Crisis Response, Means Restriction, and the Future of Suicide Prevention with Dr. Craig Brian

Dan is joined by Dr. Craig Bryan, a board-certified clinical psychologist in cognitive behavioural psychology. He is the Stress, Trauma, and Resilience (STAR) Professor of Psychiatry and Behavioral Health at The Ohio State University Wexner Medical Center.

The episode starts with Dr. Bryan sharing his journey into the field of suicide prevention, detailing his experiences in graduate school, military service, and the harsh realities of suicide he faced. Dy. Bryan critiques traditional approaches to understanding and preventing suicide, advocating for a reframing of suicide as a behavioural choice rather than solely a mental health issue. Dr. Bryan introduces crisis response planning as a vital intervention, emphasizing the importance of personalizing these plans and the role of means restriction counseling in suicide prevention. 

Special Guest: Dr. Craig Bryan

SuicidePreventionTherapy.com

Re-thinking Suicide (book)

Crisis Response Planning

Lethal Means Counseling

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Chapters

• 0:00 Introduction to the Podcast
• 1:20 Dr. Bryan’s Journey into Suicide Prevention
• 4:00 Experiences in the Military and Suicide Exposure
• 9:30 Questioning Traditional Suicide Prevention Approaches
• 14:30 Understanding Suicide as a Health Behavior
• 17:45 The Accelerator and Brake Model of Suicidal Behavior
• 23:00 Crisis Response Planning Overview
• 28:40 Personalizing Crisis Response Planning
• 33:20 Means Restriction Counseling and Suicide Prevention
• 38:30 Closing Remarks

Transcript

0:00

[Music] Podcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 41 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain and hopefully have some fun along the way. If you find our show helpful or interesting, it'd be much appreciated if you could share it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I can be more excited to welcome one of the world's authorities on suicide prevention. My guest is the Trot Gebhart Phillips professor of psychiatry and behavioral health at the Ohio State University, as well as the director of the Division of Recovery and Resilience. He's won several prestigious awards, including several from the American Psychological Association, as well as the Edwin S. Schneidman Award from the American Association of Suicideology. In part one of our conversation, we discuss several aspects of suicide prevention, including critiques of some approaches to suicide prevention. Understanding suicide prevention is a health behavior. Crisis response planning means restriction counseling, motivational interviewing, and much more. This episode starts with my guest responding to my question about how he got into studying suicide. So without further ado, it is my pleasure to welcome my very special guest, Dr. Craig Brian. Yeah, so when I was in graduate school, I guess I started over 20 years ago now, I went to Baylor University and my director of clinical training was David Rudd, who's a very prominent suicide prevention researcher. And so it was fortunate enough to learn a lot from him and to study under him. It was the end of my psychology training I enlisted in the Air Force, joined the military service as a co-cultural psychologist at that time. And that just so happened to correspond with the time when suicide in the US military started to increase. And so there was this kind of convergence of timing with this training experience mentorship that I had received from suicide prevention researcher. And so that I think really kind of came together and cemented my interest in suicide prevention. And I would say the last key moment was this part of serving in the military. I deployed to Iraq in 2009. It was while it was overseas that I really came face to face with the reality of suicide. And that's because you know, when service members and others would kill themselves, they were brought to our hospital. And we would take care of the bodies, keep them functioning, so they could transport them home and do organ donation, things like that. And so it was the first time that I had seen dead bodies like that. And it really changed my, I think, understanding of what suicide is. And especially because in that setting, you know, pretty much all the suicides were self-inflicted gunshot wound. And so that really, I think, had exposed me to the brutality that can be suicide. And so it was very different from how I'd thought about it. It was kind of experiencing it for as a health patient, behavioral health provider, you know, you don't really see those things on a regular basis. And so, so yeah, so those were kind of, I think, the three things and within the span of maybe about five or six years that really, really made a difference and pushed me down this track. What was it about the brutality that I don't know, I guess, I mean, it makes it become real, but like, what was that sort of pushed you if that makes sense? Yeah, I think, you know, I've shared this story, one particular story from my deployment where we had a week, basically where there was a sandstorm and so all the floods were grounded. And usually when suicide case was brought to us, they arrived, you know, we stuck them on the ICU, we took care of them, and then usually overnight, you know, they were on a plane to Germany and then from Germany they would come back to the US. And so because of this sandstorm, however, all the floods were grounded and we had three suicides in the unit at the same time and they were with us for several days. And so we put them next to each other and the ICU to make it easier to monitor them. And I think it was just that prolonged nature of having these soldiers with some of the units that it definitely had a psychological impact on the entire hospital staff and it had an impact on me as well. And so just not seeing, you know, what sort of the consequences of this exposure to suicide was on other medical providers. But I do remember one day, in particular, sending it you know, the foot of the beds of these three soldiers and, you know, just really questioning a lot of, you know, our assumptions about suicide. That was really in many respects the origins of a lot of my critiques of the field because for whatever reason that was a moment that really consisted of, like, "Man, we're really bad at this." And I do think there was something about the fact that it was so flip-flip-dunchup wounds and, you know, in all cases, it was to the head. And so you just, even though they had been cleaned up and taken care of, I mean, it's very brutal. I mean, incredibly violent. It is not, I think, sometimes there's, I think, an impression of it's almost like a peaceful sort of death because we can have an overdose seeing or something like that in a, it isn't that at all. And, yeah, it definitely changed things from me. What were your critiques of the field that sort of became apparent at the time? I think, you know, it really started with, you know, a very now specific question, which, you know, I mentioned before, it's like, why are we not better at this? And, you know, what are we doing wrong? It was also, while it was deployed that I, aside from those three cases, were just confronted with other cases that really defied a lot of what I've been taught about suicide. And in particular, one of the areas that I speak about a lot now is the purported role of mental illness as a cause of suicide. And it was just over and over again. I was evaluating people in the emergency department of its survived suicide attempts hearing stories, you know, from, you know, peers, friends, unit members of those who had died, where it was like, there just wasn't any sign or any evidence of mental illness. And I think of another case, I've talked about quite a bit of a, of a marine that I evaluated who, you know, had had tried to shoot himself and mist. I don't know if it was by luck or what, but had a laceration on his chin, you know, gunpowder all down his neck. And, you know, at least now we're hour and a half with him, you know, and there is no mental illness. There's no depression. There's no anxiety. You know, he didn't have any relationship problems back home, no financial strain. It was sort of like in many respects he had this queen bill of health and it was just like, what the hell happened? He could have made heads or tails of it either. He's like, I don't know. It just kind of happened. And I remember, you know, I signed the paperwork to send him to Germany. It's like, man, you're not staying here in a combat zone or everybody's packing heat, you know. And he spent a week on the inpatient unit at the Army Hospital in Germany and during our weekly consultation calls where those of us in Beater would, you know, coordinate care with, you know, Germany. I remember they were presenting the case and they were like, what's going on with this guy? We're missing something. I'm like, well, I was hoping, he's been with you for a week. I was hoping you would tell me what's going on. And this was just happening over and over again. And it really, I think those are the first major questions that I had was surrounding again, this assumed role of mental illness and maybe suicide and suicidal behavior, maybe there are other pathways that people follow or maybe there's something else beyond. It's not only mental illness, but maybe there's something bigger that's happening. So how have you come to understand that or make sense of that? Yeah, I found it helpful to think about suicide. You know, it's an essence of behavior. And actually, Rory O'Connor of another suicide researcher in the UK has framed in his book as a health behavior similar to like smoking or substance use or sexual behavior, things like that. And I found that incredibly useful to think of that way because it is a choice. It's a decision that people make that impacts mortality, well-being, so on and so forth. But it kind of, I think, amours the act itself from this sort of box of mental illness in the same way that, you know, we know things like substance use and smoking of their potentially harmful behaviors or you know, correlated with mental illness. But it's not always caused by it. It's not the same thing as mental illness. And I found that to be a really useful way of thinking about it. And even within my clinical work, as we think about treatments, approaching it from the perspective of it's a decision, it's a choice that people make in certain states of mind or under certain circumstances. And if we think of it that way and approach that way, then it really I think kind of shifts how we approach suicide prevention, how do we identify people, how do we help them, and how do we potentially prevent this behavior from occurring. I'll say one other, you know, one other, I guess kind of thing or question that I've had as well that I would say, you know, ties back to those experiences in Iraq, was really, I think you're very hard about how most of our work around suicide prevention has been largely driven by the question why you people killed themselves and why do people die by suicide. And as a clinician, I found it to be much more useful to ask a slightly inverted question, which is why do people choose to live despite wanting to kill themselves, because really when it comes to like treatment and prevention and things like that, it's what we're trying to do is kind of stop that forward momentum. And so it's kind of like I'm not as necessarily concerned about why you are racing towards that brick wall, I just want you to stop or change course or something like that. And I started thinking a lot about how, you know, in vehicles, whether it's our cars, but you know, trains, other things like that, the accelerator is different from the break. And they're totally different systems. And so how you move forward and how you stop involved different processes. And again, kind of thinking of it that way of the decision to hit the breaks might be very different from whatever it is that's propelling you towards suicide. So yeah, and so that the treatments and interventions that we've designed have really I think kind of motivated by this idea of a breaking system, an internal breaking system that people have to find and they have to be able to use. Okay, so you've said a lot. I feel like I'm going to fail. Inter, like there, I think there are many roads I sort of want to go down, but we'll make choices and some of them will be wrong, but that's okay. One of the things I just heard you say is that there are two mechanisms or two ways that a therapist can think about intervening with a person. And you, then what I heard you say sort of follow your metaphor is often we think about the gas and doing the gas is the motivators for wanting to die, wanting to that we often think about how can we help people take their foot off of the accelerator, where, but there's a second system that we also have the opportunity to engage in, which is the reasons for living and whatever language you want to use there. And so then that also gives us an opportunity to intervene with helping them put on the break. That's right. Yeah, yeah, and I think you know, I would say some of my thinking around this has, again, I'm always trying to find like metaphors or examples outside of behavioral health of how can we understand this. And I've found that to be an incredibly insightful exercise to engage in where it's like how do other disciplines do this? Or where else in life is there some sort of lesson to be learned here? And in that, I don't know how or when I came across that idea of like the breaking system different from the accelerator, but it definitely has made a big difference in how I work with my patients who are suicidal. It's also helped me to I think kind of be with like, well, why in essence, why are we not better at this? Why I think it's because we're mostly kind of thinking about taking our foot off the accelerator. And maybe we just need to completely change or look at other processes that are independent of those drivers towards suicide. Right. Well, and I'm thinking as you're talking, regardless of if we should go through door number one or door number two, the accelerator or the break, it does give it sort of opens up a second lane, a second opportunity there for therapists who might be really struggling with a client to then to reframe the question as you did and be like, oh, maybe this is maybe I'm hitting the wall with this client. This way, here's another way I can try it, right, as they're grasping to try to help their client. Yeah, yeah, absolutely. I've certainly, I've been in that position myself as a clinician plenty of times where you know, it's just it's sometimes hard. People are really stuck in life. And sometimes it's because of maybe their own histories of whether it is their own struggles of the course of life, but oftentimes it's the conditions that they're in as well, like circumstances. And you know, if we kind of focus only on removing those drivers, in some cases, it's just like completely out of our control. And so I've you know, kind of learned with patients, like I can't increase the size of your paycheck. And I'm unable to address, you know, all of these social determinants of health. And so given that in some respects, we're kind of stuck with these circumstances. What are we going to do? And so it's like, okay, well, then let's find the breaking system because you know, there might be all these, all these reasons for why you believe you should die or it's, you know, logical to die. But there are also these reasons to not do it. And so let's also think about those because there's one thing I've learned doing this for 20 years as a clinician. It's like people who have nothing to live for don't come to clinicians and say, I'm thinking about killing themselves. And so something is holding you back and something is kind of tethering you to life. And perhaps let's just talk about that even though there's all this chaos and distress and despair going on as well. I think that this conversation is a good lead in to talking about crisis response planning, which is an intervention that you've developed. I'm wondering if you could sort of start us off by just giving a broad overview of that. Yeah. So crisis response planning, and I would say now kind of the way we use the term, it's often referred to like this procedure that we use with suicidal individuals are vulnerable individuals. It's maybe like 30 minutes. It sometimes takes complete one of these plans. But the origins of crisis response planning go back, you know, decades, you could find the first hint of it and die. Let's go be avi or therapy or DBT where you know, watch a little hand, you know, kind of outlined when you're on the phone with a really high risk person who's in crisis and you're coaching them. They're kind of these steps to follow to help a person get through those urges to kill themselves. If you call them crisis response procedures. And then later on David Rudd took those ideas and he kind of formalized it within cognitive behavioral therapists or prevention as a thing we could do in therapy to help people in between sessions when we're not available. How does a patient self-regulates when they feel like they're on the edge? And then later on what we did is we said, well, hey, we're doing these. A lot of us are working in primary care settings or emergency departments or crisis call centers where you may only have that one opportunity to intervene with someone and there perhaps is no expectation of an ongoing therapeutic relationship, treatment relationship. So if you have 30 minutes or an hour with someone, like what's the best way to spend that time? And so we took this idea of crisis response planning out of these psychotherapies and we said, well, start doing it as standalone intervention. And that was, you know, sort of born out of a necessity because in my early career, the first clinical setting I worked in was primary care. I had 20 minute appointments, 15 to 20 patients a day, it was high volume low intensity. And when I was working with someone who was highly acutely suicidal, I did not have the luxury of our long therapy sessions and let's meet once a week forever. And so we started to kind of tinker with the concept and we'll be hold what we found is that it worked. And basically there's a few steps involved in in this procedure, the first of which is, you know, you're listening to the suicidal individuals narrative, their story. And so we ask people, tell us what your suicidal experience is like, maybe recently attempted suicide. Tell me the story of your suicide attempt, or maybe there's a day in the past few weeks, we really, really just really wanted to die. Tell me about that day, how would you get from what point A to point B? And as that story unfolds, it helps us to kind of understand how and why is this person sort of in this context in this space. And then we can use that information in the trust that it builds with suicidal individuals to then come up with these concrete steps where we first start with, how would you know that you're heading towards this? Before you get to the crisis, what are the warning signs? And then once we know how to identify when you're on that pathway, what are some things that you can do to feel better, to distract yourself, or to somehow change course? And so there's self-management strategies. And then we talk with them about their reasons for living. What are those sources of purpose and meaning, the good things in life that holds you on, you know, keep you here and help you wake up in the morning. And then there might be people that you can reach out to who are supportive and helpful, whether you just call and touch at with them or you get actual crisis support from them. And then the final step is professional crisis services. So how do you get the professionals involved at that point, if all well-scales? And a big piece of crisis response planning that we are now very clearly understanding in our research is that customization and personalization matter a lot. And so it's really helping an individual through their personal narrative to discover and recognize what are the very specific things that I can do that perhaps, you know, might be different from what you might do or what anybody else may do. But this sort of, and it's like six or seven steps, something like that. Like I said, you can typically do it in less than 30 minutes. We've shown, you know, significantly reduces suicide attempts by 50 percent of the 76 percent. So it's remarkably effective considering how simple in some respects the intervention is. And it sounds like what you're saying is it requires sort of in that brief intervention a notable amount of depth by the therapist to facilitate by the, I want to say therapist, but it could be obviously not a psychologist or whatever, but by the helper to understand and to personalize the plan. That's right. Yeah. Yeah. So when we're teaching clinicians, but also non-healthcare providers, we do trainings for peers, teachers, faith leaders, it's really, we kind of conceptualize that it's been very similar to kind of like CPR. Most of us are not physicians or surgeons or nurses, but if we see someone collapse around us, we might have received training on how to keep that person alive and to help them and to the paramedics show up, right? And so I think the crisis response planning is a very similar way for non-healthcare providers. And we really emphasize this notion of spending time with the person to help personalize in tailors such that if someone says, for example, this is something that I do that helps me feel better as I listen to music. And typically my follow-up question is, well, what's your favorite music artist? What type of music do you listen to? And are there some types of music that are reliably helpful, but maybe there are other types of music that are not helpful? And so how do we make sure that would that specific so that in that crisis moment when you're having a hard time, get to make a decision, you just follow the instructions, and it's much more likely to be successful. One of the challenges that I see that is that clinicians always feel a lot of pressure in those moments and are sort of, I guess what I want to ask is, how have you found to help folks not engage in this in kind of a checkboxy kind of a way? Does that make sense? Yeah, yeah, it does. It is, it is, I mean, it's one of my biggest concerns, actually, what's happening within the field is that, you know, we are moving to these checklist-based approach that are very compliance-oriented. And the, you know, a lot of the rationale for developing, you know, standardized forms and checklists, though, and the blank types of things, has been well-intentioned, right? It's sort of like here, this is a memory aid, here's what to do, you know, don't forget these different steps, but I think what has often occurred is that the like the form, the checklist is then provided to people without the context of how to use this effectively. And so it becomes an administrative task at that point. And a lot of clinicians only spend a few minutes just very quickly kind of putting it together because it's seen as, over, this is just a requirement, we have to do this. And so one of interestingly enough, one of the most effective ways that we've taught clinicians to make sure they're very patient-centered, that's they build these relationships and avoid that checklist-based approach is like, just don't use paperwork. Like, just sit down with someone, just give them a blank index card and talk with them, and you can have your cheat sheet, and we give little like pocket, you know, manuals that are about the size of an index card to help people with. So here's how to not forget the different pieces of intervention, but we found that this more tabular rassa approach really encourages and motivates clinicians to engage fully with their patient as opposed to getting overly focused on filling in the form. So just giving the patient the blank index card, so as they're, as you're having the conversation, they're writing down, the patient's writing down the various components of the plan, that is just, that that seems to, the clinician's experience of that is different than if you have a worksheet. That's all right, yeah, yeah, it's been, you know, really fascinating to hear from clinicians as we've trained them, the quality of feedback that we hear from them are things that, you know, I feel like I'm a human again, I'm not just a robot, you know, meeting requirements, I'm able to better focus and listen to my patients when I'm not sort of worried about filling out the forms, things like that, and so it's, yeah, it's just one of those, it's almost like a human factors type of thing, where sometimes, you know, we put systems or tools or strategies into place with the intention of, you know, improving or having a positive outcome, but sometimes they just don't work as intended, and I think that's, that is something that is definitely creeps into the profession over the past decade of, which is about, yeah, checking the box, instead of taking the time to sit down and say, no, just tell me what's going on and how can I help? Well, I did, I mean, I went to graduate school unfortunately well over a decade ago, and I would say that, you know, there was a lot of just check the box then. So I think in my personal experience that I think it's been around for quite a while, and so I think that it is an uphill battle to push against it. So let me ask you a question that you probably get frequently and you might find annoying, so I apologize in advance, but how does this, how does crisis response planning, if you all, as you all have sort of operationalized, hit differ from safety planning? Yeah, yeah, they're, they're basically different, I would say they're kind of like different branches on the same evolutionary tree, right? And so, you know, mentioned before, could have the history of crisis response, flying me, kind of started with DBT, and then there was this Cougar Behavioral Therapy, Pursuitive Prevention, and then we kind of plot the procedure out of there and start testing it independently, and then in a basically a newer iteration of it was the safety planning approach with the standardized forms, and so it's kind of like just the latest iteration of a different design approach to the same basic concepts. And one of the ways I've had it helpful to kind of think about the similarities and differences between them is, is the concept of route of delivery. And what I mean by that is if we think of like medications, there, we can administer medications in different ways, one of which is through oral tablets, something like that, but you could also do an intravenous or intramuscular administration, and sometimes those different routes of administration can lead to very different outcomes of like pain killers, for example, is a very obvious example that. And so I kind of feel like that's in some respects how CRP and safety planning are similar and different, and that the ingredients are very similar, but oftentimes the route of delivery is different because handing a piece of paper to someone to fill out is very different from saying let's spend some time working through this together, and we're going to come up with a customized plan as a collaborative team. So jumping to something different but very related is means restriction counseling. So could you sort of give a 30,000 foot view of means restriction counseling? Yeah, so there's, I think the way that I found it, kind of helpful to think about the role of things like means restriction, and then there's the counseling process which is designed to encourage means restriction, and there's, in essence, there are two ways that we can potentially prevent suicide, one of which is to stop people from attempting suicide, idea being that you have to make a suicide attempt in order to die by suicide, and so if we can change the decision to attempt or not attempt then we can eliminate or reduce fatal outcomes of that behavior, but there's a second way to prevent suicide, which is to help people survive their suicide attempts. And I think this second approach is actually really important and has been largely I think underappreciated by mental health professionals as well as suicide prevention advocates as a whole because we've been so focused on let's motivate people or try to convince them to not try to kill themselves. But the reality is, despite our best efforts, there will be some people who make suicide attempts anyway, whether, whether because they never came in to receive the intervention from us, or they did, and the intervention just wasn't potent enough or something like that. And so what this means is we need a backup plan and the backup plan is to help people survive their suicide attempts. It's something that I don't at least when I first pointed out to people they're kind of confused but because they're like wait a minute you're saying we shouldn't try to stop people from trying to kill themselves like oh no no no we should. I'm just saying we do need a backup plan that we need seatbelts right seatbelts won't stop people getting into a car crash but if you're in a car crash the seatbelts can save your life it helps you survive. And that's where like means restriction and means safety comes in because if people do not have easy convenient access to highly lethal highly dangerous methods for a company's suicide, then it's harder for them to die as a result. And so they may still have attempted suicide but they wake up afterwards or they you do have some sort of an effect and then they move on with their lives and that is still suicide prevention and so it's basically a harm reduction model and and a big piece of that within the clinical space is having conversations with our patients around their access to the most lethal methods for attempting suicide and how can we place time and distance between people and those methods when in acute crisis occurs so that they're much more likely to survive those moments. And so when it comes to because you've written a lot about like the process of means restriction counseling and particularly at least as I've read it sort of emphasizing how that process can unfold in a way that patients will be receptive to it. I think that's something to be super helpful for you to sort of chat about a bit here. Yeah so we advocate for a motivational interviewing based approach to these conversations and the reason for that is of course motivational interviewing is you know pretty much a hundred percent about changing a person's motivation to either stop certain behaviors or engage in alternative behaviors and part of the philosophy underlying motivational interviewing is that people have to perceive that change is important right so doing things in a different way is personally relevant to me and then they also have to feel as though they can do it so they have to be capable or have us in a self efficacy. And so as it relates to those two aspects of motivation oftentimes people have reasons to not change your behavior or to keep things the same way. And as it applies to mean safety counseling we found that there are oftentimes strong motivations to maintain access to highly homies of suicide. The clearest example and a big focus of my work in the United States is firearm access which arguably is instead a uniquely American problem but it's very very disproportionately a United States problem going to our laws around gun ownership and cultures around that. And so oftentimes there is a lot of reluctance for patients who have access to firearms to lock them off or otherwise limit their access because they are concerned about being able to protect themselves and their families and in the case of like a home invasion or something like that they feel like they have a right to to firearm access. And so we really had to learn how to kind of navigate those issues. I found that it's a there's similar dynamics that play for patients who are counseling playing other methods. So medication access is another very common issue where for some people access to medication is important for their health right so locking up all their meds if they have a chronic medical condition as you know not going to necessarily be good for them but then there are other times where there's a psychological attachment to those methods where the removal of the medications or the ligatures or the knives or the razors what are the cases if the is seen as sort of like a threat in the sense that a primary motivator of suicide is the desire to escape uncomfortable, aversive punishing life circumstances or states of mind. And so for many people the thought of I have an eject body where things get too bad I just put this into place that can actually help them to manage their emotional distress because they feel like they have an option and so if you take that away from them that can be very dysphoria inducing because it's like well I now I don't have an exit strategy and what am I going to do you like sort of condemning me to suffer and so we have to even in those circumstances then navigate these conversations of order the benefits and the drawbacks of changing how how much access or how readily convenient these different methods are for you and so the the motivational interviewing based approach we found is very successful because it really is about embracing where a person is at and and acknowledging that there actually are legitimate reasons to maintain access to those methods and their legitimate reasons to not and we try to help God the patient to a place where they are the ones who are saying I want to voluntarily reduce my access to these methods because it's in my best interest it's consistent with my values and so on. That's a wrap on the first part of our conversation as I noted at the top it would be much appreciated if you spread the word to anyone who you think might enjoy the show until next time bye.