatient unit this can also be a frightening time where they feel less supported and more isolated. CARMS therapists will continue to see people when they are discharged into the community offering support at a time which can be scary and daunting for people leaving hospital.


Approximately one quarter of suicide deaths occur within the first week of a psychiatric admission and 17% of suicides occur in the 3 months after a patient is discharged [12]. Therefore, there is a dire need for more effective therapeutic support across inpatient units, specifically geared towards suicide-prevention. Therapeutic support which breaks down the barriers to engagement on a ward and continues after a patient is discharged.


* This article contains references to suicide that some people may find distressing so if at any point you require urgent support with your mental health please contact your GP, care coordinator or crisis team. Other help can be found here:
A bit about Orla Gleeson

“I am currently a Research Assistant with the CARMS project, prior to this I have several years’ experience of working on different inpatient wards. I have worked on wards as a Healthcare Assistant and also as an Assistant Psychologist. I’ve spoken to service users about what they want to get from being on the ward and have worked with them to adapt psychoeducational groups which are being delivered to cover the topics they feel are most important. Throughout my experience, service users have said they want more therapy opportunities whilst on the wards, there is so much time which can be used more effectively to help them get to where they want to be.”

Orla has since left the CARMS project and will be starting as a Trainee Clinical Psychologist with Teeside University in late September 2020.

  1. Champs (2017). NO MORE Suicide. Preventing suicide in Cheshire & Merseyside 2017. Retrieved from https://www.champspublichealth.com/suicide-prevention
  2. Haw, C., Bergen, H., Casey, D. & Hawton, K. (2007). Repetition of deliberate self-harm: a study of the characteristics and subsequent deaths in patients presenting to a general hospital according to extent of repetition. Suicide Life Threatening Behavior, 37(4), 379-396. DOI: https://doi.org/10.1521/suli.2007.37.4.379
  3. Kapur, N., Cooper, J., King-Hele, S., Webb, R., Lawlor, M., Rodway, C., & Appleby, L. (2006). The repetition of suicidal behavior: a multicenter cohort study. J Clin Psychiatry, 67(10), 1599-1609. DOI: https://doi.org/10.4088/JCP.v67n1016
  4. The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report: England, Northern Ireland, Scotland and Wales. 2019. University of Manchester. Retrieved from http://documents.manchester.ac.uk/display.aspx?DocID=46558
  5. Awenat, Y. F., Peters, S., Gooding, P. A., Pratt, D., Shaw-Núñez, E., Harris, K., & Haddock, G. (2018). A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths. BMC psychiatry18(1), 334. DOI: https://doi.org/10.1186/s12888-018-1921-6
  6. Hunt, I., Kapur, N., Webb, R., Robinson, J., Burns, J., Shaw, J., & Appleby, L. (2009). Suicide in recently discharged psychiatric patients: A case-control study. Psychological Medicine, 39(3), 443-449.  https://doi.org/10.1017/S0033291708003644
  7. Windfuhr, K. & Kapur, N. (2011) Suicide and mental illness: a clinical review of 15 years findings from the UK National Confidential Inquiry into Suicide. British Medical Bulletin, 100, 101-121. https://doi.org/10.1093/bmb/ldr042
  8. Bajaj, P., Borreani, E., Ghosh, P., Methuen, C., Patel, M., & Joseph, M. (2008). Screening for suicidal thoughts in primary care: the views of patients and general practitioners. Mental health in family medicine5(4), 229–235.
  9. Littlewood, D.L., Quinlivan, L., Steeg, S., Bennett, C., Bickley, H., Rodway, C., … Kapur, N. (2019). Evaluating the impact of patient and carer involvement in suicide and self‐harm research: A mixed‐methods, longitudinal study protocol. Health Expectations [published online ahead of print]. DOI: https://doi.org/10.1111/hex.13000
  10. Haddock, G., Pratt, D., Gooding, P., Peters, S., Emsley, R., Evans, E., …. Awenat, Y. (2019). Feasibility and acceptability of suicide prevention therapy on acute psychiatric wards: Randomised controlled trial. BJPsych Open,5(1), E14. DOI: https://doi.org/10.1192/bjo.2018.85
  11. Gooding, P.A., Pratt, D., Awenat, Y., Drake, R., Elliott, R., Emsley, R., … Haddock, G. (2020) A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol. BMC Psychiatry,20(306). DOI: https://doi.org/10.1186/s12888-020-02697-8
  12. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report: England, Northern Ireland, Scotland and Wales. October 2017. University of Manchester. Retrieved from http://documents.manchester.ac.uk/display.aspx?DocID=37560