Science

Here you find studies on Next-Steps Plans, on letters and messages after a crisis, on belonging and on emotional pain. The results come first, the sources follow below.

What does a Next-Steps Plan offer?

The Next-Steps Plan on Helpful Neurons follows the structure of the Safety Planning Intervention by Stanley and Brown. In the title of their article, Stanley and Brown describe it as a brief intervention to mitigate suicide risk.^[1] A later study defined it as a brief clinical intervention with a prioritized list of coping skills and strategies.^[2]

In a study in emergency departments of the US Veterans Health Administration, a Next-Steps Plan with follow-up phone calls was associated with less suicidal behavior in the following six months and with higher odds of attending at least one outpatient mental health appointment.^[2]

Limits: the study was not randomized. Most participants were men, treated in emergency departments of the Veterans Health Administration. The share of the plan alone cannot be separated from the phone calls.

Does keeping in touch help?

In a randomized trial, regular letters to people who had declined further treatment were associated with fewer suicides in the first two years. After that, the difference became smaller.^[3]

A review of brief contacts such as letters, cards and calls found fewer repeated episodes of self-harm or suicide attempts per person, based on only three studies. For the number of people with a repeated episode of self-harm or suicide attempt, and for suicides, the difference was not statistically certain.^[4]

A later review found that caring messages can be associated with fewer suicide attempts in the first year. For suicides, the evidence was uncertain.^[5]

Why does belonging matter?

According to the interpersonal theory, a suicidal wish can arise when the feeling of not belonging and the feeling of being a burden to others occur together, with the sense that these states will not change.^[6] A meta-analysis of 122 samples found that these feelings in combination were associated with suicidal thoughts, with modest effect sizes.^[7]

Limits: this is a theory with a modest association. It offers no proof that more connection alone resolves a crisis.

Can the brain change?

Connections between nerve cells can decrease under lasting stress and can rebuild with treatment.^[8] A model links rigid thought patterns with changes in nerve connections that can in principle change.^[9]

Limits: these findings come from research on depression and in part from animal studies. The authors of the model note that direct evidence is still needed. The name Helpful Neurons can be read as a careful image of confidence.

What does psychache mean?

In a commentary, Edwin S. Shneidman described suicide as psychache.^[10] A systematic review found that mental pain was linked with suicide risk, even without a diagnosed mental disorder.^[11]

The pain is real and deserves to be taken seriously. It describes a state and says nothing about a person’s worth.

Does gratitude support well-being?

In a review, gratitude was strongly associated with well-being. The authors rated interventions for more gratitude as promising, with limits in the research so far. According to its summary, the review makes no statement about suicidal thoughts.^[12]

What does the sense of coherence describe?

The sense of coherence goes back to Aaron Antonovsky.^[13] His questionnaire measures it with items on three parts: comprehensibility, manageability and meaningfulness.^[19]

A systematic review of 458 scientific publications and 13 doctoral theses found that the sense of coherence was strongly related to perceived health, especially mental health. The stronger the sense of coherence, the better the perceived health in general, at least for people with an initially high sense of coherence.^[14] A meta-analysis of 41,013 children, adolescents and young adults found that a weaker sense of coherence was associated with more mental health problems. Internalizing symptoms, depressive symptoms and loneliness were more strongly associated with it than psychosomatic symptoms. Overall, the differences between symptom types were smaller than those between studies.^[15]

Among 155 people after a suicide attempt, a weak sense of coherence was associated with stronger suicidality two months later, also after taking depression into account.^[16] In a Finnish study of 8,029 employees, a strong sense of coherence was associated over 19 years with a lower risk of psychiatric disorders, measured by hospital admissions and register data.^[17]

The sense of coherence can change. A meta-analysis of 27 randomized trials found that programs can strengthen it in older adults and adults with chronic conditions for up to three months afterwards.^[18]

Limits: the studies and reviews [14]–[17] show associations and no causes. After taking depression and symptom burden into account, the sense of coherence was no longer associated with a repeat suicide attempt. After six months, the effect of the programs was no longer certain.

Which ideas help thinking?

The following ideas come from Johannes’ earlier writing. They can serve as images and carry no proof.

Fast and slow thinking. Fast, automatic thinking (often called System 1) can react strongly to emotion. Slow, deliberate thinking (System 2) can help to question first impressions. In practice: breathe slowly three times, ask yourself “What else can I do right now?”, ask another person for their view and choose one small step.

A society of inner parts. Following Marvin Minsky’s idea of a “society of mind”, the mind can be seen as many inner agents. Three steps follow from this: listening to helpful parts, getting the parts to talk with each other and bringing in a person from outside.

Which sources are there to check?

Stanley, Brown (2012). Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19, 256–264. DOI: 10.1016/j.cbpra.2011.01.001
Stanley, Brown, Brenner et al. (2018). Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department. JAMA Psychiatry. DOI: 10.1001/jamapsychiatry.2018.1776
Motto, Bostrom (2001). A Randomized Controlled Trial of Postcrisis Suicide Prevention. Psychiatric Services. DOI: 10.1176/appi.ps.52.6.828
Milner, Carter, Pirkis, Robinson et al. (2015). Letters, green cards, telephone calls and postcards: Systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide. British Journal of Psychiatry. DOI: 10.1192/bjp.bp.114.147819
Skopp, Smolenski, Bush et al. (2023). Caring contacts for suicide prevention: A systematic review and meta-analysis. Psychological Services. DOI: 10.1037/ser0000645
Van Orden, Witte, Cukrowicz, Braithwaite et al. (2010). The interpersonal theory of suicide. Psychological Review. DOI: 10.1037/a0018697
Chu, Buchman-Schmitt, Stanley et al. (2017). The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research. Psychological Bulletin. DOI: 10.1037/bul0000123
Duman, Aghajanian (2012). Synaptic Dysfunction in Depression: Potential Therapeutic Targets. Science. DOI: 10.1126/science.1222939
Price, Duman (2020, online 2019). Neuroplasticity in cognitive and psychological mechanisms of depression: an integrative model. Molecular Psychiatry. DOI: 10.1038/s41380-019-0615-x
Shneidman (1993). Commentary: Suicide as Psychache. The Journal of Nervous and Mental Disease. DOI: 10.1097/00005053-199303000-00001
Verrocchio, Carrozzino, Marchetti et al. (2016). Mental Pain and Suicide: A Systematic Review of the Literature. Frontiers in Psychiatry. DOI: 10.3389/fpsyt.2016.00108
Wood, Froh, Geraghty (2010). Gratitude and well-being: A review and theoretical integration. Clinical Psychology Review. DOI: 10.1016/j.cpr.2010.03.005
Antonovsky (1987). Unraveling the Mystery of Health. Jossey-Bass. Book, ISBN 978-1-55542-028-4
Eriksson, Lindström (2006). Antonovsky’s sense of coherence scale and the relation with health: a systematic review. Journal of Epidemiology and Community Health, 60, 376–381. DOI: 10.1136/jech.2005.041616
Schäfer, Sopp, Fuchs, Kotzur, Maahs, Michael (2023). The relationship between sense of coherence and mental health problems from childhood to young adulthood: A meta-analysis. Journal of Affective Disorders, 325, 804–816. DOI: 10.1016/j.jad.2022.12.106
Sjöström, Hetta, Waern (2012, online 2011). Sense of coherence and suicidality in suicide attempters: a prospective study. Journal of Psychiatric and Mental Health Nursing, 19, 62–69. DOI: 10.1111/j.1365-2850.2011.01755.x
Kouvonen, Väänänen, Vahtera, Heponiemi, Koskinen, Cox, Kivimäki (2010, online 2009). Sense of coherence and psychiatric morbidity: a 19-year register-based prospective study. Journal of Epidemiology and Community Health, 64, 255–261. DOI: 10.1136/jech.2008.083352
Liu, Zhang, Montayre, Koduah, Leung (2025). Non-Pharmacological Interventions Targeting Sense of Coherence Among Older Adults and Adults With Chronic Conditions: A Meta-Analysis With Trial Sequential Analysis. Journal of Advanced Nursing, 81, 2165–2198. DOI: 10.1111/jan.16558
Eriksson, Mittelmark (2017, online 2016). The Sense of Coherence and Its Measurement. The Handbook of Salutogenesis, 97–106. DOI: 10.1007/978-3-319-04600-6_12

What do studies say about Next-Steps Plans?

Every person has the right, first and foremost, to be heard and seen – without any attempt to cheer them up or to offer a solution.

Answer with warmth and without pressure, and work with me constructively. Summarize for me in plain words what studies say about Next-Steps Plans (Safety Planning Intervention) for hard moments. Name sources and studies for your statements with authors, year and DOI.

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What do studies say about caring contacts?

Every person has the right, first and foremost, to be heard and seen – without any attempt to cheer them up or to offer a solution.

Answer with warmth and without pressure, and work with me constructively. Summarize for me in plain words what studies say about caring contacts, that is, short messages or letters after a crisis. Name sources and studies for your statements with authors, year and DOI.

What do studies say about connectedness and belonging?

Every person has the right, first and foremost, to be heard and seen – without any attempt to cheer them up or to offer a solution.

Answer with warmth and without pressure, and work with me constructively. Summarize for me in plain words what studies say about connectedness, belonging and emotional well-being. Name sources and studies for your statements with authors, year and DOI.