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.

Interesting qualitative study about military mental health professionals on deployment

A group of US and UK colleagues have published an interesting qualitative study about the challenges and resiliency of military mental health professionals (MMHPs). They had a small non-representative sample of British MMHPs who had completed a period of deployment in Iraq between 2003-2005. For the study, they participated in detailed interviews about their experiences practicing in a deployment setting. The authors did a nice job pulling together themes from the interviews in order to develop a conceptual model for the goals, challenges, and resources, and to draw out some recommendations about training and planning. Recommended:McCauley, M., Liebling-Kalifani, H., & Hughes, J. H. (2011). Military Mental Health Professionals On Operational Deployment: An Exploratory Study. Community Mental Health Journal. doi:10.1007/s10597-011-9407-8

I'm an intellectual stalker!

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

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.

CTL to Healthcare Professional Mindmappers: Delurk!

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

eMJA: The effect of Web 2.0 on the future of medical practice and education: Darwikinian evolution or folksonomic revolution?

More blogging to come at URMC?

I was invited to an informal, coffee-cart conversation about blogging in a medical center.  A person in our organization wants to develop a group blog around the interest area of Community Health.

A few reflections on this conversation, which took place on Friday.

  1. We spent a fair amount of time on definitional ambiguities around the word "blog." I had never realized that the word can evoke lots of different images in people's minds. At different points, it morphed between meaning "anything RSS," "Web 2.0," "collaborative Internet", and "discussion board." That happens with any word (I say "chair" and think of this and you might think of this), but it is especially true of word describing emerging concepts.

  2. I became aware of how personal my blog is to me, and how much I resist efforts to legislate aspects of it. I didn't like ideas that entailed requiring people to commit to post once a week or something like that.  I'm sure corporate blogs do something like that, but for a blog that is about idea development, I think the frequency should match the idea generation and can't be forced.

  3. I had never thought before about how to get "buy-in" from people to blog. My recommendations to those involved in this project was that the only way to cultivate bloggers is to get people reading blogs first. Get them understanding RSS and some of the benefits to blogging (including in clinical or academic communities) from a reader's standpoint. I think it's hard to imagine why spending time writing posts would be useful to oneself or others until you've seen it in action.

  4. My other thought about "buy in" is that you have show people how any project that will require time and effort will promote their careers, not just promote a concept.  For faculty, it's about intellectual development.  You'd have to show and provide examples of how writing thoughts that are still under-development to a wide audience can be helpful.

  5. I found myself thinking a lot about (and mentioning to my colleagues in our discussion) the Merlin Mann's quote that I have referenced here before, in which he describes a blog as "only incidentally a publishing system...At its heart, your blog represents the evolving expression of your most passionately held ideas..."

  6. Web 2.0 is all the rage right now.  Articles like this one in InfoWorld talk about the growth of vendors who are trying to profit from this. There are a lot of ways leaders can go wrong when trying to jump on the Web 2.0 bandwagon. These 23 steps for learning Web 2.0 have gotten a lot of attention lately. Seems like a thoughtful approach, perhaps a prerequisite "course" for anyone interested in how a particular institution might benefit from the new web.

  7. It's important to consider which tool is right for which purpose. Blogs are great for pushing content to interested audiences, wikis for collaboration on specific projects, etc. When is it best to use multiple individual blogs and when is it better (as I think they're going to try here) to have one blog with multiple contributors?  My personal preference as a consumer is for the individual blog because part of my interest is watching the creative process take shape in an individual over time.  But maybe that's just the clinician in me.

It was fun to be part of the discussion at this early stage.  I'm excited to see where the initiative goes.

Unintended consequences of antidepressant black box warning?

An article by Charles Nemeroff and colleagues in the Archives of General Psychiatry this month reports reports on the "Impact of Publicity Concerning Pediatric Suicidality Data on Physician Practice Patterns in the United States." (If you don't have access to the journal, you can read a report on the article here.)   The authors show that antidepressant prescription rates for children and adolescents have declined and there has been a shift in proscriber patterns from "generalists" (PCPs) to "specialists" (generally psychiatrists) since the FDA placed a black box warning related to suicide risk.  The warning includes the following statement: "Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders."  You can read the entire warning in a .pdf here).

The study does not study who is not getting medication that might have in the past--just that fewer kids are getting the medicine.  Whether that is ultimately good or bad remains to be seen.

Kelly Posner, who headed the FDA/Columbia Reclassification study, spoke at our Department Grand Rounds last month and lead a seminar with a smaller group of us about the reclassification scheme.  (The reclassification project looked in detail at reported adverse events that started this controversy.)   She clearly thought the consequences of the warning would be mostly negative.   She shared her concern (which has been stated by others as well) that the unintended consequence of the black box warning will be fewer youth treated for depression and more deaths by suicide, as a result.  From what I have read, that remains an empirical question and one that will require careful interpretation of data before inferring causality. What is clear is that the black box warning was probably based more on political and emotional concerns than on science (see also Marshall, Posner, and Greenhill, 2006), and that the risk of untreated depression is probably greater than the risk of adverse events from treatment.

[mounting soapbox]  That said...when this discussion comes up I think it is important to add psychotherapy and counseling to the landscape.  Untreated depression can be deadly, but that doesn't mean the treatment has to be medication.  [coming down off soapbox]

What are the implications for risk assessment?   I'm still trying to understand that.  How I am guiding our clinicians at this point is this:   When conducting a risk assessment of an adolescent or young adult in the first weeks following initiation of antidepressants, we need to note that antidepressants have been recently started.  But rather than name this as a "risk factor" we would do better to note how the medication response will be monitored and indicate the risk-related symptoms that are being targeted by the medication.  That is, connect the medication to the risk factors it is designed to reduce, more than to the risk it might carry.


  1. Marshall, R. D., Posner, K., & Greenhill, L. (2006). Risk Perception Research and the Black Box Warning for SSRIs in Children. Journal of the American Academy of Child & Adolescent Psychiatry, 45(7), 765.

  2.  Nemeroff, C.B. et al. (2007. Impact of Publicity Concerning Pediatric Suicidality Data on Physician Practice Patterns in the United States.  Archives of General Psychiatry, 64:466-472.

Treatment teams as "Communities of Practice"

Still thinking about the intersection of clinical practice, risk assessment, knowledge management (KM), and Dave Snowden, which I blogged about yesterday.

In KM world, what mental health clinicians call a "treatment team" could be considered a Community of Practice. There are many definitions of this term and treatment teams fit some more than others. But Dave Snowden is clear in the videotaped discussion I pointed to yesterday that one of the failures of contemporary knowledge management is the inability to promote fruitful communities of practice. Snowden argues that organizations make the mistake of trying to organize communities of learning and practice using language, structures, and concepts that are not "naturalistic." That is, we ignore the processes by which people naturally come together to form knowledge-sharing communities and either over-organize (imposing a hierarchy and structure that we think will promote good functioning, but ultimately stifle innovation) or wrongly organize (bringing people together around a concept or structure that does not promote natural affinity).

Our organization is considering a redesign of our ambulatory service into diagnostic-based treatment teams (e.g. "Comorbid depression team"). The aim is to have well-functioning teams that promote evidenced-based practice. As I listened to Dave Snowden talk about communities of practice, I coudn't help but think that organizing this way has hints of the kinds of non-naturalistic grouping that Snowden warns against. The intent is good and the organizational principle makes sense on the surface, but grouping clinicans by the DSM diagnosis of their patients has the potential to be structure-rich, story-poor, and human-factor-ignoring.

One of the principal reasons stated for considering organizing by diagnosis is that the research literature about effective treatments is organized by diagnosis. It is an "evidence-based" decision. However, evidence associated with a particular epistemology (categorical psychopathology) is privileged over that of other epistemologies like cognitive science, organizational behavior, human factors research, and systems theory are ignored. Just because treatment studies organize patients into diagnostic groups, doesn't mean that human clinicians will work most effectively with the human problems and stories we see by grouping ourselves by our patients' Axis I diagnosis.

What would be a more narrative-rich way or organizing ourselves? Well, if we think of theoretical paradigm as a narrative, than perhaps that could be starting point. Or perhaps provide freedom for people to organize themselves into natural groupings. Or maybe there's a way of listening to clinicians and patients' stories about themselves and seeing trends and themes that we don't now see. It would take time and a new set of methods, those more akin to what Snowden promotes, to discover these themes. But we're taking time and energy either way. I'm not sure, to be honest, but I think the principle Snowden promotes is a good one: don't impose a community of practice based on a predetermined epistemology, especially one that is reductionist and devoid of narrative...rather, look at how productive human networks form naturally and spend your time and energy discerning the conditions in which these can develop.

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.

Blogging out in the open in a clinical setting

Roy from Shrink Rap’s commented on my post about Web 2.0 opportunities that he has "not EVEN mentioned to anyone about our psychiatry podcast." That surprised me, given how significant his web presence is. But that was certainly true of my blog until a couple of weeks ago, when I finally "decloaked" my blog to my colleagues.

I decloaked during a presentation to our group that focuses on evidence-based practice. This group includes several key leaders in our department. I was giving a progress update about my work toward our shared goal of improving the training and documentation tools for suicide risk assessment, documentation, and response. Thankfully, the project is progressing, and I had several steps forward to present. On the mindmap I was using to present, (as I've noted in a previous post, I use MindManager for presentationg), I reported progress on steps forward that I had previously committed to, then added a bubble reporting the development of this blog (along with a link to it).

I introduced it with some trepidation. By way of disclaimer, I started by recognizing that the image some think of when they hear the word "blog" (if they think of anything) is a "navel-gazing, exhibitionist teenager" sharing stories about weekend parties and rants about parents. I explained that blogs have evolved in many professional and academic circles as a way of journaling ideas and sharing emerging trends with like-minded people. I showed some sample posts and sample comments. I referred people to the About this blog page if they wanted to learn more about what I'm up to with this experiment.

The response was mostly positive--probably best described as a mixture of amusement and curiosity. No one was openly critical, and some of my colleagues thought it was pretty cool. There was one appropriate and constructive question raised about liability issues for me (what if someone follows my clinical advice and something goes wrong), but no other public comments. One colleague later comment that she had never read a blog before, and I suspect that was true for many people in the room.

Being out in the open feels good, although it has already changed the way I think about my blog. I don't think the change is good or bad, but it does change my mindset to think that my colleagues and superiors might read what I write here. Then again, they might not!