McCauley, M., Liebling-Kalifani, H., & Hughes, J. H. (2011). Military Mental Health Professionals On Operational Deployment: An Exploratory Study. Community Mental Health Journal. doi:10.1007/s10597-011-9407-8

Dr. Lang and her colleagues learned a great deal from their pilot. As someone developing clinician training in risk assessment, I was especially interested in what they discovered about the range of clinician reactions to the idea of screening for suicide risk:

• Many clinicians shared the popular myth that asking about suicide might make it more likely.
• There was more resistance to the screening than the implementation team anticipated.
• Reactions, both positive and negative toward the program were strong.

There were many other lessons, and I look forward to reading the process papers that will come out of the experience.

Reflections: Many of the experiences Dr. Lang shared point to how difficult and loaded the topic of suicide is for clinicians–even the most experienced ones. As a trainer, this highlights to me the need to find predictable and replicable ways to create a safe learning environments, where clinicians feel understood and where their current practice patterns are honored. This can be hard to do when you are suggesting a change in practice. Dr. Lang and her colleagues made huge efforts to support clinicians, yet still encountered challenges.

Making clinicians feel safe enough in a training that they’ll consider changing practice patterns involves the tone and stance, as well as the content of a training. In reviewing training curricula, I’ve discovered that tone, stance, and conceptual starting points are often not explicitly developed. Contrast this with the way people develop treatment interventions and manuals. For example, in the first chapters of Marsha Linehan‘s highly successful intervention manual, Linehan lays out an entire dialectical worldview that undergirds her intervention program. That kind of elaboration is rare in developing educational interventions. A recent conversation I had with DeQuincy Lezine, Ph.D. underscored this point for me–he advocated for using “logic models” to examine the assumptions and mechanisms behind any community or training program.

Here are a few ideas about tone, stance, and starting points that I’d like develop further:

• Drawing on Marsha Linehan’s work again, clinician training in suicide assessment requires a balance in the “dialectic” between unconditional acceptance and push for change. Why is this balance so important (and difficult) when it comes to suicide? Perhaps Linehan’s concept of “invalidating environments” may apply more than we’d like here, as well. Many of the administrative and legal systems in which we work are invalidating and blaming! Furthermore, one’s work vis-à-vis suicide is so personal and fundamental that the suggestion of need for improvement can be hard to take in.
• Another way of considering the stance and tone needed for effective clinical training in this area from a stages of change (transtheoretical) perspective, i.e. that training needs to have a motivational interviewing stance. The trainer must have an awareness of the ambivalence toward change, and present change tentatively and in a way that draws upon the internal motivation clinicians have to improve their practice in this regard. In my trainings, I’ve found that one way to do that is to talk about the unspoken dissatisfaction I carried for years about the experience of working with suicidal patients–I share with participants that I always found the experience unrewarding and that I had a vague pre-verbal sense that the way I approached suicide was probably not that helpful to the individuals I worked with. In addition to being genuine, that kind of stance may stoke clinician motivation in a way that the public health arguments do not.
• In addition to these considerations regarding the pedagogical stance, there are also content emphases that might reduce clinician resistance. As I have noted in almost every post on teaching and training, I feel training in this area should begin with what and how clinicians think and that many efforts in clinician training have the wrong starting point-i.e. they begin with the question: “what do experts say clinicians know about suicide or suicide risk assessment” rather than “what do clinicians want to know.” In my experience, clinicians are most hungry for how to document their work and decisions so that they can feel less anxious and can focus on doing what is best for the patient. If that’s the case (and this remains an empirical question), then documentation should be a starting point…through which other content (including what experts would say clinicians should know) can be delivered.

Thanks again to Dr. Lang for an informative, stimulating, and enjoyable conversation. She is doing good and interesting work with the State. I look forward to reading the papers that come out of her most recent project, and about the next stages of it development.

eMJA: The effect of Web 2.0 on the future of medical practice and education: Darwikinian evolution or folksonomic revolution?

Related posts:
How clinicians learn: Web 2.0 Opportunities?
Tech tools for clinical thinking and training
Blogging out in the open in a clinical setting
More blogging to come at URMC?

A few reflections on this conversation, which took place on Friday.

1. We spent a fair amount of time on definitional ambiguities around the word “blog.” I had never realized that the word can evoke lots of different images in people’s minds. At different points, it morphed between meaning “anything RSS,” “Web 2.0,” “collaborative Internet”, and “discussion board.” That happens with any word (I say “chair” and think of this and you might think of this), but it is especially true of word describing emerging concepts.
2. I became aware of how personal my blog is to me, and how much I resist efforts to legislate aspects of it. I didn’t like ideas that entailed requiring people to commit to post once a week or something like that.  I’m sure corporate blogs do something like that, but for a blog that is about idea development, I think the frequency should match the idea generation and can’t be forced.
3. I had never thought before about how to get “buy-in” from people to blog. My recommendations to those involved in this project was that the only way to cultivate bloggers is to get people reading blogs first. Get them understanding RSS and some of the benefits to blogging (including in clinical or academic communities) from a reader’s standpoint. I think it’s hard to imagine why spending time writing posts would be useful to oneself or others until you’ve seen it in action.
4. My other thought about “buy in” is that you have show people how any project that will require time and effort will promote their careers, not just promote a concept.  For faculty, it’s about intellectual development.  You’d have to show and provide examples of how writing thoughts that are still under-development to a wide audience can be helpful.
5. I found myself thinking a lot about (and mentioning to my colleagues in our discussion) the Merlin Mann’s quote that I have referenced here before, in which he describes a blog as “only incidentally a publishing system…At its heart, your blog represents the evolving expression of your most passionately held ideas…”
6. Web 2.0 is all the rage right now.  Articles like this one in InfoWorld talk about the growth of vendors who are trying to profit from this. There are a lot of ways leaders can go wrong when trying to jump on the Web 2.0 bandwagon. These 23 steps for learning Web 2.0 have gotten a lot of attention lately. Seems like a thoughtful approach, perhaps a prerequisite “course” for anyone interested in how a particular institution might benefit from the new web.
7. It’s important to consider which tool is right for which purpose. Blogs are great for pushing content to interested audiences, wikis for collaboration on specific projects, etc. When is it best to use multiple individual blogs and when is it better (as I think they’re going to try here) to have one blog with multiple contributors?  My personal preference as a consumer is for the individual blog because part of my interest is watching the creative process take shape in an individual over time.  But maybe that’s just the clinician in me.

It was fun to be part of the discussion at this early stage.  I’m excited to see where the initiative goes.

BlogScholar.com – Flatland Metaphor

The study does not study who is not getting medication that might have in the past–just that fewer kids are getting the medicine.  Whether that is ultimately good or bad remains to be seen.

Kelly Posner, who headed the FDA/Columbia Reclassification study, spoke at our Department Grand Rounds last month and lead a seminar with a smaller group of us about the reclassification scheme.  (The reclassification project looked in detail at reported adverse events that started this controversy.)   She clearly thought the consequences of the warning would be mostly negative.   She shared her concern (which has been stated by others as well) that the unintended consequence of the black box warning will be fewer youth treated for depression and more deaths by suicide, as a result.  From what I have read, that remains an empirical question and one that will require careful interpretation of data before inferring causality. What is clear is that the black box warning was probably based more on political and emotional concerns than on science (see also Marshall, Posner, and Greenhill, 2006), and that the risk of untreated depression is probably greater than the risk of adverse events from treatment.

[mounting soapbox]  That said…when this discussion comes up I think it is important to add psychotherapy and counseling to the landscape.  Untreated depression can be deadly, but that doesn’t mean the treatment has to be medication.  [coming down off soapbox]

What are the implications for risk assessment?   I’m still trying to understand that.  How I am guiding our clinicians at this point is this:   When conducting a risk assessment of an adolescent or young adult in the first weeks following initiation of antidepressants, we need to note that antidepressants have been recently started.  But rather than name this as a “risk factor” we would do better to note how the medication response will be monitored and indicate the risk-related symptoms that are being targeted by the medication.  That is, connect the medication to the risk factors it is designed to reduce, more than to the risk it might carry.

References

1. Marshall, R. D., Posner, K., & Greenhill, L. (2006). Risk Perception Research and the Black Box Warning for SSRIs in Children. Journal of the American Academy of Child & Adolescent Psychiatry, 45(7), 765.
2.  Nemeroff, C.B. et al. (2007. Impact of Publicity Concerning Pediatric Suicidality Data on Physician Practice Patterns in the United States.  Archives of General Psychiatry, 64:466-472.

In KM world, what mental health clinicians call a “treatment team” could be considered a Community of Practice. There are many definitions of this term and treatment teams fit some more than others. But Dave Snowden is clear in the videotaped discussion I pointed to yesterday that one of the failures of contemporary knowledge management is the inability to promote fruitful communities of practice. Snowden argues that organizations make the mistake of trying to organize communities of learning and practice using language, structures, and concepts that are not “naturalistic.” That is, we ignore the processes by which people naturally come together to form knowledge-sharing communities and either over-organize (imposing a hierarchy and structure that we think will promote good functioning, but ultimately stifle innovation) or wrongly organize (bringing people together around a concept or structure that does not promote natural affinity).

Our organization is considering a redesign of our ambulatory service into diagnostic-based treatment teams (e.g. “Comorbid depression team”). The aim is to have well-functioning teams that promote evidenced-based practice. As I listened to Dave Snowden talk about communities of practice, I coudn’t help but think that organizing this way has hints of the kinds of non-naturalistic grouping that Snowden warns against. The intent is good and the organizational principle makes sense on the surface, but grouping clinicans by the DSM diagnosis of their patients has the potential to be structure-rich, story-poor, and human-factor-ignoring.

One of the principal reasons stated for considering organizing by diagnosis is that the research literature about effective treatments is organized by diagnosis. It is an “evidence-based” decision. However, evidence associated with a particular epistemology (categorical psychopathology) is privileged over that of other epistemologies like cognitive science, organizational behavior, human factors research, and systems theory are ignored. Just because treatment studies organize patients into diagnostic groups, doesn’t mean that human clinicians will work most effectively with the human problems and stories we see by grouping ourselves by our patients’ Axis I diagnosis.

What would be a more narrative-rich way or organizing ourselves? Well, if we think of theoretical paradigm as a narrative, than perhaps that could be starting point. Or perhaps provide freedom for people to organize themselves into natural groupings. Or maybe there’s a way of listening to clinicians and patients’ stories about themselves and seeing trends and themes that we don’t now see. It would take time and a new set of methods, those more akin to what Snowden promotes, to discover these themes. But we’re taking time and energy either way. I’m not sure, to be honest, but I think the principle Snowden promotes is a good one: don’t impose a community of practice based on a predetermined epistemology, especially one that is reductionist and devoid of narrative…rather, look at how productive human networks form naturally and spend your time and energy discerning the conditions in which these can develop.

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.