NY Times: Short but Troubled Life Ended in Shooting and Suicide

This NYT article about 14 year-old boy who died on Wednesday after critically wounding a teacher and classmates, is a case study in risk for adolescent suicide.  Abuse/neglect history, legal trouble, access to weapons, social misfit, recent disciplinary action at school.    The temporal proximity of his older brother's arrest is also striking...again pointing to the systemic properties of suicide.

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!).

Murder-Suicide In Ireland

Ireland has experienced a string of murder-suicides of different types over the past 18-months.  The most recent of these events, which occurred Tuesday, prompted this Statement From The Irish Association Of Suicidology, as reported in Medical News Today.  In scanning the Irish Examiner today, I ran across this article advocating for funding psychological autopsies in the country.

Erratum on previous post: Cornell not author, just interviewed

Correction on my previous post about the Times London article about suicide turned outward.  Although the website makes it look like Dewey Cornell wrote the article I cited, Dewey has informed me that he did not author the article, but was interviewed by a reporter who wrote it.   I guess they do by-lines differently on the other side of Atlantic...

Suicide turned outward: Times of London Article by Dewey Cornell

In a previous post, I shared some raw thoughts about some of the connections between suicide and violence. Here is a thoughtful and thought-provoking piece by Dewey Cornell (a former teacher of mine at UVA) that brilliantly captures those connections and others. Strongly recommended psychological and social commentary about the VA Tech murder-suicide last week.

ChildTrends Report: Teen deaths by homiside, suicide, and firearms

Apropos of my recent posts reflecting about suicide, guns and homicide, colleague Bob Hawkes sent me a link to this report: Teen Homicide, Suicide, and Firearm Deaths, compiled by the Child Trends Databank. There are some nice figures in the report, including one nicely demonstrating recent declines in teen suicide rates (for related post see Unintended Consequences of antidepressant black box warning re: Kelly Posner's (and others') argument that these gains are threatened) . You can click on the figures from the linked page or see all together in the .pdf, which is linked to at the top of the page.

Murder-Suicide, Domestic Violence...Common threads in violence against self and others

The murder-suicide that took place at Virginia Tech on Monday on a lot of people's minds right now.  Certainly on mine.  So sad.

This event was mentioned several times at a conference I attended parts of today on "Multidisciplinary perspectives on partner violence".   In fact, one of the key speakers, Sandra M. Stith, Ph.D., is a faculty person at Virginia Tech.  She gave a marvelous talk about work she and her colleagues are doing with high conflict couples in multicouple groups.   Before speaking, she made poignant comments about her decision to speak at the conference instead of heading home.   It was clear from listening to her speak that she deeply understood the close connection between prevention of different forms of violence.

Which bring us straight to the topic of suicide.   Catherine Cerulli, a faculty member in our department and one of the conference organizers, gave a powerful presentation titled, "Domestic Violence as a risk factor for suicide and murder-suicide."   As I listened to this talk and to others today, the connection between violence and suicide was unmistakable.  The take home message for assessment is this:  we need to think about violence when we hear suicide, and suicide when we hear about violence.  History of trauma or DV are not just statistical risk factors.   They are intertwined and interrelated in substantive and clinically meaningful ways.  Cate played a horrific tape of a 911 call that illustrated this in a visceral way.  A woman with a past history of suicide attempts, ends up involved in the death of her violent male partner--which occurs during the 911 call.  (It is not clear if she actively stabbed him or just held the knife and he impaled himself).   The relationship between different kinds of risk (violence against partner and violence against self) is so complicated as to be practically indistinguishable.

So...a few free associated questions related to clinical assessment:

When we see a depressed youth with suicidal risk, are we asking enough about violence in the home (past or present, witnessed or experienced)?
When we see DV, how thorough are we about suicide assessment?
When we see suicidal individuals (especially men) who have some antisocial features are we thinking about their potential for violence against others, including (especially) against intimate others?
Are we remembering that involvement with the criminal justice system puts people at greater risk for suicide?

Murder-suicide like the one the country has experienced this week is not a statistical coincidence--it teaches us something about the heart and processes behind both.