Out of sight, out of mind? Intersession experiences as protective and risk indicators of suicidal ideation in the context of outpatient treatment.

OBJECTIVE Suicidal ideation is a central clinical risk in psychotherapy. Patients' engagement with therapy between sessions, captured by intersession processes (ISP), may be particularly informative for understanding risk and resilience. This study examined associations between ISP and suicidal ideation, distinguishing between-person vulnerabilities from within-person crisis dynamics. METHOD We analyzed routine outpatient data (N = 73, 2,586 total sessions), including an eight-item short version of the Intersession Experiences Questionnaire (IEQ-S) and the PHQ-9 suicidal ideation item. Multilevel logistic mixed-effects models treated suicidal ideation as a binary outcome, disaggregated between- and within-person effects, and included linear, quadratic, and cubic terms. RESULTS At the between-person level, more frequent problem-focused application of therapeutic insights was associated with a lower likelihood, whereas higher levels of negative emotional ISP were linked to a higher likelihood of reporting suicidal ideation, following nonlinear trajectories. At the within-person level, increases in positive emotional engagement and problem-focused application co-occurred with a lower likelihood, whereas increases in imagining therapeutic dialogue and negative emotions were related to a higher likelihood of reporting suicidal ideation. CONCLUSION ISP reflect the internalized therapeutic alliance and clinically meaningful cognitive-affective processes, signaling crisis escalation, but also pointing to mechanisms of change. ISP may be valuable monitoring targets.

• Publication year

  2026

• Venue

  Psychotherapy Research

• Publication date

  2026-02-08

• Fields of study

  Medicine, Psychology

• Identifiers
  DOI 10.1080/10503307.2026.2623939PMID 41656650
• External record

  Open on Semantic Scholar

• Source metadata

  Semantic Scholar

• No claims are published for this paper.

• No concepts are published for this paper.

• Falling into nothingness: Modeling suicidal ideation as the person × situation interaction of personality functioning and loneliness.

  2025cited by this paper
• Core principles of treating the suicidal adult: What we have learned from patients about restoring safety, emotion regulation, mentalizing, and epistemic trust.

  2025cited by this paper
• Intersession Experience Questionnaire Short (IEQ-S): psychometric properties and longitudinal associations with symptoms of an 8-item short version of the Intersession Experience Questionnaire

  2025cited by this paper
• Inpatients with a history of suicide attempts in routine clinical care exhibit specific characteristics regarding sociodemographics, life events, personality, and symptom burden

  2024cited by this paper
• The role of mentalizing in psychological interventions in adults: Systematic review and recommendations for future research.

  2024cited by this paper
• Prevalence of suicidal ideation in German psychotherapy outpatients: A large multicenter assessment.

  2024cited by this paper
• Therapeutic alliance and suicidal ideation in brief cognitive behavioral therapy for outpatients

  2024cited by this paper
• Ambulatory assessment of suicidal ambivalence: The temporal variability of the wish to live and the wish to die and their relevance in the concurrent and prospective prediction of suicidal desire.

  2024cited by this paper
• Mapping the timescale of suicidal thinking

  2023cited by this paper
• Evaluating Change in Transference, Interpersonal Functioning, and Trust Processes in the Treatment of Borderline Personality Disorder: A Single-Case Study Using Ecological Momentary Assessment.

  2023cited by this paper
• Cambridge Guide to Mentalization-Based Treatment (MBT)

  2023cited by this paper
• Emotional changes and outcomes in psychotherapy: A systematic review and meta-analysis.

  2023cited by this paper
• Ambivalent toward life, ambivalent toward psychotherapy? An investigation of the helping alliance, motivation for treatment, and control expectancies in patients with suicidal ideation in inpatient psychotherapy.

  2023cited by this paper
• Intersession experiences and internalized representations of psychotherapy: A scoping review.

  2023cited by this paper
• The Psychoanalytic Study of Suicide, Part II: An Integration of Theory, Research, and Clinical Practice

  2022cited by this paper
• Suicidal ideation and attempts in adults seeking outpatient psychodynamic psychotherapy.

  2022cited by this paper
• Is the end in the beginning? Child maltreatment increases the risk of non-suicidal self-injury and suicide attempts through impaired personality functioning.

  2022cited by this paper
• Level of Structural Integration and Its Association with Intersession Experiences and Outcomes: A Pilot Study

  2022cited by this paper
• The Psychoanalytic Study of Suicide, Part I: An Integration of Contemporary Theory and Research

  2022cited by this paper
• Distinct roles of state-like and trait-like patient–therapist alliance in psychotherapy

  2022cited by this paper
• Theory of Mind and Suicidality: A Meta-Analysis

  2021cited by this paper
• Systematic Review on Mentalization as Key Factor in Psychotherapy

  2021cited by this paper
• Early warning signals and critical transitions in psychopathology: challenges and recommendations.

  2021cited by this paper
• Nonlinear change processes and the emergence of suicidal behavior: a conceptual model based on the fluid vulnerability theory of suicide.

  2020cited by this paper
• The Mentalizing Approach to Psychopathology: State of the Art and Future Directions.

  2020cited by this paper
• A network perspective on suicidal behavior: Understanding suicidality as a complex system

  2020cited by this paper
• Toward personalized psychotherapy: The importance of the trait-like/state-like distinction for understanding therapeutic change.

  2020cited by this paper
• Quality of Internalized Object Representations and Suicidality in Individuals With Anaclitic and Introjective Personality Styles.

  2019cited by this paper
• Intersession-Online: A Smartphone Application for Systematic Recording and Controlling of Intersession Experiences in Psychotherapy

  2019cited by this paper
• The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis

  2018cited by this paper
• Daily dynamic assessment and modelling of intersession processes in ambulatory psychotherapy: A proof of concept study

  2018cited by this paper
• Psychodynamic Therapy for Personality Pathology

  2018cited by this paper
• The integrated motivational–volitional model of suicidal behaviour

  2018cited by this paper
• How do patients with anorexia nervosa “process” psychotherapy between sessions? A comparison of cognitive–behavioral and psychodynamic interventions

  2018cited by this paper
• Sexual orientation differences in treatment expectation, alliance, and outcome among patients at risk for suicide in a public psychiatric hospital

  2017cited by this paper
• The Intersession Process in Psychotherapy for Anorexia Nervosa: Characteristics and Relation to Outcome.

  2016cited by this paper
• Prognostic and prescriptive predictors of improvement in a naturalistic study on inpatient and day hospital treatment of depression.

  2016cited by this paper
• Does Suicidal Ideation as Measured by the PHQ-9 Predict Suicide Among VA Patients?

  2016cited by this paper
• Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?

  2013cited by this paper
• Alliance, reactions to treatment, and counter-transference in the process of recovery from suicidal phenomena in long-term dynamic psychotherapy

  2013cited by this paper
• A general and simple method for obtaining R2 from generalized linear mixed‐effects models

  2013cited by this paper
• Working through: in-session processes that promote between-session thoughts and activities.

  2012cited by this paper
• The structure of intersession experience in psychotherapy and its relation to the therapeutic alliance.

  2011cited by this paper
• Attachment and personality pathology.

  2010cited by this paper
• The interpersonal theory of suicide.

  2010cited by this paper
• Session and intersession experience related to treatment outcome in bulimia nervosa.

  2010cited by this paper
• The “Generic Model of Psychotherapy” after 25 years: Evolution of a research-based metatheory.

  2009cited by this paper
• Constructive and Unconstructive Repetitive Thought

  2008cited by this paper
• Internalization of the therapeutic process: differences between borderline and neurotic patients.

  2006cited by this paper
• [The Intersession Questionnaire--an inventory for the measurement of patients' processing of psychotherapy between sessions].

  2003cited by this paper
• Representations of therapists by patients with personality disorders.

  2003cited by this paper
• The PHQ-9

  2001cited by this paper
• Coming to terms with the terms of risk.

  1997cited by this paper
• The generalizability of the psychoanalytic concept of the working alliance.

  1979cited by this paper
• Attachment and loss: retrospect and prospect.

  1969cited by this paper

• No citing papers are available for this paper.