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

Health Affairs: Dr. Ashley Clayton reflects on care she received as a teenager

If my recent post on Patient and Family Centered Responses to Suicide Risk interested you–or if it didn't–I highly recommend an article by Dr. Ashley Clayton published this month in Health Affairs:  How ‘Person-Centered’ Care Helped Guide Me Toward Recovery From Mental Illness.

Thanks to Dr. Yeates Conwell for pointing me to the article.

Suicidal High School Students’ Help-Seeking and Their Attitudes and Perceptions of Social Environment

Clinicians, school personnel, parents and other adults share at least one thing in common: none of us can read minds. The only way we're going to know if an adolescent is considering suicide is if they tell us. My colleagues and I conducted a study examining some key correlates of help-seeking among adolescents who had seriously considered suicide. The results have been published in the Journal of Youth and Adolescence.

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.

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

Helping at-risk patients who rarely show up

From early on in my quest to understand the unique challenges mental health professionals face in working with patients at risk for suicide, I've wondered aloud about the things that make us the most nervous. I'm still working my way through a  list of questions I posted based on my notes from a series of trainings I delivered across New York State. One that has kept coming up since that time is this one:
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?

Mental health care was not organized to fit the way many people at risk utilize services. Much of outpatient mental health is organized around a fantasy that most patients will (1) Make an appointment ahead of time for an evaluation; (2) come to that appointment at the specified time; (3) make another appointment; (4) come to that appointment; (5) work on a signed treatment plan in between.

Now, that model probably does work well for some people. But for many individuals at risk, that level of organization and consistency is not congruent with their lives. If it were, they wouldn't need us! The situations that make professionals the most nervous are the ones where the patient (1) Makes an appointment.  (2) Comes to the appointment later in the day or the next day crying and upset, hoping to be seen. (2) Misses the next appointment.  (3) Makes it to one appointment with the psychiatrist. (4) Misses 2 of the next 3 appointments with the primary therapist (5) can't recall the treatment plan when asked about it. Naturally, clinicians get frustrated and wish the person would either sign-up or drop out.

But of course it's not the fault of the individual at risk that we're set up the way we are, or that all the empirically supported treatments assume the patient is actually in treatment. I've addressed this issue here, here, and here when I've talked about how to manage patients who violate the "social contract" of being a patient. But there's something distinctly anxiety-provoking about someone who is loosely connected to mental health services, compared with someone who actively refuses plans we suggest.  It can be especially hard if the loosely-connected person only shows up when in crisis.

This won't be a surprise to those who have followed my posts, but my approach to the loosely connected person hinges on two core clinical tasks: connection, compassion, and documentation.

Connection means that we should have the bias of keeping people involved to the level they are able.  I know that this is difficult in the context of productivity demands and limited resources.  You can't have 80 people on your caseload who all miss 75% of appointments.  But I think we should condition ourselves (and set up services) to have a least a few people like that because the resources might be well spent in being a bridge to life for the person.

Compassion is always core. It can be hard to feel and show compassion to someone in crisis when they haven't taken the least first step to try ideas you've given. It's easy to find yourself thinking, "Maybe if you came a little more often, you wouldn't be in this position." It's especially hard to find compassion for someone who is at-risk for suicide and not showing up because it feels like they could take us down with them. All of those thoughts are natural, and it shouldn't end there. Instead, we have to summon the courage to enter in to the suffering one more time, offering the main thing we can offer under these circumstances: a caring commitment to living.

Documentation is one way I get to that place. One barriers to compassion is fear.  It takes courage to keep working with someone who has only one foot in the room--especially when they present with suicide risk. Part of every clinician's brain is occupied with worry under these circumstances--worry about losing a patient, worry about being blamed, worry about being sued. It's hard to have compassion for someone if you think they could ruin your life. Having an unassailable risk assessment and other supporting documentation can put the fearful part of the clinicians brain to rest and make way for the kind of compassionate connection the hurting patient really needs. In other words, one of the key purposes of documentation is to quiet fears that might interfere with caring--and with doing the right thing. Once you're confident about documentation, you can focus on doing what's best for the patient, instead of feeling cornered into defensive courses of action.

Connection, compassion, and documentation share at least one thing in common: they are easier said than done. Their importance is so obvious that it may be tempting for an experienced clinician to speed passed these concepts. Anyone NOT think connection, compassion and documentation are important? Of course not. But, as with most simple good ideas, there are complex barriers to implementing them. Each person has to identify his or her own barriers and find a way to build these principles in to every day practice.

Clinical reflections on Army's approach in interactive suicide prevention video

A colleague pointed me to a Washington Post article describing an interactive suicide prevention video the Army has produced and will make mandatory for all soldiers.   I experimented with the online demo of Beyond the Front, which shows scenes from the life two soldiers and allows the viewer to make choices that either lead toward or away from help and survival.   The demo portion I reviewed focuses on the decision a distressed soldier faces in deciding to talk with the chaplain or not.   I was impressed with the quality of the video and interested by the approach.

I am not expert enough in public awareness and mass media approaches to prevention to comment or speculate about how effective this video might be in preventing suicide in the Army.  But I would like to comment on some intersections between the approach this video takes and some ideas about clinical practice.

To me, one of the most powerful aspects of this video is the way in which it leads the soldier-viewer to see him/herself as potentially at risk for suicide.   The video gives the message "If you don't get help, your life could be in danger."   Since the video is interactive, the viewer can actually make decisions (like keeping the distress or suicidal thoughts secret) that eventually lead to death.

From a clinical perspective, I have found that putting in front of a person--sometimes in a dramatic way--the danger he or she is in can actually help to kick in the person's survival instinct.   It sounds strange to warn someone of danger when the danger is from oneself.   But a question like this one can be sobering:  "If there were nothing we could do to move life be more livable, how likely would you be to die?"  I worked with someone who could not name a single reason why life could have worth or meaning and who could identify no chance for things to get better, but who, when asked that question, started talking about his son and two other people he wouldn't want to leave behind.   Recently, I was pleased to hear a similar question encouraged in the ASIST approach to suicide prevention and intervention.   An advanced variation of this question might even embed the prospect of hope within the danger question:  "If there were nothing we could to help life be more livable--I think there are things, but let's say we didn't pursue them--If things continue like this, how likely would you be to die?"

It is strange and surprising to some clinicans that most people who are suicidal (and I would venture to say some who actually kill themselves) don't want to die.   Many people who have survived near lethal suicide attempts have reported that.    A participant in a workshop I gave several months ago illustrated this for me in a compelling way.  This participant had, at an earlier point in her life, attempted suicide.  She had since recovered and pursued education in the mental health field.   In sharing her subjective experience of the suicidal wish, she said, "I never wanted to kill myself.  I just wanted to kill the pain."   What a gift.   Clinicians should be aware of this and look for ways to simultaneously connect with the suffering and activate the part of every person that desires life.

Clinician response to violation of the "social contract"

I had a stimulating conversation with a senior colleague in the CSPS yesterday. One part of the conversation centered around what happens for us, as clinicians, when the patient does not fulfill his/her end of the "social contract" that is implied when someone goes to a mental health professional. The assumed contract is that the professional gets to ask all kinds of personal questions, make recommendations about intimate details of a person's life, and the patient is expected to accurately, honestly, and completely answer our questions, cooperate with recommendations, and be appreciative in the process.

In a previous post about risk and patient Choice, I offered ideas about how to approach a particular instance of patient patient choice (sometime known as "noncompliance"), including some initial documentation suggestions. But that post didn't address how to handle the emotions that accompany working with a patient who exercises his/her freedom by not answering our questions or by refusing our help.

Clinicians experience a range of emotions in these situations under these circumstances. Helplessness, anger, and fear come to mind first. From a family therapy perspective, this calls for what Murray Bowen (1978) called "differentiation"--the ability to remain engaged, present, and available while not becoming reactive, defensive, or distant. Easier said than done! Especially hard when clinicians often feel a duty to protect patients from harm.

The first step is to name what is going on. "This person is violating the 'social contract' and it is making me angry. I'm also afraid that this person could die while in treatment with me." Next is some cognitive work: "This person did not give up the right to direct his life, keep his privacy, and make choices when he sought professional help." Along with that, your best friend is good old fashion consultation. I plan to post more in the future about how to get consultation from colleagues about suicide risk, but for now, I think the main thing is for us, as clinicians, to explicitly frame the consultation in term of our emotions. "I am afraid and angry because a person I am working with, who has high risk of suicide, is not cooperating with my attempts to assess and intervene." That frames the consultation discussion as being about "how am I going to work with this person given my emotions?," rather than "how can I get this person to do what I want, given how difficult he is."

As always, there is much more to say about this. This discussion of the therapeutic social contract and patient choice is not specific to patients with suicide risk. But it deserves special attention in the context of suicide risk because the stakes are high, the issue is loaded, and medical-legal preoccupations kick in and complicate everything. More to come...

References

Bowen, M. (1978). Family Therapy in Clinical Practice. New York: Aronson Publishers.

Clinician anxiety--what's it about?

When the "S" word comes up, many clinicians feel on edge. I'm sure that more than one factor (and different factors for different people) that contributes to the anxiety, but they are different enough that it affects how we would target training. Here are some possibilities:

  1. Uncomfortable with the pain and despair of another.

  2. Squemish about suicide and it's morbid implications.

  3. Unsure of having the right skills to assess and treat.

  4. Worried about medical-legal implications of losing a patient to suicide.

  5. Concerned that suicidality will "hijack" the treatment.

  6. Incredulous that someone consider destroying him/herself.

  7. Fearful of losing a person the therapist cares about.

  8. Worried about not being able to help.


As I said, the source of anxiety probably varies, but I think it's worth asking which is the most prominent so that we can (a) address it in ourselves and (b) target clinician education at the right set of issues.

Risk and patient choice

It's hard enough to assess for suicidal risk, interview, reach a formulation, and develop a plan that matches the risk level. But what do you do when the client does not agree to the plan? It is difficult to manage one's emotions, and difficult to know how to proceed. This is especially true when the recommended plan involves a higher level of care. Do you continue to work with the person in a setting that you have judged inadequate for the needs, or do you somehow insist or refuse to work with the person? How do you ddocument around these decisions?

Here are some initial thoughts I have about this unbelievably challenging clinical dilemma. I hope to articulate more principles and recommendations in future posts and papers, and would love to hear other clinicians' ideas.

1. Articulate and document the rationale for recommendation AND for the treatment decision you make. For example: "I recommended partial hospitalization because the daily therapeutic contact, extensive group work, and focus on stabilization fit Mr. X's needs in this case. I offered this recommendation to Mr. X and explained the potential benefits and risks of following this recommendation. I also explained the substantial risk I see in not pursuing this level of care at this time."

2. Respect the client's freedom, and avoid a power struggle. Most power struggles are born of anxiety. We sometimes do have totake coercive courses of action to protect a patient's safety, but many times we twist patients' arm to manage our anxiety more than their safety. This is not a black-and-white/either-or issue. We do need to honor our boundaries, our ethical/legal obligations, and have a level of comfort in order to work with someone. At the same time, clients with intact cognition (i.e, not psychotic or otherwise impaired from making rational decisions) and who are not at truly imminent risk need to have some latitude about the treatment they agree to participate in. Before drawing a line in the sand, we should be clear (and be able to articulate) why drawing that line is necessary for the patient and for the treatment.

3. If you decide to respect a client's choice that goes counter to your recommendation (a la #2), document the clinical reasons why. If Mr. X refuses my recommendation to go to a higher level of care, I might write: "Mr. X refused the offer of partial hospital; he wishes to continue weekly therapy but agrees to nothing more. I agreed to continue to see him outpatient because (a) our alliance is strong and is a protective factor, (b) Mr. X has benefited from outpatient treatment, even though his acuity level makes him more appropriate for partial, (c) he is not in imminent danger, and (d) Mr. X's cognition is grossly intact; his thought process is logical and coherent, and he is judged to have capacity to make decisions about the treatment he wishes." I'm sure this is not a perfect note (and I'd be happy to hear from others about what you might write), but it captures some of the key elements that I think should be documented.

"How bad has it gotten?"

When I teach about clinical interviewing, I often recommend this phrase (or some variation) as an entry point to questions about suicidal ideation. This accomplishes a couple of things:

1. Frames the discussion about suicidal ideation as one that is exploring the person's subjective experience and suffering, avoiding the impression of ticking through the required elements of a clinical interview.

2. It begins a sequential approach where it then feels logical to ask about the extremes of desperation.

3. Signals to the person that you want to hear the full extent of the pain.

The exact words don't matter, of course, but it is probably helpful for each clinician to develop a few standard ways he or she enters in to the conversation. This could be one of them.

Post from AAS/SPRC Workshop-Thoughts about staying therapeutic

I'm in Ohio this week at a "train the trainer" workshop developed by the American Association for Suicidology (AAS) and the Suicide Prevention Resource Center (SPRC). The workshop is called “Assessing and Managing Suicide Risk: Core competencies for mental health professionals.” The training has been excellent so far.

The material focuses a lot on the therapeutic stance and alliance, including some excellent video of a master clinician interviewing a suicidal patient. It reminded me of something I've been emphasizing in the trainings I do: that a good therapist is a good therapist....the skill set is not radically different for the suicidal person. The problem is that many of us have been trained (by formal training or by our anxiety) to go into a some other mode when we encounter a person with suicidal ideation: we throw our best therapeutic skills out the window and become the suicide police. We often deprive people of our best skills because we feel we have to focus on nothing but their immediate safety. It is an unfortunate tendency because in the midst of deperation is when people most need compassion, empathy, and humanity--and a therapist who is as interested as they are in relieving the psychache.

So the challenge in developing and delivering training is to give equal weight to two important messages that are in some tension with one another:

"You must have a knowledge, training, and competencies specific to suicide. You must ask about it, document about it, and pay special attention to it."

and

"Don't get stuck on the suicidality or go into some different interpersonal mode. Compassionately tend to the person, the pain, and the problem, just as you always you."

I think the training today did a good job of striking that balance. I hope my presentations and clinical work do too.