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

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.

If you’re going to be in Orlando on April 24, please come by and say hello.

Related posts:

Visual maps and guides in high stress situations

Mindmapping coping strategies

Mindmanager Customer Vignette

Possible implications of findings re: visual memory

Newsmap illustrates power of mapping/visualization

Although I have a section called “protective factors” in the map I use to teach about risk formulation and documentation, I am increasingly finding myself replacing these words in workshops with the awkward phrase, “Launching off point factors.”  What I mean to convey is that it is probably best to think of “protective factors” as factors that increase the likelihood of success for crisis and treatment planning, rather than factors that technically “protect” against risk previously identified.  A distraught, intoxicated individual with suicidal ideation and a gun can have all the protective factors in the world and that doesn’t change the risk one bit.   These factors may, however, present opportunities to engage in crisis planning, develop a therapeutic relationship, and engage a supportive system, all of which create conditions in which risk can be addressed, and which could ultimately influence decisions about the most appropriate level of care.

In our next revision of risk-related documentation, I’m considering recommending that we get rid of the term “protective factors” altogether because of the danger that it can be misleading.  I don’t have a great substitute, unfortunately.  Best I can come up with right now is “Opportunities for Crisis and Treatment Planning,” but I wonder if an ordinary person coming to a section so-labelled would know what it meant.  Needs more work.

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.

Other related post(s):  Reminder from the bridge: Suicidal individuals are full of ambivalence

The talking action page for clinicians is worth reading for any clinician, and could be especially useful to primary care providers.  I’m thinking a lot about primary care right now because (a) primary care psychology has beeen a focus of my career and I have a deep respect for the breadth of responsibility primary care providers carry, including in suicide prevention (b) I’m still pondering the recent question I considered about self-trasport and (c) I’m presenting a talk titled “Tips for Suicide Risk Assessment and Response in Primary Care” next month at the Highland Family Medicine center here in Rochester.