A couple of weeks ago, I had the privilege of presenting with Greg Brown and Leah Harris in a Zero Suicide webinar titled, "Screening and Assessment for Suicide in Health Care Settings: A Patient-Centered Approach" The recording of the webinar and slides are now posted on the ZS website. My part of the webinar starts at around 28:00 minutes, but watch the whole thing; my co-presenters are top notch. In my 20-minute portion, I introduced the risk formulation model I've been working on with colleagues Daniel Murrie and Mort Silverman. This model is the centerpiece of Commitment to Living and is also incorporated in the most recent revision of the Suicide Prevention Resource Center's flagship workshop, Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals.
James Fowler does it again. He has just published another terrific and useful paper, "Core principles in treating suicidal patients." This makes a terrific companion piece to his previous paper describing "guidelines for imperfect assessments" which I have raved about and recommend all the time. The current paper is elegant and straightforward. Dr. Fowler provides a rationale, evidence, and a treatment example for three core principles:
- alliance building
- enhancing curiosity about the function of suicidal thoughts and urge
- enhancing experience and epxression of intense emotions
Voila! What more do you want? You have to put Dr. Fowler's name on your search engine alert list! I just added it to the reference list that I will distribute at my next Commitment to Living workshop.
I'll be speaking in Lewiston Idaho next week at the St. Joseph's Region Medical Center's annual Rural Mental Health Symposium. I know from IP addresses that we have readers in the Northwest. If any are in the Lewiston area, please come.
I have been thinking and learning a lot about suicide risk in cancer patients because I am working with some colleagues in cancer control and prevention to identify and respond to educational needs among cancer care professionals. Related to this topic, readers might be interested a nice article by Kendal & Kendal published last year in the journal Crisis (abstract linked below). This article titled, Comparative Risk Factors for Accidental and Suicidal Death in Cancer Patients makes a number of insightful observations about risk in cancer patients based on statistical analyses of a large and impressive NCI dataset (SEER, 1973-2000).
Among the observations I found most interesting was that the well-documented increased risk of suicide in the year following cancer diagnosis, which is commonly attributed to psychological factors, may in fact be more closely related to physical factors, i.e. rapid deterioration of symptoms in rapidly progressing disease. Because many of the candidate psychological factors were not measured in this study, the question cannot be studied directly, but I found the findings compelling enough–and their treatment in the article careful enough–to warrant consideration. In the end, it may be very difficult to tease apart psychological distress from physical suffering, but I appreciate this article drawing attention to the question.
Citation: Kendal WS & Kendal WM (2012). Comparative risk factors for accidental and suicidal death in cancer patients. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 33(6):325-34. doi: 10.1027/0227-5910/a000149.
In a 6-month follow-up study of 119 hospitalized adolescents, Yen and colleagues found that many traditional risk factors including psychiatric diagnoses and past attempts failed to prospectively predict suicidal behavior. Other factors, which the authors called "cross-cutting" (because they cut across many disorders) were more potent.
These findings have direct clinical implications and indirect prevention implications. From a clinical perspective, clinicians must be cautious in applying population-generated risk factors to clinical risk formulation. Clinical training in risk formulation should emphasize dynamic factors over diagnoses and history and involve thoughtful synthesis of a wide range of factors and individual circumstances. From a broader prevention perspective, the study provides additional building blocks in the argument for focusing on cross-cutting constructs such as emotion self-regulation in suicide prevention (see our recent population-based study identifying emotion self-regulation as a critical construct for youth suicide prevention). This emphasis on "cross-cutting" constructs has interesting intersections with NIMH's effort, represented by the Research Domain Criteria (RDoC) to shift research away from DSM diagnostic categories toward dimensional assessment of more fundamental and biologically verifiable constructs. These findings are also congruent with (though they do not directly support) strategies that reach further "upstream" in adolescent development to build core "cross-cutting" protective factors.
Yen, S., Weinstock, L. M., Andover, M. S., Sheets, E. S., Selby, E. A., & Spirito, A. (2012). Prospective predictors of adolescent suicidality: 6-month post-hospitalization follow-up Psychological Medicine. Advance online publication. doi:10.1017/S0033291712001912
If my recent post on Patient and Family Centered Responses to Suicide Risk interested you–or if it didn't–I highly recommend an article by Dr. Ashley Clayton published this month in Health Affairs: How ‘Person-Centered’ Care Helped Guide Me Toward Recovery From Mental Illness.
Thanks to Dr. Yeates Conwell for pointing me to the article.
Emotion Regulation Difficulties, Youth– Adult Relationships, and Suicide Attempts Among High School Students in Underserved Communities
My colleagues and I conducted a study examining associations between self-reported suicide attempts, emotion regulation difficulties, and trusted youth–adult relationships among 7,978 high-school students. The results have been pre-published online in the Journal of Youth and Adolescence. Our findings point to adolescent emotion regulation and relationships with trusted adults as complementary targets for suicide prevention that merit further intervention studies. We argue that reaching these targets in a broad population of adolescents will require new delivery systems and “option rich” (OR) intervention designs. Print publication will follow later this year.
The New York Times published an article this week that readers of this blog should be aware of. The article is titled, Study Questions Effectiveness of Therapy for Suicidal Teenagers. The article reports on results from a study published in JAMA Psychiatry (the new name for Archives of General Psychiatry) by Matthew Nock and a team of outstanding scientists. The NYT headline is based mostly on the finding that:
...suicidal adolescents typically enter treatment before rather than after the onset of suicidal behaviors. This means that mental health professionals are not simply meeting with adolescents in response to their suicidal thoughts or behaviors, but that adolescents who are clinically severe enough to become suicidal more typically enter treatment before the onset of suicidal behaviors. There is no way to know from the NCS-A data how often this early intervention prevents the occurrence of suicidal behaviors that would otherwise have occurred but were not observed in our data. It is clear, though, that treatment does not always succeed in this way because the adolescents in the NCS-A who received treatment prior to their first attempt went on to make an attempt anyway. This finding is consistent with recent data highlighting the difficulty of reducing suicidal thoughts and behaviors among adolescents. (Nock et al, (2013) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents, JAMA Psychiatry, ePub ahead of print, p. E9)
Suicidal High School Students’ Help-Seeking and Their Attitudes and Perceptions of Social Environment
Clinicians, school personnel, parents and other adults share at least one thing in common: none of us can read minds. The only way we're going to know if an adolescent is considering suicide is if they tell us. My colleagues and I conducted a study examining some key correlates of help-seeking among adolescents who had seriously considered suicide. The results have been published in the Journal of Youth and Adolescence.
Assessments are human encounters, a chance to demonstrate compassion and instill hope. A small qualitative study by colleagues in Manchester, England illustrates the importance of caring assessments and of considering the social and family context of the individual in planning. Hunter et al conducted 13 initial interviews and 7 follow-up interviews with individuals who had been hospitalized related to some form of self-injurious behavior. Their findings are highly congruent with the hallmarks of patient and family-centered response to suicide risk that I have proposed. The article (linked below) outlines a number of lessons about what matters to patients, which boils down to having meaningful interactions with clinicians who: convey empathy, understand problems from their perspective, inspire hope, and develop plans/referrals that match their preferences and social context. None of this is rocket science; it's harder than that. Hearing how much it matters to patients should encourage all of us with a commitment to living to continually refine our approach to assessment.
Hunter, C., et al., Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: A qualitative study. Journal of Affective Disorders (2012), http://dx.doi.org/10.1016/j.jad.2012.08.009
Apropos of my post on needing more family-centered work, I came across this study out of Taiwan just published in Nurse Education Today: A suicide education programme for nurses to educate the family caregivers of suicidal individuals: A longitudinal study. It is good to see this kind of work being done, and refreshing to see people trying to test their work with controlled designs. I'm not sure I agree with how all of the concepts are laid out (and I really don't like the heavy-handed first line of the abstract: "Family members lack the ability to care for suicidal relatives"), but this is a helpful example of the kind of attention to families that is needed.
Over the past few years, many mental health care systems have adopted useful strategies and technologies to reduce risk across their systems. In my consultations with health systems, I have seen enormous advances in terms of consistent nomenclature, universal screening, documentation standards, assessment procedures, and crisis response planning. A lot of interest has coalesced around certain helpful tools such as the Columbia Suicide Severity Rating Scale and Safety Planning, which help with key tasks that are part of the overall competent care of suicidal patients.
Competent implementation of suicide prevention technologies in clinical care depends on the attitudes and approach with which the professional applies them. Even as we make progress on systematic care for suicidal individuals, have we invested enough attention to fostering the attitudes and approaches that undergird effective care for suicidal individuals and their families? Evidence-based assessment and response to suicide risk includes forming cordial and collaborative relationships, conveying human compassion, building on natural strengths and supports, and promoting dignity and hope. Many major therapeutic interventions for suicidal individuals share common foundations in this regard--DBT and CAMS are good examples--and most clinicians are highly capable of forming bonds of caring with their patients and their families. However, the well-documented challenges (uncertainty, powerlessness, time burden, anxiety) of clinical work with suicidal individuals can interfere with authentic expressions of empathy, commitment, and respect, potentially reducing the yield from other measures taken to assess and reduce suicide risk, such as well-timed screening and safety planning. These challenges also tend to narrow clinicians’ focus on the patient alone, sometimes to the exclusion of interested family and friends. As a result, continuing professional education is needed to empower clinicians with a conceptual framework for understanding and responding to suicide risk that will promote desirable attitudes and behavior across treatment modalities, prevention technologies, and episodes of care.
Patient and family centered care (PFCC) provides a useful framework for developing attitudes and behaviors consistent with best-practices in the compassionate care of suicidal patients. PFCC is a movement that is re-centering healthcare on the experience of the patient and family as a key factor in health care quality and safety. PFCC encourages envisioning all aspects of a health-care system from the patient's perspective, from policies and facility lay-out down to specifics of the clinical encounter. PFCC is a major focus across my home institution, with expertise coming from the Institute for the Family with which I am affiliated. I am not aware of any broad application of this term to the care of patients who present with suicide risk, but I have recently been thinking about CTL in these terms. I have been trying to boil down the PFCC approach I teach in CTL. This remains a work in progress. So far, I have generated these six hallmarks of patient and family-centered response to suicide risk:
- Elicit the experience and function of suicidal thinking from the perspective of the person at risk and their family members.
- Convey empathy for suffering, a desire to help relieve it, and confidence that recovery is possible.
- Invite individuals and their families to make decisions about addressing suicide risk based on their ideas, expectations, and preferences, providing informed consent about risks and benefits of various options.
- Explore how plans and decisions for responding to suicide risk will affect and be affected by the person's family, social network, interests, and responsibilities.
- Express personal and institutional commitment to alleviating current distress and supporting the life and happiness of the person and their family members.
These clinical principles are not unique or original to CTL. The SPRC/AAS Core Competencies (pdf) include these skills from a different vantage point and vernacular. There are also a host of constituent skills and attitudes that are part of specific treatment modalities. Nevertheless, I have seen a clear need for a direct and transtheoretical focus on these core points.
Because these five points are at the heart of CTL education and consultation, I have been considering re-wording the subtitle of the CTL workshop, and of this blog. For some time, the tagline for CTL has been "Understanding and Responding to Suicide Risk." I settled on that broad moniker at the advice of colleagues who thought the original title was too cumbersome: "Assessment and Decision-making for Competent and Caring Clinicians." They were right; however, as my thinking has evolved and my assessment of needs in the field has sharpened, I may want CTL to reflect the patient-centered focus more directly, perhaps with the title, “Commitment to Living: Patient and Family-Centered Response to Suicide Risk.”
Whatever the title of CTL, the time has certainly come to incorporate the helpful and empowering concepts from the PFCC movement into the way we work with individuals at risk for suicide.
Thanks to Susan H McDaniel, PhD, Dr. Laurie Sands Distinguished Prof. of Families & Health at the University of Rochester Institute for the Family, for her input on this article.
As readers here know, I’m not a fan of using SAD PERSONS as a “scale.” Some clever colleagues in Manitoba, Canada studied over 4,000 consecutive emergency department referrals for two years in two large hospitals in their province. Study conclusion: “In their current form, SAD PERSONS and MSPS do not accurately predict future suicide attempts.”
Find the article here.
I love the title of J. Christopher Fowler's article that was published in the current issue (vol 49, issue 1) of Psychotherapy, "Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments." This practice review is thorough and wise. Fowler strikes just the balance between encouraging completeness and responsibility, and acknowledging the limits inherent in assessments of risk. Dr. Fowler also masterfully weaves in the importance of self-awareness on the part of the clinician, and gives constant attention to maintaining a caring, compassionate stance. Some selected quotations to whet your appetite for this article:
"Knowing that patients frequently deny suicidal thoughts before suicide attempt and death, clinicians should remain appropriately circumspect regarding declarations of safety when a patient recently expressed suicidal ideation, feelings of hopeless, desperation, and/or affective flooding. This does not mean we should adopt a suspicious or adversarial stance—on the contrary, curiosity, concern, and calm acceptance of the patient’s emotional and cognitive states may serve to enhance the therapeu- tic alliance, encourage the patient to directly explore her or his current distress, and aid in the accurate evaluation of current functioning."
"Before conducting a formal suicide assessment, clinicians should conduct an introspective review of recent stressful life events facing the patient, including recent ruptures in the thera- peutic alliance, and disturbances in social relationships (Truscott, Evans, & Knish, 1999). Maintaining a therapeutic stance of curiosity and concern (while simultaneously remaining open to the possibility that an alliance rupture may be a precipitant to the crisis) is difficult to sustain when anxieties are running high; however, communicating genuine curiosity and concern about the causes for their unbearable suffering is critical."
"When clinicians face a potential suicide crisis, they are multi- tasking and are usually in a state of heightened alert and anxiety. Under such stressful circumstances, it is easy to get swept up in personal emotional reactions and lose sight of the patient’s suffering and their efforts to communicate distress."
My only critique involves the absence of family system context. I would have liked to see some attention to the positive role that family members can play in the assessment process. The article does mention that the quality of family relationships is an important modifiable risk factor, which should be considered and may be the focus of clinical intervention. But most of the article, and the clinical approach advocated, has a decidedly individualistic bent. The article doesn't address how to involve friends and family members in the interview process, how to build their participation into the decision-making process, how the relational context influences decisions about how to respond to identified risk. For me this is an important gap, and a contribution that is still needed.
This gap notwithstanding, this article will instantly join the Bryan et al. means restriction article on my Top 10 Most-recommended List. In fact, the Fowler article could become my primary go-to reference when clinicians ask for reading on the subject.
Fowler, J. C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49(1), 81–90. doi:10.1037/a0026148