“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

I am not expert enough in public awareness and mass media approaches to prevention to comment or speculate about how effective this video might be in preventing suicide in the Army.  But I would like to comment on some intersections between the approach this video takes and some ideas about clinical practice.

To me, one of the most powerful aspects of this video is the way in which it leads the soldier-viewer to see him/herself as potentially at risk for suicide.   The video gives the message “If you don’t get help, your life could be in danger.”   Since the video is interactive, the viewer can actually make decisions (like keeping the distress or suicidal thoughts secret) that eventually lead to death.

From a clinical perspective, I have found that putting in front of a person–sometimes in a dramatic way–the danger he or she is in can actually help to kick in the person’s survival instinct.   It sounds strange to warn someone of danger when the danger is from oneself.   But a question like this one can be sobering:  “If there were nothing we could do to move life be more livable, how likely would you be to die?”  I worked with someone who could not name a single reason why life could have worth or meaning and who could identify no chance for things to get better, but who, when asked that question, started talking about his son and two other people he wouldn’t want to leave behind.   Recently, I was pleased to hear a similar question encouraged in the ASIST approach to suicide prevention and intervention.   An advanced variation of this question might even embed the prospect of hope within the danger question:  “If there were nothing we could to help life be more livable–I think there are things, but let’s say we didn’t pursue them–If things continue like this, how likely would you be to die?”

It is strange and surprising to some clinicans that most people who are suicidal (and I would venture to say some who actually kill themselves) don’t want to die.   Many people who have survived near lethal suicide attempts have reported that.    A participant in a workshop I gave several months ago illustrated this for me in a compelling way.  This participant had, at an earlier point in her life, attempted suicide.  She had since recovered and pursued education in the mental health field.   In sharing her subjective experience of the suicidal wish, she said, “I never wanted to kill myself.  I just wanted to kill the pain.”   What a gift.   Clinicians should be aware of this and look for ways to simultaneously connect with the suffering and activate the part of every person that desires life.

The talking action page for clinicians is worth reading for any clinician, and could be especially useful to primary care providers.  I’m thinking a lot about primary care right now because (a) primary care psychology has beeen a focus of my career and I have a deep respect for the breadth of responsibility primary care providers carry, including in suicide prevention (b) I’m still pondering the recent question I considered about self-trasport and (c) I’m presenting a talk titled “Tips for Suicide Risk Assessment and Response in Primary Care” next month at the Highland Family Medicine center here in Rochester.

The Urge To End It, by Scott Anderson, is a stunning piece.  Well-written, and well-researched, it challenges the stereotype that suicide is always well thought out, carefully planned, and the result of a conscious and un-ambivalent decision.   He focuses on the impulsivity and momentary desperation involved in many suicide attempts, and raises awareness about means restriction as a potent intervention.

For clinicians, there are several important take-home points and cautions:

• Expressed suicidal ideation is only one part of an assessment of risk for suicide;  impulsivity, high intensity stressors, and agitated emotional pain signal as much about risk as suicidal ideation.
• We need to ask about available means and seek to disable lethal means whenever possible.
• We need to advocate for public policy that promotes means restriction–this may save the life of someone in our care (or in our lives).
• Ambivelance runs deep.   Even in the moment of jumping, survivors report feeling regret, not wanting to die.  We are built for living, and those who help distressed individuals have a powerful force on our side.
• We need to ask about how bad the pain is and how intense the desire for escape, even (especially) with individuals who have not previously expressed suicidal ideation.

There are probably other lessons from Anderson’s excellent article, including understanding more about the subjective experience of someone who attempts suicide.   The article is not short, but you’ll be rewarded for the time spent to read it all the way through.

Note that the post has ads embedded in it. Besides being annoying, the ads throw off some of the formatting, so you have to scroll down to read the text.

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.

Now, in all of the cases I have seen this action has been taken in full view of parents or other adults, which makes it somewhat less concerning (at least in terms of immediate risk for suicide), but nevertheless the child has taken an action which, if done at another time and in a slightly different way could be dangerous.

Our frameworks for assessing risk in adults fall short in these cases. I know I feel on less steady ground. If anyone knows of good resources–ones that not only provide risk factors, but ways of conceptualizing suicidal behavior in young children, I’d love to hear from you.