Korean Clinical Psychology Association

Current Issue

Korean Journal of Clinical Psychology - Vol. 38 , No. 4

[ Review Article ]
Korean Journal of Clinical Psychology - Vol. 38 , No. 4 , pp.400-414
ISSN: 2466-197X (Online)
publication date 30 Nov 2019
Received 04 Oct 2019 Accepted 06 Nov 2019
DOI: https://doi.org/10.15842/kjcp.2019.38.4.006

자살행동의 근거기반치료
유성은 ; 김효중
충북대학교 심리학과

Evidence-Based Psychological Treatments of Suicidal Behavior
Sungeun You ; Hyojoong Kim
Department of Psychology, Chungbuk National University, Cheongju, Korea
Correspondence to : Sungeun You, Department of Psychology, Chungbuk National University, 1 Chungdae-ro, Seowon-gu, Cheongju, Korea; E-mail: syou@chungbuk.ac.kr

© 2019 Korean Clinical Psychology Association


본 연구는 자살행동의 근거기반치료에 대한 개관을 목적으로 시행되었다. 구체적으로 본 연구에서는 메타연구와 무선할당통제연구를 중심으로 자살위기에 대한 단기 심리적 개입과 심리치료적 접근에 대한 치료 효과 연구를 개관하였다. 연구 결과, 단기 심리적 개입 중에는 WHO에서 개발한 단기 개입 및 추후 접촉(WHO-BIC), 안전계획 개입(SPI)과 위기 반응 계획(CRP)이 근거기반이 강한 또는 어느 정도인 치료인 것으로 나타났다. 심리치료적 접근 방법 중에는 자살행동의 감소를 목적으로 시행되는 인지행동치료(CBT)와 변증법적치료(DBT), 자살위기에 대한 협력적 평가 및 관리(CAMS)가 다양한 임상 집단에서 비교적 일관적으로 치료효과가 반복 검증되어 강한 근거 수준을 보였다. 하지만 자살행동에 대한 심리치료 효과에 대한 국내 연구는 자살생각의 감소만을 평가하였고 자살시도의 감소 또는 자살예방을 목적으로 한 치료효과 연구는 없는 것으로 나타나 현 시점에서 근거기반 수준을 평가하기에는 시기상조인 것으로 나타났다. 이에 본 연구에서는 해외 연구를 기반으로 자살행동에 대한 근거기반치료에 대한 권고안을 제시하였고 국내 연구 및 임상 현장에서의 적용에 대해 논의하였다.


The aim of this study was to review evidence-based psychological treatments of suicidal behavior. Specifically, the effectiveness of brief psychological crisis interventions and suicide-specific psychological treatments were examined based on meta-analytic studies and randomized controlled studies. The results of the current review indicate that brief intervention and contact developed by World Health Organization (WHO-BIC), safety planning intervention (SPI), and crisis response planning (CRP) are evidence-based brief psychological interventions. Among psychological treatments, cognitive behavioral therapy, dialectical behavioral therapy, and collaborative assessment and management of suicidality (CAMS) are evidence-based. In Korea, treatment outcome studies of suicidal behavior have targeted for reducing suicidal ideation only, but not for suicide attempt or suicide. Thus, it is premature to determine the evidence level of psychological treatments of suicidal behavior in Korea. Based on studies in other countries, evidence-based psychological treatments for suicidal behavior are recommended, and directions for domestic research and practical applications are suggested.

Keywords: suicide, suicidal behavior, evidence-based treatment
키워드: 자살, 자살행동, 근거기반치료


This work was conducted during the research year of Chungbuk National University in 2018.

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
2. Andreasson, K., Krogh, J., Wenneberg, C., Jessen, H. L. K., Krakauer, K., Gloud, C., . . . Nordentoft, M. (2016). Effectiveness of dialectical behavior therapy versus collaborative assessment and management of suicidality treatment for reduction of self-harm in adults with borderline personality traits and disorder–A randomized observer-blinded clinical trial. Depression and Anxiety, 33, 520-530.
3. Appleby, L., Kapur, N., Shaw, J., Windfuhr, K., Hunt, I. M., Flynn, D., . . . Tham, S. G. (2015). The national confidential inquiry into suicide and homicide by people with mental illness annual report 2015: England, Northern Ireland, Scotland and Wales. University of Manchester.
4. Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 97, 90-113.
5. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford.
6. Bertolote, J. M., Fleischmann, A., De Leo, D., Phillips, M. R., Botega, N. J., Vijayakumar, L., . . . Wasserman, D. (2010). Repetition of suicide attempts: Data from five culturally different low-and middle-income country emergency care settings participating in the WHO SUPRE-MISS study. Crisis, 31, 194-201.
7. Brodsky, B. S., Spruch-Feiner, A., & Stanley, B. (2018). The zero suicide model: Applying evidence-based suicide prevention practices to clinical care. Frontiers in Psychiatry, 9:33.
8. Brown, G. K., & Jager-Hyman, S. (2014). Evidence-based psychotherapies for suicide prevention: Future directions. American Journal of Preventive Medicine, 47, 186-194.
9. Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Journal of American Medical Association, 294, 563-570.
10. Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., Williams, S. R., . . . Rudd, M. D. (2017). Effect of crisis response planning vs. Contracts for safety on suicide risk in US army soldiers: A randomized clinical trial. Journal of Affective Disorders, 212, 64-72.
11. Bryan, C. J., & Rudd, M. D. (2010). Managing suicide risk in primary care. New York, NY: Springer.
12. Calati, R., & Courtet, P. (2016). Is psychotherapy effective for reducing suicide attempt and non-suicidal self-injury rates? Meta-analysis and meta-regression of literature data. Journal of Psychiatric Research, 79, 8-20.
13. Cho, Y. R. (2017). Evidence-based treatments of anxiety and anxiety-related disorders: Criteria, research issues, comments, and suggestions. Korean Journal of Clinical Psychology, 36, 449-457.
14. Comtois, K. A., Jobes, D. A., S. O’Connor, S., Atkins, D. C., Janis, K., Chessen, C. E., . . . Yuodelis‐Flores, C. (2011). Collaborative assessment and management of suicidality (CAMS): Feasibility trial for next‐day appointment services. Depression and Anxiety, 28, 963-972.
15. Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. Journal of the American Medical Association Psychiatry, 74, 319-328.
16. Cuijpers, P., de Beurs, D. P., van Spijker, B. A., Berking, M., Andersson, G., & Kerkhof, A. J. (2013). The effects of psychotherapy for adult depression on suicidality and hopelessness: A systematic review and meta-analysis. Journal of Affective Disorders, 144, 183-190.
17. DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical behavior therapy is effective for the treatment of suicidal behavior: A meta-analysis. Behavior Therapy, 50, 60-72.
18. Drew, B. L. (2001). Self-harm behavior and no-suicide contracting in psychiatric inpatient settings. Archives of Psychiatric Nursing, 15, 99-106.
19. Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Bolhari, J., Botega, N. J., . . . Thanh, H. T. T. (2008). Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bulletin of the World Health Organization, 86, 703-709.
20. Frey, L. M., & Hunt, Q. A. (2018). Treatment for suicidal thoughts and behavior: A review of family‐based interventions. Journal of Marital and Family Therapy, 44, 107-124.
21. Goodman, M., Banthin, D., Blair, N. J., Mascitelli, K. A., Wilsnack, J., Chen, J., . . . New, A. S. (2016). A randomized trial of dialectical behavior therapy in high-risk suicidal veterans. The Journal of Clinical Psychiatry, 77, 1591-1600.
22. Hawton, K., Witt, K. G., Salisbury, T. L. T., Arensman, E., Gunnell, D., Hazell, P., . . . van Heeringen, K. (2016). Psychosocial interventions following self-harm in adults: A systematic review and meta-analysis. The Lancet Psychiatry, 3, 740-750.
23. Hetrick, S. E., Robinson, J., Spittal, M. J., & Carter, G. (2016). Effective psychological and psychosocial approaches to reduce repetition of self-harm: A systematic review, meta-analysis and meta-regression. BMJ Open, 6, e011024.
24. Hofstra, E., Van Nieuwenhuizen, C., Bakker, M., Özgül, D., Elfeddali, I., de Jong, S. J., & van der Feltz-Cornelis, C. M. (in press). Effectiveness of suicide prevention interventions: A systematic review and meta-analysis. General Hospital Psychiatry..
25. Huh, D., Jobes, D. A., Comtois, K. A., Kerbrat, A. H., Chalker, S. A., Gutierrez, P. M., & Jennings, K. W. (2018). The collaborative assessment and management of suicidality (CAMS) versus enhanced care as usual (E-CAU) with suicidal soldiers: Moderator analyses from a randomized controlled trial. Military Psychology, 30, 495-506.
26. Inagaki, M., Kawashima, Y., Kawanishi, C., Yonemoto, N., Sugimoto, T., Furuno, T., . . . Yamada, M. (2015). Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: A meta-analysis. Journal of Affective Disorders, 175, 66-78.
27. Jeon, H. S., Chun, J. S., & Chung, H. E. (2017). A meta-analysis of the effectiveness of suicide prevention programs for adolescents: Focusing on middle·high school students. Mental Health & Social Work, 45, 92-121.
28. Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York, NY: Guilford.
29. Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An evolving evidence‐based clinical approach to suicidal risk. Suicide and Life‐Threatening Behavior, 42, 640-653.
30. Jobes, D. A., Comtois, K. A., Gutierrez, P. M., Brenner, L. A., Huh, D., Chalker, S. A., . . . Crow, B. (2017). A randomized controlled trial of the collaborative assessment and management of suicidality versus enhanced care as usual with suicidal soldiers. Psychiatry, 80, 339-356.
31. Kang, H. Y., & Lee, H. J. (2017). The impact of motivation enhancing-CBT program on suicide prevention among suicide attempters: A pilot study. Mental Health & Social Work, 45, 139-165.
32. Kelly, K. T., & Knudson, M. P. (2000). Are no-suicide contracts effective in preventing suicide in suicidal patients seen by primary care physicians? Archives of Family Medicine, 9, 1119-1121.
33. Kim, J. M., & Park, J. H. (2011). Core mindfulness-based cognitive behaviour therapy for female college students with high suicide risk. Korean Journal of Counseling, 12, 1451-1471.
34. Kim, M. S. (2012). The effect of suicide prevention programs: A meta-analytic review. Korean Journal of Social Welfare Research, 30, 27-56.
35. Kim, M. S., Koo, C. H., & Sohn, B. D. (2018). Meta-analysis on the effectiveness of suicide prevention program for suicide risk youth. Journal of Korean Criminological Association, 12, 107-121.
36. Kim, Y. S. (2009). The effect of a group counseling program on depression and suicidal prevention in high school students. Journal of Korean Academy of Community Health Nursing, 20, 343-350.
37. Krysinska, K., Batterham, P. J., & Christensen, H. (2017). Differences in the effectiveness of psychosocial interventions for suicidal ideation and behaviour in women and men: A systematic review of randomised controlled trials. Archives of Suicide Research, 21, 12-32.
38. Labelle, R., Pouliot, L., & Janelle, A. (2015). A systematic review and meta-analysis of cognitive behavioural treatments for suicidal and self-harm behaviours in adolescents. Canadian Psychology/Psychologie Canadienne, 56, 368-378.
39. Labouliere, C. D., Stanley, B., Lake, A. M., & Gould, M. S. (2019). Safety planning on crisis lines: Feasibility, acceptability, and perceived helpfulness of a brief intervention to mitigate future suicide risk. Suicide and Life‐Threatening Behavior..
40. Leavey, K., & Hawkins, R. (2017). Is cognitive behavioural therapy effective in reducing suicidal ideation and behaviour when delivered face-to-face or via e-health? A systematic review and meta-analysis. Cognitive Behaviour Therapy, 46, 353-374.
41. Lee, S. Y., Choi, W. Y., & Kim, C. K. (2005). Effectiveness of a reality therapy-based group counseling program on the reduction of adolescent depression and suicidal ideation. Korean Journal of Youth Studies, 12, 141-186.
42. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.
43. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., . . . Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757-766.
44. Linehan, M. M., Goodstein, J. L., Nielsen, S. L., & Chiles, J. A. (1983). Reasons for staying alive when you are thinking of killing yourself: The reasons for living inventory. Journal of Consulting and Clinical Psychology, 51, 276-286.
45. Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., . . . Hedin, H. (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association, 294, 2064-2074.
46. McCabe, R., Garside, R., Backhouse, A., & Xanthopoulou, P. (2018). Effectiveness of brief psychological interventions for suicidal presentations: A systematic review. BMC Psychiatry, 18, 120-133.
47. Milner, A. J., Carter, G., Pirkis, J., Robinson, J., & Spittal, M. J. (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. The British Journal of Psychiatry, 206, 184-190.
48. Ministry of Health & Welfare. (2019). The 2019 white paper of suicide prevention. Sejong, Korea: Author.
49. Mrazek, P. J., & Haggerty, R. J. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, D. C.: National Academy Press, Institute of Medicine.
50. Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30, 133-154.
51. Okolie, C., Dennis, M., Thomas, E. S., & John, A. (2017). A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people. International Psychogeriatrics, 29, 1801-1824.
52. Oquendo, M. A., & Baca-Garcia, E. (2014). Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: Advantages outweigh limitations. World Psychiatry, 13, 128-130.
53. Ougrin, D., Tranah, T., Stahl, D., Moran, P., & Asarnow, J. R. (2015). Therapeutic interventions for suicide attempts and self-harm in adolescents: Systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 54, 97-107.
54. Park, H. J., & Bae, J. Y. (2013). Efficient suicide prevention intervention: Meta-analysis. Journal of Korean Academy of Psychiatric and Mental Health Nursing, 22, 273-284.
55. Riblet, N. B., Shiner, B., Young-Xu, Y., & Watts, B. V. (2017). Strategies to prevent death by suicide: Meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 210, 396-402.
56. Rudd, M. D. (2012). Brief cognitive behavioral therapy (BCBT) for suicidality in military populations. Military Psychology, 24, 592-603.
57. Rudd, M. D., Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M. M., Mandrusiak, M., . . . Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36, 255-262.
58. Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., . . . Bruce, T. O. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry, 172, 441-449.
59. Rudd, M. D., Mandrusiak, M., & Joiner, T. E. (2006). The case against no‐suicide contracts: The commitment to treatment statement as a practice alternative. Journal of Clinical Psychology, 62, 243-251.
60. Ryberg, W., Zahl, P. H., Diep, L. M., Landrø, N. I., & Fosse, R. (2019). Managing suicidality within specialized care: A randomized controlled trial. Journal of Affective Disorders, 249, 112-120.
61. Seo, H. S. (2010). Effects of a cognitive-behavioral group counseling program on new generation soldiers with suicide thoughts. Korean Journal of Youth Studies, 17, 49-76.
62. Shneidman, E. S. (1993). Suicide as psychache: A clinical approach to self-destructive behavior. Lanham, Maryland: Jason Aronson.
63. Stanford, E. J., Goetz, R. R., & Bloom, J. D. (1994). The no harm contract in the emergency assessment of suicidal risk. The Journal of Clinical Psychiatry, 55, 344-348.
64. Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19, 256-264.
65. Stanley, B., Brown, G., Brent, D. A., Wells, K., Poling, K., Curry, J., . . . Hugues, J. (2009). Cognitive-behavioral therapy for suicide prevention (CBT-SP): Treatment model, feasibility, and acceptability. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 1005-1013.
66. Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., . . . Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. Journal of the American Medical Association Psychiatry, 75, 894-900.
67. Statistics Korea. (2019). The statistics for causes of death in 2018. Retrieved from http://kostat.go.kr/portal/korea/kor_nw/1/1/index.board?bmode=read&bSeq=&aSeq=377606&pageNo=1&rowNum=10&navCount=10&currPg=&searchInfo=&sTarget=title&sTxt=.
68. Tarrier, N., Taylor, K., & Gooding, P. (2008). Cognitive-behavioral interventions to reduce suicide behavior: A systematic review and meta-analysis. Behavior Modification, 32, 77-108.
69. Van der Feltz-Cornelis, C. M., Sarchiapone, M., Postuvan, V., Volker, D., Roskar, S., Grum, A. T., . . . Hegerl, U. (2011). Best practice elements of multilevel suicide prevention strategies. Crisis, 32, 319-333.
70. Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment. Applied and Preventive Psychology, 12, 189-201.
71. Wenzel, A., & Jager-Hyman, S. (2012). Cognitive therapy for suicidal patients: Current status. The Behavior Therapist, 35, 121-130.
72. Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients: Scientific and clinical applications. Washington, DC: APA Books.
73. Winter, D., Bradshaw, S., Bunn, F., & Wellsted, D. (2013). A systematic review of the literature on counselling and psychotherapy for the prevention of suicide: 1. Quantitative outcome and process studies. Counselling and Psychotherapy Research, 13, 164-183.
74. World Health Organization. (2010). Towards evidence-based suicide prevention programmes. Manila, Philippines: WHO Regional Office for the Western Pacific.
75. World Health Organization. (2018). World health statistics data visualizations dashboard. Retrieved from http://apps.who.int/gho/data/node.sdg.3-4-viz-2?lang=en.
76. Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M., . . . Zohar, J. (2016). Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry, 3, 646-659.