Where’s the Family?
At the crossroads of family therapy and suicide prevention
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.
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:
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:
-- 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.
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.