Novel Approach to Recovery After Attempted Suicide

Researchers propose a conceptual model of personal recovery after attempted suicide that focuses on nonclinical factors such as helping people find meaning and purpose in their lives.

Developed by a panel of mental health professionals and individuals who have attempted suicide, the COURAGE model has seven themes: choosing life, optimizing identity, understanding oneself, rediscovering meaning, acceptance, growing connectedness, and empowerment.



Dr. Yosef Sokol

“Clinicians can incorporate the COURAGE model into their practice by understanding the importance of each of the seven processes in the model and tailoring their interventions to meet the unique needs of their patients,” Yosef Sokol, PhD, with Touro University School of Health Sciences in New York, told Medscape Medical News.

“By recognizing the individual’s needs and experiences, practitioners can prioritize addressing issues related to ‘choosing life’ or ‘growing connectedness’ for a patient struggling with ongoing suicidality or focus on ’empowerment’ for a patient feeling disempowered in their recovery journey,” said said. Sokol.

Sokol and colleagues describe their model in an article in the British Journal of Psychiatry Open.

Unmet need

In 2020, roughly 12.2 million adults in the US seriously considered suicide, 3.2 million planned a suicide attempt, and 1.2 million attempted suicide, according to federal data.

Despite the significant need, there is currently no model for personal recovery after an acute suicidal episode that is empirically derived from the suicide literature, let alone one developed with input from individuals who have attempted suicide, the investigators say.

Individuals who attempt suicide often face existential challenges related to their life purpose and stand to benefit from a meaningful framework of recovery that goes beyond the traditional model of safety planning and risk reduction.

The COURAGE model involves the following processes.

Choosing life. The process of making a cognitive and emotional decision to live, enabling an increase in interest in life and hopefulness. This can further the recovery process by helping the patient regain a desire to live and begin investing in life by planning for the future.

Optimizing identity. The process of developing a sense of oneself as a valued individual with a coherent life story. This process may include developing self-confidence, self-esteem, a clearer life role, and a “post-suicidal” identity in which the suicidal episode itself is seen as a source of personal growth.

Understanding oneself. The process of developing an understanding of oneself through reflection on one’s life history, emotional reactions, behaviors, strengths, and weaknesses. This process often includes learning about one’s unique pattern of developing increased suicidality and moving toward personal recovery.

Rediscovering meaning.The process of discovering purpose and meaning in life enhances future-oriented beliefs and builds psychological resilience. For many, engaging in religion and/or spirituality provides a sense of community and higher purpose.

Acceptance. The process of feeling accepted by others and accepting one’s internal contradictions, pain, and misalignment with others. Feelings of acceptance often emerge in the context of a safe environment in which to securely discuss negative thoughts and experiences.

Cultivating connectedness. The process of developing quality relationships with family, friends, and community, which can decrease loneliness and increase a sense of belonging, feeling valued, gaining faith in humanity, and reintegrating into society. Support from others on a similar recovery journey will help engage a deeper sense of reintegration, belonging, and connection.

Empowerment. The dual process of developing internally focused skills (self-expression, self-compassion, and emotion regulation) and externally focused skills (empathy, hobbies, and career-oriented abilities). This process often includes developing knowledge and courage to seek and accept professional help.

“Taken in a general sense, these seven COURAGE processes span the scope of human life — what it is to live, grow, and find meaning and purpose,” the investigators write.

They hope the COURAGE model will help peers and family, researchers, and healthcare professionals reconceptualize recovery of an individual who has experienced a suicidal episode.

Sokol said it’s important to realize that “personal recovery can look different for each individual and to emphasize the importance of building upon their patient’s strengths.”

The researchers note that the COURAGE model requires empirical testing using validated measures for coherence, reliability, and validity.

They plan to test the model through the development and evaluation of a treatment that incorporates each of the COURAGE processes. “This treatment will be compared to existing interventions to determine its effectiveness in promoting recovery following a suicidal episode,” Sokol said.

The research received no specific grant from any funding agency, commercial, or not-for-profit sectors. The authors have disclosed no relevant relationships.

BJPsych Open. Published online November 17, 2022. Full text

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