In Reply: Dr. Liberman's comments are of much interest and pertinence regarding management of the risk of suicidal behavior. We believe he points to the crux of the issue with the phrase "empathic follow-up," observing that the reduction in suicide attempts among subjects in his study was similar regardless of treatment approach.
There is room for discussion about what is empathic in follow-up contacts. The patients in our study were those who had refused ongoing care after discharge. When we contacted them we assured them of our interest in hearing from them. However, out of respect for their expressed desire to remain outside the mental health system, we avoided requesting formal reassessment information or urging patients to continue in treatment. In this regard, our approach differed from the methods used in various earlier follow-up programs that showed no significant differences in reduction in suicide between the follow-up groups and the control groups. The desire to forgo further treatment was probably not an issue for Dr. Liberman's patients, who had already accepted at least ten days of treatment.
All of this reminds us that each person is unique and that what is an empathic approach to one may not be so to another. The challenge to the clinician is to discern what will generate a sense of connectedness in a given patient over a given period. It is of interest that the noted suicidologist Edwin Shneidman, in summing up more than half a century of research on suicide prevention, attributes most suicides to the frustration of one of four clusters of psychological needs—three of which include the need for "affiliation" (1). Satisfying this need can be an elusive goal; however, empathic interchange and persistence may help our patients move closer to that goal. From the viewpoint of suicide prevention, aside from the essential diagnosis and treatment of underlying pathology, it may not be primarily what you do, but the way you do it, that counts the most.