Patient and Family-Centered Responses to Suicide Risk

Over the past few years, many mental health care systems have adopted useful strategies and technologies to reduce risk across their systems. In my consultations with health systems, I have seen enormous advances in terms of consistent nomenclature, universal screening, documentation standards, assessment procedures, and crisis response planning. A lot of interest has coalesced around certain helpful tools such as the Columbia Suicide Severity Rating Scale and Safety Planning, which help with key tasks that are part of the overall competent care of suicidal patients.

Competent implementation of suicide prevention technologies in clinical care depends on the attitudes and approach with which the professional applies them. Even as we make progress on systematic care for suicidal individuals, have we invested enough attention to fostering the attitudes and approaches that undergird effective care for suicidal individuals and their families? Evidence-based assessment and response to suicide risk includes forming cordial and collaborative relationships, conveying human compassion, building on natural strengths and supports, and promoting dignity and hope. Many major therapeutic interventions for suicidal individuals share common foundations in this regard--DBT and CAMS are good examples--and most clinicians are highly capable of forming bonds of caring with their patients and their families. However, the well-documented challenges (uncertainty, powerlessness, time burden, anxiety) of clinical work with suicidal individuals can interfere with authentic expressions of empathy, commitment, and respect, potentially reducing the yield from other measures taken to assess and reduce suicide risk, such as well-timed screening and safety planning. These challenges also tend to narrow clinicians’ focus on the patient alone, sometimes to the exclusion of interested family and friends. As a result, continuing professional education is needed to empower clinicians with a conceptual framework for understanding and responding to suicide risk that will promote desirable attitudes and behavior across treatment modalities, prevention technologies, and episodes of care.

Patient and family centered care (PFCC) provides a useful framework for developing attitudes and behaviors consistent with best-practices in the compassionate care of suicidal patients. PFCC is a movement that is re-centering healthcare on the experience of the patient and family as a key factor in health care quality and safety. PFCC encourages envisioning all aspects of a health-care system from the patient's perspective, from policies and facility lay-out down to specifics of the clinical encounter. PFCC is a major focus across  my home institution, with expertise coming from the Institute for the Family with which I am affiliated. I am not aware of any broad application of this term to the care of patients who present with suicide risk, but I have recently been thinking about CTL in these terms. I have been trying to boil down the PFCC approach I teach in CTL. This remains a work in progress. So far, I have generated these six hallmarks of patient and family-centered response to suicide risk:

  1. Elicit the experience and function of suicidal thinking from the perspective of the person at risk and their family members.
  2. Convey empathy for suffering, a desire to help relieve it, and confidence that recovery is possible.
  3. Invite individuals and their families to make decisions about addressing suicide risk based on their ideas, expectations, and preferences, providing informed consent about risks and benefits of various options. 
  4. Explore how plans and decisions for responding to suicide risk will affect and be affected by the person's family, social network, interests, and responsibilities.
  5. Express personal and institutional commitment to alleviating current distress and supporting  the life and happiness of the person and their family members.

These clinical principles are not unique or original to CTL. The SPRC/AAS Core Competencies (pdf) include these skills from a different vantage point and vernacular. There are also a host of constituent skills and attitudes that are part of specific treatment modalities. Nevertheless, I have seen a clear need for a direct and transtheoretical focus on these core points.

Because these five points are at the heart of CTL education and consultation, I have been considering re-wording the subtitle of the CTL workshop, and of this blog. For some time, the tagline for CTL has been "Understanding and Responding to Suicide Risk." I settled on that broad moniker at the advice of colleagues who thought the original title was too cumbersome: "Assessment and Decision-making for Competent and Caring Clinicians." They were right; however, as my thinking has evolved and my assessment of needs in the field has sharpened, I may want CTL to reflect the patient-centered focus more directly, perhaps with the title, “Commitment to Living: Patient and Family-Centered Response to Suicide Risk.”

Whatever the title of CTL, the time has certainly come to incorporate the helpful and empowering concepts from the PFCC movement into the way we work with individuals at risk for suicide.

Thanks to Susan H McDaniel, PhD, Dr. Laurie Sands Distinguished Prof. of Families & Health at the University of Rochester Institute for the Family, for her input on this article.

Preparing my presentation for AAS 2010

I'm preparing my presentation for the April 2010 American Association of Suicidology annual conference, which will be held in Orlando, Florida.   My presentation is titled "Evaluation of Commitment to Living: a brief training to address suicide risk assessment and management."  I'm enjoying the preparations because I'm planning to present entirely using mindmaps on my curriculum which relies heavily on mindmaps!  There's a very pleasing symmetry about it.   And I'm impressed all over again with how much the maps aid the conceptual organization of the material I want to present.  I'm sure it's not for everybody, but I find it so helpful.

If you're going to be in Orlando on April 24, please come by and say hello.

Related posts:

Visual maps and guides in high stress situations

Mindmapping coping strategies

Mindmanager Customer Vignette

Possible implications of findings re: visual memory

Newsmap illustrates power of mapping/visualization

Newsmap illustrates power of mapping/visualization

This is a bit far afield from suicide, but I think worth mentioning here because it illustrates how maps and visualization can present a different, more contextually-sensitive view of a phenomenon, as compared to that which lists and other linear formats can achieve.

I recently became aware of a project called Newsmap, which takes a traditional news feed (Google News) and maps it so that you can see the news landscape in a different way.   The program purports to "to divide information into quickly recognizable bands which, when presented together, reveal underlying patterns in news reporting across cultures and within news segments in constant change around the globe."   In the quick scans I've done, I've been impressed with how much information can be presented this way, and with how much more context one apprehends from this visual view.

Mindmanager Customer Vignette

Mindjet included a vignette about my work [link updated 1/28/09] with mindmaps in a new customer vignette section of their website.   There are many other vignettes on the site that are interesting and worth reading for anyone interested in using mindmaps for thinking, planning, and presenting.

I'm an intellectual stalker!

One of the URMC colleagues with whom I previously talked about blogging, asked me about mindmapping today (see my mapping posts). Because she has sequentially hit upon a couple of my key interests, she questioned whether she's an "intellectual stalker"--a phrase I thought was just hilarious. Part of what tickles me about the phrase and concept, is that "intellectual stalking" is what the blogosphere is all about! RSS is the übertool of the intellectual stalker, allowing a person to obsessively track the thoughts and experiences of another. Best of all--it's anonymous and free! Thank you to my colleague for this great phrase!

CTL to Healthcare Professional Mindmappers: Delurk!

Gaelen O'Connell over at Mindjet contacted me to ask if I knew of other healthcare professionals who are use or write about mindmapping.   I thought it was a good question.  I couldn't think of anyone, but realized that if there were others out there, I would love to connect.    So..if there are any other healthcare professionals with an interest in mapping out there, leave a comment on this post or email me separately.  Thanks for the question, Gaelen!  

Possible implications of findings re: visual memory

Readers of this blog know that I am interested in mindmapping and other visual presentation strategies as tools for training clinicians in suicide risk assessment (see related posts listed below).  In a previous post marked "needs development" I noted:
Really, there is a “basic science” set of questions about learning and the clinician mind that gets skipped over when we do the necessary and important work of evaluating educational interventions.

Thanks to a post on PsychNews, I came across this interesting article in Cognitive Daily that attempts to provide some explanations for why visual memories are often so vivid.  One of the take-home points of the study cited in the article is that the vividness of visual memory is directly related to the duration of viewing.    This is unsurprising in some ways, but it supports the educational strategy of using one or two maps or other graphics (rather than a multitude of Powerpoint slides or text handouts) to teach about a clinical concept like risk assessment.   Participants in my trainings, for example, view one map (whose branches I dynamically hid and show) for nearly the entire presentation.

These little bits of basic science evidence remind me, once again, that we pay too little attention to the evidence base of our teaching techniques.   It is well and good to decideto pursue evidence-based interventions and therapuetics (EBIT, as we call it around here), but what is often missing (besides a coherent notion of what constitutes evidence--a topic for another day) is an evidence-based way of disseminating evidence-based practice to clinicians.

Related Posts:

Visual maps and guides in high stress situations

Mindmapping coping strategies

Evidence for visually different presentation format

Tech tools for clinical thinking and training

Conversation with Paul Quinnett, Founder/CEO of QPR

I talked yesterday with Paul Quinnett, Ph.D. Founder and CEO of the QPR Institute. He has been working in the field of suicide prevention for decades and has developed an excellent set of tools for clinicians. I enjoyed the conversation because Dr. Quinnett is bright, experienced, and passionate about his work, and also because of the conceptual overlaps I observed through our conversation. Here are a few from my notes:

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.


Drawing on experience in other fields that do risk assessment.  In a previous post, (Reflecting on Intersections with Knowledge Management, Dave Snowden, and Singapore’s Risk Assessment and Horizon Scanning System), I shared my reactions to Dave Snowden’s work on detecting terrorist threats. Dr. Quinnett was struck in a similar way by Gavin deBecker’s work in threat assessment. I had not heard of deBecker but apparently his California firm, Gavin deBecker and Associates works with high-profile clients (including Hollywood celebrities) to analyzing potential threats to their safety. He has written a book called “The Gift of Fear,” which I plan to read on Dr. Quinnett’s recommendation.

Along similar lines, I have consulted with a forensic psychologist and friend, Daniel Murrie, Ph.D., who co-authored a book (with Mary Alice Conroy) coming out this fall about assessment of risk for violence, “Forensic Assessment of Violence Risk: A Guide for Risk Assessment and Risk Management.” This book, which I’ve seen excerpts of, presents an approach to assessment of risk for violence that is clear and accessible to clinicians and retains the richness and clinical complexity that appropriate to the challenging work of predicting an individual’s risk of being violent. The approach that Conroy and Murrie take has potential applicability for suicide risk assessment, for which we’ve never quite had such a clear model for conducting and writing assessments.

I guess the intersection here relates to seeing potential for developments in threat and violence prediction work to help our efforts to improve detection of suicide risk.

Desire to understand the clinician’s state of mind when faced with risk assessment. I have noted before (see my post on Visual maps and guides in high stress situations) that I’m interested in learning what the cognitive science would be related to how people best access information for decision making in high arousal situations. Similarly, Dr. Quinnett mentioned that he would like to test clinician perceptions about information gathering in risk assessment. What kind of cost/benefit appraisals do they make about asking questions and gathering collateral info?

In my view, the clinician’s state of mind/emotion and cognitive heuristics are underappreciated in most approaches to training about suicide risk. As I noted in my post about clinician anxiety (Clinician anxiety–what’s it about?), what we believe about the most pressing concerns for clinicians will influence what and how we teach. Likewise, understanding how clinicians learn best is important for modes of dissemination (for example, see my post on How clinicians learn: Web 2.0 Opportunities?).

Summary: “Needs Development.” This is another post I’ll tag “needs development” because much of this raises more questions than it answers.   But reflecting on these conceptual intersections helps me to see how much is not known about how to approach training in suicide risk assessment.   Really, there is a “basic science” set of questions about learning and the clinician mind that gets skipped over when we do the necessary and important work of evaluating educational interventions (which, of course, we don’t do enough of either!).

Visual maps and guides in high stress situations

I had a stimulating conversation about the directions my work is heading with two of my mentors last week.   One part of the conversation was about further examining the potential of visual mapping in clinical teaching, especially in the area of suicide risk assessment.  I need to understand the cognitive science of mapping more.  One of the questions we discussed in this meeting is whether there is a special benefit of visual mapping for situations that involve high arousal (such as that which a clinician faces when assessing an individual with high risk of suicide).   Is there better recall of previously presented material?  Can a clinician process a visual aide in the midst of the clinical moment better than text?   I'd imagine these things have been explored, at least in some form, by educational psychologists, cognitive scientists, and neuroscientists.    I recently added a tag for "needs development" so I can review things that I've noted needing more work.  This post will get that tag. :)

Example of risk map

In a comment on my previous post about visual presentation for clinical training in risk assessment, Avi of GUI Yourself requested an example. Here is a .pdf of a map I use. The details are collapsed, but you can get the idea.  I also teach using a map of the options available to clinicians in our system.  I am working to customize that map for each service area I train (with the aim of influencing implementation and transfer, as discussed in this post).

Evidence for visually different presentation format

The materials I am working on to train clinicians in risk assessment involve visual maps which I present using Mindmanager. I have blogged about this learning tool before (here and here). Well...I haven't read the source research that this article from the Sidney Morning Herald is based on, but it looks like it provides data to back up the contention that people learn best by being presented visual stimuli that complement and enrich what the presenter is saying, rather than repeating or rewording it like many Powerpoint presentations or other handouts do.

Tip of the hat to LifeDev, where I first learned about this article.

How clinicians learn: Web 2.0 Opportunities?

A thoughtful colleague of mine observed yesterday that, although there is a range of ways clinicians get clinical information about suicide (articles, workshops, books, practice manuals), a lot of clinical learning takes place informally--by doing the work and by talking with other clinicians. That is probably especially true for the busiest front-line clinicians.

I later reflected about what this could mean in terms of Web 2.0 opportunities to change clinician behavior. First, the narrative, personal feel of blogs might appeal to clinicians in a way that practice manuals and official websites don't.   Second, the conversational opportunities of wiki (Wiki in wikipedia, Using Wiki in Education), RSS feeds, podcasts, and other Web 2.0 venues also have potential to reach people in a fresh way.

Would a front-line clinician who does not regularly read research journals subscribe to a weekly 10 minute podcast conversation between a suicide researcher and a clinician who works with high-risk patients? Maybe. It's mostly an empirical question at this point, but there are several experiments going on in the field, some of which are on my blogroll.

Tech tools for clinical thinking and training

Whenever I present, I get questions about the technology I use. I work on a Fujitsu T Series Lifebook (T is for Tablet PC), and use MindManger by Mindjet for almost everything I think about or present. I'm happy to let people know what I use because I think they are tools that lend themselves well to the clinical enterprise.

I like using a Tablet for presenting or for taking notes when meeting with families because it sits in front of my like a pad of paper. For some reason, I am also able to listen better when I'm only working with one hand on a computer. It's hard for me to listen, write, and engage when I'm using both hands on a keyboard.

I first learned about MindMapping from a classic book on the subject by Tony Buzon. I use it for brainstorming, project management, and presenting. I'm still in the process of investigating the relationship between visual maps (mind-mapping or concept mapping) and learning complex concepts. I've done a partial lit review about it in the educational literature and it seems like there are a lot of theories (and, of course, few data) about why visual maps would promote learning different from plain text. For suicide risk, I think it helps to be able to visualize connections between concepts on a map because it makes complex material more accessible. I have a map of risk factors to consider that somehow enlivens discussion of something that could feel quite rote or overwhelming.

It may be that these tools are also effective because they haven't yet (and I mean yet) become mainstream. People are intrigued because they are different. I'm OK with that, but I hope that's not the only factor at play.