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

What matters to patients in an assessment interview

Assessments are human encounters, a chance to demonstrate compassion and instill hope. A small qualitative study by colleagues in Manchester, England illustrates the importance of caring assessments and of considering the social and family context of the individual in planning. Hunter et al conducted 13 initial interviews and 7 follow-up interviews with individuals who had been hospitalized related to some form of self-injurious behavior. Their findings are highly congruent with the hallmarks of patient and family-centered response to suicide risk that  I have proposed. The article (linked below) outlines a number of lessons about what matters to patients, which boils down to having meaningful interactions with clinicians who: convey empathy, understand problems from their perspective, inspire hope, and develop plans/referrals that match their preferences and social context. None of this is rocket science; it's harder than that. Hearing how much it matters to patients should encourage all of us with a commitment to living to continually refine our approach to assessment.

Hunter, C., et al., Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: A qualitative study. Journal of Affective Disorders (2012), http://dx.doi.org/10.1016/j.jad.2012.08.009

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.

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

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.

"Trusting" a person at risk who agrees to transport self

A colleague  forwarded me the following excellent question posted to a listserv:
One question that has been raised is how to handle an individual who reports willingness to voluntarily go to the ER for psychiatric assessment.  Since trusting a questionably unstable and suicidal individual to present for treatment opens our agency and the patient up to considerable risk, I wanted to get input on this issue from professionals in the field.

My questions are: What is the process that you use when you genuinely believe an adult patient will voluntarily present her/him self for possible commitment/assessment?  How do you manage patient risk and your own liability in this instance? (e.g . requiring family members to be involved; or requiring a signed written contract to present at the hospital, etc) What do you do to ensure/confirm that they do indeed go to the hospital? What do you do when they do not go to the hospital, as agreed?

I'm looking for both a description of specific steps that you take and what variables you take into consideration as you decide what to do in this case.

This is an excellent question for several reasons:

  • the writer wants to support patient agency, preferring in principle to go with the patients voluntary wishes, rather than become unnecessarily coercive.

  • the writer is correctly concerned about putting all eggs in the self-report basket.   A person at risk who is not stable may not be able to follow through with intentions to get help.   It is central to both really listen people in our care AND understand that self-report has limitations and has to be considered in context

  • the writer has shared honestly her concern about both patient safety and his/her own liability—almost everyone who works with individuals at risk has these dual concerns and needs to think openly about how to balance them.


This is such a good question that I wish I had put it on my docket of questions to blog about.  And it relates as a follow-up question to one that is on that docket, "When it comes to hospitalizing isn’t it always best to “err on the side of caution”?

Here is my attempt to offer some principles for the assessment and documentation of a patient's agreement to voluntary actions:

  • Document assessment of reliability of self-report.  When assessing and documenting self-report the following should be considered and noted:

    • past experience, if any with the patient as a reliable reporter or not.   “Pt. has reliably followed through on medical decisions and plans in the past.”

    • evidence of psychosis, thought disorder, intoxication, extreme agitation or other factor that would put the person’s capacity to make decisions in question.   If not, “Pt’s thinking is logical, coherent, and reasonable.  Judgment is intact.   No indication of impaired capacity to make decisions and follow through with them.”

    • degree of patient cooperation.  Explicitly note that the person volunteered information, though s/he didn’t have to.   “The patient has been open, cooperative, and collaborative in the assessment and planning process.  There is little reason to doubt his/her sincerity in agreeing to seek help and additional evaluation.”

    • impulsivity.   The greatest risk here would be that the person would all of a sudden feel overwhelmed with pain and impulsively kill him/herself.  If there is not strong evidence of that kind of impulsivity (even if there has been some in the past) note that.  “The patient has a past history of mild impulsive behavior, however, this was several years ago and under very different circumstances..."



  • Show your reasoning.  The key to great documentation is to state each of the factors considered, then show that the plan came as a result of synthesizing these factors.  This can come in a statement like “In light of these factors, the plan for voluntary self-transport seems reasonable and prudent.”

  • Say what you didn't do.  Related to the previous point, it as as important to document the road NOT taken.   This shows that you took the situation seriously and considered the full range of options.

    • A corollary to this principle is to note risks associated with alternative courses of action.   “Involuntary transport has potential of violating the patient’s rights and of harming the patient’s opportunity to benefit from hospitalization.   The risk associated with involuntary transport outweigh the relatively small risk that the patient will precipitously abandon our plan and harm him/herself.”



  • Document consultation.   Much more consultation occurs in primary care than is ever documented.   This would be a time to do it.  One line is sufficient:  “Discussed case with Dr. X who concurred with the plan.”


Note that each of these points needs only a sentence or bullet-point, and not all will be applicable in every circumstance.

I'd be interested in feedback and ideas from who employs these principles in their documentation.  I would also be interested in reading comments with other ideas about how to address the situation the questioner described.

Warning: Non-family Tx may be hazardous to your (family’s) health

A clever article in the September 2007 issue of the Journal of Family Psychology by Jose Szapocznik and Guillermo Prado suggests that "psychosocial treatments with vulnerable populations have the potential to produce negative side effects on families."

The authors reported unexpected findings from three separate studies that compared the efficacy of a family and non-family treatment. In brief, they found that family-level outcomes measured after applying non-family treatments didn't just remain static (as they had expected), they actually declined. This relationship is correlational and does not necessarily mean that the treatments in question caused the decline, but the authors argue that the findings are striking enough to raise the question about whether unintended side effects psychosocial treatments should be subject to "safety monitoring" along the lines that biomedical products are. Something like a black box label: "Warning: This treatment manual may be hazardous to your family."

In the discussion section, Szapocznik and Prado hypothesize about the systemic mechanism for the results they found:

"The family is a system that must be viewed as composed of interdependent or interrelated members.... Family members tend to develop habitual patterns of behavior over time such that each individual in the family is accustomed to act in a certain way that in turn elicits specific predictable behaviors from others. One possible hypothesis is that if an individual is changed by an intervention that is design to change individual and not help the family adjust to these changes....the family may be negatively affected...."

Nothing in these studies relate directly to suicide. But I think there are implications for how we think about intervention, especially in light of what I've been reflecting on lately about suicide as a family issue (see posts related to family therapy)

  • Need for more systemic work on suicide. With respect to suicide, this article emphasized to me the need for greater conceptual clarity among systems thinkers about suicide in the context of the family system. We need to articulate in what ways suicidality might be a property of the system in which it resides, and what are the mechanisms by which family relationships might reduce the likelihood of suicide.



  • The complexity of defining "evidence-based practice." I've posted before (vis-à-vis the ambulatory redesign aspirations in our department) about my concerns that "evidence-based" can get too narrowly defined. What is evidence-based depends a lot on what evidence you look at, and, more to the point here, on what outcomes are measured in the studies that provide supporting evidence for an intervention. Given the documented importance of family functioning for long-term outcomes of many kinds, perhaps one of the criteria we should consider in evaluating the utility of a given treatment approach is its ability to promote family functioning.



  • This relates to suicide because of the ways in which I have heard distressed individuals conceptualize their presenting problem. When people seek help it is usually with a functional outcome in mind, often one that has to do with their relationships. Research studies measure symptom reduction, people care about love, work, and play. In delivering a human service, we should organize ourselves in congruence with human concerns. If we organize ourselves around "reducing depression" we run the risk that our language will become reified in our practice-the result of which could be a less connected stance toward a suicidal individual who sees his relationships, finances, or health as the primary problem, not his "symptoms." As one person I worked with paradoxically stated, "I don't care about feeling better, I just want all of these problems to go away."


Ideas around evidence-based practice are evolving. In our department, a vibrant conversation is underway. Simplistic views of what is evidence-based seem to be disappearing, as everyone realizes that "evidence-based" is a much broader and trickier term than we might like. Ultimately, I suspect that the way out of the dilemmas inherent in the term is for clinicians to collect evidence (in informal and formal ways) about change in their own cases. This kind of internal monitoring process will probably promote effectiveness more than selecting the right branded treatment, which may have aggregate data that allows it to be certified as "evidence based," but which may or may not be helping the particular individual and family we're working with.

Reference


Szapocznik, J. & Prado, G. (2007) Negative effects on family functioning from psychosocial treatments: A recommendation for expanded safety monitoring. Journal of Family Psychology. Vol 21, p. 468-478.

Reminder from the bridge: Suicidal individuals are full of ambivalence

Sign on NYS BridgesToday Mike Hogan, Ph.D., the Commissioner of the New York State Office of Mental Health honored RNN-TV and the NYS Bridge authority for their work in suicide prevention. The bridge authority put up signs and installed lifeline phones with direct link to the National Suicide Prevention Lifeline.

For clinicians assessing and managing suicide risk, the fact that phones installed on a bridge have been used by individuals who went on to live is testimony to just how much ambivalence remains, even in people who have gone very far toward resolved plans and preparatory behavior.

Understanding that ambivalence is key to clinical work with suicidal individuals. When I train clinicians about assessment and response to suicide risk, I often get questions about whether it is useful or even right to assess suicide risk. I'm also asked, "What about people who have good reasons for killing themselves or who rationally decide they want to end their lives?" My answer goes something like this:

Thankfully, for health care professionals there is no practical dilemma here. If you find out about a person's suicidal thinking, then there is some degree of ambivalence. Everyone knows that psychotherapy or primary care are about health...that is life. We're not about suicide and death. So if someone is coming to us, at least some small part of them is aligned in that direction. And it's our job to understand that ambivalence and work toward health and life until such time as the ambivalence is resolved in one direction or the other.

That line of thinking can apply to any person, really--not just healthcare professionals. Except in some rare circumstance that you'd have to work hard to construct, the fact that someone is still alive and letting someone know by words or action about suicidality reflects ambivalence.

The fact that people read signs and use phones on bridges also discourages a fatalistic stance on the part of clinicians. We can't simplify the matter by saying "If someone really wants to kill themselves they will, so what's the point of screening or assessing?" That question misses the point. We assess because people don't want to kill themselves. Some just don't see options for life and, under the wrong circumstances (like under the influence of substances or after a particularly deep emotional wound), they overcome their ambivalence just long enough to do the unthinkable. We need to have deep compassion for the amount of pain that must be, and nurture the life-embracing side of the ambivalence until the person can see options again.

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.

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.