Having COURAGE: Using Science to Develop a Framework for Healthy Recovery after a Suicide Attempt

Dr. Yosef Sokol is an AFSP-funded researcher who studies recovery after suicidal crises. His research looks at how a sense of personal identity and connection to one’s future self may lower suicide risk and help people build a fulfilling life after a suicidal crisis.

“Everyone keeps saying I should feel grateful to be alive,” said David,* a U.S. Army veteran sitting across from me. We were in my office at the VA, where I work as a psychologist and researcher. “But I don’t know why I should feel grateful or even want to be alive.” In his words, I heard something that many suicide attempt survivors come to understand all too clearly: surviving the crisis is only the beginning.

David was not alone. According to the CDC, 2.2 million adults in the U.S. attempted suicide in 2024. Unfortunately, while we have made significant progress in learning how to help people in crisis, including the development of safety plans and the 988 Suicide and Crisis Lifeline, we have made less progress in learning how to help people recover after the crisis.

How do people move toward healing and a life of meaning? How do they rebuild? What helps people find their purpose and move from staying alive to wanting to live?

I have talked with or worked on research projects with many people who have survived a suicidal crisis, including veterans, college students, healthcare workers and teachers. Through many conversations like the one I had with David, I began to find some answers to these questions. Some had found purpose in unexpected places: community gardening, a newfound spirituality, art therapy, or an online support group for teenagers. Across these conversations, and from my team’s review of the research, we identified seven recurring processes that people found essential to their recovery. These processes became what I now call the COURAGE framework, and I am currently evaluating it with a research grant from the American Foundation for Suicide Prevention (AFSP).

Each letter in COURAGE stands for something people found vital to their recovery:

Choosing life daily

Optimizing a new sense of identity

Understanding oneself better

Rediscovering personal meaning

Acceptance of their experiences and themselves

Growing richer connections, and

Empowering oneself through new skills. 

While these are recurring themes in our research, recovery looks different for everyone. Each attempt survivor I meet combines the seven elements in their own way.

For example, I saw these elements clearly in Maria’s recovery over the last year. From talking with her, it seems her recovery began with small steps at her local VA. “First, I just joined a group of veterans to talk. Not that I did much talking at first,” she said. “But I got more comfortable as time went on, and then one day I heard about a new initiative where veterans help others in crisis. I started volunteering, and now I can be there for others when they need me, sometimes just sitting quietly, and sometimes supporting them in whatever way I think might be helpful.” Last time we met, she told me she still struggles, especially with not knowing how things turn out for the people who come to her for help. But she also told me she feels she is doing something difficult and meaningful.

I am grateful that AFSP recognizes the importance of understanding recovery after a suicide attempt and has funded the study I am now beginning. This will be one of the largest studies to systematically follow people after a suicidal crisis to examine factors that aid in their recovery. Before this grant, AFSP gave me something that is perhaps even more valuable: a chance to connect with other early career investigators, learn from one another, and strengthen our proposed suicide studies.

Last summer, AFSP’s Early Career Researcher Reapplication Lab (then called the Mentoring Immersion for Early Career Researchers program) brought a small group of early career suicide researchers to New York City to work intensively with their mentor  . We gathered at AFSP’s offices overlooking the Hudson River, and in between intensive workshops led by accomplished scientists, we discussed research ideas over coffee, debated theories over lunch, and formed relationships that have endured.

My mentor since my postdoc, Dr. Marianne Goodman, was with me for the full three days. Her decades of experience in veteran suicide prevention helped me to reshape my study design. Other researchers there found weak points in my methods and challenged my assumptions, such as the length of the immediate recovery period and the statistical analyses to be used. I learned a great deal and left the three days with a stronger research plan, better suited to identifying what supports recovery after a crisis.

The ReApp Lab experience was enlightening for reasons beyond the scientific. Researching suicide recovery can feel isolating. Sometimes it can feel like we spend a bit too much time examining life’s darkest moments and talking with people in such great pain. But being there, in a room full of researchers who care as much as I do about understanding how to help people who are suffering, made me feel like I was part of a community.

That community means a lot to me. What helps me most, though, is seeing the people I work with get better. Recently, David, the veteran I described at the start, has begun to talk about his life and his future differently.

We spent many weeks discussing his values, his purpose, and what he wants the rest of his story to look like. Over time, our conversations have shifted from “Why should I live?” to “How shall I live?” He used to say, “I can’t imagine myself existing in the future.” But at our most recent session, he told me, “I don’t care about having monuments and being famous. I want a story where I become a better person. If I can look back and see that, this will be a story and a life that was worth it.”

We need to understand what it takes for people to move from surviving, to building a life they find meaningful. That is what our AFSP-funded research sets out to do. 

Once you have thought about ending your life, it is not enough to decide not to die. You need to decide to live, again and again, so that you can create the person you want to become.

*Names and identifying details have been changed to protect privacy. Quotations have been lightly edited for clarity.

The views expressed here are the author's own and do not represent the Department of Veterans Affairs or the US government.