At the crossroads of family therapy and suicide prevention

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.