Core principles in treating suicidal patients

James Fowler does it again. He has just published another terrific and useful paper, "Core principles in treating suicidal patients." This makes a terrific companion piece to his previous paper describing "guidelines for imperfect assessments" which I have raved about and recommend all the time. The current paper is elegant and straightforward. Dr. Fowler provides a rationale, evidence, and a treatment example for three core principles:

  • alliance building
  • enhancing curiosity about the function of suicidal thoughts and urge
  • enhancing experience and epxression of intense emotions

Voila! What more do you want? You have to put Dr. Fowler's name on your search engine alert list! I just added it to the reference list that I will distribute at my next Commitment to Living workshop.

Fowler, James Christopher. (2013). Core principles in treating suicidal patients. Psychotherapy, 50(3), 268-272. doi: 10.1037/a0032030

Pragmatic guidelines for imperfect assessments

I love the title of J. Christopher Fowler's article that was published in the current issue (vol 49, issue 1) of Psychotherapy, "Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments." This practice review is thorough and wise. Fowler strikes just the balance between encouraging completeness and responsibility, and acknowledging the limits inherent in assessments of risk. Dr. Fowler also masterfully weaves in the importance of self-awareness on the part of the clinician, and gives constant attention to maintaining a caring, compassionate stance. Some selected quotations to whet your appetite for this article:

"Knowing that patients frequently deny suicidal thoughts before suicide attempt and death, clinicians should remain appropriately circumspect regarding declarations of safety when a patient recently expressed suicidal ideation, feelings of hopeless, desperation, and/or affective flooding. This does not mean we should adopt a suspicious or adversarial stance—on the contrary, curiosity, concern, and calm acceptance of the patient’s emotional and cognitive states may serve to enhance the therapeu- tic alliance, encourage the patient to directly explore her or his current distress, and aid in the accurate evaluation of current functioning."
"Before conducting a formal suicide assessment, clinicians should conduct an introspective review of recent stressful life events facing the patient, including recent ruptures in the thera- peutic alliance, and disturbances in social relationships (Truscott, Evans, & Knish, 1999). Maintaining a therapeutic stance of curiosity and concern (while simultaneously remaining open to the possibility that an alliance rupture may be a precipitant to the crisis) is difficult to sustain when anxieties are running high; however, communicating genuine curiosity and concern about the causes for their unbearable suffering is critical."
"When clinicians face a potential suicide crisis, they are multi- tasking and are usually in a state of heightened alert and anxiety. Under such stressful circumstances, it is easy to get swept up in personal emotional reactions and lose sight of the patient’s suffering and their efforts to communicate distress."

My only critique involves the absence of family system context. I would have liked to see some attention to the positive role that family members can play in the assessment process. The article does mention that the quality of family relationships is an important modifiable risk factor, which should be considered and may be the focus of clinical intervention. But most of the article, and the clinical approach advocated, has a decidedly individualistic bent. The article doesn't address how to involve friends and family members in the interview process, how to build their participation into the decision-making process, how the relational context influences decisions about how to respond to identified risk. For me this is an important gap, and a contribution that is still needed.

This gap notwithstanding, this article will instantly join the Bryan et al. means restriction article on my Top 10 Most-recommended List. In fact, the Fowler article could become my primary go-to reference when clinicians ask for reading on the subject.

Fowler, J. C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49(1), 81–90. doi:10.1037/a0026148

Thorough and practical article about means-restriction counseling (finally!)

I am a huge fan of Craig Bryan. He, Sharon Stone, and David Rudd (another person whose work I really admire) have just published an article titled, "A Practical, Evidence-Based Approach for Means-Restriction Counseling With Suicidal Patients." I know I will be recommending this article a lot. Questions about means restriction come up just about every time I teach or consult with mental health professionals about managing suicide risk. This will be my go-to resource from now on. The authors carefully present the evidence for means restriction, and provide a clear and immediately useful guide for conducting means restriction counseling. Highly recommended:
A practical, evidence-based approach for means-restriction counseling with suicidal patients.

Bryan, Craig J.; Stone, Sharon L.; Rudd, M. David

Professional Psychology: Research and Practice, Vol 42(5), Oct 2011, 339-346. doi: 10.1037/a0025051

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

Speaking of nomenclature...what about "protective factors"?

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.

A better term for "high risk"?

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.

Teaching and learning at New York State psychiatric facilities

I've returned from a fascinating series of trips to two New York State psychiatric facilities (St. Lawrence Psychiatric and Pilgrim Psychiatric), as part of a project I'm working on with the Office of Mental Health.  I learned a great deal from talking about suicide risk with over 500 clinicians from a variety of disciplines and settings--psychologists, RNs, case managers, social workers, psychiatrists, mobile crisis clinicians, family therapists and others.   It would be hard to find a group of professionals with more experience working with individuals at-risk, and the questions, comments, and concerns the participants contributed matched that level of experience.

I have made some notes about issues that were raised by clinicians, and plan to blog my thoughts about these in coming months as I get pockets of time to reflect on my travels.   As I have stated before, I think it's important for educational initiatives to map closely onto the real-life concerns of clinicians, rather than simply reflecting content that experts deem important.   Here are a few concerns and questions that I hope to think more about when I have time:/

  • When it comes to hospitalizing isn't it always best to "err on the side of caution?"

  • Why are we focusing on suicide so much when the people we work with have so many other problems?

  • Why are we focusing on suicide when it's so rare and most people who die by suicide weren't in treatment when they die?

  • How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?

  • Does doing a better job with risk for suicide always mean more work and writing?

  • Is there anyone for whom it is not indicated to ask about suicidal thoughts?

  • How often should we do a risk assessment?

  • What kinds of lawsuits have and have not been successful against clinicians in cases of completed suicide?

  • Even if we do everything right, can suicide really be prevented?

Along the lines of that last question, several clinicians shared moving stories about ways in which suicide has touched their lives, personally and professionally.   It is always so sad to hear about these deaths, and so encouraging to hear that some of the ideas I brought for discussion felt relevant to these experiences.

A big thanks to the professionals at OMH, St. Lawrence, and Pilgrim who supported and hosted me during these trips.   And to the clinicians at both facilities who made these trainings so stimulating and enjoyable.

Conversation with Michelle Lang, Ph.D. of RFMH

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.

Thoughts about SAD PERSONS Screen

I've gotten a few questions from colleagues and trainees lately about using the SADPERSONS screen. Most recently, a colleague pointed me to an article in Psychiatric Times titled, "APA: Simple Screen Improves Suicide Risk Assessment." The topic seems worthy of a post to think through both the appeal and risks of the SADPERSONS scale.

For those who are not aware of SAD PERSONS, it is a 10-item scale to purports to screen for suicide risk. An individual is given one point for each item for which he or she screens positive:

  • Sex (male)

  • Age less than 19 or greater than 45 years

  • Depression (patient admits to depression or decreased concentration, sleep, appetite and/or libido

  • Previous suicide attempt or psychiatric care

  • Excessive alcohol or drug use

  • Rational thinking loss: psychosis, organic brain syndrome

  • Separated, divorced, or widowed

  • Organized plan or serious attempt

  • No social support

  • Sickness, chronic disease

The word "simple" in headline of this Psychiatric Times article linked above captures what makes the tool sound appealing, especially for the thousands of health care systems that need a quick way to respond to the JCAHO patient safety goal 15 and 15A: "The organization identifies safety risk inherent in its client populations" and "The organization identifies clients at risk for suicide" (see this .pdf for explication of these goals).

From one perspective, there is nothing wrong with using acronym like this. It can remind clinicians (assuming they can remember what all the letters stand for!) of some of the risk factors and warning signs of suicide. Who can argue with that? However, from a training and clinical perspective, there are a few problems with this approach, especially when the screen is put forward as a scored scale. Let me summarize a few of these. Note that my thinking about some of these concerns is strongly influenced by concerns articulated by my senior (and very brilliant) colleagues in email exchanges we have had about this. I don't claim originality here, just summary:

  1. The "scale" assigns risk level on the basis of a point system: A score of 1 or 2 points indicates low risk, 3-5 points indicates moderate risk, and 7-10 indicates high risk. This approach works under the assumption that these factors are equally weighted. A separated, 46-year old male with diabetes with no depression would have a higher risk level (score=4, moderate), than 40 year-old married woman with chronic depression, current hopelessness who was just released from a psychiatric hospital after a near-hanging. (score=2, low risk).

  2. Having a risk "score" creates conditions for clinicians to rely on a number instead of developing an informed clinical formulation of risk.

  3. The suggestion that risk for suicide can be boiled down to a single number--even for screening purposes--presents a misleading picture of the complexity phenomenon and how to think about it as a clinician.

  4. The evidence that the linked article gathered does not correspond with the alluring headline, "Simple Screen Improves Suicide Risk Assessment." Evidence reported by those who conducted the study was that, after using the computerized screen, nurses tested showed more knowledge about risk factors for suicide. Of course, knowledge about factors is a long way from demonstrating improved assessment. Obviously, the physicians who reported their study at APA the study did not write the headline. The semantic overreach of the headline speaks to the understandable desire to find easy ways of doing hard things.

  5. Finally, from a training perspective, I find acronyms longer that 3 letters almost impossible to remember! SAD PERSONS particularly clumsy, and, IMHO a bit forced. "O" stands for "Organized plan or serious attempt" whereas I would probably make plan a "P" if I were trying to remember it, but of course that's already taken by "P" for "Previous." That often ends up being the problem with trying to make these things fit into an acronym. In a way, this gets back to the theme I've been harping on lately in my posts about teaching and training about needing a basic-science base about how clinicians learn, remember, and use principles or practices we learn. I'd imagine an expert in human memory could graph the inverse relationship between recall rate and number of letters in an acronym--add to that the need to recall these letters that signify words or concepts with high emotional impact.

In summary, while SAD PERSONS may be helpful to some people as a tool for remembering risk factors, it has some serious limitations as risk assessment "scale" and probably as a mnemonic.

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.

Organizational factors that support care of suicidal person

Wendi Cross, a gifted and innovative colleague in our department, presented at our Family Research Roundtable yesterday. One of the ways she is contributing to the field is to raise awareness about, and develop methodology to study, the factors surrounding implementation of an evidence-based intervention (be it training, prevention, or therapeutic intervention) that influence its ultimate impact. Right now her focus is on implementers of an intervention, but in the course of discussion she mentioned that there are other extra-intervention factors, such as institutional and organizational factors that influence how, how much, and how well evidence-based interventions are put into practice after someone is trained.

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.