Speaking of nomenclature…what about “protective factors”?

23 10 2008

Speaking of nomenclature, I’m increasingly growing mistrustful of the term “protective factors.”   It sounds very “evidence-based” to refer to “risk and protective factors” when discussing one’s approach to risk assessment.   However, I’ve noticed a subtle misunderstanding that has creeped in along with the popularity of these terms.  Often, it sounds like some clinicians are thinking of risk and protective factors are two sides of the same coin or–better put–two sides of the same scale and you arrive at a formulation of risk by weighing one against the other.   The potential mistake is to think that protective factors “cancel out” risk factors.

Although I have a section called “protective factors” in the map I use to teach about risk formulation and documentation, I am increasingly finding myself replacing these words in workshops with the awkward phrase, “Launching off point factors.”  What I mean to convey is that it is probably best to think of “protective factors” as factors that increase the likelihood of success for crisis and treatment planning, rather than factors that technically “protect” against risk previously identified.  A distraught, intoxicated individual with suicidal ideation and a gun can have all the protective factors in the world and that doesn’t change the risk one bit.   These factors may, however, present opportunities to engage in crisis planning, develop a therapeutic relationship, and engage a supportive system, all of which create conditions in which risk can be addressed, and which could ultimately influence decisions about the most appropriate level of care.

In our next revision of risk-related documentation, I’m considering recommending that we get rid of the term “protective factors” altogether because of the danger that it can be misleading.  I don’t have a great substitute, unfortunately.  Best I can come up with right now is “Opportunities for Crisis and Treatment Planning,” but I wonder if an ordinary person coming to a section so-labelled would know what it meant.  Needs more work.


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Categories : documentation, risk assessment, suicide, teaching/training

A better term for “high risk”?

22 10 2008

At a recent workshop I presented, a senior colleague commented that our clinical vernacular needs a more apt phrase than “high risk” to describe individuals whose clinical and historical presentation suggests risk for suicide.   “High risk for suicide,” he pointed out, sounds like suicide is probable, when in fact the likelihood of suicide in any given “high risk” case is still low in absolute terms.    So, I’ve been struggling to think about an alternative.  “Elevated risk?”  “Multiple indicators of risk?”   I don’t know.   This is not the only area in clinical suicidology with nomenclature problems, but it’s the one I need to figure out right now in order to make some recommendations for documentation standards in our department.   If you have any ideas, please leave them in the comment section or use the contact page to email me.


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Categories : Needs development, documentation, risk assessment, suicide, teaching/training

Means restriction and impulsivity in fantastic NY Times piece

8 09 2008

I have mentioned quite a few NY Times articles in this blog because I think they cover suicide really well.   Last month they published a piece in the NY Times Magazine that I keep recommending to people in informal and clinical discussions, so I thought I’d link to it here.   Many thanks to my colleague Bill Watson for first alerting me to the article.

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.


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Categories : current events, needed contributions, risk assessment, suicide

“Trusting” a person at risk who agrees to transport self

2 09 2008

A colleague  forwarded me the following excellent question posted to a listserv:

One question that has been raised is how to handle an individual who reports willingness to voluntarily go to the ER for psychiatric assessment.  Since trusting a questionably unstable and suicidal individual to present for treatment opens our agency and the patient up to considerable risk, I wanted to get input on this issue from professionals in the field.

My questions are: What is the process that you use when you genuinely believe an adult patient will voluntarily present her/him self for possible commitment/assessment?  How do you manage patient risk and your own liability in this instance? (e.g . requiring family members to be involved; or requiring a signed written contract to present at the hospital, etc) What do you do to ensure/confirm that they do indeed go to the hospital? What do you do when they do not go to the hospital, as agreed?

I’m looking for both a description of specific steps that you take and what variables you take into consideration as you decide what to do in this case.

This is an excellent question for several reasons:

  • the writer wants to support patient agency, preferring in principle to go with the patients voluntary wishes, rather than become unnecessarily coercive.
  • the writer is correctly concerned about putting all eggs in the self-report basket.   A person at risk who is not stable may not be able to follow through with intentions to get help.   It is central to both really listen people in our care AND understand that self-report has limitations and has to be considered in context
  • the writer has shared honestly her concern about both patient safety and his/her own liability—almost everyone who works with individuals at risk has these dual concerns and needs to think openly about how to balance them.

This is such a good question that I wish I had put it on my docket of questions to blog about.  And it relates as a follow-up question to one that is on that docket, “When it comes to hospitalizing isn’t it always best to “err on the side of caution”?

Here is my attempt to offer some principles for the assessment and documentation of a patient’s agreement to voluntary actions:

  • Document assessment of reliability of self-report.  When assessing and documenting self-report the following should be considered and noted:
    • past experience, if any with the patient as a reliable reporter or not.   “Pt. has reliably followed through on medical decisions and plans in the past.”
    • evidence of psychosis, thought disorder, intoxication, extreme agitation or other factor that would put the person’s capacity to make decisions in question.   If not, “Pt’s thinking is logical, coherent, and reasonable.  Judgment is intact.   No indication of impaired capacity to make decisions and follow through with them.”
    • degree of patient cooperation.  Explicitly note that the person volunteered information, though s/he didn’t have to.   “The patient has been open, cooperative, and collaborative in the assessment and planning process.  There is little reason to doubt his/her sincerity in agreeing to seek help and additional evaluation.”
    • impulsivity.   The greatest risk here would be that the person would all of a sudden feel overwhelmed with pain and impulsively kill him/herself.  If there is not strong evidence of that kind of impulsivity (even if there has been some in the past) note that.  “The patient has a past history of mild impulsive behavior, however, this was several years ago and under very different circumstances…”
  • Show your reasoning.  The key to great documentation is to state each of the factors considered, then show that the plan came as a result of synthesizing these factors.  This can come in a statement like “In light of these factors, the plan for voluntary self-transport seems reasonable and prudent.”
  • Say what you didn’t do.  Related to the previous point, it as as important to document the road NOT taken.   This shows that you took the situation seriously and considered the full range of options.
    • A corollary to this principle is to note risks associated with alternative courses of action.   “Involuntary transport has potential of violating the patient’s rights and of harming the patient’s opportunity to benefit from hospitalization.   The risk associated with involuntary transport outweigh the relatively small risk that the patient will precipitously abandon our plan and harm him/herself.”
  • Document consultation.   Much more consultation occurs in primary care than is ever documented.   This would be a time to do it.  One line is sufficient:  “Discussed case with Dr. X who concurred with the plan.”

Note that each of these points needs only a sentence or bullet-point, and not all will be applicable in every circumstance.

I’d be interested in feedback and ideas from who employs these principles in their documentation.  I would also be interested in reading comments with other ideas about how to address the situation the questioner described.


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Categories : documentation, patient choice, primary care, risk assessment, suicide, treatment planning

Possible contagion effect in Nantucket

18 03 2008

The small island of Nantucket, MA has seen 3 teen suicides in a short period of time, according to the New York Times.  Very sad.   Statistically, three suicides in a high school of 400 represents a meaningful cluster, and a possible contagion effect.   Whether it is or it isn’t contagion in Nantucket (it is impossible to know for sure and the article suggests some disagreement in this case), the key thing for clinicians to know is that vulnerability to contagion has been documented in adolescents.  Clinicians working with adolescents at risk at the time of a public or peer suicide should consider reassessing their clients’ risk for suicide when news of a peer death becomes public.


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Categories : child & adolescent, current events, risk assessment, screening, suicide

Irreverant documentation post

12 10 2007

I came across this irreverent, but pretty informative post by the Last Psychiatrist about documentation for patients with suicidal thoughts or behavior. He is writing from the perspective of an acute services physician, but much of what he says applies across settings.

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.


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Categories : documentation, needed contributions, risk assessment

Nice article on risk assessment

28 09 2007

A colleague pointed me to a nice article on suicide risk assessment written by David J. Muzina, MD in the September issue of Current Psychiatry Online.   The article is well-written and well-organized.  The stepwise approach described can be quite helpful.  I wish the article included more on documentation (there is only one sample note, and I’m not sure how helpful it is).   The article also pays scant attention to families.  But otherwise this is a really solid general reference on the subject.

Related Posts:

Where’s the Family?

At the crossroads of family therapy and suicide prevention


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Categories : dissemination, evidence-based therapuetics, risk assessment

Reminder from the bridge: Suicidal individuals are full of ambivalence

28 09 2007

Sign on NYS BridgesToday Mike Hogan, Ph.D., the Commissioner of the New York State Office of Mental Health honored RNN-TV and the NYS Bridge authority for their work in suicide prevention. The bridge authority put up signs and installed lifeline phones with direct link to the National Suicide Prevention Lifeline.

For clinicians assessing and managing suicide risk, the fact that phones installed on a bridge have been used by individuals who went on to live is testimony to just how much ambivalence remains, even in people who have gone very far toward resolved plans and preparatory behavior.

Understanding that ambivalence is key to clinical work with suicidal individuals. When I train clinicians about assessment and response to suicide risk, I often get questions about whether it is useful or even right to assess suicide risk. I’m also asked, “What about people who have good reasons for killing themselves or who rationally decide they want to end their lives?” My answer goes something like this:

Thankfully, for health care professionals there is no practical dilemma here. If you find out about a person’s suicidal thinking, then there is some degree of ambivalence. Everyone knows that psychotherapy or primary care are about health…that is life. We’re not about suicide and death. So if someone is coming to us, at least some small part of them is aligned in that direction. And it’s our job to understand that ambivalence and work toward health and life until such time as the ambivalence is resolved in one direction or the other.

That line of thinking can apply to any person, really–not just healthcare professionals. Except in some rare circumstance that you’d have to work hard to construct, the fact that someone is still alive and letting someone know by words or action about suicidality reflects ambivalence.

The fact that people read signs and use phones on bridges also discourages a fatalistic stance on the part of clinicians. We can’t simplify the matter by saying “If someone really wants to kill themselves they will, so what’s the point of screening or assessing?” That question misses the point. We assess because people don’t want to kill themselves. Some just don’t see options for life and, under the wrong circumstances (like under the influence of substances or after a particularly deep emotional wound), they overcome their ambivalence just long enough to do the unthinkable. We need to have deep compassion for the amount of pain that must be, and nurture the life-embracing side of the ambivalence until the person can see options again.


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Categories : current events, risk assessment, screening, suicide, treatment planning

Conversation with Michelle Lang, Ph.D. of RFMH

18 09 2007

I had an interesting conversation a few weeks ago with Michelle Lang, PhD, a colleague with the New York State Research Foundation for Mental Hygiene. RFMH is essentially the research and program evaluation arm of the NYS Office of Mental Health. Dr. Lang has completed a pilot study on the feasibility of routine suicidality screening in community mental health, which she conducted in collaboration with the CSPS here at the University of Rochester.

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.


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Categories : Needs development, professional culture, risk assessment, screening, teaching/training

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

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