Where’s the Family?

28 03 2007

I was just looking at the post counts on my categories and seeing few posts I have (only 2) family therapy category.   I think that reflects the state of the field right now, as well as my own internal conceptual development which is not yet entirely integrated.  Two things for sure:

1.  Almost everything I’ve read in the clinical suicide assessment literature assumes a one-on-one context.   Family therapy is usually not mentioned.  Families are sometimes mentioned, usually as potential sources of information when things get really risky, but without much attention to how to do that.

2. Family therapists tend to get pretty individualistic when they teach or write about suicide prevention.   This tendency was unmistakable in a recent Family Therapy Magazine, a publication of AAMFT that is distributed free to all members.   The July/Aug 2006 issues was titled “Suicide in the Family.”   Yet if you look at the articles there is almost no content related to family therapy.  In fact, if you removed the cover and took out a couple of intro paragraphs, the articles would be indistinguishable as a family therapy publication.   Remarkable.

I think this state of affairs reflects that fact that it’s not easy to bring the two together in practice.   How, when and of whom do you ask about suicidality in a room full of family members of different ages?  How do you bring up a topic that is hard enough to bring up with one person in front of you?   How much history about self-harm do you gather in front of children?  I don’t think anyone has really spelled out how to translate the relatively linear risk assessment principles to skillful systems work. If there is work in this area, I’d be interested to learn more about it.That said, I think it’s hard and we don’t have good models, but it is not impossible.  I see our trainees doing it exceptionally well.   It is demanding, but do it well because they are talented and devoted–and because we emphasize it, in part, because of my developing expertise in the area.  But I don’t think any of us yet has a clearly-enough articulated model to present as the standard of care.

I feel obligated to add here, that there are some equally hard questions that a family therapist could ask an individual therapist too.  Like…how can you possibly get a complete risk assessment picture without talking with family members, seeing the patient interact with them, understanding the family pathology and strengths?  How do you monitor warning signs without inside players?   I’ve lately been reading extensive case reports of people who died by suicide.  In each of the cases I read, it would have been impossible to understand the risk picture without extensive information from family members.  Many of those truly at risk of killing themselves just do not disclose enough and the right kind of information.

This is an area in much need of development.


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Categories : Needs development, clinical interview, family, health care delivery, risk assessment, suicide

“Truth about self-harm” from MHF in UK

20 03 2007

Thanks to a recent link from Psychsplash to the Mental Health Foundation in the U.K., I discovered a helpful publication called “The truth about self-harm.” Here is a description from the website:

The booklet is for anyone who wants to understand self-harm among young people – why it happens, how to deal with it, and how to recover from what can be become a very destructive cycle.

It written for self-injurious youth, their friends, and families, and is available as a downloadable .pdf. This publication is psychoeducational that grew out of an “inquiry” aimed at gathering available evidence to understand self-harm. The final report from the inquiry is also available.


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Categories : family, self-harm

Gender, race, and culture in risk formulations

14 03 2007

I’m trying to think about how to categorize risk factors related to gender, race, culture when presenting about risk and guiding people to make risk formulations. In my initial concept maps, I included “male gender” as one of the “predisposition” factors, following categories offered by Bryan & Rudd (2006). But then when I saw how therapists used this in clinical practice, I noticed that people would list male gender right alongside suicidal ideation or behavior as if one carries risk in the same way as the other. Obviously they don’t.

We have factors like race, where risk looks quite different for men and women and over the lifespan (with young black men at greater risk, and older black women much less). Not to mention other unique contours of suicidality among black Americans (Joe et al, 2006). So race is a factor to consider carefully, but not list as a “risk factor” in the same way as others like depression, family history of suicide, past suicidal behavior.

One suicide researcher in our department with whom I shared this dilemma suggested that perhaps demographic and cultural factors are best represented of factors that, if properly considered, decrease likelihood of false negatives (i.e., underestimating risk). That makes sense to me. Being a man, an older adult, or African American doesn’t put you at risk of suicide, but if you are working with an older adult male you ought to pay special attention to suicide risk and know that you might be likely to underestimate it.   In this way of understanding this category, a full risk assessment could include:

  • Suicide-specific ideation, behavior and history
  • Risk Factors (history, current sx presentation, hopelessness, impulsivity, identifiable stressor)
  • Demographic and cultural considerations
  • Protective Factors

There’s still work to be done, but that seems like a better way than lumping gender, race, and culture in with other risk factors.

References

Bryan, C. J., & Rudd, M. (2006). Advances in the assessment of suicide risk. Journal of Clinical Psychology, 62(2), 185-200.

Joe, S., Baser, R. E., Breeden, G., Neighbors, H. W., & Jackson, J. S. (2006). Prevalence of and risk factors for lifetime suicide attempts among blacks in the United States. JAMA, 296(17), 2112-2123.


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Categories : Gender-race-culture, documentation, risk assessment, suicide

Organizational factors that support care of suicidal person

7 03 2007

Wendi Cross, a gifted and innovative colleague in our department, presented at our Family Research Roundtable yesterday. One of the ways she is contributing to the field is to raise awareness about, and develop methodology to study, the factors surrounding implementation of an evidence-based intervention (be it training, prevention, or therapeutic intervention) that influence its ultimate impact. Right now her focus is on implementers of an intervention, but in the course of discussion she mentioned that there are other extra-intervention factors, such as institutional and organizational factors that influence how, how much, and how well evidence-based interventions are put into practice after someone is trained.

This got me thinking about what might be the institutional factors that enable (rather than hinder) adoption and competence in evidence-based risk assessment. I started making a list of these. In the course of doing so, I realized that, without having the language for it, this is part of what I have been working to build in to my trainings about risk assessment. I accompany training about risk-factors with documentation examples and templates and with a map of the procedures, options, and services available to a clinician if elevated risk is identified. It dawned on me that the reason participants find this part of it helpful is that it embeds the training in institutional resources.

Here is my initial brainstorm of potential institutional/organizational enabling factors. Whether these actually make a difference is an empirical question, of course, but these are the ones that occur to me based on my experience:

  1. Documentation prompts. Embedding risk assessment in required documentation templates can support risk assessment training by providing ongoing “booster training” in risk factors and risk formulation. In terms of risk assessment training this is “external” to the training, but can enable its implementation.
  2. Clear instruction about what to do when risk is detected. As I noted above, my trainings bring together risk assessment with specific information about resources and procedures at the local level. We have gotten feedback that this improves implementation of the risk formulation training.
  3. A non-blaming, supportive environment. Clinicians will distance themselves from patients with suicide risk if they fear they will be blamed (in any way) if injures or kills him/herself. There needs to be a consistent message from every level of an organization that understands how difficult clinical work is. There needs to be a healthy respect for the courage it takes to stick with a person at risk—especially if the person is not as cooperative as we would like (see my previous posts about patient choice). A non-blaming environment needs to be in place around all kinds of clinical issues and outcomes, not just suicide—otherwise it will not appear genuine.
  4. A culture that emphasizes patient choice, informed consent, and meeting people where they are. A “comply or bye-bye” approach will probably discourage thorough and honest risk assessment. In a previous post on risk and patient choice I gave an example of how to handle a patient’s refusal to comply with a recommendation to attend a partial hospitalization program.  I have a suspicion that clinicians sometimes downplay risk or avoid asking too many questions about suicide when we suspect that a patient would not comply with the recommendation that higher risk would compel us to make. For example, if a clinician knows that the patient will refuse an E.D. for evaluation, the clinician might de-emphasize or not ask about risk factors that could signal need for such an evaluation, thereby avoiding appearing negligent for not referring.
    In contrast, we might promote risk assessment if the clinician knows his her her job is to make an assessment, inform the patient of options, present risks and benefits, and work with whatever the patient decides. I think this would be a significant mindset shift for many systems, and one that I think could be one of those enabling factors.
    We can take a lesson from our colleagues in family medicine about how to continue a supportive, therapeutic relationship with patients who do not follow our recommendations (who do not abide by the “social contract” as discussed in this post). Family physicians are accustomed to recommending treatments, medications, and interventions, and knowing that some proportion of patients will not end up following them. This is not without frustration, to be sure. But, except in rare cases, family physicians continue to work the patient, meeting the patient where he or she is, and hoping to move them slowly toward change. As one of our clinical leaders pointed out to me yesterday, that is where a motivational interviewing (MI) approach would come in handy. And, in fact, one of ther research fellows at our institution is studying on an MI intervention with suicidal individuals in the emergency department.

There are lots of others, but these are the ones that first come to mind. I welcome comments with other ideas about factors, outside of training and the individual clinician, that would enable good care and assessment for patient with risk for suicide.


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Categories : evidence-based therapuetics, health care delivery, patient choice, professional culture, risk assessment, teaching/training