Consumer experiences and perceptions of change during psychotherapy for suicide imagery – a mixed-methods case series of Integrated skills for SUicide IMagery (I-SUIM)

Background and objectives: This study is the first to explore mechanisms of change and engagement experiences for consumers completing a tailored intervention involving imagery rescripting, replacement implementation intentions, and imagery rehearsal to target hypothesised mechanisms of suicide imagery (Integrated skills for SUicide IMagery; I-SUIM).Design and Methods: Adult participants with suicide imagery (N = 8) completed two weekly baseline surveys, followed by 3-4 I-SUIM sessions with post-session measures, and a two-week follow-up survey. Evaluation included qualitative interviews at follow-up and mixed-methods surveys collecting qualitative feedback and quantitative ratings of suicide imagery duration, coping, imagery meaning, distress, suicide urge, imagery features, and metacognitions.Results: No participants dropped out of treatment, and there were no series adverse events. All participants endorsed the intervention as beneficial. Most reported improved understanding of imagery precipitants and function, meaning, and safety plan use. Improvements in other mechanisms were more variable, including changes to imagery features, defusion, emotion changes, and metacognitive shifts. Participants noted some challenges including temporary imagery salience and negative affect immediately following rescripting and difficulty practicing independently. Participants described the role of an experienced and empathetic therapist important to guide intervention and help them feel less alone. Limitations: There was no control arm and the study was not designed to demonstrate efficacy.Conclusions: I-SUIM appears safe and acceptable with qualitatively reported improvements. However, the specific nature of improvements may vary between individuals, and future research is required to assess efficacy across a range of cognitive, emotional, and behavioural outcomes.