The literature on treating suicidal patients via telehealth group therapy is sparse. Suicide prevention, assessment, and intervention concerns are particularly alarming when working with veterans. The U.S. Department of Veterans Affairs (VA) has estimated that 7 veterans die by suicide daily (2021).
Published in the Journal for Technology in Behavioral Science in early 2023, a team of researchers led by Sapana Patel published the results of a study that identified and treated high-risk patients through group telehealth systems known as “Project Life Force” (PLF). Initial interest in exploring the telehealth possibilities was fueled by the urgent need for effective interventions for veterans who had chosen to move to rural and frontier areas.
In an attempt to find emotional healing, many veterans choose to move to deeply rural areas, away from the excesses and demands of routine urban life. Unfortunately, living at a comfortable distance from urban centers also means they often live in geographically remote areas that are cumbersome to travel for traditional in-person care. The project’s findings can be helpful to clinicians working with other potentially high-risk, suicidal clients and patients.
Telehealth Group Study Overview
Seventeen participants were enrolled in a 10-week, manualized video group. The study was designed to evaluate the “acceptability, feasibility, and impact” of a telehealth suicide safety planning intervention (SPI). Recognized as a best practice, the brief SPI intervention encourages the client and therapist to collaborate in developing a safety plan to manage short-term suicide risk.
The plan is considered conducive to telehealth because it involves a heavy focus on:
- A written, prioritized list of personal suicide warning signs
- Internal coping strategies; social contacts or settings offering support and distraction from suicidal thoughts
- Contact information for available VA professionals
- A crisis line and emergency services
- Specific steps for making the immediate environment safer (Stanley & Brown, 2012; Stanley et al., 2008).
The study was conducted at two VA medical centers: James J. Peters VA (JJPVA) Medical Center in the Bronx, New York, and Michael J. Crescenz VA Medical Center in Philadelphia, Pennsylvania. The video equipment chosen to deliver PLF via telehealth included either VA Video Connect (VVC) or VA WebEx software. The project’s group facilitators included training and experienced DBT and SPI clinicians, a psychiatrist, and a clinical psychologist.
The majority of veteran group participants were the following:
- Male (88%)
- Age 50 (SD = 15.6)
- Ethnically diverse
- Either divorced or separated (54%).
Suicide symptoms at the beginning of the study included the following:
- Past month ideation with methods (100%)
- Past year aborted, interrupted, or actual suicide attempt (59%).
To be included, participants had to be the following:
- Between 18–89 years old
- Reporting a heightened suicide risk, defined as a current suicide-related inpatient admission
- Presence on the high-risk list
- For outpatients, either a suicide attempt in the past year or active suicidal ideation with at least some intent within the past month using the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011).
Reasons for excluding potential participants excluded from the study included the following:
- Being unable to speak English or consent
- Unable to tolerate group intervention format
- Being medically supervised for substance use withdrawal
- Diagnosis of schizophrenia
- Participating in another intervention concurrently (Goodman et al., 2020).
Veterans were interviewed after the intervention, and the following themes emerged from those interviews. They include the following:
- Accessibility by veterans – participants commented on the convenience and low cost of accessing the group; some commented that the facilitator tried to be inclusive to ensure equitable participation
- Convenience – this theme included mention of reduced financial strain, increased ability to attend, how it was easier to balance competing demands like other appointments or child care, and the elimination of the need to travel.
- Feasibility – several participants commented on how they were able to overcome the common challenges with Internet connectivity in rural and frontier areas. Many commented that being able to participate by telephone or video made it easier to participate and hope they appreciated the technical assistance, earbuds, headphones, and having someone call them by telephone if they had not joined in time. They suggested that future versions of the program provide training for participants on how to use the video platform, offer them mobile phone cards for participants who had limited minutes to use their phones, and Webex pre-installed apps on their iPads for ease of use.
Participant interviews revealed an overall positive endorsement of telehealth group therapy with enhanced suicidal disclosure and improved ability to manage urges and mitigate loneliness. On scales from 1 to 20, telehealth was rated as highly acceptable (M = 17.50; SD = 2.92), appropriate (M = 17.25; SD = 3.59), and feasible (M = 18; SD = 2.45) by participants.
Positive outcomes included increased awareness of suicidal thoughts and behaviors and appreciation of the connection between how their safety plan provided coping strategies for dealing with suicidal thoughts and feelings. They also expressed an increase in the following:
- A better understanding of warning signs
- Connection between their suicidality and substance abuse, PTSD, and depression
- Support from “brothers” and “sisters”
- Safe space to open up
Of particular interest to this article is the study’s last paragraph, which summarizes several helpful telehealth adaptations to this type of telehealth group therapy. They include the following:
- The use of a communications coordinator to conduct assertive outreach to facilitate engagement, such as calling the participant to ensure their participation
- Access to a telehealth orientation session
- Restructuring sessions as needed to deal with more severe suicidal ideation
- Emailing and screen sharing the PLF manual and safety plans to enhance learning.
- Telehealth group members were invited to speak to a group facilitator before joining the group.
The study’s research team members also commented on the need to further operationalize the assessment of suicide risk before weekly telehealth group sessions as an adaptation that they would suggest in the future.
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