Moving N.Y. Times Op-Ed by Roger Cohen

15 10 2007

Roger Cohen has written a moving Op-Ed piece in which he describes the way in which a recent suicide in the Phoenix airport transported him back to his own mother’s decades long battle with suicidal thoughts and attempts.


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Categories : current events, family, suicide

NY Times: Short but Troubled Life Ended in Shooting and Suicide

12 10 2007

This NYT article about 14 year-old boy who died on Wednesday after critically wounding a teacher and classmates, is a case study in risk for adolescent suicide.  Abuse/neglect history, legal trouble, access to weapons, social misfit, recent disciplinary action at school.    The temporal proximity of his older brother’s arrest is also striking…again pointing to the systemic properties of suicide.


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Categories : child & adolescent, current events, family, suicide, violence

Warning: Non-family Tx may be hazardous to your (family’s) health

12 10 2007

A clever article in the September 2007 issue of the Journal of Family Psychology by Jose Szapocznik and Guillermo Prado suggests that “psychosocial treatments with vulnerable populations have the potential to produce negative side effects on families.”

The authors reported unexpected findings from three separate studies that compared the efficacy of a family and non-family treatment. In brief, they found that family-level outcomes measured after applying non-family treatments didn’t just remain static (as they had expected), they actually declined. This relationship is correlational and does not necessarily mean that the treatments in question caused the decline, but the authors argue that the findings are striking enough to raise the question about whether unintended side effects psychosocial treatments should be subject to “safety monitoring” along the lines that biomedical products are. Something like a black box label: “Warning: This treatment manual may be hazardous to your family.”

In the discussion section, Szapocznik and Prado hypothesize about the systemic mechanism for the results they found:

“The family is a system that must be viewed as composed of interdependent or interrelated members…. Family members tend to develop habitual patterns of behavior over time such that each individual in the family is accustomed to act in a certain way that in turn elicits specific predictable behaviors from others. One possible hypothesis is that if an individual is changed by an intervention that is design to change individual and not help the family adjust to these changes….the family may be negatively affected….”

Nothing in these studies relate directly to suicide. But I think there are implications for how we think about intervention, especially in light of what I’ve been reflecting on lately about suicide as a family issue (see posts related to family therapy)

  • Need for more systemic work on suicide. With respect to suicide, this article emphasized to me the need for greater conceptual clarity among systems thinkers about suicide in the context of the family system. We need to articulate in what ways suicidality might be a property of the system in which it resides, and what are the mechanisms by which family relationships might reduce the likelihood of suicide.
  • The complexity of defining “evidence-based practice.” I’ve posted before (vis-à-vis the ambulatory redesign aspirations in our department) about my concerns that “evidence-based” can get too narrowly defined. What is evidence-based depends a lot on what evidence you look at, and, more to the point here, on what outcomes are measured in the studies that provide supporting evidence for an intervention. Given the documented importance of family functioning for long-term outcomes of many kinds, perhaps one of the criteria we should consider in evaluating the utility of a given treatment approach is its ability to promote family functioning.
  • This relates to suicide because of the ways in which I have heard distressed individuals conceptualize their presenting problem. When people seek help it is usually with a functional outcome in mind, often one that has to do with their relationships. Research studies measure symptom reduction, people care about love, work, and play. In delivering a human service, we should organize ourselves in congruence with human concerns. If we organize ourselves around “reducing depression” we run the risk that our language will become reified in our practice-the result of which could be a less connected stance toward a suicidal individual who sees his relationships, finances, or health as the primary problem, not his “symptoms.” As one person I worked with paradoxically stated, “I don’t care about feeling better, I just want all of these problems to go away.”

Ideas around evidence-based practice are evolving. In our department, a vibrant conversation is underway. Simplistic views of what is evidence-based seem to be disappearing, as everyone realizes that “evidence-based” is a much broader and trickier term than we might like. Ultimately, I suspect that the way out of the dilemmas inherent in the term is for clinicians to collect evidence (in informal and formal ways) about change in their own cases. This kind of internal monitoring process will probably promote effectiveness more than selecting the right branded treatment, which may have aggregate data that allows it to be certified as “evidence based,” but which may or may not be helping the particular individual and family we’re working with.

Reference

Szapocznik, J. & Prado, G. (2007) Negative effects on family functioning from psychosocial treatments: A recommendation for expanded safety monitoring. Journal of Family Psychology. Vol 21, p. 468-478.


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Categories : Needs development, evidence-based therapuetics, family, health care delivery, needed contributions, suicide, treatment planning

Presentation to Board of Wynne Center for Family Research

9 09 2007

I presented at the Wynne Center for Family Research (WCFR) board meeting today. I presented about our clinical services and about my work in suicide risk assessment, including how it grew out of experiences with suicidal patients in couples and families. The Center board and the faculty of the WCFR were present.

The Board is unbelievable–a real dream team for family systems fans:

Barbara Fiese, Ph.D., Syracuse University
Nadine Kaslow, Ph.D., Emory University
William Pinsof, Ph.D., Northwestern University
Harry Reis, Ph.D., University of Rochester (Liaison)
Frederick S. Wamboldt, M.D., National Jewish Medical Center
Karen Weihs, M.D., University of Arizona

Given the stature and brilliance of this audience, I was both nervous and eager to get their feedback about our clinical service and about the work that has grown out of it. Here are my notes, and some reflections, from the discussion that followed my presentation:

— One board member shared an experience she had many years ago working with a prominent family therapist as her supervisor. She recounted the following experience:

She worked with the family of an adolescent who had attempted suicide. She wanted to do a suicide risk assessment as part of her session with the family. Her supervisor, at first, discouraged her because it wasn’t “systemic.” She persisted and ultimately prevailed by offering to do a suicide assessment for each person present (not just the child) and to invite others present to provide input on the others’ assessment! The supervisor allowed this as sufficiently systemic.

Reflection: This is a fascinating story that highlights the tension inherent in melding an activity that has traditionally been part of an individualistic medical model with a family systems view of people, their problems, and their strengths. I think few family therapy supervisors nowadays would advise against suicide risk assessment. Suicide risk assessment is taught (with a range of how much) in every family therapy training program. But I’m not sure if we’ve developed a lot further in terms of the actual how-to. My impression is that most of the time, there continues to be a one-dimensional linear approach to training suicide assessment that implicitly assumes individual therapy and interviewing.

– Other thoughts:  One key to resolving the potential tension is to think about suicide as residing in a family system. This view goes beyond thinking about family members a “collateral informants”, which is how family involvement is often described in the suicide literature. Instead, we need to develop conceptual AND CLINICAL models for assessing risk through the lens of interactions, relationships, roles, and family myths. For example, how does the hopeless that registers in the individual grow out of family roles and interactions…or from a strength-based approach how might shifts in the family give greater hope to the individual experiencing suicidality.  It is not that this is never talked about, it’s just that the focus on individual psychopathology and personality often overshadows this dimension–and perhaps more so than with other behaviors we assess and intervene with because the act of suicide is ultimately unilateral and done when alone.

– One member asked about me “sharing” what I’m working on. This is an important question to me on several levels:

  1. Blog. This blog is one mechanism I’m using to share thoughts and discoveries.
  2. Planned publications. I am on the cusp of conducting an evaluation of my risk assessment workshop and plan to publish the results. I am also working on another publication in which I’m collaborating with two faculty members of the Deaf-Wellness Center.
  3. Career Direction. If what I’m doing turns out to be helpful to clinicians and to families, I want to share it widely. That brings up interesting questions about how I spend my time professionally. Given the range of my interests (in terms of content (peds primary care, suicide) and professional activities (teaching, writing, clinical work), it is hard to know the right direction. A career in research is appealing in ways it hasn’t been in the past. This is probably a dilemma many of my readers (especially those in academia) are familiar with. I’ll be focusing on discerning this over the next year or so.

– After I talked about this blog, a board member recommended using it as a way of helping to disseminate science to general audience. I have done this a little (such as here), but could probably do more.

– A board member suggested that, in light of how heavy it is to focus on suicide (an adverse outcome), it would be advisable for our clinical service to also gather stories and data about positive outcomes of family therapy. This is a perceptive and appreciated comment because prevention of a bad outcome does have a peculiar emotional tone for an individual or group. I named this blog “Commitment to living” in part to cast this work in a positive direction. This comment is a good reminder to do that kind of thing in many ways also at a system level.

All of that in 30 minutes! I appreciated the opportunity to consult with such bright and experienced senior experts in our field.


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Categories : blogging, career/life of author, dissemination, family, risk assessment

Conversation with Paul Quinnett, Founder/CEO of QPR

1 08 2007

I talked yesterday with Paul Quinnett, Ph.D. Founder and CEO of the QPR Institute. He has been working in the field of suicide prevention for decades and has developed an excellent set of tools for clinicians. I enjoyed the conversation because Dr. Quinnett is bright, experienced, and passionate about his work, and also because of the conceptual overlaps I observed through our conversation. Here are a few from my notes:

Technology Transfer. Dr. Quinnett’s interest is technology transfer, i.e. taking what is known from the literature and clinical experience giving it legs for the working clinician and healthcare system. This the primary thrust of my evolving work, as well. I also have an interest finding the most efficient and effective pedagogical method for transferring information.  This is where my interest in mapping and other forms of visual representations comes in (see my previous mapping posts). This topic is also part of what has interested me when I heard Wendi Cross speak (see my post reflecting on Organizational factors that support care of suicidal person).

Family involvement. I’ve posted several times (see Where’s the Family?, and At the crossroads of family therapy and suicide prevention) about the conundrum that family involvement presents for suicide risk assessment: we don’t have good models for talking about suicide with family members present, we don’t have clear ideas about how to incorporate families in the assessment process, AND in many cases it is impossible to imagine performing a worthwhile assessment and management plan without family input.  Dr. Quinnett has been working on this very issue from two interesting perspectives. The first is what he called “the cost of data collection.” That is, he is curious about how clinicians perceive the cost of collecting information from 3rd parties. The second is that he is working on developing a protocol of the key questions and info one should ask/gather from family members to guide clinicians in their interviews. Dr. Quinnett has been working on this with Sergio Perez Barrero, MD, a psychiatrist in Cuba who founded the Suicidology Section of World Psychiatry Association and also the World Suicidology Net.Dr. Perez Barrero is a QPR trainer, who has translated the materials in to Spanish.

Drawing on experience in other fields that do risk assessment.  In a previous post, (Reflecting on Intersections with Knowledge Management, Dave Snowden, and Singapore’s Risk Assessment and Horizon Scanning System), I shared my reactions to Dave Snowden’s work on detecting terrorist threats. Dr. Quinnett was struck in a similar way by Gavin deBecker’s work in threat assessment. I had not heard of deBecker but apparently his California firm, Gavin deBecker and Associates works with high-profile clients (including Hollywood celebrities) to analyzing potential threats to their safety. He has written a book called “The Gift of Fear,” which I plan to read on Dr. Quinnett’s recommendation.

Along similar lines, I have consulted with a forensic psychologist and friend, Daniel Murrie, Ph.D., who co-authored a book (with Mary Alice Conroy) coming out this fall about assessment of risk for violence, “Forensic Assessment of Violence Risk: A Guide for Risk Assessment and Risk Management.” This book, which I’ve seen excerpts of, presents an approach to assessment of risk for violence that is clear and accessible to clinicians and retains the richness and clinical complexity that appropriate to the challenging work of predicting an individual’s risk of being violent. The approach that Conroy and Murrie take has potential applicability for suicide risk assessment, for which we’ve never quite had such a clear model for conducting and writing assessments.

I guess the intersection here relates to seeing potential for developments in threat and violence prediction work to help our efforts to improve detection of suicide risk.

Desire to understand the clinician’s state of mind when faced with risk assessment. I have noted before (see my post on Visual maps and guides in high stress situations) that I’m interested in learning what the cognitive science would be related to how people best access information for decision making in high arousal situations. Similarly, Dr. Quinnett mentioned that he would like to test clinician perceptions about information gathering in risk assessment. What kind of cost/benefit appraisals do they make about asking questions and gathering collateral info?

In my view, the clinician’s state of mind/emotion and cognitive heuristics are underappreciated in most approaches to training about suicide risk. As I noted in my post about clinician anxiety (Clinician anxiety–what’s it about?), what we believe about the most pressing concerns for clinicians will influence what and how we teach. Likewise, understanding how clinicians learn best is important for modes of dissemination (for example, see my post on How clinicians learn: Web 2.0 Opportunities?).

Summary: “Needs Development.” This is another post I’ll tag “needs development” because much of this raises more questions than it answers.   But reflecting on these conceptual intersections helps me to see how much is not known about how to approach training in suicide risk assessment.   Really, there is a “basic science” set of questions about learning and the clinician mind that gets skipped over when we do the necessary and important work of evaluating educational interventions (which, of course, we don’t do enough of either!).


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Categories : Knowledge Management, Needs development, dissemination, family, mapping/visualization, risk assessment, suicide, teaching/training, violence

Reflecting on Intersections with Knowledge Management, Dave Snowden, and Singapore’s Risk Assessment and Horizon Scanning System

3 04 2007

Warning: This post starts out a bit far afield from clinical work. My ideas about how it ultimately connect back, but they’re still forming, so this is definitely a “put on your seatbelt” kind of post.

For some time, I have been following the work and blog of Dave Snowden, founder of Cognitive Edge. Snowden is an scientist, theorist, and organizational consultant at the cutting edge of the Knowledge Management (KM) field. Or perhaps it would be more accurate to say that Snowden is a pioneer and visionary who is try to push KM to an entirely different dimension (call it KM 2.0). I must admit that I am still trying to get a handle on Snowden’s thinking (it’s broader and more complex than I can yet grasp), but one of the most interesting things to me about his work is that he emphasizes narrative (versus purely numerical) approach to “sensemaking.” Snowden and others of his ilk argue that you can learn more useful information, detect more weak signals, capture trends earlier through gathering stories than you can by gathering numbers. Stories show emerging trends. Numbers tell you what has already happened.   (For a popular version of this argument see Lori Silverman’s provocatively titled book “Wake me up when the data are over: How Organizations Use Stories to Drive Results“)

Snowden and another KM guru, Gary Klein, were recently videotaped discussing the methodology (and software) that the Government of Singapore has developed to help them detect terrorist risk, the Risk Assessment and Horizon Scanning (RAHS) system. I found their videotaped discussion fascinating, especially Snowden’s critique on the failures of knowledge management (2nd clip on the page). I don’t know enough to understand the differences between the perspectives Klein and Snowden offer (and, can’t in fact follow all of what either one says), but I listened with great interest to their perspective on how one approaches information-gathering, sensemaking, and decision-making in an uncertain, unpredictable, and unstable environment.

Obviously, clinical sensemaking and decision-making is quite different from government counter-terrorism operations. But I could not help but think of parallels, especially for assessment of suicide risk. Here are a couple of developing (and somewhat random) reflections I had:

  1. We know about statistical risk factors, but how do we do sensemaking with a particular person’s set of stories. Clinicians have access to rich narratives, but we generally lack methodologies and technologies for sensemaking that retains complexity and guides decision making.
  2. Traditional documentation (the principal knowledge management system for clinical care), including the diagnostic evaluation reports, usually flatten the richness of stories (by design) into a language that is more technical, linear, and sterile than real life. We usually don’t capture stories on their own or track raw data, but rather we move quickly to interpretation and synthesis.
  3. I noted in a previous post that I use mindmapping to teach about suicide risk. In that post, I suggested one benefit might be “it helps to be able to visualize connections between concepts on a map because it makes complex material more accessible.” In light of what I’m learning from Snowden and KM, I wonder if mindmapping also facilitates sensemaking from narratives better because it is nonlinear and attempts to replicate connections in human thought patterns.
  4. Apropos of my previous post, Where’s the family?…family therapy offers an opportunity for gathering anecdotes from multiple perspectives. Snowden has a KM exercise called “Anecdote Circles,” which he uses to help organizations gather information through story. The techniques he uses would be interesting to apply to a family, and to gathering information from family members about suicide risk. This kind of raw data is not available without family members.
  5. Our models and language around risk assessment needs to better reflect how fluid and unstable the phenomena of risk and suicidality really are. The act of suicide is a momentary coalescing of a multitude of snippets and anecdotes and narratives. Reading retrospective case studies of people who died by suicide makes that really clear–all of what we categorize as “risk” comes together in a certain way at a certain point in time. As one of my mentors pointed out to me last week, we can “predict” suicide retrospectively, but it is almost impossible to detect prospectively.  As clinicians we want to be sensitive to the snippets, so that we can scan the horizon (a la RAHS) and sense emerging trends, far before the data ever catches up.

As I warned in the beginning, these thoughts are pretty raw, but I’m interested in exploring this intersection more.


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Categories : Knowledge Management, Needs development, documentation, evidence-based therapuetics, family, risk assessment, technology

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

Clinician response to violation of the “social contract”

7 02 2007

I had a stimulating conversation with a senior colleague in the CSPS yesterday. One part of the conversation centered around what happens for us, as clinicians, when the patient does not fulfill his/her end of the “social contract” that is implied when someone goes to a mental health professional. The assumed contract is that the professional gets to ask all kinds of personal questions, make recommendations about intimate details of a person’s life, and the patient is expected to accurately, honestly, and completely answer our questions, cooperate with recommendations, and be appreciative in the process.

In a previous post about risk and patient Choice, I offered ideas about how to approach a particular instance of patient patient choice (sometime known as “noncompliance”), including some initial documentation suggestions. But that post didn’t address how to handle the emotions that accompany working with a patient who exercises his/her freedom by not answering our questions or by refusing our help.

Clinicians experience a range of emotions in these situations under these circumstances. Helplessness, anger, and fear come to mind first. From a family therapy perspective, this calls for what Murray Bowen (1978) called “differentiation”–the ability to remain engaged, present, and available while not becoming reactive, defensive, or distant. Easier said than done! Especially hard when clinicians often feel a duty to protect patients from harm.

The first step is to name what is going on. “This person is violating the ’social contract’ and it is making me angry. I’m also afraid that this person could die while in treatment with me.” Next is some cognitive work: “This person did not give up the right to direct his life, keep his privacy, and make choices when he sought professional help.” Along with that, your best friend is good old fashion consultation. I plan to post more in the future about how to get consultation from colleagues about suicide risk, but for now, I think the main thing is for us, as clinicians, to explicitly frame the consultation in term of our emotions. “I am afraid and angry because a person I am working with, who has high risk of suicide, is not cooperating with my attempts to assess and intervene.” That frames the consultation discussion as being about “how am I going to work with this person given my emotions?,” rather than “how can I get this person to do what I want, given how difficult he is.”

As always, there is much more to say about this. This discussion of the therapeutic social contract and patient choice is not specific to patients with suicide risk. But it deserves special attention in the context of suicide risk because the stakes are high, the issue is loaded, and medical-legal preoccupations kick in and complicate everything. More to come…

References

Bowen, M. (1978). Family Therapy in Clinical Practice. New York: Aronson Publishers.


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Categories : family, patient choice, psychotherapy, therapeutic alliance, treatment planning

At the crossroads of family therapy and suicide prevention

3 01 2007

I recently led a discussion about “Evidence-based risk assessment: implications for family therapy education, research, and practice?” at the Family Research Roundtable, which is a collaborative venture chaired by Susan McDaniel and Jane Tuttle, and funded by the University Committee on Interdisciplinary Studies.

My interest in the nexus between suicidology and family therapy is a natural one given the way my work has been evolving over the past year, but the intellectual spark for drawing the connection was a Grand rounds presentation by Paul Duberstein. In a brilliant talk titled, Standing at the crossroads of personology and prevention science: a view from suicide research, he made the following three statements that have stuck with me:

  • “Many people take their own lives because they did not receive adequate mental health treatment. Their traits, motives, and attitudes made it difficult for them to engage effectively with the mental health care delivery system and form a life-saving therapeutic alliance…It is this failure to seek and receive adequate treatment, perhaps more so than a mental or medical disorder, that is fatal.”
  • “We need to be creative and target at-risk patients, their family members, healthcare providers, and institutional settings. We need to enhance the ability to detect signs of distress, refer to treatment, and encourage treatment adherence and the development of the therapeutic alliance.”
  • “A truly person-centered health care delivery system is responsive to the “inseparable biopsychosocial entity” – and tailored to individual traits, preferences, attitudes, and communication styles.”

As a family therapist, my first thought was about the patients and family members we see who might not otherwise have contact with a mental health professional. Dr. Duberstein later made that same observation about family therapy in a subsequent talk I attended: During the presentation of a psychological autopsy he noted two points in the person’s life when marital and/or family therapy might have been helpful. These are potential “missed opportunities” we have to reach people who would not probably not otherwise seek treatment (i.e. they might come in because of marital problems or problems with their children, even when they might not seek help for themselves (or even conceptualize their problem as having to do with themselves).

There is lots of fodder for discussion here, but here are some possibilities occur to me. These are not formed conclusions, just ideas for exploration, comment, and study:

  1. Family therapists need to be strong in suicide assessment, including of family members who are not the identified patients.
  2. We need to figure out how to invite people in for treatment based on how they conceptualize their problems, and not force them to fit their problems into the way we organize our delivery system.
  3. (corollary to 2). We need to develop a flexible mental set about what kind of treatment we think is needed for people who contemplate suicide. A common assumption is that every person with significant risk for suicide or suicidal ideation needs to be first and foremost in individual treatment. If we think about suicide as failure in problem solving and an escape from pain, we have to ask…what problem and pain is the person motivated to address? Many people see their relationship difficulties as central and many (especially, perhaps, older men) will feel more comfortable learning problem-solving in the context of their family than in other forms of therapy we might offer.
  4. We need models for assessment and engagement with people who are not the identified (index) patient.
  5. No matter what the modality or paradigm, perhaps we need to think about who in a family needs help beyond the person who is the patient.

An additional empirical question that occurs to me is: how many people who died by suicide had a family member who was in treatment? We know that most people how die by suicide are never enrolled treatment, but I wonder how the numbers would look for family members.

Lots of thoughts, lots of questions swirling around as I stand at the crossroads of family therapy and suicide prevention.


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Categories : evidence-based therapuetics, family, health care delivery, suicide